Evidence-based Surgery of Aortic Regurgitation: Results of a Questionnaire in German-speaking Countries.

BACKGROUND: evidence-based medicine (EBM) approaches have reached broad acceptance, both in conservative and surgical disciplines. The aim of this study is to clarify the role of EBM in a rare condition of aortic regurgitation (AR) with surgical indication. METHODS: A purpose-built Internet-based questionnaire was sent to 607 cardiovascular surgeons in Germany, Austria, and Switzerland. A virtual 64-year-old patient's medical history was presented, including two ultrasound images and one computed tomography scan, showing a 58-mm aortic root aneurysm and a severe trileaflet regurgitant aortic valve. Participants had to choose their preferred therapeutic strategy from a list. Additionally, demographics including nationality, the center size, and the frequency of similar types of patients referred to their departments were collected. RESULTS: Of 607 questionnaires, 100 were returned (16%). One participant was excluded due to conflicting answers. Most surgeons (n = 84; 84%) chose a valve-sparing root replacement (VSRR). A Bentall procedure was preferred by 13 surgeons (13%). Two surgeons voted for aortic valve replacement combined with partial root resection. The decision-making process was not significantly influenced by center size, nationality, or frequency of patients. CONCLUSION: Applying the current guidelines to our virtual study patient, 84% of participants acted accordingly choosing VSRR. Remarkably, 14% of these surgeons see less than 10 and 43% see not more than 20 comparable patients per year. Since the guidelines reserve VSRR for competent centers, those numbers as well as the guidelines themselves should be further discussed.

Four-tiered echocardiographic analysis approach for congenital mitral valve malformations: Four years of experience.

BACKGROUND: Traditional methods of describing and classifying congenital mitral valve malformations (CMVMs) often lack specificity and scientificity. Thus, documentation is incomplete, especially in terms of ultrasound findings. METHODS: Data were collected from 436 patients (mean age, 36.6±26.8years; male 47.9%), each subjected to echocardiographic evaluation of CMVM. Valvar characteristics were studied and analyzed via a four-tiered echocardiographic analysis (FTEA) approach: (1) supravalvular region and annulus, (2) valvar leaflets and commissures, (3) chordae tendineae, and (4) papillary muscles. A clinical random ultrasonic reading controlled trial was designed to the compare conventional diagnostic method and FTEA in patients with CMVMs. RESULTS: From a total of 246,507 echocardiograms, CMVMs were methodically investigated in 436 (0.18%) patients. Of these, 16 (3.7%) had multi-level malformations; and in 133 (30.5%), CVCMs were associated with other cardiac defects. Using a FTEA approach, involvement was distributed as follows: (1) supravalvular region and annulus (n=7 [1.6%]; excessive supravalvular tissue, 3; abnormal annulus, 4 [overriding, 1; shifted, 2; bridging/cord-like accessory tissue, 1]); (2) valvar leaflets and commissures (n=421 [96.3%]; lengthy or excessive, 210; underdeveloped, 35; contracture,12; atretic, 3; anomalously connected, 1; loose or billowy, 63; clefts, 57; dual orifice, 5; localized bulging, 6; accessory tissue element, 4; fibrotic, 18; fused leaflet cusps, 3; abnormal commissures, 4 [fused, 1; clefts, 3]); (3) chordae tendineae (n=14 [3.2%]; confined to single papillary muscle, 4; excessive, 2; thickened and fused, 2; shortened, 2; fibrotic, 2; accessory tissue element, 1; straddling, 1); and (4) papillary muscles (n=13 [3.0%]; absent, 2; single, 5; asymmetric, 2; abnormally located, 3; fibrotic, 1). According to the report comparing one by one each section among the inexperienced (groups A and B) and experienced (group C) groups out of 100 patients with CMVMs, group A of the inexperienced group using the conventional diagnostic method had a score of 76±12, while group B of the inexperienced group using the FTEA method had a score of 85±11; group B scored significantly higher than group A (all P<0.05). CONCLUSIONS: Detailed incremental FTEA method in a systematic manner clearly defines malformations of the MV apparatus, ensuring more accurate diagnostic imaging. The results of clinical randomized controlled trials confirm that FTEA diagnostic accuracy was higher than conventional methods in CMVMs.

Perioperative transoesophageal echocardiography: current status and future directions.

Transoesophageal echocardiography (TOE) is used in the perioperative arena to monitor patients during life-threatening emergencies, cardiac and high-risk non-cardiac surgeries. It provides qualitative and quantitative information on valvular and ventricular functions, and dynamic cardiac anatomy can be displayed with a physiological perspective. This technology has evolved from two-dimensional (2D) to the ready availability of real-time three-dimensional (RT-3D) imaging in the operating rooms. Enhanced spatial and temporal resolutions with 3D imaging have most significantly impacted the quality of intraoperative surgical valve repair and replacement decisions. Additionally, 3D imaging has facilitated the advent of minimally invasive and percutaneous interventions for structural heart disease. Information derived from TEE is routinely used to evaluate a patient's suitability for an intervention, provide guidance during the intervention and eventually comment on the quality and success of the procedure. Expertise in perioperative TEE is an integral component of a cardiac anaesthesiologist's skill sets. With structural heart disease interventions becoming more minimally invasive, the intraoperative guidance provided by TEE will continue to be a critical component of these procedures. With improving computational and processing power, the expectations from TEE will continue to be incremental in the perioperative arena.

Stress echo applications beyond coronary artery disease.

Stress echocardiography is an established method for the diagnosis and prognostic stratification of coronary artery disease. In the last few years, the tremendous technological and conceptual versatility of this technique has been increasingly applied in challenging diagnostic fields. Today, in the echocardiography laboratory we can detect not only ischaemia from coronary artery stenosis, but can also recognize abnormalities of the coronary microvessels, myocardium, heart valves, pulmonary circulation, alveolar-capillary barrier, and right ventricle. Therefore, we evaluate coronary arteries as well as coronary microvascular disease (associated with diabetes and hypertension), suspected or overt dilated cardiomyopathy, systolic and diastolic heart failure, hypertrophic cardiomyopathy, athletes' hearts, valvular heart disease, congenital heart disease, incipient or overt pulmonary hypertension, and heart transplant patients for early detection of chronic or acute rejection as well as potential donors for better selection of suitable donor hearts. From a stress echo era with a one-fits-all approach (wall motion by 2D-echo in the patient with known or suspected coronary artery disease) now we have moved on to an omnivorous, next-generation laboratory employing a variety of technologies (from M-Mode to 2D and pulsed, continuous and colour Doppler, to lung ultrasound and real-time 3D echo, 2D speckle tracking and myocardial contrast echo) on patients covering the entire spectrum of severity (from elite athletes to patients with end-stage heart failure) and ages (from children with congenital heart disease to the elderly with low-flow, low-gradient aortic stenosis). For each patient, we can tailor a dedicated stress protocol with a specific method to address a particular diagnostic question. Provided that the acoustic window is acceptable and the necessary expertise available, stress echocardiography is useful and convenient in many situations, from valvular to congenital heart disease, and whenever there is a mismatch between symptoms during stress and findings at rest. Increasing societal concern regarding cost, environment and radiation risks of medical imaging will lead to a preferential application of ultrasound over competing techniques, due to its unsurpassed versatility, portability, absence of radiation, and low cost.

Intracardiac flow visualization: current status and future directions.

Non-invasive cardiovascular imaging initially focused on heart structures, allowing the visualization of their motion and inferring its functional status from it. Colour-Doppler and cardiac magnetic resonance (CMR) have allowed a visual approach to intracardiac flow behaviour, as well as measuring its velocity at single selected spots. Recently, the application of new technologies to medical use and, particularly, to cardiology has allowed, through different algorithms in CMR and applications of ultrasound-related techniques, the description and analysis of flow behaviour in all points and directions of the selected region, creating the opportunity to incorporate new data reflecting cardiac performance to cardiovascular imaging. The following review provides an overview of the currently available imaging techniques that enable flow visualization, as well as its present and future applications based on the available literature and on-going works.

Emerging trends in CV flow visualization.

Blood flow patterns are closely linked to the morphology and function of the cardiovascular system. These patterns reflect the exceptional adaptability of the cardiovascular system to maintain normal blood circulation under a wide range of workloads. Accurate retrieval and display of flow-related information remains a challenge because of the processes involved in mapping the flow velocity fields within specific chambers of the heart. We review the potentials and pitfalls of current approaches for blood flow visualization, with an emphasis on acquisition, display, and analysis of multidirectional flow. This document is divided into 3 sections. First, we provide a descriptive outline of the relevant concepts in cardiac fluid mechanics, including the emergence of rotation in flow and the variables that delineate vortical structures. Second, we elaborate on the main methods developed to image and visualize multidirectional cardiovascular flow, which are mainly based on cardiac magnetic resonance, ultrasound Doppler, and contrast particle imaging velocimetry, with recommendations for developing dedicated imaging protocols. Finally, we discuss the potential clinical applications and technical challenges with suggestions for further investigations.

Intracardiac echocardiography for the guidance of percutaneous procedures.

Interventional cardiology has seen great advances in the past decade. A wide range of interventional procedures has been established as standard therapeutic modalities and more are yet to come. Multiple imaging modalities have been used to guide these procedures. Intracardiac echocardiography (ICE) provides an accurate imaging tool to guide the appropriate performance of many of these procedures. Early studies compared ICE as a new imaging modality to guide interventional closure of atrial communications with other more established imaging techniques, such as transesophageal echocardiography, with excellent accuracy. In this article, we discuss the value of using ICE in guiding some percutaneous interventional procedures. We also discuss the imaging protocol for using ICE to guide atrial level shunt device closure. Our experience in using ICE for guiding percutaneous valve placement is also discussed.

Actualización en técnicas de imagen cardiaca: ecocardiografía, resonancia magnética en cardiología y tomografía computarizada con multidetectores / Update on cardiac imaging techniques: echocardiography, cardiac magnetic resonance, and multidetector computed tomography

En este artículo se revisan las publicaciones más relevantes sobre la imagen cardiaca que han aparecido en2008. Hemos asistido a la introducción en la clínica de la ecocardiografía transesofágica tridimensional en tiempo real a la selección de casos y la monitorización ecocardiográfica de pacientes sometidos a sustitución percutánea de la válvula aórtica, aún en fase de aprendizaje para la mayoría de los centros que la practican, y a la irrupción en el campo clínico de las técnicas de estudio de deformación miocárdica. Se realiza también un resumen de lo más relevante en el ecocardiograma de la cardiopatía isquémica y la resincronización y de dos técnicas en expansión constante: la cardiorresonancia magnética y la tomografía computarizada cardiaca con multidetectores. Este trabajo de revisión termina con la descripción del estado de los contrastes ecocardiográficos, con especial énfasis en cuanto a su seguridad, tras las recomendaciones realizadas a finales de 2007 por la Food and Drug Administration (AU)

This article contains a review of the most importantpublications on cardiac imaging that have appearedduring 2008. During the year, we assisted with theclinical implementation of three-dimensional realtimetransesophageal echocardiography, with the useof echocardiography for selecting patients for andmonitoring those who underwent percutaneous aorticvalve replacement (the majority of centers performingthe technique were still in the learning phase), andwith the emergence in the clinic of techniques forstudying myocardial deformation. Also reviewed arethe most significant developments in the application ofechocardiography to coronary heart disease and cardiacresynchronization therapy and in 2 other techniqueswhose use is constantly increasing: cardiac magneticresonance and multidetector cardiac computedtomography. The review ends with a description of thecurrent state of the art in contrast echocardiography,with particular emphasis on safety in the context ofrecommendations made by the US Food and DrugAdministration at the end of 2007 (AU)

Cardiac resynchronization therapy and the emerging role of echocardiography (part 1): indications and results from current studies.

Cardiac resynchronization therapy (CRT) has been established as an adjunctive treatment for patients with left ventricular systolic dysfunction and medically refractory heart failure with a wide QRS interval. Echocardiography can be used to determine the response in left ventricular structure and function after device implantation and emerging evidence as a method for selection of patients who may derive clinical benefit from CRT. This review discusses the applications of CRT, including results of clinical trials and the current experience using echocardiography. Part 2 will address the practical aspects of obtaining echocardiographic data in patients who are potential candidates for CRT and optimization of pacemaker settings after device implantation.

Cardiac resynchronization therapy and the emerging role of echocardiography (part 2): the comprehensive examination.

Cardiac resynchronization therapy has been established as an adjunctive treatment for patients with severe left ventricular systolic dysfunction and medically refractory heart failure symptoms with a prolonged electrocardiographic QRS interval. Echocardiography has emerged as a useful method to evaluate patients who are considered for cardiac resynchronization therapy. This review outlines measurements of ventricular performance to be used in this patient population including echocardiographic optimization of cardiac resynchronization therapy device settings.

Second-generation real-time three-dimensional echocardiography. Finally on its way into clinical cardiology?

Three-dimensional (3D) echocardiographic imaging has been introduced as a tool to improve the assessment of both morphologic and functional parameters of the cardiovascular system. In the past, data acquisition was limited due to time-consuming sequential acquisition of multiple triggered 2D image planes from 10-60 heart cycles using transesophageal rotational, transthoracic rotational or transthoracic freehand approaches. Recent improvements in the size of matrix array probes and in computing power of modern ultrasound equipment have significantly increased both spatial and temporal resolution of "second-generation" real-time 3D scanners. Although the superiority of 3D echocardiography in the determination of ventricular volume, ventricular mass or valvular orifice area had already been demonstrated in the late 1990s, widespread use in clinical cardiology was limited on account of difficulties in acquisition and post-processing. Clinical use of modern 3D echocardiography is boosted by the marked reduction in acquisition time and the unique possibility of on-line rendering on the ultrasound system. The ability to visualize a virtual 3D surface in real time-although limited to a sector size of about 30 degrees-offers new insights into cardiac pathomorpholgy even in patients with arrhythmias and may in realtime 3D-contrast flow analysis. Analysis of wide-angle 3D datasets (90 by 90 degree pyramidal shape) is possible by combining the 3D information of several [4-7] consecutive heart cycles. 3D datasets including the complete left ventricle provide comprehensive information on ventricular and mitral valve morphology and function. Qualitative and quantitative analyses of regional wall motion at rest and during stress become possible. Combination with 3D color Doppler data allows additional assessment of valvular function as well as determination of flow in the left ventricular outflow tract and across septal defects. The integration and future quantification of these new parameters together with on-line review allows new insights into cardiac function, morphology and synchrony that offer great potentials in the evaluation of right and left ventricular global and regional function, diagnosis of small areas of ischemia, congenital and valvular heart disease and effects of biventricular pacing in dilated heart asynchrony.

[Contrast echocardiography: clinical applications and future prospects]. / Kontrastechokardiographie: klinische Anwendung und Zukunftsperspektiven.

BACKGROUND: Contrast echocardiography has been used as a clinical method for more than 20 years. Using conventional ultrasound techniques the clinical use of contrast was limited. Now the development of "contrast specific" imaging modalities has increased the indications for contrast echocardiography. CONTRAST AGENTS: For clinical use two classes of contrast agents are available: 1. "right heart" contrast media (Echovist, agitated solutions), which do not cross the pulmonary vascular bed following intravenous injection and which can be used with conventional (fundamental) imaging methods, 2. "left heart" contrast media (Levovist, Optison, SonoVue) which need "contrast specific" imaging modalities for optimal use. INDICATIONS: Despite of the developments in Doppler methods and transesophageal echocardiography "right heart" contrast media still are needed in some patients with atrial and pulmonary shunts, complex congenital heart disease, noisy Doppler recordings of tricuspid regurgitation. For "left heart" contrast media improvement of endocardial border definition is the most important indication, which has been validated in a series of well performed studies. Therefore contrast enhanced recordings are recommended in the clinical echo laboratory when unenhanced recordings are suboptimal. Coronary flow reserve of the LAD can be measured using contrast enhanced Doppler echocardiography. All contrast specific imaging modalities provide assessment of myocardial perfusion. The previously used imaging modalities (Harmonic B mode, Pulse Inversion and Harmonic Power Doppler) did not provide sufficient myocardial contrast signals using real-time imaging. Although intermittent imaging resulted in good myocardial opacification, this modality did not gain wider clinical acceptance. NEW TECHNOLOGIES: Using new contrast specific imaging technologies like Power Pulse Inversion, Power Modulation and Coherent Imaging myocardial perfusion can be evaluated in "real-time". Thus simultaneous assessment of left ventricular wall motion and myocardial perfusion became a reality and facilitated the data acquisition. New ultrasound contrast media like SonoVue can be used for all imaging modalities. Recent studies have demonstrated that the information derived from myocardial contrast echocardiography provides clinically relevant information on top of the findings obtained from conventional left ventricular wall motion analysis.

Doppler myocardial imaging in the assessment of normal and ischemic myocardial function--past, present and future.

Myocardial ischemia is associated with impaired regional myocardial function. Echocardiography is a suitable technique for the assessment of regional myocardial function as it is easily applicable and commonly available. However, most of the currently used echo-techniques are based on 2D images or M-mode traces. Therefore, they are limited either to the assessment of myocardial segments that can be insonated at 90 degrees or are based on visually assessed wall motion scoring which is semiquantitative at best. Doppler myocardial imaging (DMI) is a new ultrasound technique which assesses the velocity of myocardial motion. Different parameters can be derived from this velocity information such as velocity time integrals, intramural velocity gradients and strain/strain-rate information. Moreover, DMI provides information of the timing of regional motion related to myocardial contraction and relaxation. These parameters are all assessed quantitatively, therefore, DMI is a promising technique to quantify myocardial function, avoiding the disadvantages of observer-dependant judgement of myocardial contraction.

[Hopeful future for echocardiography. Progress within both the function and perfusion areas]. / Förhoppningsfull framtid för ekokardiografin. Utveckling sker inom såväl funktions- som perfusionsområdet.

Echocardiography is presently a feasible method for quantitative estimation of intracardiac flows, pressure levels and for hemodynamic evaluation of valvular disease. The evaluation of regional myocardial function is still based on subjective scrutiny, and no routine method for the estimation of myocardial blood flow is available. We present an overview of newly developed techniques that are beginning to gain purchase in clinical practice. The use of native second harmonic imaging to improve image quality and of tissue Doppler to provide objective measurements of regional myocardial function is discussed. This article describes the transformation of tissue Doppler information into parametric images as in strain rate imaging, and overviews the use of ultrasound contrast agents. Used together with new imaging modalities, myocardial contrast echocardiography holds promise for future quantification of myocardial blood volume and flow. Other emerging echocardiographic technologies discussed are non-invasive measurement of coronary flow reserve and three dimensional cineloop visualization, developed to increase our understanding of cardiovascular physiological and anatomical coupling.