Effect of diastolic dysfunction on intraventricular velocity behavior in early diastole by flow mapping.

Intraventricular velocity distribution reflects left ventricular (LV) diastolic function and can be measured non-invasively by flow mapping technologies. We designed our study to compare intraventricular velocities and gradients, obtained by vector flow mapping (VFM) technology during early diastole in consecutive patients diagnosed with mild and advanced diastolic dysfunction at echocardiography and a control group with a purpose to validate the hypothesis of relationship between new parameters and severity of diastolic dysfunction and conventional markers of elevated LV filling pressure. Two-dimensional streamline fields were obtained using VFM technology in 121 subjects (57 with normal diastolic function, 38 with mild diastolic dysfunction and 26 with advanced diastolic dysfunction). We measured several velocities and calculated a gradient along the selected streamline, which we compared between groups and correlated them with conventional echocardiographic parameters. Apical intraventricular velocity gradient (GrIV) was the lowest in control group, followed by mild and advanced diastolic dysfunction groups (5.3 ± 1.9 vs. 6.8 ± 2.5 vs. 13.6 ± 5.0/s, p < 0.001) and showed good correlation with E/e' (r = 0.751, p < 000.1). GrIV/e' ratio was the strongest single predictor of severity of diastolic dysfunction. Different degrees of diastolic dysfunction affect the Intraventricular velocity behavior during early diastole obtained by VFM. GrIV could discriminate between groups with different levels of diastolic dysfunction and was closely associated with classical echocardiographic indices of elevated LV filling pressure. GrIV/e' ratio has a potential to become a single parameter needed to assess left ventricular diastolic function.

Mid-term outcome of severe tricuspid regurgitation: are there any differences according to mechanism and severity?

AIMS: Patients with significant tricuspid regurgitation (TR) addressed according the new classification in torrential TR may have different prognosis compared with just severe TR patients. We sought to determine distribution and mechanism of consecutive severe TR patients, in accordance with aetiology and severity by applying the new proposed classification scheme and their long-term outcomes. METHODS AND RESULTS: Between January and December 2013, 249 patients with significant TR referred to the cardiac imaging unit (mean age 79.9 ± 10.2 years; 29.8% female) were included. Patients were divided according to aetiology in six groups, and TR severity was reclassified into severe, massive, and torrential TR. The follow-up period was of 313 ± 103 days. When considering cardiovascular mortality, patients in the massive/torrential group showed the highest number of events (P < 0.007). Patients with TR due to pulmonary diseases had the worst prognosis according to different aetiology. Noteworthy, the best predictors for the combined endpoint [cardiovascular mortality and readmission admission for heart failure (HF)] were TR severity according to the new classification [hazard ratio (HR) 2.48, 95% confidence interval (CI) 1.25-4.93] and clinical scores such as New York Heart Association classification and congestive status (HR 1.78, 95% CI 1.28-2.49; HR 2.08, 95% CI 1.06-4.06, respectively). CONCLUSION: Patients with massive/torrential TR and patients with comorbidities, especially pulmonary disease, were identified as populations at higher risk of death and readmission for HF. New classification scheme and clinical assessment may establish who may benefit the most of intensive therapeutic treatments and intervention on the tricuspid valve.

Geometrical and functional cardiac changes after cardiac surgery: a phisiopatological explanation based on speckle tracking.

Cardiac surgery induces geometrical and functional changes, which are not clearly explained. Objective: to investigate the physiopathology of the heart after cardiac surgery using advanced techniques of echocardiography. Thirty patients undergoing cardiac surgery had echocardiographic study prior and after surgery. Left and right ventricular (RV) longitudinal displacement and strain were studied with speckle-tracking. Using longitudinal displacement, we defined a static longitudinal reference-point (sLRP) to which the other segments moved during systole. Transversal displacement and global function were determined by conventional-echo. Left and RV segments showed systolic longitudinal displacement towards the apex, which was the sLRP before surgery; and towards the medium segment of lateral RV-wall one week after surgery. The displacement of basal RV segment towards this sLRP was smaller, causing decreased TAPSE. Apical segments showed an inverse displacement towards the new sLRP, and septum displacement was decreased or inverted towards the lateral RV-wall, causing paradoxus septal motion. RV-wall longitudinal strain was reduced (- 23.1 ± 8.6 vs. - 14.6 ± 5.3;p < 0.001), RV transversal fractional shortening was increased (36.5 ± 10.5 vs. 41.7 ± 13; p = 0.011), and the RV fractional area change was unchanged (46.7 ± 9.5 vs. 47.8 ± 11.7; p = 0.625). The medium segment of RV lateral wall, in contact with sternotomy, remains static after surgery and acts as a new sLRP towards which the rest of segments move, explaining the reduction of TAPSE and paradoxus septal motion. The longitudinal strain of the lateral RV-wall gets impaired, but an increase of transversal motion maintains global RV function.

Area strain from 3D speckle-tracking echocardiography as an independent predictor of early symptoms or ventricular dysfunction in asymptomatic severe mitral regurgitation with preserved ejection fraction.

The indication for surgery in asymptomatic severe mitral regurgitation (SMR) with preserved left ventricular ejection fraction (LVEF) is controversial. We sought to study 3D myocardial mechanics in this population and test 3D-speckle tracking (3DST) parameters as possible predictors of events. 45 asymptomatic patients with SMR and LVEF >60 % and 20 control individuals without cardiac disease underwent 3DST echocardiography. MR group additionally underwent further clinical monitoring. Dyspnea, LVEF under 60 %, or admissions for heart failure were considered as events. When compared with control group, MR group showed lower percentage of global 3D strain, (35.4 ± 9.1 vs. 43.9 ± 10.6; p = 0.003), lower radial strain, lower area change rate and higher end-diastolic volume. In a follow-up time of 23.2 ± 14.5 months we found 15 events (33.3 %). When comparing the remaining patients with this new-onset HF group we found significant differences in longitudinal strain (-17.9 ± 3.3 vs. -15.8 ± 2.1; p = 0.036), area strain (AS) (-48.6 ± 4.6 vs. -43.7 ± 6.2; p = 0.006), circumferential strain (-35.8 ± 4.7 vs. -31.8 ± 6.1; p = 0.034), 3D LVEF (67.1 ± 4.6 vs. 63.0 ± 7.4; p = 0.034) and E/E' index (13.5 ± 3.9 vs. 19.3 ± 9.5; p = 0.006). In multivariate Cox regression AS alone was the only independent predictor. A cutoff value of AS greater than -41.6 % reached a hazard ratio of 4.41 (p = 0.004) for prediction of events. In asymptomatic patients with SMR and preserved ejection fraction, 3DST derived AS is a promising tool for predicting the development of heart failure. This finding may be useful for guiding the selection of patients for early mitral valve repair/replacement surgery even if they are asymptomatic.

Ventricular septal rupture in a case of myocardial infarction with normal coronary arteries: Case report.

Ventricular wall rupture has become an infrequent complication of myocardial infarction due to widespread use of prompt reperfusion strategies. Patients suffering myocardial infarction with normal coronary arteries seldom develop severe mechanical complications. We present the case of a patient who developed a ventricular septal rupture following an anteroseptal myocardial infarction and who presented normal coronary arteries at the time of coronary angiography.

Accuracy and reproducibility of novel echocardiographic three-dimensional automated software for the assessment of the aortic root in candidates for thanscatheter aortic valve replacement.

AIMS: A specialized three-dimensional transoesophageal echocardiography (3D-TOE) reconstruction tool has recently been introduced; the system automatically configures a geometric model of the aortic root from the images obtained by 3D-TOE and performs quantitative analysis of these structures. The aim of this study was to compare the measurements of the aortic annulus (AA) obtained by the new model to that obtained by 3D-TOE and multidetector computed tomography (MDCT) in candidates to transcatheter aortic valve implantation (TAVI) and to assess the reproducibility of this new method. METHODS AND RESULTS: We included 31 patients who underwent TAVI. The AA diameters and area were evaluated by the manual 3D-TOE method and by the automatic software. We showed an excellent correlation between the measurements obtained by both methods: intra-class correlation coefficient (ICC): 0.731 (0.508-0.862), r: 0.742 for AA diameter and ICC: 0.723 (0.662-0.923), r: 0.723 for the AA area, with no significant differences regardless of the method used. The interobserver variability was superior for the automatic measurements than for the manual ones. In a subgroup of 10 patients, we also found an excellent correlation between the automatic measurements and those obtained by MDCT, ICC: 0.941 (0.761-0.985), r: 0.901 for AA diameter and ICC: 0.853 (0.409-0.964), r: 0.744 for the AA area. CONCLUSION: The new automatic 3D-TOE software allows modelling and quantifying the aortic root from 3D-TOE data with high reproducibility. There is good correlation between the automated measurements and other 3D validated techniques. Our results support its use in clinical practice as an alternative to MDCT previous to TAVI.

Four chamber right ventricular longitudinal strain versus right free wall longitudinal strain. Prognostic value in patients with left heart disease.

BACKGROUND: There is no consensus on which right ventricle (RV) strain parameter should be used in the clinical practice: four chamber RV longitudinal strain (4CH RV-LS) or free wall longitudinal strain (FWLS). The aim of this study was to analyze which RV strain parameter better predicts prognosis in patients with left heart disease. METHODS: One hundred and three outpatients with several degrees of functional tricuspid regurgitation severity secondary to left heart disease were prospectively included. 4CH RV-LS and FWLS were assessed using speckle tracking. Left ventricular (LV) systolic function was determined using LV ejection fraction and RV systolic function using tricuspid annular plane systolic excursion (TAPSE). Patients were followed up for 23.1 ± 12.4 months for an endpoint of cardiac hospitalization due to heart failure. RESULTS: The cutoff value related to RV dysfunction (TAPSE < 17 mm) was lower, in absolute value, for 4CH RV-LS (4CH RV-LS = -17.3%; FWLS = -19.5%). There were 33 adverse events during the follow-up. Patients with 4CH RV-LS > -17.3% (log rank [LR] = 22.033; p < 0.001); FWLS > -19.5% (LR = 12.2; p < 0.001), TAPSE < 17 mm (LR = 17.4; p < 0.001) and LV systolic dysfunction (LR = 13.3; p < 0.001) had lower event-free survival (Kaplan Meier). In Cox multivariate analysis, 4CH RV-LS > -17.3% (hazard ratio [HR] = 3.593; p < 0.002), TAPSE < 17 (HR = 2.093; p < 0.055) and LV systolic dysfunction (HR = 2.087; p < 0,054) had prognostic value, whereas FWLS did not reach significance. CONCLUSIONS: Although both 4CH RV-LS and FWLS have prognostic value, 4CH RV-LS is a better predictor of episodes of heart failure in patients with left heart disease, providing additional information to that obtained by TAPSE.

Left ventricular vortices as observed by vector flow mapping: main determinants and their relation to left ventricular filling.

BACKGROUND: Swirling flow, organized in vortices, contributes to adequate left ventricular function. In this study, we apply a novel echocardiographic flow-mapping technique, vector flow mapping (VFM), to evaluate the main characteristics of left ventricular vortices and its relation to filling parameters. METHODS: Forty-eight subjects underwent conventional transthoracic echocardiographic examination with additional intracardiac flow assessment with VFM using a Aloka Alpha-10 system and experimental VFM analysis software. To analyze vortex behavior, its rotation direction, duration, location inside the left ventricle, size, and intensity were assessed in apical long-axis view. Its relation to conventional left ventricular filling parameters was then analyzed. RESULTS: Two vortex components were consistently identified following each transmitral filling wave. The anterior component of these visualized vortices was analyzed, due to its higher significance in the cardiac cycle, following early filling (V1) and atrial contraction (V2). Differences were observed in several aspects of vortex behavior between V1 and V2, particularly in patients with normal left ventricular filling parameters. These differences may be related to varying roles of vortices in different periods of the cardiac cycle. CONCLUSIONS: Vector flow mapping allowed visualization and measurement of several parameters defining vortex behavior inside the cardiac cycle. The differences observed in these parameters between vortices in different phases of the cardiac cycle may be related to their role in optimizing cardiac function.