Two-chamber Views Research Articles

Assessment of left ventricular diastolic function after mitral valve replacement using color M-mode Doppler flow propagation velocity

Objective To evaluate the clinical value of color M-mode Doppler echocardiography (CMM) in assessing left ventricular(LV) diastolic function after mitral valve replacement(MVR). Methods Fifty-two patients who had received the implantation for more than three months were examined by echoeardiography (MVR group). Thirty age and sex-adjusted normal volunteers served as control group. Dimensions of left atrium and ventricle,ejection fraction(EF) and mitral inflow velocity(E) were measured by two-dimensional and Doppler eehocardiography. Color M-mode Doppler flow propagation velocity(Vp) and TDl-derived diastolic mitral annular velocity(Em) were measured from the apical four-chamber and two-chamber views. Then two new indexes based on the ratio of E to Vp(E/Vp) and E to Era' (E/Em') were while E/Vp and E/Era' increased, there were significant differences(P 0.05). dysfunction were 2.00. Conclusions CMM is an effective technique to assess LV diastolic function after MVR. E/Vp has good consistency with E/Era and may be a potential useful parameter for assessing LV diastolic function. Key words: Echocardiography; Heart valve prosthesis implantation; Ventricular function,left

Failed Closure of Paravalvular Leak with an Amplatzer® Occluder Device After Mitral Valve Replacement

Failed Closure of Paravalvular Leak with an Amplatzer® Occluder Device After Mitral Valve Replacement

Assessment of left atrial appendage function with transthoracic tissue Doppler echocardiography

A transthoracic echocardiographic (TTE) parameter that would stratify atrial fibrillation (AF) risk would be useful. Tissue Doppler imaging can quantify left atrial appendage contraction velocity (LAA A(M)). We studied 141 patients referred for transoesophageal echocardiogram (TEE); 48 were in AF. We obtained TEE and TTE LAA A(M) velocities from the LAA apex on the parasternal short-axis and apical two-chamber views. Adequate traces were obtained in 118 patients (84%). In these patients, we measured 5382 LAA A(M) velocity tracings. There was a strong correlation between LAA A(M) on TEE and TTE parasternal short-axis (r = 0.741; P < 0.0001) and apical two-chamber views (r = 0.729; P < 0.0001). Patients in AF had lower LAA A(M) than those with sinus rhythm on parasternal short-axis (12 +/- 5 vs. 23 +/- 7 cm/s, P < 0.0001) and apical two-chamber (14 +/- 5 vs. 23 +/- 8 cm/s, P < 0.0001) views. On parasternal short axis, LAA A(M) velocities were lower in patients with spontaneous echo contrast, 11 +/- 4 vs. 22 +/- 8 cm/s (P < 0.0001), and in those with thrombus, 8 +/- 2 cm/s (P < 0.0001). On apical two-chamber, LAA A(M) velocities were also lower with spontaneous echo contrast, 12 +/- 4 vs. 22 +/- 7 cm/s (P < 0.0001), and with thrombus, 10 +/- 4 cm/s (P < 0.0001). In patients with AF and TTE LAA A(M) < or =11 cm/s, we found that nearly one-third had LAA thrombus. In patients with AF and a history of stroke or transient ischaemic attack (TIA), LAA A(M) velocities were lower compared with those without history of stroke or TIA in the parasternal short-axis (9 +/- 3 vs. 13 +/- 5 cm/s, P = 0.02) and apical two-chamber views (11 +/- 3 vs. 15 +/- 6 cm/s, P = 0.008). Acquiring and quantifying LAA A(M) contraction velocity is feasible on TTE in a high percentage of patients and correlates with TEE. LAA A(M) was lower in AF compared with sinus rhythm, with spontaneous echo contrast compared to without spontaneous echo contrast, and in AF patients with a history of stroke or TIA. Those with LAA thrombus had the lowest LAA A(M) velocities. LAA A(M) is a novel functional parameter that may prove useful for risk stratification of AF.

Strain rate imaging in assessing the size of acute ischemic myocardium in dogs

Since the size of ischemic myocardium is closely related with both global and regional function of the myocardium, it is of great significance to measure the size of ischemic myocardium with non-invasive methods. Eleven mongrel dogs were subjected to occlusion of the left anterior descending coronary artery for acute ischemia. Strain rate imaging had M-mode of strain-rate (CAMM) curve pointed from the basal segment of the anterior wall to the basal segment of the inferior wall to detect the border of ischemia size. The strain rate (SR) defined the cut-off value of ischemic myocardium in a two-chamber apical view, and marked by the anterior and inferior wall on two-dimensional images respectively. Along the endocardium and epicardium, the ischemic size was curved on two-dimensional images by the trackball method and then compared with the pathologically ischemic size. And then longitudinal strain rates were compared in the cut-off value, adjacent non-ischemic and ischemic segments at which the cut-off point was defined by changing the curve M-mode of strain rate after ischemia. Linear correlation existed between pathology and strain rate ischemic size (r = 0.884, P < 0.001). The SR parameters were lower in ischemia and cut-off point than in non-ischemic segments. The peak SRs of systole (S(SR)), early diastole (E(SR)), late diastole (A(SR)), strain during ejection time (epsilon(et)), and the maximum length change during the entire heart cycle (epsilon(max)) in ischemic segments lowered (P < 0.05). Time to onset of regional relaxation (T(R)) was prolonged (P = 0.012). SR imaging can accurately assess the size of ischemic myocardium.

Interobserver, Intraobserver and Intrapatient Reliability Scores of Myocardial Strain Imaging with 2-D Echocardiography in Patients Treated with Anthracyclines

Myocardial strain imaging with 2-D echocardiography is a relatively new noninvasive method to assess myocardial deformation. To determine the interobserver, intraobserver and intrapatient reliability scores, we evaluated myocardial strain measurements of 10 asymptomatic survivors of childhood cancer. Ten patients were selected randomly out of a follow-up cohort of childhood cancer survivors. All 10 patients underwent a transthoracic echocardiographic examination. Two-dimensional gray scale images were made in parasternal apical four-chamber, apical two-chamber, midcavity short-axis and basal short-axis views. Offline analysis was performed using software for echocardiographic quantification (Echopac 6.1.0, GE Medical Systems, Horten, Norway). All echocardiographic studies were analyzed offline by three observers, separately (A.M., G.W., M.P.). A custom-made software package was designed for averaging the strain curves of three consecutive cardiac cycles. Values of peak systolic strain, time-to-peak strain and time-to-end systole of the different segments of the left ventricle were used for statistical analysis. Interobserver, intraobserver and intrapatient reliability were expressed as intraclass correlation coefficients (ICCs). Interobserver ICCs of peak strain, time to peak strain and time to aortic valve closure (AVC) were generally good to very good in all views and segments, except for in the two-chamber view. Intraobserver ICCs were rated as very good for almost all segments, except for the longitudinal peak strain values of the two-chamber view. Intrapatient ICCs were generally good for the two-chamber, four-chamber and midcavity short-axis views, but fair to moderate for the segments of the basal short-axis view (SaxMV). We recommend use of the four-chamber view for longitudinal peak strain values, and the basal and midcavity short-axis views for radial and circumferential peak strain values. Furthermore, we strongly recommend using the average of three cardiac cycles for peak strain values in clinical studies. (E-mail: A.Mavinkurve@cukz.umcn.nl)

Hamo-study i: investigation of the effect of breathing on the position of the heart

Introduction: One of the most important notions in osteopathy is that our body structures possess a certain freedom of motion, which is necessary to function properly. We also know that respiration influences the motion of the heart. This study proposes a method to quantify this motion of the heart. Design: Observational study Methods: A Gyroscan T10-NT (magnetic resonance) has been used. In order to obtain a good three-dimensional image, localizer images were made in the three orthogonal planes (axial, sagittal and frontal). After this images were made in the long axis (two-chamber view), short axis and four-chamber view. Images were made in expiration, inspiration and in neutral position using ECG-triggering. The research group for this study consisted of 10 healthy subjects (5 men, 5 woman). A total of 5021 images were made and all results were analysed with the Friedman test, with significant results if p p<0.1. Results: The position of the apex cordis showed a significant (p<0.01) movement in the three orthogonal planes. The apex moved caudally (20.3mm, SD. 8.59mm). anteriorly (17.1mm, SD. 4.70mm) an to the right (13.9mm, SD. 8.46mm) during inhalation (meaning the difference between maximal exhalation and maximal inhalation). The axis changes measured on the long axis did not achieve statistical significance. Although, at sight, a clear verticalization was observed in all subjects, measurements only showed a tendency (p¼0.067) to verticalization during inhalation. No axis changes have been observed in the short axis. Conclusions: Despite the small group of subjects, this study clearly shows a change in position of the heart under influence of breathing. The apex moves caudal, anterior and to the right. The heart tends to verticalize and so to say stand on his apex. During expiration the opposite movement has been found.

Spinal and sacroiliac joint assessment and treatment within the American osteopathic profession

Introduction: One of the most important notions in osteopathy is that our body structures possess a certain freedom of motion, which is necessary to function properly. We also know that respiration influences the motion of the heart. This study proposes a method to quantify this motion of the heart. Design: Observational study Methods: A Gyroscan T10-NT (magnetic resonance) has been used. In order to obtain a good three-dimensional image, localizer images were made in the three orthogonal planes (axial, sagittal and frontal). After this images were made in the long axis (two-chamber view), short axis and four-chamber view. Images were made in expiration, inspiration and in neutral position using ECG-triggering. The research group for this study consisted of 10 healthy subjects (5 men, 5 woman). A total of 5021 images were made and all results were analysed with the Friedman test, with significant results if p p<0.1. Results: The position of the apex cordis showed a significant (p<0.01) movement in the three orthogonal planes. The apex moved caudally (20.3mm, SD. 8.59mm). anteriorly (17.1mm, SD. 4.70mm) an to the right (13.9mm, SD. 8.46mm) during inhalation (meaning the difference between maximal exhalation and maximal inhalation). The axis changes measured on the long axis did not achieve statistical significance. Although, at sight, a clear verticalization was observed in all subjects, measurements only showed a tendency (p1⁄40.067) to verticalization during inhalation. No axis changes have been observed in the short axis. Conclusions: Despite the small group of subjects, this study clearly shows a change in position of the heart under influence of breathing. The apex moves caudal, anterior and to the right. The heart tends to verticalize and so to say stand on his apex. During expiration the opposite movement has been found.

Abstract 4710: Diagnostic Accuracy of Myocardial Perfusion on Myocardial Contrast Echocardiography in Patients with Acute Coronary Syndrome: Results from the Assessment of Coronary Heart Disease with Myocardial Contrast Echocardiography 2 (ACTMCE2) Multicenter Trial

Background: Intravenous myocardial contrast echocardiography (MCE) at rest and during vasodilator stress is a reliable bedside technique for assessment of myocardial perfusion in patients with coronary artery disease. The aim of this study is to evaluate diagnostic accuracy of myocardial perfusion abnormalities using MCE at rest in patients with acute coronary syndrome (ACS). This study is the first MCE multicenter trial for the evaluation of ACS in Japan. Methods: We performed triggered MCE at rest in 102 patients (mean age: 65 ± 11 years) with suspected ACS. We obtained 1:1 and 1:6 end-systolic triggered MCE images at four- and two-chamber views. We detected myocardial ischemia by the appearance of myocardial perfusion abnormalities (defect or reduction) in 1:1 end-systolic triggered MCE image. We assessed the appearance of regional wall motion abnormality (RWMA) at the same time. Quantitative coronary angiography was performed in all patients within 1 week (2.6 ± 2.2 days) after MCE. Results: Eighty-four of 102 (82%) patients were diagnosed ACS (unstable angina: 70 patients; non-ST-segment elevation myocardial infarction: 11 patients; ST-segment elevation myocardial infarction: 3 patients) and demonstrated significant coronary artery stenosis (stenosis = or &gt;75%) that required coronary revascularization therapy. The sensitivity, specificity, and accuracy of myocardial perfusion abnormality by MCE at rest for diagnosing ACS were 79%, 86%, and 83%, respectively. On each coronary artery, the sensitivity, specificity, and accuracy of MCE for diagnosing ACS were 85%, 71%, and 79% in the left anterior descending artery; 70%, 92%, and 84% in the left circumflex artery; 77%, 89%, and 84% in the right coronary artery, respectively. The sensitivity, specificity, and accuracy of RWMA for diagnosing ACS were 49%, 90%, and 71%, respectively, and the sensitivity of MCE for diagnosing ACS was significantly higher than that of RWMA. Conclusion: Intravenous myocardial contrast echocardiography at rest without stress examination is a feasible noninvasive method for accurate diagnosis of ACS. In this multicenter study, MCE at rest improved the diagnostic accuracy of echocardiography for diagnosing ACS.

Comparison of different views with three‐dimensional echocardiography: apical views offer superior visualization compared with parasternal and subcostal views

Studies seeking to validate real-time three-dimensional echocardiography (3DE) with regard to cardiac function and dimensions have almost exclusively used apical views. However, it has never been examined whether apical views are preferable to parasternal or subcostal views. In the present study, we compared the feasibility of 3DE volumetric measurements of the four heart chambers in three different views. We included 40 patients planned for a routine two-dimensional transthoracic echocardiography examination (2DE). All patients were scanned with both 2DE and 3DE (Sonos 7500; Philips Medical Systems Andover, MA, USA). Parasternal, apical and subcostal views were used for 3DE. Volumes were calculated using manual tracing in 16 planes. 2DE was performed in parasternal longaxis, subcostal and apical four- and two-chamber views. Manual tracing was used for area calculations. To be judged fully traceable, 5/6 (85%) or more of the ventricular and atrial walls had to be adequately visualized in each plane. The left ventricle and left atrium were adequately visualized in the 3DE apical view in 34 (85%) and 40 (100%) patients, respectively. Visualization of the right atrium was adequate in 31 (78%) patients, whereas the right ventricle was adequately visualized in only 12 (30%) patients. The apical view of 3DE provided superior visualization of all four heart chambers compared with the parasternal and subcostal views, when applying a slight off-axis approach for both ventricles when needed. Thus, in the present study, there was no incremental value of assessment of chamber volumes in the parasternal and subcostal views.

Cardiac magnetic resonance imaging of noncompaction cardiomyopathy

Stephenson CMR Centre, Foothills Medical Centre, Calgary, Alberta Correspondence: Dr Oliver Strohm, Stephenson CMR Centre, Foothills Medical Centre, Suite 700, Special Services Building, 1403–29 Street Northwest, Calgary, Alberta T2N 2T9. Telephone 403-944-8806, fax 403-944-8510, e-mail oliver.strohm@calgaryhealthregion.ca Received for publication November 9, 2006. Accepted December 3, 2006 Cardiovascular magnetic resonance (CMR) imaging was performed in a 31-year-old patient who was referred for further workup of recently diagnosed dilated cardiomyopathy. The CMR imaging study (Figures 1A and 1B show a diastolic four-chamber view and a twochamber view of a high-resolution cine sequence, respectively) demonstrated enlargement and thinning of the midventricular and apical segments, together with prominent trabeculation (left ventricular end-diastolic volume 381 mL, left ventricular end-systolic volume 216 mL and ejection fraction 43%). The ratio of noncompacted to compacted wall was 3.6 at the midventricular level and 6.3 at the apex, with a cut-off value of less than 2.3 (1). Findings were consistent with a diagnosis of previously undetected left ventricular noncompaction cardiomyopathy. The clinical presentation of noncompaction cardiomyopathy includes depressed systolic function and heart failure (2,3). Recent data (1,4) suggest that CMR imaging might improve the diagnosis of noncompaction due to its increased image quality and visualization of the entire left ventricle. A diagnosis of noncompaction cardiomyopathy has important implications because of the need for familial screening and follow-up studies for potential progressive left ventricular dilation and dysfunction. IMAGES IN CARDIOLOGY

Clinical application of 64-slice spiral CT for apical hypertrophic cardiomyopathy

Objective To evaluate the clinical application values of 64-row MSCT for apical hypertrophic cardiomyopathy(AHCM).Methods Twenty-one patients with AHCM were included in this study,14 patients were diagnosed by echocardiography(UCG),and 7 patients were diagnosed by MRL AU patients underwent MSCT exam,and 5 patients also had ventriculography and coronary angiography.The left ventricular wall thickness in end-systole and end-diastole phases were measured at MSCT workstation,the left ventricular apex thickening rate(LVAT)and the ratio of maximum wall thickness of the left ventrieular apex(LVA)to the left ventricular posterior wall thickness(LVA/LVPW)in end-diastole phase were calcdated.The left ventricular end-diastolie volume(LVEDV)and left venueular ejection fraction (LVEF)were quantitively evaluated with cardiac functional analysis software.The results were compared with the measurement results from the normal control group(30 volunteers).The independent-samples t test was used for the statistics.At the same time.the coronary stenosis was measured.Results Diffuse or partial thickening of the LV apical myocardium were found in the four-chamber view and two-chamber view of MSCT images.which leaded to the deformation of the left ventricle chamber.The LVEDV were(82.6±11.4)and(108.5±10.6)ml in the AHCM group and the control group,respectively;the LVA were (20.6±3.4)and(9.9±1.5)mm;LVA/LVPW were 2.1±0.5 and 1.1±0.2;the LVAT were(25.6±4.7)%and(81.5±8.5)%.There were significant differences in LVEDV,LVA,LVA/LVPW and LVAT between the two groups(t=8.32 and 15.29,P＜0.05;t=9.91 and 27.30,P＜0.05;respectively),but there were no statistical differences in LVPW and LVEF between the two groups(t=0.26 and 1.13.P＞0.05).Five patients had myocardium bridging and 4 patients had coronary stenosis.Conclusion AHCM can be diagnosed accurately with MSCT,and the cardiac anatomy.function and coronary artery are also assessed simultaneously. Key words: Myocardial diseases; Coronary angiography; Tomography.X-ray computed

Quantitative Analysis of Echocardiographic Cine-Loops Using a 2D-Strain Algorithm in Correlation with Thallium-201 SPECT Imaging

The aim of this study was to investigate the correlation between the regional left ventricular (LV) contractility, assessed by two-dimensional (2D)-strain echocardiographic images, and regional LV perfusion, determined by thallium-201 single photon emission computed tomography (SPECT) imaging. Forty-five hospitalized patients with suspected myocardial ischemia (32 males, mean age 69 ± 12 years) have undergone both echocardiography and SPECT imaging on the same day. The echocardiographic data has been obtained in three apical views. The data for each view has been processed by the 2D-strain algorithm, to produce six peak systolic longitudinal strain measurements per view, one per segment. The resulting measurements have been compared with the corresponding regions within the SPECT bull's-eye map (at rest). In order to handle inaccuracies in the positioning of the echocardiographic transducer, the two datasets have undergone registration based on local correlation. The mean correlation coefficients between SPECT perfusion and peak systolic longitudinal strain for the apical long-axis, apical two-chamber, and apical four-chamber views were 0.55 ± 0.36, 0.47 ± 0.35, and 0.64 ± 0.30 respectively (negative correlation coefficients have been considered as zero). The overall mean correlation coefficient was 0.56 ± 0.34. The scatter graphs of the average values of perfusion and the strain values showed a nonlinear relation between the two parameters. The average correlation coefficient is comparable to the values reported for the correlation between the average LV function, based on visual analysis of echocardiographic imaging, and the average LV perfusion, based on SPECT imaging. (E-mail: aaronisme@yahoo.com)

Parachute mitral valve abnormality and bicuspid aortic valve in an asymptomatic adult patient

Transesophageal echocardiography of a 54-year-old asymptomatic man revealed a bicuspid aortic valve (Figure 1, upper left panel) and elongated chordae converging and inserting into one of the papillary muscles. There was a redundant anterior mitral leaflet, as well as a rudimentary posterior leaflet during systole (Figure 1, upper right panel). Mitral commissural and a two-chamber view during diastole demonstrated a papillary muscle and elongated chordae, as well as a parachute-like mitral valve abnormality (Figure 1, bottom left and right panels). Figure 1) Transesophageal echocardiography revealing a bicuspid aortic (Ao) valve (upper left panel), a redundant anterior mitral leaflet (AML) and a rudimentary posterior leaflet during systole (upper right panel). Mitral commissural and two-chamber view during ... Parachute mitral valve is a rare congenital cardiac anomaly in which the chordae tendinae of both leaflets of the mitral valve insert into a single papillary muscle. This is called a ‘true parachute’ mitral valve, whereas the presence of two papillary muscles, with all chordae inserting into one muscle, is called a ‘parachute-like’ mitral valve (1). A true parachute mitral valve is usually associated with mitral stenosis and may cause symptoms early in life. Despite the presence of moderate mitral regurgitation, the asymptomatic course of our patient until adulthood may likely be explained by the absence of mitral stenosis.

Congenital left ventricular diverticuli with anomalous course of right coronary artery surrounding diverticular neck

A 20-year-old woman presented with atypical chest pain. Her past medical and family histories were unremarkable. Her physical examination was normal. Electrocardiogram revealed normal sinus rhythm. Cardiac enzymes were within normal limits. On transthoracic echocardiography, parasternal long-axis and apical four-chamber views were normal; however, parasternal short-axis and apical two-chamber views revealed contractile diverticuli in the inferior wall of the left ventricle at its junction …

Massive intraventricular thrombus complicating extracorporeal membrane oxygenation support

A 65-year old man was admitted for cardiogenic shock complicating acute inferolateral myocardial infarction. Coronary angiography revealed occlusion of the three main arteries, and echocardiography showed massive left ventricular (LV) dysfunction without mechanical complications. Urgent coronary artery bypass grafting was performed. Implantation of a central, venoarterial, extracorporeal membrane oxygenation (ECMO) device was required because of the impossibility of weaning from extracorporeal circulation. In the early postoperative period, circulation was maintained by the laminar blood flow generated by the ECMO, with no pulsatile activity originating from the heart. Transesophageal echocardiography showed an akinetic, dilated LV without aortic valve opening in systole, and a voluminous thrombus that nearly obliterated the LV cavity in end-systole (Figure 1). The thrombus persisted despite therapeutic anticoagulation. Because no LV recovery was observed on day 6, long-term circulatory support appeared to be necessary, and a HeartMate II LV assist device (Thoratec, USA) was implanted to replace ECMO. The thrombus was removed during the procedure (Figure 2). Postoperative transesophageal echocardiography showed no subsequent thrombus formation in the LV cavity. Figure 1 Transesophageal echocardiography showing a dilated left ventricle and a voluminous thrombus (asterisk) in the transgastric two-chamber view (A) and mid-short axis view (B) Figure 2 Thrombus removed during implantation procedure Intraventricular thrombi are a classic complication of myocardial infarction, particularly if systolic dysfunction is massive. Their incidence may be increased by the unloading of cardiac chambers observed with LV assist devices.

Characteristics of myocardial postsystolic shortening in patients with coronary artery disease assessed by strain rate imaging

Postsystolic shortening (PSS) has been proposed as a marker of myocardial dysfunction. Strain rate imaging (SRI) is a novel ultrasonic technique, allowing reliable and noninvasive measurement of myocardial deformation. The purpose of this study was to investigate the characteristics of myocardial longitudinal PSS by SRI in ischemic and infarct myocardium in patients with coronary artery disease, and to explore its clinical applicability. Eleven patients with angina pectoris, 21 patients with myocardial infarction and 20 healthy subjects were included in the study. Apical four-, three- and two-chamber views were displayed; and septal, lateral, anteroseptal, posterior, anterior and inferior walls of the left ventricle were scanned, respectively. PSS strain (epsilon(pss)), the ratio of epsilon(pss) and systolic strain (epsilon(pss)/epsilon(sys)), the ratio of epsilon(pss) and maximum strain (epsilon(pss)/epsilon(max)) and the duration of PSS (T(pss)) in ischemic, infarct and normal myocardium were analyzed. PSS was found more frequent in the ischemic and infarct segments compared with the normal segments (39% vs 22% and 56% vs 22%, respectively; both P < 0.01). It was even more frequent in the infarct segments than in the ischemic segments (56% vs 39%, P < 0.01). The absolute magnitude of epsilon(pss), epsilon(pss)/epsilon(sys), epsilon(pss)/epsilon(max) were significantly larger and T(pss) significantly longer in the ischemic and infarct segments compared with that in the normal myocardium (P < 0.01). epsilon(pss)/epsilon(sys), epsilon(pss)/epsilon(max) were even larger and T(pss) even longer in the infarct than in the ischemic segments (P < 0.01). PSS is a common and important feature of the ischemic and infarct myocardium. epsilon(pss), epsilon(pss)/epsilon(sys), epsilon(pss)/epsilon(max) and T(pss) as measured by SRI may be promising markers for the quantitative assessment of regional myocardial dysfunction in patients with coronary artery disease. epsilon(pss)/epsilon(sys), epsilon(pss)/epsilon(max) and T(pss) may be helpful in differentiating infarct from ischemic myocardium.

Left Atrial Size by Planimetry is Superior to M-mode Diameter: Biochemical Calibration by Atrial and Brain Natriuretic Peptide

Left atrial (LA) size is routinely assessed by M-mode on echocardiography. Recently, a superiority of apical measures of LA size has been suggested, but no biochemical calibration has been attempted yet. The aim of the current study was to compare echocardiographic parameters of LA size through biochemical calibration with the natriuretic peptides atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). A total of 610 middle-aged (50-67 years) subjects from a population-based sample (MONICA Augsburg, Germany) were characterized with respect to LA area and volume from the apical two-chamber (2C) and four-chamber (4C) views in addition to M-mode echocardiography. ANP and BNP concentrations were determined by radioimmunoassay. A significant correlation to ANP and BNP was present with all measures on LA size. The univariate correlation was lowest with M-mode diameter (r = 0.11 with ANP; r = 0.09 with BNP, both P < .03), whereas 2C volume displayed the closest correlation (r = 0.20 with ANP and r = 0.28 with BNP, both P < .001) and even slightly exceeded 2C area, 4C volume, and 4C area. 2C volume further displaced LV systolic function, mass index, and heart rate as statistically significant predictors of ANP (P < .001) and BNP (P < .001) on adjusted regression analysis, whereas M-mode diameter was displaced as a significant predictor of ANP and BNP (P = not significant). The current population-based echocardiographic study allows new insight into the value of different measures of LA size. The closer association between natriuretic peptide concentrations and parameters derived from planimetry and volumetry suggests a superiority of these parameters LA diameter. LA volumetry should be included in routine echocardiography for optimized assessment of LA size.

Can Transesophageal Pulse‐Wave Tissue Doppler Imaging Be Used to Evaluate Left Ventricular Function?

This study aimed to evaluate the efficiency of transesophageal tissue Doppler echocardiography (TDE) in evaluation of the left ventricular functions. To this end, the data obtained by transoesophageal tissue Doppler echocardiography and by transthoracic tissue Doppler echocardiography were compared simultaneously. Nineteen consecutive patients (7 female and 12 male) underwent a clinically indicated study. In transthoracic (TTE) and transoesophageal (TEE) echocardiographic study, a Vingmed System Five Doppler echocardiographic unit (GE Vingmed) was used. For the assessment of the left ventricular function using transthoracic and transoesophageal TDE, the mitral annular peak systolic (S), early diastolic (E), late diastolic velocities (A), late to early velocity ratio (E/A), deceleration times (DT), left ventricular isovolumetric relaxation times (IVRT) were measured at the lateral, medial, anterior, and posterior corners at the mitral annulus by activating TDE mode in the transthoracic and transoesophageal apical four- and two-chamber view. Bland-Altman plots were used to compare the two measurement techniques. The differences between the groups were assessed by Mann-Whitney U test. All the data were expressed as mean +/- SD. A P-value of <0.05 was considered significant. There were no significant differences between two techniques in terms of blood pressure and heart rate. Two techniques were compared for the transthoracic and transoesophageal TDE parameters. Bland-Altman analysis showed comparable values for E, A, E/A, S, and mE/E, although the measurements of DT and IVRT were different. PW tissue Doppler echocardiographic approach during TEE may be suitable for assessment of the left ventricular function.

Reference Values Describing the Normal Mitral Valve and the Position of the Papillary Muscles

In patients with functional mitral regurgitation (MR), the principal mechanisms are insufficient coaptation due to dilatation of the mitral annulus (MA), global ventricular dysfunction with tethering of leaflets, or restricted leaflet motion with incorrect apposition due to regional ventricular dysfunction and displacement of the papillary muscles (PMs). These different entities often coexist and for this reason, knowledge of the normal reference values describing the shape and size of the MA and the position of the PMs is essential. In the present study, we describe the MA dimensions and the position of the PMs in a group of normal individuals (n = 38, 60% women, age [mean +/- SD] 51 +/- 9 years and BSA 1.83 +/- 0.16 m(2)) investigated with transthoracic echocardiography. The anteroposterior dimension (AP) of the ellipse-shaped MA was measured in a parasternal long axis, while the distance from the posteromedial (PoM) to the anterolateral (AL) commissure was measured in a parasternal short axis (CC). The annular area was calculated assuming elliptic geometry. The MA shape was described by the ratios AP/CC and AP/length of the anterior leaflet. The PMs' position was described by the following distances: (a) from the MA to the tip of the PoM and AL, PMs measured in a modified two-chamber view where both PMs could be identified, (b) the interpapillary distance, and (c) the tethering distance from the tip of the PM to the contralateral MA. These data on the normal mitral valve morphology should provide useful information when assessing the underlying mechanism of functional MR.

Segmental atrial contraction in patients restored to sinus rhythm after cardioversion for chronic atrial fibrillation: A colour Doppler tissue imaging study

There is little known about segmental atrial function in patients with atrial arrhythmias. We evaluated segmental atrial contractility using colour Doppler tissue imaging (CDTI) in patients with chronic atrial fibrillation (CAF) who were successfully restored and maintained in sinus rhythm (SR). We compared the segmental atrial contractility in 39 CAF patients who were successfully cardioverted and maintained in SR for 6 months. Follow up echocardiograms were performed at baseline, 1 week, 1 month and 6 months and compared to a normal age matched cohort (n = 34). Using CDTI, mean peak velocities of atrial contraction were measured from annular, mid and superior segments of lateral and septal walls of the left atrium and right atrium in the apical four-chamber view. Segmental velocities from the posterior and anterior walls of the left atrium were measured from the apical two-chamber view. Segmental left atrial velocities improved over time in the CAF group, with the majority of the recovery occurring in the first month, but failed to normalise even at 6 months. In comparison, the right atrial velocities in the AF group had normalised at 1 month. Patients with CAF have persistent segmental left atrial dysfunction even 6 months after restoration and maintenance of SR, though right atrial velocities appear to normalise. This differential recovery indicates that left atrial function remains subnormal in patients with CAF despite maintenance of SR, suggesting underlying atrial myopathy or fibrosis as a consequence of CAF.