Left Ventricular Function in Patients on Maintenance Hemodialysis: A Three-Dimensional Speckle-Tracking Imaging Study.

INTRODUCTION: Although maintenance hemodialysis (MHD) in end-stage renal disease (ESRD) appears to induce some risk factors and strengthen cardiac function, the morbidity of ESRD patients receiving hemodialysis remains high. This study aimed to identify left ventricular (LV) structural and functional abnormalities in ESRD patients on MHD using three-dimensional speckle-tracking imaging (3D-STI). METHODS: Eighty-five ESRD patients with normal LV ejection fraction (LVEF >50%) participated in this study, including 55 MHD patients comprising the chronic kidney disease (CKD) V-D group and 30 nondialysis patients comprising the CKD V-ND group. Thirty age- and sex-matched control participants who had normal kidney function were enrolled as the N group. Conventional echocardiography and 3D-STI were conducted, and global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS), and global radial strain (GRS) values were measured. RESULTS: No substantial differences in two-dimensional LVEF were observed among the three groups, and LV hypertrophy was the most common abnormality in patients with ESRD, irrespective of whether they had received or not received MHD. There were no significant differences in the 3D LV mass index between the CKD V-ND and N groups (p > 0.05). Conversely, the 3D LV mass index was considerably higher in the CKD V-D group than in both the N and CKD V-ND groups. The GLS, GAS, and GRS values were significantly lower in the CKD V-ND group than in the N group (p < 0.05). Furthermore, the CKD V-D group had significantly lower GLS, GCS, GAS, and GRS values than the N and CKD V-ND groups (p < 0.05). The interventricular septal thickness and E/e' ratio were independently associated with LV strain values in all patients with ESRD. CONCLUSIONS: MHD can exacerbate LV deformation and dysfunction in ESRD patients with preserved LVEF, and 3D-STI can be potentially useful for detecting these asymptomatic preclinical abnormalities.

Contribution of Three-Dimensional Echocardiography Xplane Mode in the Evaluation of Semilunar Cusps: Two Different Case Reports.

Orthogonal-biplane imaging (X-plane) is relatively a new tooL and provides comprehensive information about mitral valve and left atrial appendage evaluation. On the other hand, X-plane method is a promising method in the diagnosis of semilunar valve pathologies. Below, we report 2 cases, in which X-plane method was used, in order to clarify diagnosis. Case 1: Case 1 was a 63-year-old male patient who was admitted to our clinic with dyspnea. Right ventricular dilatation and hypertrophy were assessed. In order to determine the exact reason for right ventricular pressure overload, the pulmonary valve was evaluated by X-plane, and a bicuspid pulmonary valve was represented. This patient underwent pulmonary valve percutaneous valvuloplasty. Case 2: Case 2 was a 48-year-old male patient who was admitted to our hospital with a history of cerebrovascular event. His initial transthoracic and transesophageal echocardiography showed a hyperechoic mobile mass on the non-coronary cusp. However, after X-plane was used to detect the aortic valve, it was the prolapsed part of the non-coronary cusp adjacent to the commissure. These 2 case reports demonstrated the efficacy of the X-plane method in the diagnosis of semilunar valve pathologies in daily practice.

A deeper look into the functions of right ventricle using three-dimensional echocardiography: the forgotten ventricle in children with systemic lupus erythematosus.

Studies on the right ventricular dysfunction (RV) in systemic lupus erythematosus (SLE) patients are limited, particularly in the pediatric age group. The study aimed to identify subclinical RV alterations in childhood-onset SLE (c-SLE) using conventional and three-dimensional echocardiography (3DE). Forty SLE pediatric patients and 40 healthy controls were included. Disease activity and chronicity were evaluated by SLE disease activity index (SLEDAI) score and SLE damage index (SDI). Participants underwent detailed RV echocardiographic examination with conventional and 3DE assessment using 3D auto RV software. Patients included 35/40 (87.5%) females with mean age of 15.6 ± 1.7 years. Using conventional pulmonary artery systolic pressure echocardiography-derived measurement, none of the c-SLE patients had pulmonary hypertension. By 3DE, RV end-systolic and end-diastolic volumes (p = < 0.001, 0.02, respectively) were greater, whereas 3D-derived RV ejection fraction (p < 0.001), septal, and lateral longitudinal strain (both p < 0.001) were lower in SLE. SDI displayed a significant correlation with 3D auto RV ejection fraction (EF), tricuspid annular plane systolic excursion (TAPSE), fractional area change, and RV longitudinal strain (RVLS)-free wall (p = 0.01, 0.003, 0.007, and < 0.001, respectively). Cumulative SLEDAI score also showed a significant correlation with RV EF, TAPSE, FAC, and RVLS-free wall (p = 0.03, 0.007, 0.002, and < 0.001, respectively). By multivariate regression analysis, SDI remained an independent predictor of RVLS-free wall (ß coefficient - 0.4, p = 0.03) and TAPSE (ß - 0.5, p = 0.02).  Conclusion: Subtle right ventricular myocardial dysfunction could be detected in childhood-onset SLE patients, especially via 3D-derived auto RV echocardiographic parameters, despite the absence of evident pulmonary hypertension. These parameters correlate with the SLE disease activity and chronicity scores. What is Known: •Diseases of the cardiovascular system are one of the most common causes of morbidity and mortality in SLE patients. •RV labeled the forgotten ventricle in many diseases, was also forgotten in SLE patients and has been rarely addressed in adults, with scarce research in pediatrics. What is New: •Right ventricular functions are affected in children with SLE in comparison to healthy controls, especially three-dimensional echocardiography-derived parameters, which is an aspect that has not been investigated in previous research in the pediatric age group. •Some of the detected myocardial dysfunctions of the right ventricle correlated with SLE disease activity and chronicity-related scores.

Papillary muscle avulsion following balloon mitral valvotomy evaluated with three-dimensional echocardiography.

BACKGROUND: Percutaneous balloon mitral valvotomy is a common therapeutic approach for rheumatic mitral stenosis. Avulsion of the papillary muscle is a rare but serious complication of balloon mitral valvotomy. The papillary muscles are derived from the trabecular layer of the developing ventricular walls. When subjected to a force, avulsion of papillary muscle from the trabecular layer may occur. CASE PRESENTATION: In this case report, we describe a patient with rheumatic mitral stenosis, who experienced avulsion of the mitral papillary muscle from the left ventricular wall after undergoing balloon mitral valvotomy. Papillary muscle alvusion resulted in severe mitral regurgitation, which was finally treated by mitral valve replacement. CONCLUSION: We successfully diagnosed avulsion of the papillary muscle following balloon mitral valvotomy. Three-dimensional transthoracic echocardiography provides more information on mitral apparatus structure than two-dimensional transthoracic echocardiography.

Right ventricular function in ß-thalassemia children: comparing three-dimensional echocardiography with other functional parameters.

BACKGROUND: Cardiomyopathy is a major cause of mortality and morbidity in beta-thalassemia major (ß-TM), and its early detection is critical for prompt management. We aimed to evaluate right ventricle (RV) function in ß-TM, in absence of cardiac symptoms, using 3D echocardiography, and compare it with other functional parameters. METHODS: Cross-sectional cohort study was conducted on 50 ß-TM children with no cardiac manifestations and 50 healthy controls of matched age and sex. We evaluated RV function using; Fraction Area Change (2DE-RV FAC), Ejection Fraction (3D-RVEF), Tricuspid annular plane systolic excursion (TAPSE), Tissue Doppler imaging (TDI) systolic (S') and diastolic (E', A'), Myocardial performance index (MPI), and speckle tracking (2D-STE) of RV global longitudinal strain (LSS), systolic strain rate (SSR), early diastolic strain rate (DSR E), and late diastolic strain rate (DSR A). RESULTS: 3D-RVEF, MPI, and 2D-STE showed significant differences between the two groups. ROC curve analysis measurements had an AUC above 0.7-which indicate at least a fair discriminatory power between the ß-TM group with RV dysfunction and normal controls. CONCLUSIONS: ß-TM patients have decreased RV function indices at a pre-symptomatic stage. Early detection of RV dysfunction is feasible and can allow for closer follow-up to detect pre-clinical changes. IMPACT: The key message of this article is to emphasize the importance of the evaluation of right ventricular function in children with beta-thalassemia major. This article adds to the existing literature the use of recent echocardiographic modalities as three-dimensional echocardiography and two-dimensional speckle tracking in the evaluation of right ventricular dysfunction in beta-thalassemia children while cardiac affection is still subclinical. IMPACT: Recent echocardiographic functional parameters can be effectively used to evaluate the right ventricle in beta-thalassemia and can detect dysfunction in asymptomatic patients allowing for early intervention.

3D Echocardiography - A Useful Method for Cardiovascular Risk Assessment in End-Stage Renal Disease Patients.

Patients with chronic kidney disease (CKD) have an increased risk of premature mortality, mainly due to cardiovascular causes. The association between hemodialysis and accelerated atherosclerosis has long been described. The ankle-brachial index (ABI) is a surrogate marker of atherosclerosis and recent studies indicate its utility as a predictor of future cardiovascular disease and all-cause mortality. The clinical implications of ABI cut-points are not well defined in patients with CKD. Echocardiography is the most widely used imaging method for cardiac evaluation. Structural and functional myocardial abnormalities are common in patients with CKD due to pressure and volume overload as well as non-hemodynamic factors associated with CKD. Our study aimed to identify markers of subclinical cardiovascular risk assessed using ABI and 2D and 3D echocardiographic parameters evaluating left ventricular (LV) structure and function in patients with end-stage renal disease (ESRD) (patients undergoing dialysis), patients after kidney transplantation and non-ESRD patients (control). In ESRD, particularly in hemodialysis patients, changes in cardiac structure, rather than function, seems to be more pronounced. 3D echocardiography appears to be more sensitive than 2D echocardiography in the assessment of myocardial structure and function in CKD patients. Particularly 3D derived end-diastolic volume and 3D derived LV mass indexed for body surface appears to deteriorate in dialyzed and transplanted patients. In 2D echocardiography, myocardial mass represented by left ventricular mass/body surface area index (LVMI) appears to be a more sensitive marker of cardiac structural changes, compared to relative wall thickness (RWT), left ventricle and diastolic diameter index (LVEDDI) and left atrial volume index (LAVI). We observed a generally favorable impact of kidney transplantation on cardiac structure and function; however, the differences were non-significant. The improvement seems to be more pronounced in cardiac function parameters, peak early diastolic velocity/average peak early diastolic velocity of mitral valve annulus (E/e´), 3D left ventricle ejection fraction (LV EF) and global longitudinal strain (GLS). We conclude that ABI is not an appropriate screening test to determine the cardiovascular risk in patients with ESRD.

Feasibility and Safety of Using a Fused Echocardiography/Fluoroscopy Imaging System in Patients with Congenital Heart Disease.

BACKGROUND: Fused real-time three-dimensional transesophageal echocardiography and fluoroscopy has been used in adult patients during percutaneous mitral valve and aortic valve procedures. The use of fused echocardiographic/x-ray fluoroscopic imaging (FEX) in pediatric patients undergoing congenital heart disease catheterization has not been evaluated for feasibility and safety. The aims of this study were to assess the feasibility and safety of FEX for interventional guidance and to perform a comparison of atrial septal defect (ASD) device closure using this technology with traditional guidance methods. METHODS: Prospective evaluation of FEX in congenital cardiac interventions was conducted. A subset of patients with ASD closures were compared with patients with historical ASD closures with and without FEX. The interventionalist and echocardiographer rated the anatomic quality of the fusion imaging as (1) excellent, (2) good, or (3) poor. In addition, the utility of FEX procedural guidance was graded as (1) superior, (2) no added benefit, or (3) inferior to that of standard guidance by fluoroscopy and transesophageal echocardiography. RESULTS: FEX was successfully used in 26 procedures on 25 patients with congenital heart disease from January 2013 to February 2015. The median age was 9 years (range, 3-26 years), and the median weight was 29 kg (range, 16-77 kg). Twenty-six procedures were performed, including ASD closure, Fontan fenestration closure, and transcatheter valve placement in the tricuspid valve position. There was reduced fluoroscopy time and radiation dose in patients with ASDs who underwent imaging using this new technology (P < .001 and P < .03, respectively). There were no statistically significant differences in procedural times between the two groups. Anatomic definition was rated as excellent in 20 of 26 procedures, with the remaining six rated was good. Twenty-one of 26 procedures were graded as superior (81%), and five of 26 (19%) were graded as providing no added benefit. There were no complications in any of the procedures. CONCLUSIONS: In this early experience, FEX is feasible and safe in patients undergoing congenital heart disease catheterization and provides useful guidance in the majority of interventional procedures. There were relative reductions in fluoroscopy time and radiation dose with the use of FEX for ASD closure.

Progress in perioperative echocardiography: focus on safety, clinical outcomes, 3-dimensional imaging, and education.

Gastric decompression with an orogastric tube after anesthetic induction does not appear to enhance image quality for routine cases. The insertion of a transesophageal echocardiographic (TEE) probe can cause significant upper-airway trauma, which can be minimized with rigid laryngoscopy. Limited TEE imaging without transgastric views appears to be safe and clinically adequate in patients with advanced liver disease and esophageal varices. Although esophagogastric perforation because of transesophageal echocardiography is rare, the risk is significantly higher with advanced age and female sex. The echocardiographic assessment of right ventricular function and left ventricular diastolic function can improve the prediction of atrial arrhythmias after elective lung resection. Furthermore, asymptomatic left ventricular systolic or diastolic dysfunction is an independent predictor of cardiovascular mortality and morbidity after open vascular surgery. Advances in 3D echocardiography have shown that hypertrophic cardiomyopathy frequently is associated with changes in the mitral valve complex that predispose to left ventricular outflow tract obstruction. Furthermore, 3D imaging of the mitral apparatus has highlighted the importance of the annular saddle shape and the anatomic variability in ischemic mitral regurgitation. Education in perioperative echocardiography is experiencing high demand that can be satisfied partially with simulators and Internet-based educational activities. These modalities will aid in the dissemination of echocardiography through perioperative practice.

Feasibility, safety, and efficacy of real-time three-dimensional transoesophageal echocardiography for guiding device closure of interatrial communications: initial clinical experience and impact on radiation exposure.

AIMS: Our aim was to assess the feasibility and safety of real-time (RT) three-dimensional (3D) transoesophageal echocardiography (TEE) for guiding transcatheter closure of interatrial communications and to evaluate its additional benefit over conventional 2D TEE in reducing radiation exposure for the patient. METHODS AND RESULTS: Twenty-five patients undergoing device closure of their interatrial defect had the procedure guided by fluoroscopy, 2D TEE, and RT 3D TEE. We retrospectively compared this group with a historical control group in which interventional guidance was performed using fluoroscopy and 2D TEE alone. The application of RT 3D TEE allowed safe device deployment in all patients without any complications, resulting in a reduction of mean fluoroscopy time (10 +/- 6 to 6 +/- 4 min, P < 0.01), mean dose area product (DAP) (964 +/- 628 to 535 +/- 464 cGy cm(2), P < 0.01), and mean DAP per individual body surface area (494 +/- 317 to 273 +/- 221 cGy cm(2)/m(2), P < 0.01). CONCLUSION: RT 3D TEE as an adjunct to 2D TEE is a feasible and safe tool to guide transcatheter device closure of interatrial communications, resulting in a reduction of radiation exposure. These data indicate that RT 3D TEE can be used to safely monitor interatrial defect closure in clinical routine.

Avaliação do tamanho do átrio esquerdo pelo ecocardiografia tridimensional em indivíduos com anatomia cardíaca normal, em pacientes com cardiopatia dilatada ou cardiomiopatia hipertrófica: comparação com medidas do ecocardiograma bidimensional / Evaluation of the left atrium by tridimensional echocardiography in normal volunteers, in patients with dilated and hypertrophic cardiomyopathy: comparison with bidimensional echocardiography

Introdução: A análise do átrio esquerdo (AE) é importante para o entendimento da fisiopatologia de diferentes doenças cardíacas. Objetivo: Comparar as medidas do AE pelo ecocardiografia bidimensional (eco 2D) com as realizadas ao ecocardiograma tridimensional (eco 3D). Método: estudo prospectivo de medidas do AE ao eco 2D e 3D em 110 indivíduos: 47 com anatomia cardíaca normal (N),44 com cardiomiopatia dilatada (CMD), 19 com cardiomiopatia hipertrofica (HOCM), 62 eram homens, e a média de idade de 42 mais ou menos 16 anos). As medidas do AE pelo eco 2D foram: diâmetro ântero-posterior (AP), diâmetro inferior-superior(IS), médio-lateral (ML), área (2DAr), volume (2DV). Pelo eco 3D foi medido o volume do AE (3DV).Para a análise estatística foram aplicados: coeficiente de correlação de Spearman(r), 95 por cento IC, teste de Bland & Altman e regressão linear. Resultados: Os valores do volume do AE (ml) ao eco 3D e eco 2D, foram, respectivamente, no grupo N de 38 mais ou menos e 32,2 mais ou menos 78, no grupo CMD de 81,2 mais ou menos 30 e 63,6 mais ou menos 24 e no grupo HOCM de 75 mais ou menos 26 e 62,8 mais ou menos 21. No grupo N o coeficiente de correlação entre o 3DV com o...

Early experience with real-time three-dimensional echocardiographic guidance of right ventricular biopsy in children.

BACKGROUND: Right ventricular endomyocardial biopsy is the gold standard for detecting active myocardial inflammation in cardiomyopathy as well as rejection after cardiac transplantation. This procedure has historically required the exclusive use of fluoroscopic guidance to guide catheter, sheath, and bioptome manipulation. The current study evaluates the feasibility and utility of real-time transthoracic three-dimensional echocardiography (3DE) to guide right ventricular endomyocardial biopsies in children. METHODS: From July 2003 to April 2004, we utilized real-time 3DE in 28 consecutive cardiac catheterizations in children aged 18 months to 16 years who were undergoing endomyocardial biopsy. A commercially available 3DE scanner (Philips Sonos 7500) equipped with a 2-4 MHz 3D matrix array transthoracic probe was utilized in all cases. RESULTS: A total of 123 endomyocardial biopsy samples were obtained in nine patients (BSA 0.85 m(2)+/- 0.33 m(2)). Of these 123 samples, 99 (80%) were obtained with the use of real-time transthoracic 3DE. There were no complications, including no new tricuspid valve leaflet flail or pericardial effusion. 3DE proved to be a reliable noninvasive modality to properly direct the bioptome to the desired site of biopsy within the right ventricle. As familiarity with this technique increased, the need for fluoroscopic guidance of bioptome manipulation in the right ventricle was minimized. CONCLUSIONS: The use of real-time transthoracic 3DE in endomyocardial right ventricular biopsies in children is both feasible and safe. Further study to determine the impact of real-time 3DE guidance on fluoroscopy and case times for endomyocardial biopsies is warranted.