Association of Thromboembolic Risk Score with Left Atrial Thrombus and Spontaneous Echocardiographic Contrast in Non-Anticoagulated Nonvalvular Atrial Fibrillation Patients.

OBJECTIVES: The aim of the study was to examine the association of CHADS2/CHA2DS2-VASc scores with left atrial thrombus (LAT) and spontaneous echocardiographic contrast (SEC) in non-anticoagulated nonvalvular atrial fibrillation (NVAF) spontaneous patients, and to develop a new scoring system for LAT/SEC prediction. METHODS: Consecutive non-anticoagulated NVAF patients with or without LAT/SEC by transesophageal echocardiography were identified in the Guangdong General Hospital. RESULTS: Among 2,173 patients, the prevalence of LAT/SEC was 4.9%. Both predictive values of CHADS2 and CHA2DS2-VASc scores for the presence of LAT/SEC were low-to-moderate (receiver operating characteristic [ROC] = 0.591 and 0.608, respectively, p = 0.90). By multivariate analysis, non-paroxysmal AF, decreased left ventricular ejection fraction, and left atrial enlargement were positively associated with LAT/SEC, while CHADS2/CHA2DS2VASc scores were not. A new scoring system based on these 3 factors above significantly improved the discrimination for LAT/SEC (ROC = 0.792). CONCLUSIONS: CHADS2/CHA2DS2-VASc scores had limited value in predicting LAT/SEC; a new scoring system that combines AF type and echocardiographic parameters may better predict LAT/SEC as a surrogate for cardioembolic risk in NVAF patients.

Left Ventricular Global Longitudinal Strain in HER-2 + Breast Cancer Patients Treated with Anthracyclines and Trastuzumab Who Develop Cardiotoxicity Is Associated with Subsequent Recovery of Left Ventricular Ejection Fraction.

AIM: The combination of anthracyclines (AC) and trastuzumab (TRZ) is highly effective in patients with aggressive HER-2 + breast cancer, but has a significant risk of cardiotoxicity (CT). Trastuzumab-induced CT may be reversible. The aim of this study was to identify echocardiographic parameters associated with recovery of left ventricular ejection fraction (LVEF) in patients who developed CT after AC and TRZ treatment. METHODS AND RESULTS: Women with newly diagnosed breast cancer treated with AC followed by TRZ and monitored with serial echocardiograms were retrospectively studied. Left ventricular end-diastolic and systolic volumes, LVEF, and global longitudinal strain (GLS) were examined. Development and reversibility of CT were defined based on changes in LVEF according to the 2014 ASE/EACVI recommendations. Cox analysis was used to determine the association of echocardiographic variables with the subsequent development and reversibility of CT. Ninety-five patients underwent 5 echocardiograms or more in a 17-month (13-28 months) follow-up period. Nineteen patients (20%) developed CT. Left ventricular volumes, LVEF, and GLS measured after AC completion identified the subsequent development of CT. Of the 19 patients with CT, the LVEF partially or fully recovered in 13 (68%). GLS at the time of CT diagnosis was associated with subsequent recovery of LVEF (P = 0.004). CONCLUSION: In patients with breast cancer treated with AC and TRZ who develop CT, GLS at the time of CT diagnosis is associated with subsequent recovery of LVEF and may be useful for risk stratification and to guide treatment.

Transesophageal echocardiography for coronary sinus imaging in partially unroofed coronary sinus.

BACKGROUND: Partially unroofed coronary sinus (PUCS) is a rare congenital cardiac anomaly and prone to be misdiagnosed. The purpose of this study was to explore the value of transesophageal echocardiography (TEE) in CS imaging for the detection of PUCS and to develop a special two-dimensional TEE-based en face view of CS. METHODS: Twenty adult patients with suspected PUCS, showing a dilated coronary sinus and an enlarged right heart on transthoracic echocardiography (TTE), underwent TEE examination. In the mid-esophageal plane and close to an angle of 120°, the en face view of the CS successfully imaged the roof of the CS, which was beyond the realm of the atrial septum, and the interatrial septum was obtained simultaneously in the same view. Meanwhile, the 3D zoom mode could clearly display the comprehensive volume image and the adjacent structures of the PUCS. The results of TEE were compared with the findings of surgery or catheterization. RESULTS: En face view of the CS was obtained successfully by 2DTEE in 20 patients. In addition, 3DTEE was used for imaging of PUCS in 11 of the 20 patients. PUCS was ultimately confirmed in 13 patients either by surgery or catheterization. The TEE for PUCS diagnosis was consistent with the surgical findings. CONCLUSION: Transesophageal echocardiography can be successfully applied to obtain the comprehensive view of CS and its surrounding structures. The en face view of CS provided by 2DTEE may be helpful in better understanding PUCS and discriminating it from associated atrial septal defects.

[Distribution of variant alleles association with warfarin pharmacokinetics and pharmacodynamics in the Han population in China].

OBJECTIVE: To investigate distribution of CYP2C9, CYP3A4, VKORC1 and GGCX gene polymorphisms in the Han population of Guangdong. METHODS: The subjects included were 970 Chinese Han patients who received long-term warfarin anticoagulant therapy orally after valve replacement in Guangdong General Hospital between 2000 and 2008. By selecting and analyzing the 12 single nucleotide polymorphisms (SNPs) loci, rs12572351 G>A, rs9332146 G>A, rs4917639 G>T, rs1057910 A>C (CYP2C9*3), rs1934967 G>T, rs1934968 G>A, rs2242480 T>C, rs2246709 G>A, rs9923231 C>T (VKORC1-1639 G>A), rs2359612 G>A (VKORC1*2), rs10871454 C>T, and rs699664 T>C, in 4 genes including CYP2C9, CYP3A4, VKORC1 and GGCX that were possibly correlated with warfarin pharmacodynamics and pharmacokinetics through literature retrieval, the distribution of mutation frequencies of the 12 SNPs loci in Chinese Han population were obtained systematically. SNaPshot technique was used to detect gene SNPs, Hardy-Weinberg genetic equilibrium test was used to test population representativeness. RESULTS: The allelic mutation frequency at CYP2C9 gene rs12572351 G>A, rs9332146 G>A, rs4917639 C>A, rs1057910 A>C (*3), rs1934967 G>T and rs1934968 G>A loci was 32.53%, 2.16%, 8.25%, 3.61%, 19.18% and 37.37%, respectively; the allelic mutation frequency at CYP3A4 gene rs2242480 T>C and rs2246709 G>A loci was 29.07% and 40.41%, respectively; the allelic mutation frequency at VKORC1 gene rs9923231 C>T, rs2359612 G>A and rs10871454 C>T SNPs loci was 87.99%, 87.94% and 91.34%, respectively; the allelic mutation frequency at GGCX gene rs699664 T>C locus was 31.86%. CONCLUSION: It is of important clinical significance in individualized warfarin therapy to systematically study distribution of mutation frequencies at 12 polymorphisms loci in 4 genes including CYP2C9, CYP3A4 , VKORC1 and GGCX related to warfarin pharmacodynamics and pharmacokinetics in the Chinese Han population receiving valve replacement.

[Impact of CYP2C9 and VKORC1 polymorphism on warfarin response during initiation of therapy].

OBJECTIVE: To investigate potential contributions of genetic variants of cytochrome P-450 2C9 (CYP2C9) and vitamin K expoxide reductase (VKORC1) to the anticoagulation response during the initiation of warfarin therapy in the Han Chinese population. METHODS: A total of 798 Han Chinese patients received long-term warfarin anticoagulant therapy orally after valve replacement in our hospital between 2000 and 2008 were included in this study. Nine single nucleotide polymorphism (SNP) loci [rs12572351 G > A, rs9332146 G > A, rs4917639 G > T, rs1057910 A > C (CYP2C9(*)3), rs1934967 G > T, rs1934968 G > A, rs9923231 C > T (VKORC1-1639 G > A), rs2359612 G > A and rs10871454 C > T] in 2 genes including CYP2C9 and VKORC1, which were possibly correlated with warfarin pharmacokinetics and pharmacodynamics through literature retrieval, were selected and analyzed. Warfarin steady-state dose requirement, time to the INR (the international normalized ratio) within the therapeutic range and percent of the INR of more than 3.5 were compared among genotype subgroups. SNaPshot technique was used to detect gene SNPs; Hardy-Weinberg genetic equilibrium test was used to test population representativeness. RESULTS: CYP2C9(*)3 genotype did not affect the required warfarin dose while it was associated with increased risk of bleeding when treated with routine dosage regimen during the initiation of treatment. The allelic mutation frequency at VKORC1 gene rs10871454G > A and VKORC1-1639G > A SNP loci was 92.04% and 88.03%, respectively and rs10871454 was in perfect linkage disequilibrium with-1639. Patients with VKORC1 rs10871454 genetic mutation required lower warfarin dose in the first 28 days of therapy. VKORC1-1639 genetic polymorphism was also associated with shorter time to the INR within the therapeutic range and increased risk of over-anticoagulation. CONCLUSION: Detecting genetic polymorphism of CYP2C9 and VKORC1 could guide clinical use of warfarin to reduce the risk of adverse reactions including bleeding in patients receiving chronic anticoagulation therapy.

Prediction value of pulmonary hypertension in newly identified left ventricular dysfunction among adult patients after patent ductus arteriosus closure.

The present study aimed to propose the pulmonary hypertension for predicting left ventricular dysfunction in adults after patent ductus arteriosus closure. A total of 183 patients (age ≥18 years) after patent ductus arteriosus occlusion were retrospectively collected in this study. In brief, pre-, post-procedure and short-term follow-up transthoracic echocardiography were performed. Simpson's method was used to measure the left ventricular ejection fraction (LVEF), and LVEF less than 50% after procedure was utilized as a criterion to identify left ventricular dysfunction. As a result, 36 (19.67%) patients developed newly identified left ventricular dysfunction. The rate of newly identified left ventricular dysfunction was significantly higher in moderate or severe pulmonary hypertension groups compared to the groups of mean pulmonary artery pressure (mPAP) <25 mmHg (P < .001). Logistic regression analysis showed that elevated mPAP ( ≥25 mmHg) was an independent predictive value for newly identified left ventricular dysfunction (OR = 3.584, 95%CI: 1.186-10.832, P = .024) after adjusting confounders. The ROC curve revealed a good discrimination power for predicting newly identified left ventricular dysfunction (AUC = 0.924, 95%CI: 0.885-0.963, P < .001). Taken together, newly identified left ventricular dysfunction after patent ductus arteriosus closure was prevalent in patients with elevated mPAP. The pre-procedure elevated mPAP is an independent risk factor for the prediction of the newly identified left ventricular dysfunction in adult patients undergoing percutaneous patent ductus arteriosus closure. It is feasible to propose a risk model for predicting post-procedure left ventricular dysfunction and a heart function monitoring in pulmonary hypertension patients.

[Thoracic aorta echocardiographic features of patients with bicuspid aortic valve].

OBJECTIVE: To observe the thoracic aorta features in patients with bicuspid aortic valve (BAV) with echocardiography. METHODS: We retrospectively analyzed the echocardiographic features and clinical manifestations in 273 patients with BAV detected from 1991-04 to 2006-02. RESULTS: (1) Aortic dimensions of the anulus, the sinuses of valsalva, the sinotubular junction, the ascending aorta at the level of its largest diameter of 31 patients with functionally normal BAV were significantly increased compared that in control subjects (P < 0.01 to P < 0.001) while the dimension of the descending aorta posterior to the left atrium was similar between the two groups (P > 0.05). (2) There is no relation between the vulval positions of BAV and aortic dimensions (P > 0.05). (3) The dimensions of the annulus as well as the sinuses of valsalva were negatively related to the aortic valve gradient, and the dimension of the annulus, the sinuses of valsalva and sinotubular junction were positively related to the degree of aortic regurgitation in 273 patients with BAV (all P < 0.05). CONCLUSION: Our results show there is a hemodynamic independent thoracic aortic dilation in patients with functionally normal BAV. Gradient and aortic regurgitation are related to the dimension of the annulus, the sinuses of valsalva and sinotubular junction in patients with BAV.

[Left atrial size and function after radiofrequency catheter ablation for paroxysmal atrial fibrillation].

OBJECTIVE: To evaluate the impact of radiofrequency catheter ablation on left atrial (LA) size and function in patients with paroxysmal atrial fibrillation (PAF) and whether there is any difference between segmental pulmonary vein ostial isolation (SPVI) and circumferential pulmonary vein ablation (CPVA). METHODS: Sixty-six patients with highly symptomatic atrial fibrillation were assigned to undergo either SPVI or CPVA. Transthorax echocardiography was performed before, 1 day, 1 months and 3 months after the procedure. LA dimension, LA area, late diastolic peak velocity of mitral valve inflow (A) and peak atrial systolic mitral annulus velocity (A') were recorded. RESULTS: Of 66 consecutive patients with symptomatic PAF, 30 patients underwent SPVI and 36 underwent CPVA. After a mean follow-up of (315 +/- 153) days, 21 patients (70%) after SPVI and 28 patients (75%) after CPVA were free of atrial tachyarrhythmia. As compared with the baseline, LA area decreased at 1-month after ablation in SPVI group and at 3-month in CPVA group. LA dimension decreased also in SPVI group, but did not in CPVA group. A velocity and A' velocity declined remarkably 1 day after CPVA, and restored 3 months later. The former went back to the level of baseline, and the latter exceeded it apparently. In SPVI group, A velocity increased at 1-month, and maintained in 3-month after ablation. A' velocity increased at 3-month after ablation. No reduction of A velocity or A' velocity was found after SPVI. CONCLUSIONS: This study demonstrated a decrease in LA area and an improvement in LA systolic function 3 months after ablation for PAF. The LA damage by CPVA was more than that by SPVI, which was characterized by the reduction of LA function 1 day after procedure and the delayed improvement of LA size and functional parameters.

Activation of miR-34a-5p/Sirt1/p66shc pathway contributes to doxorubicin-induced cardiotoxicity.

The molecular mechanisms underlying anthracyclines-induced cardiotoxicity have not been well elucidated. MiRNAs were revealed dysregulated in the myocardium and plasma of rats received Dox treatment. MicroRNA-34a-5p (miR-34a-5p) was verified increased in the myocardium and plasma of Dox-treated rats, but was reversed in rats received Dox plus DEX treatments. Human miR-34a-5p was also observed increased in the plasma of patients with diffuse large B-cell lymphoma after 9- and 16-week epirubicin therapy. Up-regulation of miR-34a-5p was observed in Dox-induced rat cardiomyocyte H9c2 cells. MiR-34a-5p could augment Bax expression, but inhibited Bcl-2 expression, along with the increases of the activated caspase-3 and mitochondrial potentials in H9C2 cells. MiR-34a-5p was verified to modulate Sirt1 expression post-transcriptionally. In parallel to Sirt1 siRNA, miR-34a-5p could enhance p66shc expression, accompanied by increases of Bax and the activated caspase-3 and a decrease of Bcl-2 in H9c2 cells. Moreover, enforced expression of Sirt1 alleviated Dox-induced apoptosis of H9c2 cells, with suppressing levels of p66shc, Bax, the activated caspase-3 and miR-34a-5p, and enhancing Bcl-2 expression. Therefore, miR-34a-5p enhances cardiomyocyte apoptosis by targeting Sirt1, activation of miR-34a-5p/Sirt1/p66shc pathway contributes to Dox-induced cardiotoxicity, and blockage of this pathway represents a potential cardioprotective effect against anthracyclines.

Myocardial Strain Is Associated with Adverse Clinical Cardiac Events in Patients Treated with Anthracyclines.

BACKGROUND: Anthracycline-induced symptomatic heart failure is often irreversible, underlining the usefulness of pretreatment risk assessment. Global longitudinal strain (GLS) before or after chemotherapy is associated with a later decrease in left ventricular ejection fraction (LVEF); however, whether prechemotherapy GLS is associated with symptomatic heart failure and cardiac death in patients treated with anthracyclines is unknown. METHODS: Patients with hematologic cancers treated with anthracyclines who underwent prechemotherapy echocardiography between November 2006 and June 2011 were retrospectively recruited. Basic demographic data, end-diastolic and end-systolic left ventricular volumes, LVEF, and GLS were measured. Clinical cardiac events (CEs) were defined as cardiac death or symptomatic heart failure. The association of prechemotherapy parameters with CEs was analyzed using proportional hazard analysis. RESULTS: Over a median follow-up period of 1,593 days (range, 13-2,891 days) after the start of chemotherapy, 28 of 450 patients (6%) experienced CEs. Prechemotherapy LVEF and GLS were lower in patients with CEs compared with those without CEs (58 ± 10% vs 62 ± 7% [P = .005] and -15.0 ± 2.8% vs -19.7 ± 2.7% [P < .0001], respectively). Diabetes (hazard ratio [HR], 7.06; P < .0001), hypertension (HR, 2.22; P = .04), LVEF (HR, 0.93; P = .005), and GLS (HR, 1.47; P < .0001) were associated with CEs. After controlling for clinical variables, prechemotherapy GLS remained independently associated with CEs (P < .0001). GLS less than the absolute value of -17.5% was found in 105 patients (23%) and was associated with a sixfold increase in CEs (P < .0001). CONCLUSIONS: Prechemotherapy GLS is an effective tool to stratify patients at high risk for CEs after anthracycline therapy and may help tailor treatments to decrease anthracycline-induced cardiotoxicity.

Tricuspid leaflet resection in an open beating heart for the creation of a canine tricuspid regurgitation model.

OBJECTIVES: Outcomes of tricuspid valve replacement are poor, partly due to right heart remodelling. The research on its underlying mechanisms is hampered by a lack of animal models of tricuspid regurgitation (TR). Our objective was to create a reproducible and clinically compatible TR animal model to study right heart remodelling caused by TR. METHODS: Fourteen juvenile male Beagle dogs were divided randomly into an intervention group (n = 11) and a sham-operated control group (n = 3). The intervention group underwent thoracotomy and right atrial incision following superior and inferior vena caval occlusion. The anterior leaflet, together with the chordae, of the tricuspid valve was resected in eight dogs ('one leaflet' group), whereas both anterior and posterior leaflets, together with the chordae, were resected in three dogs ('two leaflets' group). The right atrium and chest were then closed. The control group underwent the same procedure, except leaflet resection. One dog from the 'two leaflets' group and one control dog were sacrificed and autopsy was performed at 12 months post-surgery. RESULTS: All dogs survived over the 1-year observation period postoperatively. TR grade IV occurred immediately postoperatively in the 'one leaflet' group, and TR grade IV plus in the 'two leaflets' group. The overall procedure lasted 30-40 min, and the mean time of vena caval occlusion was 87 ± 10 s. Central venous pressure increased from 6 ± 1.2 at baseline to 13 ± 1.7 mmHg (P < 0.01). By 12 months after TR creation, both in the 'one leaflet' group and in the 'two leaflets' group, the right atrial area, tricuspid annular diameter and right ventricular index of myocardial performance increased significantly, right ventricular fractional area change and tricuspid annular plane systolic excursion decreased significantly. Autopsy of the intervention dog revealed oedema, ascites and cirrhosis. CONCLUSIONS: Our surgical technique to create a TR animal model was reproducible with high success and survival rates. This animal model would prove suitable to investigate the mechanisms of right heart remodelling.

Right ventricular outflow tract septal pacing versus apical pacing: A prospective, randomized, single-blind 5-years follow-up study of ventricular lead performance and safety.

Lead placement for ventricular pacing variably impacts the physiological benefit of the patient. This study evaluated the ventricular lead performance and safety of right ventricular outflow tract septal pacing in patients with bradyarrhythmia in South China over 60-month follow-up. Totally, 192 patients (108 males, and 84 females, 63±21 years old) with bradyarrhythmia were randomly divided into two groups. The right ventricular outflow tract septum (RVOTs) group had lead placement near the septum (n=97), while the right ventricular apex (RVA) group had a traditional apical placement (n=95). RV septal lead positioning was achieved with a specialized stylet and confirmed using fluoroscopic projection. All patients were followed up for 60 months. Follow-up assessment included stimulation threshold, R-wave sensing, lead impedance and lead complications. The time of electrode implantation in both the ROVTs and RVA groups were significantly different (4.29±0.61 vs. 2.16±0.22 min; P=0.009). No differences were identified in threshold, impedance or R-wave sensing between the two groups at 1st, 12th, 36th and 60th month during the follow-up period. No occurrence of electrode displacement, increased pacing threshold or inadequate sensing was found. The long-term active fixation ventricular electrode performance in RVOTs group was similar to that in RVA group. RVOTs pacing near the septum using active fixation electrodes may provide stability during long-term follow-up period.

Validation of real-time three-dimensional echocardiography for quantifying left and right ventricular volumes: an experimental study.

BACKGROUND: Assessment of the left ventricular (LV) and the right ventricular (RV) volumes and their functions is important for prognostic prediction and clinical decision making. We compared the accuracy for quantifying the LV and the RV volumes in vitro between conventional two-dimensional echocardiography (2DE) and real-time three-dimensional echocardiography (RT3DE). METHODS: The volumes of 37 rubber-models (10 regularly shaped to simulate normal LV, 7 shaped to simulate LV with symmetric aneurysm, 8 shaped to simulate LV with asymmetric aneurysm, and 12 irregularly shaped to simulate normal RV) and 10 excised canine hearts were measured by RT3DE and 2DE. On RT3DE "full volume" imaging, the inner-surfaces of the rubber-models and canine LV and RV were outlined and the volumes were measured using 2-, 4-, 8- and 16-plane methods with the RT3DE analysis software. On 2DE imaging, the volumes were measured by the Simpson method. The LV and RV volumes measured by drained water were served as reference values, with which we compared RT3DE and 2DE data. RESULTS: In rubber models mimicking normal LV and LV with symmetric aneurysms, RT3DE results were strongly correlated with reference values (r = 0.795 - 0.998) and there was a good correlation between 2DE estimates and reference values (r = 0.715 - 0.729). There were no significant differences between RT3DE estimates, 2DE results and reference values (P > 0.05). In rubber models mimicking the RV and LV with asymmetric aneurysm, RT3DE strongly correlated with reference values (r = 0.765 - 0.988), but 2DE weakly correlated with reference values (r = 0.518 - 0.592). There were no differences between RT3DE and reference values (P > 0.05), but a significant difference between 2DE and reference values occurred (P < 0.05). For excised canine hearts, there was a strong correlation between RT3DE and reference values (r = 0.728 - 0.914), while 2DE showed a less obvious correlation (r = 0.502 - 0.615). Again, there were no significant differences between RT3DE and reference values (P > 0.05), but there was a significant difference between 2DE and reference values (P < 0.05). CONCLUSIONS: RT3DE can accurately quantify LV and RV volumes and provides a new tool to evaluate LV and RV function. For LV and RV measurements by RT3DE, 8-plane strategy is the optimum choice for accuracy and convenience.

Real-time three-dimensional myocardial contrast echocardiography in assessment of myocardial perfusion defects.

BACKGROUND: Both real-time three-dimensional echocardiography (RT3DE) and myocardial contrast echocardiography (MCE) are novel imaging techniques. The purpose of this study was to confirm the feasibility and accuracy of RT3DE combined with MCE for quantitative evaluation of myocardial perfusion defects. METHODS: Thirteen dogs underwent ligation of the left anterior descending artery (LAD, n = 6) or distal branch of the left circumflex artery (LCX, n = 7) under general anaesthesia. Three to four ml of a perfluoropropane (C3F8) microbubble contrast agent was injected intravenously to assess the resulting myocardial perfusion defects with a commercially available Philips SONOS-7500 ultrasound system. After removal of the dog hearts, Evans blue dye was injected via the left and right coronary arteries to stain the myocardium at risk. In vitro anatomic measurements of myocardial mass after removal of the animals' hearts were used as controls. RESULTS: Left ventricular (LV) mass determined by RT3DE ranged 36.7 - 68.9 g [mean, (54.6 +/- 9.6) g] before coronary artery ligation, and correlated highly (r = 0.99) with in vitro measurement of LV mass [range, 38.9 - 71.1 g; mean, (55.6 +/- 9.3) g]. There was no significant difference between RT3DE and in vitro measurements of LV mass [range, 36.7 - 68.9 g; mean, (51.3 +/- 12.5) g. Or range, 38.9 - 71.1 g; mean, (53.7 +/- 12.3) g, respectively] and under-perfused mass [range, 0 - 21.4 g; mean, (12.0 +/- 6.9) g. Or range, 0 - 19.8 g; mean, (10.8 +/- 6.3) g, respectively] after the LAD ligation (P > 0.05). Likewise, no significant difference was present between RT3DE and in vitro measurements of LV mass [range, 50.1 - 65.4 g; mean, (57.5 +/- 5.9) g. Or range, 51.5 - 65.8 g; mean, (57.3 +/- 6.4) g, respectively] and under-perfused mass [range, 0 - 25.6 g; mean, (13.3 +/- 9.6) g. Or range, 0 - 22.7 g; mean, (12.8 +/- 8.1) g, respectively] after the LCX ligation (P > 0.05). For all the animals with coronary ligation, LV mass measured by RT3DE ranged 35.9 - 68.6 g [mean, (54.8 +/- 10.0) g] and there was no significant difference between RT3DE and in vitro measurements of LV mass and under-perfused mass (P > 0.05, r = 0.99). Further, the under-perfused mass derived from RT3DE [range, 0 - 25.6 g; mean, (12.7 +/- 8.2) g] correlated strongly with the in vitro measurements [range, 0 - 22.7 g; mean, (11.9 +/- 7.2) g] (r = 0.96). CONCLUSION: RT3DE with MCE is a rapid and accurate method for estimating LV myocardial mass and quantifying perfusion defects.

Real-time three-dimensional echocardiography for quantifying left ventricular mass.

OBJECTIVE: To test the accuracy of real-time three-dimensional echocardiography (RT3DE) imaging system for evaluating left ventricular mass (LVM) in phantom and excised canine heart. METHODS: Ten left ventricular (LV) wall phantoms made of two rubber-bursas, ten excised canine hearts underwent RT3DE and two-dimensional echocardiography (2DE). In RT3DE "full volume" imaging, the myocardial volume was measured using 2, 4, 8, and 16-plane method with the analysis software of RT3DE. Mass was then calculated by multiplying the resulting myocardial volume by specific density of myocardial tissue. In 2DE the masses were measured by area-length method. The true LV wall phantom mass was measured by water displacement and the canine LVM was weighed by anatomy, which served as a reference standard. We compared RT3DE or 2DE with true mass. RESULTS: In LV wall phantoms, RT3DE correlated with true masses strongly (r = 0.813-0.994) and weakly correlated between 2DE and true masses (r = 0.628). In excised canine hearts, there is an excellent correlation between RT3DE and true masses (r = 0.764-0.991), while 2DE value showed a lesser correlation (r = 0.514). There are no difference between RT-3DE and true masses (P > 0.05) but different between 2DE and true masses (P < 0.05). In different planes, there was no difference between 8-plane and 16-plane (P > 0.05) but different between 8-plane and 2, 4-plane (P < 0.05). CONCLUSION: RT3DE can accurately quantify LVM and provide a new tool to evaluate LV function. For LVM by RT3DE, 8-plane measurement method is the best choice for accuracy and convenience.

Real-time three-dimensional transesophageal echocardiography to predict artificial chordae length for mitral valve repair.

BACKGROUND: Artificial chordae replacement is an effective technique for mitral valve repair, however, it is difficult to accurately determine the length of artificial chordae. This study aimed to assess the reliability and accuracy of real-time three-dimensional transesophageal echocardiography (TEE) to predict the length of artificial chordae preoperatively. METHODS: From December 2008 to December 2010, 48 patients with severe mitral regurgitation successfully underwent mitral valve repair using artificial chordae replacement. The patients were divided into a TEE pre-measurement group (n = 26) and a direct measurement group (n = 22), according to the method used to determine the length of artificial chordae. Cardiopulmonary bypass time, aortic cross-clamp time, and the recurrence rate of moderate or severe mitral regurgitation were compared between the two groups. RESULTS: There were no operative deaths in either group. The mean cardiopulmonary bypass time was 113.0 ± 18.7 min and 127.0 ± 28.9 min (p < 0.05), and the aortic cross-clamp time was 70.0 ± 16.6 min and 86.0 ± 20.7 min (p < 0.05) in the TEE pre-measurement group and direct measurement group, respectively. The difference between the pre-measured artificial chordal length and actual constructed artificial chordal length was not significant in the TEE pre-measurement group (p > 0.05). Although the difference in the incidence of moderate or severe mitral regurgitation between the two groups was not significant (p > 0.05), the incidence in the TEE pre-measurement group (3.8%) was lower than that in the direct measurement group (18.2%). CONCLUSIONS: Real-time three-dimensional transesophageal echocardiography can accurately predict the length of artificial chordae required for mitral valve repair, and shortens cardiopulmonary bypass time and aortic cross-clamp time while improving the results of mitral valve repair.

[Clinical application of anticoagulation treatment with warfarin after prosthetic heart valve replacement: a single center-based survey].

OBJECTIVE: To investigate the clinical application of anticoagulation treatment with warfarin after prosthetic heart valve replacement and compare the effect and safety of different anticoagulant intensities. METHODS: A total of 845 Chinese patients receiving oral warfarin for anticoagulant treatment after prosthetic heart valve replacement in Guangdong General Hospital between 2000 and 2008 were enrolled in this survey. The general data, clinical data, medications, international normalized ratio (INR) and results of echocardiogram of these patients were followed up to observe the incidence of complication of thrombo-embolism and such adverse effect as hemorrhage. RESULTS: All the patients were of Han nationality, and Cantonese accounted for 88.04%. The daily mean maintenance dose of warfarin was 2.92∓0.88 mg in these patients with a median INR of 2.09∓0.39. Of these patients, 44.62% received low-intensity anticoagulant treatment with warfarin with the INR maintained between 1.5 and 2.0, and 56.45% had standard anticoagulant intensity with the INR maintained between 2.0 and 3.0. The total incidence of thrombo-embolism was 4.14%. Severe hemorrhage occurred in 14 cases (1.66%), most frequently in the alimentary tract. The events of hemorrhage were correlated to the type of prosthetic heart valve replacement, occurring more frequently in patients with mechanical prosthetic heart valve replacement than in those with biological ones. No significant difference was found in the incidence of thrombo-embolism and server hemorrhage between the two groups receiving low and standard intensity therapy anticoagulant. CONCLUSION: The effect and safety of low-intensity anticoagulant treatment are comparable to that of standard intensity treatment in Chinese Han patients, and anticoagulation treatment with warfarin is effective and safe to maintain the INR between 1.8-3.0.

Experimental study of quantitative assessment of left ventricular mass with contrast enhanced real-time three-dimensional echocardiography.

OBJECTIVES: To evaluate the feasibility and accuracy of measurement of left ventricular mass with intravenous contrast enhanced real-time three-dimensional (RT3D) echocardiography in the experimental setting. METHODS: RT3D echocardiography was performed in 13 open-chest mongrel dogs before and after intravenous infusion of a perfluorocarbon contrast agent. Left ventricular myocardium volume was measured according to the apical four-plane method provided by TomTec 4D cardio-View RT1.0 software, then the left ventricular mass was calculated as the myocardial volume multiplied by the relative density of myocardium. Correlative analysis and paired t-test were performed between left ventricular mass obtained from RT3D echocardiography and the anatomic measurements. RESULTS: Anatomic measurement of total left ventricular mass was 55.6 +/- 9.3 g, whereas RT3D echocardiographic calculation of left ventricular mass before and after intravenous perfluorocarbon contrast agent was 57.5 +/- 11.4 and 55.5 +/- 9.3 g, respectively. A significant correlation was observed between the RT3D echocardiographic estimates of total left ventricular mass and the corresponding anatomic measurements (r = 0.95). A strong correlation was found between RT3D echocardiographic estimates of left ventricular mass with perfluorocarbon contrast and the anatomic results (r = 0.99). Analysis of intraobserver and interobserver variability showed strong indexes of agreement in the measurement of left ventricular mass with pre and post-contrast RT3D echocardiography. CONCLUSIONS: Measurements of left ventricular mass derived from RT3D echocardiography with and without intravenous contrast showed a significant correlation with the anatomic results. Contrast enhanced RT3D echocardiography permitted better visualization of the endocardial border, which would provide a more accurate and reliable means of determining left ventricular myocardial mass in the experimental setting.