Assessment of Left Ventricular Volumes and Function by Real Time Three‐Dimensional Echocardiography in a Pediatric Population: A TomTec versus QLAB Comparison

Background: Three‐dimensional echocardiography (3DE) allows accurate calculation of ventricular volumes despite a remaining geometric assumption on the ventricular shape. Few studies involving full volume reconstruction software have been performed on children. Our aim was to compare the left ventricular (LV) volume measurements obtained with the most used 3D analysis software in a pediatric population. Methods: Fifty patients (median age: 9.5 years) without cardiac disease were included in the study. 3DE was performed with the X4–2 or X7–2 matrix probe (ie33, Philips). The LV volume analysis was performed with QLAB 6.0 (semiautomated border detection) and TomTec 4D LV (primary manual tracking with semiautomated border detection). Results: TomTec analysis feasibility amounted to 94% whereas QLAB analysis feasibility only reached 80% (P = 0.037). The analysis time was shorter with QLAB than TomTec (5 ± 2 versus 6 ± 3 minutes, P < 0.05). The stroke volume, end diastolic and end systolic LV volume measurements performed on the 40 patients were strongly correlated (r > 0.97; P < 0.0001) with minimal bias. The LV ejection fraction was well correlated (r = 0.79; P < 0.0001). Conclusion: 3D LV volume quantification is feasible either by using manual or automated reconstruction software in a normal pediatric population. LV Measurements are well correlated. Differences in volume reconstruction algorithms provide specific software performance characteristics. TomTec is a more feasible method but requires a longer analysis time. Further studies are needed to validate the accuracy of the method to calculate enlarged LV volumes in patients with congenital heart diseases. (Echocardiography 2010;27:1263‐1273)     

Left Ventricular Lateral Annulus and Left Atrial Free‐Wall Velocity Time Integral Indicate Thromboembolism in Patients with Rheumatic Atrial Fibrillation

Background: Low wall motion and stasis increase the likelihood of clot formation. We hypothesized that tissue Doppler indices of left atrial (LA) motion are reduced in the presence of LA thrombi and may be predictive for clot formation in patients with atrial fibrillation (AF). Methods: We did an observational study for 3 years in 118 patients with rheumatic mitral valve disease in chronic AF who had not received anticoagulation, with (Group 1, n = 36) and without (Group 2, n = 82) thromboembolism. Pulsed tissue Doppler systolic velocities and velocity time integrals (VTIs) were measured in all four chambers. A mean LA VTI was calculated. LA strain during ventricular systole was calculated using VTI and distance between two LA locations. Results: Logistic regression analysis showed that, after adjusting for age, gender, diabetes, hypertension, LA size, and left ventricular (LV) ejection fraction, mean LA VTI [Odds ratio (OR) 0.69, 95%CI (0.56–0.86, P = 0.03)] and lateral mitral annulus VTI [OR 0.15 (0.04–0.56, P = 0.03)] were associated with clot formation. The addition of these two parameters to the conventional risk factors increased the ability to predict thromboembolism (Nagelkerke R²= 0.32–0.50, P = 0.01; area under the curve 0.83 by receiver operating characteristic analysis, P = 0.01). LA strain also had potential to indicate clot formation (0.9 ± 13.8 vs. ?8.2 ± 15.1%, group 1 vs. 2, respectively, P = 0.01). Conclusion: Patients with chronic AF and thromboembolism have reduced LA and LV motion independently of LA size and LV ejection fraction. Tissue Doppler parameters may have potential to predict clot formation in these patients. (Echocardiography 2010;27:1038‐1048)     

Right Atrial Appendage Function in Different Etiologies of Permanent Atrial Fibrillation: A Transesophageal Echocardiography and Tissue Doppler Imaging Study

Objectives: Several studies exist on the left atrial appendage function (LAA) in permanent atrial fibrillation (AF). However, knowledge about the right atrial appendage (RAA) function is limited. We investigated RAA function with TEE and tissue Doppler imaging (TDI) in permanent AF patients with different etiologies and evaluated predictive parameters of right atrial spontaneous echo contrast (SEC) and thrombi. Methods: Patients with permanent AF developed due to three different etiologies (20 mitral stenosis, 44 hypertension, 20 hyperthyroidism) and 23 subjects with sinus rhythm were included into the study. RAA was examined with TEE and pulsed‐wave and TDI velocities of RAA were measured. Results: Both PW‐Doppler and TDI velocities were significantly impaired in all AF groups compared to controls. The lowest velocities were recorded in mitral stenosis patients. Right atrial moderate–severe SEC was observed in 75% of the mitral stenosis patients, in 25% of hypertensive patients, and in 30% of hyperthyroidism patients. Right atrial thrombus was observed in 25% of mitral stenosis, 4.5% of hypertension, and in none of the hyperthyroidism patients. In the multivariate analysis, the most important parameter associated with the severity of RAA SEC was the percent change in RAA area (B =−0.034, P = 0.03). Conclusion: In patients with permanent AF, impairment of RAA function and development of right atrial SEC‐thrombus are closely related to the underlying etiology. These results suggested that evaluation of RAA functions may have an incremental value over the assessment of the LAA for determining thromboembolic risk. (Echocardiography 2010;27:384‐393)     

Diastolic Function Study with Conventional and Pulsed Tissue Doppler Echocardiography Imaging in Acromegalic Patients

Acromegaly is associated with myocardial hypertrophy and it can progress to diastolic and systolic dysfunction. Purpose: To evaluate diastolic function in acromegalic patients through conventional echocardiography (CD) and tissue Doppler imaging (TDI). Methods: Seventeen acromegalic patients were submitted to CD and TDI, and early (E) and atriogenic (A) transmitral flow were evaluated in mitral, septal, and tricuspid regions. Results: In comparison with controls the means of conventional (1.06), septal (1.01), and tricuspid (0.98) E/A ratio were significantly lower in acromegalic patients. E/A ratio <1.0 was demonstrated in 41% and 49% of acromegalics by DC and TDI, respectively, with no statistical difference among the two methods. An inverse linear correlation was shown between mitral E/A ratio and acromegalic age (r =−0.7). Conclusion: In this study, DC and TDI were equally effective in demonstrating diastolic dysfunction, a common finding in acromegalic patients.     

Myocardial Contrast Echocardiography in Assessment of Stable Coronary Artery Disease at Intermediate Dobutamine-Induced Stress Level

Background: Myocardial contrast stress echocardiography (stress MCE) is a novel method for diagnosing coronary artery disease (CAD). Few studies have compared the diagnosis of ischemia by stress MCE to angiographic CAD. Methods: Dobutamine stress MCE and SonoVue contrast infusion were performed before an elective percutaneous coronary intervention in 37 patients (8 women) aged 45–75 years with symptomatic CAD and at least one significant coronary artery stenosis measured by quantitative coronary angiography (QCA). The total and regional perfusion and wall motion (WM) were scored as normal or abnormal and attributed to the three main epicardial coronary arteries using a 17-segment left ventricular model. Results: An intermediate stress level was obtained in 29 (78%) patients, and 2 (5%) patients obtained peak stress. A perfusion defect was detected in 92% and WM abnormality in 57% of the patients at peak stress (P < 0.01). By perfusion, 70% of stenoses were both detected and correctly anatomically located, compared to 42% by WM (P < 0.01). All 21 patients with multivessel disease and/or proximal left anterior descending (LAD) stenosis measured by QCA were identified by stress-induced perfusion defects, while only 11 of them were identified by WM abnormalities (P < 0.01). Conclusion: Perfusion scoring is superior to WM scoring during stress MCE for diagnosing significant CAD in patients obtaining intermediate stress level, in particular, when multivessel disease or proximal LAD stenosis is present.     

Hand-Held Echocardiogram Does Not Aid in Triaging Chest Pain Patients from the Emergency Department

Background: Accurate triage of emergency department (ED) patients presenting with chest pain is a primary goal of the ED physician. In addition to standard clinical history and examination, a hand-held echocardiogram (HHE) may aid the emergency physician in making correct decisions. We tested the hypothesis that an HHE performed and interpreted by a cardiology fellow could help risk-stratify patients presenting to the ED with chest pain. Methods: ED physicians evaluated 36 patients presenting with cardiovascular symptoms. Patients were then dispositioned to either an intensive care bed, a monitored bed, an unmonitored bed, or home. Following disposition, an HHE was performed and interpreted by a cardiology fellow to evaluate for cardiac function and pathology. The outcomes evaluated (1) a change in the level of care and (2) additional testing ordered as a result of the HHE. Results: The HHE showed wall motion abnormalities in 31% (11 out of 36) of the studies, but the level of care did not change after HHE for any patients who presented with chest pain to the ED. No additional laboratory or imaging tests were ordered for any patients based on the results of the HHE. Eighty-six percent (31 out of 36) of the studies were of adequate quality for interpretation, and 32 out of 36 (89%) interpretations correlated with an attending overread. Conclusion: Despite the high prevalence of abnormal wall motion in this population, hand-held echocardiography performed in this ED setting did not aid in the risk stratification process of chest pain patients.     

Complementary Roles of Transthoracic Two-Dimensional Color Doppler Imaging and Myocardial Contrast Echocardiography in Diagnosis of Endomyocardial Fibrosis

Endomyocardial fibrosis (EMF) is a rare progressive restrictive cardiomyopathy of unknown etiology that mainly presents with heart failure. The presence of a small ventricle with obliteration of the apex and a large atrium are two-dimensional echocardiographic findings that are highly suggestive of EMF. Cardiac magnetic resonance with delayed enhancement allows detection of subendocardial fibrosis with good histopathological correlation, providing a noninvasive modality for diagnosing EMF. We herein report a case of EMF in which the complementary role of two-dimensional color Doppler imaging and myocardial contrast echocardiography proved to be useful in the diagnosis of this clinical entity, which was later confirmed by cardiac magnetic resonance, surgery, and histopathology.     

Association of Left Atrial Strain and Strain Rate Assessed by Speckle Tracking Echocardiography with Paroxysmal Atrial Fibrillation

Background: We hypothesized that contraction of the LA wall could be documented by speckle tracking and could be applied for assessment of LA function. This study tried to identify the association between LA longitudinal strain (LAS) and strain rate (LASR) measured by speckle tracking with paroxysmal atrial fibrillation (PAF). Methods: Fifty‐two patients (61 ± 17 years old, 23 men) with sinus rhythm at baseline referred for the evaluation of episodic palpitation were included. Standard four‐chamber and two‐chamber views were acquired and analyzed off‐line. Peak LAS and LASR were carefully identified as the peak negative inflection of speckle tracking waves after P‐wave gated by electrocardiography. Results: Ten patients (19%) had PAF. LAS, LASR, age, left ventricular end‐diastolic dimension, left ventricular mass, LA volume, and mitral early filling‐to‐annulus early velocity ratio were different between patients with and without PAF. After multivariate analysis, LASR was significantly independently associated with PAF (OR 8.56, 95% CI 1.14–64.02, P = 0.036). Conclusion: Speckle tracking echocardiography could be used in measurements of LAS and LASR. Decreased negative LASR was independently associated with PAF. (ECHOCARDIOGRAPHY, Volume 26, November 2009)