Transthoracic Color Doppler Echocardiography Research Articles

Abnormal aortic origin of coronary arteries

The anomalous aortic origin of the coronary arteries has an estimated prevalence of 0.02-5.7%. It can be associated with sudden death when it has an interarterial or intramural pathway or be damaged during interventions on the mitral, pulmonary and/or aortic annulus or percutaneous closure of an interatrial septal defect. To identify these patients by imaging techniques such as transthoracic color Doppler echocardiography (TTE), computed tomography (CT) multislice angiography or coronary angiography. The imaging techniques used for the detection of coronary anomalies were TTE, multislice coronary angiography or coronary angiography according to what is generally accepted. Fifteen patients were identified; in 12 of them the suspicion was due to TTE and in the remaining 3, CT multislice angiography was diagnostic. The circumflex artery was the coronary artery most involved, associated or not with another coronary anomaly (12/15 patients) and in the other three cases, the anomalous coronary artery had an interarterial course, with the right coronary arteries and the anterior descending coronary arteries being involved. The under diagnosis by TTE of coronary artery abnormalities may be due to the difficulty of visualization that is accentuated with age. Their detection is crucial because they can both, lead to sudden death associated with an intramural and/or interarterial pathway and complicate an interventional procedure on the interatrial septum or within the mitral, pulmonary and/or aortic rings.

P436 ASSOCIATION BETWEEN REVERSE–TAKO–TSUBO E NEUROLOGICAL DISORDER

Abstract Reverse–Tako–tsubo (r–TTC) is a rare variant of Tako–tsubo syndrome (TTC). TTC is characterized by transient and reversible left ventricular systolic dysfunction, for which an emotional or physical stressful trigger can usually be identified. Clinically, it mimics an acute myocardial infarction, with elevation of myocardial cytonecrosis enzymes and no obstractive coronary artery stenosis. On imaging, r–TTC is characterized by hypokinesia of the mid–basal regions associated with hyperkinesia of the apical region that resolves spontaneously. Case report: 78–year–old female affected by cerebral atrophy, leukoencephalopathy, cognitive impairment, behavior disorders. Reported episode of loss of consciousness lasting several minutes, associated with spontaneously resolving tremors and left hemisome hyposthenia. When she arrived in the emergency room, the haematological tests found high troponin values. On CT brain without contrast, no evidence of alterations of the encephalic tissues referable to acute lesions, but it showed of diffuse supratentorial leukoaraiosis and widening of the cerebrospinal fluid spaces on an atrophic basis. The neurological evaluation excludes the presence of a seizure. The electrocardiogram showed diffuse negative T waves and QTc 636 ms. The coronary angiography didn’t show significant coronary arteries stenosis and the ventriculography showed normal ventricular dimensions with total akinesia of the mid segments and normokinesia of the apical region with an ejection fraction of 50%. With these findings a diagnosis of mid left ventricular Tako–tsubo (r–TTC) was made. Transthoracic color Doppler echocardiography confirmed the alterations of the left ventricular kinetics observed by ventriculography. Conclusions compared to CTT, r–TTC is associated with a lower decline in global systolic function and, as reported in the literature, there is a greater connection to neurological insults as triggering factors, such as episodes of aneurysmal subarachnoid hemorrhage, brain surgery, ischemic stroke seizures and traumatic brain injury. The underlying mechanisms are still unknown, a crucial role in catecholamine–induced cardiotoxicity, coronary microvascular dysfunction or coronary vasospasm and/or estrogen deficiency is hypothesized.

Bone fragility, sarcopenia and cardiac calcifications in an elderly population: a preliminary study

Cardiovascular disease, osteoporosis and sarcopenia are very common age-related conditions. This study aimed at investigating the relationships of cardiac calcifications, as assessed by using GCCS with BMD, fragility fractures and sarcopenia in elderly subjects. In a cohort of 106 subjects (age 70.4 ± 5.8 yrs) we measured lumbar (BMD-LS), femoral BMD (femoral neck: BMD-FN, total femur: BMD-TH) and body composition (BMD-WB) with Dual-energy X-ray Absorptiometry (DXA) method. We also evaluated the presence of sarcopenia on the basis of the EWGSOP Consensus. All subjects, simultaneously, underwent to a transthoracic color doppler echocardiography exam to assess the presence of cardiac calcifications. The degree of non coronaric cardiac calcifications was evaluated using the Global Cardiac Calcium Score (GCCS). The degree of cardiac calcification assessed by GCCS was significantly higher in osteoporotic patients (p < 0.001). Furthermore, an inverse correlation emerged between BMD and GCCS, statistical significance was found at lumbar spine and femoral sub-regions in female population (p < 0.01). Moreover by dividing population according to the presence of fragility fractures, we observed that GCCS values were significantly higher in subjects with fractures in respect of non-fractured ones (p < 0.05). Multiple regression models showed that BMD-LS and BMD-FT were independently associated with cardiac calcification. GCCS values were significantly associated with BMI and ASMM in women (p < 0.01 and p < 0.05, respectively) and with handgrip strength in men (p < 0.05). Our data confirm the presence of a relationship between cardiac calcifications and decreased BMD values. It's also the first study that relates sarcopenia and valvular calcifications.

Sources of Variability in Vena Contracta Area Measurement for Tricuspid Regurgitation Severity Grading: Comparison of Technical Settings and Vendors

Previous studies found different cutoffs of vena contracta area (VCA) to define severe tricuspid regurgitation (TR). The aim of this study was to investigate the factors associated with such variability by comparing technical variables and vendors. Sixty-nine patients with scheduled tricuspid surgery were included in this prospective study. For each patient, TR data sets were obtained on three-dimensional color Doppler transthoracic echocardiography on at least two of three systems: GE Vivid E95 (n=39), Siemens SC2000 Prime (n=64), and Philips EPIQ 7C (n=60). VCA was measured using default settings or with color baseline shifted on all three platforms and with minimal color gain (10%-20%) on the GE platform. Color gain reduction and baseline shift caused significant change sin VCA measurement (-46% and 10%, respectively). Intervendor comparison exhibited wide limits of agreement (narrowest range, -74% to 167%), with either default or optimized settings. Different technical settings, platforms, and reference methods all produced different VCA cutoffs for severe TR. VCA measurement in TR is sensitive to technical factors and demonstrates intervendor variability. Technical variables in VCA measurement should be reported in detail to allow comparison among research studies. The same vendor and settings should be used for longitudinal analysis of TR VCA in the same patient in multivendor echocardiography laboratories.

Radiological and hemodynamic parameters in patients with suspected ventricular aneurysm and interventricular septal perforation after acute myocardial infarction: A comparison of non-invasive and invasive diagnostic modalities.

Transthoracic echocardiography is a rapid, sensitive and non-invasive technique for diagnosing ventricular septal perforation. Furthermore, left ventricular angiography is generally used for left ventricular aneurysm but right heart catheterization is the gold standard for septal perforation following myocardial infarction. The objectives of the present study were to compare radiological and hemodynamic diagnostic parameters of non-invasive methods with those of right heart catheterization in patients with suspected ventricular aneurysm and interventricular septal perforation after acute myocardial infarction. Data regarding demographics and clinical characteristics, as well as right heart catheterization, echocardiography and angiographic parameters of 199 patients examined within 21 days after myocardial infarction due to suspected ventricular septal defect indicated by persistent colic pain in the pre-cardiac region were collected and analyzed. Coronary angiography identified 149 (75%) patients with single-vessel disease, 42 (21%) patients with two-vessel disease and 8 (4%) patients with triple-vessel disease. Transthoracic color Doppler echocardiography strengthened the diagnostic performance of right heart catheterization regarding segmental motor abnormalities but underestimated the right atrial pressure, systolic pulmonary artery pressure, mean pulmonary artery pressure and pulmonary capillary wedge pressure compared with right heart catheterization (P<0.0001 for all). Overall, there was no procedural complication requiring emergency intervention, no major complications and no conditions resulting in death due to diagnostic modalities. Transthoracic color Doppler echocardiography may strengthen the diagnostic performance of right heart catheterization regarding radiological measurements but underestimated hemodynamic measurements (level of evidence: 3).

A new noninvasive method for assessing mild coronary atherosclerosis: transthoracic convergent color Doppler after heart rate reduction. Validation vs. intracoronary ultrasound.

A more sensitive transthoracic color Doppler technology (convergent color Doppler), along with a heart rate (HR) reduction and new tomographic planes, can greatly improve coronary blood flow velocity (BFV) recordings in the left main (LMCA) and left anterior descending (LAD) coronary arteries, allowing the detection of even a slight acceleration of BFV due to mild coronary stenosis. A group of 26 patients underwent convergent color Doppler transthoracic echocardiography (CC-Doppler TTE) in the LMCA and in the LAD coronary arteries before and after HR lowering. A second group of 71 patients scheduled for intravascular ultrasound, expanded to 96 with 25 more patients with normal LAD (by angiography/low likelihood of disease), underwent BFV Doppler recordings by CC-Doppler TTE of the whole LAD (specifically the proximal, mid and distal segments) to detect a localized increase in BFV, after attaining maximal and reference BFV in each segment. In the first group, HR reduction dramatically improved the detection of optimal flow in the LMCA and LAD, from 4 to 54% and from 6 to 94% of the segments, respectively (P < 0.001). In the second group intravascular ultrasonography (IVUS) showed mild stenoses in 60 patients. The maximum velocity was higher in the diseased segment than normal segments (49 ± 24 vs. 33 ± 11 cm/s; P < 0.001) and as the reference velocity was similar (32 ± 9 vs. 33 ± 11 cm/s; P = ns), the % increase was also higher (52 ± 52 vs. 0.7 ± 3%; P < 0.001). Using a >21% increase in velocity as a cutoff value, the sensitivity and specificity of CC-Doppler TTE in detecting at least one LAD plaque were 87% (52/60 patients [pts]) and 100% (36/36 pts), respectively. CC-Doppler TTE evaluation of LAD BFV is greatly improved after reducing HR, allowing accurate noninvasive assessment of mild LAD stenosis with no radiation exposure.

Percutaneous Atrial Septal Defect Closure Using the Occlutech Figulla Device in Adults: More than 800 Patient-Years of Follow-Up.

Purpose The Occlutech Figulla occluder has been proven safe and effective at midterm follow-up after percutaneous atrial septal defect (ASD) closure. We describe the safety and efficacy at long-term follow-up in adults. Methods All consecutive adult patients that underwent ASD closure between 2008 and 2015 were included. All complications were registered. Residual left-to-right shunt (LRS) was diagnosed using color-Doppler transthoracic echocardiography (TTE). Right-to-left shunting was diagnosed using contrast TTE. Successful closure was defined as no LRS at follow-up. Results In total, 166 patients (mean age 56.7 ± 16.1 years; 62% female) underwent percutaneous ASD closure using the Occlutech Flex I (70%) or Flex II (30%) device (diameter 24 mm; range 10–40 mm) under general anaesthesia and transoesophageal echocardiographic guidance. Long-term follow-up data were available for 144 patients (87%) with a mean follow-up of 5.9 ± 2.6 years, a total of 814 patient-years. During hospitalization, device embolization occurred in three patients (1.8%) with successful extraction in all. During the long-term follow-up, 15 patients (9.8%) suffered new-onset atrial fibrillation and stroke occurred in 2.1%. There was no residual LRS at 12-month follow-up. No device embolization occurred during the long-term follow-up. Conclusion Percutaneous ASD closure using the Occlutech device appears to be safe at long-term follow-up with a high successful closure rate at one year.

Use of echocardiography and glutathione S-transferase to detect heart complications in β-thalassemic patients

Background and objective β-Thalassemia major (TM) is an inherited disorder of hemoglobin synthesis and characterized by defective hemoglobin synthesis, resulting in ineffective erythropoiesis, severe anemia, increased erythrocyte turnover, and excessive iron absorption. Accordingly, iron overload develops and may accumulate in the liver, heart, and endocrine organs. Several gene polymorphisms have been studied as protective or predisposing factors for cardiac dysfunction in patients with TM. Moreover, echocardiographic left ventricular (LV) diastolic evaluation is used to detect early myocardial dysfunction secondary to iron overload. This study aimed at determining some diastolic and tissue Doppler echo indices to predict iron load. Materials and methods This study included 42 β-thalassemic patients, among whom, 16 proved to have cardiac complications after clinical evaluation. Their age ranged from 3 to 25 years. Participants were subjected to clinical evaluation, molecular analysis to detect glutathione S-transferase M1 (GSTM1) gene polymorphism, and transthoracic color Doppler echocardiography to detect early myocardial dysfunction. Results Seven (43.7%) patients had the functional wild-type allele (GSTM1 non-null genotypes), whereas nine (56.2%) patients were homozygous for the GSTM1 null allele. There was a statistically significant increase regarding both right and LV E/A in GSTM1 null genotype when compared with GSTM1 non-null genotype in β-thalassemic patients with cardiac complications. Moreover, LV and right ventricular diastolic function has been significantly affected in participants with GSTM1 null genotype in β-thalassemic patients with cardiac complications, and particularly, LV diastolic function has been significantly impaired in cases experiencing frequent blood transfusion in β-thalassemic patients with cardiac complications. Conclusion Follow-up of patients with β-thalassemia and evaluating echocardiographic changes may permit better assessment of patients and early recognition of cardiac affection before disease progression.

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.

Determinants of microvascular dysfunction in normotensive offsprings of hypertensive parents

Objective: Microvascular dysfunction usually precedes the onset of hypertension. We hypothesized that offspring of offsprings of hypertensive parents (OHP) would have coronary microvascular dysfunction. Yet, the determinants of microvascular dysfunction in OHP are not fully determined. We, therefore, studied coronary flow reserve (CFR) in OHP in relation to ambulatory blood pressure and lipid profiles. Subjects and Methods: One hundred and twenty-five healthy normotensive offsprings with family history of hypertension and 40 age- and sex-matched healthy normotensive offsprings without family history of hypertension (ONP) were enrolled for the study. All participates underwent transthoracic color Doppler echocardiography at rest and during adenosine (0.14 mg/kg) infusion. CFR was calculated as the ratio between hyperemic diastolic coronary flow to the resting diastolic coronary flow. All participates had ambulatory blood pressure monitoring. In addition, lipid profile was obtained, and triglycerides (TGs)/high-density lipoprotein cholesterol (HDL-C) was calculated. Results: CFR was significantly reduced among OHP compared with ONP (P

The Effect of Preoperative Pulmonary Arterial Hypertension on Incidence of Postoperative Atrial Fibrillation after Surgical Closure of Atrial Septal Defect (Secundum)

Background: Atrial tachyarrhythmias are common among adults with ASD and contribute to substantial morbidity. Atrial flutter and atrial fibrillation are well-described complications of atrial septal defect (ASD) and are associated with substantial morbidity. The cause of AF in ASD is multifactorial in nature. It has been proposed that it is related to atrial dilatation, the increase in pulmonary pressure, and ventricular dysfunction. Early surgical intervention may reduce the long-term risk of developing atrial arrhythmias. Studies demonstrated that cardiac remodeling occurred after closure of an ASD, even in older patients. This study aimed to find out the pulmonary hypertension (PAH) as a predictor of postoperative atrial fibrillation in patients after surgery for secundum type atrial septal defect closure.Methods: This Prospective Observational Study carried out in department of cardiac surgery, National Institute of Cardiovascular Disease (NICVD) and Hospital, Dhaka, Bangladesh during the period of July, 2015 to June, 2016. Total 54 patients are taken and then grouped into group A and group B. Each group contains 27 patients. Group A include Patients with ASD secundum without PAH. Group B Patients with ASD secundum with PAH. All patients were evaluated with M-mode, 2D and color Doppler transthoracic echocardiography and ECG before operation, at discharge, after one month and at 3 months follow-up. Statistical analysis of the results was obtained by windows based computer software with statistical package for the social sciences program (SPSS version 21).Results: To compare atrial fibrillation postoperative at discharge and postoperative after 1 and 3 months follow-up it was found In group B 8 (29.62%) patients had AF postoperatively, during discharge 8 (29.62%) patients had AF, after 1 month 7 (25.93%) patient had AF, after 3 months 6 (22.22%) patients had AF. No AF was found in Group A patients during postoperatively, during discharge, after 1 month &amp; 3 months follow up. Statistical significant difference was found in between two groups (p&lt;0.05).Conclusion: The surgical correction of atrial septal defect (ASD) is safe and effective procedure. Our studyshowed that the haemodynamic and electrophysiological results of the surgical repair of ASD secundum was superior before the development of pulmonary arterial hypertension. After surgical correction of ASD secundum raised pulmonary artery pressure became lower gradually. Atrial fibrillation developed in patient group with pulmonary arterial hypertension in postoperative period remain persistent in most patients in the follow up period, few converted to sinus rhythmUniversity Heart Journal Vol. 13, No. 1, January 2017; 17-20

Clinical Implications of Three-Dimensional Real-Time Color Doppler Transthoracic Echocardiography in Quantifying Mitral Regurgitation: A Comparison with Conventional Two-Dimensional Methods

Automatic quantification of real-time three-dimensional (3D) full-volume color Doppler transthoracic echocardiography (FVCD) has been proposed as a feasible and accurate method for quantifying MR. We aimed to explore the clinical implications of real-time 3D-FVCD for mitral regurgitation (MR) with various clinical manifestations, in comparison with the conventional two-dimensional (2D) proximal isovelocity surface area (PISA) and volumetric method and cardiac magnetic resonance imaging (CMR) methods. A total 186 patients with MR were enrolled prospectively. Based on exclusion criteria and image quality review, 152 patients were included in the final analysis for 3D-FVCD and 2D transthoracic echocardiography. Among them, 37 patients underwent subsequent CMR for the validation of 3D-FVCD. MR volume from 3D-FVCD demonstrated a better agreement (r=0.94) with CMR than 2D-PISA or the 2D volumetric method (VM; r=0.87 vs 0.56). Overall, 2D methods underestimated MR when compared with 3D-FVCD (35.4±28.4mL for 2D-VM vs 43.8±24.6mL for 2D-PISA vs 64.6±35.1mL for 3D-FVCD; P<.001). In subgroup analysis, multijet MR (odds ratio [OR], 6.30; 95% CI, 2.52-15.72) and dilated left ventricular end-systolic diameter ≥40mm (OR, 2.90; 95% CI, 1.12-7.50) were predictors of significant difference in MR volume (>30mL for primary MR and >15mL for secondary MR) between 2D-PISA and 3D-FVCD. In identifying surgical candidates, patients with multijet MR (OR, 4.53, 95% CI, 1.99-10.35) demonstrated a higher risk of discrepancy between 2D-PISA and 3D-FVCD, which were consistent in both primary and secondary MR, respectively. MR quantification with 3D-FVCD showed better correlation and agreement than conventional 2D methods. MR was underestimated by 2D methods, especially in multijet and dilated left ventricle. Multijet MR demonstrated higher risk of discrepancy for the identification of surgical candidate, regardless of MR etiology.

Fenestration closure with Amplatzer Duct Occluder II in patients after total cavo-pulmonary connection.

IntroductionCreation of a fenestration during completion of a total cavopulmonary connection (TCPC) has been associated with a reduction in early mortality and morbidity. However, the long-term benefits are negated by an associated limitation in exercise tolerance and the potential risks of thrombo-embolic complications. We sought to describe the safety and efficacy of an Amplatzer Duct Occluder II (ADO II) for transcatheter fenestration closure following TCPC.Material and methodsBetween January 2000 and July 2014, 102 patients underwent percutaneous closure of extra-cardiac TCPC fenestrations with a range of devices. Patients in whom fenestration closure was performed with an ADO II and who had at least 6 months of follow-up were included in this study.ResultsForty-seven patients had successful fenestration occlusion with an ADO II. The mean oxygen saturation and mean systemic venous pressures increased from 84.8 ±6.1% before to 97.6 ±2.9% (p < 0.001) after and from 14.2 ±2.15 mm Hg before to 15.6 ±2.2 mm Hg after closure (p < 0.001). Eight patients developed heart failure symptoms, managed by optimization of medical therapy, with 1 patient requiring device removal to reopen the fenestration. Color Doppler transthoracic echocardiography demonstrated residual flow across the device in 18 (38%), 10 (22%), 5 (11%) and 4 (9%) patients before discharge, at 1 and 6 months, and at the latest outpatient visit, respectively.ConclusionsThe ADO II can be safely and effectively used to close fenestrations in extra-cardiac type Fontan completions. Many of the design features of this device confer potential benefit in this population.

Coronary flow reserve in patients with resistant hypertension.

Resistant hypertension is associated with increased risk for cardiovascular events. Coronary flow reserve (CFR) is impaired in patients with hypertension and an independent predictor of cardiac mortality. However, there are no published data on CFR in the subset of treatment-resistant hypertension. The aim of this study was to assess CFR in patients with resistant hypertension. Twenty-five consecutive patients with primary resistant hypertension, scheduled for renal denervation, 25 matched patients with controlled hypertension, and 25 healthy controls underwent transthoracic colour Doppler echocardiography at rest and during adenosine infusion. Patients with hypertension were pair-matched with regard to age, sex, ischemic heart disease, diabetes mellitus, smoking status, and body-mass index. Healthy controls were selected according to age and sex. Mean flow velocity was measured in the left coronary anterior descending artery. Baseline mean flow velocities were similar in patients with controlled and resistant hypertension. CFR was significantly lower in patients with resistant hypertension as compared to individuals with non-resistant hypertension (2.7±0.6 vs. 3.1±0.8; p=0.03). Systolic office blood pressure was significantly higher in patients with resistant hypertension (169±20 vs. 144±21mm Hg; p<0.01). Heart rate, ventricular mass, and ejection fraction were similar in the two groups. Healthy controls showed significantly lower baseline velocity, higher CFR, and lower blood pressure as compared to hypertensives. Resistant hypertension was associated with impaired CFR as compared to individuals with non-resistant hypertension indicating impaired cardiac microvascular function which may contribute to the increased risk of adverse outcome in patients with resistant hypertension.

Normal Values of Aortic Root Dimensions in Healthy Adults

The reported ranges of aortic root (AR) diameters are limited by small sample size, different measurement sites, and heterogeneous cohorts. The aim of this study was to explore the full spectrum of AR diameters by 2-dimensional transthoracic color Doppler echocardiography (TTE) in a large cohort of healthy adults. From June 2007 to December 2013, a total of 1,043 Caucasian healthy volunteers (mean age 44.7 ± 15.9 years, range 16 to 92 years, 503 men [48%]) underwent comprehensive TTE. TTE measurements of the AR were made at end-diastole in parasternal long-axis views at 4 levels: (1) annulus, (2) sinuses of Valsalva, (3) sinotubular junction, and (4) proximal ascending aorta. The absolute aortic diameters were significantly greater in men than in women at all levels, whereas body surface area-indexed aortic diameters were greater in women (p = 0.0001). No significant gender differences were registered for sinuses of Valsalva and sinotubular junction to annulus diameter ratios (p = 0.9), whereas ascending aorta to annulus diameter ratio was higher in women (p = 0.0001). There was a straight correlation between aortic diameters (absolute and indexed values), their ratios, and age in both genders (p = 0.0001). In conclusion, we provide the full range of AR diameters by TTE. Knowledge of upper physiological limits of aortic dimensions is mandatory to detect aorta dilatation, follow up the disease over time, and plan appropriate therapeutic interventions.

Immediate- and medium-term effects of simultaneous percutaneous corrections of secundum type atrial septal defect combined with pulmonary valve stenosis in local anesthesia and without transesophageal echocardiography guidance

BackgroundThe feasibility and efficacy of simultaneous percutaneous treatment of secundum type atrial septal defect (ASD) combined with pulmonary valve stenosis (PS) have not been proved. ObjectiveTo evaluate the safety and efficacy on the clinical benefit of simultaneous percutaneous correction of these two pathologies under local anesthesia and without transesophageal echocardiography guidance. MethodsTranspulmonary gradient, functional status, pulmonary regurgitation (PR), and tricuspid regurgitation (TR) were studied in 35 patients undergoing percutaneous balloon pulmonary valvuloplasty and ASD closure from March 2004 to July 2012. All patients were followed up until January 2013, an average of 39 months. ResultsAccording to color Doppler transthoracic echocardiography (TTE) before the intervention, the ASD defect size and transpulmonary gradient were 17±8.4mm and 88±37.8mmHg, respectively. Post-interventionally, the peak-to-peak transpulmonary gradient decreased from 77±37.6mmHg to 20±16.2mmHg (p<0.001) and the ASD occluder size was 23±10.5mm. In all those patients, there was no residual shunt detected, and moderate and severe TR decreased from 45.7% (16/35) and 20% (7/35) to 8.6% (3/35) and 5.7% (2/35) before and after intervention detected by TTE, respectively. Eight patients had mild PR after procedure and two of them recovered at 6 months and no patient encountered severe adverse events at the latest follow-up. ConclusionSimultaneous percutaneous corrections of ASD combined with PS are feasible, safe, and effective with satisfactory results.

Intramyocardial Dissecting Hematoma Following Myocardial Infarction

An 80-year-old woman with hypertension and a double aortocoronary bypass 20 years previously was hospitalized with a diagnosis of subacute infarction. At 24 hours after hospitalization, she experienced an onset of heart failure symptoms. Transthoracic color Doppler echocardiography in apical four-chamber view showed features of a neocavity in the laterobasal region (delimited by arrows), with end-diastolic flow in the interior, a communication with the cardiac chamber, and no evidence of pericardial effusion (Figure 1. LA, left atrium; LV, left ventricle; MV, mitral valve). Multidetecter chest computed tomography with electrocardiogram gating was performed, with contrast enhancement in the arterial phase. The study showed a collection communicating with the ventricular chamber, with extravasated contrast in the interior and an ascending course lateral to the left atrium, consistent with myocardial rupture in the laterobasal region (Figures 2 and 3). A decision was made to perform percutaneous closure of the ventricular wall defect by placement of an Amplatzer device, which failed. The procedure was converted to open surgery, which revealed pericardial adhesions and an intramyocardial cavity that did not communicate with the pericardium. Plication of the left ventricular border and tip was performed. Unfortunately, the patient experienced multiorgan failure in the postoperative period and died 72 hours later. Intramyocardial dissection is an uncommon condition that usually occurs in inferoposterior infarctions. Echocardiography and computed tomography are the imaging modalities used for the diagnosis. It is difficult to evaluate the prognosis of these cases or the appropriate management, which should be individualized according to the clinical situation and the experience of the surgical or interventional teams. LV 10 10

Comparison of Two- and Three-Dimensional Transthoracic Echocardiography to Cardiac Magnetic Resonance Imaging for Assessment of Paravalvular Regurgitation After Transcatheter Aortic Valve Implantation

This study evaluated 2-dimensional (2D) transthoracic echocardiography (TTE) using Valve Academic Research Consortium-2 (VARC-2) criteria and 3-dimensional (3D) TTE for assessment of aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) in comparison with cardiac magnetic resonance (CMR) imaging. In 71 patients, 2D TTE, 3D TTE, and CMR imaging were performed to assess AR severity after TAVI. Using 2D TTE, AR severity was graded according to VARC-2 criteria and regurgitant volume (RVol) was determined. Three-dimensional color Doppler TTE allowed direct planimetry of the vena contracta area of the paravalvular regurgitation jet and calculation of the RVol as product with the velocity-time integral. RVol by CMR imaging was measured by phase-contrast velocity mapping in the ascending aorta. After TAVI, mean RVol determined by CMR imaging was 9.2 ± 9.6 ml/beat and mean regurgitant fraction was 13.3 ± 10.3%. AR was assessed as none or mild in 58 patients (82%) by CMR imaging. Correlation of 3D TTE and CMR imaging on RVol was better than correlation of 2D TTE and CMR imaging (r = 0.895 vs 0.558, p <0.001). There was good agreement between RVol by CMR imaging and by 3D TTE (mean bias = 2.4 ml/beat). Kappa on grading of AR severity was 0.357 between VARC-2 and CMR imaging versus 0.446 between 3D TTE and CMR imaging. Intraobserver variability for analysis of RVol of AR after TAVI was 73.5 ± 52.2% by 2D TTE, 16.7 ± 21.9% by 3D TTE, and 2.2 ± 2.0% by CMR imaging. In conclusion, 2D TTE considering VARC-2 criteria has limitations in the grading of AR severity after TAVI when CMR imaging is used for comparison. Three-dimensional TTE allows quantification of AR with greater accuracy than 2D TTE. Observer variability on RVol after TAVI is considerable using 2D TTE, significantly less using 3D TTE, and very low using CMR imaging.

Quantification of paravalvular regurgitation after transcatheter aortic valve implantation by 3D transthoracic echocardiography in comparison with cardiac magnetic resonance imaging

Purpose: Paravalvular aortic regurgitation is common after transcatheter aortic valve implantation (TAVI). Assessment of regurgitation severity is limited by conventional 2-dimensional (2D) transthoracic echocardiography (TTE). 3-dimensional (3D) TTE has shown to accurately allow quantification of regurgitation in native valves. This study sought to evaluate 3D TTE for quantification of paravalvular aortic regurgitation after TAVI and compare it with cardiac magnetic resonance imaging (CMR). Methods: In 71 patients (age 81±6 years) with severe aortic stenosis 2D TTE, 3D TTE and CMR were performed to assess paravalvular regurgitation severity after TAVI. Aortic regurgitation after TAVI was graded mild, moderate or severe by 2D TTE analysis as recommended by the valve academic research consortium. 3D color Doppler TTE was used for direct planimetry of the vena contracta area of paravalvular regurgitation jet. Regurgitant volume (RV) by 3D TTE was calculated by multiplying the vena contracta area with the velocity time integral of paravalvular regurgitation assessed by continuous-wave Doppler echocardiography. CMR was used for quantitative flow measurement of the ascending aorta. RV by CMR was assessed by quantification of diastolic aortic backward flow. Results: In 53 patients (74%) paravalvular regurgitation after TAVI was mild, in 14 patients (20%) moderate and in 4 patients (5%) severe as assessed by 2D TTE. In patients with mild paravalvular regurgitation RV quantified by 3D TTE was lower compared to quantification by CMR (3.5±5.8 ml/beat vs. 6.5±5.4 ml/beat; p=0.0080). There was no significant difference of RV assessed by 3D TTE and by CMR in patients with moderate (10.1±8.8 ml/beat vs. 11.7±7.0 ml/beat; p=0.5986) and severe paravalvular regurgitation (38.4±8.3 ml/beat vs. 37.2±14.8 ml/beat; p=0.8905). In all patients paravalvular RV assessed by 3D TTE (6.8±10.5ml/beat) correlated well with RV assessed by CMR (9.2±9.6ml/beat; r=0.895). Bland Altman plot showed good agreement between measurements of RV by CMR and by 3D TTE (mean bias=2.4 ml/beat, 95% CI -6.7 to 11.6 ml/beat). Conclusions: 3D TTE allows accurate quantification of paravalvular aortic regurgitation after TAVI in comparison with analysis by CMR.

Accuracy of Three-Dimensional Versus Two-Dimensional Echocardiography for Quantification of Aortic Regurgitation and Validation by Three-Dimensional Three-Directional Velocity-Encoded Magnetic Resonance Imaging

Quantitative assessment of aortic regurgitation (AR) remains challenging. The present study evaluated the accuracy of 2-dimensional (2D) and 3-dimensional (3D) transthoracic echocardiography (TTE) for AR quantification, using 3D 3-directional velocity-encoded magnetic resonance imaging (VE-MRI) as the reference method. Thirty-two AR patients were included. With color Doppler TTE, 2D effective regurgitant orifice area (EROA) was calculated using the proximal isovelocity surface area method. From the 3D TTE multiplanar reformation data, 3D-EROA was calculated by planimetry of the vena contracta. Regurgitant volumes (RVol) were obtained by multiplying the 2D-EROA and 3D-EROA by the velocity-time integral of AR jet and compared with that obtained using VE-MRI. For the entire population, 3D TTE RVol demonstrated a strong correlation and good agreement with VE-MRI RVol (r = 0.94 and -13.6 to 15.6 ml/beat, respectively), whereas 2D TTE RVol showed a modest correlation and large limits of agreement with VE-MRI (r = 0.70 and -22.2 to 32.8 ml/beat, respectively). Eccentric jets were noted in 16 patients (50%). In these patients, 3D TTE demonstrated an excellent correlation (r = 0.95) with VE-MRI, a small bias (0.1 ml/beat) and narrow limits of agreement (-18.7 to 18.8 ml/beat). Finally, the kappa agreement between 3D TTE and VE-MRI for grading of AR severity was good (k = 0.96), whereas the kappa agreement between 2D TTE and VE-MRI was suboptimal (k = 0.53). In conclusion, AR RVol quantification using 3D TTE is accurate, and its advantage over 2D TTE is particularly evident in patients with eccentric jets.