Importance of Preoperative Computed Tomography Assessment of the Membranous Septal Anatomy in Patients Undergoing Transcatheter Aortic Valve Replacement With a Balloon-Expandable Valve.

BACKGROUND: Cardiac conduction disturbance (CD) is the most frequent complication following transcatheter aortic valve replacement (TAVR). This study examined whether the anatomy of the membranous septum (MS) could provide useful information about the risk of CD following TAVR with a balloon-expandable valve (BEV).Methods and Results:Among 132 consecutive patients, 106 (mean age, 85.6±5.1 years; 75 females) were included in the study. Using preoperative CT and angiography, MS length and implantation depth (ID) were assessed. The MS length minus the prosthesis ID was calculated (∆MSID). Correlation between CD, defined as new-onset left-bundle branch block (LBBB) or the need for permanent pacemaker (PPM) within 1 week after the procedure, and MS length were evaluated. A total of 19 patients (18%) developed CD following TAVR. MS length was significantly shorter in these patients than in those without CD (5.3±1.3 vs. 6.6±1.4; P<0.001), and was the important predictor of CD (odds ratio [OR]: 0.43, 95% confidence interval [CI]: 0.27-0.69, P<0.001). When considering the pre- and postprocedural parameters, the ∆MSID was smaller in patients with CD (-1.7±1.5 vs. 0.8±1.9, P<0.001), and emerged as the important predictor of CD (OR: 0.47, 95% CI: 0.33-0.69, P<0.001). CONCLUSIONS: Short MS is associated with an increased risk of CD after TAVR with BEV.

Should the septum be included in the assessment of right ventricular longitudinal strain? An ultrasound two-dimensional speckle-tracking stress study.

Right ventricular longitudinal strain (RVLS) by 2D speckle-tracking echocardiography (2D-STE) is a useful parameter for assessing systolic function. However, the exact method to perform it is not well defined as some authors evaluate only free wall (FW) segments while others include all six RV segments. To compare the assessment of RVLS at rest and during exercise by these two approaches. Echocardiography was performed on 80 healthy subjects at rest and during exercise. The analysis consisted of standard and 2D-STE assessment of RV global and segmental strain tracing only RVFW and also tracing all six RV segments. At rest, RVLS could be assessed in 78 (feasibility 97.5%) subjects by both methods. However, during exercise, RVLS by RVFW method was feasible in 67 (83.8%) as compared to 74 (92.5%) by RV6S approach. Both at rest and during exercise, RVLS values by the two methods showed excellent correlation (r = > 0.90). However, RVLS values assessed by RV6S were lower (absolute values) than those by RVFW approach (RV6S vs. RVFW; rest: - 27.0 ± 3.9 vs. - 9.5 ± 3.9, p < 0.001 and exercise: - 30.7 ± 5.2 vs. - 33.3 ± 5.1, p < 0.001). Furthermore, basal strain was higher and apical strain lower (absolute values) by RV6S approach. At rest, reproducibility for RVLS was excellent and similar for the two methods. However, during exercise, reproducibility for RVFW method was poorer, especially at the apex. The two currently described methods for RVLS assessment by 2D-STE demonstrated excellent agreement. However, the RV6S approach seemed to be more feasible and reproducible, particularly during exercise. Moreover, global and segmental strain values are different with both methods and should not be interchanged.

Assessment of Subclinical Cardiac Alterations and Atrial Electromechanical Delay by Tissue Doppler Echocardiography in Patients with Nonfunctioning Adrenal Incidentaloma / Avaliação de Alterações Cardíacas Subclínicas e Atraso Eletromecânico Atrial por Ecocardiografia com Doppler Tecidual em Pacientes com Incidentaloma Adrenal Não Funcionante

Abstract Background: Majority of the incidentally discovered adrenal masses, called adrenal incidentaloma (AI), are nonfunctioning adrenal adenomas. The appropriate management of AI is still a matter debate, so it is necessary to investigate their associated morbidity. However, data regarding morphological and functional cardiac alterations are limited in this group. Objective: In this study, we aimed to assess cardiac structural and functional characteristics and atrial conduction properties in patients with nonfunctioning AI. Methods: Thirty patients with nonfunctioning AI and 46 properly matched control subjects were included in the study. After hormonal and biochemical analysis, all participants underwent transthoracic echocardiography to obtain systolic and diastolic parameters of both ventricles, in addition to atrial conduction times by tissue Doppler echocardiography. Data were analyzed with Statistical Package for the Social Sciences (SPSS, Chicago, IL, United States) statistics, version 17.0 for Windows. P < 0.05 was considered statistically significant. Results: Left ventricular (LV) mass index and LV myocardial performance index were significantly increased in AI group. Among atrial conduction times, both intra- and interatrial electromechanical delays were significantly prolonged in patients with nonfunctioning AI. Other laboratory and echocardiographic findings were similar between groups. Conclusion: Our study revealed that intra- and inter-atrial conduction times were prolonged, and LV mass index was increased in patients with nonfunctioning AI. These findings may be markers of subclinical cardiac involvement and tendency to cardiovascular complications. Close follow-up is necessary for individuals with nonfunctioning AI for their increased cardiovascular risk.

Resumo Fundamento: A maioria das massas adrenais descobertas incidentalmente, denominadas incidentaloma adrenal (IA), são adenomas adrenais não funcionantes. O manejo adequado da IA ainda é um tema de debate, e por isso é necessário investigar suas morbidades associadas. Entretanto, dados referentes a alterações cardíacas morfológicas e funcionais são limitados nesse grupo. Objetivo: Neste estudo, objetivamos avaliar as características estruturais e funcionais cardíacas e as propriedades de condução atrial em pacientes com IA não funcionante. Métodos: Trinta pacientes com IA não funcionante e 46 controles adequadamente pareados foram incluídos no estudo. Após análise hormonal e bioquímica, todos os participantes foram submetidos a ecocardiograma transtorácico para obtenção de parâmetros sistólicos e diastólicos de ambos os ventrículos, além dos tempos de condução atrial pelo ecocardiograma com Doppler tecidual. Os dados foram analisados com o Statistical Package for the Social Sciences (SPSS, Chicago, IL, Estados Unidos), versão 17.0 para Windows. P < 0,05 foi considerado estatisticamente significativo. Resultados: O índice de massa do ventrículo esquerdo (VE) e o índice de desempenho miocárdico do VE foram significativamente aumentados no grupo IA. Entre os tempos de condução atrial, os atrasos eletromecânicos intra- e interatriais foram significativamente prolongados em pacientes com IA não funcionante. Outros achados laboratoriais e ecocardiográficos foram semelhantes entre os grupos. Conclusão: Nosso estudo revelou que os tempos de condução intra- e interatrial estavam prolongados e o índice de massa do VE estava aumentado em pacientes com IA não funcionante. Esses achados podem ser marcadores de envolvimento cardíaco subclínico e de tendência a complicações cardiovasculares. Um acompanhamento rigoroso é necessário para indivíduos com IA não funcionante, devido ao aumento do risco cardiovascular.

Assessment of Subclinical Cardiac Alterations and Atrial Electromechanical Delay by Tissue Doppler Echocardiography in Patients with Nonfunctioning Adrenal Incidentaloma.

BACKGROUND: Majority of the incidentally discovered adrenal masses, called adrenal incidentaloma (AI), are nonfunctioning adrenal adenomas. The appropriate management of AI is still a matter debate, so it is necessary to investigate their associated morbidity. However, data regarding morphological and functional cardiac alterations are limited in this group. OBJECTIVE: In this study, we aimed to assess cardiac structural and functional characteristics and atrial conduction properties in patients with nonfunctioning AI. METHODS: Thirty patients with nonfunctioning AI and 46 properly matched control subjects were included in the study. After hormonal and biochemical analysis, all participants underwent transthoracic echocardiography to obtain systolic and diastolic parameters of both ventricles, in addition to atrial conduction times by tissue Doppler echocardiography. Data were analyzed with Statistical Package for the Social Sciences (SPSS, Chicago, IL, United States) statistics, version 17.0 for Windows. P < 0.05 was considered statistically significant. RESULTS: Left ventricular (LV) mass index and LV myocardial performance index were significantly increased in AI group. Among atrial conduction times, both intra- and interatrial electromechanical delays were significantly prolonged in patients with nonfunctioning AI. Other laboratory and echocardiographic findings were similar between groups. CONCLUSION: Our study revealed that intra- and inter-atrial conduction times were prolonged, and LV mass index was increased in patients with nonfunctioning AI. These findings may be markers of subclinical cardiac involvement and tendency to cardiovascular complications. Close follow-up is necessary for individuals with nonfunctioning AI for their increased cardiovascular risk.

Assessment of optimal right ventricular pacing site using invasive measurement of left ventricular systolic and diastolic function.

AIMS: Right ventricular apical pacing has a detrimental effect on left ventricular (LV) function. More optimal pacing site may be found by invasive measurement of LV mechanical performance during pacing from different RV pacing sites. We aimed to investigate the effect of RV pacing lead location on invasive indices of LV mechanical performance. METHODS AND RESULTS: Patients undergoing catheter ablation for persistent atrial fibrillation were enrolled. Single-site endocardial pacing from the lateral LV region was periodically switched to pacing from the mapping catheter navigated to different RV sites within the three-dimensional electroanatomical RV map. SystIndex, DiastIndex, and PPIndex were defined as the ratio of LV dP/dtmax, LV dP/dtmin, and arterial pulse pressure during RV pacing to corresponding values from adjacent periods of LV pacing. Haemodynamic data were analysed in 18 RV segments created by dividing RV horizontally (basal, mid, and apical portion), vertically (inferior, mid, and superior portion) and frontally (septum and free wall). Eight patients (58 ± 7 years; 2 females; 26 ± 4 RV pacing sites per patient) were enrolled into the study. Compared with LV pacing, the best RV pacing values of SystIndex and DiastIndex were achieved in basal-mid-septal segment (+6.9%, P = 0.02 and +3.4%, P = 0.36, respectively) while the best PPIndex was obtained in superior-mid-septal segment of RV (+4.5%, P = 0.02). All indices were fairly concordant showing significant improvement of haemodynamics during RV pacing in the direction from free wall to septum, from apex to base, and from inferior to superior segments. CONCLUSION: The best LV mechanical performance was achieved by RV septal pacing in the non-apical mid-to-superior segments.

Assessment of left ventricular functions in patients with isolated coronary artery ectasia by conventional and tissue Doppler imaging.

The authors sought to determine left ventricular functions by conventional and tissue Doppler imaging in patients with isolated coronary artery ectasia and controls. Peak early (E) and late (A) mitral inflow velocity, E/A ratio, E deceleration time, and isovolumetric relaxation time were obtained. Peak systolic velocity (Sm), diastolic early (Em), and late (Am) velocities were measured by tissue Doppler imaging. Interventricular septum velocities, including peak systolic (Ss), diastolic early (Es), and late (As) velocities, were recorded. Peak early (E) velocity, E/A ratio, and E deceleration time were different in both groups. Isovolumetric relaxation time was prolonged in patients with coronary artery ectasia than controls. Em and Em/Am ratio were lower in patients with coronary artery ectasia than controls. Diastolic early and Es/As velocities were lower in patients with coronary artery ectasia compared with controls. The authors showed that mitral inflow-lateral annulus and interventricular septum velocities were lower in patients with coronary artery ectasia than controls indicating left ventricular diastolic dysfunction.

Assessment of regional atrial function in patients with hypertrophic cardiomyopathies using tissue Doppler imaging.

BACKGROUND: This study applied tissue Doppler imaging and color tissue Doppler imaging to study atrial function changes in patients with hypertrophic cardiomyopathy (HCM). The profile of the segmental atrial velocities and the strain rate were determined and compared with those of normal matched control subjects. METHODS: This study investigated 20 patients with HCM and 20 age-matched healthy control subjects. In a four-chamber apical view, tissue Doppler imaging was used to measure the lateral left and right atrial (LA and RA) and interatrial septal (IAS) wall systolic, early, and late diastolic velocities. Similarly, the atrial strain rate during ventricular systole (SR(S)) and the early (SR(E)) and late (SR(A)) diastolic phases in patients and control subjects were measured. The interventricular septal tissue Doppler-derived isovolumic relaxation time was calculated. RESULTS: Only the IAS annular and middle segments showed a significant reduction in the early diastolic velocity (mean, 4.01 +/- 2.2 vs 8.7 +/- 1.1, p = 0.001; 3.23 +/- 2 vs 6.01 +/- 1.9, p = 0.001, respectively) for the patients with HCM in comparison with the control subjects. Generally, the atrial strain rate was clearly reduced. The systolic strain rate (SR(S)) was significantly reduced in the LA wall in the annular (p = 0.007) and middle (p = 0.001) segments and in the IAS middle segment (p = 0.007). Similarly, there was a reduction of the early diastolic strain rate (SR(E)) in the LA annular (p = 0.001) and middle (p = 0.01) segments and in the IAS annular (p = 0.05) and middle (p = 0.001) segments, as well as in the RA annular segment (p = 0.02). The RA middle segments showed insignificant changes. CONCLUSION: Atrial function may be affected by HCM due to impairment of myocardial diastolic function. Strain rate imaging is reproducible, yields readily obtained parameters that provide unique data about global and longitudinal segmental atrial contraction, and can quantify the atrial dysfunction in patients with HCM.