RESUMEN
INTRODUCTION AND OBJECTIVES: Using existing transthoracic echocardiographic indices to quantify left ventricular wall motion abnormalities (WMAs) can be difficult due to the variations in the location of the abnormalities within the left ventricle, the quality of examinations, and the inter-/intra-observer variability of available indices. This study aimed to evaluate a new approach for measuring the extent of WMA by calculating the percentage of abnormal wall motion and comparing it to the wall motion score index (WMSI). The study also sought to assess inter- and intra-observer variability. METHODS: The study included 140 echocardiograms from 54 patients presenting with ST-elevation myocardial infarction or Takotsubo syndrome. All patients underwent an echocardiographic examination according to a standard protocol and the images were used to measure the extent of akinesia (proportion akinesia, PrA), akinesia and hypokinesia (proportion akinesia/hypokinesia, PrAH), and WMSI. The inter-observer variability between the two operators was analyzed. The intra-observer analysis was performed by one observer using the same images at least 1 month after the first measurement. The agreement was analyzed using the Pearson correlation coefficient and Bland-Altman plots. RESULTS: Inter- and intra-observer variability for PrA and PrAH were low and comparable to those for WMSI. CONCLUSION: PrA and PrAH are reliable and reproducible echocardiographic methods for the evaluation of left ventricular wall motion.
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Infarto del Miocardio con Elevación del ST , Cardiomiopatía de Takotsubo , Humanos , Variaciones Dependientes del Observador , Infarto del Miocardio con Elevación del ST/complicaciones , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Cardiomiopatía de Takotsubo/diagnóstico por imagen , Hipocinesia , Ecocardiografía/métodosRESUMEN
PURPOSE: Recognition of congestion and hypoperfusion in patients with chronic left ventricular dysfunction (LVD) has therapeutic and prognostic implications. In the present study we hypothesized that a multiparameter echocardiographic grading of right ventricular dysfunction (RVD) can facilitate the characterization of hemodynamic profiles. METHODS: Consecutive patients (n = 105, age 53 ± 14 years, males 77%, LV ejection fraction 28 ± 11%) referred for heart transplant or heart failure work-up, with catheterization and echocardiography within 48 h, were reviewed retrospectively. Three hemodynamic profiles were defined: compensated LVD (cLVD, normal pulmonary capillary wedge pressure (PCWP < 15 mmHg) and normal mixed venous saturation (SvO2 ≥ 60%)); decompensated LVD (dLVD, with increased PCWP) and LV failure (LVF, increased PCWP and reduced SvO2). We established a 5-point RVD score including pulmonary hypertension, reduced tricuspid annular plane systolic excursion, RV dilatation, ≥ moderate tricuspid regurgitation and increased right atrial pressure. RESULTS: The RVD score [median (IQR 25%;75%)] showed significant in-between the three groups differences with 1 (0;1), 1 (0.5;2) and 3.0 (2;3.5) in patients with cLVD, dLVD and LVF, respectively. The finding of RVD score ≥ 2 or ≥ 4 increased the likelihood of decompensation or LVF 5.2-fold and 6.7-fold, respectively. On the contrary, RVD score < 1 and < 2 reduced the likelihood 11.1-fold and 25-fold, respectively. The RVD score was more helpful than standard echocardiography regarding identification of hemodynamic profiles. CONCLUSIONS: In this proof of concept study an echocardiographic RVD score identified different hemodynamic severity profiles in patients with chronic LVD and reduced ejection fraction. Further studies are needed to validate its general applicability.
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Insuficiencia Cardíaca , Disfunción Ventricular Izquierda , Disfunción Ventricular Derecha , Adulto , Anciano , Ecocardiografía , Insuficiencia Cardíaca/diagnóstico , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Volumen Sistólico , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/etiología , Disfunción Ventricular Derecha/diagnóstico por imagen , Disfunción Ventricular Derecha/etiología , Función Ventricular DerechaRESUMEN
OBJECTIVES: We examined the association between obesity and early-onset cryptogenic ischemic stroke (CIS) and whether fat distribution or sex altered this association. MATERIALS AND METHODS: This prospective, multi-center, case-control study included 345 patients, aged 18-49 years, with first-ever, acute CIS. The control group included 345 age- and sex-matched stroke-free individuals. We measured height, weight, waist circumference, and hip circumference. Obesity metrics analyzed included body mass index (BMI), waist-to-hip ratio (WHR), waist-to-stature ratio (WSR), and a body shape index (ABSI). Models were adjusted for age, level of education, vascular risk factors, and migraine with aura. RESULTS: After adjusting for demographics, vascular risk factors, and migraine with aura, the highest tertile of WHR was associated with CIS (OR for highest versus lowest WHR tertile 2.81, 95%CI 1.43-5.51; P=0.003). In sex-specific analyses, WHR tertiles were not associated with CIS. However, using WHO WHR cutoff values (>0.85 for women, >0.90 for men), abdominally obese women were at increased risk of CIS (OR 2.09, 95%CI 1.02-4.27; P=0.045). After adjusting for confounders, WC, BMI, WSR, or ABSI were not associated with CIS. CONCLUSIONS: Abdominal obesity measured with WHR was an independent risk factor for CIS in young adults after rigorous adjustment for concomitant risk factors.
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Accidente Cerebrovascular Isquémico , Migraña con Aura , Índice de Masa Corporal , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Obesidad/complicaciones , Obesidad/diagnóstico , Obesidad/epidemiología , Estudios Prospectivos , Factores de Riesgo , Circunferencia de la Cintura , Relación Cintura-Cadera , Adulto JovenRESUMEN
Objective. Skeletal muscle perfusion during walking relies on complex interactions between cardiac activity and vascular control mechanisms, why cardiac dysfunction may contribute to intermittent claudication (IC) symptoms. The study aims were to describe cardiac function at rest and during stress in consecutive IC patients, to explore the relations between cardiac function parameters and treadmill performance, and to test the hypothesis that clinically silent myocardial ischemia during stress may contribute to IC limb symptomatology. Design. Patients with mild to severe IC (n = 111, mean age 67 y, 52% females, mean treadmill distance 195 m) underwent standard echocardiography, dobutamine stress echocardiography (SE) and treadmill testing. The patient cohort was separated in two groups based on treadmill performance (HIGH and LOW performance). Results. Ten patients (9%) had regional wall motion abnormalities of which three had left ventricular ejection fraction <50% at standard echocardiography. A majority had lower than expected systolic- and diastolic ventricular volumes. LOW performers had smaller diastolic left ventricular volumes and lower global peak systolic velocity during dobutamine stress. No patient demonstrated significant cardiac dysfunction during dobutamine provocation that was not also evident at standard echocardiography. Conclusions. Most IC patients were without signs of ischemic heart disease or cardiac failure. The majority had small left ventricular volumes. The hypothesis that clinically silent myocardial ischemia impairing left ventricular function during stress may contribute to IC limb symptomatology was not supported.
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Agonistas de Receptores Adrenérgicos beta 1/administración & dosificación , Dobutamina/administración & dosificación , Ecocardiografía de Estrés/métodos , Prueba de Esfuerzo , Claudicación Intermitente/diagnóstico por imagen , Función Ventricular Izquierda , Anciano , Femenino , Humanos , Claudicación Intermitente/fisiopatología , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: In this observational study, the effects of norepinephrine-induced changes in mean arterial pressure (MAP) on right ventricular (RV) systolic function, afterload and pulmonary haemodynamics were studied in septic shock patients. We hypothesised that RV systolic function improves at higher doses of norepinephrine/MAP levels. METHODS: Eleven patients with septic shock requiring norepinephrine after fluid resuscitation were included <24 hours after ICU arrival. Study enrolment and insertion of a pulmonary artery catheter was performed after written informed consent from the next of kin. Norepinephrine infusion was titrated to target mean arterial pressures (MAP) of 60, 75 and 90 mmHg in a random sequential order. At each target MAP, strain-and conventional echocardiographic-and pulmonary haemodynamic variables were measured. RV afterload was assessed as effective pulmonary arterial elastance, (Epa ) and pulmonary vascular resistance index, (PVRI). RV free wall peak strain was the primary end-point. RESULTS: At highest compared to lowest norepinephrine dose/MAP level, RV free wall peak strain increased from -19% to -25% (32%, P = .003), accompanied by increased tricuspid annular plane systolic excursion (22%, P = .01). At the highest norepinephrine dose/MAP, RV end-diastolic area index (16%, P < .001), central venous pressure (38%, P < .001), stroke volume index (7%, P = .001), mean pulmonary artery pressure (19%, P < .001) and RV stroke work index (15%, P = .045) increased, with no effects on PVRI or Epa . Cardiac index did not change, assessed by thermodilution (P = .079) and echocardiography (P = .054). CONCLUSIONS: Higher doses of norepinephrine to a target MAP of 90 mm Hg improved RV systolic function while RV afterload was not affected.
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Ecocardiografía/métodos , Norepinefrina/farmacología , Choque Séptico/diagnóstico por imagen , Choque Séptico/fisiopatología , Función Ventricular Derecha/efectos de los fármacos , Anciano , Femenino , Hemodinámica/efectos de los fármacos , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Myocardial injury with regional wall motion abnormalities (RWMA) is common in subarachnoid haemorrhage (SAH). We hypothesized that the diagnostic performance of left ventricular (LV) global and regional longitudinal strain (GLS and RLS, respectively), assessed with speckle tracking echocardiography is superior to standard echocardiography for the detection of myocardial injury in SAH. METHODS: Seventy-one unselected patients with verified SAH were included. Echocardiography was performed within 48 hours after admission. hsTnT was followed daily up to 3 days post-admission. RWMA, LV ejection fraction (LVEF), GLS and RLS were analysed by two experienced echocardiographists, blinded to the information on plasma hsTnT. A reduced GLS was defined as >-15%. Two cut-off levels were used for the definition of RLS, ie when segmental strain was >-15% (liberal) or >-11% (conservative) in ≥2 adjacent segments. Myocardial injury was defined as a peak hsTnT ≥90 ng/L. RESULTS: The incidence of myocardial injury was 25%. The hsTnT (median, 25% and 75% percentile) in patients with (a) reduced LV ejection fraction (LVEF <50%, n = 10) was 502 (175-718), (b) RWMA (n = 12) was 648 (337-750), (c) reduced GLS (n = 12) was 502 (132-750) and (d) reduced RLS (n = 42) was 40 (10-216), respectively. The specificity/sensitivity for LVEF, RWMA, GLS and RLS to detect myocardial injury 98%/50%, 100%/67%, 96%/56% and 54%/94%, respectively. The intra- and inter-observer variability for assessment of RLS was high. CONCLUSION: The diagnostic performance of GLS by strain imaging is not superior to standard echocardiography for the detection of myocardial injury in SAH. RLS could not reliably detect regional myocardial injury.
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Ecocardiografía/métodos , Lesiones Cardíacas/diagnóstico por imagen , Hemorragia Subaracnoidea/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/análisis , Femenino , Lesiones Cardíacas/epidemiología , Lesiones Cardíacas/etiología , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Sensibilidad y Especificidad , Volumen Sistólico , Hemorragia Subaracnoidea/complicaciones , Función Ventricular IzquierdaRESUMEN
BACKGROUND: Myocardial deformation imaging using speckle-tracking echocardiography to assess global longitudinal strain (GLS) is today considered a more sensitive measure of left ventricular (LV) systolic function than ejection fraction. General anesthesia and positive pressure ventilation (PPV) are known to change the right ventricular (RV) and LV loading conditions. However, little is known about the effects of anesthesia and PPV on RV free wall and LV GLS. We studied the influence of general anesthesia and PPV on RV and LV longitudinal strain in patients without myocardial disease. METHODS: Twenty-one patients scheduled for non-cardiac surgery were included. The baseline examination was performed on the un-premedicated patients within 60 min of anesthesia. The second examination was performed 10-15 min after induction of anesthesia (propofol, remifentanil), intubation and start of PPV. The examinations included apical four-, two- and three-chamber projections, mitral and aortic Doppler flow velocities and tissue Doppler velocities of tricuspid and mitral annulus. LV end-systolic elastance (Ees) and aortic elastance were determined (Ea). RESULTS: General anesthesia and PPV reduced the mean arterial blood pressure (- 29%, p < 0.0019), stroke volume index (- 13%, p < 0.001) and cardiac index (- 23%, p < 0.001). RV end-diastolic area index and LV end-diastolic volume index decreased significantly, while systemic vascular resistance was not significantly affected. Ees decreased significantly with the induction of anaesthesia (- 23%, p = 0.002), while there was a trend for a decrease in Ea (p = 0.053). The ventriculo-arterial coupling, Ea/Ees, was not significantly affected by the anesthetics and PPV. The LV GLS decreased from - 19.1 ± 2.3% to - 17.3 ± 2.9% (p < 0.001) and RV free wall strain decreased from - 26.5 ± 3.9% to - 24.1 ± 4.2% (p = 0.001). One patient (5%) had at baseline a LV GLS > - 16% compared with 6 patients (28%) during general anesthesia and PPV. Three patients (14%) had a RV free wall strain > - 24% compared to 8 patients (38%) during general anesthesia and PPV. CONCLUSIONS: General anesthesia and PPV reduces systolic LV and RV function to levels considered indicating dysfunction in a substantial proportion of patients without myocardial disease.
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Anestesia General/efectos adversos , Ecocardiografía Doppler/métodos , Ventrículos Cardíacos/fisiopatología , Respiración con Presión Positiva/efectos adversos , Procedimientos Quirúrgicos Operativos , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Derecha/fisiopatología , Cardiomiopatías , Femenino , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Volumen Sistólico , Sístole , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/etiología , Disfunción Ventricular Derecha/diagnóstico , Disfunción Ventricular Derecha/etiología , Función Ventricular Izquierda/fisiología , Función Ventricular Derecha/fisiologíaRESUMEN
OBJECTIVES: In heart transplantation (HTx) with the bicaval technique the whole right atrium (RA) is donor tissue while the left atrium (LA) consists of both donor and recipient tissue. The aims of the study were to describe atrial function in comparison with healthy controls and to identify determinants of dysfunction. DESIGN: Forty-three patients and 30 controls were retrospectively included. Echocardiography was performed within 24 h of right heart catheterization (RHC) (HTx recipients). RESULTS: The peak longitudinal atrial systolic strain (É) described the atrial reservoir function. The LA and RA reservoir function were reduced versus controls (LA-É 18 ± 8 versus 44 ± 10%; RA-É 22 ± 10 versus 69 ± 17%, p < 0.001). There were moderate relationships between atrial-É and ventricular filling pressure (r = -0.64 for LA-É; r = -0.57 for RA-É). In a multiple regression analysis the LA-É was determined by pulmonary capillary wedge pressure (PCWP) and LA minimum volume index (r = -0.71) while RA-É was dependent on the right ventricular É (r = -0.77). CONCLUSIONS: Atrial reservoir function is markedly reduced in HTx recipients related to elevated PCWP and LA-enlargement in the LA and in the RA impaired longitudinal right ventricular function.
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Función del Atrio Izquierdo , Función del Atrio Derecho , Atrios Cardíacos/trasplante , Trasplante de Corazón/métodos , Adulto , Fenómenos Biomecánicos , Cateterismo Cardíaco , Ecocardiografía Doppler de Pulso , Electrocardiografía , Femenino , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/fisiopatología , Trasplante de Corazón/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Contracción Miocárdica , Presión Esfenoidal Pulmonar , Estudios Retrospectivos , Estrés Mecánico , Resultado del Tratamiento , Función Ventricular Izquierda , Función Ventricular Derecha , Adulto JovenRESUMEN
Objectives Cut-off values for left ventricular (LV) dimensions indicating severe valve regurgitation have not been defined. The aim of this study was to establish echocardiographic cut-off values for LV dimensions indicating severe chronic aortic (AR) or mitral (MR) regurgitation. Design The hemodynamic significance was confirmed by documented reduction of end-diastolic volume (EDV) and symptom relief after surgery. Eighty-three patients with moderate or severe regurgitation (AR, n = 41; MR, n = 42) without other cardiac conditions underwent prospectively two-dimensional (2DE), real-time three-dimensional (RT3DE) echocardiography and cardiovascular magnetic resonance (CMR) exams within 4 h. Results The relationship between EDVCMR and EDV2DE and EDVRT3DE were strong (R 0.95 and 0.91). EDV index cut-offs for 2DE/RT3DE >87/104 ml/m(2) identified AR patients with severe regurgitation with a positive likelihood ratio (PLR) of 5.0/5.0. The corresponding in patients with MR EDV index cut-offs were >69/87 ml/m(2) with a PLR of 14.9/5.5. LV linear dimensions could not identify patients with severe regurgitation. Conclusions LV volumes by echocardiography can support the diagnosis of severe chronic regurgitation. Importantly, other causes for LV enlargement have to be considered.
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Insuficiencia de la Válvula Aórtica , Ecocardiografía Tridimensional/métodos , Ventrículos Cardíacos , Insuficiencia de la Válvula Mitral , Volumen Sistólico , Adulto , Anciano , Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/cirugía , Enfermedad Crónica , Precisión de la Medición Dimensional , Femenino , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/patología , Humanos , Hipertrofia Ventricular Izquierda/diagnóstico , Hipertrofia Ventricular Izquierda/etiología , Imagen por Resonancia Cinemagnética/métodos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/cirugía , Tamaño de los Órganos , Índice de Severidad de la Enfermedad , Estadística como Asunto , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/etiologíaRESUMEN
Background Increased wall thickness in the aortic root has been suggested as an early sign of prosthetic valve endocarditis (PVE). However, there are no previous studies on the aortic wall thickness after aortic valve replacement (AVR) or in patients with PVE. Purpose To identify a clinically useful cutoff value for aortic wall thickness to detect PVE. Material and Methods Chest computed tomography (CT) studies (n = 303) on patients with a prosthetic aortic valve were retrospectively analyzed. CT studies on patients without PVE (n = 260) were compared with CT studies on patients with definite PVE (n = 43). A receiver operator characteristic (ROC) analysis was performed. Results In non-PVE patients, the wall thickness during the first 3 months postoperatively (n = 70, 4.5 ± 1.7 mm) was increased compared to beyond 3 months postoperatively (n = 190, 3.2 ± 1.0 mm, P < 0.001). Beyond 3 months postoperatively, the wall thickness 95th percentile was 5.0 mm without signs of further decrease with time. The wall thickness in PVE patients was 6.8 ± 3.0 mm (n = 43). Beyond 3 months postoperatively, ROC analysis yielded an area under the curve of 0.89 (95% CI, 0.81-0.96). With a cutoff value of 5 mm the sensitivity was 67%, specificity 95%, positive likelihood ratio 14.1, and negative likelihood ratio 0.35 of increased wall thickness in detecting PVE. Conclusion In the early postoperative period after AVR, the aortic wall thickness is increased compared to the late postoperative period. After 3 months, the wall thickness has decreased and stabilized. Increased wall thickness (>5 mm) beyond 3 months postoperatively significantly increases the likelihood of PVE.
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Aorta/diagnóstico por imagen , Endocarditis/diagnóstico por imagen , Prótesis Valvulares Cardíacas/microbiología , Infecciones Relacionadas con Prótesis/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Estudios RetrospectivosRESUMEN
BACKGROUND: Myocardial dysfunction is recognized in sepsis. We hypothesized that mechanical left (LV) and right (RV) ventricular function analysed using 2-dimensional speckle-tracking echocardiography in a cohort of early severe sepsis or septic shock patients, would be different to that of a group of critically ill, non-septic patients. METHODS: Critically ill adult patients with early, severe sepsis/septic shock (n = 48) and major trauma patients with no sepsis (n = 24) were included retrospectively, as well as healthy controls (n = 16). Standard echocardiographic examinations, including right (RV) left (LV) volumes and mitral, aortic and pulmonary vein Doppler flow profiles, were retrospectively identified and the studies were then reanalysed for assessment of myocardial strain using speckle-tracking echocardiography. Endocardial tracing of the LV was performed in apical four-chamber (4-Ch), two-chamber (2-Ch), apical long-axis (3-Ch) and apical views of RV determining the longitudinal LV and RV free wall strain in each subject. RESULTS: In septic patients, heart rate was significantly higher (p = 0.009) and systolic (p < 0.001) and mean arterial pressures (p < 0.001), as well as systemic vascular resistance (p < 0.001) were significantly lower when compared to the non-septic trauma group. Ninety-three per cent of the septic patients and 50% of the trauma patients were treated with norepinephrine (p < 0.001). LV ejection fraction (LVEF) was lower in the septic patients (p = 0.019). In septic patients with preserved LVEF (>50%, n = 34), seventeen patients (50%) had a depressed LV global longitudinal function, defined as a LV global strain > -15%, compared to two patients (8.7%) in the non-septic group (p = 0.0014). In septic patients with preserved LVEF, LV global and RV free wall strain were 14% (p = 0.014) and 17% lower (p = 0.008), respectively, compared to the non-septic group with preserved LVEF. There were no significant differences between groups with respect to LV end-diastolic or end-systolic volumes, stroke volume, or cardiac output. There were no signs of diastolic dysfunction from the mitral or pulmonary vein Doppler profiles in the septic patients. CONCLUSIONS: LV and RV systolic function is impaired in critically ill patients with early septic shock and preserved LVEF, as detected by Speckle-tracking 2D echocardiography. Strain imaging may be useful in the early detection of myocardial dysfunction in sepsis.
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Ecocardiografía/métodos , Diagnóstico por Imagen de Elasticidad/métodos , Choque Séptico/fisiopatología , Volumen Sistólico , Disfunción Ventricular/diagnóstico por imagen , Disfunción Ventricular/fisiopatología , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Choque Séptico/complicaciones , Choque Séptico/diagnóstico por imagen , Disfunción Ventricular/etiologíaRESUMEN
Diastolic dysfunction is a recognized complication in heart transplant (HTx) recipients that limits exercise capacity and is a risk factor for mortality. We investigated the ability of echocardiography to detect elevated pulmonary capillary wedge pressure (mean PCWP>15 mmHg) in HTx recipients. This retrospective study comprised HTx recipients with echocardiography and right heart catheterization within 24 hours (n = 100, 113 investigations). Echocardiographic assessment was performed using mitral inflow (E/A ratio, deceleration time [DT], isovolumic relaxation time [IVRT]), tissue Doppler (E/E' lateral) parameters, and the Doppler-estimated pulmonary artery systolic pressure (Doppler PASP). The right atrial pressure (RAP) was estimated based on size and the effect of respiration or sniffing on the inferior vena cava diameter. Cutoff values were determined from a derivation group (n = 57, receiver operator characteristic curve analysis) and evaluated in a test group (n = 56). Elevated PCWP were found in 38%. The RAP and PCWP were both normal in 58 investigations and elevated in 39 investigations (concordance rate of 86.6%). The presence of signs of increased RAP by echocardiography or with three of five parameters (E/A, DT, IVRT, E/E' lateral, and Doppler PASP) reaching the cutoff values ruled in elevated PCWP with positive likelihood ratios ranging from 15.3 to 9. With normal RAP by echocardiography or none of the other parameters reaching cutoff values elevated PCWP can be ruled out with negative likelihood ratios ranging from 0.07 to 0.19. In conclusion, elevated PCWP in HTx recipients can be assessed using echocardiography.
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Ecocardiografía Doppler/métodos , Trasplante de Corazón/efectos adversos , Interpretación de Imagen Asistida por Computador/métodos , Volumen Sistólico , Disfunción Ventricular Izquierda/etiología , Disfunción Ventricular Izquierda/fisiopatología , Adolescente , Adulto , Presión Sanguínea , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y Especificidad , Resultado del Tratamiento , Disfunción Ventricular Izquierda/diagnóstico por imagen , Adulto JovenRESUMEN
Proper interpretation of the spectral Doppler signal and elucidation of the underlying hemodynamics can at times be problematic due to confounding factors, one of them being a rapid heart rate. In this article, we discuss the use of carotid sinus massage (CSM) in the echocardiography laboratory as a maneuver to reduce the resting heart rate and thus render the transmitral Doppler signal more amenable to analysis. We provide examples of the value of the CSM in the assessment of left ventricular filling pressure.
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Seno Carotídeo/diagnóstico por imagen , Ecocardiografía Doppler/métodos , Masaje Cardíaco/métodos , Aumento de la Imagen/métodos , Palpación/métodos , Disfunción Ventricular Izquierda/diagnóstico por imagen , Anciano , Femenino , Humanos , MasculinoRESUMEN
Careful analysis of the Doppler profile, performance of maneuvers during image acquisition, and comparison of data with prior studies are basic tools that allow us to provide useful clinical information and improved diagnostic accuracy. Here, we discuss a patient in whom a thorough evaluation of the Doppler pattern at rest and during maneuvers and the identification of temporal changes in cardiac hemodynamics helped establish a diagnosis.
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Derivación Arteriovenosa Quirúrgica/efectos adversos , Cateterismo Cardíaco/efectos adversos , Ecocardiografía Doppler/métodos , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/etiología , Diálisis Renal/efectos adversos , Adulto , Humanos , MasculinoRESUMEN
Systematic imaging of the abdominal aorta during transthoracic echocardiography is advocated as a useful screening tool for aortic aneurysms. The addition of pulse Doppler interrogation to the two-dimensional imaging can be highly valuable and provides incremental hemodynamic information regarding a wide spectrum of diseases that involve the left heart, aorta, and vasculature. In this manuscript, we review the usefulness of pulse Doppler recording of the abdominal aorta and provide case examples of its value in various disease states.
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Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Arteriopatías Oclusivas/diagnóstico por imagen , Enfermedades Cardiovasculares/diagnóstico por imagen , Ecocardiografía Doppler de Pulso/métodos , Ecocardiografía/métodos , Femenino , Hemodinámica/fisiología , Humanos , Masculino , Valor Predictivo de las PruebasRESUMEN
AIMS: This study aimed to assess the use of high-sensitivity troponin T (hsTNT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in screening for cardiac dysfunction [left ventricular (LV) systolic or diastolic dysfunction or right ventricular (RV) dysfunction] in mixed intensive care unit (ICU) patients and establish whether these biomarkers are independently associated with an increased risk of death. METHODS: We performed a secondary analysis of a single-centre prospective observational study in which consecutive ICU patients were examined with transthoracic echocardiography (TTE) and cardiac biomarkers. Patients with systolic or diastolic LV dysfunction, RV dysfunction or a combination of these were compared with patients with normal cardiac function. Sensitivity and specificity for different cut-off levels were calculated using receiver operating characteristic curves. Regression models were used to evaluate the associations between cardiac biomarkers, sepsis, renal failure and mortality. RESULTS: A total of 276 patients were included. Most of the patients had cardiac dysfunction on TTE (64%). Combined cardiac dysfunction was most prevalent (71 patients, 26%), followed by isolated diastolic LV dysfunction (40 patients, 15%). Levels of hsTNT and NT-proBNP were higher in all types of cardiac dysfunction versus patients with normal cardiac function. The area under the curve (AUC) for hsTNT to detect any cardiac dysfunction was 0.75. An optimal cut-off at 30.5 ng/L rendered a positive predictive value (PPV) of 80% and a negative predictive value (NPV) of 58%. The AUC for NT-proBNP to detect any cardiac dysfunction was 0.788. Using an optimal cut-off at 1145 ng/L rendered a PPV of 86% and an NPV of 58%. Using a clinically relevant 90% sensitivity for detecting cardiac dysfunction put the cut-offs at 14.1 ng/L for hsTNT and 247 ng/L for NT-proBNP, resulting in a specificity of 48% and 46%, respectively. Levels of NT-proBNP were associated with sepsis and renal failure (P < 0.001), while levels of hsTNT were associated with renal failure only (P < 0.001) after adjustment for cardiac dysfunction. Levels of biomarkers were associated with an increased risk of 90 day mortality after adjustments for age, Simplified Acute Physiology Score 3, cardiac dysfunction and factors independently associated with biomarker increase (sepsis and renal failure) (P = 0.048 for hsTNT and P < 0.006 for NT-proBNP). CONCLUSION: Cardiac biomarkers, hsTNT and NT-proBNP, are strongly correlated to cardiac dysfunction in ICU patients and have a robust association with increased mortality. However, the relatively low NPV and the low specificity at relevant sensitivity levels of the biomarkers make them unsuitable for use in screening for cardiac dysfunction.
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AIMS: Risk stratification of patients with new-onset acute heart failure (AHF) is important but remains challenging. In the present study, we evaluated the prognostic value of a new multiparameter right ventricular dysfunction (RVD) score. METHODS AND RESULTS: Patients (n = 210) hospitalized due to new-onset AHF between 2015 and 2018 were retrospectively included. Mean age was 56 ± 10 years, 24% were female and median left ventricular ejection fraction was 28% (interquartile range 20; 34%). The RVD score, tricuspid annular plane systolic excursion (TAPSE), and fractional area change (FAC) were determined at index hospitalization and after therapy titration. The 4-point RVD score included reduced TAPSE, right ventricular enlargement, moderate or severe tricuspid regurgitation and increased central venous pressure. The study endpoint was a composite of all-cause mortality, left ventricular assist device implantation, and heart transplantation. After 60 months median follow-up time, 53 (25%) patients met the endpoint. At index hospitalization, there were no significant differences in any echocardiographic parameter between patients with and without the endpoint. After therapy titration, there were differences in TAPSE (16 vs. 19 mm, P = 0.001), FAC (33 vs. 40%, P < 0.001) and the proportion of patients with RVD score ≥2 (36 vs. 4%, P < 0.001). The presence of RVD despite therapy titration had different impact on survival depending on the parameter considered: the proportion of patients free from events after 1 year was 87% in patients with TAPSE <17 mm, 89% in patients with FAC <35% and 65% in patients with RVD score ≥2. In a multivariable analysis, RVD score ≥2 after therapy titration, but not TAPSE <17 mm or FAC < 35%, remained associated with a higher risk of the composite endpoint (hazard ratio 3.11, 95% confidence interval 1.44-6.74). CONCLUSIONS: A novel multiparametric RVD score might improve prognostic stratification in patients with new-onset AHF. RVD after therapy titration, but not at index hospitalization is associated with a higher risk of the composite endpoint.
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Background: Incidence of cryptogenic ischemic stroke (CIS) in young adults is increasing. Early left atrial (LA) myopathy might be 1 of the underlying mechanisms, but this has only been scarcely explored. Objectives: The purpose of this study was to assess the association between increased LA stiffness and CIS in young adults. Methods: In the multicenter SECRETO (Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome) study, LA function was analyzed by speckle tracking echocardiography in 150 CIS patients (aged 18-49 years) and 150 age- and sex-matched controls. Minimum and maximum LA volumes, LA reservoir and contractile strain were measured. LA stiffness was calculated by the ratio: mitral peak E-wave velocity divided by mitral annular e' velocity (E/e')/LA reservoir strain and considered increased if ≥0.22. Increased LA volumes, LA stiffness, and/or reduced LA strain indicated LA myopathy. Logistic regression was used to determine the relation between LA stiffness and CIS and the clinical variables associated with LA stiffness. Results: Increased LA stiffness was found in 36% of patients and in 18% of controls (P < 0.001). Increased LA stiffness was associated with a 2.4-fold (95% CI: 1.1-5.3) higher risk of CIS after adjustment for age, sex, comorbidities, and echocardiographic confounders (P = 0.03). In patients, obesity, pre-CIS antihypertensive treatment, older age, and lower LA contractile strain were all related to increased LA stiffness (all P < 0.05). Conclusions: LA myopathy with increased LA stiffness and impaired LA mechanics more than doubles the risk of CIS in patients under the age of 50 years. This provides new insights into the link between LA dysfunction and CIS at young ages. (Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome [SECRETO]; NCT01934725).
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BACKGROUND: Pulmonary hypertension (PH) is frequent in patients with heart failure and reduced ejection fraction (HFrEF) with 2 different phenotypes: isolated postcapillary PH (IpcPH) and, with the worst prognosis, combined pre- and postcapillary PH (CpcPH). The aims of the present echocardiography study were to investigate (1) the ability to identify PH phenotype in patients with HFrEF using the newly adopted definition of PH (mean pulmonary artery pressure >20 mm Hg) and (2) the relationship between PH phenotype and right ventricular (RV) function. METHODS: One hundred twenty-four patients with HFrEF consecutively referred for heart transplant or heart failure workup were included with echocardiography and right heart catheterization within 48 hours. We estimated systolic pulmonary artery pressure (sPAPDoppler) and used a method to detect increased pulmonary vascular resistance (>3 Wood units) based on predefined thresholds of 3 pressure reflection (PRefl) variables (the acceleration time in the RV outflow tract [RVOT], the interval between peak RVOT and peak tricuspid regurgitant velocity, and the RV pressure augmentation following peak RVOT velocity). RESULTS: Using receiver operator characteristic analysis in a derivation group (n = 62), we identified sPAPDoppler ≥35 mm Hg as a cutoff that in a test group (n = 62) increased the likelihood of PH 6.6-fold. The presence of sPAPDoppler >40 mm Hg and 2 or 3 positive PRefl variables increased the probability of CpcPH 6- to 8-fold. A 2-step approach with primarily assessment of sPAPDoppler and the supportive use of PRefl variables in patients with mild/moderate PH (sPAPDoppler 41-59 mm Hg) showed 76% observer agreement and a weighted kappa of 0.63. The steady-state (pulmonary vascular resistance) and pulsatile (compliance, elastance) vascular loading are increased in both IpcPH and CpcPH with a comparable degree of RV dysfunction. CONCLUSIONS: The PH phenotype can be identified in HFrEF using standard echocardiographic assessment of pulmonary artery pressure with supportive use of PRefl variables in patients with mild to moderate PH.
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Insuficiencia Cardíaca , Hipertensión Pulmonar , Disfunción Ventricular Izquierda , Humanos , Hipertensión Pulmonar/diagnóstico , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/diagnóstico por imagen , Arteria Pulmonar/diagnóstico por imagen , Volumen Sistólico , Ecocardiografía , FenotipoRESUMEN
PURPOSE: Left ventricular (LV) diastolic dysfunction is important in critically ill patients, but prevalence and impact on mortality is not well studied. We classified intensive care patients with normal left ventricular function according to current diastolic guidelines and explored associations with mortality. MATERIAL AND METHODS: Echocardiography was performed within 24 h of intensive care admission. Patients with reduced LV ejection fraction, regional wall motion abnormality, or a history of cardiac disease were excluded. Patients were classified according to the 2016 EACVI guidelines, Recommendations for the Evaluation of LV Diastolic Function by Echocardiography. RESULTS: Out of 218 patients, 162 (74%) had normal diastolic function, 21 (10%) had diastolic dysfunction, and 35 (17%) had indeterminate diastolic function. Diastolic dysfunction were more common in female patients, older patients and associated with sepsis, respiratory and cardiovascular comorbidity as well as higher SAPS Score. In a risk-adjusted logistic regression model, patients with indeterminate diastolic dysfunction (OR 4.3 [1.6-11.4], p = 0.004) or diastolic dysfunction (OR 5.1 [1.6-16.5], p = 0.006) had an increased risk of death at 90 days compared to patients with normal diastolic function. CONCLUSION: Isolated diastolic dysfunction, assessed by a multi-parameter approach, is common in critically ill patients and is associated with mortality. TRIAL REGISTRATION: Secondary analysis of data from a single-center prospective observational study focused on systolic dysfunction in intensive care unit patients (Clinical Trials ID: NCT03787810.