Comparison of resting and exercise echocardiographic parameters as indicators of outcomes in hypertrophic cardiomyopathy.

BACKGROUND: Both resting echocardiography and exercise echocardiography produce variables predictive of outcomes in patients with hypertrophic cardiomyopathy (HCM). The aim of the present study was to compare the respective value of resting and exercise echocardiographic parameters as indicators of clinical outcomes in patients with HCM. METHODS: Resting and exercise echocardiography was performed prospectively in patients with HCM evaluated at the HCM Competence Center of Bordeaux and followed up every 6 months. A composite cardiac event was defined. RESULTS: One hundred fifteen patients (mean age, 51.9 ± 15.2 years; 66% men) were evaluated by echocardiography and followed for a mean period of 19 ± 11 months. Eighteen patients (16%) reached the composite end point, including 10 progressions to New York Heart Association functional class III or IV. On rest echocardiography, in patients with cardiac events during follow-up, left atrial volume index was significantly more increased, as were lateral E/E' ratio and left ventricular outflow tract (LVOT) gradient, whereas mean global longitudinal strain (GLS) expressed in magnitude (14.0 ± 2.6% vs 17.0 ± 3.6%, P < .001) and peak velocities at the lateral annulus by Doppler tissue imaging were significantly reduced compared with patients without events. At peak exercise, patients who developed cardiac events were characterized by lower ejection fractions and greater LVOT gradients (76 ± 55 mm Hg vs 40 ± 40 mm Hg, P < .002). A Cox backward-entry selection model revealed that GLS ≤ 15% at rest and LVOT gradient ≥ 50 mm Hg at peak exercise were independently associated with an increased risk for poor outcomes in patients with HCM (hazard ratios, 3.8 [P = .017] and 3.3 [P = .028], respectively). On Kaplan-Meier survival analyses, peak exercise LVOT gradient evaluation showed additive value to predict outcomes, particularly in patients with rest GLS > 15% (log-rank P = .001) and despite a resting LVOT gradient ≥ 30 mm Hg (log-rank P = .001). CONCLUSION: This study supports the value of resting GLS and of peak LVOT gradient, measured during exercise echocardiography, in identifying patients with HCM at increased risk for adverse events during follow-up.

Paradoxical response to exercise in asymptomatic hypertrophic cardiomyopathy: a new description of outflow tract obstruction dynamics.

OBJECTIVES: The purpose of this study was to analyze left ventricular obstruction in patients with hypertrophic cardiomyopathy (HCM) during exercise echocardiography. BACKGROUND: Despite the association of symptoms with left ventricular outflow tract obstruction in HCM, there exist paradoxical situations in which significant intraventricular gradients (>50 mm Hg) at rest occur in conjunction with excellent exercise tolerance. METHODS: To examine this phenomenon, we performed exercise echocardiography and analyzed the clinical status of 107 HCM patients with and without resting obstruction. RESULTS: At rest, 69 patients had no obstruction and 38 exhibited an intraventricular gradient, 9 of whom exhibited a decrease in gradient of at least 30 mm Hg (99.4 ± 35.5 mm Hg to 30.2 ± 14.3 mm Hg, p < 0.001) during exercise (paradoxical response to exercise [PRE]). The PRE patients presented with a significantly lower New York Heart Association clinical class and higher left ventricular volumes and arterial pressure both at rest and during exercise than HCM patients in whom the gradient increased or did not change during stress echocardiography. Finally, PRE patients exhibited a trend toward a reduced rate of cardiac events. CONCLUSIONS: Our study reports a subgroup of HCM patients, designated PRE based on a decreased intraventricular gradient during exercise. The reduced exertional obstruction may account for the better functional class and trend toward fewer clinical events in PRE patients.

Estimation of pulmonary pressures and diagnosis of pulmonary hypertension by Doppler echocardiography: a retrospective comparison of routine echocardiography and invasive hemodynamics.

BACKGROUND: To date, Doppler echocardiography is the most widespread and well-recognized technique for the noninvasive evaluation of systolic pulmonary artery pressure (sPAP). However, recent studies have reported reservations about the relevance of Doppler echocardiography or the tool's reliability in the diagnosis and follow-up of patients with pulmonary hypertension (PH). Thus, the aim of this dedicated retrospective study was to address the questions of Doppler echocardiography's relevance and accuracy for PH diagnosis in the routine activity of a conventional echocardiography department. METHODS: Institutional databases were used to extract and analyze the records of 310 patients who underwent both hemodynamic and echocardiographic investigations within a single hospitalization period. RESULTS: Despite an underestimation of absolute Doppler sPAP values compared with measurements on right heart catheterization, data analysis revealed a strong correlation (r = 0.80, P < .00001, n = 310). Targeting a mean pulmonary pressure on right heart catheterization of 25 mm Hg for the definition of PH, receiver operating characteristic curve analysis demonstrated a strong association between sPAP and PH diagnosis (area under the curve, 0.82; n = 155). The cutoff obtained for sPAP was 38 mm Hg, and when applied on a second-test subgroup population (n = 155), sensitivity, specificity, and accuracy were 88%, 83%, and 86%, respectively. When patients with examination intervals of <2 days were selected (n = 115), sensitivity and specificity reached 89% and 89%, respectively. No combination of parameters produced an improvement on the initial results. CONCLUSIONS: In the real-world practice of a conventional echocardiography department, Doppler echocardiography is associated with high accuracy, sensitivity, and specificity for PH evaluation, thus confirming its major position as a primary noninvasive tool.

Early detection of left ventricular systolic dysfunction using two-dimensional speckle tracking strain evaluation in healthy subjects after acute alcohol intoxication.

OBJECTIVES: We evaluated the ability of two-dimensional speckle tracking strain echocardiography to detect left ventricular (LV) systolic dysfunction as compared with LV ejection fraction (EF) in healthy subjects following acute alcohol intoxication. METHODS AND RESULTS: In total, 25 healthy subjects were investigated using echocardiography 4-6 hours after the onset of alcohol intoxication at a regional festive gathering, and then compared to 23 healthy control subjects without alcohol consumption. Heart rate, blood pressure, blood alcohol level, LV volumes, EF, shortening fraction, E/A ratio, as well as global longitudinal strain (LS) were recorded. Mean blood alcohol level was 1.3 ± 0.3 g.L(-1) . Mean systolic blood pressure and heart rate were slightly increased in the alcohol group compared to controls (147.5 ± 21.8 mmHg vs 127.0 ± 9.9 mmHg, P = 0.003, and 79.7 ± 10.7 bpm vs 70.6 ± 7.6 bpm, P < 0.001, respectively). While there was no significant difference in terms of LVEF (62.9 ± 4.4% vs 64.8 ± 5.9%, P = 0.18) or shortening fraction (34.7 ± 5.9% vs 36.0 ± 4.3%, P = 0.54), global LS was significantly impaired (-17.8 ± 2.0% vs -21.2 ± 1.8%, P < 0.001). In addition, subjects who consumed alcohol had increased LV end-diastolic (108.3 ± 20.1 mL vs 95.5 ± 14.6 mL, P = 0.037) and end-systolic volumes (41.6 ± 11.4 mL vs 33.7 ± 6.9 mL, P = 0.024), along with depressed aortic time-velocity integral (19.9 ± 3.2 mL vs 21.9 ± 2.5 mL, P = 0.034). According to multivariate linear regression analyses, blood alcohol level was the only factor significantly associated with global LS (ß=-3.6 ± 1.0, P = 0.005). CONCLUSION: Alcohol intoxication around festive days induces acute LV contraction abnormalities, which may be detected using global LS by speckle tracking at an earlier stage and more accurately than LVEF decreases.

Syncope in Brugada syndrome patients: prevalence, characteristics, and outcome.

BACKGROUND: The report from the 2nd Consensus Committee on BrS suggests that all patients with syncope without a "clear extracardiac cause" should have an implantable cardioverter-defibrillator (ICD). However, a clear extracardiac cause for syncope may be difficult to prove. OBJECTIVE: The purpose of this study was to characterize syncope in patients with Brugada syndrome (BrS). METHODS: All patients diagnosed with BrS at our institution between 1999 and 2010 were enrolled in a prospective registry. Patients with suspected arrhythmic syncope (group 1) were compared to patients with nonarrhythmic syncope (group 2) and to patients with syncope of doubtful origin (group 3). RESULTS: Of 203 patients with BrS, 57 (28%; 44 male, age 46 ± 12 years) experienced at least 1 syncope. Group 1 consisted of 23 patients, all of whom received an ICD. In group 2 (17 patients), 3 received an ICD because of a positive electrophysiologic study. In group 3 (17 patients), 6 received an implantable loop recorder and 6 received an ICD. After mean follow-up of 65 ± 42 months, 14 patients in group 1 remained asymptomatic, 4 had recurrent syncope, and 6 had appropriate ICD therapy. In group 2, 9 patients remained asymptomatic and 7 had recurrent neurocardiogenic syncope. In group 3, 7 remained asymptomatic and 9 had recurrent syncope. One patient from each group died from a noncardiac cause. CONCLUSION: In the present study, syncope occurred in 28% of patients with BrS. The ventricular arrhythmia rate was 5.5% per year in group 1. In 30%, the etiology of the syncope was questionable. No sudden cardiac death occurred in groups 2 and 3.

Evaluation of global left ventricular systolic function using three-dimensional echocardiography speckle-tracking strain parameters.

BACKGROUND: The aim of this study was to evaluate the capacity and reproducibility of three-dimensional echocardiographic (3DE) strain parameters in the assessment of global left ventricular (LV) systolic function. METHODS: A total of 128 subjects with differing LV ejection fractions were investigated using two-dimensional echocardiographic (2DE) and 3DE strains. Three-dimensional echocardiographic strain allows obtaining longitudinal, circumferential, radial, and area strains. First, values of global longitudinal strain (GLS) by 2DE and 3DE speckle-tracking analyses were compared. Thereafter, 3DE strain parameters were correlated with LV ejection fraction and indexed output. Last, the variability of 3DE versus 2DE strain measurements as well as recorded time of analysis were assessed. RESULTS: After excluding 21 patients for insufficient image quality, four for arrhythmia, two for severe valvular disease, and one for severe dyspnea, the final population consisted of 100 patients. Comparison between 2DE and 3DE GLS revealed high correspondence (r = 0.91, y = 1.04x - 0.71) and mean error measurement of -1.3% (95% confidence interval, -5.7 to 3.2). Among strain parameters, global area strain exhibited the highest correlation with LV ejection fraction (y = -1.65 + 10.4, r = -0.92, P < .001). Intraobserver measurement variability proved acceptable: 8% for GLS (vs 6% on 2DE analysis), 7% for circumferential strain (vs 15% on 2DE analysis), 7% for radial strain (vs 33% on 2DE analysis), and 5% for global area strain. The mean error between two measurements was lower with 3DE than 2DE analysis for circumferential and radial strains but similar for GLS. The mean time of analysis was of 117 ± 16 sec for 3DE analysis, which was 25% less than for 2DE analysis (P < .001). CONCLUSIONS: Of all strain parameters, new 3DE area strain correlated best with common LV systolic function parameters and is thus the most promising approach, while all 3DE strain markers exhibited good reproducibility.

Robustness of a new three-dimensional echocardiographic algorithm for left ventricular volume and ejection fraction quantification: experts vs. novices.

AIMS: We evaluated the ability of a new simplified algorithm for three-dimensional echocardiography (3DE) left ventricular (LV) measurements with minimal operator interaction to be reproducible and robust, independently of the experience. METHODS AND RESULTS: A total of 163 subjects were investigated using two-dimensional echocardiography (2DE) and 3DE. The 3D data sets were blindly analysed offline by novice investigators and experts. A subgroup of 30 patients was assessed using cardiac magnetic resonance imaging (CMRI) to compare end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF) obtained by 2DE, 3DE, and CMRI. Intra-observer and inter-observer variabilities of 2DE and 3DE measurements were evaluated according to level of experience. Mean time analysis of 3DE data was 23.2 ± 6.3s for the novice and 26.1 ± 4.1 s for the expert (P = ns). Correlations (r) and mean error measurements (MEM) between 3DE analysis by experts and novices were 0.91 and -3.5 mL for EDV, 0.97 and 4.3 mL for ESV, and 0.91 and -2.6% for EF, respectively. Correlations between 3DE and CMRI were good with low variability and greater agreement when compared with those between 2DE and CMRI. For the novice, MEM was -21.3 mL for EDV, -15.0 mL for ESV, and 2.3% for EF. MEM and 95% confidence intervals were wider for 2DE vs. CMRI than for 3DE vs. CMRI in relation to both expert and novice. CONCLUSION: This new semi-automated algorithm of LV endocardial border detection based on 3DE data appears suitable for clinical use by either expert or novice investigators with greater reproducibility and time of analysis than 2DE.

Validation of a new bedside echoscopic heart examination resulting in an improvement in echo-lab workflow.

BACKGROUND: In daily cardiology practice, porters are usually required to transfer inpatients who need an echocardiogram to the echocardiographic department (echo-lab). AIMS: To assess echo-lab personnel workflow and patient transfer delay by comparing the use of a new, ultraportable, echoscopic, pocket-sized device at the bedside with patient transfer to the echo-lab for conventional transthoracic echocardiography, in patients needing pericardial control after cardiac invasive procedures. METHODS: After validation of echoscopic capabilities for pericardial effusion, left ventricular function and mitral regurgitation grade compared with conventional echocardiography, we evaluated echo-lab personnel workflow and time to perform bedside echoscopy for pericardial control evaluation after invasive cardiac procedures. This strategy was compared with conventional evaluation at the echo-lab, in terms of personnel workflow, and patients' transfer, waiting and examination times. RESULTS: Concordance between echoscopy and conventional echocardiography for evaluation of pericardial effusion was good (0.97; kappa value 0.86). For left ventricular systolic function and mitral regurgitation evaluations, concordances were 0.96 (kappa value 0.90) and 0.96 (kappa value 0.86), respectively. In the second part of the study, the mean total time required in the bedside echoscopy group was 20.3±5.4 mins vs. 66.0±16.4 mins in the conventional echo-lab group (p<0.001). The echo-lab strategy needed porters in 100% of cases; 69% of patients needed a wheelchair. CONCLUSION: The use of miniaturized echoscopic tools for pericardial control after invasive cardiac procedures was feasible and accurate, allowing improvement in echo-lab workflow and avoiding patient waiting time and transfer.