Three-dimensional echocardiography and 2D-3D speckle tracking imaging in chronic pulmonary hypertension. diagnostic accuracy in detecting hemodynamic signs of RV failure

Background and objective. Our aim was to compare three-dimensional (3D) and 2D and 3D speckle tracking (2D-STE, 3D-STE) echocardiographic parameters with conventional right ventricular (RV) indexes in patients with chronic pulmonary hypertension (PH), and investigate whether these techniques could result in better correlation with hemodynamic variables indicative of heart failure. Methods. Seventy-three adult patients (mean age, 53±13 years; 44% male) with chronic PH of different etiologies were studied by echocardiography and cardiac catheterization (25 precapillary PH from pulmonary arterial hypertension, 23 obstructive pulmonary heart disease, and 23 postcapillary PH from mitral regurgitation). Thirty healthy subjects (mean age, 54±15 years; 43% male) served as controls. Standard 2D measurements (RV-FAC -fractional area change-, TAPSE -tricuspid annular plane systolic excursion-) and mitral and tricuspid tissue Doppler annular velocities were obtained. RV 3D volumes, and global and regional ejection fraction (3D-RVEF) were determined. RV strains were calculated by 2D-STE and 3D-STE. Results. RV 3D global-free-wall longitudinal strain (3DGFW-RVLS), 2D global-free-wall longitudinal strain (GFW-RVLS), apical-free-wall longitudinal strain (AFW-RVLS), basal-free-wall longitudinal strain (BFW-RVLS), and 3D-RVEF were lower in patients with pre-capillary PH (p<0.0001) and post-capillary PH (p<0.01) compared to controls. 3DGFW-RVLS (HR 4.6, 95% CI 2.79-8.38, p=0.004) and 3D-RVEF (HR 5.3, 95% CI 2.85-9.89, p=0.002) were independent predictors of mortality. ROC curves showed that the thresholds offering an adequate compromise between sensitivity and specificity for detecting hemodynamic signs of RV failure were 39% for 3D-RVEF (AUC 0.89), -17% for 3DGFW-RVLS (AUC 0.88), -18% for GFW-RVLS (AUC 0.88), -16% for AFW-RVLS (AUC 0.85), 16mm for TAPSE (AUC 0.67), and 38% for RV-FAC (AUC 0.62). Conclusions. In chronic PH, 3D, 2D-STE and 3D-STE parameters indicate global and regional RV dysfunction that is associated with RV failure hemodynamics better than conventional echo indices

Assessment of biventricular strain by 3-dimensional speckle-tracking echocardiography in chronic aortic regurgitation

Background. Patients with chronic severe aortic regurgitation (AR) represent a challenging cohort with high morbidity and mortality. It is known about the implication of left ventricular (LV) strain as a predictor for mortality in patients with chronic AR. The prevalence and clinical impact of right ventricular dysfunction (RVD) on risk stratification and prognosis in these patients is unknown. Methods. Eighteen patients (mean age 64±13 years) with severe chronic AR and eighteen age-matched healthy subjects selected as controls were studied. LV and RV longitudinal, circumferential and radial strains were calculated by three-dimensional speckle tracking echocardiography (3DSTE). Global area strain (GAS) was obtained by 3DSTE as the percentage variation in the surface area defined by the longitudinal and circumferential strain vectors. Data analysis was performed offline. RVD was defined as global longitudinal strain of RV free-wall <15%. Cox proportional hazards modeling was used to risk-adjust comparisons for the end point of all-cause mortality. Results. Impairment of LV global longitudinal strain (-15.9% vs -19.3%, p = .015), global circumferential strain (-17.8% vs -26.4%, p = .006), global radial strain (27.3% vs 34.6%, p = .026) and global area strain (-21.4% vs -38.5%, p = .008) was observed in patients with AR compared to controls. The presence of RVD (hazard ratio, 2.86; 95% CI, 1.36-7.13; p = 0.032) was an independent risk factor associated with all-cause mortality despite several adjustments for potential clinical and echocardiographic confounders such as aortic valve replacement, severity of tricuspid regurgitation, and left ventricular global longitudinal strain. Conclusions. Baseline RVD is common in patients with chronic severe aortic regurgitation. Quantification of right ventricular systolic function in these patients provides important additional prognostic value and risk stratification

Assessment of biventricular and vascular function using three-dimensional speckle tracking echocardiography in adult patients with surgical repair of tetralogy of Fallot

Background: In patients late after correction of Tetralogy of Fallot (TF) the combined effects of preoperative hypertrophy and hypoxia, possible intraoperative myocardial damage, type of reconstruction, acquired postoperative lesions such as pulmonary or aortic regurgitation, and congenital vasculopathy may result in impaired right ventricular (RV) as well as left ventricular (LV) function. We hypothesized that a comprehensive assessment of ventricular, aortic and pulmonary artery function could help to better understand the pathophysiology of this complex disease. Methods: Eighteen patients (mean age 37 ± 14 years) with repaired TF and eighteen age-matched healthy subjects selected as controls were studied. LV and RV longitudinal, circumferential, and radial strains were calculated by three-dimensional speckle tracking echocardiography (3DSTE). Global area strain (GAS) was obtained by 3DSTE as the percentage variation in the surface area defined by the longitudinal and circumferential strain vectors. Pulmonary artery (PA) and ascending aorta (Ao) stiffness and strain were determined using M-mode and speckle tracking echocardiography. Data analysis was performed offline. Results: Overall, Ao and PA stiffness were increased (p=0.0003) and Ao and PA strains were decreased (p=0.0002) in TF patients compared to controls. Stiffness index had a negative correlation with Ao (p<0.001) and PA (p<0.005) strain. Ao and PA strains correlated with LV and RV longitudinal strain (p<0.05 and p<0.01 respectively) and LV and RV area strain (p=0.02 and p<0.01 respectively). A significant correlation was found between PA stiffness and pulmonary regurgitant fraction and volume (p=0.004), and between Ao stiffness and aortic regurgitant fraction and volume (p<0.001). Conclusions: In patients with repaired TF increased PA and Ao stiffness are associated with reduced RV and LV 3DSTE parameters. Changes in PA and Ao stiffness and strain are more pronounced in the presence of pulmonary or aortic regurgitation and should be taken into account when evaluating post-operative TF

assessment of light-chain amyloidosis using 3D speckle tracking echocardiography: Differentiation from other forms of myocardial hypertrophy

Background. Cardiac amyloidosis (CA) is an infiltrative disease primarily caused by extracellular tissue deposition of amyloid fibrils in the myocardial interstitium. Over half of affected patients show cardiac involvement at diagnosis, and this condition is the most important prognostic factor in the natural progression of the disease. The aim of the present study was to examine left ventricular (LV) rotational mechanics in biopsy-proven CA by three-dimensional speckle-tracking echocardiography (3DSTE). Methods. Ten patients (67.9±10.3 years) with CA, 10 patients (68.6±11.7 years) with systemic arterial hypertension (HTN), 10 patients (59.9±13.8 years) with hypertrophic cardiomyopathy (HCM), and 10 age-matched normal controls were studied by conventional echocardiography and 3DSTE. LV longitudinal strain and systolic and diastolic strain rate were obtained in the basal, mid and apical segments of septal and lateral walls in apical 4-chamber view. Circumferential and radial strain and averaged LV rotation and rotational velocities from the base and apex were also determined. Results. LV longitudinal and circumferential strain were reduced in CA patients compared to controls (-14.6% vs -19.7%, p =.005, and -16.9% vs -27.1%, p =.013, respectively) with the most prominent impairment at the basal segments. Peak basal rotation (-5.1±1.4 vs -6.8±2.2degree, p =.001), peak apical rotation (8.7±3.1 vs 10.8±3.4degree, p <.05), and peak untwisting rate (64.3±11 vs 79.3±14degree/s, p =.02) were significantly lower compared to controls. Significant impairment of peak basal rotation was shown in CA patients compared to HTN (p<.05) and HCM patients (p<.01). Comparison of ROC curves for detecting CA showed that the AUC using basal rotation was significantly larger than the other echocardiographic parameters used for diagnosing CA (AUC 0.95, 95% CI 0.87-0.98). Conclusions. Different aspects of LV rotational mechanics are shown in CA, with significant basal hyporotation being the most frequent pattern. This pattern could identify early cardiac involvement and help to differentiate patients with CA from patients with other causes of increased LV wall thickness

Three-dimensional speckle tracking echocardiographic assessment of right ventricular function in chronic obstructive pulmonary disease with and without pulmonary hypertension.

Background: The purpose of this study was to assess right ventricular (RV) function in patients with chronic obstructive pulmonary disease (COPD) with and without pulmonary hypertension (PH) using three-dimensional speckle tracking echocardiography (3DSTE) and compare 3DSTE parameters with conventional RV function indexes. Methods: Thirty-two patients with COPD and thirty-two healthy subjects were studied. Twelve patients had PH confirmed by right heart catheterization (mean pulmonary artery pressure >25mmHg). Twenty patients had normal pulmonary artery pressures. Standard 2D measurements (tricuspid annulus excursion -TAPSE-, fractional area change -RVFAC-) and mitral and tricuspid tissue-Doppler annular velocities were obtained. RV 3D volumes, and RV global and regional ejection fraction (3DRVEF) were determined. Peak systolic velocities and strain were measured in the LV and RV free-wall segments. Respiratory function tests were performed (FEV1/VC = forced expiratory volume in one second / vital capacity; DLCO/VA = carbon monoxide diffusion lung capacity per unit of alveolar volume). Results: Global free-wall RV longitudinal strain (GFW-RVLS) and 3DRVEF were significantly lower compared to controls both in patients with PH (p<0.0001 and p=0.0003 respectively) and without PH (p<0.001 and p<0.005 respectively). Both GFW-RVLS and 3DRVEF correlated similarly with mean pulmonary artery pressure (r=0.62 and r=0.64; p=0.004 for both) and with pulmonary vascular resistance (r=0.65 and r=0.67; p=0.003 for both). No correlation was observed between RV and LV strain parameters. A significant relationship was shown between GFW-RVLS and DLCO/VA (r=0.72, p<0.005), and GFW-RVLS and FEV1/VC (r=0.75, p<0.001). Conclusions: RV 3D and 3DSTE parameters were abnormal in COPD patients compared to normals and had a higher association with COPD severity compared to standard RV function measurements. RV deformation changes did not appear to be a consequence of LV dysfunction. Detection of RV systolic impairment, even in the absence of pulmonary hypertension, suggests that RV myocardial damage in COPD cannot be blamed solely to pressure overload

Circumferential deformation of the thoracic aorta in hypertensive patients by three-dimensional speckle tracking echocardiography

Background: Aortic stiffness may be associated with an increased incidence of cardiovascular events and has been reported to be related to arterial wall motion velocities as measured by tissue Doppler imaging (TDI). The aim of this study was to investigate the potential clinical apllication of three-dimensional speckle tracking echocardiography (3DSTE) for the assessment of aortic function parameters in healthy and hypertensive adults. Methods: We examined 95 hypertensive (mean age, 67 ± 14 years; 53% male) and 95 healthy adults (mean age 69 ± 12 years; 51% male). Ascending aorta M-mode, TDI and STE parameters were measured. Aortic distensibility (D) and aortic stiffness index (SI) were calculated using accepted formulae. Global peak circumferential ascending thoracic aorta strain by 3DSTE (3D-AoS) was determined (GE EchoPAC) as an average of multiple segments of arterial wall deformation. The corrected 3D-AoS was calculated as the global 3D-AoS/pulse pressure. Comprehensive echocardiography was performed for the assessment of the LV systolic/diastolic function. Results: Intraobserver variation of 3D-AoS ranged from 3% to 5% and interobserver variation ranged from 4% to 7%. Both D (p<0.05) and 3D-AoS (p<0.001) were significantly lower in hypertensive compared to control subjects. Reduced D and increased SI were consistent with evidence of increased aortic stiffness in both male and female hypertensive patients. SI increased and D decreased with increasing age or systolic blood pressure. Multivariate analysis showed 3D-AoS to be independently related to pulse pressure (p<0.01), LV mass index (p=0.003), and diastolic function (p=0.002). Conclusions: Aortic 3DSTE parameters have higher reproducibility compared to TDI and 2D indices, differentiate hypertensive from healthy adults, and reflect aortic compliance changes related to age and sex and LV diastolic function

Early, mid and long term echocardiographic results of percutaneous closure in simple and complex patent foramen ovale.

Background. The interpretation of residual shunts after implantation of different devices for patent foramen ovale (PFO) with different morphologies after cerebrovascular events due to paradoxical embolism is controversial. Methods. Transcatheter PFO closure was performed in 123 patients with a history of ≥1 paradoxical embolism using three different devices: Amplatzer (n=46), Figulla Occlutech (n=41) and Atriasept Cardia (n=36). PFO was a simple flap (S-PFO) in 59 patients and complex (C-PFO) in 64 patients. Complex PFO included isolated aneurysmal septum, long tunnel–type, presence of a small additional atrial septal defect, septum primum deviation, and prominent Eustachian valve. All patients were studied with contrast-enhanced transesophageal echocardiography (TEE) before interventional procedure and thereafter at 1 and 6 months and every 6 to 12 months in case of incomplete closure. Definite closure was confirmed in at least two consecutive studies. Results. The diameter of the occluder varied according to the size of the atrial septum and the size of PFO at the TEE examination prior to implantation. The closure rate between simple and complex PFO concerning all implanted occluders was significantly different (p=0.03). Devices of 25 mm or less had a better occlusion rate. The difference between the closure rate of S-PFO and C-PFO concerning each device type was significant (Amplatzer, p<0.01; Figulla, p<0.01; Atriasept, p<0.05). In two patients thrombi were detected in the six month TEE controls and in two patients the implantation of an adjunctive device was necessary for residual shunt. The mean follow up period was 3.1 years (median 2.3 years) with a re-event-rate of 0.6% per year. Overall, no relation to residual PFO shunting or thrombus formation was seen. There were no peri-interventional major complications. Conclusions. The PFO closure rate is dependent on septal anatomy more than occluder size and type. An adjunctive device may be necessary in selected cases

Biatrial function before and after percutaneous closure of atrial septum in patients with and without paroxysmal atrial fibrillation. a two-dimensional and three-dimensional speckle tracking echocardiographic study

We aimed to analyze atrial function by two-dimensional (2DSTE) and three-dimensional (3DSTE) speckle-tracking echocardiography in patients with atrial septal devices and paroxysmal atrial fibrillation (PAF). One hundred sixteen patients and a subgroup of 22 patients who developed PAF after device insertion were studied. Left (LA) and right atrial (RA) peak longitudinal strain (PS) and standard deviations(SDs) of times to peak strain (TPS) were calculated using 2DSTE. LA-RA emptying fraction (EF) and expansion index (EI) were determined using 3DSTE. By multivariate analysis, pre-closure 3D-RA-EI, LA-TPS, and 3D-LA-EI were independently associated with PAF. ROC analysis showed better diagnostic accuracy of the combination of pre-closure TPS and 3D-EI for detecting PAF than the other indices. Patients with atrial septal devices have pre-existent left and right atrial dilatation and dysfunction as assessed by 2DSTE and 3DSTE that appear sensitive for the stratification of PAF risk in this population

Can prosthesis type influence the recurrence of infective endocarditis after surgery for native valve endocarditis? A propensity weighted comparison

Objectives: Our goal was to investigate whether the incidence of valve-related adverse events might be different depending on the valve substitute after valve replacement for left-sided native valve endocarditis. Methods: We assessed the long-term freedom from recurrence, reoperation and survival of 395 patients who had valve replacements for native valve endocarditis (314 mechanical vs 81 biological). Age &lt;18 years, reoperation, prosthetic endocarditis, right valve involvement, valve repair and homograft implants were the main exclusion criteria. The balance between the 2 groups was addressed by weighting the results on the inverse of the propensity score. Results: After inverse probability of treatment weighting (IPTW), freedom from recurrence of infective endocarditis was not significantly different (mechanical 84.1 ± 3.2% vs 50.6 ± 21.7%; P = 0.29) nor was freedom from reoperation different (mechanical 85.7 ± 3.1% vs biological 50.9 ± 21.9%; P = 0.29). Excluding competing deaths, patients receiving a bioprosthesis had a similar subdistribution hazard of the above end points compared to recipients of a mechanical valve [recurrence IPTW: hazard ratio (HR) 1.631, 95% confidence interval (CI) 0.756-3.516; P = 0.21; reoperation IPTW-HR 1.737, 95% CI 0.780-3.870; P = 0.18]. Mechanical valves were associated with improved long-term survival (34.9 ± 5.8% vs 10.5 ± 7.4% at 30 years; P = 0.0009; in particular: aortic valve subgroup 41.6 ± 9.3% vs 10.1 ± 8.2%; P &lt; 0.0001), although the hazard of cardiovascular mortality did not favour either valve type (IPTW: HR 1.361, 95% CI 0.771-2.404; P = 0.29). Conclusions: Our analysis showed a clinical trend in favour of mechanical valves as valve substitutes for native valve endocarditis, especially in the aortic position. In view of long-term freedom from adverse events, the choice of the valve type should be tailored according to patient characteristics and specific clinical conditions.OBJECTIVES: Our goal was to investigate whether the incidence of valve-related adverse events might be different depending on the valve substitute after valve replacement for left-sided native valve endocarditis.METHODS: We assessed the long-term freedom from recurrence, reoperation and survival of 395 patients who had valve replacements for native valve endocarditis (314 mechanical vs 81 biological). Age &lt;18 years, reoperation, prosthetic endocarditis, right valve involvement, valve repair and homograft implants were the main exclusion criteria. The balance between the 2 groups was addressed by weighting the results on the inverse of the propensity score.RESULTS: After inverse probability of treatment weighting (IPTW), freedom from recurrence of infective endocarditis was not significantly different (mechanical 84.1 +/- 3.2% vs 50.6 +/- 21.7%; P = 0.29) nor was freedom from reoperation different (mechanical 85.7 +/- 3.1% vs biological 50.9 +/- 21.9%; P = 0.29). Excluding competing deaths, patients receiving a bioprosthesis had a similar subdistribution hazard of the above end points compared to recipients of a mechanical valve [recurrence IPTW: hazard ratio (HR) 1.631, 95% confidence interval (CI) 0.756-3.516; P = 0.21; reoperation IPTW-HR 1.737, 95% CI 0.780-3.870; P = 0.18]. Mechanical valves were associated with improved long-term survival (34.9 +/- 5.8% vs 10.5 +/- 7.4% at 30 years; P = 0.0009; in particular: aortic valve subgroup 41.6 +/- 9.3% vs 10.1 +/- 8.2%; P &lt; 0.0001), although the hazard of cardiovascular mortality did not favour either valve type (IPTW: HR 1.361, 95% CI 0.771-2.404; P = 0.29).CONCLUSIONS: Our analysis showed a clinical trend in favour of mechanical valves as valve substitutes for native valve endocarditis, especially in the aortic position. In view of long-term freedom from adverse events, the choice of the valve type should be tailored according to patient characteristics and specific clinical conditions