Advanced Quantitative Echocardiography: Guiding Therapy for Heart Failure

The aim of this thesis was to investigate the potential application of echocardiography for an efficient management of heart failure (HF) patients. The thesis is presented in four parts as follows: part I (introduction), part II (assessment of global left ventricular systolic function), part III (assessment of cardiac resynchronization therapy), and part IV (summary and conclusion). The general introduction (Chapter 1) of this thesis provides an overview of HF management using cardiac resynchronization therapy (CRT). HF constitutes an increasing and prevalent health burden worldwide. Echocardiography is a versatile non-invasive imaging modality that can be used for an efficient management of HF by proper diagnosis and guiding therapeutic interventions. Accurate assessment of left ventricular (LV) volumes and ejection fraction (LV-EF) would have important prognostic implications. CRT is a technique in which atrio-biventricular pacing is used to improve clinical and echocardiographic outcome for selected HF patients. The rationale behind CRT is the restoration of atrio-ventricular, inter-ventricular and intra-ventricular synchrony by stimulation of the delayed ventricular sites. It results in effective LV filling and emptying, reducing ventricular size improving ventricular geometry and most importantly improves survival. However, these impressive results of CRT are not seen in ~30% of patients. There are several unresolved and potentially other undetected reasons behind the high percentage of CRT failure. The echocardiography may improve the efficacy of CRT by reducing the non –response rate. The potential fields of echocardiography are: proper selection of candidates; optimization of atrio- and inter-ventricular pacing; guiding lead placement and proper detection of the response to CRT by accurate assessment of atrial and ventricular structure and function. These fields are mostly the topics of this thesis

Impact of technological changes and economic liberalization on agricultural labor employment and Productivity

Egypt has passed dramatic economic changes over the last two decades. Such program has different impacts on agricultural sector performance, including the mechanization, expansion and substitutability for human labor. Therefore the objectives of this study are to assess the impacts oftechnological changes and economic liberalization on agricultural labor employment and Productivity. The analytical procedures included was the estimation of crop production function for rice before and after the economic reform application in agricultural sector. The study used two field survey data in two sucessive periods conducted in "Sharkia Governorate". It was concluded that the optimum allocation of inputs for rice production implied to decrease the human labor use on farms, even though under the export border price of rice. It means that such major crop in Egypt as a case study of the agricultural sector can not provide a feasible employment opportunity for human labor. To reach amaximum income from such agricultural activities a less labor intensity should be used. Positive analysis approach showed that the employment of human labor has decreased by almost one-fourth due to all technological changes and economic reform policies practiced over the last decade. The normative approach analysis (least cost combination of inputs), showed that the human labor employment should be decreased by about two-thirds, in order to maximize income. All economic criteria, derived from the normative approach analysis,in this study showed that the growth in production and maximization of income must rely upon physical and biological technologies (new varieties, fertilizers and mechanization of farm operations. Rural development programs and economic development plants should create employment opportunities for such excess agriculture labor,either in agricultural related industries of non-agricultural small industries in villages or other economic activities in rural towns, in order to keep agriculture growing at an economic competitive performance

マレーカンポンの経済・環境・社会・文化におけるマレーシアホームステイプログラムの効果 : セランゴール州のバングリスホームステイを事例として

To assess the feasibility and accuracy in measuring left ventricular (LV) end-diastolic volume (EDV), end-systolic volume (ESV) and ejection fraction (EF) with Siemens single-beat real-time 3D transthoracic echocardiography. The LV volumes and EF were measured in 3D datasets acquired by six imaging modes (time-1-harmonic (T1H), time-1-fundamental, time-2-harmonic, time-2-fundamental, space-1-harmonic (S1H), and space-1-fundamental) in 41 patients using the automated contouring algorithm and compared with manually corrected 3DE QLAB measurements. The main determinates of the temporal and spatial resolutions of 3D datasets acquired were the fundamental and harmonic modes. Consequently, the S1H mode had the lowest volume rate and highest spatial resolution. Compared with the 3DE QLAB analysis, the S1H mode resulted in the best LV volumes and EF estimates in all patients (0 ± 10 % for EF, -7 ± 44 ml for EDV, -7 ± 39 ml for ESV) and in the 10 patients with correct LV contour tracking according to a visual assessment from the multiplanar reconstruction views in all six modes (0 ± 9 % for EF, -3 ± 23 ml for EDV, -2 ± 14 ml for ESV). The T1H mode was the best alternative. Overall 28 patients (68 %) could be analysed automatically and satisfyingly with the S1H and T1H modes: 0 ± 8 % (EF), 0 ± 27 ml (EDV) and -1 ± 16 ml (ESV). The accuracy of the Siemens automated RT-3D algorithm in measuring LV volumes and EF is significantly influenced by the different imaging modes. The S1H mode may be the preferred 3D acquisition mode, supplemented by the T1H mode in enlarged LVs that do not fit in the S1H acquisition sector

Advances in transcatheter mitral and tricuspid therapies

BACKGROUND: While rheumatic mitral stenosis has been effectively treated percutaneously for more than 20 years, mitral and tricuspid regurgitation treatment appear as a contemporary unmet need. The advent of transcatheter therapies offer new treatment options to often elderly and frail patients at high risk for open surgery. We aimed at providing an updated review of fast-growing domain of transcatheter mitral and tricuspid technology. MAIN BODY: We reviewed the existing literature on mitral and tricuspid transcatheter therapies. Mitraclip is becoming an established therapy for secondary mitral regurgitation in selected patients with disproportionately severe regurgitation associated with moderate left ventricle dysfunction. Evidence is less convincing for primary mitral regurgitation. Transcatheter mitral valve replacement is a promising emerging alternative to transcatheter repair, for secondary as well as primary mitral regurgitation. But further development is needed to improve delivery. Transcatheter tricuspid intervention arrives late after similar technologies have been developed for aortic and mitral valves and is currently at its infancy. This is likely due in part to previously under-recognized impact of tricuspid regurgitation on patient outcomes. Edge-to-edge repair is the most advanced transcatheter solution in development. Data on tricuspid annuloplasty and replacement is limited, and more research is warranted. CONCLUSION: The future appears bright for transcatheter mitral therapies, albeit their place in clinical practice is yet to be clearly defined. Tricuspid transcatheter therapies might address the unmet need of tricuspid regurgitation treatment

Assessment of pulmonary valve and right ventricular outflow tract with real-time three-dimensional echocardiography

Aim: Assessment of pulmonary valve (PV) and right ventricular outflow tract (RVOT) using real-time 3-dimensional echocardiography (RT3DE). Methods: Two-dimensional echocardiography (2DE) and RT3DE were performed in 50 patients with congenital heart disease (mean age 32 ± 9.5 years, 60% female). Measurements were obtained at parasternal views: short axis (PSAX) at aortic valve level and long axis (PLAX) with superior tilting. RT3DE visualization was evaluated by 4-point score (1: not visualized, 2: inadequate, 3: sufficient, and 4: excellent). Diameters of PV annulus (PVAD), and RVOT (RVOTD) were measured by both 2DE and RT3DE, while areas (PVAA) and (RVOTA) by RT3DE only. Results: By RT3DE, PV was visualized sufficiently in 68% and RVOTexcellently in 40%. PVAD and PVAA were measured in 88%. RVOTD and PVAD by 2DE at PLAX were significantly higher than PSAX (P < 0.0001) and lower than that by RT3DE (P < 0.001). Conclusion: RT3DE helps inRVOT and PV assessment adding more details supplemental to 2DE

Haemolysis as a first sign of thromboembolic event and acute pump thrombosis in patients with the continuous-flow

Background Despite advances in pump technology, thromboembolic events/acute pump thrombosis remain potentially life-threatening complications in patients with continuous-flow left ventricular assist devices (CF-LVAD). We sought to determine early signs of thromboembolic event/ pump thrombosis in patients with CF-LVAD, which could lead to earlier intervention. Methods We analysed all HeartMate II recipients (n = 40) in our centre between December 2006 and July 2013. Thromboembolic event/pump thrombosis was defined as a transient ischaemic attack (TIA), ischaemic cerebrovascular accident (CVA), or pump thrombosis. Results During median LVAD support of 336 days [IQR: 182–808], 8 (20%) patients developed a thromboembolic event/pump thrombosis (six TIA/CVA, two pump thromboses). At the time of the thromboembolic event/pump thrombosis, significantly higher pump power was seen compared with the no-thrombosis group (8.2 ± 3.0 vs. 6.4 ± 1.4 W, p = 0.02), as well as a trend towards a lower pulse index (4.1 ± 1.5 vs. 5.0 ± 1.0, p = 0.05) and a trend towards higher pump flow (5.7 ± 1.0 vs. 4.9 ± 1.9 L m, p = 0.06). The thrombosis group had a more than fourfold higher lactate dehydrogenase (LDH) median 1548 [IQR: 754– 2379] vs. 363 [IQR: 325–443] U/L, p = 0.0001). Bacterial (n = 4) or viral (n = 1) infection was present in 5 out of 8 patients. LDH > 735 U/L predicted thromboembolic events/ pump thrombosis with a positive predictive value of 88%. Conclusions In patients with a CF-LVAD (HeartMate II), thromboembolic events and/or pump thrombosis are associated with symptoms and signs of acute haemolysis as manifested by a high LDH, elevated pump power and decreased pulse index, especially in the context of an infection

Evaluation of pericardial hydatid cysts by different echocardiographic imaging modalities

Cardiac hydatid disease or echinococcosis is a rare complication of Echinococcus granulosus infection. Traditionally, the diagnosis is made with two-dimensional transthoracic echocardiography. This case report shows the complementary function of the different echo modalities (two-dimensional, three-dimensional, and contrast echocardiography) and MRI in the evaluation of pericardial hydatid cyst

The Effectiveness of Levosimendan on Veno-Arterial Extracorporeal Membrane Oxygenation Management and Outcome: A Systematic Review and Meta-Analysis

Objectives: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides a temporary support system for patients with cardiogenic shock refractory to conventional medical therapies. It has been reported that levosimendan may facilitate VA-ECMO weaning and improve survival. The primary objective of this review was to examine the effect of levosimendan use on VA-ECMO weaning and mortality in critically ill patients on VA-ECMO. Design: MEDLINE, EMBASE, and CENTRAL were searched. A pair of reviewers identified eligible clinical trials. Two reviewers extracted data and independently assessed the risk of bias. A random-effect model was used to combine data. The primary outcome was the success of weaning from VA-ECMO. Measurements and Main Results: Seven studies of observational design, including a total of 630 patients, were selected in the final analysis. The sample size ranged from ten-to-240 patients, with a mean age between 53 and 65 years, and more than half of them underwent cardiac surgeries. The VA-ECMO durations varied between four and 11.6 days. Overall, levosimendan use was significantly associated with successful weaning compared with control (odds ratio [OR] 2.89, 95% CI, 1.53-5.46; poverall effect = 0.001); I2 = 49%). For survival, six studies (n = 617) were included in the meta-analysis involving 326 patients in the levosimendan group and 291 in the comparator group. Pooled results showed a significantly higher survival rate in the levosimendan group (OR 0.46, 95% CI, 0.30-0.71; poverall effect = 0.0004; I2 = 20%). Conclusions: Levosimendan therapy was significantly associated with successful weaning and survival benefit in patients with cardiogenic or postcardiotomy shock needing VA-ECMO support for severe cardiocirculatory compromise. To date, there is limited literature and absence of evidence from randomized trials addressing the use of levosimendan in VA-ECMO weaning. This study may be considered a hypothesis-generating research for randomized controlled trials to confirm its findings

True mitral annulus diameter is underestimated by two-dimensional echocardiography as evidenced by real-time three-dimensional echocardiography and magnetic resonance imaging

Background: Mitral annulus assessment is of great importance for the diagnosis and treatment of mitral valve disease. The present study sought to assess the value of real-time three-dimensional echocardiography for the assessment of true mitral annulus diameter (MAD). Methods: One hundred and fifty patients (mean age 38 ± 18 years) with adequate two-dimensional (2D) echocardiographic image quality underwent assessment of MAD2Dand MAD3D(with real-time three-dimensional echocardiography). In a subgroup of 30 patients true MAD was validated with magnetic resonance imaging (MRI). Results: There was a good interobserver agreement for MAD2D(mean difference = -0.25 ± 2.90 mm, agreement: -3.16, 2.66) and MAD3D(mean difference = 0.29 ± 2.03, agreement = -1.74, 2.32). Measurements of MAD2Dand MAD3Dwere well correlated (R = 0.81, P < 0.0001). However, MAD3Dwas significantly larger than MAD2D(3.7 ± 0.9 vs. 3.3 ± 0.8 cm, P < 0.0001). In the subgroup of 30 patients with MRI validation, MAD3Dand MADMRIwere significantly larger than MAD2D(3.3 ± 0.5 and 3.4 ± 0.5 cm vs. 2.9 ± 0.4 cm, both P < 0.001). There was no significant difference between MADMRIand MAD3D. Conclusion: MAD3Dcan be reliably measured and is superior to MAD2Din the assessment of true mitral annular size