Echocardiographic selection of candidates for cardiac resynchronization therapy: The lack of evidence! Reply

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Diastolic heart failure: Standard Doppler approach and beyond

Evidence of normal systolic left ventricular function has been reported in vp to 30-40% of patients with clinical signs of congestive heart failure, suggesting that diastolic dysfunction is an important predictor of prognosis and mortality. Doppler echocardiography as a noninvasive diagnostic procedure is able to provide immediate and relevant information on functional and structural changes underlying the clinical syndrome of heart failure. Four distinct early filling/late diastole (E/A) ratio patterns (normal, delayed relaxation, pseudonormal, restrictive) can be discerned if viewed within the context of other available clinical information. These patterns evolve from one to another in a single individual, with changes in disease evolution, treatment, and loading condition. They represent a continuum from normal to severe diastolic dysfunction, showing progressively increasing left ventricular (LV) chamber stiffness and subsequently decreasing deceleration time. The combination of Doppler restrictive filling pattern and decreased deceleration time provides important information that helps to differentiate gradations of diastolic dysfunction and has been found to be a potent predictor of prognosis and mortality in various cardiac conditions. When clinical and transthoracic data alone are not sufficient in guiding therapy of congestive heart failure, transesophageal echocardiography can be used to assess most Doppler flows, especially pulmonary venous and left atrial (LA) appendage flows. The use of the multiplane transducer in multiple intermediate scan planes further improves the possibility of optimizing the Doppler incident angle and obtaining the best Doppler recordings of the left upper or right upper pulmonary venous flow. Whereas LV diastolic dysfunction is common in patients with congestive heart failure and appears to be an important predictor of prognosis, little information is available about right ventricular (RV) diastolic dysfunction, The role of RV function in congestive heart failure has probably been underestimated and it is possible that RV diastolic dysfunction assessment is equally important in the follow-up of heart failure patients. Recently, 2 novel echocardiographic technologies for the assessment of ventricular wall dynamics have been developed-color kinesis and tissue Doppler imaging. Both techniques have recently been shown to provide global as well as regional information on LV contraction and filling. Complementary use of both techniques may allow a more complete noninvasive assessment of global and regional systo-diastolic LV function, (C) 1998 by Excerpta Medico, Inc

Transthoracic and transesophageal echocardiography in the hemodynamic assessment of patients with congestive heart failure

All methods for estimating the severity of heart failure, such as clinical and radiographic examination, measures of ventricular performance, and exercise capacity, when used independently, have major limitations. Echocardiography can be used, not only to assess left-ventricular ejection fraction but also other determinants of prognosis (i.e., left-ventricular size and shape, estimation of left atrial and pulmonary artery pressures, right side involvement). The availability of continuous-wave Doppler has permitted us to evaluate pulmonary artery systolic pressure from tricuspid regurgitation, and this contributes to additional powerful data. In long-standing heart failure, pulmonary artery wedge pressure is a predictor of survival, and aggressive therapy to reduce wedge pressure improves survival. Noninvasive estimation of left-atrial pressure and left-ventricular filling pressure have been attempted by continuous-wave Doppler echocardiography in patients with heart failure and mitral regurgitation and by tissue Doppler imaging at the mitral annulus level. A significant relation has been reported between profiles of pulmonary venous flow and left-atrial pressure, but pulmonary venous flow indexes can be better assessed by transesophageal echocardiography (TEE) in terms of detection rate. It has recently been recognized that TEE can provide valuable information on intracardiac hemodynamics and ventricular function. Two-dimensional evaluation of ventricular function and pulsed- and continuous-wave Doppler recordings from the pulmonary artery, pulmonary vein, and mitral inflow are combined to provide these data, which are both qualitative and quantitative, and permit estimation of ventricular ejection fraction, left-atrial pressure, and cardiac output. It would be important to be able to stratify patients with congestive heart failure according to groups with the highest risk for early death because heart transplantation or aggressive medical treatment could be specifically applied to this population. Serial echocardiographic evaluations of the classic variables of systolic left-ventricular function as well as Doppler transmitral flow may be useful in monitoring the progression of the disease and the effects of medical treatment. The degree of pulmonary hypertension is independently associated with the restrictive left-ventricular diastolic filling pattern and with the degree of functional mitral regurgitation. Future studies on the impact of these hemodynamic variables on the outcome of patients with left-ventricular dysfunction are desirable

Tissue Doppler Imaging in the assessment of selection and response from cardiac resynchronization therapy

Mechanistic studies, observational evaluations, and randomized trials have consistently demonstrated the beneficial effects of cardiac resynchronization therapy (CRT) in patients with moderate-to-severechronic systolic heart failure and ventricular dyssynchrony who have failed optimal medical treatment. However, despite the promising results, in some patients undergoing CRT, the symptoms of heart failure do not improve or even worse. One of the most important reasons for this failure is probably the lack of distinct mechanical dyssynchrony before implantation. This review discusses the actual and potential role of Tissue Doppler Imaging in selection of patients and optimisation of CRT. (c) 2007 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved

Sequential study of echocardiographic changes in purulent pericarditis

Serial echocardiographic studies were performed in a child with purulent pericarditis. Besides demonstrating the pericardial effusion, echocardiography was used to assess cardiac function. Computer analysis of changes in left ventricular dimension showed impaired diastolic filling, persisting after pericardiocentesis but normalizing after pericardiectomy

Echocardiographic evaluation of left ventricular outflow tract obstruction in complete transposition of the great arteries

Subpulmonic stenosis in complete d-transposition of the great arteries (d-TGA) is a frequently associated malformation, the precise diagnosis of which is essential for optimal medical and surgical treatment. Sixteen patients with d-TGA and subpulmonic stenosis have been studied by M-mode and two-dimensional (2DE) echocardiography and cardiac catheterization. Dynamic obstruction was found in six patients and fixed stenosis in 10. Systolic anterior motion of the mitral valve without fixed obstruction of the left ventricular outflow tract (LVOT) was present in patients with dynamic stenosis. Measurements of left ventricular end-diastolic posterior wall thickness to minor semiaxis ratio correlated well (p < 0.001) with the pressure gradient across the LVOT. Various types of anatomic fixed obstruction are described. M-mode echocardiography provides assessment of dynamic obstruction but does not allow quantitative evaluation of the length of the narrowed segment. The latter can be achieved by 2DE, which offers improved definition of different anatomic types

Echocardiographic assessment of congenital mitral stenosis.

To assess the severity and precise anatomy of congenital mitral stenosis (MS), 17 patients with congenital left ventricular inflow obstruction were studied by M-mode and two-dimensional echocardiography (2DE) and by cardiac catheterization. In six patients MS was an isolated lesion and in 11 it was combined with other cardiovascular malformations. The diagnosis was confirmed at operation or autopsy in 15 patients. Twenty normal subjects of the same age and sex were selected as controls. M-mode amplitude and speed of diastolic closure (E-F slope) of the anterior mitral valve leaflet were determined in all patients. Mitral valve areas were traced after careful short-axis 2DE scans in 15 patients. Supravalvar, valvar, or subvalvar obstruction was evaluated in patients with surgical or autopsy documentation. Analysis of M-mode echocardiograms showed a reduction of E-F slope in all patients compared to normal control subjects but a poor correlation between E-F slope and hemodynamic data (mitral valve areas or pressure gradients). Diastolic fluttering of either or both mitral valve leaflets was found in 12 patients. It is concluded that M-mode echocardiography may be useful for qualitative assessment of congenital MS, even in the presence of associated heart defects, but less useful in evaluating its severity. Analysis of 2DE revealed good correlation between mitral valve areas as calculated with 2DE and with the Gorlin formula at cardiac catheterization, despite the complexity of the congenital mitral lesion. Anatomic varieties of congenital left ventricular inflow obstruction, such as stenosing supravalvar mitral ring or parachute deformity of the mitral valve, were recognized at 2DE.(ABSTRACT TRUNCATED AT 250 WORDS

Value of transesophageal dobutamine stress echocardiography in assessing coronary artery disease

The introduction of digital echocardiography has significantly enhanced our ability to select the best set of frames for analysis. However, despite the beneficial attributes of transthoracic dobutamine stress echocardiography, poor quality 2-dimensional images continue to be a significant limiting factor in patients with chest deformities, severe chronic obstructive lung disease, marked obesity, and previous chest surgery. Transesophageal echocardiography provides a new window to monitor left ventricular contractility without the interference of bone and air-filled structures of the thoracic cage. The transesophageal dobutamine stress test is a logical but poorly explored modality to image/stress the heart in certain patients with known or suspected myocardial ischemia. Overall sensitivity (< or = 85%) and specificity (< or = 95-100%) of transesophageal dobutamine stress echocardiography appear to be similar to that of previous transthoracic studies, although no direct comparison has been accomplished between transthoracic and transesophageal stress images. False negative transesophageal dobutamine stress echocardiography results have been described in patients with single-vessel disease in whom ischemic regions may not have been visualized throughout the entire study. False positive study results may be present in patients with hypertension and myocardial hypertrophy that may have signs and symptoms of myocardial ischemia in absence of obstructive disease of the epicardial coronary arteries, presumably related to either microvascular disease or impaired vasodilatory reserve. The proportion of patients with coronary artery disease who need a transesophageal examination for reliable assessment of echocardiographic response to stress varies depending on the operators' skills, the interpreters' experience, and the use of videotape or digitizing systems for image analysis. Although clinically useful in its present transthoracic and transesophageal form, a major limitation of dobutamine stress echocardiographic study is the subjective visual interpretation of endocardial motion and wall thickening, which is only semiquantitative. Color kinesis and tissue Doppler imaging (TDI) are 2 novel echocardiographic techniques that color code endocardial motion and myocardial velocity online and have the potential to objectively quantify regional left ventricular function. Quantitative standardization of transthoracic and transesophageal data interpretation, such as establishing endocardial motion by color kinesis or velocity thresholds by TDI for an abnormal segmental response to stress, has the potential to decrease interobserver variability and increase interinstitutional agreement