Clinical Applications of Strain Imaging in Aortic Valve Disease

The prevalence of aortic valve disease, particularly aortic stenosis, is increasing in parallel to the aging of the population, making it the most prevalent form of valvular heart disease. Surgery and percutaneous interventions of the aortic valve are conditional to a comprehensive evaluation of the aortic valve and the left ventricle (LV). Favorable results from aortic valve surgery or intervention are influenced by LV ejection fraction (EF), presence and severity of left ventricular hypertrophy (LVH), LV end-systolic volume (LVESV), degree of leaflet calcification, and trans-aortic valve gradients. Deformation imaging, particularly global longitudinal strain, is evolving as a powerful tool in the evaluation of ventricular function in patients with aortic stenosis. GLS is particularly suited to detect subclinical LV dysfunction, before a drop in LV ejection fraction, providing the opportunity to intervene earlier to prevent serious and permanent LV dysfunction. Similar added value has been demonstrated in the application of GLS in the detection of subclinical LV dysfunction in patients with aortic regurgitation. Very little information exists in the use of GLS in patients with mixed aortic valve disease, providing an opportunity for future research in this important group of patients with aortic valve disease

Differentiation of constrictive pericarditis from restrictive cardiomyopathy by Doppler transesophageal echocardiographic measurements of respiratory variations in pulmonary venous flow

AbstractObjectives. The purpose of this study was to test the utility of measuring respiratory variation in pulmonary venous flow by transesophageal echocardiography.Background. Respiratory variation of atrioventricular and central venous flow velocities by Doppler echocardiography has been used to differentiate constrictive pericarditis from restrictive cardiomyopathy.Methods. We performed pulsed wave Doppler transesophageal echocardiography of the left or right pulmonary veins in 31 patients with diastolic dysfunction. Fourteen patients had constrictive pericarditis, and 17 had restrictive cardiomyopathy. We measured the pulmonary venous peak systolic and diastolic flow velocities and the systolic/diastolic flow ratio with transesophageal echocardiography during expiration and inspiration. The percent change in Doppler flow velocity from expiration to inspiration (%E) was calculated.Results. Pulmonary venous peak systolic flow in both inspiration and expiration was greater in constrictive pericarditis than in restrictive cardiomyopathy. The %E for peak systolic flow tended to be higher in constrictive pericarditis (19% vs. 10%, p = 0.09). In contrast, pulmonary venous peak diastolic flow during inspiration was lower in constrictive pericarditis than in restrictive cardiomyopathy. The %E for peak diastolic flow was larger in constrictive pericarditis (29% vs. 16%, p = 0.008). The pulmonary venous systolic/diastolic flow ratio was greater in constrictive pericarditis in both inspiration and expiration. The combination of pulmonary venous systolic/diastolic flow ratio ≥0.65 in inspiration and a %E for peak diastolic flow ≥40% correctly classified 86% of patients with constrictive pericarditis.Conclusions. The relatively larger pulmonary venous systolic/ diastolic flow ratio and greater respiratory variation in pulmonary venous systolic, and especially diastolic, flow velocities by transesophageal echocardiography can be useful signs in distinguishing constrictive pericarditis from restrictive cardiomyopathy

A Sinus Venosus Atrial Septal Defect Is Diagnosed by Echocardiography with an Unusual Bubble Study

A 68-year-old man underwent echocardiogram with agitated saline for a presumed diagnosis of primary pulmonary hypertension. Surprisingly, the bubbles from the agitated saline enter the left heart before filling the right side, leading to a diagnosis of Eisenmeger's syndrome from a sinus venosus atrial septal defect. Because of high right-sided pressure, the bubbles preferentially travel from the superior vena cava through the defect to the right superior pulmonary vein and left atrium, rather than the right side. This diagnosis was later confirmed on cardiac MRI

Benefits of intraoperative echocardiography in the surgical management of hypertrophic cardiomyopathy

Objectives. The purpose of this study was to determine the role of intraoperative echocardiography in planning the site and extent of myectomy and in ensuring adequate control of the left ventricular outflow tract gradient. Background. Although intraoperative echocardiography has been found to be beneficial in patients undergoing valve repair, its impact on surgical decisions in patients undergoing septal myectomy for hypertrophic cardiomyopathy has not been described. Methods. In 50 patients undergoing septal myectomy over a 5-year period, epicardial echocardiography was performed before cardiopulmonary bypass to establish the extent of outflow tract obstruction, locate its site and plan the myectomy. In 30 patients, transesophageal echocardiography was also used to corroborate data on outflow tract anatomy and examine the mitral valve. Results. In 40 patients (80%) the initial myectomy resulted in a reduction of the maximal outflow tract gradient from 88 ± 45 to 24 ± 11 mm Hg, measured by epicardial continuous wave Doppler echocardiography. Ten patients (20%) were shown by postbypass intraoperative echocardiography to have an unsatisfactory result, based on a persistent gradient 50 mm Hg (n = 7) or persistent mitral regurgitation of greater than moderate severity (n = 3). The postbypass two-dimensional echocardiogram was then used to direct the surgeon toward the most likely site of continued obstruction, and cardiopulmonary bypass was reinstituted to permit further myectomy (n = 9) or mitral valve repair (n = 1). After the second or subsequent period of cardiopulmonary bypass, the outflow tract gradient (26 ± 14 mm Hg) was substantially reduced and was not significantly different from the postbypass gradient (24 ± 11 mm Hg) in the group with initial surgical success. At postoperative follow-up (20 ± 37 weeks), the maximal measured outflow tract gradient (22 ± 21 mm Hg) showed no difference between patients with immediate surgical success and those requiring a second period of cardiopulmonary bypass for further resection. Conclusions. Intraoperative echocardiography proved a useful tool to guide the site and extent of septal myectomy, leading to more adequate surgical resection and to persistence of satisfactory control of the outflow tract obstruction into the early follow-up period