Use of Real-Time Cine MRI to Assess the Respirophasic Variation of the Inferior Vena Cava-Proof-of-Concept and Validation Against Transthoracic Echocardiography.

BACKGROUND: In clinical practice, the right heart filling status is assessed using the respirophasic variation of the inferior vena cava (IVC) assessed by transthoracic echocardiography (TTE) showing moderate correlations with the catheter-based reference standard. PURPOSE: To develop and validate a similar approach using MRI. STUDY TYPE: Prospective. POPULATION: 37 male elite cyclists (mean age 26 ± 4 years). FIELD STRENGTH/SEQUENCE: Real-time balanced steady-state free-precession cine sequence at 1.5 Tesla. ASSESSMENT: Respirophasic variation included assessment of expiratory size of the upper hepatic part of the IVC and degree of inspiratory collapse expressed as collapsibility index (CI). The IVC was studied either in long-axis direction (TTE) or using two transverse slices, separated by 30 mm (MRI) during operator-guided deep breathing. For MRI, in addition to the TTE-like diameter, IVC area and major and minor axis diameters were also assessed, together with the corresponding CIs. STATISTICAL TESTS: Repeated measures ANOVA test with Bonferroni correction. Intraclass correlation coefficient (ICC) and Bland-Altman analysis for intrareader and inter-reader agreement. A P value <0.05 was considered statistically significant. RESULTS: No significant differences in expiratory IVC diameter were found between TTE and MRI, i.e., 25 ± 4 mm vs. 25 ± 3 mm (P = 0.242), but MRI showed a higher CI, i.e., 76% ± 14% vs. 66% ± 14% (P < 0.05). As the IVC presented a noncircular shape, i.e., major and minor expiratory diameter of 28 ± 4 mm and 21 ± 4 mm, respectively, the CI varied according to the orientation, i.e., 63% ± 27% vs. 75% ± 16%, respectively. Alternatively, expiratory IVC area was 4.3 ± 1.1 cm2 and showed a significantly higher CI, i.e., 86% ± 14% than diameter-based CI (P < 0.05). All participants showed a CI >50% with MRI versus 35/37 (94%) with TTE. ICC values ranged 0.546-0.841 for MRI and 0.545-0.704 for TTE. CONCLUSION: Assessment of the respirophasic IVC variation is feasible with MRI. Adding this biomarker may be of particular use in evaluating heart failure patients. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 2.

Evolution of ventricular and valve function in patients with right ventricular pacing - A randomized controlled trial comparing leadless and conventional pacing.

BACKGROUND: Leadless pacemakers (PMs) were recently introduced to overcome lead-related complications. They showed high safety and efficacy profiles. Prospective studies assessing long-term safety on cardiac structures are still missing. OBJECTIVE: The purpose of this study was to compare the mechanical impact of Micra with conventional PM on heart function. METHODS: We conducted a non-inferiority trial in patients with an indication for single chamber ventricular pacing. Patients were 1:1 randomized to undergo implantation of either Micra or conventional monochamber ventricular pacemaker (PM). Patients underwent echocardiography at baseline, 6 and 12 months after implantation. Analysis included left ventricular ejection fraction (LVEF), global longitudinal strain (GLS) and valve function. N-terminal-pro hormone B-type natriuretic peptide (NT-pro-BNP) levels were measured at baseline and 12 months. RESULTS: Fifty-one patients (27 in Micra group and 24 in conventional group) were included. Baseline characteristics were similar for both groups. At 12 months, (1) the left ventricular function as assessed by LVEF and GLS worsened similarly in both groups (∆LVEF -10 ± 7.3% and ∆GLS +5.7 ± 6.4 in Micra group vs. -13.4 ± 9.9% and +5.2 ± 3.2 in conventional group) (p = 0.218 and 0.778, respectively), (2) the severity of tricuspid valve regurgitation was significantly lower with Micra than conventional pacing (p = 0.009) and (3) median NT-pro-BNP was lower in Micra group (970 pg/dL in Micra group versus 1394 pg/dL in conventional group, p = 0.041). CONCLUSION: Micra is non inferior to conventional PMs concerning the evolution of left ventricular function at 12-month follow-up. Our data suggest that Micra has a comparable mechanical impact on the ventricular systolic function but resulted in less valvular dysfunction.

[Echocardiography with high frame rates in the clinical practice : Principles, applications and perspectives]. / Echokardiographie mit hohen Bildraten in der klinischen Praxis : Grundlagen, Anwendungen, Perspektiven.

Continuous developments in cardiovascular imaging, software and hardware have led to technological advancements that open new ways for assessing myocardial mechanics, hemodynamics, and function. Through new scan modalities, echocardiographic scanners can nowadays achieve very high frame rates up to 5000 frames s-1 which enables a wide variety of new applications, including shear wave elastography, ultrafast speckle tracking, the visualization of intracardiac blood flow and myocardial perfusion imaging. This review provides an overview of these advances and demonstrates possible applications and their potential added value in the clinical practice.

Left ventricular regional glucose metabolism in combination with septal scar extent identifies CRT responders.

BACKGROUND: Cardiac resynchronization therapy (CRT) is effective in selective heart failure (HF) patients, but non-response rate remains high. Positron emission tomography (PET) may provide a better insight into the pathophysiology of left ventricular (LV) remodeling; however, its role for evaluating and selecting patients for CRT remains uncertain. PURPOSE: We investigated if regional LV glucose metabolism in combination with myocardial scar could predict response to CRT. METHODS: Consecutive CRT-eligible HF patients underwent echocardiography, cardiac magnetic resonance (CMR), and 18F-fluorodeoxyglucose (FDG) PET within 1 week before CRT implantation. Echocardiography was additionally performed 12 months after CRT and end-systolic volume reduction ≥ 15% was defined as CRT response. Septal-to-lateral wall (SLR) FDG uptake ratio was calculated from static FDG images. Late gadolinium enhancement (LGE) CMR was analyzed semi-quantitatively to define scar extent. RESULTS: We evaluated 88 patients (67 ± 10 years, 72% males). 18F-FDG SLR showed a linear correlation with volumetric reverse remodeling 12 months after CRT (r = 0.41, p = 0.0001). In non-ischemic HF patients, low FDG SLR alone predicted CRT response with sensitivity and specificity of more than 80%; however, in ischemic HF patients, specificity decreased to 46%, suggesting that in this cohort low SLR can also be caused by the presence of a septal scar. In the multivariate logistic regression model, including low FDG SLR, presence and extent of the scar in each myocardial wall, and current CRT guideline parameters, only low FDG SLR and septal scar remained associated with CRT response. Their combination could predict CRT response with sensitivity, specificity, negative, and positive predictive value of 80%, 83%, 70%, and 90%, respectively. CONCLUSIONS: FDG SLR can be used as a predictor of CRT response and combined with septal scar extent, CRT responders can be distinguished from non-responders with high diagnostic accuracy. Further studies are needed to verify whether this imaging approach can prospectively be used to optimize patient selection.

Impact of left bundle branch block on myocardial perfusion and metabolism: A positron emission tomography study.

BACKGROUND: Better understanding of pathophysiological changes, induced by left bundle branch block (LBBB), may improve patient selection for cardiac resynchronization therapy (CRT). Therefore, we assessed the effect of LBBB on regional glucose metabolism, 13N-NH3-derived absolute and semiquantitative myocardial blood flow (MBF), and their relation in non-ischemic CRT candidates. METHODS: Twenty-five consecutive non-ischemic patients with LBBB underwent 18F-FDG and resting dynamic 13N-NH3 PET/CT prior to CRT implantation. Regional 18F-FDG uptake, absolute MBF, and late 13N-NH3 uptake were analyzed and corresponding septal-to-lateral wall ratios (SLR) were calculated. Segmental analysis was performed to evaluate "reverse mismatch," "mismatch," and "match" patterns, based on late 13N-NH3/18F-FDG uptake ratios. RESULTS: A significantly lower 18F-FDG uptake was observed in the septum compared to the lateral wall (SLR 0.53 ± 0.17). A similar pattern was observed for MBF (SLR 0.68 ± 0.18), whereas late 13N-NH3 uptake showed a homogeneous distribution (SLR 0.96 ± 0.13). 13N-NH3/18F-FDG "mismatch" and "reverse mismatch" segments were predominantly present in the lateral (52%) and septal wall (61%), respectively. CONCLUSIONS: Non-ischemic CRT candidates with LBBB demonstrate lower glucose uptake and absolute MBF in the septum compared to the lateral wall. However, late static 13N-NH3 uptake showed a homogenous distribution, reflecting a composite measure of altered regional MBF and metabolism, induced by LBBB.

Concepts and applications of ultrafast cardiac ultrasound imaging.

The concept of ultrafast echocardiographic imaging has been around for decades. However, only recent progress in ultrasound machine hardware and computer technology allowed to apply this concept to echocardiography. High frame rate echocardiography can visualize phenomena that have never been captured before. It enables a wide variety of potential new applications, including shear wave imaging, speckle tracking, ultrafast Doppler imaging, and myocardial perfusion imaging. The principles of these applications and their potential clinical use will be presented in this manuscript.

Imaging predictors of response to cardiac resynchronization therapy: left ventricular work asymmetry by echocardiography and septal viability by cardiac magnetic resonance.

AIMS: Left ventricular (LV) failure in left bundle branch block is caused by loss of septal function and compensatory hyperfunction of the LV lateral wall (LW) which stimulates adverse remodelling. This study investigates if septal and LW function measured as myocardial work, alone and combined with assessment of septal viability, identifies responders to cardiac resynchronization therapy (CRT). METHODS AND RESULTS: In a prospective multicentre study of 200 CRT recipients, myocardial work was measured by pressure-strain analysis and viability by cardiac magnetic resonance (CMR) imaging (n = 125). CRT response was defined as ≥15% reduction in LV end-systolic volume after 6 months. Before CRT, septal work was markedly lower than LW work (P < 0.0001), and the difference was largest in CRT responders (P < 0.001). Work difference between septum and LW predicted CRT response with area under the curve (AUC) 0.77 (95% CI: 0.70-0.84) and was feasible in 98% of patients. In patients undergoing CMR, combining work difference and septal viability significantly increased AUC to 0.88 (95% CI: 0.81-0.95). This was superior to the predictive power of QRS morphology, QRS duration and the echocardiographic parameters septal flash, apical rocking, and systolic stretch index. Accuracy was similar for the subgroup of patients with QRS 120-150 ms as for the entire study group. Both work difference alone and work difference combined with septal viability predicted long-term survival without heart transplantation with hazard ratio 0.36 (95% CI: 0.18-0.74) and 0.21 (95% CI: 0.072-0.61), respectively. CONCLUSION: Assessment of myocardial work and septal viability identified CRT responders with high accuracy.

Inter-vendor reproducibility and accuracy of segmental left ventricular strain measurements using CMR feature tracking.

OBJECTIVES: Our aim was to evaluate the inter-vendor reproducibility of cardiovascular MR feature tracking (CMR-FT) for the measurement of segmental strain (SS) of the left ventricle (LV) as well as to test the accuracy of CMR-FT to detect regional myocardial pathology. METHODS: We selected 45 patients: 15 with normal CMR findings, 15 with dilated cardiomyopathy, and 15 with acute myocardial infarction. Segmental longitudinal, circumferential, and radial strains were assessed with 4 different software. The inter-vendor difference as well as intra- and inter-observer variability was investigated. Furthermore, the accuracy of CMR-FT for the detection of structural (infarcted segments) as well as functional pathology (septal vs. lateral wall strain in left bundle branch block) was tested. RESULTS: Between vendors, there were significant differences in values for all strains (p < 0.001). The software using a non-rigid algorithm for image registration and segmentation demonstrated the best intra- as well as inter-observer variability with interclass correlation coefficient (ICC) > 0.962 and coefficient of variation (CV) < 24%. For infarct location, the same software yielded the highest area under the curve values for radial and circumferential SS (0.872 and 0.859, respectively). One of the other three software using optical flow technology performed best for longitudinal SS (0.799) and showed the largest differences in SS between septum and lateral wall in the dilated cardiomyopathy group. CONCLUSION: SS values obtained by CMR-FT are not interchangeable between vendors, and intra- and inter-observer reproducibility shows substantial variability among vendors. Overall, the different packages score relatively well to depict focal structural or functional LV pathology. KEY POINTS: • Segmental myocardial strain values obtained by CMR feature tracking are not interchangeable between different vendors. • Intra- and inter-observer reproducibility shows substantial variability among vendors. • Segmental myocardial strains measured by CMR feature tracking score relatively well to depict focal structural or functional LV pathology.

Temporal changes in left ventricular longitudinal strain in general population: Clinical correlates and impact on cardiac remodeling.

BACKGROUND: Recent studies in patients and general population have reported the role of left ventricular (LV) longitudinal strain (LS) as an independent predictor of outcome. However, there are few data on changes in LS over time. We therefore investigated in a general population clinical correlates of temporal changes in LS. We also explored the potential correlation between temporal changes in LV volumes and LS. METHODS AND RESULTS: We measured LV end-systolic (ESV) and end-diastolic (EDV) volumes by conventional echocardiography and LS by 2D speckle tracking in 627 participants (mean age 50.6 years, 51.4% women; 41.3% hypertensives) at baseline and after 4.7 years. For statistical analysis, we used the absolute values of LS. In stepwise regression, the magnitude of the decrease in all LV LS indexes over time was greater in men than in women (P < 0.0001). Higher baseline mean arterial pressure (MAP), a larger longitudinal increase in MAP, and stopping diuretic treatment during follow-up were related to larger decreases in LS indexes. In multivariable-adjusted analysis, we observed an inverse correlation between baseline ESV and LV LS (P ≤ 0.0017). Similarly, lower baseline LS and a larger decrease in LS over time were correlated with a lesser longitudinal decrease in ESV (P ≤ 0.0004). CONCLUSIONS: A significant decrease in LS over time was associated with male sex, higher baseline MAP, ∆MAP, and alteration in antihypertensive treatment. We suggested an interaction between a longitudinal decrease in LV deformation and adverse cardiac remodeling, while underscoring the importance of deformation analysis based on LS assessment in patients at risk.

Pediatric Outcome after Maternal Cancer Diagnosed during Pregnancy.

BACKGROUND: Data on the long-term outcome of children who are exposed to maternal cancer with or without treatment during pregnancy are lacking. METHODS: In this multicenter case-control study, we compared children whose mothers received a diagnosis of cancer during the pregnancy with matched children of women without a cancer diagnosis. We used a health questionnaire and medical files to collect data regarding neonatal and general health. All children were prospectively assessed (by means of a neurologic examination and the Bayley Scales of Infant Development) at 18 months, 36 months, or both. A cardiac assessment was performed at 36 months. RESULTS: A total of 129 children (median age, 22 months; range, 12 to 42) were included in the group whose mother had cancer (prenatal-exposure group) with a matching number in the control group. During pregnancy, 96 children (74.4%) were exposed to chemotherapy (alone or in combination with other treatments), 11 (8.5%) to radiotherapy (alone or in combination), 13 (10.1%) to surgery alone, 2 (1.6%) to other drug treatments, and 14 (10.9%) to no treatment. Birth weight was below the 10th percentile in 28 of 127 children (22.0%) in the prenatal-exposure group and in 19 of 125 children (15.2%) in the control group (P=0.16). There was no significant between-group difference in cognitive development on the basis of the Bayley score (P=0.08) or in subgroup analyses. The gestational age at birth was correlated with the cognitive outcome in the two study groups. Cardiologic evaluation among 47 children at 36 months of age showed normal cardiac findings. CONCLUSIONS: Prenatal exposure to maternal cancer with or without treatment did not impair the cognitive, cardiac, or general development of children in early childhood. Prematurity was correlated with a worse cognitive outcome, but this effect was independent of cancer treatment. (Funded by Research Foundation-Flanders and others; ClinicalTrials.gov number, NCT00330447.).

Left ventricular global myocardial strain assessment comparing the reproducibility of four commercially available CMR-feature tracking algorithms.

OBJECTIVES: To compare the reproducibility of cardiovascular magnetic resonance feature-tracking (CMR-FT) packages to assess global left ventricular (LV) myocardial strain. METHODS: In 45 subjects (i.e. 15 controls, 15 acute myocardial infarction, 15 dilated cardiomyopathy patients), we determined inter-vendor, inter-observer (two readers) and intra-observer reproducibility of peak systolic global radial, circumferential and longitudinal strain (GRS, GCS and GLS, respectively) comparing four commercially available software packages. Differences between vendors were assessed with analysis of variance (ANOVA), between observers and readings with intraclass correlation coefficient (ICC) and coefficient of variation (CV). RESULTS: The normalised end-diastolic volume was 91, 77 and 119 ml/m2 (median, Q1, Q3) and ejection fraction was 41 ± 14%, range 12-67%. Global longitudinal strain (GLS), global circumferential strain (GCS) and global radial strain (GRS) values were 13.9% ± 5.4% (3.9-23.8%), 12.2% ± 5.8% (1.0-25.1%) and 32.0% ± 14.7 (3.6-67.8%), respectively. ANOVA showed significant differences between vendors for GRS (p < 0.001) and GLS (p = 0.018), not for GCS (p = 0.379). No significant bias was found for both intra- and inter-observer variability. The ICC for inter- and intra-observer reproducibility ranged 0.828-0.991 and 0.902-0.997, respectively. The CV, however, ranged considerably, i.e. 4.0-28.8% and 2.8- 27.7% for inter- and intra-observer reproducibility, respectively. In particular, for GRS differences in CV values between vendors were large, i.e. 5.2-28.8% and 2.8-27.7%, for inter- and intra-observer reproducibility, respectively. CONCLUSIONS: In a cohort of subjects with a wide range of cardiac performances, GRS and GLS values are not interchangeable between vendors. Moreover, although intra- and inter-observer reproducibility amongst vendors is excellent, some vendors encounter problems to reproducibly measure global radial strain. KEY POINTS: • Different software packages are currently available for myocardial strain assessment using routinely acquired cine CMR images. • Global myocardial strain values are not interchangeable between vendors for global longitudinal and global radial strain. • Inter- and intra-observer reproducibility for global strain assessment is excellent. However, some vendors encounter problems to reproducibly measure global radial strain.

Right ventricular remodelling after transcatheter pulmonary valve implantation.

OBJECTIVES: To define the optimal timing for percutaneous pulmonary valve implantation (PPVI) in patients with severe pulmonary regurgitation (PR) after Fallot's Tetralogy (ToF) correction. BACKGROUND: PPVI among the aforementioned patients is mainly driven by symptoms or by severe right ventricular (RV) dilatation/dysfunction. The optimal timing for PPVI is still disputed. METHODS: Twenty patients [age 13.9 ± 9.2 years, (range 4.3-44.9), male 70%] with severe PR (≥3 grade) secondary to previous correction of ToF, underwent Melody valve (Medtronic, Minneapolis, MN) implantation, after a pre-stent placement. Full echocardiographic assessment (traditional and deformation analysis) and cardiovascular magnetic resonance evaluation were performed before and at 3 months after the intervention. 'Favorable remodelling' was considered the upper quartile of RV size decrease (>20% in 3 months). RESULTS: After PPVI, indexed RV effective stroke volume increased from 38.4 ± 9.5 to 51.4 ± 10.7 mL/m2 , (P = 0.005), while RV end-diastolic volume and strain indices decreased (123.1 ± 24.1-101.5 ± 18.3 mL/m2 , P = 0.005 and -23.5 ± 2.5 to -21 ± 2.5%, P = 0.002, respectively). After inserting pre-PPVI clinical, RV volumetric and deformation parameters in a multiple regression model, only time after last surgical correction causing PR remained as significant regressor of RV remodelling [R2 = 0.60, beta = 0.387, 95%CI(0.07-0.7), P = 0.019]. Volume reduction and functional improvement were more pronounced in patients treated with PPVI earlier than 7 years after last RV outflow tract (RVOT) correction, reaching close-to-normal values. CONCLUSIONS: Early PPVI (<7 years after last RVOT operation) is associated with a more favorable RV reverse remodelling toward normal range and should be considered, before symptoms or RV damage become apparent. © 2017 Wiley Periodicals, Inc.

Prognostic significance of improvement in right ventricular systolic function during cardiac resynchronization therapy.

Objectives There is conflicting evidence concerning the role of right ventricular (RV) systolic dysfunction in the long-term clinical outcome after cardiac resynchronization therapy (CRT). Therefore we aimed to assess evolution of RV systolic function during CRT, covariates associated with its improvement, and its impact on outcome. Methods and results All CRT device implantations (Jan 2009-Dec 2011) in our institution were reviewed. Records of 69 patients (25% female, mean age 62.8 ± 9.2 years, mean left ventricular (LV) ejection fraction 27 ± 8%) were analyzed. Baseline RV fractional area change (FAC) < 35% was present in 37 patients (54%). At one year, 24 of them (65%) improved in RV FAC. LV remodeling and mitral regurgitation were significantly associated with the likelihood of RV FAC improvement (OR 4.80, 95% CI 1.13-20.46, P = 0.034 and OR 0.32, 95% CI 0.12-0.89, P = 0.029, respectively). The composite endpoint of death or heart transplantation occurred in 23 patients (33%) over a mean follow-up of 2.8 ± 1.4 years. RV FAC at one year (HR 0.90, 95% CI 0.86-0.94, P < .001) was, independently of NYHA class and LV remodeling, associated with clinical outcome. Conclusions RV systolic function might improve during CRT. This seems mainly due to changed left-sided hemodynamics and LV remodeling. Good RV systolic function is independently related with better outcome.

Dabigatran versus warfarin in patients with mechanical heart valves.

BACKGROUND: Dabigatran is an oral direct thrombin inhibitor that has been shown to be an effective alternative to warfarin in patients with atrial fibrillation. We evaluated the use of dabigatran in patients with mechanical heart valves. METHODS: In this phase 2 dose-validation study, we studied two populations of patients: those who had undergone aortic- or mitral-valve replacement within the past 7 days and those who had undergone such replacement at least 3 months earlier. Patients were randomly assigned in a 2:1 ratio to receive either dabigatran or warfarin. The selection of the initial dabigatran dose (150, 220, or 300 mg twice daily) was based on kidney function. Doses were adjusted to obtain a trough plasma level of at least 50 ng per milliliter. The warfarin dose was adjusted to obtain an international normalized ratio of 2 to 3 or 2.5 to 3.5 on the basis of thromboembolic risk. The primary end point was the trough plasma level of dabigatran. RESULTS: The trial was terminated prematurely after the enrollment of 252 patients because of an excess of thromboembolic and bleeding events among patients in the dabigatran group. In the as-treated analysis, dose adjustment or discontinuation of dabigatran was required in 52 of 162 patients (32%). Ischemic or unspecified stroke occurred in 9 patients (5%) in the dabigatran group and in no patients in the warfarin group; major bleeding occurred in 7 patients (4%) and 2 patients (2%), respectively. All patients with major bleeding had pericardial bleeding. CONCLUSIONS: The use of dabigatran in patients with mechanical heart valves was associated with increased rates of thromboembolic and bleeding complications, as compared with warfarin, thus showing no benefit and an excess risk. (Funded by Boehringer Ingelheim; ClinicalTrials.gov numbers, NCT01452347 and NCT01505881.).

Is Right Ventricular Remodeling in Pulmonary Hypertension Dependent on Etiology? An Echocardiographic Study.

AIMS: Survival in patients (pts) with pulmonary hypertension (PH) differs between subgroups at similar levels of pressure overload. We set to analyze right ventricular (RV) morphology and function in different types of PH using conventional and deformation imaging echocardiography. MATERIAL AND METHODS: Thirty-four pts with PH: 12 pts with idiopathic pulmonary arterial hypertension (IPAH, 42.2 ± 13 years), 11 pts with chronic thromboembolic PH (CTEPH, 50.8 ± 12 years), 11 pts with Eisenmenger syndrome [ES 41.2 ± 15 years, 4 with atrial septal defect (ASD) and 7 with ventricular septal defect (VSD)], and 13 age-matched healthy individuals (38.1 ± 15 years) were evaluated. The following echocardiographic parameters were measured: echo-derived systolic pulmonary pressure (sPAPecho), RV end-diastolic diameter (RVEDD), RV wall thickness (RVWT), TAPSE, RV fractional area change (RVFAC), Tei index, peak systolic velocity of the tricuspid ring (S't), and speckle tracking-derived RV free wall strain. Furthermore, right heart catheterization (RHC) was performed in pts with PH and mean, and systolic pulmonary artery pressure (mPAPcath, sPAPcath), cardiac output (CO), cardiac index (COi), and pulmonary vascular resistance (PVR) were noted. RESULTS: The levels of mPAPcath and sPAPcath were similar between pts with PH (pANOVA = NS). Patients with ES had higher COi compared to other groups (2.94 ± 0.79, 2.28 ± 0.69, and 1.74 ± 0.46 L/min/m(2) for pts with ES, IPAH, and CTEPH respectively, pANOVA = 0.004, P post hoc ES versus all other groups < 0.05). TAPSE, Tei index, and S't were similar between groups and impaired versus controls (pANOVA < 0.001, P post hoc between groups of patients = NS). Patients with ES had better RVFAC (41.1 ± 9, 30.5 ± 10.8, 23.2 ± 9.8%) and RV free wall strain (-20.6 ± 3.5, -16.3 ± 7.5, -10.8 ± 5%), as well as an increased thickness of the RV free wall compared to other groups of patients (9.2 ± 1.5, 7.2 ± 1 and 7.2 ± 1.6 mm for pts with ES, IPAH and CTEPH, respectively) (pANOVA<0.001, P post hoc <0.05 ES versus all other groups). RVFAC and RV free wall strain significantly correlated with COi (r = 0.53, P = 0.006 and r = -0.77, P < 0.001, respectively). CONCLUSION: Patients with ES have a more hypertrophied RV free wall, better RV performance as assessed by RVFAC and RV free wall strain and increased COi compared to other types of PH. Furthermore, RV performance appears to be less dependent on the level of pressure overload. These findings could contribute to the better survival profile of patients with ES.

Exercise-induced right ventricular dysfunction is associated with ventricular arrhythmias in endurance athletes.

AIMS: Intense exercise places disproportionate strain on the right ventricle (RV) which may promote pro-arrhythmic remodelling in some athletes. RV exercise imaging may enable early identification of athletes at risk of arrhythmias. METHODS AND RESULTS: Exercise imaging was performed in 17 athletes with RV ventricular arrhythmias (EA-VAs), of which eight (47%) had an implantable cardiac defibrillator (ICD), 10 healthy endurance athletes (EAs), and seven non-athletes (NAs). Echocardiographic measures included the RV end-systolic pressure-area ratio (ESPAR), RV fractional area change (RVFAC), and systolic tricuspid annular velocity (RV S'). Cardiac magnetic resonance (CMR) measures combined with invasive measurements of pulmonary and systemic artery pressures provided left-ventricular (LV) and RV end-systolic pressure-volume ratios (SP/ESV), biventricular volumes, and ejection fraction (EF) at rest and during intense exercise. Resting measures of cardiac function were similar in all groups, as was LV function during exercise. In contrast, exercise-induced increases in RVFAC, RV S', and RVESPAR were attenuated in EA-VAs during exercise when compared with EAs and NAs (P < 0.0001 for interaction group × workload). During exercise-CMR, decreases in RVESV and augmentation of both RVEF and RV SP/ESV were significantly less in EA-VAs relative to EAs and NAs (P < 0.01 for the respective interactions). Receiver-operator characteristic curves demonstrated that RV exercise measures could accurately differentiate EA-VAs from subjects without arrhythmias [AUC for ΔRVESPAR = 0.96 (0.89-1.00), P < 0.0001]. CONCLUSION: Among athletes with normal cardiac function at rest, exercise testing reveals RV contractile dysfunction among athletes with RV arrhythmias. RV stress testing shows promise as a non-invasive means of risk-stratifying athletes.

Dynamic relationship of left-ventricular dyssynchrony and contractile reserve in patients undergoing cardiac resynchronization therapy.

AIMS: Contradicting reports have been published regarding the relation between a dobutamine-induced increase in either cardiac dyssynchrony or left-ventricular ejection fraction (LVEF) and the response to cardiac resynchronization therapy (CRT). Using apical rocking (ApRock) as surrogate dyssynchrony parameter, we investigated the dobutamine stress echocardiography (DSE)-induced changes in left-ventricular (LV) dyssynchrony and LVEF and their potential pathophysiological interdependence. METHODS AND RESULTS: Fifty-eight guideline-selected CRT candidates were prospectively enrolled for low-dose DSE. Dyssynchrony was quantified by the amplitude of ApRock. An LVEF increase during stress of >5% was regarded significant. Scar burden was assessed by magnetic resonance imaging. Mean follow-up after CRT implantation was 41 ± 13 months for the occurrence of cardiac death. ApRock during DSE predicted CRT response (AUC 0.88, 95% CI 0.77-0.99, P < 0.001) and correlated inversely with changes in EF (r = -0.6, P < 0.001). Left-ventricular ejection fraction changes during DSE were not associated with CRT response (P = 0.082). Linear regression analysis revealed an inverse association of LVEF changes during DSE with both, total scar burden (B = -2.67, 95CI -3.77 to -1.56, P < 0.001) and the DSE-induced change in ApRock amplitude (B = -1.23, 95% CI -1.53 to -0.94, P < 0.001). Kaplan-Meier analysis revealed that DSE-induced increase in ApRock, but not LVEF, was associated with improved long-term survival. CONCLUSION: During low-dose DSE in CRT candidates with baseline dyssynchrony, myocardial contractile reserve predominantly results in more dyssynchrony, but less in an increase in LVEF. Dyssynchrony at baseline and its dobutamine-induced changes are predictive of both response and long-term survival following CRT.

Tissue Doppler, strain and strain rate in ischemic heart disease "how I do it".

Echocardiography is the standard method for assessing myocardial function in patients with ischemic heart disease. The acquisition and interpretation of echocardiographic images, however, remains a highly specialized task which often relies entirely on the subjective visual assessment of the reader and requires therefore, particular training and expertise. Myocardial deformation imaging allows quantifying myocardial function far beyond what can be done with sole visual assessment. It can improve the interpretation of regional dysfunction and offers sensitive markers of induced ischemia which can be used for stress tests. In the following, we recapitulate shortly the pathophysiological and technical basics and explain in a practical manner how we use this technique in investigating patients with ischemic heart disease.

Ultrasound Shear Wave Elastography in Cardiology.

The advent of high-frame rate imaging in ultrasound allowed the development of shear wave elastography as a noninvasive alternative for myocardial stiffness assessment. It measures mechanical waves propagating along the cardiac wall with speeds that are related to stiffness. The use of cardiac shear wave elastography in clinical studies is increasing, but a proper understanding of the different factors that affect wave propagation is required to correctly interpret results because of the heart's thin-walled geometry and intricate material properties. The aims of this review are to give an overview of the general concepts in cardiac shear wave elastography and to discuss in depth the effects of age, hemodynamic loading, cardiac morphology, fiber architecture, contractility, viscoelasticity, and system-dependent factors on the measurements, with a focus on clinical application. It also describes how these factors should be considered during acquisition, analysis, and reporting to ensure an accurate, robust, and reproducible measurement of the shear wave.

Aorta pathology and pregnancy-related risks in adult congenital cardiac disease: does the aorta dilate during pregnancy?

Background: Aortic dilatation and pregnancy are major concerns in women with aortopathy (AOP). This single-centre retrospective analysis focuses on the evolution of aortic diameters during and after pregnancy in women with Marfan syndrome (MS), Turner syndrome (TS) and bicuspid aortic valve (BAV) aortopathy. Methods and results: Thirty-eight women who had one or more single pregnancies were included. The ascending aorta was measured during pregnancy and postpartum. During pregnancy, a significant increase of diameters of the sinus aortae (median 1.4 mm; [-1.3; 3.8]) and ascending aorta (median 2.1 mm; [0.0; 4.0]) was noted. Systemic hypertension gives dilation of the aorta, but it did not influence the overall trajectory during pregnancy. Conclusion: Significant aortic dilatation is noted during pregnancy in women with underlying AOP, even persisting in the long term. Pre-existing systemic hypertension is associated with larger aortic diameters prior to pregnancy. More research on a larger study population however is needed.