Noninvasive estimation of left ventricular filling pressures in patients with heart failure after surgical ventricular restoration and restrictive mitral annuloplasty

ObjectiveDoppler echocardiography, including tissue Doppler imaging, is widely applied to assess diastolic left ventricular function using early transmitral flow velocity combined with mitral annular velocity as a noninvasive estimate of left ventricular filling pressures. However, the accuracy of early transmitral flow velocity/mitral annular velocity in patients with heart failure, particularly after extensive cardiac surgery, is debated. Global diastolic strain rate during isovolumic relaxation obtained with 2-dimensional speckle-tracking analysis was recently proposed as an alternative approach to estimate left ventricular filling pressures.MethodsWe analyzed diastolic function in patients with heart failure after surgical ventricular restoration and/or restrictive mitral annuloplasty. Echocardiography, including tissue Doppler imaging and speckle-tracking analysis, was performed to determine early transmitral flow velocity/atrial transmitral flow velocity, isovolumetric relaxation time, deceleration time, early transmitral flow velocity/mean mitral annular velocity, strain rate during isovolumic relaxation, and early transmitral flow velocity/strain rate during isovolumic relaxation. These noninvasive indices were correlated with relaxation time constant Tau, peak rate of pressure decline, and left ventricular end-diastolic pressure obtained in the catheterization room using high-fidelity pressure catheters.ResultsTwenty-three patients were analyzed 6 months after restrictive mitral annuloplasty (n = 8), surgical ventricular restoration (n = 4), or a combined procedure (n = 11). The strongest correlation with invasive indices, in particular left ventricular end-diastolic pressure, was found for strain rate during isovolumic relaxation (r = −0.76, P < .001). Early transmitral flow velocity/mean mitral annular velocity did not correlate significantly with any of the invasive indices. Strain rate during isovolumic relaxation (cutoff value < 0.38 s−1) accurately predicted left ventricular end-diastolic pressure of 16 mm Hg or more with 100% sensitivity and 93% specificity.ConclusionsIn a group of patients with heart failure who were investigated 6 months after cardiac surgery, early transmitral flow velocity/mean mitral annular velocity correlated poorly with invasively obtained diastolic indexes. Global strain rate during isovolumic relaxation, however, correlated well with left ventricular end-diastolic pressure and peak rate of pressure decline. Our data suggest that global strain rate during isovolumic relaxation is a promising noninvasive index to assess left ventricular filling pressures in patients with heart failure after extensive cardiac surgery, including restrictive mitral annuloplasty and surgical ventricular restoration

A modified echocardiographic protocol with intrinsic plausibility control to determine intraventricular asynchrony based on TDI and TSI

<p>Abstract</p> <p>Background</p> <p>Established methods to determine asynchrony suffer from high intra- and interobserver variability and failed to improve patient selection for cardiac resynchronization therapy (CRT). Thus, there is a need for easy and robust approaches to reliably assess cardiac asynchrony.</p> <p>Methods and Results</p> <p>We performed echocardiography in 100 healthy subjects and 33 patients with left bundle branch block (LBBB). To detect intraventricular asynchrony, we combined two established methods, i.e., tissue synchronization imaging (TSI) and tissue Doppler imaging (TDI). The time intervals from the onset of aortic valve opening (AVO) to the peak systolic velocity (S') were measured separately in six basal segments in the apical four-, two-, and three-chamber view. Color-coded TSI served as an intrinsic plausibility control and helped to identify the correct S' measuring point in the TDI curves. Next, we identified the segment with the shortest AVO-S' interval. Since this segment most likely represents vital and intact myocardium it served as a reference for other segments. Segments were considered asynchronous when the delay between the segment in question and the reference segment was above the upper limit of normal delays derived from the control population. Intra- and interobserver variability were 7.0% and 7.7%, respectively.</p> <p>Conclusion</p> <p>Our results suggest that combination of TDI and TSI with intrinsic plausibility control improves intra- and interobserver variability and allows easy and reliable assessment of cardiac asynchrony.</p

3D echocardiographic reference ranges for normal left ventricular volumes and strain: Results fromthe EACVI NORRE study

Aim To obtain the normal ranges for 3D echocardiography (3DE) measurement of left ventricular (LV) volumes, function, and strain from a large group of healthy volunteers. Methods and results A total of 440 (mean age: 45613 years) out of the 734 healthy subjects enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study had good-quality 3DE data sets that have been analysed with a vendor-independent software package allowing homogeneous measurements regardless of the echocardiographic machine used to acquire the data sets. Upper limits of LV end-diastolic and end-systolic volumes were larger in men (97 and 42 mL/m2) than in women (82 and 35 mL/m2; P<0.0001). Conversely, lower limits of LV ejection fraction were higher in women than in men (51% vs. 50%; P<0.01). Similarly, all strain components were higher in women than in men. Lower range was -18.6% in men and -19.5% in women for 3D longitudinal strain, -27.0% and -27.6% for 3D circumferential strain, -33.2% and -34.4% for 3D tangential strain and 38.8% and 40.7% for 3D radial strain, respectively. LV volumes decreased with age in both genders (P<0.0001), whereas LV ejection fraction increased with age only in men. Among 3DE LV strain components, the only one, which did not change with age was longitudinal strain. Conclusion The NORRE study provides applicable 3D echocardiographic reference ranges for LV function assessment. Our data highlight the importance of age- and gender-specific reference values for both LV volumes and strain. All rights reserved

Contrast-enhanced whole-heart coronary MRA at 3.0T for the evaluation of cardiac venous anatomy

This study was designed to evaluate the value of contrast-enhanced whole-heart coronary MRA (CMRA) at 3.0T in depicting the cardiac venous anatomy. In cardiac resynchronization therapy (CRT), left ventricular (LV) pacing is achieved by positioning the LV lead in one of the tributaries of the coronary sinus (CS). Pre-implantation knowledge of the venous anatomy may help determine whether transvenous LV lead placement for CRT is feasible. Images of 51 subjects undergoing contrast-enhanced whole-heart CMRA at 3.0T were retrospectively analyzed. Data acquisition was performed using electrocardiography-triggered, navigator-gated, inversion-recovery prepared, segmented gradient-echo sequence. A 32-element cardiac coil was used for data acquisition. The visibility of the cardiac veins was graded visually using a 4-point scale (1: poor–4: excellent). The paired Student t test was used to evaluate differences in diameters of the ostium of the CS in anteroposterior and superoinferior direction. The cardiac veins were finally evaluated in 48 subjects with three anatomic variations. The diameter of the CS ostium in the superoinferior direction (1.13 ± 0.26 cm) was larger than in the anteroposterior direction (0.82 ± 0.19 cm) (P < 0.05). The mean visibility score of CS, posterior interventricular vein, posterior vein of the left ventricle, left marginal vein, and anterior interventricular vein was 4.0 ± 0.0, 3.4 ± 0.5, 3.4 ± 0.5, 3.0 ± 0.8, and 3.3 ± 0.5, respectively. In conclusion, contrast-enhanced whole-heart CMRA at 3.0T can depict the normal and variant cardiac venous anatomy

Cardiac resynchronization therapy; the importance of evaluating cardiac metabolism

Cardiac Dysfunction and Arrhythmia

Evidence of scar tissue: contra-indication to cardiac resynchronization therapy?

Ventricular Dysfunction & Heart Failur