Three-dimensional Transthoracic Echocardiography Research Articles

P350 Right atrial remodelling in atrial fibrillation using three dimensional transthoracic echocardiography and strain imaging

Abstract Background Evaluation of right atrial cavities and right atrial (RA) remodelling in atrial fibrillation (AF) has been poorly studied. Purpose The aim of this study was to evaluate in AF, the role of three-dimensional (3D) transthoracic echocardiography (TTE) and strain to refine the evaluation of the RA according to evolution of cardiac rhythm ad mid-term follow-up. Methods A complete 2D and 3D TTE was performed in patient hospitalized for AF. In addition to the usual parameters, RA parameters were specifically assessed: 3D RA end-systolic (ES) and end-diastolic (ED) volume, RA ejection fraction (EF) and the global longitudinal strain (GLS) of the RA. A complete clinical evaluation and electrocardiogram were performed at admission (M0) and 6 months after inclusion (M6) to determine the cardiac rhythm at follow-up. Results 34 consecutive patients hospitalized for AF were analysed. At M0, there was no significant difference between 2D RA ES volume and the 3D RA ES volume. Three groups of patients were individualized according to cardiac rhythm at M0 and M6: AF at M0 and AF at M6 (AF-AF), AF at M0 and sinus rhythm (SR) at M6 (AF-SR), SR at M0 (spontaneous reduction before the admission ECG) and SR at M6 (SR-SR). At M0 echocardiography, in the AF-AF group and AF-SR in comparison with SR-SR group were as follow: the 3D RA ED volume was significantly higher (respectively 21.6 (18.2-26.6) and 26.9 (19.4-36.8) versus 11.3 (6.9-16.6) mL/m2 ; p = 0.0025), the 3D RAEF was significantly lower (42.2 (35.1-44.7) and 34.5 (24.1-38.6) versus 57.6 (53.4-62.2)%; p = 0.0105) and the RA GLS was also significantly lower (7.6 (6.5-10.5) and 9.1 (5.8-11.2) versus 26.6 (22.0-35.0)%; p = 0.0001) (Figure 1). Conclusion 3D ultrasound and strain could be useful tools for evaluating the anatomical and functional RA remodelling in AF, to be further validated in a larger ongoing study. Abstract P350 Figure 1

Quantification of rheumatic mitral stenosis severity with three dimensional vena contracta area

Rheumatic mitral stenosis is a real public health problem in developing countries. Assessment of the mitral valve area (MVA) is essential for the choice of the intervention time. Most of the evaluation parameters of rheumatic MS are derived of two-dimensional echocardiography (2D). Three-dimensional transthoracic echocardiography (3D) is commonly used in our daily practice today. The purpose of this study was to evaluate the value of the vena contracta area (VCA) to predict the severity of rheumatic MS by comparing 3D planimetry. Patients who were diagnosed with severe rheumatic MS with conventional methods (half-pressure, planimetry) by 2D transthoracic echocardiography (TTE), underwent 3D TTE assessment. The VCA of the mitral valve was measured at maximum opening, with measurement planimetry MVA by metre/cropping TTE 3D. We studied 92 patients (mean age: 42 years) with Rheumatic MS. 15% (14 cases) had a 3D mitral area smaller than the mitral area per vena contracta, 80% (73 cases) the mitral area per vena contracta was smaller than 3D and 5% (5 cas) SP was equal in the two methods. The results of our study provide evidence that the VCA of the 3D TTE mitral valve can be used routinely to detect the severity of mitral stenosis.

Feasibility and Accuracy of Two-and Three-Dimensional Transthoracic Echocardiography in patients with Right Atrial Dilatation using the Right Parasternal Approach

Background: Echocardiography increasingly used for diagnosis of right atrial dilatation. Three dimensional is superior than two dimensional echocardiography. However, advances and new windows continues to emerge to increase its accuracyAim of the work: to show the feasibility and accuracy of right parasternal approach and its usefulness in qualitative and quantitative assessments of right atrium in patients with right atrial dilatation in comparison with transesophageal approach.Patients and Methods: The study included thirty patients with right atrial dilatation. All patients underwent full history taking, clinical, 12-lead electro-cardiography and echocardiography. Transesophageal Echocardio-graphy was used as a gold standard for the accuracy of the right parasternal approach.Results: The study includes 30 patients with right atrial dilatation the right parasternal (RPS) view obtained in 18 patients (60%), and not obtained in 12 patients (40%). There was significant decrease of SVC anteroposterior minimal diameter (Min AP), crista terminalis (CT) width, CT length, right atrial appendage (RAA) base Maximum diameter and RAA base Minimum diameter, in 2D Echocardiography when compared to 3D Echocardiography. On the other side, there was no statistically significant difference in Right parasternal approach (3D) and Transesophageal approach.Conclusions: Parasternal approach is feasible in imaging right heart structures. In addition, three dimensional TTE had an incremental value over two dimensional TTE in the assessment of these structures

Assessment of Left Ventricular Remodeling Index in Hypertensive Patients Using Two- and Three-Dimensional Transthoracic Echocardiography

Background: Hypertensive heart disease (HHD) and coronary artery disease (CAD) generally develop left ventricular remodeling. Therefore, it is of great importance for how to assess HHD and CAD’s left ventricular remodeling which can influence vital diagnosis, therapeutic decisions and prognosis. Aim of the Work: to assess left ventricular remodeling index in HTN patients compared to normal patients using 2D and 3D transthoracic echocardiography. Patients and Methods: This study included 120 subjects at Cardiology Department, Faculty of Medicine, Al-Azhar University during the period from October 2018 to June 2019. They were divided into two groups: Group A (Patient group): which included (100) hypertensive patient. Group B (Control group): which included (20) age and sex matched apparently healthy individuals. Results: There were no significant differences in age and sex inter-group. LVRI detected by RT3DE and 2DE showed significant differences inter-group (1.72±0.04 vs 1.94±0.07, 1.73±0.04 vs 2.17±0.05); and significant differences in patient (1.94±0.07 vs 2.17±0.05), but no significant differences in control group (1.72±0.04 vs 1.73±0.04). Correlation analysis indicated that there was a good positive correlation between LVRI detected by RT3DE and 2DE in control and patient groups (r=0.91, 0.79, all P<0.001). Conclusion: LVRI derived from RT3DE can provide more superiority to LVRI derived from 2DE as an index for evaluating left ventricular remodelling.

Accuracy of Left Ventricular Volumes and Ejection Fraction Measurements by Contemporary Three-Dimensional Echocardiography with Semi- and Fully Automated Software: Systematic Review and Meta-Analysis of 1,881 Subjects

Although left ventricular (LV) quantification software for transthoracic three-dimensional echocardiography (3DE) have been steadily advancing, the measurement accuracy of semiautomated and fully automated software has not been systematically investigated. We performed a systematic review and meta-analysis following a search of the PubMed, Embase, and Scopus databases for studies that directly compared LV volumes and ejection fraction (EF) using 3DE with ultrasound machines manufactured by one of the four manufacturers with either semiautomated (n=4) or fully automated software (n=2) and cardiac magnetic resonance (CMR) during the period from January 1, 2011, to July 23, 2018. A random effects model was used to determine the bias and 95% CI of LV end-diastolic volume (EDV), end-systolic volume (ESV), and EF. A metaregression and subgroup analysis were performed to investigate intersoftware variabilities. Of a total of 38 studies (1,881 subjects), the pooled bias and 95% CI for EDV, ESV, and EF of semiautomated software were -39.3mL (-49.2 to -29.5mL, P<.001), -19.6mL (-25.9 to -13.3mL, P<.001), and -0.6% (-2.0% to 0.7%, P=.360), respectively. The corresponding values for fully automated software were -14.5mL (-25.7 to -3.3mL, P=.011), -6.3mL (-11.4 to -1.2mL, P=.016), and -1.1% (-3.5% to 1.3%, P=.356) compared with CMR. The EDV and ESV biases for 3DE and CMR became significantly smaller and less heterogeneous when fully automated software was used. A metaregression analysis revealed that EDV bias became larger with an increase in EDV when semiautomated software was used but not when fully automated software was used. Although 3DE still underestimates LV volumes, EF showed similar values to CMR for both types of software. The adoption of fully automated software could further improve measurement accuracy with fewer observer variabilities.

Combined flow-based imaging assessment of optimal cardiac resynchronization therapy pacing vector: a\xa0case report

BackgroundThere are still many pendent issues about the effective evaluation of cardiac resynchronization therapy impact on functional mitral regurgitation. In order to reduce the intrinsic difficulties of quantification of functional mitral regurgitation itself, an automatic quantification of real-time three-dimensional full-volume color Doppler transthoracic echocardiography was proposed as a new, rapid, and accurate method for the assessment of functional mitral regurgitation severity. Recent studies suggested that images of left ventricle flow by echo-particle imaging velocimetry could be a useful marker of synchrony. Echo-particle imaging velocimetry has shown that regional anomalies of synchrony/synergy of the left ventricle are related to the alteration, reduction, or suppression of the physiological intracavitary pressure gradients.Case summaryWe describe a case in which the two technologies are used in combination during acute echocardiographic optimization of left pacing vector in a 63-year-old man, Caucasian, who showed worsening heart failure symptoms a few days after an implant, and the effect of the device’s optimization at 6-month follow-up.DiscussionThe degree of realignment of hemodynamic forces, with quantitative analysis of the orientation of blood flow momentum (φ), can represent improvement of fluid dynamics synchrony of the left ventricle, and explain, with a new deterministic parameter, the effects of cardiac resynchronization therapy on functional mitral regurgitation. Real-time three-dimensional color flow Doppler quantification is feasible and accurate for measurement of mitral inflow, left ventricular outflow stroke volumes, and functional mitral regurgitation severity.ConclusionThis clinical case offers an innovative and accurate approach for acute echocardiographic optimization of left pacing vector. It shows clinical utility of combined three-dimensional full-volume color Doppler transthoracic echocardiography/echo-particle imaging velocimetry assessment to increase response to cardiac resynchronization therapy, in terms of reduction of functional mitral regurgitation, improving fluid dynamics synchrony of the left ventricle.

A closer look at right ventricular 3D volume quantification by transthoracic echocardiography and cardiac MRI

To compare right ventricular (RV) volumetry using state-of-the-art three-dimensional (3D) transthoracic echocardiography (3DE) and cardiac magnetic resonance imaging (CMR) near-simultaneously in a clinical setting. Forty-seven consecutive patients received comprehensive echocardiography including 3DE within 30 minutes of CMR. RV volumetry was performed offline with semi-automated 3D endocardial border tracing as well as manual delineation of the compacted myocardium in short-axis views by CMR. Forty-two examinations (89%) could be analysed offline by 3D RV reconstruction. Mean RV volumes assessed by CMR and 3DE were 215±63 and 127±42 ml for end-diastole (RV-EDV), as well as 110±43 and 62±27 ml for end-systole (RV-ESV). RV-EDV, RV-ESV, and RV stroke volume measured by 3DE were significantly lower than RV volumetry by CMR. Mean bias were -88, -48, and -41 ml, respectively. Mean RV ejection fraction (-EF) showed a non-significant deviation of +2% between 3DE and CMR and the correlation coefficient was r=0.58 for RV-EF. RV-EF can be assessed reliably using transthoracic 3DE in patients with good image quality; however, absolute RV volumes measured by 3DE show a systematic deviation to CMR volumetry that has been previously neglected and requires careful interpretation regarding anatomical cardiac imaging.

Reliability of three-dimensional color flow Doppler and two-dimensional pulse wave Doppler transthoracic echocardiography for estimating cardiac output after cardiac surgery

BackgroundThree-dimensional color flow Doppler (3DCF) is a new convenient technique for cardiac output (CO) measurement. However, to date, no one has evaluated the accuracy of 3DCF echocardiography for CO measurement after cardiac surgery. Therefore, this single-center, prospective study was designed to evaluate the reliability of three-dimensional color flow and two-dimensional pulse wave Doppler (2D-PWD) transthoracic echocardiography for estimating cardiac output after cardiac surgery.MethodsPost-cardiac surgical patients with a good acoustic window and a low dose or no dose of vasoactive drugs (norepinephrine < 0.05 μg/kg/min) were enrolled for CO estimation. Three different methods (third generation FloTrac/Vigileo™ [FT/V] system as the reference method, 3DCF, and 2D-PWD) were used to estimate CO before and after interventions (baseline, after volume expansion, and after a dobutamine test).ResultsA total of 20 patients were enrolled in this study, and 59 pairs of CO measurements were collected (one pair was not included because of increasing drainage after the dobutamine test). Pearson’s coefficients were 0.260 between the CO-FT/V and CO-PWD measurements and 0.729 between the CO-FT/V and CO-3DCF measurements. Bland-Altman analysis showed the bias between the absolute values of CO-FT/V and CO-PWD measurements was − 0.6 L/min with limits of agreement between − 3.3 L/min and 2.2 L/min, with a percentage error (PE) of 61.3%. The bias between CO-FT/V and CO-3DCF was − 0.14 L/min with limits of agreement between − 1.42 L /min and 1.14 L/min, with a PE of 29.9%. Four-quadrant plot analysis showed the concordance rate between ΔCO-PWD and ΔCO-3FT/V was 93.3%.ConclusionsIn a comparison with the FT/V system, 3DCF transthoracic echocardiography could accurately estimate CO in post-cardiac surgical patients, and the two methods could be considered interchangeable. Although 2D-PWD echocardiography was not as accurate as the 3D technique, its ability to track directional changes was reliable.

Dynamic Three-Dimensional Geometry of the Tricuspid Valve Annulus in Hypoplastic Left Heart Syndrome with a Fontan Circulation

Tricuspid regurgitation (TR) is a significant contributor to morbidity and mortality in patients with hypoplastic left heart syndrome. The goal of this study was to characterize the dynamic annular motion of the tricuspid valve in patients with HLHS with a Fontan circulation and assess the relation to tricuspid valve function. Tricuspid annuli of 48 patients with HLHS with a Fontan circulation were modeled at end-diastole, mid-systole, end-systole, and mid-diastole using transthoracic three-dimensional echocardiography and custom code in 3D Slicer. The angle of the anterior papillary muscle (APM) relative to the annular plane in each systolic phase was also measured. Imaging was performed 5.0years (interquartile range, 2-11years) after Fontan operation. The tricuspid annulus varies in shape significantly throughout the cardiac cycle, changing in sphericity (P<.001) but not in annular height or bending angle. In univariate modeling, patients with significant TR had larger changes in septolateral diameter, lateral quadrant area, and posterior quadrant area (P<.05 for all) as well as lower (more laterally directed) APM angles (P<.001) than patients with mild or less TR. In multivariate modeling, a 1mm/(body surface area)0.5 increase in the maximum change in septolateral diameter was associated with a 1.7-fold increase in having moderate or greater TR, while a 10° decrease in APM angle at mid-systole was associated with an almost 2.5-fold increase in moderate or greater TR (P≤.01 for all). The tricuspid annulus in patients with HLHS with a Fontan circulation changes in shape significantly throughout the cardiac cycle but remains relatively planar. Increased change in septolateral diameter and decreased APM angle are strongly associated with the presence of TR. These findings may inform annuloplasty methods and subvalvular interventions in these complex patients.

Stepwise Protocols for Scoring of Mitral Valve using Three-Dimensional Transthoracic Echocardiography in Mitral Stenosis.

Aim:This study aims to propose protocols that enable scoring of mitral valve (MV) in mitral stenosis using the three-dimensional (3D) scoring system.Methods:A two-staged study was conducted. The first stage was designed to select the best 3D images of MV leaflets and chordae through analysis of 471 images. The second stage was designed to organize the best 3D images into protocols for complete scoring of MV. It included 35 consecutive patients; 23 had sinus rhythm (SR) and 12 had atrial fibrillation (AF). Both single- and multi-beat 3D acquisition from apical and parasternal windows were focused on MV leaflets and chordae using all 3D modalities (live, zoom, and full volume). To propose the protocols, 1563 images were analyzed.Results:In SR with good apical window, 2 protocols were recommended for complete scoring of leaflets and chordae (4 zoom 3D images [1 image for leaflets and 3 images for chordae] and 1 full-volume 3D image) using single- and multi-beat acquisition. In AF, the same 2 protocols using single-beat acquisition were recommended. From parasternal window, complete scoring of leaflets was obtained by 3 recommended protocols (single- or multi-beat zoom 3D images from parasternal short axis [PSAX], multibeat live 3D images from PSAX, and single- or multi-beat full-volume 3D images from parasternal long axis) in SR and 1 protocol in AF (single-beat zoom 3D images from PSAX). Scoring of chordae was incomplete in all patients by all 3D modalities.Conclusions:The proposed 3D-transthoracic echocardiography protocols suit all patients regardless of echo window and heart rhythm and enabled complete MV scoring.

Evaluation of the volume and function of left atrial appendage and left atrium in patients with atrial fibrillation by three-dimensional transesophageal echocardiography and transthoracic echocardiography

To evaluate the volume and function of left atrium and left atrial appendage in patients with atrial fibrillation by three-dimensional transesophageal echocardiography and transthoracic echocardiography. Methods: A total of 112 patients with atrial fibrillation were divided into two groups: a paroxysmal atrial fibrillation (ParAF) group (n=80) and a persistent atrial fibrillation (PerAF) group (n=32). Control group was people without atrial fibrillation (n=40). Clinical data of the participants were collected. Left atrial dimension (LAD), left atrial volume (LAV), left ventricular end-diastolic volume (LVEDV) and left ventricular end-systolic volume (LVESV) were measured by transthoracic echocardiography, while left atrial appendage peak emptying flow velocity (LAAeV), left atrial appendage peak filling flow velocity (LAAfV), left atrial appendage maximum volume (LAAVmax) and left atrial appendage minimum volume (LAAVmin) were measured by three-dimensional transesophageal echocardiography. Left atrial volume index (LAVI), left ventricular ejection fraction (LVEF) and left atrial appendage ejection fraction (LAAEF) were calculated. Results: Compared with the control group, LAAEF, LAAeV and LAAfV in the ParAF group were decreased obviously, while LAD, LAV, LAVI, LAAVmax and LAAVmin in the ParAF group were increased obviously (P<0.05). Compared with the ParAF group, LAAEF, LAAeV and LAAfV in the PerAF group were also decreased obviously, and LAD, LAV, LAVI, LAAVmax and LAAVmin in the ParAF group were also increased obviously (P<0.05). There was no statistically significant difference in LVEDV, LVESV, LVEF between the ParAF group and the PerAF group (P<0.05). Conclusion: Left atrium and left atrial appendage were enlarged and the function of left atrial appendage was declined in patients with AF, and the changes were more obvious in patients with PerAF compared with patients with ParAF by three-dimensional transesophageal echocardiography and transthoracic echocardiography.

Quantitative assessment of two- and three-dimensional transthoracic and two-dimensional transesophageal echocardiography, computed tomography, and magnetic resonance imaging in normal canine hearts

IntroductionThe objective of the study was to evaluate the accuracy of two- and three-dimensional (2D, 3D) transthoracic echocardiography (TTE), 2D transesophageal echocardiography, and computed tomography angiography (CTA) compared with cardiac magnetic resonance imaging (CMR) in normal dogs and to assess repeatability of 2D and 3D TTE for the assessment of left ventricular (LV) and left atrial (LA) dimensions. AnimalsThe study was performed on six healthy dogs. Materials and MethodsTransthoracic echocardiography, transesophageal echocardiography, CTA, and CMR were performed on each dog. Right ventricular (RV) and LV volumes (in systole and diastole), ejection fraction (EF), and LA and right atrial (RA) volumes were assessed. Repeatability and intrarater and interrater measurements of variability were quantified by average coefficient of variation (CV) for 2D and 3D TTE. ResultsNo clinically relevant differences in LV volume were detected between CMR and all modalities. Importantly, 3D TTE had the lowest CV (6.45%), correlated with (rs = 0.62, p = 0.01), and had the highest overlap in distribution with CMR (OVL >80%). Left ventricular EF and LA size via CTA compared best with CMR and RV and RA volumes were best estimated by 3D TTE. Assessment of LV and LA volumes via 3D TTE had moderate repeatability (15–21%) compared with LV M-mode measurements and 2D LA-to-aortic ratio (<10%), respectively. For LV size, interrater CV for 3D TTE (19.4%) was lower than 2D TTE (23.1%). ConclusionsMeasurements of LV, RV, and RA volumes via 3D TTE and LA volume and LV EF assessed by CTA compared best with CMR. Three-dimensional echocardiography had lower interrater and intrarater CV compared with 2D TTE.

Comparative assessment of ascending aorta diameter using three-dimensional trans-thoracic echocardiography vs. ECG-gated computerized tomographic angiography.

Currently, 2D TTE is used in routine practice for the follow-up of ascending aorta aneurism (AAA). When the maximal aortic diameter reaches the surgical threshold, ECG-gated computerized tomographic angiography (CT) is used to confirm the diameter. No study has evaluated ascending aortic diameter measurement with 3D trans-thoracic echocardiography (3DTTE). The aim of this study was to compare 3DTTE with CT for assessment of the aortic root diameters. Standard 2D-TTE, followed with a 3D volume acquisition (3DTTE), and CT were performed in patients seen in our clinic for an AAA. After a double oblique reconstruction, measurements were obtained, using the inner-to-inner technique in end-diastole in a strict transverse plane passing through the maximal diameter ‘cusp to cusp’ for each cusp in 3D-TTE and CT. CT and TTE were performed within 3 months. Transverse plan of the sinus of Valsalva was used in 2DTTE, 3DTTE and CT to measure: diameters between non-coronary and right coronary sinuses (2DNR, 3DNR and CTNR), between left and right coronary sinuses (2DLR, 3DLR, CTLR), and between left and non-coronary sinuses (2DLN 3DLN, CTLN). Correlation between diameters was evaluated by Bland–Altmann diagrams and Spearman's correlation coefficient. Forty-four consecutive patients with ascending aortic aneurysm were included (49 +/ − 15 years, men 77%). Diameters between CT and 2DTTE were statistically different except for the NR diameter (mean differences: CTNR-2DNR = 0.02 mm, P = 0.48, CTLR-2DLR = −2.1 mm, P = 0.0003, CTLN-2DLN = − 2.1 mm, P = 0.01). Diameters between MDCT and 3DTTE were similar (mean differences: CTNR −3DNR = 0 mm, P = 0.3, CTLR-3DLR = 0.1 mm, P = 0.3, CTLN − 3DLN = −0.2 mm, P = 0.4). In addition, MDCT and 3DTTE diameters showed a good correlation (rNR = 0.95, rLR = 0.94 rLN = 0.91) ( Fig. 1 ). Aortic root diameters obtained with 3DTTE are highly correlated with CT diameters. 3D TTE may be an additional follow-up technique in patients with aortic root aneurysms.

Sutureless Valve Replacement Through a Right Anterior Mini-thoracotomy in Elderly Patients With Stenotic Bicuspid Aortic Valve

Several indications for sutureless aortic valve replacement (SU-AVR) have been a matter of debate. We evaluated our experience with Perceval-S (LivaNova group, Saluggia, Italy) SU-AVR in patients with severe aortic stenosis (AS) involving bicuspid aortic valve (BAV), even though presence of BAV is still considered to be a contraindication for sutureless valves. From January 2013 through March 2018, 13 patients with severe AS involving BAV underwent SU-AVR with the Perceval-S (LivaNova group, Saluggia, Italy) prosthesis in a single center. Preoperative evaluation included coronary catheterization and multisliced computerized tomography was performed in all patients. Three-dimensional transthoracic echocardiography was used to evaluate for obtaining the anatomy and phenotype of BAV. Minimally invasive approach through right anterior thoracotomy from third intercostal space was performed for all patients. The mean age was 72.8 ± 2.26 years ranging from 70 to 77, and 53.8% (n = 7) were male. The mean aortic valve gradient decreased from 46.4 ± 13.8 to 13.6 ± 4.4 mmHg postoperatively. The mean aortic valve area increased from 0.69 ± 0.22 to 1.81 ± 0.38 cm2. There was no in-hospital mortality. One patient (7.6%) had third-degree atrioventricular block requiring permanent pacemaker implantation. Mean follow-up was 15.1 ± 6.3 months (maximum 2 years). No major paravalvular leakage or valve migration occurred postoperatively. This study shows that SU-AVR is a technically feasible and safe procedure in patients with severe AS and BAV with acceptable good surgical outcomes. Presence of BAV in AS should not be considered a contraindication to Perceval-S prosthesis (LivaNova group, Saluggia, Italy).

Evaluation of coronary sinus morphology by three-dimensional transthoracic echocardiography in patients undergoing electrophysiological study.

BackgroundIn this study, we aimed to evaluate the coronary sinus (CS) morphology with three‐dimensional transthoracic echocardiography (3D‐TTE) in patients with supraventricular tachycardia (SVT) who underwent electrophysiological study (EPS).MethodsThis cross‐sectional study was conducted with 187 patients who underwent EPS between November 2016 and April 2017. Patients were divided into three groups: atrioventricular nodal reentrant tachycardia (AVNRT) (n = 72), non‐AVNRT SVT (n = 58), and normal EPS (n = 57). All patients were evaluated with electrocardiography, TTE, and 3D‐TTE.ResultsThe CS diameter (CSD) and area (CSA) were found significantly lower in the normal EPS group than in the other groups. There was no significant difference in the CSD between AVNRT and non‐AVNRT SVT groups. However, it was found that the CSA was significantly larger in the AVNRT group than in the non‐AVNRT SVT group. In linear regression analysis, age and left atrial diameter were determined as independent predictor for CSD and CSA (P < 0.001 for each one).ConclusionsThe CSD and CSA assessed by 3D‐TTE were different and dilated in the patients with SVT compared to those in the normal individuals. There was no significant difference in the CSD between the AVNRT and non‐AVNRT SVT groups. However, the AVNRT group had a larger CSA than the non‐AVNRT SVT group.

Medida tridimensional del área del anillo tricúspide. Un nuevo criterio en la selección de candidatos a anuloplastia

Introduction and objectivesLate functional tricuspid regurgitation after rheumatic left-sided valve surgery is an important predictor of poor prognosis. This study investigated the usefulness and accuracy of 3-dimensional transthoracic echocardiography tricuspid area compared with conventional 2-dimensional diameter (2DD) for assessing significant tricuspid annulus dilatation, providing cutoff values that could be used in clinical practice to improve patient selection for surgery. MethodsWe prospectively included 109 patients with rheumatic heart disease in the absence of previous valve replacement. Tricuspid regurgitation was divided into 3 groups: mild, moderate, and severe. Optimal 3-dimensional area (3DA) and 2DD cutoff points for identification of significant tricuspid annulus dilatation were obtained and compared with current guideline thresholds. Predictive factors for 3DA dilatation were also assessed. ResultsOptimal cutoff points for both absolute and adjusted to body surface area (BSA) tricuspid annulus dilatation were identified (3DA: 10.4 cm2, 6.5 cm2/m2; 2DD: 35 mm, 21 mm/m2); 3DA/BSA had the best diagnostic performance (AUC=0.83). Three-dimensional transthoracic echocardiography tricuspid area helped to reclassify surgical indication in 14% of patients with mild tricuspid regurgitation (95%CI, 1%-15%; P=.03) and 37% with moderate tricuspid regurgitation (95%CI, 22%-37%; P<.0001), whereas 3DA/BSA changed surgery criteria in cases of mild tricuspid regurgitation (17%; 95%CI, 3%-17%; P=.01) compared with 2DD/BSA. On multivariable analysis, right and left atrial volumes and basal right ventricle diameter were independently correlated with 3DA. ConclusionsThe current 40 mm threshold underestimates tricuspid annulus dilatation. Although 21 mm/m2 seems to be a reasonable criterion, the combination with 3DA assessment improves patient selection for surgery.Full English text available from:www.revespcardiol.org/en

Feasibility of New Transthoracic Three-Dimensional Echocardiographic Automated Software for Left Heart Chamber Quantification in Children

New three-dimensional echocardiographic automated software (HeartModel) is now available to quantify the left heart chambers. The aims of this study were to assess the feasibility, reproducibility, and analysis time of this technique and its correlation with manual three-dimensional echocardiography (3DE) and cardiac magnetic resonance (CMR) in children. Ninety-two children (5-17years of age) were prospectively included in two separate protocols. In protocol 1, 73 healthy children underwent two-dimensional and three-dimensional transthoracic echocardiography. Left ventricular (LV) end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV ejection fraction (LVEF), and left atrial volume at ventricular end-systole (LAV) by automated 3DE were compared with the same measurements obtained using manual 3DE. In protocol 2, automated three-dimensional echocardiographic measurements from 19 children with cardiomyopathy were compared with CMR values. Automated 3DE was feasible in 77% of data sets and significantly reduced the analysis time compared with manual 3DE. In protocol 1, there were excellent correlations for LVEDV, LVESV, and LAV between automated 3DE and manual 3DE (r=0.89 to 0.99, P<.0001 for all) and a weak correlation for LVEF, despite contour adjustment (r=0.57, P<.0001). Automated 3DE overestimated LVEDV, LVEF, and LAV with small biases and underestimated LVESV with wider bias. With contour adjustment, the biases and limits of agreement were reduced (bias: LVEDV, 0.9mL; LVESV, -1.2mL; LVEF, 2.2%). In protocol 2, correlations between automated 3DE with contour edit and CMR were good for LV volumes and LAV (r=0.76 to 0.94, P<.0003 for all) but remained weak for LVEF (r=0.46, P=.05). Automated 3DE slightly underestimated LV volumes (relative bias, -7.2% to -7.8%) and significantly underestimated LAV (relative bias, -31.6%). The limits of agreement were clinically acceptable only for LVEDV. Finally, test-retest, intraobserver, and interobserver variability values were low (<12%). HeartModel is feasible, reproducible, faster than manual 3DE, and comparable with manual 3DE for measurements of LV and left atrial volumes in children >5years of age. However, compared with CMR, only LVEDV measured by automated 3DE with contour edit seems applicable for clinical practice.

Pacemaker-associated thrombosis in ongoing therapy with edoxaban tosylate

Thromboembolism is a known complication of pacemaker implantation. However, published literature describes only a few cases, in which the events occurred in absence of antithrombotic prophylaxis, not routinely employed for its prevention in current clinical practice. We report a case of pacemaker lead-associated thrombosis in a patient taking continuative oral anticoagulant therapy with edoxaban tosylate (edoxaban). No data in present literature supports the use of anticoagulant prophylaxis for pacemaker lead thrombosis. In our report ongoing treatment with edoxaban proved ineffective for thrombosis prevention. We also discuss the role of three-dimensional transthoracic echocardiography for diagnostic assessment of thrombosis in a fragile patient.

Three-Dimensional Mitral Valve Morphology in Children and Young Adults With Marfan Syndrome

Mitral valve (MV) prolapse is common in children with Marfan syndrome (MFS) and is associated with varying degrees of mitral regurgitation (MR). However, the three-dimensional (3D) morphology of the MV in children with MFS and its relation to the degree of MR are not known. The goals of this study were to describe the 3D morphology of the MV in children with MFS and to compare it to that in normal children. Three-dimensional transthoracic echocardiography was performed in 27 patients (3-21years of age) meeting the revised Ghent criteria for MFS and 27 normal children matched by age (±1year). The 3D geometry of the MV apparatus in midsystole was measured, and its association with clinical and two-dimensional echocardiographic parameters was examined. Compared with age-matched control subjects, children with MFS had larger 3D annular areas (P<.02), smaller annular height/commissural width ratios (P<.001), greater billow volumes (P<.001), and smaller tenting heights, areas, and volumes (P<.001 for all). In multivariate modeling, larger leaflet billow volume in MFS was strongly associated with moderate or greater MR (P<.01). Intra- and interuser variability of 3D metrics was acceptable. Children with MFS have flatter and more dilated MV annuli, greater billow volumes, and smaller tenting heights compared with normal control subjects. Larger billow volume is associated with MR. Three-dimensional MV quantification may contribute to the identification of patients with MFS and other connective tissue disorders. Further study of 3D MV geometry and its relation to the clinical progression of MV disease is warranted in this vulnerable population.

A New Three-Dimensional Echocardiography Method to Quantify Aortic Valve Calcification

Aortic valve calcification (AVC) quantification is computed from multidetector computed tomography (MDCT). The aim of this study was to test the hypothesis that three-dimensional (3D) transthoracic echocardiography can be used to provide a bedside method to assess AVC. The study included 94 patients (mean age, 78±12years; mean aortic valve [AV] area, 1.0±0.6cm2) referred for MDCT and echocardiography for AV assessment. Apical 3D full-volume data sets focused on the AV region were acquired during transthoracic echocardiography, and a region-growing algorithm was applied offline to compute 3D transthoracic echocardiographic AVC (AVC-3DEcho). AVC-3DEcho was compared with AVC by MDCT and with calcium weight in the subgroup of patients referred for surgery, with explanted AVs analyzed by a pathologist (n=22). In the explanted valve group, AVC-3DEcho score exhibited fair correlations with MDCT score (r=0.85, P<.001), calcium load (r=0.81, P<.001), and peak AV velocity (r=0.64, P<.001). In the overall population, AVC-3DEcho score correlated modestly with MDCT score (r=0.61, P<.001) but had similar accuracy to identify severe aortic stenosis (area under the curve=0.94). AVC-3DEcho > 1,054mm3 identified severe aortic stenosis with specificity of 100% and sensitivity of 76%. In addition, AVC-3DEcho was associated with the presence of significant paravalvular regurgitation after transcatheter aortic valve implantation. Finally, intraobserver and interobserver variability for AVC-3DEcho score was 4.2% and 8.9%, respectively. AVC-3DEcho correlated with calcium weight obtained from pathologic analysis and MDCT. These data suggest that a bedside method for quantifying AV calcification with ultrasound is feasible.