Three-dimensional transesophageal echocardiography in degenerative mitral regurgitation

The morphology of mitral valve (MV) prolapse and flail may be extremely variable, with dominant and secondary dynamic lesions. Any pathologic valve appears unique and different from any other. Three-dimensional (3D) transesophageal echocardiography is a powerful tool to evaluate the geometry, dynamics, and function of the MV apparatus and may be of enormous value in helping surgeons perform valve repair procedures. Indeed, in contrast to the surgical view, 3D transesophageal echocardiography can visualize MV prolapse and flail in motion and from different perspectives. The purpose of this special article is not to provide a comprehensive review of degenerative MV disease but rather to illustrate different types of mitral prolapse and flail as they appear from multiple 3D transesophageal echocardiographic perspectives using a series of clinical scenarios. Because in everyday practice, 3D transesophageal echocardiographic images of MV prolapse and flail are usually observed in motion, each scenario is accompanied by several videos. Finally, the authors provide for each scenario a brief description of the surgical techniques that are usually performed at their institution

Speckle-tracking layer-specific analysis of myocardial deformation and evaluation of scar transmurality in chronic ischemic heart disease

BACKGROUND: Identification of the extent of scar transmurality in chronic ischemic heart disease is important because it correlates with viability. The aim of this retrospective study was to evaluate whether layer-specific two-dimensional speckle-tracking echocardiography allows distinction of scar presence and transmurality. METHODS: A total of 70 subjects, 49 with chronic ischemic cardiomyopathy and 21 healthy subjects, underwent two-dimensional speckle-tracking echocardiography and late gadolinium-enhanced cardiac magnetic resonance. Scar extent was determined as the relative amount of hyperenhancement using late gadolinium-enhanced cardiac magnetic resonance in an 18-segment model (0% hyperenhancement = normal; 1%-50% = subendocardial scar; 51%-100% = transmural scar). In the same 18-segment model, peak systolic circumferential strain and longitudinal strain were calculated separately for the endocardial and epicardial layers as well as the full-wall myocardial thickness. RESULTS: All strain parameters showed cutoff values (area under the curve > 0.69) that allowed the discrimination of normal versus scar segments but not of transmural versus subendocardial scars. This was true for all strain parameters analyzed, without differences in efficacy between longitudinal and circumferential strain and subendocardial, subepicardial, and full-wall-thickness strain values. Circumferential and longitudinal strain in normal segments showed transmural and basoapical gradients (greatest values at the subendocardial layer and apex). In segments with scar, transmural gradient was maintained, whereas basoapical gradient was lost because the reduction of strain values in the presence of the scar was greater at the apex. CONCLUSIONS: The two-dimensional speckle-tracking echocardiographic values distinguish scar presence but not transmurality; thus, they are not useful predictors of scar segment viability. It remains unclear why there is a greater strain value reduction in the presence of a scar at the apical level

L'emergente ruolo dell'ecocardiografia transesofagea tridimensionale come guida durante la procedura di MitraClip

Percutaneous edge-to-edge mitral valve repair with the MitraClip device has been shown to be a safe and effective procedure in selected patients with moderate-to-severe mitral regurgitation. Two-dimensional transesophageal echocardiography (2D TEE) is the primary imaging modality for guidance of the procedure. Real-time three-dimensional (3D) TEE has recently been used as additional imaging modality during the MitraClip procedure. In comparison with 2D TEE, 3D TEE provides additional information in several steps of the procedure, including precise positioning of the clip delivery system into the left atrium, correct alignment of the clip arms perpendicular to the coaptation line and confirmation of the correct grasping location. This review describes the relevant role of 3D TEE imaging during the procedure, but also its limitations

Predictors of disagreement between prospectively ECG-triggered dual-source coronary computed tomography angiography and conventional coronary angiography

AIMS To identify causes of misinterpretation in second generation, dual-source coronary computed tomography angiography (CCTA). METHODS A retrospective re-interpretation was performed on 100 consecutive CCTA studies, previously performed with a 2×128 slice dual-source CT. Results were compared with coronary angiography (CA). CCTA and CA images were interpreted by 2 independent readers. At CCTA vessel diameter, image quality, plaque characteristics and localization (bifurcation vs. non) were described for all segments. Finally, aortic contrast-to-noise ratio (CNR) and the total Agatston calcium score were quantified. Agreement between CCTA and CA was assessed with the Kappa statistic after categorizing the stenosis severity at significant (≥50%) and critical (≥70%) cut-offs, and independent predictors of disagreement were determined by multivariable logistic regression, including patient characteristics such as body mass index (BMI), heart rate (HR), age and gender. RESULTS Per-segment sensitivity and specificity at ≥50% and ≥70% stenosis was of 83-95%, and 73-97%, respectively. There was a substantial agreement between CCTA and CA (kappa-50%=0.78, SE=0.03; kappa-70%=0.72, SE=0.03). Worse motion-related quality score, smaller vessel diameter, calcification within the segment of interest and LAD location were independent predictors of disagreement at 50% stenosis. The same factors, excluded LAD location, in addition to bifurcation-location of the coronary lesion predicted misdiagnosis at 70% stenosis. HR per se and BMI did not predict disagreement. CONCLUSION According to the literature a substantial agreement between CCTA and CA was found. However, discrepancies exist and are mainly related with motion-related degradation of image quality, specific vessel anatomy and plaque characteristics. Awareness of such potential limitations may help guiding interpretation of CCTA

CAP-Inhibition, Molecular Diagnostics, and Total IgE in the Evaluation of Polistes and Vespula Double Sensitization

Cross-reactions between Polistes dominula and Vespula species are common in southern Europe. Currently, only CAP-inhibition demonstrates high accuracy in identifying genuine sensitizations, but this method is time-consuming and expensive, so a new approach is required. This study investigates skin tests, molecular diagnostics, total IgE (tIgE), and the Ves v 5/Pol d 5 (or vice versa) ratio. The ratio generated low-accuracy results and poor agreement with CAP-inhibition, and we did not find any agreement between CAP-inhibition test and double values of Ves v 5/Pol d 5. Nevertheless, a slight diagnostic improvement was obtained when Ves v 5/tIgE and Pol d 5/tIgE were measured

3D TEE during catheter-based interventions

Guidance of catheter-based procedures is performed using fluoroscopy and 2-dimensional transesophageal echocardiography (TEE). Both of these imaging modalities have significant limitations. Because of its 3-dimensional (3D) nature, 3D TEE allows visualizing the entire scenario in which catheter-based procedures take place (including long segments of catheters, tips, and the devices) in a single 3D view. Despite these undeniable advantages, 3D TEE has not yet gained wide acceptance among most interventional cardiologists and echocardiographists. One reason for this reluctance is probably the absence of standardized approaches for obtaining 3D perspectives that provide the most comprehensive information for any single step of any specific procedure. Therefore, the purpose of this review is to describe what we believe to be the most useful 3D perspectives in the following catheter-based percutaneous interventions: transseptal puncture; patent foramen ovale/atrial septal defect closure; left atrial appendage occlusion; mitral valve repair; and closure of paravalvular leaks