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AIMS: Pulmonary veins (PVs) isolation is the cornerstone of atrial fibrillation (AF) ablation and can be achieved either by conventional radiofrequency ablation or by cryoenergy. Left atrial appendage (LAA) closure has been proposed as alternative treatment to vitamin K antagonists (VKA). We aimed to evaluate the feasibility of combining cryoballoon (CB) ablation and LAA occlusion in patients with AF and a high thromboembolic risk or contraindication to antithrombotic therapy. METHODS AND RESULTS: Thirty-five patients (28 males, 74 ± 2 years) underwent CB ablation. Left atrial appendage occlusion was carried out by using two occluder devices (Amplatz Cardiac Plug, ACP, St. Jude Medical, MN, USA, in 25 patients; Watchman, Boston Scientific, MA, USA, in 10 patients). Thirty patients (86%) had previous stroke/TIA episodes, 6 patients (17%) had major bleeding while on VKA therapy, and 7 patients (20%) had inherited bleeding disorders. Over the follow-up (24 ± 12 months), atrial arrhythmias recurred in 10 (28%) patients. Thirty patients (86%) had complete sealing; 5 patients (14%) showed a residual flow (<5 mm) at first transoesophageal echocardiography (TEE) check, while at 1-year TEE residual flow was detected in 3 patients. In 13 patients (37%), VKA therapy was immediately discontinued. Six patients (17%) received novel oral anticoagulants treatment and then discontinued 3 months thereafter. No device-related complications or clinical thromboembolic events occurred. CONCLUSION: Combined CB ablation and LAA closure using different devices appears to be feasible in patients with non-valvular AF associated with high risk of stroke or contraindication to antithrombotic treatment.
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Apéndice Atrial/cirugía , Fibrilación Atrial/terapia , Ablación por Catéter/métodos , Venas Pulmonares/cirugía , Dispositivo Oclusor Septal , Anciano , Anticoagulantes/administración & dosificación , Ecocardiografía Tridimensional , Femenino , Estudios de Seguimiento , Hemorragia/etiología , Humanos , Masculino , Estudios Prospectivos , Recurrencia , Accidente Cerebrovascular/etiología , Resultado del Tratamiento , Estados UnidosRESUMEN
MitraClip (MC) is the most common percutaneous treatment for severe mitral regurgitation (MR). An accurate two-dimensional and three-dimensional echocardiographic (3DTEE) imaging is mandatory for the optimal procedural result. Recently transillumination 3DTEE rendering (3DTr) has been introduced integrating a virtual light source into the dataset and with the addition of glass effect (3DGl) allows to adjust tissue transparency improving depth perception and anatomical structure delineation in comparison with the standard 3DTEE (3DSt). The aim of this retrospective study in 30 patients undergoing MC, was to compare 3DSt, 3DTr, and 3DGl in mitral valve (MV) evaluation and procedural result assessment. 3DTEE acquisitions obtained before and after MC were processed with 3DSt, 3DTr, and 3DGl rendering. Each reconstruction was scored for quality and for ability to recognize MV anatomy, MR origin, clip position, dimension and grasping. Imaging quality was judged good or optimal in 52%, 76%, and 96% in 3DSt, 3DTr, and 3DGl reconstructions respectively. In 26/30 patients a diagnostic incremental value was found with 3DTr vs. 3DSt and in 15/26 with 3DGl vs. 3DTr and 3DSt. Only 3DGl with perpendicular cropping of the clip allowed to visualize and measure the grasped portion of each mitral leaflets. 3DTEE imaging during MC may be improved by 3DTr and 3DGl providing a better evaluation of MV, of leaflet grasping and of residual MR jets after MC.
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AIMS: The aim of this study, undertaken in patients who underwent mitral valve (MV) repair surgery, was to evaluate the accuracy of pre-operative three-dimensional (3D) transthoracic echocardiography (TTE) in the evaluation of MV pathology in cases with simple or complex lesions. METHODS AND RESULTS: Two hundred consecutive patients with severe mitral regurgitation due to degenerative MV prolapse underwent a complete 3DTTE the day before surgery. Three-dimensional TTE data were compared with MV surgical inspection. Three-dimensional echocardiography was feasible in a relatively short time (5 ± 3 min) with good (67%) and optimal (21%) imaging quality in the majority of cases. Three-dimensional TTE allowed an accurate identification (95% accuracy) of all MV lesions. Seventy-three (36.5%) patients had simple lesions at 3DTTE and 71 of them (97.2%) underwent a simple surgical procedure; 127 (63.5%) had complex lesions at 3DTTE and, in these cases, surgeons performed either simple procedures (48%) or complex procedures (47.2%) or valve replacement in 4.7% (after a first attempt for repair). CONCLUSION: Three-dimensional TTE is feasible, not time-consuming, and accurate in identifying cases with simple vs. complex MV lesions.
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Ecocardiografía Tridimensional/métodos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Prolapso de la Válvula Mitral/diagnóstico por imagen , Prolapso de la Válvula Mitral/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/fisiopatología , Prolapso de la Válvula Mitral/fisiopatología , Cuidados Preoperatorios , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
BACKGROUND: Percutaneous left atrial appendage closure (LAAC) requires accurate pre- and intraprocedural measurements, and multimodality imaging is an essential tool for guiding the procedure. Two-dimensional (2D TOE) and three-dimensional (3D TOE) transoesophageal echocardiography, cardiac computed tomography (CCT), and conventional cardiac angiography (CCA) are commonly used to evaluate left atrial appendage (LAA) size. However, standardized approaches in measurement methods by different imaging modalities are lacking. The aims of the study were to evaluate the LAA dimension and morphology in patients undergoing LAAC and to compare data obtained by different imaging modalities: 2D and 3D TOE, CCT, and CCA. METHODS: A total of 200 patients (mean age 70 ± 8 years, 128 males) were examined by different imaging techniques (161 2D TOE, 103 3D TOE, 98 CCT, and 200 CCA). Patients underwent preoperative CCT and intraoperative 2D and 3D TOE and CCA. RESULTS: A significant correlation was found among all measurements obtained by different modalities. In particular, 3D TOE and CCT measurements were highly correlated with an excellent agreement for the landing zone (LZ) dimensions (LZ diameter: r = 0.87; LAA depth: r = 0.91, p < 0.001). CONCLUSIONS: Head-to-head comparison among imaging techniques (2D and 3D TOE, CCT, and CCA) showed a good correlation among LZ diameter measurements obtained by different imaging modalities, which is a parameter of paramount importance for the choice of the LAAC device size. LZ diameters and area by 3D TOE had the best correlation with CCT.
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AIMS: Blood stasis is the main cause of left atrial thrombosis (LAT) in atrial tachyarrhythmias. The high-velocity flow inside the left atrium, due to mitral valve regurgitation, may prevent clot formation but the topic has never been investigated in large-scale studies. The aim of our study was to evaluate whether the presence and degree of mitral regurgitation have a protective role against LAT risk. METHODS: A total of 1302 consecutive adult patients with paroxysmal or persistent atrial fibrillation or flutter undergoing cardioversion, submitted to transesophageal echocardiography, were retrospectively enrolled in the study. The study population was divided into three groups according to the mitral regurgitation degree: absent, mild-to-moderate and severe. RESULTS: Among 1302 patients enrolled in the study, patients without mitral regurgitation were 248 (19%), those with mild-to-moderate 970 (75%), whereas 84 had severe mitral regurgitation (6%). LAT incidence was significantly lower in patients with severe mitral regurgitation compared with those with mild-to-moderate (mitral regurgitation) (2.4 vs. 8.9%, Pâ<â0.05), and similar to subjects without mitral regurgitation (2.4%). CONCLUSION: Despite patients with severe regurgitation having clinical and echo characteristics predisposing to LAT (higher age, heart failure, higher atrial size, lower ventricular function) thrombosis prevalence was significantly lower than for those with mild-to-moderate mitral regurgitation. The percentage of LAT in severe mitral regurgitation cases was very low and similar to that of cases without regurgitation which were characterized by lower age, normal left ventricular function or other risk factors, reinforcing the hypothesis of a protecting role against atrial thrombosis of mitral regurgitation.
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Fibrilación Atrial/fisiopatología , Aleteo Atrial/fisiopatología , Hemodinámica , Insuficiencia de la Válvula Mitral/fisiopatología , Válvula Mitral/fisiopatología , Trombosis/prevención & control , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Aleteo Atrial/diagnóstico , Aleteo Atrial/epidemiología , Ecocardiografía Transesofágica , Femenino , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/epidemiología , Prevalencia , Factores Protectores , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Trombosis/diagnóstico , Trombosis/epidemiología , Trombosis/fisiopatologíaRESUMEN
BACKGROUND: The combined left atrial appendage closure (LAAC) and cryoenergy pulmonary vein isolation (PVI) procedure has been proven safe and effective in managing stroke in patients with nonvalvular atrial fibrillation (AF), although most data refer to procedures performed using radiofrequency as the main energy source. OBJECTIVE: The purpose of this study was to evaluate long-term follow-up of patients with AF undergoing concomitant LAAC and cryoenergy PVI. METHODS: Patients undergoing LAAC and cryoballoon PVI at our institution were enrolled. At 3, 6, and 24 months from the index procedure, we determined the atrial arrhythmia recurrence rate, the extent of LAAC, and the rate of cerebrovascular/bleeding events. RESULTS: Forty-nine patients (mean age 69 ± 8 years; 32/49 (67%) men; CHA2DS2-VASc score 2.8 ± 1.2; HAS-BLED score 3 ± 1) with a guideline-recommended LAAC indication were included. Acute PVI and complete LAAC were achieved in 100% of patients. All patients completed at least 24 months of follow-up. At 8 weeks and 6 months, complete or satisfactory (<5 mm leak) LAAC rates were achieved in 40 (82%) and 9 (18%) and in 42 (86%) and 7 (14%) of patients, respectively. The overall freedom from atrial arrhythmia rate at 24 months was 29 (60%), and 45 (92%) of patients were off antithrombotic drugs. The observed annualized stroke and bleeding rates were 1% and 2%, respectively, a 71% and 60% risk reduction in comparison to event rates predicted from CHA2DS2-VASc and HAS-BLED scores. CONCLUSION: Concomitant cryoballoon ablation and LAAC procedures appear safe and effective at long-term follow-up, with high antithrombotic drug withdrawal rates at 24 months.
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Apéndice Atrial , Fibrilación Atrial , Procedimientos Quirúrgicos Cardíacos , Criocirugía , Hemorragia , Efectos Adversos a Largo Plazo/epidemiología , Accidente Cerebrovascular , Anciano , Anticoagulantes/uso terapéutico , Apéndice Atrial/diagnóstico por imagen , Apéndice Atrial/cirugía , Fibrilación Atrial/complicaciones , Fibrilación Atrial/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/instrumentación , Procedimientos Quirúrgicos Cardíacos/métodos , Criocirugía/efectos adversos , Criocirugía/métodos , Ecocardiografía Transesofágica/métodos , Femenino , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Humanos , Masculino , Evaluación de Procesos y Resultados en Atención de Salud , Venas Pulmonares/cirugía , Recurrencia , Dispositivo Oclusor Septal , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & controlRESUMEN
BACKGROUND: We sought to evaluate the additional value of left atrial appendage (LAA) 3D printing derived from computed tomography (CCT) in determining the size for LAA occlusion (LAAO) devices as compared to standard measurement by using occurrence of LAA leak as endpoint. METHODS: We evaluated 6 patients with LAA leak (cases) and 14 matched patients without LAA leak (controls) after LAAO. For each group, a patient-specific 3D printed model of LAA was manufactured using CT pre-operative images. The size recommended by the 3D printed model was compared with the size of the implanted device. RESULTS: Compared to the 3D printed model, 55% of the devices were underestimated, the two sizing approaches agreed in 35% of the patients, while the 3D printed model overestimated the size in 10% of patients. The prevalence of LAA leak was significantly higher in the subset of patients with underestimation of prosthesis implanted with the standard approach as compared to the other patients (pâ¯=â¯0.019). CONCLUSION: 3D printing of the LAA may provide additional value to standard practice for LAAO device prosthesis sizing with the potential impact to reduce LAA leak.
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Apéndice Atrial/diagnóstico por imagen , Apéndice Atrial/cirugía , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/cirugía , Modelos Anatómicos , Modelos Cardiovasculares , Impresión Tridimensional , Diseño de Prótesis , Implantación de Prótesis/instrumentación , Tomografía Computarizada por Rayos X , Anciano , Apéndice Atrial/fisiopatología , Fibrilación Atrial/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Complicaciones Posoperatorias/etiología , Valor Predictivo de las Pruebas , Implantación de Prótesis/efectos adversos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Right ventricular (RV) dimensions and function are of diagnostic and prognostic importance in cardiac disease. Because of the peculiar morphology of the right ventricle, 2-dimensional echocardiography has several limitations in RV evaluation. Recently, new 3-dimensional transthoracic echocardiographic software adapted for RV morphology was introduced. The aims of this study were to evaluate the feasibility of 3-dimensional RV analysis in a large population and to compare and correlate 3-dimensional RV data with classic 2-dimensional and Doppler parameters, including tricuspid annular plane systolic excursion and peak systolic velocity on Doppler tissue imaging, RV fractional shortening area, RV stroke volume (by the Doppler method), and pulmonary arterial systolic pressure. Two hundred subjects were studied: 48 normal controls and 152 patients with valvular heart disease (104 patients), idiopathic dilated cardiomyopathy (20 patients), or pulmonary hypertension (28 patients). The mean times for 3-dimensional acquisition and 3-dimensional reconstruction were 3 +/- 1 and 4 +/- 2 minutes, respectively. Imaging quality was good in most cases (85%). The mean RV diastolic and systolic volumes were 103 +/- 38 and 46 +/- 28 ml, respectively. The RV ejection fraction (RVEF) was correlated negatively with pulmonary arterial systolic pressure and positively with tricuspid annular plane systolic excursion, peak systolic velocity, and fractional shortening area. The pathologic group was characterized by larger RV volumes and lower RVEFs. Three-dimensional echocardiography clearly showed that in the pathologic group, patients with pulmonary hypertension had the largest RV volumes and the lowest RVEFs and that those with idiopathic dilated cardiomyopathy were characterized by RVEFs lower than those of patients with valvular disease. In conclusion, this new quantitative 3-dimensional method to assess RV volumes and function is feasible, relatively simple, and not time consuming. Data obtained with 3-dimensional analysis are well correlated with those obtained by 2-dimensional and Doppler methods and can differentiate normal and pathologic subjects.
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Ecocardiografía Tridimensional , Disfunción Ventricular Derecha/diagnóstico por imagen , Disfunción Ventricular Derecha/fisiopatología , Función Ventricular Derecha , Estudios de Casos y Controles , Diástole , Ecocardiografía Tridimensional/instrumentación , Ecocardiografía Tridimensional/métodos , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/fisiopatología , Volumen Sistólico , SístoleRESUMEN
AIMS: The aim of this study was to investigate the feasibility, safety and efficacy of percutaneous closure for prevention of thromboembolic events in patients with atrial fibrillation (AF) and left atrial appendage (LAA) thrombus. METHODS AND RESULTS: The study included consecutive patients with AF and LAA thrombus who underwent transcatheter occlusion in eight high-volume centres. Clinical and transoesophageal echocardiography (TEE) follow-up was carried out as per each centre's protocol. Twenty-eight patients were included. The location of the LAA thrombus was distal in 100% of cases. Technical and procedural success was achieved in all patients. A cerebral protection device was used in six cases. There were no periprocedural adverse events. Follow-up was complete in all patients (total 32 patient-years). No death or thromboembolic events were reported. There was one major bleeding during follow-up. Among the 23 patients undergoing TEE, device thrombosis was present in one patient. No significant peri-device leaks were observed. CONCLUSIONS: In this multicentre study, percutaneous closure in selected patients with distal LAA thrombus appears to be feasible and safe, and is associated with high procedural success and a favourable outcome for the prevention of AF-related thromboembolism. Special implant techniques avoiding mechanical mobilisation of the thrombotic mass and the liberal use of cerebral embolic protection devices are recommended.
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Apéndice Atrial , Fibrilación Atrial/terapia , Cateterismo Cardíaco , Tromboembolia/prevención & control , Trombosis/etiología , Adulto , Anciano , Anciano de 80 o más Años , Apéndice Atrial/diagnóstico por imagen , Apéndice Atrial/fisiopatología , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Bases de Datos Factuales , Ecocardiografía Transesofágica , Europa (Continente) , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Tromboembolia/etiología , Trombosis/diagnóstico por imagen , Trombosis/fisiopatología , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Aortic valve diseases, hypertension, and connective tissue disorders may be causes of ascending aortic aneurysms. Aortic enlargement monitoring is essential for surgical timing and for operative design. In this regard, several imaging techniques may have limitations: magnetic resonance is not widespread and is expensive, computed tomography uses radiation, and transesophageal echocardiography is a semi-invasive method. The aim of this study was to analyze the feasibility of transthoracic echocardiography in the evaluation of aortic dimensions and its accuracy in comparison with multidetector computed tomography. In 44 patients with known ascending aortic aneurysms, transthoracic echocardiographic and computed tomographic measurements were obtained and compared at different levels: the annulus, sinuses of Valsalva, sinotubular junction, ascending aorta, and aortic arch. Transthoracic echocardiographic diameters were obtained in all patients, apart from the aortic arch, which was measured in 40 cases. Transthoracic echocardiographic and computed tomographic diameters correlated significantly (p <0.001), with very small SEEs: for the annulus, r = 0.846 (SEE 0.37); for the sinuses of Valsalva, r = 0.967 (SEE 0.35); for the sinotubular junction, r = 0.965 (SEE 0.33); for the ascending aorta, r = 0.976 (SEE 0.41); and for the aortic arch, r = 0.87 (SEE 0.50). In conclusion, transthoracic echocardiography is a feasible and accurate technique for the assessment and follow-up of thoracic aortic diameters in patients with ascending aortic aneurysms.
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Aorta/diagnóstico por imagen , Aneurisma de la Aorta/diagnóstico por imagen , Aortografía , Anciano , Medios de Contraste , Estudios de Factibilidad , Femenino , Humanos , Yopamidol/análogos & derivados , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Reproducibilidad de los Resultados , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
AIMS: Echocardiographic evaluation of 2D longitudinal peak systolic strain (LPSS) can detect initial impairment of left ventricular (LV) function in heart disease. Global LPSS (GLPSS) variability has been assessed in small groups and segmental LPSS has not been determined. We compared variability of GLPSS and segmental LPSS with that of 2D LV volumes and ejection fraction (EF) in patients with and without heart diseases. METHODS AND RESULTS: 2D speckle tracking analysis was performed on LV apical views using automated function imaging (AFI) software (GE Healthcare). Intra-operator, inter-cycle, and test-retest variability (bias and CR, coefficient of reproducibility; MPE, mean percent error; CV, coefficient of variation) was assessed for GLPSS, 18 segments of LPSS, and LV volumes and EF in 40 patients (720 segments), and inter-operator variability in 250 patients (4500 segments). Feasibility of segmental tracking was 93.1%. Variability of GLPSS increased from a minimum intra-operator CV = -2.6% to a maximum test-retest CV = -5.4% and was lower than that assessed for volumes and EF. Segmental intra-operator LPSS CV ranged from -5.6 to -14.7%, and test-retest from -8 to -22%, and was at worst similar to variability of end-systolic volume. In the 8.3% of segments with the highest variability, this was related to suboptimal imaging, minor changes in scan angulation, and insufficient ROI width. CONCLUSION: Overall, reproducibility of GLPSS is excellent and superior to that of 2D EF, whereas segmental LPSS reproducibility is good and similar to that of LV volumes. Both are suitable for diagnosis and follow-up of LV global and regional systolic function.
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Ecocardiografía/métodos , Interpretación de Imagen Asistida por Computador/instrumentación , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/fisiopatología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Reproducibilidad de los Resultados , Programas InformáticosRESUMEN
Eighty-eight patients referred for transcatheter closure of atrial septal or patent foramen ovale defects underwent 3-dimensional transesophageal echocardiography to correlate preclosure anatomy with the morphology and positioning of the atrial septal occluder. Despite the effectiveness of the trancatheter closure and absence of complications, 2 linear indentations of the aortic root by the 2 discs of the device were clearly demonstrated in 16 cases, suggesting caution in the choice of very large occluders.
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Ecocardiografía Tridimensional , Ecocardiografía Transesofágica , Defectos del Tabique Interatrial/cirugía , Prótesis e Implantes , Adulto , Cateterismo Cardíaco , Femenino , Defectos del Tabique Interatrial/diagnóstico por imagen , Humanos , Procesamiento de Imagen Asistido por Computador , Masculino , Persona de Mediana EdadRESUMEN
We sought to review echocardiographic incidence of anomalous images (AI) as false tendons and trabeculations of the left ventricle (LV) in light of recent advancements in echocardiographic evaluation of heart anatomy. In 1580 patients the presence of false tendons, trabeculations, or thrombi was evaluated with transthoracic echocardiography and correlated to clinical characteristics and echocardiographic parameters. Incidence of AI was 46.7% (75% false tendons, 23% trabeculations, 2% thrombi), slightly higher in pathologic (48.9%) than in normal hearts (40.8%). AI were more frequent in male patients (52%) than in female patients (39.7%) and associated with LV dilatation, hypertrophy, and systolic dysfunction. False tendons and trabeculations were not related to age. Male sex was the most significant independent predictor of AI. In 2 patients, isolated LV noncompaction of myocardium was diagnosed and confirmed by magnetic resonance imaging. This study shows a high prevalence of AI for patients with and without pathologic hearts suggesting the need of updating LV echocardiographic anatomy. It also emphasizes the necessity for an awareness of these anatomic variants when evaluating patients for mural thrombi and cardiomyopathies.
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Ecocardiografía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Cardiomiopatía Dilatada/diagnóstico por imagen , Cardiomiopatía Dilatada/epidemiología , Cardiomiopatía Dilatada/patología , Niño , Ecocardiografía Doppler en Color , Femenino , Tabiques Cardíacos/diagnóstico por imagen , Tabiques Cardíacos/patología , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/patología , Humanos , Hipertrofia Ventricular Izquierda/diagnóstico por imagen , Hipertrofia Ventricular Izquierda/epidemiología , Hipertrofia Ventricular Izquierda/patología , Incidencia , Masculino , Persona de Mediana Edad , Análisis Multivariante , Miocardio/patología , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Estadística como Asunto , Volumen Sistólico/fisiología , Trombosis/diagnóstico por imagen , Trombosis/epidemiología , Trombosis/patologíaRESUMEN
BACKGROUND: The normal and dilated heart behaves as a single functional unit during preload reduction: volume unloading in the setting of diastolic ventricular interaction allows for increased left ventricular (LV) filling. HYPOTHESIS: We hypothesized that reduction of venous return induced by a physiologic stimulus (tilting) or by acute angiotensin-converting enzyme (ACE) inhibitors in dilated heart is likely to have a marked and similar effect on ventricular chamber geometry and filling. This study was designed to assess how the normal and dilated heart adapts to preload reduction. METHODS: Twenty normal subjects and 20 patients with moderate heart failure due to dilated cardiomyopathy were studied with two-dimensional and Doppler echocardiography in supine position (B) and after 40 degrees of head-up tilting (T). The following day, patients repeated supine (C) and tilting test (TC) after administration of captopril (25 mg s.l.). Right ventricular (RV) and LV dimensions, LV geometry, and tricuspid, mitral, and pulmonary venous flow patterns were recorded at each step of the study. RESULTS: In the two groups, T was associated with reduction of RV area and LV volumes; C and TC produced a similar effect on RV and LV. Changes in LV septal-lateral diameter and anterior-posterior diameter were different at each step of the study: during T (both groups) and after C and TC, the septallateral diameter increased slightly while the anterior-posterior diameter decreased. During T, mitral and tricuspid peak flow velocities decreased, peak late velocities were unchanged, and the deceleration time of mitral flow increased; the systolic forward flow of pulmonary venous flow decreased, the diastolic forward flow did not change, and the difference in duration between reverse pulmonary flow and mitral peak late flow decreased: C and CT induced similar changes. CONCLUSION: Preload reduction induced by tilting or by ACE inhibitors induces profound and similar effects on LV and RV dimensions, LV geometry, and biventricular filling. Reduction of RV dimension is associated with adaptation of LV geometry and decrease of LV diastolic pressure, which facilitates LV filling and pulmonary venous drainage: ACE inhibition associated with tilting exerts an additional effect on these changes. These data confirm the role of ventricular interaction in modulating LV filling in heart failure.
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Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Cardiomiopatía Dilatada/tratamiento farmacológico , Adulto , Anciano , Presión Sanguínea/efectos de los fármacos , Presión Sanguínea/fisiología , Captopril/uso terapéutico , Cardiomiopatía Dilatada/fisiopatología , Diástole/efectos de los fármacos , Diástole/fisiología , Ecocardiografía Doppler , Estudios de Seguimiento , Frecuencia Cardíaca/efectos de los fármacos , Frecuencia Cardíaca/fisiología , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/efectos de los fármacos , Ventrículos Cardíacos/fisiopatología , Humanos , Italia , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/efectos de los fármacos , Válvula Mitral/fisiopatología , Variaciones Dependientes del Observador , Flujo Sanguíneo Regional/efectos de los fármacos , Flujo Sanguíneo Regional/fisiología , Estadística como Asunto , Volumen Sistólico/efectos de los fármacos , Volumen Sistólico/fisiología , Sístole/efectos de los fármacos , Sístole/fisiología , Pruebas de Mesa Inclinada , Factores de Tiempo , Resultado del Tratamiento , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/efectos de los fármacos , Válvula Tricúspide/fisiopatología , Disfunción Ventricular Izquierda/tratamiento farmacológico , Disfunción Ventricular Izquierda/fisiopatologíaRESUMEN
BACKGROUND: Despite its wide diagnostic potential, three-dimensional (3D) echocardiography is a quite rarely employed technique. The ideal method to obtain transthoracic 3D imaging is on-line 3D echocardiography, but first-generation real-time instruments had technical limitations. A new on-line 3D technology which allows true real-time volume rendering of the cardiac anatomy has been recently introduced and its feasibility and diagnostic advantages have been evaluated in the clinical setting. METHODS: The system utilizes a "matrix" transducer with a dedicated software. It allows instantaneous acquisition and rendering on-line 3D images and interactive manipulation of 3D data. Eighty-three adult patients with various cardiac pathologies underwent on-line 3D echocardiography. Long- and short-axis views of the aorta, mitral valve and left ventricle and surgical views of these structures were attempted. The duration of acquisition and reconstruction, and the quality and incremental clinical value of 3D images in comparison with two-dimensional imaging were annotated. RESULTS: The mean time of 3D examination was 10 +/- 5 min; the mean number of acquisitions was 10.8 per patient. The quality of the 3D images was optimal in 39%, good in 37%, sufficient in 19%, and insufficient in 5% of the patients. In all cases at least one optimal or good live 3D image was obtained from the parasternal and apical views. The reconstruction of surgical or en face views was easily and rapidly (1-2 min) achieved by two experts in 3D echocardiography. The additional clinical values of 3D vs two-dimensional imaging was demonstrated in 7 patients with mitral valve disease, 3 with aortic valve pathology, and 3 with congenital heart disease. Several on-line 3D images that have not correspondence with two-dimensional echocardiography were reconstructed, creating projections dedicated to the diagnostic goal. CONCLUSIONS: On-line 3D echocardiography can be easily performed in adult patients and allows for unique planes and projections. The instant rendering of 3D images facilitates the recognition of cardiac structures and increases the diagnostic potential of transthoracic echocardiography.
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Ecocardiografía Tridimensional/instrumentación , Cardiopatías Congénitas/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Procesamiento de Imagen Asistido por Computador , Válvula Mitral/diagnóstico por imagen , Adolescente , Adulto , Anciano , Diseño de Equipo , Estudios de Factibilidad , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador/métodos , Masculino , Persona de Mediana Edad , TransductoresRESUMEN
BACKGROUND: Transesophageal echocardiography (TEE) is the method of choice for the evaluation of the left atrium and of left atrial appendage (LAA) thrombosis. However, the anatomy of the left appendage is complex and reverberations from anatomical structures may create images and ghosting which mimic left atrial thrombosis. The purpose of this study was to investigate whether a systematic approach through TEE may facilitate the recognition of LAA anatomical variants and artifacts. METHODS: One hundred and sixty-four consecutive patients scheduled for cardioversion of atrial fibrillation (study population) and 30 patients (control group) undergoing mitral valve surgery were submitted to TEE using a multiplane probe in order to obtain a systematic evaluation of the LAA. The number of LAA lobes and the presence of thrombi and artifacts were evaluated. RESULTS: The majority of the study patients had a bilobed (53.1%) or single-lobed (34.1%) LAA. Thrombi were identified in 6%. Artifacts were found in 38 cases (23.2%) and their position was localized precisely at a distance from the transducer which was twice that from the partition-bend between the left upper pulmonary vein and left appendage, suggesting a reverberation. No differences in echocardiographic parameters were found in patients with (group 1) or without (group 2) artifacts. Cardioversion was successful in a similar percentage of cases in the two groups (group 1 68%, group 2 76%) without complications. In controls, the percentages of a single-(33%) and bilobed (40%) left appendage were similar to those found in the study population. Artifacts were identified in 11 controls (37%); no thrombi were detected during surgical left appendage inspection in these cases. CONCLUSIONS: A systematic approach with multiplane TEE facilitates the evaluation of the LAA anatomy and the recognition of artifacts, thus reducing the likelihood of false positive or negative diagnoses of left appendage thrombi.
Asunto(s)
Artefactos , Fibrilación Atrial/diagnóstico por imagen , Ecocardiografía Transesofágica , Trombosis/diagnóstico por imagen , Adulto , Anciano , Anticoagulantes/uso terapéutico , Fibrilación Atrial/terapia , Aleteo Atrial/diagnóstico por imagen , Aleteo Atrial/terapia , Diagnóstico Diferencial , Ecocardiografía , Cardioversión Eléctrica , Femenino , Atrios Cardíacos/anatomía & histología , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/patología , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/anatomía & histología , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/patología , Prolapso de la Válvula Mitral/diagnóstico por imagen , Prolapso de la Válvula Mitral/terapia , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/terapia , Prevalencia , Estudios Prospectivos , Resultado del Tratamiento , Warfarina/uso terapéuticoRESUMEN
A new generation of transoesophageal echocardiographic probes with a novel matrix array technique has been recently introduced, allowing three-dimensional (3D) presentation of cardiac structures in real-time. This new tool may potentially provide fast and complete 3D information about cardiac structures improving spatial orientation and overcoming limitations of offline 3D technologies. The aim of this study was to demonstrate the feasibility and usefulness of real-time 3D transoesophageal echocardiography (TOE) for the intraoperative evaluation of cardiac surgery procedures. One-hundred patients underwent transoesophageal echocardiographic examination during cardiac surgery as a part of their routine clinical practice. In the intraoperative pre- and post-cardiopulmonary bypass periods complete 2D and 3D transoesophageal examinations were performed. Feasibility and duration of examinations, and immediate additional anatomical value of 3D versus 2D-TOE were annotated intraoperatively. Image quality, additional clinical value of 3D- compared to standard 2D-TOE and the accuracy in the description of mitral valve pathology by a surgeon and an echocardiographer were evaluated off-line. No complications related to transoesophageal examination occurred and successful intubation was achieved in all 100 patients. Therefore, 200 examinations were performed and analysed considering the pre- and post-cardiopulmonary bypass periods. The mean number of acquisitions per patient was 16 +/- 14, including 3D real-time, zoom, full-volume and colour full volume modalities. The duration of the 3D examination was 16 +/- 10 min and the mean image quality score 2.8 +/- 0.7 (in a scale 1-4). In 36 out of 100 cases (36%) 3D-TOE provided additional anatomical information. The surgeon evaluated 3D images easier and more accurately than 2D images (88% vs. 76% in the evaluation of mitral valve scallop). Real-time 3D TOE may be used routinely for the intraoperative evaluation of cardiac surgery. Imaging with this new probe facilitates intraoperative evaluation of several surgical procedures with an additional clinical value in selected cases.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Ecocardiografía Doppler en Color , Ecocardiografía Tridimensional , Ecocardiografía Transesofágica , Anciano , Estudios de Factibilidad , Femenino , Humanos , Cuidados Intraoperatorios , Italia , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Factores de TiempoAsunto(s)
Oclusión con Balón/instrumentación , Ecocardiografía Tridimensional , Ecocardiografía Transesofágica , Defectos del Tabique Interatrial/diagnóstico por imagen , Defectos del Tabique Interatrial/terapia , Adolescente , Adulto , Anciano , Remoción de Dispositivos , Ecocardiografía Tridimensional/estadística & datos numéricos , Ecocardiografía Transesofágica/estadística & datos numéricos , Diseño de Equipo , Femenino , Defectos del Tabique Interatrial/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Estudios Prospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: Transesophageal echocardiography (TEE)-guided cardioversion has been demonstrated to be well tolerated in patients with atrial fibrillation. Guidelines do not suggest whether patients with severe spontaneous echocontrast (SEC) and sludge can be safely submitted to cardioversion. In our observational study, we analyzed the prevalence of SEC in patients with atrial fibrillation taking different anticoagulant therapies, the incidence of embolic complications after cardioversion in patients with severe SEC or sludge and the usefulness of TEE in reducing embolic complications in these patients. METHODS: The study population consisted of 1104 patients with atrial fibrillation, candidates for cardioversion and submitted to TEE. They were divided into four groups: effective conventional oral anticoagulation, short-term anticoagulation, subtherapeutic anticoagulation and effective oral anticoagulation for less than 3 weeks for different clinical reasons. Cardioversion was postponed in patients with atrial thrombosis; in the presence of severe SEC, the decision to cardiovert was left to the treating physician. RESULTS: Atrial thrombosis was detected in 65 (5.9%) patients, and SEC was detected in the majority of patients independent of the anticoagulant scheme; in 131 patients, it was severe and, in this group, sludge was identified in 57 patients. Cardioversion was performed in 922 patients and was successful in 849 (including 22 patients with severe SEC and four with sludge) with one minor embolic event. CONCLUSION: SEC and sludge are frequently observed in patients with atrial fibrillation undergoing cardioversion. A TEE approach may prevent the risk of embolic events. In the presence of severe SEC and sludge, treating physicians frequently postpone cardioversion, even though in the patients submitted to cardioversion, no events were observed.
Asunto(s)
Anticoagulantes/uso terapéutico , Fibrilación Atrial/diagnóstico por imagen , Aleteo Atrial/diagnóstico por imagen , Medios de Contraste , Ecocardiografía Transesofágica , Cardioversión Eléctrica , Trombosis/diagnóstico por imagen , Administración Oral , Anciano , Anticoagulantes/administración & dosificación , Fibrilación Atrial/complicaciones , Fibrilación Atrial/terapia , Aleteo Atrial/complicaciones , Aleteo Atrial/terapia , Cardioversión Eléctrica/efectos adversos , Embolia/diagnóstico por imagen , Embolia/etiología , Embolia/prevención & control , Femenino , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Trombosis/etiología , Trombosis/prevención & control , Resultado del TratamientoRESUMEN
The evaluation of right ventricular (RV) systolic function is important for its clinical and prognostic value but difficult to obtain due to RV complex anatomy. Aims of this study were to evaluate the feasibility of a routine use of RV fractional shortening area (FSA), systolic excursion (TAPSE) and peak systolic velocity (PSV) of tricuspidal annular motion in a large series of cases (900 pts), to determine the values in normal subjects (150) and in patients (750) with different pathologies and to correlate these indexes to clinical and echo-Doppler variables. FSA (50.3+/-10% vs 54.6+/-9% p<0.01), TAPSE (20.2+/-5 vs 24.7+/-4 mm, p<0.01) and PSV (16.2+/-4 vs 20+/-4 cm/s, p<0.01) were lower in patients than in normals, correlated positively to left ventricular ejection fraction and negatively to the pulmonary pressure. The values of 17 mm for TAPSE, 12 cm/s for PSV and 37% for FSA identified patients with high specificity. The values in subgroups of pathological patients were evaluated and compared.