The role of advanced echocardiography and cardiovascular magnetic resonance in the assessment of myocardial function in Marfan syndrome—An update

Cardiovascular assessment of patients with Marfan syndrome has normally focused on the aortic root and vascular manifestations of the disease due to the high risk of aortic dissection. Although primary myocardial impairment has long been suspected in these patients, the evidence has been controversial. Advanced echocardiography and cardiovascular magnetic resonance imaging have proven to be effective, accurate, and more sensitive in the detection of subtle cardiac dysfunction. The application of these techniques to Marfan syndrome over the last 10 years has made significant progress in demonstrating the presence of primary myocardial impairment in these patients, but further work is still required to obtain confirmatory molecular, pathophysiological, and prognostic clinical data. Phenotypic expression of the disease has prognostic value, also suggesting potential effective medical therapy.     

Using traditional measurements of the left atrial diameter to predict the left atrial volume index

BACKGROUND: Left atrial enlargement by echocardiography is associated with adverse cardiovascular outcomes, yet the best method for assessing left atrial size has not been established. We sought to correlate the traditional left atrial diameter (LAD) measured in the parasternal view with the recently characterized left atrial volume index (LAVI). METHODS: 100 routine clinical patients who received a transthoracic echocardiogram for customary indications were studied. The LAD and LAVI were measured in each patient. RESULTS: The mean LAVI was 32.8 milliliters per square meter (ml/m(2)) and the LAD was 46.8 millimeters (mm). LAD > 4.7 centimeters (cm) was predictive of LAVI > 32 ml/m(2) (P < 0.001; OR 17.33; 95% CI = 5.96-50.44). CONCLUSION: LAD > 4.7 cm via the traditional method can be used to indicate left atrial enlargement. However, a LAD < or = 4.7 cm does not correlate well with the LAVI, and in such patients, extreme caution should be employed when using the LAD to estimate cardiac prognosis.     

Comparison of left atrial size by freehand scanning three-dimensional echocardiography and two-dimensional echocardiography.

AIMS: As the left ventricular (LV) dimension is a poor indicator of LV volume, there are well-known limitations of left atrial (LA) antero-posterior dimensions as indicators of chamber size. LA volume has been shown to provide a more accurate assessment of LA size than LA dimension. To evaluate two-dimensional (2D)-derived LA volume in assessing LA size, we compared LA dimension and 2D LA volume with three-dimensional (3D)-derived LA volume. METHODS: We performed transthoracic freehand scanning 3D echocardiography (3D EchoTech, Germany) using magnetic fields and a harmonic imaging system in 32 patients. We collected a series of LA tomograms by slowly tilting the probe (fan-like scanning) in the parasternal position. The 3D LA volume was calculated by using the multiplanar Simpson's method. The 2D LA volume was measured by using the modified biplane Simpson's rule. RESULTS: LA antero-posterior dimensions and 2D volumes showed a significant positive correlation with 3D LA volumes. However, the correlation coefficient was significantly greater for the relationship between 2D LA volumes and 3D LA volumes than for that between LA dimensions and 3D LA volume. CONCLUSIONS: The 2D LA volumes provide a more accurate measure of the true size of the LA and are more sensitive to changes in LA size.     

Utility of postural change in differentiating sludge from thrombus in the left atrial appendage: A case report

We detected symptomatic atrial fibrillation in a 64‐year‐old man who had undergone mitral valvuloplasty. While performing transesophageal echocardiography (TEE) in the left lateral decubitus position, we detected an isoechoic mass lesion at the bottom of the left atrial appendage (LAA). After changing the patient's position from left to right, the mass lesion dropped down from the bottom of the LAA, spread out into the left atrium, and appeared as a spontaneous echocardiographic contrast with mobility. We therefore diagnosed the mass lesion as not a thrombus but sludge. Changing the patient's position during TEE is useful for distinguishing sludge from thrombi.     

右心房功能的评价

与左心房相似,右心房据有储蓄、管道、辅泵三种功能。现将对一些疾病中,右房功能发生的不同改变进行综述,同时总结目前用于右心房研究的一些指标及方法。     

Usefulness of three-dimensional echocardiography for evaluation of pathological mass in the right atrium

The authors present a case of 51-year-old male patient with symptoms of congestive heart failure. Two-dimensional transthoracic echocardiography (2D TTE) at the time of admission revealed a spherical, highly mobile structure in the right atrium (4.5 cm in diameter). Despite using multiple views it was impossible to distinguish if this structure had a stalk or was free-floating. The real time three-dimensional transthoracic echocardiography (3D TTE) revealed the presence of thin stalk attached to the roof of the right atrium. Guidance of 2D TTE by 3D TTE findings finally allowed the recognition of the stalk in modified subcostal view.     

A primary benign cardiac tumor misdiagnosed as cardiac metastasis in the right atrium

We present a patient with breast cancer with multiple metastases who had an unusual cardiac mass in the right atrium. The cardiac mass was initially diagnosed as malignant metastasis by transthoracic echocardiogram (TTE) but subsequently diagnosed as benign by contrast-enhanced ultrasonography, cardiac magnetic resonance imaging (MRI), and positron emission tomography/computed tomography (PET/CT). TTE is the preferred imaging method for examination of cardiac masses. However, this case demonstrates that contrast-enhanced ultrasonography, MRI, and PET/CT are useful to differentiate between diagnoses of benign and malignant tumor. The combination of multiple diagnostic imaging modalities is necessary to confirm the diagnosis of cardiac tumors.     

Two‐Dimensional Tissue Tracking: A Novel Echocardiographic Technique to Measure Left Atrial Volume: Comparison with Biplane Area Length Method and Real Time Three‐Dimensional Echocardiography

Enlargement of the left atrium is an independent predictor of adverse cardiovascular outcomes, and an accurate, convenient imaging modality is necessary for clinical practice. The objectives of this study were to evaluate the feasibility of a novel imaging technique, two‐dimensional tissue tracking (2DTT), for assessment of left atrial (LA) volume and function and to compare its correlation and agreement with biplane area length (AL) method and real time three‐dimensional echocardiography (RT3DE). A total of 105 patients prospectively underwent 2DTT, AL and RT3DE. The LA volume index (LAVI) and emptying fraction were measured. In addition, intra‐ and inter‐observer agreement were calculated by using the intraclass correlation coefficient. There were no significant differences in LAVI and emptying fraction measured by 2DTT in comparison with those made by AL or RT3DE, furthermore Bland–Altman analysis showed that 2DTT had significantly better agreement for LAVI and emptying fraction with AL and RT3DE. 2DTT also exhibited smaller intra‐ and inter‐observer variability as compared with AL or RT3DE. Furthermore, the time to measure LA volume and acquire time–volume curve was significantly less by 2DTT than that by RT3DE (U = 49.00, P < 0.001). These observations suggest that the 2DTT could provide valuable information which is consistent with the standard AL and RT3DE measurements for LAVI and function with potentially lower intra‐ and inter‐observer variability.     

Left Atrial Volume Index in Healthy Subjects: Clinical and Echocardiographic Correlates

Left atrial (LA) size is related to cardiovascular morbidity and mortality. The relative role of multiple determinants of LA morphology in healthy subjects remains incompletely defined. The aim of this study is to define normal ranges for LA diameters and volume index (LAVi), and to investigate clinical and echocardiographic correlates. A total of 1480 healthy individuals (mean age 36.1 ± 15.5 years, range 20–80; 61% males) underwent a comprehensive transthoracic echocardiography exam including assessment of LAVi calculated using the biplane area‐length method at the apical four‐chamber and two‐chamber views at ventricular end systole (maximum LA size) and indexed for body surface area (BSA). Mean LAVi in the overall population was 29.5 ± 10.8 mL/m² (range: 26.1–41.8 mL/m²). Distinct higher values were found in subjects ≥50 years as compared with those <50 years of age (33.4 ± 12.5 vs. 29.1 ± 13.5; P < 0.001). On univariate analysis, LA volume was significantly associated with age (r = 0.48, P < 0.0001), male gender (r = 0.28, P < 0.05), BSA (r = 0.51, P < 0.0001), mitral E/E' (r = 0.47, P < 0.0001), LV end‐diastolic volume (r = 0.52, P < 0.0001), and LV mass index (r = 0.31, P < 0.05). Multivariable analysis identified age, BSA, LV end‐diastolic volume, and mitral E/E' ratio as the only independent determinants of LA volume (model R² = 0.54, P < 0.0001). Gender was an independent predictor of most absolute LA volume, but following normalization to BSA, some associations became nonsignificant. In healthy individuals LAVi vary significantly by age, BSA, diastolic function, and LV dimensions, with lesser effects of gender.     

Association between Left Atrium Enlargement and Intradialytic Hypotension: Role of Diastolic Dysfunction in the Hemodynamic Complications during Hemodialysis

Symptomatic intradialytic hypotension (IH) continues to be an important complication of hemodialysis treatment. It has been suggested that patients with left ventricular (LV) diastolic dysfunction may be more sensitive to the effects of reduced cardiac filling. Left atrial volume index (LAVi) reflects the chronicity of exposure to elevated LV filling pressures. The aim of this study was to identify the association between echocardiographic disease, in particular left atrium enlargement, and IH. Echocardiograms obtained in 172 patients undergoing hemodialysis in sinus rhythm and with no significant valvular or pericardial disease were analyzed. The independent association between LAVi and IH was assessed using multivariate logistic regression. IH was identified in 27 patients (16%). The patients who experienced the hypotensive episodes had a greater prevalence of previous heart failure (59% vs 22%, P < 0.001), systolic dysfunction (33% vs 14%, P = 0.003), and LAVi > 35 mL/m² (59% vs 32%, P = 0.008). No differences were noted for age, gender, body mass index, duration of dialysis, blood pressure, use of drugs, and proportions of arterial hypertension, diabetes, LV hypertrophy and diastolic dysfunction by Doppler. After multivariate analysis, only heart failure and LAVi > 35 mL/m² were seen to be independent predictors of IH. The finding of left atrium enlargement in patients undergoing hemodialysis may be useful in the clinical prediction of IH.     

Cor triatriatum dexter assessed by three-dimensional echocardiography reconstruction in two adult patients

Cor triatriatum dexter is a rare congenital anomaly caused by persistence of the right valve of the embryonic sinus venosus, and this results in septation of the right atrium. Three-dimensional echocardiography is a novel technique that can be used to identify and characterize this entity. Here, we report two women with cor triatriatum dexter.     

Reference values of right atrial longitudinal strain imaging by two-dimensional speckle tracking

Background: The role of speckle tracking in the assessment of right atrial (RA) deformation dynamics has not been established yet. The reference ranges of RA longitudinal strain indices were measured by speckle tracking in a population of normal subjects. Methods: In 84 healthy individuals, peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and time to peak longitudinal strain (TPLS) were measured using a six‐segment model for the RA. Strain rate (SR) was also measured starting from the QRS‐wave onset, peak positive (x‐wave), first peak negative (y‐wave), and second negative peak (z‐wave). The time from the QRS onset was measured to each wave peak. Results: Adequate tracking quality was achieved in 64% of segments analyzed. Inter‐ and intraobserver variability coefficients of measurements ranged between 6% and 11%. Global PALS was 49 ± 13%, global TPLS was 363 ± 59 msec, x‐wave was 2.12 ± 0.58 sec^?1, y‐wave was ?1.91 ± 0.63 sec^?1, and z‐wave was ?2.18 ± 0.78 sec^?1. Conclusion: Speckle tracking is a feasible technique for the assessment of longitudinal myocardial RA deformation. Reference ranges of strain indices were reported. (Echocardiography 2012;29:147‐152)     

An unusual case of recurrent mass in the right atrium: intravenous leiomyomatosis

Intravenous leiomyomatosis with a cardiac extension is an extremely rare condition. In this report, a case of a 43-year-old female patient is described: she was operated for right atrial mass protruding into the inferior vena cava, which was later diagnosed as leiomyoma. After a 3-year symptom-free period, recurrence of the extension through the inferior vena cava was observed. After abdominal ultrasonographic examination, which revealed bilateral ovarian and retroperitoneal mass, bilateral oopherectomy, retroperitoneal, and right atrial mass excision was done. The retroperitoneal and right atrial mass was reported as leiomyoma. On her last admission, she had complaints of dizziness, abdominal pain, and bilateral leg edema; and right atrial mass extending through the common iliac vein was noted, but the patient did not accept any further treatment modality.