The Role of Quantitative Aortographic Assessment of Aortic Regurgitation by Videodensitometry in the Guidance of Transcatheter Aortic Valve Implantation.

BACKGROUND: Balloon post-dilatation (BPD) is often needed for optimizing transcatheter heart valve (THV) implantation, since paravalvular leak (PVL) after transcatheter aortic valve implantation is associated with poor outcome and mortality. Quantitative assessment of PVL severity before and after BPD is mandatory to properly assess PVL, thus improving implantation results and outcomes. OBJECTIVE: To investigate a quantitative angiographic assessment of aortic regurgitation (AR) by videodensitometry before and after BPD. METHODS: Videodensitometric-AR assessments (VD-AR) before and after BPD were analysed in 61 cases. RESULTS: VD-AR decreased significantly from 24.0[18.0-30.5]% to 12.0[5.5-19.0]% (p < 0.001, a two-tailed p < 0.05 defined the statistical significance). The relative delta of VD-AR after BPD ranged from -100% (improvement) to +40% (deterioration) and its median value was -46.2%. The frequency of improvement, no change, and deterioration were 70% (n = 43), 25% (n = 15) and 5% (n = 3), respectively. Significant AR (VD-AR > 17%) was observed in 47 patients (77%) before and in 19 patients (31%) after BPD. CONCLUSIONS: VD-AR after THV implantation provides a quantitative assessment of post-TAVI regurgitation and can help in the decision-making process on performing BPD and in determining its efficacy.

The Role of Quantitative Aortographic Assessment of Aortic Regurgitation by Videodensitometry in the Guidance of Transcatheter Aortic Valve Implantation / Papel da Avaliação Aortográfica Quantitativa da Regurgitação Aórtica por Videodensitometria na Orientação do Implante da Valva Aórtica Transcateter

Abstract Background: Balloon post-dilatation (BPD) is often needed for optimizing transcatheter heart valve (THV) implantation, since paravalvular leak (PVL) after transcatheter aortic valve implantation is associated with poor outcome and mortality. Quantitative assessment of PVL severity before and after BPD is mandatory to properly assess PVL, thus improving implantation results and outcomes. Objective: To investigate a quantitative angiographic assessment of aortic regurgitation (AR) by videodensitometry before and after BPD. Methods: Videodensitometric-AR assessments (VD-AR) before and after BPD were analysed in 61 cases. Results: VD-AR decreased significantly from 24.0[18.0-30.5]% to 12.0[5.5-19.0]% (p < 0.001, a two-tailed p < 0.05 defined the statistical significance). The relative delta of VD-AR after BPD ranged from -100% (improvement) to +40% (deterioration) and its median value was -46.2%. The frequency of improvement, no change, and deterioration were 70% (n = 43), 25% (n = 15) and 5% (n = 3), respectively. Significant AR (VD-AR > 17%) was observed in 47 patients (77%) before and in 19 patients (31%) after BPD. Conclusions: VD-AR after THV implantation provides a quantitative assessment of post-TAVI regurgitation and can help in the decision-making process on performing BPD and in determining its efficacy.

Resumo Fundamento: A pós-dilatação com balão (PDB) é normalmente necessária para otimização do implante da válvula cardíaca transcateter (THV), uma vez que o "escape" ou leak paravalvar (PVL) após implante de valva aórtica transcateter está associada com desfecho ruim e mortalidade. A avaliação quantitativa da gravidade do PVL antes e após a PDB é mandatória para se avaliar adequadamente o PVL e, assim, melhorar os resultados e os desfechos do implante. Objetivo: Investigar uma avalição angiográfica quantitativa da regurgitação aórtica (RA) por videodensitometria (VD-RA) antes e após a PDB. Métodos: Resultados da VD-RA antes e após a PDB foram analisados em 61 casos. Resultados Houve diminuição significativa da VD-RA de 24,0(18,0-30,5)% para 12,0(5,5-19,0)% (p < 0,001; p < 0,05 bilateral foi definido como significância estatística). O delta relativo de VD-RA após a PDB variou de -100% (melhora) a +40% (piora) e o valor mediano foi -46,2%. As frequências de melhora, ausência de mudança, e piora foram 70% (n = 43), 25% (n = 15) e 5% (n = 3), respectivamente. Observou-se RA significativo (VD-RA > 17%) em 47 pacientes (77%) antes e em 19 pacientes (31%) após a PDB. Conclusões: A VD-RA após o implante de THV possibilita a avaliação quantitativa da regurgitação pós-TAVI, e pode auxiliar na tomada de decisão quanto à realização ou não da PDB, bem como na avaliação de sua eficácia.

Inter-Technique Consistency and Prognostic Value of Intra-Procedural Angiographic and Echocardiographic Assessment of Aortic Regurgitation After Transcatheter Aortic Valve Implantation.

BACKGROUND: We investigated the relationship between intraprocedural angiographic and echocardiographic AR severity after TAVI, and the clinical robustness of angiographic assessment. Methods and Results: In 74 consecutive patients, the echocardiographic circumferential extent (CE) of the paravalvular regurgitant jet was retrospectively measured and graded based on the VARC-2 cut-points; and angiographic post-TAVI AR was retrospectively quantified using contrast videodensitometry (VD) software that calculates the ratio of the contrast time-density integral in the LV outflow tract to that in the ascending aorta (LVOT-AR). Seventy-four echocardiograms immediately after TAVI were analyzable, while 51 aortograms were analyzable for VD. These 51 echocardiograms and VD were evaluated. Median LVOT-AR across the echocardiographic AR grades was as follows: none-trace, 0.07 (IQR, 0.05-0.11); mild, 0.12 (IQR, 0.09-0.15); and moderate, 0.17 (IQR, 0.15-0.22; P<0.05 for none-trace vs. mild, and mild vs. moderate). LVOT-AR strongly correlated with %CE (r=0.72, P<0.0001). At 1 year, the rate of the composite end-point of all-cause death or HF re-hospitalization was significantly higher in >mild AR patients compared with no-mild AR on intra-procedural echocardiography (41.5% vs. 12.4%, P=0.03) as well as in patients with LVOT-AR >0.17 compared with LVOT-AR ≤0.17 (59.5% vs. 16.6%, P=0.03). CONCLUSIONS: VD (LVOT-AR) has good intra-procedural inter-technique consistency and clinical robustness. Greater than mild post-TAVI AR, but not mild post-TAVI AR, is associated with late mortality.

A novel synchronised diastolic injection method to reduce contrast volume during aortography for aortic regurgitation assessment: in vitro experiment of a transcatheter heart valve model.

AIMS: In the minimalist transcatheter aortic valve implantation (TAVI) era, the usage of transoesophageal echocardiography has become restricted. Conversely, aortography has gained clinical ground in quantifying prosthetic valve regurgitation (PVR) during the procedure. In a mock circulation system, we sought to compare the contrast volume required and the accuracy of aortographic videodensitometric PVR assessment using a synchronised diastolic and standard (non-synchronised) injection aortography. METHODS AND RESULTS: Synchronised diastolic injection triggered by the signal stemming from the mock circulation was compared with standard non-synchronised injection. A transcatheter heart valve was implanted and was deformed step by step by advancing a screw perpendicularly to the cage of the valve in order to create increasing PVR. Quantitative measurement of PVR was derived from time-density curves of both a reference area (aortic root) and a region of interest (left ventricle) developed by a videodensitometric software. The volume of contrast required for the synchronised diastolic injection was significantly less than in the non-synchronised injection (8.1 [7.9-8.5] ml vs. 19.4 [19.2-19.9] ml, p<0.001). The correlation between the two methods was substantial (Spearman's coefficient rho ranging from 0.991 to 0.968). Intraobserver intra-class correlation coefficient for both methods of injection was 0.999 (95% CI: 0.996-1.000) for the synchronised diastolic and 0.999 (95% CI: 0.996-1.000) for the non-synchronised injection group. The mean difference in the rating was 0.17% and limits of agreement were ±1.64% for both groups. CONCLUSIONS: A short synchronised diastolic injection enables contrast volume reduction during aortography without compromising the accuracy of the quantitative assessment of PVR using videodensitometry.

Accuracy of an automated transthoracic echocardiographic tool for 3D assessment of left heart chamber volumes.

AIMS: The feasibility and accuracy of an automated adaptive algorithm (Heart Model) for the quantification of left heart chamber volumes and left ventricular ejection fraction has been reported earlier. An improved version of the algorithm is available, and we aimed to test its accuracy compared with manual 3D echocardiography. METHODS AND RESULTS: Apical 3D transthoracic datasets were obtained in 67 patients. Acquisitions covering ventricles and atria were performed for analysis using the automated software (Heart Model, Philips Healthcare). In addition, acquisitions focused on the left ventricle were acquired for left ventricle manual 3D measurements (QLAB 10 3DQA, Philips Healthcare). Automated results using endocardial contouring settings at 50% showed a strong correlation with manual 3D measurements (r=.84-.97). Left ventricular end-diastolic volumes were underestimated (bias -5.9 mL, LOA ±38.5 mL), with no significant differences in other parameters. Intra-observer variability using the automated algorithm was zero for all parameters given the lack of human interaction. Manual corrections of the automatic algorithm introduced small but significant differences in volumes but not in ejection fraction when compared with automatic results. Manually corrected results of the automatic algorithm were not significantly different from those obtained with manual 3D echocardiography, except for a small underestimation of left atrial volumes (bias -2.1 mL, LOA ±15.2 mL). CONCLUSIONS: The current improved version of the automated adaptive algorithm is accurate for the assessment of left heart chamber volumes, albeit a small underestimation of left ventricular end-diastolic volume is seen, when compared with manual 3D echocardiography.

Angiographic assessment of aortic regurgitation by video-densitometry in the setting of TAVI: Echocardiographic and clinical correlates.

OBJECTIVES: We sought to investigate a new angiographic method for aortic regurgitation (AR) severity assessment in the setting of transcatheter aortic valve implantation (TAVI). BACKGROUND: AR after TAVI is common but challenging to quantitate, especially in the cath-lab. METHODS: In 228 patients, AR was quantitated before and after TAVI by echocardiography and by video-densitometric analysis of aortograms. Contrast time-density curves for the aortic root (the reference region) and the left ventricular outflow tract, LVOT were generated. LVOT-AR was calculated as the area under the curve of the LVOT as a fraction of the area under the curve of the reference region. RESULTS: LVOT-AR was 0.10 ± 0.08, 0.13 ± 0.10 and 0.28 ± 0.14 in none-trace, mild and moderate-severe post-TAVI AR as defined by echocardiography (P < 0.001) and a cutpoint of >0.17 corresponded to moderate-severe AR on echocardiography (area under the curve = 0.84). At follow-up (median, 496 days), patients with LVOT-AR ≤ 0.17 showed a significant reduction of LV mass index (LVMi; 121 [95-148] vs. 140 [112-169] g/m2 , P = 0.009) and the prevalence of LV hypertrophy (LVH; 64 vs. 88%, P = 0.001) compared to baseline. In patients with LVOT-AR > 0.17, LVMi (149 [121-178] vs. 166 [144-188] g/m2 , P = 0.14) and the prevalence of LVH (74 vs. 87%, P = 0.23) did not show a significant change. Compared to patients with LVOT-AR ≤ 0.17, those with LVOT-AR > 0.17 had an increased 30-day (16.4% vs. 7.1%, P = 0.035) and one year mortality (32.9 vs. 14.2%, log rank P value = 0.001; HR: 2.690 [1.461-4.953], P = 0.001). CONCLUSIONS: LVOT-AR > 0.17 corresponds to greater than mild AR as defined by echocardiography and predicts impaired LV reverse remodeling and increased early and midterm mortality after TAVI. © 2017 Wiley Periodicals, Inc.

Quantitative assessment of the entire right ventricle from one acoustic window: an attractive approach.

AIMS: The aim of this prospective study was to evaluate the feasibility and establish normal values of functional right ventricle (RV) parameters as assessed in our four, long-axis view RV model using iRotate echocardiography. Furthermore, we evaluated the potential use of this model in patients with abnormally loaded RVs. METHOD AND RESULTS: One hundred and fifty-five healthy subjects aged 20-72 years (≥28 subjects per decile) were prospectively recruited. We used non-dedicated RV speckle-tracking software to test the feasibility and to establish normal range values of peak systolic global longitudinal RV strain (RV-GLS) from the RV free-walls (septum was excluded). Also normal range values for: dimensions, tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular peak systolic velocity (TDI-S') were established. The feasibility of RV-GLS was 88, 84, and 62%, respectively, in the lateral, inferior, and anterior free wall. Mean RV-GLS normal values were -24.5 ± 4.9% for lateral wall and -25.4 ± 5.0% for anterior wall. Mean RV-GLS in the inferior wall was -23.2 ± 4.4% in the aortic (Ao) view and -20.7 ± 5.0% in the coronal (CV) view. The feasibility of mean RV-GLS was 100% in the anterior, lateral, and inferior walls in abnormally dilated RVs. CONCLUSION: The feasibility of all RV parameters assessed in the four-view iRotate model is good to excellent. Normal values for RV dimension and function of the anterior, inferior, and lateral RV walls have been established. Further studies and dedicated RV speckle-tracking software are warranted to discover the full potential of this new technique.

Limitations and difficulties of echocardiographic short-axis assessment of paravalvular leakage after corevalve transcatheter aortic valve implantation.

To make assessment of paravalvular aortic leakage (PVL) after transcatheter aortic valve implantation (TAVI) more uniform the second Valve Academic Research Consortium (VARC) recently updated the echocardiographic criteria for mild, moderate and severe PVL. In the VARC recommendation the assessment of the circumferential extent of PVL in the short-axis view is considered critical. In this paper we will discuss our observational data on the limitations and difficulties of this particular view, that may potentially result in overestimation or underestimation of PVL severity.

A granular approach to improve reproducibility of the echocardiographic assessment of paravalvular regurgitation after TAVI.

Paravalvular leak (PVL) after transcatheter aortic valve implantation (TAVI) is challenging to quantitate. Transthoracic echocardiography (TTE) is the main tool used for the assessment of PVL but is modestly reproducible. We sought to develop a reproducible echocardiographic approach to assess PVL in the post-TAVI setting. Four observers independently analyzed eleven parameters of PVL severity in 50 pre-discharge TTE studies performed after TAVI. The parameters included color-Doppler parameters [jet circumferential extent (CE) and planimetered vena contracta area in the short-axis view and jet breadth and qualitative features in the long-axis views], continuous-wave Doppler parameters [jet velocity time integral (VTI) and pressure half time (PHT)], quantitative Doppler parameters (regurgitation volume and fraction and effective regurgitant orifice area), aortic diastolic flow reversal and valve stent eccentricity. Intraclass correlation coefficient (ICC) and coefficient of variation (CV) for numerical parameters and kappa coefficient (κ) for categorical parameters were calculated for inter- and intra-observer comparisons. Inter-observer ICC was highest and CV lowest for CE (0.88 and 0.36), jet origin breadth (0.82 and 0.39), jet qualitative features in long-axis views (0.87 and 0.26), jet VTI (0.87 and 0.04) and PHT (0.73 and 0.10). Similar results were found in intra-observer comparisons. A 2-step granular approach combining the most reproducible parameters was used to grade PVL by the four observers. Inter-observer agreement was achieved in 86 % of cases (κ = 0.79). Combining color Doppler and continuous wave Doppler parameters in a granular algorithm yields excellent reproducibility of PVL assessment by TTE.

Echocardiographic and angiographic assessment of paravalvular regurgitation after TAVI: optimizing inter-technique reproducibility.

AIMS: Aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) is often first diagnosed by angiography and then confirmed and followed-up by transthoracic echocardiography (TTE). Consistency between both methods is important for follow-up. We sought to determine inter-technique reproducibility of the assessment of paravalvular AR after TAVI. METHODS AND RESULTS: The study included 165 patients treated with a self-expanding bioprosthesis and had angiography and TTE performed at a median interval of 4 days. TTE parameters of AR severity included VARC score (the average AR grade determined by the echocardiographic VARC-II criteria), pressure half time (PHT), regurgitation jet features in long-axis views (LAX score) and colour Doppler (CD) score (=paravalvular AR jet circumferential extent (%) + LAX score). Using receiver-operating characteristics curves, the cut-points that best defined an angiographic >mild AR were identified.On TTE, AR was paravalvular in all cases, multi-jet in 28%, and predominantly (64%) detected in the commissural region between the right and left coronary sinuses. Using VARC-II criteria (combining at least two), TTE agreed with angiographic classification in 53% of cases (k = 0.14). Greater than mild AR could better be defined by one of the following combinations of criteria: (i) LAX score >4.25 and VARC-II score >1.33; (ii) CD score >11.5 and PHT <400 ms. The combination of the CD score with PHT gave the best sum of sensitivity, specificity, positive, and negative predictive values. CONCLUSIONS: Agreement between angiography and TTE (using the VARC-II criteria) in the grading of post-TAVI AR is modest, and this might have contributed to the inconsistency of data on the rate and fate of paravalvular AR. Inter-technique reproducibility can be improved using a combination of CD and hemodynamic parameters.

Video densitometric assessment of aortic regurgitation after transcatheter aortic valve implantation: results from the Brazilian TAVI registry.

AIMS: We sought to examine the feasibility and reproducibility of a new video densitometric (VD) quantification of aortic regurgitation (AR) on aortography, and its long-term clinical impact. METHODS AND RESULTS: Using dedicated video densitometry software, AR after TAVI was quantified, and inter- and intra-observer reproducibility was investigated in 182 aortograms of the Brazilian TAVI registry. The aortograms were analysed using two software algorithms: 1) the quantitative regurgitation analysis (qRA) index interrogating the entire left ventricle (LV), and 2) a new method with the left ventricle outflow tract (LVOT) as a region of interest (ROI) (LVOT-AR). LVOT-AR was feasible in 64.8% vs. 29.7% of aortograms, compared with qRA index. Using the LVOT-AR, inter-observer variability was low (mean difference±standard deviation [SD]: 0.01±0.05, p=0.53), and the two observers' measurements were highly correlated (r=0.95, p<0.001). Patients with LVOT-AR >0.17 had a significantly higher one-year all-cause mortality risk compared with patients with LVOT-AR ≤0.17 (37.1% vs. 11.2%, p=0.0008). CONCLUSIONS: This study proposes an alternative methodology for AR assessment after TAVI by using the LVOT method (LVOT-AR) of VD angiography. The assessment of LVOT-AR is feasible, reproducible and potentially predictive of one-year mortality.

A Novel 13-Segment Standardized Model for Assessment of Right Ventricular Function Using Two-Dimensional iRotate Echocardiography.

AIMS: The aim of this study was to evaluate the feasibility of transthoracic two-dimensional (2D) iRotate, a new echo modality, to assess the whole right ventricle (RV) from a single transducer position based on anatomic landmarks. METHODS AND RESULTS: The anatomic landmarks were first defined based on three-dimensional echocardiographic datasets using multiplane reconstruction analyses. Thereafter, we included 120 healthy subjects (51% male, age range 21-67 years). Using 2D iRotate, four views of the RV could be acquired based on these landmarks. The anterior, lateral, inferior wall (divided into three segments: basal-mid-apical), and right ventricular outflow tract (RVOT) anterior wall of the RV were determined. The feasibility of visualization of RV segments and tricuspid annular plane systolic excursion (TAPSE) and tissue Doppler imaging (TDI) measurements were assessed. To evaluate this model for diseased RVs, a small pilot study of 20 patients was performed. In 98% of healthy subjects and 100% of patients, iRotate mode was feasible to assess the RV from one single transducer position. In total, 86% and 95%, respectively, of the RV segments could be visualized. The visualization of the RVOT anterior wall was worse 23% and 75%, respectively. TAPSE and TDI measurements on all four views were feasible 93% and 92%, respectively, of the healthy subjects and in 100% of the patients. CONCLUSION: With 2D iRotate, a comprehensive evaluation of the entire normal and diseased RV is feasible from a fixed transducer position based on anatomic landmarks. This is less time-consuming than the multiview approach and enhances accuracy of RV evaluation. Imaging of the RVOT segment remains challenging.

Assessment of subendocardial contractile function in aortic stenosis: a study using speckle tracking echocardiography.

BACKGROUND: Angina and an electrocardiographic strain pattern are potential manifestations of subendocardial ischemia in aortic stenosis (AS). Left ventricular (LV) twist is known to increase proportionally to the severity of AS, which may be a result of loss of the inhibiting effect of the subendocardial fibers due to subendocardial dysfunction. It has also been shown that the ratio of LV twist to circumferential shortening of the endocardium (twist-to-shortening ratio [TSR]) is a reliable parameter of subendocardial dysfunction. The aim of this study was to investigate whether these markers are increased in AS patients with angina and/or electrocardiographic strain. METHODS: The study comprised 60 AS patients with an aortic valve area <2.0 cm(2) and LV ejection fraction >50%, and 30 healthy-for age and gender matched-control subjects. LV rotation parameters were determined by speckle tracking echocardiography. RESULTS: Comparison of patients without angina and strain (n = 22), with either angina or strain (n = 28), and with both angina and strain (n = 8), showed highest peak systolic LV apical rotation, peak systolic LV twist, and TSR, in patients with more signs of subendocardial ischemia. In a multivariate linear regression model, only severity of AS and the presence of angina and/or strain could be identified as independent predictors of peak systolic LV twist and TSR. CONCLUSIONS: Peak systolic LV twist and TSR are increased in AS patients and related to the severity of AS and symptoms (angina) or electrocardiographic signs (strain) compatible with subendocardial ischemia.

New Scores for the Assessment of Mitral Stenosis Using Real-Time Three-Dimensional Echocardiography.

Nonsurgical management of patients with symptomatic mitral valve stenosis has been established as the therapeutic modality of choice for two decades. Catheter-based balloon dilation of the stenotic valvular area has been shown, at least, as effective as surgical interventions. Unfavorable results of catheter-based interventions are largely due to unfavorable morphology of the valve apparatus, particularly leaflets calcification and subvalvular apparatus involvement. A mitral valve score has been proposed in Boston, MA, about two decades ago, based on morphologic assessment of mitral valve apparatus by two-dimensional (2D) echocardiography to predict successful balloon dilation of the mitral valve. Several other scores have been developed in the following years in order to more successfully predict balloon dilatation outcome. However, all those scores were based on 2D echocardiography, which is limited by ability to distinguish calcification and subvalvular involvement. The introduction of new matrix-based ultrasound probe has allowed 3D echocardiography (3DE) to provide more detailed morphologic analysis of mitral valve apparatus including calcification and subvalvular involvement. Recently, a new 3DE scoring system has been proposed by our group, which represents an important leap into refinement of the use of echocardiography guiding mitral valve interventions.

Validation of a new score for the assessment of mitral stenosis using real-time three-dimensional echocardiography.

BACKGROUND: The aim of this study was to validate a new real-time three-dimensional echocardiography (RT3DE) score for evaluating patients with mitral stenosis (MS). METHODS: A two-staged study was conducted. In the first stage, the feasibility of a new RT3DE score was assessed in 17 patients with MS. The second stage was planned to validate the RT3DE score in 74 consecutive patients undergoing percutaneous mitral valvuloplasty. The new RT3DE score was constructed by dividing each mitral valve (MV) leaflet into 3 scallops and was composed of 31 points (indicating increasing abnormality), including 6 points for thickness, 6 for mobility, 10 for calcification, and 9 for subvalvular apparatus involvement. The total RT3DE score was calculated and defined as mild (<8), moderate (8-13), or severe (>or=14). MV morphology was assessed using Wilkins's score and compared with the new RT3DE score. RESULTS: In the first stage, the RT3DE score was feasible and easily applied to all patients, with good interobserver and intraobserver agreement. In the second stage, RT3DE improved MV morphologic assessment, particularly for the detection of calcification and commissural splitting. Both scores were correlated for assessment of thickness and calcification (r = 0.63, P < .0001, and r = 0.44, P < .0001, respectively). Predictors of optimal percutaneous mitral valvuloplasty success by Wilkins's score were leaflet calcification and subvalvular apparatus involvement, and those by RT3DE score were leaflet mobility and subvalvular apparatus involvement. The incidence and severity of mitral regurgitation were associated with high-calcification RT3DE score. CONCLUSION: The new RT3DE score is feasible and highly reproducible for the assessment of MV morphology in patients with MS. It can provide incremental prognostic information in addition to Wilkins's score.

Assessment of mitral annular velocities by speckle tracking echocardiography versus tissue Doppler imaging: validation, feasibility, and reproducibility.

BACKGROUND: Mitral annular velocity may be measured angle independently by speckle tracking echocardiography (STE), in contrast with tissue Doppler imaging (TDI). The purpose of the current study was to compare STE and TDI, with respect to 1) the accuracy of velocity measurements in a moving phantom, 2) the feasibility and reproducibility of measurement of mitral annular velocities in a clinical setting, and 3) the estimation of left ventricular filling pressures using mitral annular velocities. METHODS: The velocity of a moving phantom, using different angles of insonation, and mitral annular velocities of 80 nonselected patients and 50 healthy volunteers were determined using TDI and STE. A subgroup of 20 patients was studied during right-sided heart catheterization. RESULTS: When the motion direction of the phantom was parallel to the ultrasound beam, both TDI and STE determined velocities accurately. With increasing angle of insonation, TDI-derived velocity decreased, whereas STE-derived velocity remained unchanged. The feasibility of mitral annular velocities measured by TDI and STE was comparable (98% vs 95%, P = not significant). Although for both techniques correlations between measured mitral annular velocities at repeated examinations were good, the test-retest variability of mitral annular velocities by TDI was higher. E/Em ratio by STE correlated better to pulmonary capillary wedge pressure (R(2) = 0.51, P < .001) compared with E/Em ratio derived from TDI (R(2) = 0.35, P < .01), although the difference in correlation was not statistically significant because of the limited sample size. CONCLUSION: Tissue velocities can be accurately determined by STE in a moving phantom and are angle independent, in contrast with TDI measurements. Furthermore, STE is a feasible and better reproducible method for the assessment of mitral annular velocities in a clinical setting.

Importance of transducer position in the assessment of apical rotation by speckle tracking echocardiography.

BACKGROUND: Speckle tracking echocardiography is increasingly used to quantify left ventricular (LV) twist. However, one of the limitations of the assessment of LV twist by speckle tracking echocardiography is the crucial dependence on correct acquisition of a LV apical short-axis. This study sought to assess the influence of transducer position on LV apical rotation measurements. METHODS: The study population consisted of 58 consecutive healthy volunteers (mean age 38 +/- 13 years, 25 men). To obtain parasternal short-axis images at the LV apical level, the following protocol was used. From the standard parasternal position (LV and aorta most inline, with the mitral valve tips in the middle of the sector) an as-circular-as-possible short-axis image of the LV apex, just proximal to the level with end-systolic LV luminal obliteration, was obtained by angulation of the transducer (position 1). From this position, the position of the transducer was changed to one (position 2) and two (position 3) intercostal spaces more caudal with subsequent similar transducer adaptations. RESULTS: In 8 volunteers (14%) parasternal image quality was insufficient for speckle tracking echocardiography. In 13 volunteers (22%) the LV apical short-axis could only be obtained from one transducer position. In the remaining volunteers with two (n = 27) or three (n = 10) available transducer positions, a more caudal transducer position was associated with increased measured LV apical rotation. Mean measured LV apical rotation was 5.2 +/- 1.8 degrees at position 1, 7.3 +/- 2.6 degrees at position 2 (P < .001), and 8.7 +/- 2.2 degrees at position 3 (P < .001 vs position 1 and P < .05 vs position 2). CONCLUSION: A more caudal transducer position is associated with increased measured LV apical rotation.

Assessment of left atrial volume and function by real-time three-dimensional echocardiography.

BACKGROUND: Determination of left atrial (LA) size and function is important in clinical decision-making. Calculation of LA volume (LAV) is the most accurate index of LA size. AIM: To compare real-time 3-dimensional echocardiography (RT3DE) and 2-dimensional echocardiography (2DE) for calculation of LAV and function. METHODS: Fifty patients were studied using 2DE and RT3DE for calculating LAV including: Maximum (V max), minimum (V min) and pre-atrial contraction (V pre A) volumes. For 2DE, the formula: LAV=8(A1) (A2)/3pi (L) was used, while for RT3DE, offline analysis was performed using commercially available software. LA function indices including Total Atrial Stroke Volume (TASV), active ASV (AASV), Total Atrial Emptying Fraction (TAEF), active AEF (AAEF), passive AEF (PAEF), and Atrial Expansion Index (AEI) were calculated. RESULTS: Patients were classified into 2 equal groups: group I with normal V max (< 50 ml) and group II with V max (> or = 50 ml). Good correlation was obtained between RT3DE and 2DE for LAV (r=0.64, p=0.001) in group I and (r=0.83, p<0.0001) in group II. In group I, LAV and functions showed no significant difference by both techniques, while in group II, the V min and V pre A were significantly lower by RT3DE than 2DE (p=0.009, 0.006). TAEF, AEI, and PAEF indices were significantly higher by RT3DE than 2DE in group II. CONCLUSION: RT3DE provides a reproducible assessment of active and passive LA function by volumetric cyclic changes. It is comparable and may be superior to 2DE due to its higher sensitivity to volume changes.

Assessment of left atrial ejection force in hypertrophic cardiomyopathy using real-time three-dimensional echocardiography.

The study included 30 patients with hypertrophic cardiomyopathy (HCM) (obstructive and nonobstructive) and 15 control subjects. End-diastolic mitral annulus area (MAA(3D)) and mitral valve area (MVA(3D)) were measured by real-time 3-dimensional (3D) echocardiography. MVA(2D) and peak mitral inflow A wave velocity (V) were measured by 2-dimensional (2D) echocardiography. Left atrial ejection force (LA-EF) was calculated by 2D echocardiography and real-time 3D echocardiography using the formula: 0.5 x 1.06 x (MAA or MVA) x V2, where (1.06) is blood viscosity. LA-EF(2D-MVA), LA-EF(3D-MVA), LA-EF(3D-MAA), and V were significantly higher in patients with HCM than control subjects (P < .001). LA-EF(2D-MVA) and LA-EF(3D-MVA) were lower than LA-EF(3D-MAA) in HCM only (P < .001). In obstructive HCM, LA-EF(2D-MVA), LA-EF(3D-MVA), LA-EF(3D-MAA), and V were significantly higher than in nonobstructive HCM (P < .05). Left ventricular outflow tract gradient contributed independently to high LA-EF in obstructive HCM. We concluded that HCM is associated with higher LA-EF than normal, and higher in obstructive HCM than nonobstructive indicating a higher atrial workload that is reflected by LA-EF(3D-MAA).