Hemodynamic Classifications of Aortic Stenosis and Relevance to Prognosis

Hemodynamic classifications of aortic valve stenosis (AS) have important prognostic implications. In normal flow state, severe AS is defined as peak aortic velocity ≥ 4.0 m/s, mean transaortic gradient (MG) ≥ 40 mmHg, and aortic valve area (AVA) < 1.0 cm2. However, numerous studies have shown that severe AS (based on AVA < 1.0 cm2) with low gradient (MG < 40 mmHg) is prevalent due to low flow state, in the setting of reduced and preserved left ventricular ejection fraction (LVEF). Thus, the hemodynamic classifications of AS with AVA < 1.0 cm2 were expanded to include the transvalvular flow state and pressure gradients. These flow-gradient patterns include normal flow/very high gradient, normal flow/high gradient, low flow/high gradient, low flow/low gradient with reduced LVEF, low flow/low gradient with preserved LVEF, and normal flow/low gradient. Among these, the low-gradient AS subgroups are challenging, particularly to differentiate true-severe AS (where aortic valve replacement is necessary) and pseudo-severe AS (where conservative management is recommended). Additional diagnostic studies such as dobutamine stress echocardiography and/or cardiac computed tomography, as well as other parameters such as projected AVA and/or valvuloarterial impedance may be helpful. This chapter will review diagnostic approaches and prognostic implications of different AS subtypes

In vivo effects of nonionic and ionic contrast media on beta-thromboglobulin and fibrinopeptide levels

AbstractNonionic contrast media are suggested to cause increased thromboembolism (in vivo), platelet aggregation and procoagulant effect (in vitro) as compared with ionic contrast media. To study these effects in vivo, 30 consecutive patients undergoing routine angiography were prospectively randomized to three groups of 10 patients each. Group A received diatrizoate (ionic, high osmolality), Group B ioxaglate (ionic, low osmolality) and Group C iohexol (nonionic, low osmolality). In vivo platelet alpha-granule release and fibrin-1 formation were measured by radioimmunoassay of beta-thromboglobulin and fibrinopeptide A in peripheral venous samples.Levels were estimated at three stages daring the procedure: before and after left ventriculography and after coronary angiography. No differences were noted (p = NS) when the ratios of beta-thromboglobulin and fibrinopeptide A were compared among the three groups. These data suggest that the newer nonionic contrast media do not demonstrate enhanced systemic platelet activation or fibrin formation as compared with standard ionic contrast media. However, larger randomized clinical studies are necessary to conclusively establish the suggested thromboembolic potential of nonionic contrast media

Comparison of two- and three-dimensional echocardiography with cineventriculography for measurement of left ventricular volume in patients

AbstractObjectives. We compared two- and three-dimensional echocardiopaphy with cineventriculography for measurement of left ventricular volume in patients.Background. Three-dimensional echocardiography has been shown to be highly accurate and superior to two-dimensional echocardiography in measuring left ventricular volume in vitro. However, there has been little comparison of the two methods in patients.Methods. Two- and three-dimensional echocardiography were performed in 35 patients (mean age 48 years) 1 to 3 h before left ventricular cineventriculography. Three-dimensional echocardiography used an acoustic spatial locator to register image position. Volume was computed using a polyhedral surface reconstruction algorithm based on multiple nonparallel, unevenly spaced short-axis cross sections. Two-dimensional echocardiography used the apical biplane summation of disks method. Single-plane cineventriculographic volumes were calculated using the summation of disks algorithm. The methods were compared by linear regression and a limits of agreement analysis. For the latter, systematic error was assessed by the mean of the deferences (cineventriculography minus echocardiography), and the limits of agreement were defined as ±2 SD from the mean difference.Results. Three-dimensional echocardiographic volumes demonstrated excellent correlation (end-diastole r = 0.97; end-systole r = 0.98) with cineventriculography. Standard errors of the estimate were approximately half those of two-dimensional echocardiography (end-diastole ±11.0 ml vs. ±21.5 ml; end-systole ±10.2 ml vs. ±17.0 ml). By limits of agreement analysis the end-diastolic mean diferences for two- and three-dimensional echocardiography were 21.1 and 12.9 ml, respectively. The limits of agreement (±2 SD) were ±54.0 and ±24.8 ml, respectively. For end-systole, comparable improvement was obtained by three-dimensional echocardiography. Results for ejection fraction by the two methods were similar.Conclusions. Three-dimensional echocardiography correlates highly with cineventriculography for estimation of ventricular volumes in patients and has approximately half the variability of two-dimensional echocardiography for these measurements. On the basis of this study, three-dimensional echocardiography is the preferred echocardiographic technique for measurement of ventricular volume. Three-dimensional echocardiography is equivalent to two-dimensional echocardiography for measuring ejection fraction

743-2 Superiority of 3D Echo vs 2D Echo for Quantitating Wall Motion Abnormality as an Index of Myocardial Infarction Size

Two-dimensional echo estimations of the fraction of myocardium showing abnormal wall motion (AWM) are often used as an index of infarct size, to establish prognosis and guide therapy. However 2D echo methods rely on image plane and geometric assumptions which may not be valid when infarction affects ventricular shape. 3D echo reconstruction of the endocardial surface can eliminate the need for these assumptions. Purpose; To use 3D echo and 2D echo to quantitate AWM in experimental acute infarction, and to correlate the extent of AWM with the pathologic determination of infarct size.MethodsCoronary ligation was performed in 14 open chest dogs, and echo imaging performed after 6 hours. 3D echo used 7–8 spatially registered short axis cross-sections to measure % of endocardial surface showing AWM. Two 2D echo methods using multiple, non-spatially registered images were evaluated. Both compared summed endocardial length showing AWM to the total of the endocardial circumferences, expressed as %. Method #1 used 7-8 short-axis slices. Method #2 used basal, mid, apical short axis + apical 4-and 2-chamber views. Percent LV mass (% mass) infarcted was determined by a standard technique.Resultsregression of [x = echo %AWM] vs [y = %mass infarcted]Echo Methodr valueStandard Error of the EstimateEquationp value3D0.94±2.6%y =0.71x-1.81%&lt;0.000120-#10.82±4.3%y =0.50x-0.66%0.001520-#2074±5,1%Y =0.47x-1.25%0.0058ConclusionThree-dimensional echocardiography is a more accurate means of non-invasively estimating myocardial infarct size in this animal model, compared to 2D echo methods

A Right Atrial Hemangioma Mimicking Thrombus In A Patient With Atrial Arrhythmias

Cardiac hemangiomas are rare tumors, accounting for only 2.8% of all benign primary cardiac tumors and occur at any age. Clinical presentations vary depending on the tumor location (myocardial, endocardial or pericardial). In many cases, this may be an incidental finding. We report the case of a patient with paroxysmal atrial fibrillation who had a right atrial hemangioma detected with transesophageal echocardiography prior to having percutaneous pulmonary vein isolation performe