Assessment of severity in aortic stenosis – Incremental value of endocardial function parameters compared to standard indexes

Several studies have reported that patients (pts) with severe aortic stenosis and similar pressure gradients or even similar aortic valve areas may have quite different symptomatic status and clinical outcomes suggesting that other factors might have a significant impact on the pathophysiology of this disease. Our purpose was to assess the severity of subendocardial wall dysfunction in symptomatic and asymptomatic pts with aortic stenosis using tissue Doppler imaging (TDI), strain rate imaging (SRI) and cyclic variation of integrated backscatter (IB). We studied 68 pts with aortic valvar stenosis and 46 subjects with no signs of heart disease. SRI/IB indexes were calculated in the apical four chambers views at endocardial level. Early diastolic endocardial strain rate showed the best correlation with transvalvar pressure gradients and valve areas. Compared with controls, symptomatic pts showed a more marked decrease in endocardial strain, strain rate and cyclic variation of IB. Receiver operating characteristic (ROC) curves suggested that the thresholds offering an adequate compromise between sensitivity and specificity for the prediction of symptoms were >/=60 mm Hg for the pressure gradient, less than 0.60 cm(2)/m(2) for aortic valve area, less than 20% for strain, less than 2.0 s(-1) for strain rate and less than 3.0 dB for cyclic variation. The combination of pressure gradient, aortic valve area and SRI/IB parameters resulted in an improvement of the overall performance for predicting the symptomatic state. Thus, SRI/IB parameters have an incremental value in differentiating symptomatic and asymptomatic pts with aortic stenosis compared with conventional hemodynamic parameters

Utility of Strain Echocardiography at Rest and After Stress Testing in Arrhythmogenic Right Ventricular Dysplasia

The introduction of speckle tracking imaging (STI) allowed the quantification of the regional myocardial function in the right ventricular (RV) free wall using deformation parameters. We sought to evaluate the potential utility of STI at rest and after stress to predict arrhythmogenic RV dysplasia (ARVD). We studied 19 patients with ARVD (diagnosed according to the task force criteria) and 19 healthy age- and gender-matched subjects. Both 2-dimensional and 3-dimensional echocardiography were performed. The RV and left ventricular annular peak systolic velocities were measured using tissue Doppler imaging. The RV-left ventricular peak systolic longitudinal strain (LS) was obtained in the basal, mid, and apical segments in the apical 4-chamber view using STI. An exercise stress-echocardiographic test was undertaken using bicycle ergometry with the patient in the supine position for all patients, and the indexes were assessed at peak effort. The STI measurements were determined using offline analysis programs. The 3-dimensional RV ejection fraction and strain were significantly lower in patients with ARVD than in the controls. The RV strain values at rest did not change significantly during maximum physical effort in the patients with ARVD. The receiver operating characteristic curves suggested that the thresholds offering an adequate compromise between sensitivity and specificity for the detection of ARVD were 9.35 cm/s for the RV annular peak systolic velocity (area under the curve 0.81), 42% for 3-dimensional RV ejection fraction (area under the curve 0.85), -25% for mean global RV-LS (area under the curve 0.86), -18% for the lowest peak systolic RV-LS (area under the curve 0.88), and -1.2 for peak minus baseline global change of stress RV-LS (area under the curve 0.92). In conclusion, STI at rest and during stress might enable quantitative assessment of RV function and the detection of ARVD and have potential clinical value in the treatment of these patients

Three-dimensional echocardiography and myocardial imaging echocardiography in the evaluation of arrhythmogenic right ventricular dysplasia

Purpose. Arrhythmogenic right ventricular dysplasia (ARVD) is a heritable cardiomyopathy characterized by the fibrofatty replacement of right ventricular (RV) myocardium leading to RV failure and arrhythmias in young athletes. In this study we sought to evaluate the potential utility of three-dimensional echocardiography (3DE), tissue Doppler imaging (TDI) and speckle tracking imaging (STI) to quantitate RV function and their potential role in diagnosing ARVD. Methods. We studied 13 patients with ARVD (diagnosed by task force criteria) and 13 healthy age- and sex-matched subjects. RV internal diameters, outflow tract diameter, fractional area change and tricuspid annular systolic excursion were determined by transthoracic echocardiography. 3DE was performed as a full-volume scan of the LV and RV from the apical position using a system equipped with a real-time X3 transducer (Vivid 9 ultrasound system, GE, Horten, Norway). RV and LV annular peak systolic velocities (S) were measured by TDI. RV and LV peak systolic strain (), peak systolic strain rate (SR-S), and early (SR-E) and late (SR-A) diastolic strain rate were obtained in the basal, mid and apical segments in apical 4-chamber view both by TDI and STI. Averaged LV rotation and rotational velocities from the base and apex were also obtained by STI and used for calculation of LV torsion. All measurements were taken from an acceptable tracing and determined using offline analysis programs (EchoPAC, version 9.0, GE Ultrasound). Results. Patients with ARVD had a decreased RV ejection fraction (3D-RVEF) compared to controls (0.46± 0.11 vs 0.55±0.06, p<.01). STI- (all segments pooled: -9.7±3.0% vs -27±3.2%, p<.001), TDI- (-10.1±3.6% vs -28±4.4%, p<.001), STI-SR-S (-0.89±0.39 vs -1.66±0.89 s-1, p<.005), TDI-SR-S (-1.09±0.38 vs -1.82±0.93 s-1, p<.005), STI-SR-E (1.58±0.47 vs 2.27±0.88 s-1, p<.005), and TDI-SR-E (1.67±0.68 vs 2.42±1.03 s-1, p<.005) were significantly lower in patients with ARVD compared with controls, even in the subset of patients with apparently normal RV by conventional echocardiography. In 3/13 patients LV strain and torsion were significantly lower compared with controls (p<.005). ROC curves suggested that the thresholds offering an adequate compromise between sensitivity and specificity for detection of ARVD were 42% for 3D-RVEF (AUC 0.89), -22% for RV STI- (AUC 0.87), -26% for RV TDI- (AUC 0.79), -7.2 cm/sec for RV TDI-S velocity (AUC 0.75), -0.63 sec-1 for RV STI-SR-S (AUC 0.74), and -0.71 sec-1 for RV TDI-SR-S (AUC 0.72). Conclusions. Our data show that 3DE, TDI and STI have potential clinical value in the management of patients with suspected ARVD and may enable quantitative assessment of RV function and detection of ARVD

Triplane tissue Doppler echocardiography and radionuclide angiocardiography in the assessment of ventricular asynchrony in patients with heart failure

Purpose. Several parameters have recently been proposed to assess mechanical dyssynchrony both in tissue Doppler / strain Doppler imaging (TDI/SRI) and radionuclide angioscintigraphy (RNA). It is unknown whether large differences exist between TDI and RNA to evaluate inter- and intra-ventricular dyssynchrony and whether the results are interchangeable. Methods. Thirty-four patients with dilated cardiomyopathy (NYHA class II or greater), left bundle branch block (QRS 120ms), and LV ejection fraction 35% were studied with triplane TDI echocardiography (Vivid 9 ultrasound system, GE, Horten, Norway) and RNA before and after biventricular pacing (BP). Intraventricular dyssynchrony was determined as the difference between the longest and shortest electromechanical coupling times in the basal septal, lateral, and posterior LV segments. Interventricular dyssynchrony was determined as the difference between electromechanical coupling times in the basal lateral RV segment and the most delayed LV segment. On line continuous LV volume changings were recorded using RNA and interventricular delay and basal-apical contraction were obtained. Results. At six months follow-up after BV implantation, patients functional status improved by one NYHA class or more and LVEF improved overall from 20.46.5% to 29.511.1%. Interventricular dyssynchrony by triplane TDI was reduced from 75.729 ms to 32.620.9 ms (p<0.005) and intraventricular dyssynchrony from 7924.7 ms to 28.312.8 ms (p<0.001). Interventricular dyssynchrony by RNA was reduced from 7728 ms to 13.725.3 ms (p<0.001) and apicobasal intraventricular dyssynchrony from 68.626.4 ms to 17.119.2 ms (p<0.001). Triplane TDI and RNA parameters had optimal predictive accuracy of the effects of BP on LV function and a larger area under the receiver operating characteristic curve than the QRS duration. Overall agreement between TDI and RNA was 89% (k= 0.67). Conclusions. Triplane TDI and RNA dyssynchrony measurements have an acceptable observer variability and values are largely comparable in pts with poor LV function and broad QRS

Evaluation of right ventricular function in patients with post-operative pulmonary regurgitation by transesophageal echocardiography

Background: We explored the accuracy of transesophageal strain Doppler echocardiography in detecting RV dysfunction in patients (pts) with postoperative tetralogy of Fallot (T/F) and hemodinamically significant pulmonary regurgitation (PR). Methods: Transesophageal echocardiography with TDI and strain capabilities was performed in 14 pts aged 13-45 years who had repair of T/F. 12 age- and sex-matched subjects with no signs of heart disease were selected as normal controls (CTR). A thorough esophageal, low esophageal and transgastric scanning was performed. The ratio of PR jet width measured by color Doppler to the infundibulum diameter was used to quantify the severity of PR (ratio >50% = moderate to severe PR). Right ventricular ejection fraction (EF), fractional shortening (FS), and tricuspid flow filling parameters (E/A ratio, DT) were determined. Offline analysis of the myocardial velocity data sets was performed using dedicated software. Velocity and strain traces from right ventricular free wall at 3 levels (basal, mid cavity, and apical) were processed in the esophageal 4-chamber view. Systolic and diastolic TDI values (Sw, Ew, Aw), peak systolic strain and systolic and diastolic strain rate values were determined. Results: Three pts presented with severely dilated RV and decreased fractional area change for progressive pulmonary insufficiency due to an outflow patch and were excluded from analysis. 11 pts with dilated RV and normal fractional area change were analysed. Ew/Aw ratio was lower in pts than in CTR (p<0.005). Peak systolic strain and systolic and diastolic strain rate were also reduced in pts compared to CTR (p<0.001). E/A ratio and DT were not different among the two groups. No correlation was found between E/A ratio, DT, and severity of PR. A highly significant relationship was shown between early diastolic SR and degree of PR (r=-0.79, p<0.001). Conclusion: In adolescent and adult pts after repair of T/F, TEE is recommended to assess morphofunctional details especially when transthoracic images are limited by paucity of acoustic windows. In the presence of hemodinamically significant pulmonary regurgitation, strain Doppler echocardiography can detect RV systo-diastolic impairment not shown by conventional echo-Doppler echocardiography

Assessment of right ventricular function by three-dimensional and myocardial imaging echocardiography after percutaneous atrial septal defect closure in adults

Purpose. The measurement of accurate right ventricular (RV) end-diastolic volume (EDV) is difficult because of RV complex geometry. Real-time three-dimensional (3D) echocardiography allows us to measure ventricular volume irrespective of its shape. Tissue Doppler imaging (TDI) and speckle tracking imaging (STI) are new tools to assess myocardial function. We sought to evaluate RV function by 3D and myocardial imaging echocardiography in adult patients with atrial septal defect (ASD) before and six months after transcatheter closure. Methods. Fifteen ASD patients were studied using a system equipped with a real-time X3 transducer (Vivid 9 ultrasound system, GE, Horten, Norway). Standard parameters of RV function (fractional area change, tricuspid annular plane systolic excursion -TAPSE-, Tei index) were obtained. RV and LV peak systolic velocities, peak systolic strain (), peak systolic strain rate (SR-S), and early (SR-E) and late (SR-A) diastolic strain-rate were obtained in the basal, mid and apical segments in apical 4-chamber view both by TDI and STI. Data were compared with those from 15 age-matched adults with patent foramen ovale selected as a control group. All measurements were taken from an acceptable tracing and determined using offline analysis programs (EchoPAC BT09, GE Ultrasound). Results. RV ejection fraction (3D-RVEF) was significantly larger compared to the control group and decreased significantly after closure (0.46± 0.11 vs 0.55±0.06, p<.01). 3D-EDV showed better correlations than 2D-EDV with the invasive and non-invasive parameters of RV function, suggesting the validity of volume measurement by 3D echocardiography. TAPSE decreased significantly (22.4±8.3 vs. 17.9±5.7 mm, p<.05) after interventional closure of the defect. Higher RV mid-segment peak systolic velocities were recorded, which returned to normal values after closure of the defect. Global longitudinal strain of the right ventricle was significantly higher than in the control group (223.4+4.5 vs. 221.4+4.3%, P , 0.05) and had a significant reduction after defect closure. Strain was reduced especially in RV median and apical lateral segments (median strain: -16.39±5.27 vs. -24.74±8.00, p=0.002; apical strain -13.01±6.84 vs. 22.53±11.32, p=0.03) with a very good correlation with RVEF (r=-0.717, p=0.0001). There was no significant change in the global RV strain-rate. By multivariate analysis, apical strain (p=0.004) and TAPSE (p=0.029) were predictive of a decreased 3D-RVEF. Conclusions. 3D and myocardial imaging echocardiography appear to be helpful for a quantitative assessment of RV function after ASD closure. Velocity parameters are the most dependent and strain-rate values the less dependent on RV volume overload

Prognostic value of tissue Doppler Tei index after experimental myocardial infarction

Background: It has been reported that tissue Doppler imaging (TDI) derived Tei index, defined as the sum of isovolumetric contraction and relaxation time divided by ejection time, is a valuable tool in assessing combined systolic and diastolic function with a better reproducibility than pulsed Doppler Tei index. Therefore, we hypothesized that early measurement of TDI Tei index could provide prognostic survival information beyond standard systolic and diastolic echo parameters on an animal model of acute myocardial infarction (AMI). Methods: In 64 adult consecutive mice (CB57/BL6, age 10-12 weeks, weight 22.7 3g) a large AMI was created by proximal LAD ligation. Echocardiography (Sequoia 512, Acuson) was performed 48 7 hours after surgery. Left ventricular (LV) diastolic (LVED) and systolic (LVES) dimensions, LV fractional shortening (LVFS), LV ejection fraction (LVEF), LV wall motion score index (WMSI), LV E/A ratio and LV TDI Tei index were measured using a 15MHz transducer. The smallest TDI sample volume was placed at the level of the lateral side of the mitral annulus in parasternal long axis view. Systolic (Sa), early (Ea) and late (Aa) diastolic myocardial velocities were recorded from the annulus site. TDI Tei index was calculated as TI=(a-b)/b where a is the time interval from the end of Aa wave to the onset of Ea wave and b the time from the onset to the end of Sa wave. Results: High operative mortality rate of this model (12.5%) was correlated to AMI. During a follow-up of 165 11 days, 8 mice (14.28%) died. TDI Tei index was significantly lower in survivors than in deceased mice (0.47 0.09 versus 0.83 0.12, p 0.15) - p < 0.0001 -. In a stepwise multivariate Cox proportional-hazard analysis including the different indices of cardiac function that were found to be independent predictors of cardiovascular mortality in the univariate analyses, a high TDI Tei index remained a significant predictor above LVEF, LV WMSI and E/A ratio (chi-square = 7.9, p = 0.003). Conclusions: Our data suggest that early assessment of TDI Tei index is a powerful predictor of mortality after AMI in mice and provides important prognostic information beyond other measurements of cardiac function

Right ventricular function in Ebstein disease: Comparative value of three-dimensional echocardiography and myocardial imaging echocardiography

Background: The aim of the present study was to assess right ventricular function in Ebstein’s patients (pts) using three-dimensional echocardiography (3DE), Tissue Doppler Imaging (TDI) and Speckle Tracking Imaging (STI) to better understand the relationship between anatomic derangement and functional severity. Methods: We studied 13 pts aged 16-67 years and 13 age- and gender-matched controls with no signs of heart disease (CTR). Standard 2D and Doppler parameters were assessed. 3DE was performed as a full-volume scan of the LV and RV from the apical position using a system equipped with a real-time X3 transducer (Vivid 9 ultrasound system, GE, Horten, Norway). RV and LV annular peak systolic and diastolic velocities were measured by TDI. RV and LV peak systolic strain, peak systolic strain rate, and early and late diastolic strain rate were obtained in the basal, mid and apical segments in apical 4-chamber view both by TDI and STI. All measurements were taken from an acceptable tracing and determined using offline analysis programs (EchoPAC, version 9.0, GE Ultrasound). Results: Peak systolic strain and systolic and diastolic strain rate at apical and mid level were lower in pts than in CTR (p<0.001). No correlation was found between E/A ratio, deceleration time, and anatomic derangement. A significant relationship was shown between apical peak systolic strain and the ratio of proximal to distal right ventricle (r=-0.72, p<0.005) and between apical peak systolic strain and apical displacement of septal/posterior leaflet (r=-0.61, p<0.05). A significant relationship was also obtained between mean peak systolic strain at RV free wall (RVFW) site and 3DE-RVEF (r=0.81, p<0.001) and mean peak systolic strain rate at RVFW site and 3DE-RVEF (r=0.84, p<0.001). Conclusion: Our data show that 3DE and myocardial imaging echocardiography (TDI, STI) have potential clinical value in the management of patients with Ebstein disease and may enable morphological and functional assessment of this complex heart disease

Echocardiographic assessment of ventricular asynchrony in dilated cardiomyopathy and congenital heart disease: Tools and hopes

Ventricular dyssynchrony is a relatively common problem in patients with heart failure, in particular those with wide QRS complex, and appears to have a deleterious effect on the natural history of heart failure, as it has been associated with increased mortality. Mechanistic studies, observational evaluations, and randomized trials have consistently demonstrated the beneficial effects of cardiac resynchronization therapy (CRT) in patients with moderate-to-severe chronic systolic heart failure and ventricular dyssynchrony who have failed optimal medical treatment. However, despite the promising results, it is estimated that in approximately 30% of patients undergoing CRT, the symptoms of heart failure do not improve or become even worse. one of the most important reasons for this failure is probably the lack of distinct mechanical dyssynchrony before implantation. A number of echocardiographic tools have been developed during the past 3 years for quantitative measurement of the severity of dyssynchrony before and after CRT. This review discusses the actual and potential role of different echocardiographic techniques in selection of patients and optimization of CRT and the value of some new clinical applications such as in congenital heart disease

Right ventricular function after cardiac resynchronization therapy: A strain Doppler imaging study

Background . Although cardiac resynchronization therapy (CRT) has been demonstrated to result in a sustained improvement in symptoms and left ventricular (LV) systolic function in patients with advanced heart failure, very few data are available regarding the effects of CRT on right ventricular (RV) function. The purpose of our study was to analyse the evolution of LV as well as RV tissue Doppler / strain Doppler imaging (TDI/SRI) parameters after CRT. Methods. Fifty-six patients with dilated cardiomyopathy (NYHA class II or greater), left bundle branch block (QRS >120ms), and LV ejection fraction <35% were studied with TDI/SRI echocardiography before and after CRT. Intraventricular dyssynchrony was determined as the difference between the longest and shortest electromechanical coupling times in the basal septal, lateral, and posterior LV segments. Interventricular dyssynchrony was determined as the difference between electromechanical coupling times in the basal lateral RV segment and the most delayed LV segment. Velocity and strain traces from RV free wall were processed in the apical 4-chamber view. Systolic (Sw) and diastolic (Ew, Aw) TDI values, peak systolic strain and systolic and diastolic strain rate values were determined. Results. At six months follow-up after CRT, patients functional status improved by one NYHA class or more and LVEF improved overall from 19.7 ± 6.9% to 28.8 ± 10.9%. A significant reduction in severity of tricuspid regurgitation and pulmonary artery pressure was also observed. Interventricular dyssynchrony by SRI was reduced from 81.3 ± 28 ms to 35.8 ± 21.5 ms (p<0.005) and intraventricular dyssynchrony from 78 ± 30.6 ms to 24.1 ± 14.8 ms (p<0.001). The degree of dyssynchrony correlated significantly with the improvement in LVEF and LV end-diastolic diameter. An increase of Ew at basal RV level from -11.6 ± 1.8 cm/s to -16.1 ± 1.4 cm/s was shown (p<0.005). Peak systolic strain and systolic and early diastolic strain rate at basal RV level increased, respectively, from 21.2 ± 6.3% to 30.7 ± 6.9%, -2.9 ± 1.7 cm/s to -4.8 ± 1.2 sec-1, and 5.1 ± 1.6 cm/s to 8.1 ± 1.2 sec-1 (p<0.001). RV reverse remodeling was only observed in patients with highest degrees of LV dyssynchrony at baseline. Conclusions. Our data show that CRT not only induced LV reverse remodeling, but also resulted in a significant increase of RV deformation parameters. RV reverse remodeling was associated with a reduction in the severity of tricuspid regurgitation and a significant decrease in pulmonary artery pressure