Simplified Single Plane Echocardiography Is Comparable to Conventional Biplane Two‐Dimensional Echocardiography in the Evaluation of Left Atrial Volume: A Study Validated by Three‐Dimensional Echocardiography in 143 Individuals

The left atrial volume index (LAVI) is a biomarker of diastolic dysfunction and a predictor of cardiovascular events. Three‐dimensional echocardiography (3DE) is highly accurate for LAVI measurements but is not widely available. Furthermore, biplane two‐dimensional echocardiography (B2DE) may occasionally not be feasible due to a suboptimal two‐chamber apical view. Simplified single plane two‐dimensional echocardiography (S2DE) could overcome these limitations. We aimed to compare the reliability of S2DE with other validated echocardiographic methods in the measurement of the LAVI. We examined 143 individuals (54 ± 13 years old; 112 with heart disease and 31 healthy volunteers; all with sinus rhythm, with a wide range of LAVI). The results for all the individuals were compared with B2DE‐derived LAVIs and validated using 3DE. The LAVIs, as determined using S2DE (32.7 ± 13.1 mL/m²), B2DE (31.9 ± 12.7 mL/m²), and 3DE (33.1 ± 13.4 mL/m²), were not significantly different from each other (P = 0.85). The S2DE‐derived LAVIs correlated significantly with those obtained using both B2DE (r = 0.98; P < 0.001) and 3DE (r = 0.93; P < 0.001). The mean difference between the S2DE and B2DE measurements was <1.0 mL/m². Using the American Society of Echocardiography criteria for grading LAVI enlargement (normal, mild, moderate, severe), we observed an excellent agreement between the S2DE‐ and B2DE‐derived classifications (κ = 0.89; P < 0.001). S2DE is a simple, rapid, and reliable method for LAVI measurement that may expand the use of this important biomarker in routine echocardiographic practice.     

Early Left Atrial Mechanics and Volume Abnormalities in Subjects with Prehypertension: A Real Time Three‐Dimensional Echocardiography Study

The aim of this study was to evaluate left atrial (LA) volume and mechanical functions by real time three‐dimensional echocardiography (RT3DE) in prehypertensive subjects. The study included 54 (34 male and 20 female) prehypertensive subjects and 36 (14 male and 22 female) healthy control subjects. Transthoracic echocardiography and RT3DE were performed in all patients. Interventricular septum thickness and isovolumetric relaxation time were significantly higher in prehypertensives than in controls (10.7 ± 0.7 vs. 10.1 ± 0.8 P = 0.001 and 89.9 ± 10 vs. 82.4 ± 11 P = 0.002, respectively). LA maximum volume, volume before atrial contraction, total and active stroke volume, total and active emptying fractions, expansion index, and LA max volume index were significantly higher in prehypertensives when compared with controls (P < 0.0001 for all). However, the passive emptying fraction was significantly lower in prehypertensives than controls (45.7 ± 5.6 vs. 48.6 ± 4.1, P = 0.006), and the minimum LA volume between the two groups was similar. The main finding of this study was that although LA volume and LA active systolic functions were significantly increased in prehypertensive people, there was a reduction in passive LA systolic functions. These parameters may be important in showing hemodynamic and structural changes in cardiac tissue caused by prehypertension.     

Left Atrial Function during Pregnancy: A Three‐Dimensional Echocardiographic Study

Background: Alteration of diastolic function is considered a sensitive means for detecting changes in the normal cardiac adaptation to pregnancy. Our aim was to evaluate volumetric and functional atrial parameters, using real time three‐dimensional echocardiography (RT3DE) in women in early and late third trimester of pregnancy. Methods: We studied pregnant women in early third trimester (III‐E = gestational age 26–33 weeks), in late third trimester (III‐L = gestational age 34–40 weeks), and control nonpregnant women (C). Two‐dimensional (2D‐Echo) and RT3DE were used to study 3D left atrial (LA) systolic and diastolic stroke volumes and index (LASVI, LAEDVI), emptying fraction, left ventricular and LA cavities. Results: Although the LA end systolic volume index increased significantly (from 19.42 ± 0.1 to 24.7 ± 3.5 mm², P < 0.01), the EF did not change significantly. This was mainly achieved by increasing atrial contraction (A‐wave), maintaining cardiac output by increasing heart rate. A decrease in diastolic E‐wave, increased atrial kick (A‐wave) with reduced E/A ratio, was noted as the pregnancy progressed. Pulmonary pressure increased from 16.9 ± 6.6 to 20.5 ± 2.9 mmHg (P < 0.01), Using 2D‐Echo revealed no change in LA diameter from control to III‐E and III‐L, respectively (from 17.1 ± 2.3 to 16.7 ± 2.6, 17.5 ± 2.2 mm) and area (from 11.7 ± 3.1 to 16.5 ± 2.3, 17.6 ± 1.6 cm²). However, using RT3DE, a significant increase in the LASVI, LAEDVI, and LA stroke volume index (from 12.02 ± 2.5 to 14.7 ± 3.2, and 15.1 ± 2.7 mL/m²) was detected. Conclusions: Enlargement of the LA volume with unchanged blood pressure values, as found using RT3DE, may be part of the adaptation to increased blood volume during pregnancy.     

Assessment of Interventricular Dyssynchrony by Real Time Three‐Dimensional Echocardiography: An In Vitro Study in a Porcine Model

Background: Loss of synchronous contraction between or within the right and left ventricle (RV, LV) leads to adverse ventricular function. We used real time three‐dimensional echocardiography (RT3DE) for evaluation of severity of interventricular dyssynchrony and function in a porcine heart model. Methods: Six fresh in vitro porcine hearts were used to create a controlled model of LV and RV dyssynchrony using two sets of pulsatile pumps. Synchronized and dyssynchronized pump settings were used with two different dyssynchronized settings: LV filled first and RV filled first. Results: There was good correlation between actual measurement and RT3DE for interventricular time difference (r = 0.95, P < 0.0001) and stroke volume (SV) for LV and RV (0.89, 0.85; P < 0.0001, respectively). RT3DE data showed a small but significant underestimation for actual volume (P < 0.05). The intra‐ and interobserver variabilities are 2.9 ± 1.5% and 3.1 ± 5.4% for LV and RV SVs, and 1.7 ± 2.4% and 2.2 ± 3.2% for time differences by RT3DE. There was significant difference in RV SV between synchrony and dyssynchrony when the RV filled first (P < 0.05), but not in other groups. The same pattern was found in RT3DE derived SVs (synchrony versus dyssynchrony with RV filled first, P < 0.05). Conclusions: There is no compromise in LV SV during interventricular dyssynchrony; but RV SV was significantly diminished when the RV filled first. RT3DE is a feasible, robust and reproducible method to identify interventricular dyssynchrony and to evaluate ventricular SVs. (Echocardiography 2010;27:709‐715)     

Functional Assessment of Donor and Recipient Left Atrium in Heart Transplant Patients Using Full‐Volume Three‐Dimensional Echocardiography

Background: Atrial function plays an important role in many cardiac conditions, how recipient and donor compartments of left atrium (LA) of transplanted hearts differentially contribute to overall LA function in transplanted hearts has not been described. We tested whether three‐dimensional transthoracic echocardiography (3DE) could be used to calculate these compartment‐specific atrial functions. Methods and Results: We analyzed 3DE images of 22 consecutive transplant patients who had diagnostic imaging quality (ages 59 ± 16 years) using TomTec Research Arena. The contour of the recipient and total LA were traced frame by frame, and the donor LA volume was calculated as the difference of the total LA volume minus the recipient LA volume. The LA ejection fractions of total LA, donor LA, and recipient LA were also calculated as (LA atrial end‐diastolic volume ? LA atrial end‐systolic volume)/LA atrial end‐diastolic volume of each compartment. Interobserver variability of LA volumes for the total, recipient, and donor compartments were 5.6 ± 2.4, 5.4 ± 2.0, and 9.3 ± 3.2 mL, respectively (n = 11). The donor LA ejection fraction was higher than that of recipient (41 ± 18% vs. 30 ± 14%, P = 0.013). When the patients were categorized as asymptomatic (New York Heart Association functional class [NYHA] functional class I) and symptomatic (NYHA functional class II–III), indexed donor LA atrial end‐diastolic volume was significantly lower in asymptomatic patients as compared with symptomatic patients. Conclusions: Compartment‐specific LA volumes can be calculated in orthotopic heart transplant patients using full‐volume 3DE. Our findings may suggest that unique contribution of each LA compartment of transplanted hearts toward the symptoms of these patients.     

Is Combined Atrial Volumetrics by Two‐Dimensional Echocardiography a Suitable Measure for Quantitative Assessment of the Hemodynamic Significance of Patent Ductus Arteriosus in Neonates and Infants?

Background: Patent ductus arteriosus (PDA) is a common cardiac problem in neonates and infants, but determination of its hemodynamic significance can be challenging. We hypothesized that combined left (LA) and right atrial (RA) volumes physiologically best reflect hemodynamically significant patent ductus arteriosus (HSPDA), and utilized two‐dimensional echocardiography (2DE) derived atrial volumes to test this hypothesis. Methods: 2DE examinations with good‐quality images in 138 neonates <3 months corrected gestational age with PDA, and 50 normal neonates without PDA were selected. Measurements of LA, RA, and combined atrial volumes were performed, in addition to transductal diameters, left atrial to aortic dimension (LA:Ao), and left ventricular end‐diastolic to aortic dimension ratios. An experienced cardiologist, blinded to 2DE images of atria and ventricles and to the above measurements, independently assessed HSPDA based only on images and Doppler data of the ductus itself, thus identifying each PDA as of low hemodynamic significance or HSPDA. Results: Receiver operating characteristic (ROC) curves showed indexed LA volumes and LA/RA volume ratios to have moderate power to discriminate HSPDA from low hemodynamic burden PDA. Classic LA:Ao ratio, combined atrial volumes, and RA volumes yielded ROC areas that appeared less promising as discriminators for HSPDA. Conclusion: Atrial volume measurements in neonates and infants have a linear association with body surface area and show acceptable inter‐ and intraobserver agreement. Indexed LA volume and LA/RA volume ratio are potentially useful markers for HSPDA. RA dilation due to left to right shunting through the patent foramen ovale as quantified by RA volume measurements does not appear to be an important marker for HSPDA. (Echocardiography 2010;27;696‐701)     

The Impact of Mitral Stenosis on Left Atrial Function Assessed by Two‐Dimensional Speckle Tracking Echocardiography

Aims: The aim of this study is to investigate the effect of mitral stenosis (MS) on left atrial (LA) function using two‐dimensional speckle tracking echocardiography (2DSTE). Methods and Results: The study subjects consisted of 52 patients with asymptomatic MS and 52 control subjects. LA function was assessed using prototype speckle tracking software and manual tracking method. Maximal LA volume (LAVmax) and minimal LA volume (LAVmin) and LA volume before atrial contraction (LAVpre‐a) were measured. Using these volumes, LA reservoir, conduit and booster pump fuction parameters were calculated. Indexed LAVmax, LAVmin, and LAVpre‐a measurements via speckle tracking were highly correlated with manual tracing methods in both groups. Expansion index (67.8 ± 36.4 vs. 148.3 ± 44.2), diastolic emptying index (37.7 ± 12.9 vs. 58.0 ± 8.5), passive emptying (37.3 ± 14.1 vs. 70.4 ± 10.4) and passive emptying index (13.3 ± 6.3 vs. 41.3 ± 10.6) were decreased significantly in MS patients (P < 0.001). In contrast active emptying index (62.6 ± 4.1 vs. 29.5 ± 10.1) increased in MS group (P < 0.001) while active emptying (28.1 ± 13.0 vs. 28.3 ± 6.9) remained same among both groups. Conclusions: This is the first study relating LA volumes and function assessed by 2DSTE to MS. 2D speckle tracking analysis of LA volume is relatively easy and provides more detailed information regarding the changes in LA volumes during the cardiac cycle.     

Observer Variation in the Echocardiographic Measurement of Maximum Atrial Septal Excursion: A Comparison of M‐Mode with Two‐Dimensional or Transesophageal Echocardiography

Background: Atrial septal aneurysm is typically diagnosed by transthoracic two‐dimensional or transesophageal echocardiography (2DE or TEE). Such techniques are highly dependent on visual inspection which predisposes to observer variation. This study compares inter‐ and intraobserver variations in the measurement of maximum atrial septal excursion (MASE) obtained using transthoracic M‐mode echocardiography (MME) with that obtained using 2DE or TEE. Methods: Consecutive patients with highly mobile atrial septal motion by visual inspection during 2DE or TEE were studied. MASE was estimated visually on 2DE or TEE. MME tracings were obtained with the cursor bisecting the parabola formed by the atrial septum at its maximum deviation from the midline. Electronic calipers were used to measure MASE for all echocardiographic techniques. Two observers provided two measurements each. Observer variation was determined by assessing standard deviation and confidence intervals of inter‐ and intraobserver differences. Results: Interobserver analysis showed standard deviations of 0.077 cm (95% CI 0.065–0.094) for MME and 0.280 cm (95% CI 0.242–0.334) for 2DE or TEE. Intraobserver analysis showed standard deviations of 0.08 cm (95% CI 0.068–0.101) for MME and 0.318 cm (95% CI 0.274–0.381) for 2DE or TEE. The mean magnitude of measured MASE was 0.44 cm higher with MME than with 2DE or TEE (95% CI 0.068–0.101). Conclusions: MME assessment of MASE is associated with substantially lower inter‐ and intraobserver variation than 2DE or TEE assessment. The magnitude of MASE is substantially higher with MME than with 2DE or TEE. (ECHOCARDIOGRAPHY, Volume **, ********)     

Assessment of echocardiographic left atrial size: accuracy of M-mode and two-dimensional methods and prediction of diastolic dysfunction

Background: Despite the American Society of Echocardiography recommendation to use left atrial volume indexed for body surface area (LAVI) for quantification of left atrial size, a variety of methods are used in clinical practice. Our objectives were to evaluate the accuracy of M‐mode and two‐dimensional (2D) echocardiographic LA size estimates to LAVI and to determine their ability to predict left ventricular diastolic dysfunction. Methods: In 150 consecutive patients, LA diameter (LAD), LA diameter indexed for body surface area (LADI), LA area in the apical two‐ and four‐chamber views (LAA 2c and LAA 4c), biplane area–length LA volume (LAV), and LAVI were obtained. The accuracy of these methods to quantify LA enlargement by LAVI, correlation with clinical parameters, and ability to act as a surrogate for diastolic dysfunction were determined using Pearson correlation coefficients along with univariate and multiple logistic analysis. Results: The true degree of LA size (with LAVI as standard) was identified by LAD in 45%, LADI in 42%, LAA 4c in 43%, and LAA 2c in 41%. All methods showed positive correlation with age, E/E′, mitral regurgitation, and right atrial size and negative correlation with ejection fraction. LAVI was the strongest method to predict any (c = 0.655, P = 0.012) or moderate–severe (P = 0.856 and P < 0.001) diastolic dysfunction. All methods have greater capacity to identify moderate or severe diastolic dysfunction than any degree of diastolic dysfunction alone. Conclusions: One‐dimensional and 2D methods inaccurately quantify LA size and are inferior to LAVI to predict diastolic dysfunction. (Echocardiography 2012;29:379‐384)     

Segmental Contribution to Left Ventricular Systolic Function at Rest and Stress: A Quantitative Real Time Three‐Dimensional Echocardiographic Study

Objective: To assess the relative contribution of each myocardial segment to global systolic function during stress using real time three‐dimensional echocardiography (RT3DE). Background: During stress, global augmentation in contractility results in an increased stroke volume. The relative contribution of each myocardial segment to these volumetric changes is unknown. Methods: Full volume was acquired using RT3DE at rest and following peak exercise in 22 patients who had no ischemia and no systolic dyssynchrony on two‐dimensional (2D) stress echocardiography. The following were calculated at rest and peak stress: end‐diastolic volume (EDV), end‐systolic volume (ESV), stroke volume (SV), ejection fraction (EF), relative SV, and relative EF. Results: With stress, an increase in global EDV from 90.8 to 101.1 ml (P < 0.001), SV from 59 to 78.4 ml (P = 0.01), and EF from 65.6 to 78.4% (P = 0.001) was observed. ESV decreased from 31.8 to 22.7 ml (P < 0.001). Segmental analysis revealed significantly higher SV, relative SV, and relative EF for the basal anterior, basal anterolateral, and basal inferolateral segments compared with the apical septum and apical inferior segments at both rest and stress (P < 0.001). The SV, relative SV, and relative EF increased significantly from apex to mid to base at both rest and stress (P < 0.001). Conclusions: The relative volumetric contribution of each myocardial segment to global left ventricular systolic function at rest and stress is not uniform. The basal segments contribute more than the mid and apical segments. Specifically, the basal anterior, basal anterolateral, and basal inferolateral segments contribute the most to augmentation of left ventricular systolic function with exercise. (ECHOCARDIOGRAPHY 2010;27:167‐173)     

Real Time Three‐Dimensional Echocardiographic Assessment of Left Ventricular Regional Systolic Function and Dyssynchrony in Patients with Dilated Cardiomyopathy

Purpose: To evaluate left ventricular (LV) regional systolic function and dyssynchrony in patients with dilated cardiomyopathy (DCM) by real time three‐dimensional echocardiography (RT‐3DE). Methods: The study population comprised 30 normal controls (NOR) and 44 patients with DCM. We divided the left ventricle into apical, middle, and basal regions. We calculated the LV regional end‐diastolic volume (_REDV), regional end‐systolic volume (_RESV), regional ejection fraction (_REF), and standard deviation in the time to minimal systolic volume in each level segment (Tmsv‐SD) of the three regions by RT‐3DE. Results: Compared with NOR, the _REDV, _RESV, and Tmsv‐SD of DCM were significantly higher, whereas the _REF was lower (P < 0.01). In DCM, the Tmsv‐SD increased smoothly from base to apex, and the _REF gradually decreased from base to apex (P < 0. 05). Linear correlation was observed between the Tmsv‐SD of the middle region and 3D‐EF in DCM (r =?0. 6829, P < 0.01). Conclusion: RT‐3DE provides a simple and feasible approach to quantify LV regional systolic function and dyssynchrony. (ECHOCARDIOGRAPHY 2010;27:415‐420)     

Left Atrial Longitudinal Speckle Tracking Echocardiography in Healthy Aging Heart

Background:

Left atrial volume (LAV) and function are connected to the left ventricular (LV) haemodynamic patterns. To define the changes of LAV and functions to counterbalance age-related LV diastolic impairment, this study was undertaken.

Methods:

2D-Left Atrial Speckle Tracking Echocardiography (2D-LASTE) was used to define both LAV and functions in an aged healthy population (group II) respect to adult healthy controls (group I).

Results:

Results showed an increasing of left atrial volume indices (LAVI) (maximum, minimum, pre-a) in old subjects in comparison with those obtained in adult healthy controls. On the contrary, LAVI passive emptying unchanged and LAVI passive fraction reduced with advanced age. Finally, LAVI active emptying increased with advancing age to compensate the age-dependent left ventricular diastolic dysfunction. The values of global systolic strain (S); systolic strain rate (SrS); early diastolic strain rate (SrE), and late diastolic strain rate (SrA) were also calculated. With reference to the function, our study confirmed that LA conduit function deteriorates with age while booster pump increases respect to adult controls and reservoir phase is maintained.

Conclusions:

The echocardiographic findings obtained with conventional and tissue Doppler confirmed the connection between LA functions and volumes and age-related LV dysfunction. Conclusively, 2D-LASTE appears to be a reliable tool to evaluate the role of LA to compensate the derangement of left ventricle happening with ageing.     

Assessment of Left Ventricular Size and Function during Cardiac Surgery. An Intraoperative Evaluation of Six Two‐Dimensional Echocardiographic Methods with Real Time Three‐Dimensional Echocardiography as a Reference

Transesophageal echocardiography is recommended to monitor left ventricular (LV) size and function in various operations. Generally, two‐dimensional (2D) methods are applied intraoperatively. The aim of this study was to compare the accuracy and feasibility of 6 commonly used 2D methods to assess LV function during surgery. LV function in 120 consecutive patients was evaluated. Real time three‐dimensional transesophageal echocardiograpy (3DTEE) served as reference. End‐diastolic and end‐systolic volumes and ejection fraction (EF) were analyzed with Simpson's method of discs (monoplane [MP] and biplane [BP]), eyeball method, Teichholz' method, and speckle tracking (ST) methods. Furthermore, fractional area change (FAC) and peak systolic pressure rise (dP/dt) were determined. Each 2D method was evaluated regarding correlation and agreement with 3DE, intra‐ and interobserver variability and the time required for evaluation. Simpson BP showed the strongest correlation and best agreement with 3DE for EF (limits of agreement 3.7 ± 11.6%) and volumes. Simpson MP showed similar agreement with 3DE compared to ST (2.8 ± 14.5% vs. 2.0 ± 15.3% and 3.8 ± 14.4% vs. 1.9 ± 15.6%, respectively). Both the eyeball method and Teichholz' method showed wide limits of agreement (?1.5 ± 18.2% and 5.2 ± 22.1%, respectively). DP/dt did not correlate with 3DE. FAC and ST FAC showed similar agreement. Application of 3DE (429 ± 108 seconds) took the longest time, and the eyeball method took the shortest time (8 ± 5 seconds) for analysis. Simpson BP is the most accurate intraoperative 2D method to evaluate LV function, followed by long‐axis MP evaluations. Short‐axis views were less accurate but may be suited for monitoring. We do not recommend using dP/dt.     

The Impacts of Transcatheter Occlusion for Congenital Atrial Septal Defect on Left Ventricular Systolic Synchronicity: A Three‐Dimensional Echocardiography Study

Objectives: To investigate the impacts of transcatheter occlusion for congenital atrial septal defect (ASD) on left ventricular (LV) systolic synchronicity using a real time three‐dimensional echocardiography (RT3DE). Methods: Thirty patients with ASD closure were recruited for the study. Realtime three‐dimensional echocardiographic data sets were acquired for the measurement of LV volumes LV ejection fractions and LV three‐dimensional systolic synchronicity before and at 6 months after transcatheter occlusion for ASD. M‐mode echocardiography and RT3DE were performed to characterize interventricular septal (IVS) motion. Results: There were no differences in LV systolic synchronicity between before and after transcatheter closure of ASD (Tmsv‐16SD%: 5.6%± 1.4% vs 5.8%± 1.8%, P > 0.05; Tmsv—12SD%: 5.2 ± 1.1% vs 5.4 ± 1.2%, P > 0.05). But the abnormal IVS motion was found before device closure and normalized after transcatheter occlusion for ASD using M‐mode echocardiography and the excursion‐time figure (bull's‐eye derived from RT3DE); At the same time, LV ejection fraction (59.8 ± 2.6 vs 66.7 ± 5.9, P < 0.05) stroke volume (49 ± 14 vs 63 ± 11, P < 0.05) was improved significantly as well as normalization of IVS motion after transcatheter occlusion for ASD. The correlation between ASD diameter and change of LVEF is significant (r = 0.85, P < 0.001). Conclusion: Although transcatheter occlusion did not significantly impact on intrinsic LV systolic synchronicity in patients with ASD, LV systolic function can be improved through normalization of IVS abnormal motion after transcatheter ASD occlusion. (Echocardiography 2010;27:324‐328)     

Direct Measurement of Left Ventricular Outflow Tract Area Using Three‐Dimensional Echocardiography in Biplane Mode Improves Accuracy of Stroke Volume Assessment

Aims: The aim of the study was to investigate whether left ventricular stroke volume (LVSV) assessment using direct measurement of left ventricular outflow tract area (LVOT_A) is superior to conventional methods for SV calculation. Methods and results: Thirty patients were included in the study (39 ± 12 years). LVSV was assessed by multiplying LVOT velocity time integral (VTI) by LVOT_A provided by direct planimetrical measurements from real time three‐dimensional echocardiography (RT3DE) in biplane mode (SV₂). These measurements were compared to conventional methods using either the LVOT diameter for LVOT_A multiplied with VTI (SV₁) or biplane Simpson (SV₃). Direct SV measurements by RT3DE were used as gold standard (SV_ref). There was an excellent correlation and agreement between SV determined by SV₂ and 3DE (r = 0.98, mean difference 0.5 ± 3.3 mL). However, the concordance of the traditional methods (SV₁ and SV₃) with 3DE was weaker (r = 0.38, mean difference ?2.0 ± 17.6 mL, r = 0.84, mean difference ?7.6 ± 8.7 mL, respectively). Furthermore, cardiac output (CO) measurements performed by the different modalities were not concordant with wide limits of agreement, except by SV₂ the mean difference of CO by SV₁ was ?0.12 ± 1.05 L/min, 0.03 ± 0.20 L/min by SV₂, and ?0.45 ± 0.52 L/min by SV₃. Conclusions: SV and CO calculations using direct measurement of LVOT area is a feasible, accurate and reproducible method and correlates extremely well with 3DE volume measurements. SV and CO calculation by LVOT_A is therefore an appealing method for LVSV assessment in clinical routine. (Echocardiography 2010;27:1078‐1085)     

Quantification of the area and shunt volume of multiple,circular, and noncircular ventricular septal defects: A 2D/3D echocardiography comparison and real time 3D color Doppler feasibility determination study

Background

Quantification of defect size and shunt flow is an important aspect of ventricular septal defect (VSD) evaluation. This study compared three‐dimensional echocardiography (3DE) with the current clinical standard two‐dimensional echocardiography (2DE) for quantifying defect area and tested the feasibility of real time 3D color Doppler echocardiography (RT3D‐CDE) for quantifying shunt volume of irregular shaped and multiple VSDs.

Methods

Latex balloons were sutured into the ventricles of 32 freshly harvested porcine hearts and were connected with tubing placed in septal perforations. Tubing was varied in area (0.13–5.22 cm²), number (1–3), and shape (circle, oval, crescent, triangle). A pulsatile pump was used to pump “blood” through the VSD (LV to RV) at stroke volumes of 30–70 mL with a stroke rate of 60 bpm. Two‐dimensional echocardiography (2DE), 3DE, and RT3D‐CDE images were acquired from the right side of the phantom.

Results

For circular VSDs, both 2DE and 3DE area measurements were consistent with the actual areas (R² = 0.98 vs 0.99). For noncircular/multiple VSDs, 3DE correlated with the actual area more closely than 2DE (R² = 0.99 vs 0.44). Shunt volumes obtained using RT3D‐CDE positively correlated with pumped stroke volumes (R² = 0.96).

Conclusions

Three‐dimensional echocardiography (3DE) is a feasible method for determining VSD area and is more accurate than 2DE for evaluating the area of multiple or noncircular VSDs. Real‐time 3D color Doppler echocardiography (RT3D‐CDE) is a feasible method for quantifying the shunt volume of multiple or noncircular VSDs.     

Feasibility of Two‐Dimensional Global Longitudinal Strain and Strain Rate Imaging for the Assessment of Left Atrial Function: A Study in Subjects with a Low Probability of Cardiovascular Disease and Normal Exercise Capacity

Background: Two‐dimensional (2D) speckle imaging has shown that it could evaluate not only regional but also global strain (?) and strain rate (SR) of the left and right ventricles. There are no data for global ?/SR imaging for left atrial (LA) function evaluation. Methods: A total of 54 subjects (37 men; mean age, 44 ± 10 years) with normal treadmill exercise stress echocardiography and no coronary risk factors were enrolled. Global longitudinal LA ?/SR data obtained by 2D speckle imaging with automated software (EchoPAC, GE Medical) were compared with LA volumetric parameters. Results: LA ?/SR imaging was acceptable in all patients. Bland‐Altman analysis for these parameters showed no evidence of any systematic difference regarding inter‐ and intraobserver variabilities. Global longitudinal LA strain during systole and peak systolic global longitudinal LA SR were correlated with LA total emptying fraction (EF) (r = 0.399, P = 0.004; r = 0.366, P = 0.008). Global longitudinal LA strain during early diastole and peak early diastolic global longitudinal LA SR were correlated significantly with LA passive EF (r = 0.476, P < 0.001; r = 0.507, P < 0.001). Global longitudinal LA strain during late diastole and peak late diastolic global longitudinal LA SR were not correlated with LA active EF (r = 0.198, P = 0.163; r = 0.265, P = 0.060). Conclusions: Global longitudinal LA ?/SR parameters determined by 2D speckle tracking echocardiography are feasible and reproducible indices for the evaluation of LA function. (ECHOCARDIOGRAPHY, Volume 26, November 2009)     

Prognostic Value of Left Atrial Functional Measures in Heart Failure With Reduced Ejection Fraction

Background

The prognostic value of LA functional measures in heart failure patients with reduced ejection fraction (HFrEF) is unclear. Therefore, this study investigated the prognostic value of left atrial (LA) functional measures such as the left atrial emptying fraction (LAEF) and the minimal LA volume compared with left atrial volume index (LAVI) in HFrEF patients.

Comparison of Left Ventricular Stroke Volume Assessment by Two‐ and Three‐Dimensional Echocardiography in a Swine Model of Acute Myocardial Infarction Validated by Thermodilution Method

Background: Accurate left ventricular stroke volume (LVSV) measurement is clinically important in patients presenting with acute myocardial infarction. Three‐dimensional echocardiography (3DE) is expected to overcome limitations of two‐dimensional echocardiography (2DE). However, inaccuracy in volumetry by 3DE has often been reported hindering further clinical application. This study aimed at comparing agreement and correlation with the thermodilution method (TDM) between 2DE and 3DE measurement of LVSV. Methods: Swine model of myocardial infarction was created and LVSV was measured by 3DE by subtracting end‐systolic from end‐diastolic volume (3DE‐method). Pulsed Doppler ultrasound and left ventricular outlet tract area were used to measure LVSV by 2DE (2DE‐method). TDM was performed by the Swan‐Ganz catheter. Bland–Altman analysis followed by assessment of intraclass correlation coefficient (ICC) were performed between 2DE‐method and TDM as well as 3DE‐method and TDM. Results: A total of 25 comparisons revealed a significant overestimation of LVSV by the 2DE‐method (bias = 6.5 mL; 95% confidence interval [CI], 3.9–9.0 mL; P < 0.0001), whereas there was no significant bias by the 3DE‐method (bias =–1.6; 95% CI, –4.3 to 1.1 mL; P = 0.22). The ICC between 2DE and TDM was 0.49 (95% CI, 0.14–0.74) whereas ICC between 3DE and TDM was 0.75 (95% CI, 0.51–0.88). Conclusions: This study elucidated that LVSV is better estimated by 3DE‐method compared to the conventional 2DE‐method. This investigation will provide a more accurate, quick and noninvasive way of LVSV and cardiac output assessment at bedside by further application of 3DE.     

Live/Real Time Three‐Dimensional Transesophageal Echocardiographic Assessment of Ventricular Septal Volume and Mass before and after Myectomy in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is the most common genetically transmitted cardiomyopathy. In patients resistant to medical management, myectomy is the surgical procedure of choice to reduce the symptoms of left ventricular outflow obstruction. Two‐dimensional transesophageal echocardiography (2DTEE) has become part of the operative procedure by decreasing the incidence of postoperative complications. However, because of the three‐dimensional geometry of left ventricular outflow tract, it is unable to comprehensively assess the location and severity of the obstruction and to provide accurate guidance during myectomy. In this study, 10 patients with HCM underwent live/real time three‐dimensional transesophageal echocardiography (3DTEE) intra‐operatively to measure the volume of the resected septum. This volume correlated well with the volume of the resected septal muscle directly obtained using a graduating cylinder containing water (r = 0.9, P < 0.000). 3DTEE may be potentially used as an adjunct to guide the surgeon in performing an adequate myectomy with a lower incidence of residual obstruction and complications such as an iatrogenic ventricular septal defect.