Assessment of atrial function by myocardial deformation techniques in hypertrophic cardiomyopathy.

BACKGROUND: Diastolic dysfunction in hypertrophic cardiomyopathy (HCM) is common, but its assessment is difficult using conventional echocardiography. AIMS: To assess left atrial (LA) function in HCM by longitudinal strain and determine its role in understanding of symptoms. METHODS: We studied 144 patients divided into 3 age- and sex-matched groups: 48 consecutive patients with HCM, 48 control subjects, and 48 athlete subjects. We assessed LA function by conventional echocardiographic parameters and by longitudinal atrial strain (early-diastolic left atrial strain during reservoir phase [LASr]; end-diastolic left atrial strain during conduit phase; end-systolic peak of the left atrial strain during contraction phase). RESULTS: NYHA classification was as follows in HCM group: I in 46%, II in 31%, III in 19%, and IV in 4%. Conventional echocardiographic parameters of diastolic function were depressed in the HCM group as compared to the control and athlete groups, but not related to symptoms. All longitudinal atrial strain parameters were significantly reduced in HCM group as compared to two groups (P < .0001). LASr was significantly correlated to peak VO2 (r = 0.44, P = .01) and was the best parameter for detecting symptomatic patients presenting with HCM, with a cutoff value of 15%: Sensitivity was 71%, specificity was 79%, PPV was 77%, and NPV was 73%. CONCLUSION: Assessment of LA function in HCM is feasible using longitudinal strain, and this technique is more reliable than conventional echocardiographic parameters for the understanding of determinants of symptoms.

Prospective assessment of incidence of Tako-Tsubo cardiomyopathy in a very large urban agglomeration.

BACKGROUND: Tako-Tsubo cardiomyopathy (TTC) is a recently described medical entity and the incidence of TTC in a global population is still uncertain. We sought to prospectively assess the incidence of TTC in a large urban area. METHODS AND RESULTS: We included all consecutive patients referred for coronary angiography in three hospitals located in Paris and its suburbs. We prospectively estimated the percentage of TTC among patients referred for coronary angiography and extrapolated the number of cases of TTC in the greater Paris area (11,598,866 inhabitants) according to the CARDIO-ARHIF registry (government agency). Among 2547 patients (2972 coronary angiographies) including 815 acute coronary syndromes, 20 patients presented with TTC (19 women, mean age 66 ± 13 years). The percentage of TTC among suspected acute coronary syndromes was 2.5% (8.2% in women versus 0.2% in men, p<0.001). In the CARDIO-ARHIF registry, we individualized 51,403 coronary angiographies performed in all catheterization laboratories in one year (13,820 women and 10,246 women ≥ 60 years). In this region, the yearly number of TTC cases is estimated to be 346 (95% CI: 216-520). The annual incidence of TTC is estimated to be 29.8 per 1,000,000 inhabitants (95% CI: 18.6-44.9), 48.2 per 1,000,000 inhabitants (95% CI: 29.7-73.0) among women and 187.4 per 1,000,000 inhabitants (95% CI: 103.3-307.2) among women ≥ 60 years. CONCLUSIONS: Within a large urban agglomeration, the incidence of TTC is high in women ≥ 60 years. The current rate of this recently described cardiomyopathy has been underestimated in previous retrospective studies and will probably rise with the increase of life expectancy.

Usefulness of contrast echocardiography for assessment of intracardiac masses.

BACKGROUND: Conventional echocardiography is not a reliable method for characterizing tissue patterns of intracardiac masses. AIMS: To assess the ability of contrast echocardiography to characterize intracardiac masses. METHODS: Thirty-one consecutive patients with an intracardiac mass were included in this prospective study. All patients underwent conventional and contrast echocardiographic examinations. Analysis of characteristics by contrast agent allowed classification of intracardiac masses as follows: complete lack of enhancement, suggesting thrombus; partial and/or incomplete enhancement, suggesting myxoma; complete enhancement, suggesting intracardiac tumor. Tissue characteristics of intracardiac masses were also analyzed using at least one of the following techniques: cardiac magnetic resonance, pathology of intracardiac mass and/or mass resolved after anticoagulation during follow-up. RESULTS: Using contrast echocardiography, an accurate diagnosis was made in all patients by an experienced investigator and in all patients except one (97%), by a physician trainee (p=0.31). Among patients with a history of tumor, echocardiography allowed accurate diagnosis of the nature of the mass in all patients; 50% of these patients presented with a secondary cardiac tumor and the others had a thrombus. Of the 14patients with a thrombus located in the left ventricle, 12 (86%) presented with left ventricular motion abnormalities using conventional echocardiography, whereas wall motion abnormalities were observed in all 14patients (100%) using contrast agent. In these patients, 91 and 99% of left ventricular segments were well visualized using conventional and contrast echocardiography, respectively (p<0.0001). CONCLUSIONS: Contrast echocardiography may be useful for the tissue characterization of intracardiac masses.

Usefulness of two-dimensional speckle tracking echocardiography for assessment of Tako-Tsubo cardiomyopathy.

The aim of this study was to characterize left ventricular (LV) systolic function using 2-dimensional strain in Tako-Tsubo cardiomyopathy (TTC). Forty-two women were prospectively studied using 2-dimensional speckle-tracking echocardiography, divided into 3 groups: 14 patients with TTC (group 1), 14 patients with coronary artery disease (group 2), and 14 healthy patients (group 3). In patients with TTC, mean values of systolic peak velocity, strain, and strain rate were significantly lower than those in group 3 (p <0.04), but these values were similar between the basal septum and lateral wall, between the middle septum and lateral wall, and between the apical septum and lateral wall. LV ejection fractions were significantly improved during follow-up (p <0.0001). All values of velocities were significantly increased at day 7 compared with the acute phase (p < or =0.01). This improvement differed between the middle septum and lateral wall (p <0.0001), and values for the middle septum and lateral wall in patients with TTC were not significantly different from those observed in patients with coronary artery disease (p = NS). At 1-month follow-up, no significant difference was noted between patients in groups 1 and 3. In conclusion, 2-dimensional speckle-tracking echocardiography is a reliable tool for assessing circular dysfunction in patients with TTC. Once the acute phase has passed, TTC may mimic the LV systematized dysfunction observed in patients with coronary artery disease and so lead to misdiagnosis. This novel echocardiographic technique can also be used in the follow-up of LV functional recovery.

Reliability of echocardiography for hemodynamic assessment of end-stage heart failure.

The management of patients with end-stage heart failure is difficult and may require the monitoring of intracardiac pressures. The aim of this prospective study was to assess the reliability of echocardiography in patients with end-stage HF. Twenty consecutive patients presenting with severe left ventricular dysfunction in end-stage heart failure were prospectively studied. All patients underwent right-sided cardiac catheterization and transthoracic echocardiography. Right atrial pressure, estimated using a new echocardiographic parameter, was significantly improved. There was good agreement between systemic and pulmonary vascular resistance, determined by catheterization and echocardiography. All patients with echocardiographic pulmonary vascular resistance<6 Wood units also had invasive pulmonary vascular resistance<6 Wood units. Only echocardiographic mean right atrial pressure was related to the use of saline infusion or bolus infusion of furosemide. All patients requiring intravenous furosemide had pulmonary capillary wedge pressures persistently>or=15 mm Hg despite adequate medication. In conclusion, this study indicates that echocardiography may be a reliable tool for the management of patients with end-stage heart failure.

Usefulness of contrast echocardiography for assessment of left ventricular thrombus after acute myocardial infarction.

Fifty consecutive patients referred to a coronary care unit for acute anterior myocardial infarction with ST-segment elevation underwent coronary arteriography, left ventricular (LV) angiography, and revascularization. Transthoracic echocardiography was systematically performed using fundamental imaging, second harmonic imaging, and contrast agents to assess the LV chamber. Six patients (12%) presented with a confirmed LV mural thrombus. Thirty-five percent of patients with time to revascularization>3 hours presented with an LV mural thrombus versus 0 patients with time to revascularization3 hours.

Assessment of patent foramen ovale in carcinoid heart disease.

BACKGROUND AND OBJECTIVE: Carcinoid syndrome may involve right carcinoid heart disease (CHD), secondary to the release of vasoactive substances. Left CHD is rare, as the inactivation of serotonin by the lung protects the left heart. We attempted to evaluate the prevalence of CHD and patent foramen ovale (PFO) with serial contrast transthoracic echocardiographic studies and to determine the markers of right and left CHD progression. METHODS: Forty-one consecutive patients with proved digestive endocrine tumor and carcinoid syndrome were prospectively enrolled. All patients underwent serial conventional and contrast transthoracic echocardiographic studies. Right and left CHD, PFO, radiological examinations, and biological carcinoid markers were systematically assessed. RESULTS: Left CHD was present in 5 patients at baseline and in 13 patients (32%) during follow-up (P = .03). The 13 patients with left CHD also had PFO, and no left CHD occurred without PFO (P < .0001). Right CHD was present in 16 patients (39%) at baseline and in 25 patients (61%) at the end of follow-up (P = .04). The prevalence of right and left CHD was significantly higher in patients with PFO (88% and 76%, respectively; P < .04). A progression of right and left CHD was present, respectively, in 19 and 9 patients but was mainly found in patients with PFO (15 and 9 patients; P < .0001). The main marker of CHD progression was the presence of PFO (odds ratio 44.2, 95% confidence interval 4.4-447.7; P = .001). CONCLUSIONS: PFO is a new marker of CHD progression and should be systematically assessed with routine contrast transthoracic echocardiography in patients with carcinoid syndrome to determine patients at high risk of CHD progression.