The Clinical Impact and Good Practices of Remote Patient Monitoring for Chronic Heart Failure: A French Case Report.

Purpose: Remote patient monitoring (RPM) can improve the management of chronic diseases. Since 2019, RPM in chronic heart failure (CHF) management has been internationally supported. However, evidence on the clinical impact and good practices of RPM is scarce. We present a case of a patient with CHF that used RPM in France. Patients and Methods: A 74-year-old male was diagnosed with CHF (NYHA I) at the AP-HP Cochin Hospital in January 2020. He faced repetitive hospitalizations for acute heart failure and acute kidney injury. The causes of these acute episodes were unknown. Three therapeutic interventions were implemented (diuretic treatment, RPM and therapeutic education sessions). The patient answered questionnaires regularly and directly through the RPM web application named Satelia®Cardio. Therapeutic education was provided to instruct the patient about his symptoms and treatment management. Results: Since November 11, 2020, the patient had seven hospitalizations representing a total length of stay of 76 days over a period of 15 months and 2 weeks. Pericarditis was diagnosed as a potential cause and a pre-operative checkup was performed. No tangible benefits were found with diuretic treatment and therapeutic education since they had no effect on stopping the acute episodes leading to hospitalization. RPM did not trigger any clinical alerts until his last hospitalization. During this stay, a clinical telehealth nurse reviewed the patient's clinical setup and found that his initial baseline weight was incorrectly inputted. Since amending this, there were no new episodes. A high-risk, complex and costly heart surgery for pericardial decortication was avoided, and patient satisfaction has increased. Conclusion: To respect good practices, inclusion not only involves adding or registering a patient to a telehealth activity and database but involves redesigning the management and pathway of patients in order to conduct periodic and personalized clinical care via integrated technology into routine care.

Right ventricular diastolic function in aging: a head-to-head comparison between phase-contrast MRI and Doppler echocardiography.

To evaluate right ventricle (RV) diastolic function from phase-contrast MRI (PC-MRI) in aging. 89 healthy individuals (50 men, 43 ± 15 years) underwent cardiac MRI including 2D PC-MRI (1.5T) and reference Doppler echocardiography of both ventricles on the same day. Conventional echocardiographic parameters were estimated: early (E, cm/s) and atrial (A) peak velocities as well as myocardial early peak longitudinal velocity (E'). PC-MRI images were analyzed using custom software, providing: E', E and A waves along with respective peak flow rates (Ef, Af, mL/s) and filling volume (mL), for both ventricles. Intra- and inter-observer reproducibility was studied in 30 subjects and coefficients of variation (CoV) as well as intra-class correlation coefficients (ICC) were provided. RV diastolic function indices derived from PC-MRI data were reproducible (CoV ≤ 21%, ICC ≥ 0.75) and reliable as reflected by significant associations with left ventricular diastolic function indices assessed using both echocardiography (linear regression Pearson correlation coefficient r ≤ 0.59) and PC-MRI (r ≤ 71). Despite the fair associations between RV echocardiography and PC-MRI (r ≤ 0.25), the highest correlation with age was obtained for MRI Ef/Af ratio (r = - 0.64, p < 0.0001 vs. r = - 0.40, p = 0.0001 for echocardiographic E/A). Among PC-MRI E/A ratios, highest correlations with age were observed for flow rate and mean velocity ratios (r = - 0.61, p < 0.0001) as compared to maximal velocity ratios (r = - 0.56, p < 0.0001). Associations with age for E' were equivalent between PC-MRI (mean velocity: r = - 0.40, p < 0.0001; maximal velocity: r = - 0.36, p = 0.0005) and echocardiography (r = - 0.36, p = 0.0006). Finally, the significant and age-independent associations between RV mass/end-diastolic volume and E' were stronger for PC-MRI (mean velocity: r = - 0.36, p = 0.0006; maximal velocity: r = - 0.28, p = 0.007) than echocardiography (r = - 0.09, p = 0.38). PC-MRI tricuspid inflow and annulus myocardial velocity parameters were reproducible and able to characterize age-related variations in RV diastolic function.

Understanding Left Ventricular Assist Devices.

BACKGROUND/AIMS: Long-term mechanical assist devices are now commonly used in the treatment of severe heart failure to unload the failing ventricle, maintain sufficient end-organ perfusion and improve functional capacity. Depending on the assisted ventricles, 3 categories of long-term assist devices are available: left ventricular assist device (LVAD), biventricular assist device and total artificial heart. Improvements in technology, especially the advent of smaller, durable continuous flow pumps, have led to the use of LVADs in a much broader population of patients in the last 10 years. Both the number of patients living with LVADs and the life expectancy of these patients are increasing. Regarding this growing number of patients with LVAD, intensivists need to understand the physiology of the devices, their functioning, potential complications and their management. METHODS: We performed a narrative review of relevant medical literature regarding the physiology of patients with LVAD and management of common complications relevant to the critical care physicians. RESULTS: The most frequent complications occurring in the LVAD patients after the post-operative period are bleeding, driveline infections, thrombosis, device malfunction, right ventricular failure and arrhythmias. Bleeding is the most frequent adverse event in LVAD due to a combination of anticoagulation and acquired von Willebrand disease secondary to shear stress produced within the pump. Their management includes antiplatelet therapy arrest, reduction of the anticoagulation regimen and specific therapy if feasible. Infection is the second most common cause of death after cardiac failure in LVAD patients. All infections must be aggressively treated to avoid seeding the device. Device thrombosis can develop even when patients are adequately anticoagulated and taking antiplatelet therapy because the LVAD is responsible for a chronic hypercoagulable state. CONCLUSION: Management of these unique patients in the ICU is best accomplished with a multidisciplinary team that includes specialists in advanced heart failure, LVAD nurse coordinators and intensivists.

Coronary microcirculation in acute myocardial ischaemia: From non-invasive to invasive absolute flow assessment.

Although substantial progress has been made in recent decades in reducing mortality and performing optimal revascularization in patients with myocardial infarction, ischaemic heart disease, including acute coronary syndrome, remains the leading cause of mortality worldwide. One of the remaining challenges is to better detect, prevent and treat extended myocardial damage despite angiographically optimal revascularization. Several indices are available in clinical practice to evaluate myocardial damage, infarct size and potential myocardial recovery. These indices are divided into two categories: non-invasive, generally performed after revascularization; and invasive, performed during the revascularization procedure. They allow the clinician to detect patients at risk and may help us to tailor the medical therapy and discharge strategy according to myocardial damage. Because of the number of indices, it is difficult to properly evaluate new therapeutics or to adopt one index that will provide sufficient data to better evaluate and understand the part of the coronary vasculature that is not seen - the microcirculation or so-called "black box". The aim of this review is to describe the non-invasive and invasive indices used to describe the microcirculation and their ability to predict clinical impact, and current dedicated therapeutics that may help to reduce microvascular damage and improve clinical outcomes.

Management of end-stage heart failure patients with or without ventricular assist device: an observational comparison of clinical and economic outcomes.

OBJECTIVES: Heart transplantation (HT) and ventricular assist devices (VAD) for the management of end-stage heart failure have not been directly compared. We compare the outcomes and use of resources with these 2 strategies in 2 European countries with different allocation systems. METHODS: We studied 83 patients managed by VAD as the first option in Bad Oeynhausen, Germany (Group I) and 141 managed with either HT or medical therapy, as the first option, in Paris, France (Group II). The primary end-point was 2-year survival. Kaplan-Meier analyses were performed after the application of propensity score weights to mitigate the effects of non-random group assignment. The secondary end-points were resource utilization and costs. Subgroup analyses were performed for patients undergoing HT and patients treated with inotropes at the enrolment time. RESULTS: The Group I patients were more severely ill and haemodynamically compromised, and 28% subsequently underwent HT vs 55% primary HT in Group II, P < 0.001. The adjusted probability of survival was 44% in Group I vs 70% in Group II, P <0.0001. The mean cumulated 2-year costs were €281 361 ± 156 223 in Group I and €47 638 ± 35 061 in Group II, P < 0.0001. Among patients who underwent HT, the adjusted probability of survival in Group I (n = 23) versus Group II (n = 78) was 76% versus 68%, respectively (0.09), though it differed in the inotrope-treated subgroups (77% in Group I vs 67% in Group II, P = 0.04). CONCLUSIONS: HT should remain the first option for end-stage heart failure patients, associated with improved outcomes and better cost-effectiveness profile. VAD devices represent an option when transplant is not possible or when patient presentation is not optimal.

Scan-rescan reproducibility of ventricular and atrial MRI feature tracking strain.

BACKGROUND: A feature tracking (FT) was designed to simultaneously extract myocardial strains in main cardiac chambers from cine MRI images. Its inter-observer and scan-rescan reproducibility was assessed and sample sizes required to detect predefined longitudinal changes in strain values were provided. METHOD: FT was applied on left (LV) and right (RV) ventricles as well as left atrium (LA) of 21 individuals (66 ± 10 years) who underwent 2 MRIs 2 weeks apart. Global peaks for radial, circumferential, longitudinal strains, radial motion fraction (Mr), fractional area change (FAC) and tricuspid annular plane excursion (TAPSE) were estimated. Inter-operator and inter-exam reproducibility were evaluated using coefficients of variations (CV) and intra-class correlation coefficients (ICC). RESULTS: Reproducibility of all measurements were good to excellent for inter-operator (LV:CV<6.5%, ICC>0.91; RV:CV<12%, ICC>0.86; LA:CV<14%, ICC>0.85) and inter-study (LV:CV<15%, ICC>0.65; RV:CV<20%, ICC>0.71; LA:CV<20.5%, ICC>0.83) evaluations. Reasonable sample sizes are required to detect a longitudinal difference of 10-15% in strain values (LV:5 to 33 individuals, RV:14 to 62 individuals, LA:4 to 65 individuals). CONCLUSIONS: FT-based functional evaluation of main heart chamber deformation from cine MRI is repeatable and thus suitable for follow-up. Strain measurements may help for the joint clinical evaluation of LV, RV or LA implication in various cardiomyopathies.

Head-to-head comparison of the diagnostic performance of coronary computed tomography angiography and dobutamine-stress echocardiography in the evaluation of acute chest pain with normal ECG findings and negative troponin tests: A prospective multicenter study.

OBJECTIVE: To perform a head-to-head comparison of coronary CT angiography (CCTA) and dobutamine-stress echocardiography (DSE) in patients presenting recent chest pain when troponin and ECG are negative. METHODS: Two hundred seventeen patients with recent chest pain, normal ECG findings, and negative troponin were prospectively included in this multicenter study and were scheduled for CCTA and DSE. Invasive coronary angiography (ICA), was performed in patients when either DSE or CCTA was considered positive or when both were non-contributive or in case of recurrent chest pain during 6month follow-up. The presence of coronary artery stenosis was defined as a luminal obstruction >50% diameter in any coronary segment at ICA. RESULTS: ICA was performed in 75 (34.6%) patients. Coronary artery stenosis was identified in 37 (17%) patients. For CCTA, the sensitivity was 96.9% (95% CI 83.4-99.9), specificity 48.3% (29.4-67.5), positive likelihood ratio 2.06 (95% CI 1.36-3.11), and negative likelihood ratio 0.07 (95% CI 0.01-0.52). The sensitivity of DSE was 51.6% (95% CI 33.1-69.9), specificity 46.7% (28.3-65.7), positive likelihood ratio 1.03 (95% CI 0.62-1.72), and negative likelihood ratio 1.10 (95% CI 0.63-1.93). The CCTA: DSE ratio of true-positive and false-positive rates was 1.70 (95% CI 1.65-1.75) and 1.00 (95% CI 0.91-1.09), respectively, when non-contributive CCTA and DSE were both considered positive. Only one missed acute coronary syndrome was observed at six months. CONCLUSIONS: CCTA has higher diagnostic performance than DSE in the evaluation of patients with recent chest pain, normal ECG findings, and negative troponine to exclude coronary artery disease.

New estimate of valvuloarterial impedance in aortic valve stenosis: A cardiac magnetic resonance study.

PURPOSE: Valvuloarterial impedance (ZVA ), estimating left ventricle (LV) afterload, has been proposed in transthoracic echocardiography (TTE) as a predictor of mortality in aortic valve stenosis (AVS). However, its calculation differs from arterial characteristic impedance (ZC ). Our aim was to apply the concept of ZC calculation to estimate ZVA from MR with carotid tonometry and to evaluate these indices through their associations with symptoms, LV diastolic function and aortic stiffness. MATERIALS AND METHODS: In 40 patients with AVS (76 ± 13 years), ZVA-TI derived from velocity time integral and E/Ea were estimated by TTE. ZVA-INS , based on ZC formula, calculated as the instantaneous pressure gradient to peak flow ratio and aortic compliance were estimated by using MRI at 1.5 Tesla. RESULTS: Both ZVA estimates were higher in symptomatic than asymptomatic patients (707 ± 22 versus 579 ± 53 dyne.s/cm5 , P = 0.031 for ZVA-INS and 4.35 ± 0.16 versus 3.33 ± 0.38 mmHg.m2 /mL, P = 0.018 for ZVA-TI ). Although they were both associated with aortic compliance (r = -0.45; P = 0.006 for ZVA-INS and r = -0.43; P = 0.008 for ZVA-TI ) only ZVA-INS was associated with E/Ea (r = 0.50; P < 0.001). In multivariate analysis to identify determinants of E/Ea, a model including age, mean blood pressure, LV ejection fraction, LV mass, and aortic valve area was performed (R2 = 0.41; P < 0.01). When ZVA-INS was added to the model, its overall significance was higher R2 = 0.56 (P < 0.01) and ZVA-INS and LV mass were the only significant determinants. CONCLUSION: ZVA-INS was more strongly associated with diastolic dysfunction than usual parameters quantifying AVS severity. This new ZVA estimate could improve LV afterload evaluation. LEVEL OF EVIDENCE: 1 J. Magn. Reson. Imaging 2017;45:795-803.

Pathophysiology of dyspnoea in acute pulmonary embolism: A cross-sectional evaluation.

BACKGROUND AND OBJECTIVE: Dyspnoea in pulmonary embolism (PE) remains poorly characterized. Little is known about how to measure intensity or about the underlying mechanisms that may be related to ventilatory abnormalities, alveolar dead space ventilation or modulating factors such as psychological modulate. We hypothesized that dyspnoea would mainly be associated with pulmonary vascular obstruction and its pathophysiological consequences, while the sensory-affective domain of dyspnoea would be influenced by other factors. METHODS: We undertook a prospective study of 90 consecutive non-obese patients (mean ± SD age: 49 ± 16 years, 41 women) without cardiorespiratory disease. All patients were hospitalized with symptoms for <15 days and a confirmed PE (multi-detector computed tomography (MDCT) scan, n = 87 and high-probability ventilation/perfusion scan, n = 3). Patients underwent assessment of dyspnoea using the Borg score, modified Medical Research Council (mMRC) scale, assessment of psychological trait, state of anxiety and depression and chest pain via the Visual Analogical Scale at the time of maximum dyspnoea. Functional evaluations such as the quantitative ventilation-perfusion lung scan, echocardiography, alveolar dead space fraction and tidal ventilation measurements were completed within 48 h of admission. RESULTS: Multivariate analyses demonstrated that dyspnoea was mainly linked to pulmonary vascular obstruction and/or its consequences such as raised pulmonary arterial pressure and chest pain. The sensory-affective domain of dyspnoea showed additional determinants such as age, depression and breathing variability. CONCLUSION: Dyspnoea is mainly related to vascular consequences of PE such as increased pulmonary arterial pressure or chest pain. The sensory-affective domain of dyspnoea also correlates with age, depression and breathing variability.

Left atrial aging: a cardiac magnetic resonance feature-tracking study.

Importance of left atrial (LA) phasic function evaluation is increasingly recognized for its incremental value in terms of prognosis and risk stratification. LA phasic deformation in the pathway of normal aging has been characterized using echocardiographic speckle tracking. However, no data are available regarding age-related variations using feature-racking (FT) techniques from standard cine magnetic resonance imaging (MRI). We studied 94 healthy adults (41 ± 14 yr, 47 women), who underwent MRI and Doppler echocardiography on the same day for left ventricular (LV) diastolic function evaluation. From cine MRI, longitudinal strain and strain rate, radial motion fraction, and radial relative velocity, respectively, corresponding to the reservoir, conduit, and LA contraction phases, were measured using dedicated FT software. Longitudinal strain and radial motion fraction decreased gradually and significantly with aging for both reservoir (r > 0.31, P < 0.003) and conduit (r > 0.54, P < 0.001) phases, whereas they remained unchanged during the LA contraction phase. Subsequently, the LA contraction-to-reservoir ratio increased significantly with age (r > 0.44, P < 0.001). Longitudinal strain rate and radial relative velocity significantly decreased with age (reservoir: r = 0.39, P < 0.001, conduit: r > 0.54, P < 0.001), and these associations tended to be stronger in women than in men. Finally, associations of LA functional indexes with age were stronger in individuals with lower transmitral early-to-atrial maximal velocity ratio and mitral annulus maximal longitudinal velocity, as well as higher transmitral early maximal-to-mitral annulus maximal longitudinal velocity ratio, highlighting the LV-LA interplay. Age-related changes in LA phasic function indexes were quantified by cine MRI images using a FT technique and were significantly related to age and LV diastolic function.

Assessment of right ventricular dysfunction predictors before the implantation of a left ventricular assist device in end-stage heart failure patients using echocardiographic measures (ARVADE): Combination of left and right ventricular echocardiographic variables.

BACKGROUND: Right ventricular failure (RVF) is a major cause of morbidity and mortality in left ventricular assist device (LVAD) recipients. OBJECTIVES: To identify preoperative echocardiographic predictors of post-LVAD RVF. METHODS: Data were collected for 42 patients undergoing LVAD implantation in Germany. RVF was defined as the need for placement of a temporary right ventricular assist device or the use of inotropic agents for 14 days. Data for RVF patients were compared with those for patients without RVF. A score (ARVADE) was established with independent predictors of RVF by rounding the exponentiated regression model coefficients to the nearest 0.5. RESULTS: RVF occurred in 24 of 42 LVAD patients. Univariate analysis identified the following measurements as RVF risk factors: basal right ventricular end-diastolic diameter (RVEDD), minimal inferior vena cava diameter, pulsed Doppler transmitral E wave (Em), Em/tissue Doppler lateral systolic velocity (SLAT) ratio and Em/tissue Doppler septal systolic velocity (SSEPT) ratio. Em/SLAT≥18.5 (relative risk [RR] 2.78, 95% confidence interval [CI] 1.38-5.60; P=0.001), RVEDD≥50 mm (RR 1.97, 95% CI 1.21-3.20; P=0.008) and INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) level 1 (RR 1.74, 95% CI 1.04-2.91; P=0.04) were independent predictors of RVF. An ARVADE score>3 predicted the occurrence of post-implantation RVF with a sensitivity of 89% and a specificity of 74%. CONCLUSION: The ARVADE score, combining one clinical variable and three echocardiographic measurements, is potentially useful for selecting patients for the implantation of an assist device.

Age-specific changes in left ventricular diastolic function: a velocity-encoded magnetic resonance imaging study.

OBJECTIVES: Our objectives were to assess the ability of phasecontrast MRI (PC-MRI) to detect sub-clinical age-related variations of left ventricular (LV) diastolic parameters and thus to provide age-related reference ranges currently available for echocardiography but not for MRI-PC, and to identify independent associates of such variations. METHODS: We studied 100 healthy volunteers (age = 42 ± 15years, 50 females) who had MRI with simultaneous blood pressure measurements. LV mass and volumes were assessed. Semiautomated analysis of PC-MRI data provided: 1) early transmitral (Ef) and atrial (Af) peak filling flow-rates (ml/s) and filling volume (FV), 2) deceleration time (DT), isovolumic relaxation time (IVRT), and 3) early myocardial longitudinal (E') peak velocity. RESULTS: MRI-PC diastolic parameters were reproducible as reflected by low coefficients of variations (ranged between 0.31 to 6.26 %). Peak myocardial velocity E' (r = -0.63, p < 0.0001) and flow-rate parameters were strongly and independently associated to age (Ef/Af:r = -0.63, DT:r = 0.46, IVRT:r = 0.44, Ef/FV:r = -0.55, Af/FV:r = 0.56, p < 0.0001). Furthermore, LV relaxation parameters (E', DT, IVRT), were independently associated to LV remodelling (LV mass/end-diastolic volume) and myocardial wall thickness (p < 0.01). CONCLUSIONS: PC-MRI age-related reference ranges of diastolic parameters are provided. Such parameters might be useful for a fast, reproducible and reliable characterization of diastolic function in patients referred for clinical MRI exam KEY POINTS: • MRI age-related reference values of left ventricular diastolic parameters are provided. • MRI diastolic parameters can characterise sub-clinical age-related variations in healthy individuals. • Diastolic function would complement cardiac MRI exam with currently neglected data. • Diastolic function would enhance MRI diagnostic value in cardiomyopathy and heartfailure.

Impact of inodilator drugs on echocardiographic assessments of left ventricular filling pressure in patients with decompensated end-stage heart failure*.

OBJECTIVES: We investigated the impact of inodilators on the accuracy of E/e' ratio as a surrogate for pulmonary artery occlusion pressure in patients with decompensated end-stage systolic heart failure. SETTING: The ratio of early diastolic transmitral flow velocity to tissue Doppler mitral annular early diastolic velocity, E/e', and pulmonary artery occlusion pressure have been shown to be correlated. The validity of E/e' for predicting pulmonary artery occlusion pressure in patients with decompensated end-stage systolic heart failure was recently challenged, but the influence of inodilators was not taken into account, despite the reported influence of these drugs on left ventricular relaxation properties. PATIENTS AND INTERVENTION: Invasive hemodynamic monitoring and echocardiographic data were collected prospectively from 39 patients with decompensated end-stage systolic heart failure (92% male), aged 56 ± 13 years. These patients had dilated ventricles with a low cardiac index (1.9 ± 0.6 L/min/m) and high pulmonary artery occlusion pressure (22 ± 8 mm Hg), and 90% required inodilator support during hospitalization. MEASUREMENTS AND MAIN RESULTS: The correlation between septal E/e' and pulmonary artery occlusion pressure was good for examinations in the absence of inodilators (n = 21) (r = 0.7; p < 0.001), but no correlation was found when inodilators were used (n = 31). Lateral and mean E/e' were poorly correlated with pulmonary artery occlusion pressure, if at all, in both cases. CONCLUSIONS: By modifying ventricular relaxation properties and the influence of filling pressure on e', inodilator agents severely impair the correlation between E/e' and pulmonary artery occlusion pressure in patients with decompensated end-stage systolic heart failure.

Galectin-3: a new biomarker for the diagnosis, analysis and prognosis of acute and chronic heart failure.

Heart failure constitutes an important medical, social and economic problem. The prevalence of heart failure is estimated as 2-3% of the adult population and increases with age, despite the scientific progress of the past decade, especially the emergence of natriuretic peptides, which have been widely used as reliable markers for diagnostic and prognostic evaluation. Identification of new reliable markers for diagnosis, analysis, prognosis of mortality and prevention of hospitalization is still necessary. Galectin-3 is a soluble ß-galactoside-binding protein secreted by activated macrophages. Its main action is to bind to and activate the fibroblasts that form collagen and scar tissue, leading to progressive cardiac fibrosis. Numerous experimental studies have shown the important role of galectin-3 in cardiac remodelling due to fibrosis, independent of the fibrosis aetiology. Galectin-3 is significantly increased in chronic heart failure (acute or non-acute onset), independent of aetiology. Some clinical studies have confirmed the predictive value of galectin-3 in all-cause mortality in patients with heart failure. In our review, we aim to analyse the role of galectin-3 in the development of heart failure, its value in screening and clinical decision making and its possible predictive application in follow-up as a "routine" test in an addition to established biomarkers, such as B-type natriuretic peptide and N-terminal prohormone of B-type natriuretic peptide.

Heart failure while on ventricular assist device support: a true clinical entity?

Ventricular assist devices (VADs) have become an established therapeutic option for patients with end-stage heart failure. The appearance of heart failure in VAD patients seems unexpected. Nevertheless, this phenomenon is not rare. We report six cases of VAD patients with clinical presentation of heart failure at different times after implantation and describe the mechanisms involved. The aetiology of this heart failure, like its clinical presentation, varies and has yet to be identified.

Evaluation of aortic valve stenosis using cardiovascular magnetic resonance: comparison of an original semiautomated analysis of phase-contrast cardiovascular magnetic resonance with Doppler echocardiography.

BACKGROUND: Accurate quantification of aortic valve stenosis (AVS) is needed for relevant management decisions. However, transthoracic Doppler echocardiography (TTE) remains inconclusive in a significant number of patients. Previous studies demonstrated the usefulness of phase-contrast cardiovascular magnetic resonance (PC-CMR) in noninvasive AVS evaluation. We hypothesized that semiautomated analysis of aortic hemodynamics from PC-CMR might provide reproducible and accurate evaluation of aortic valve area (AVA), aortic velocities, and gradients in agreement with TTE. METHODS AND RESULTS: We studied 53 AVS patients (AVA(TTE)=0.87±0.44 cm(2)) and 21 controls (AVA(TTE)=2.96±0.59 cm(2)) who had TTE and PC-CMR of aortic valve and left ventricular outflow tract on the same day. PC-CMR data analysis included left ventricular outflow tract and aortic valve segmentation, and extraction of velocities, gradients, and flow rates. Three AVA measures were performed: AVA(CMR1) based on Hakki formula, AVA(CMR2) based on continuity equation, AVA(CMR3) simplified continuity equation=left ventricular outflow tract peak flow rate/aortic peak velocity. Our analysis was reproducible, as reflected by low interoperator variability (<4.56±4.40%). Comparison of PC-CMR and TTE aortic peak velocities and mean gradients resulted in good agreement (r=0.92 with mean bias=-29±62 cm/s and r=0.86 with mean bias=-12±15 mm Hg, respectively). Although good agreement was found between TTE and continuity equation-based CMR-AVA (r>0.94 and mean bias=-0.01±0.38 cm(2) for AVA(CMR2), -0.09±0.28 cm(2) for AVA(CMR3)), AVA(CMR1) values were lower than AVA(TTE) especially for higher AVA (mean bias=-0.45±0.52 cm(2)). Besides, ability of PC-CMR to detect severe AVS, defined by TTE, provided the best results for continuity equation-based methods (accuracy >94%). CONCLUSIONS: Our PC-CMR semiautomated AVS evaluation provided reproducible measurements that accurately detected severe AVS and were in good agreement with TTE.

Two-dimensional strain rate and Doppler tissue myocardial velocities: analysis by echocardiography of hemodynamic and functional changes of the failed left ventricle during different degrees of extracorporeal life support.

BACKGROUND: To evaluate hemodynamic and functional changes of the failed left ventricle by Velocity Vector Imaging (VVI) and tissue Doppler, 22 patients with cardiogenic shock supported by extracorporeal life support (ECLS) were imaged during ECLS output variations inducing severe load manipulations. METHODS: The following data were acquired: (1) mean arterial pressure, aortic Doppler velocity-time integral, left ventricular end-diastolic volume, and mitral Doppler E wave; (2) tissue Doppler systolic (Sa) and early diastolic (Ea) velocities; and (3) systolic peak velocity (Sv), strain, and strain rate using VVI. RESULTS: Load variations were documented by a significant decrease in afterload (mean arterial pressure, -21%), an increase in preload (left ventricular end-diastolic volume, +12%; E, +46%; E/Ea ratio, +22%), and an increase in the velocity-time integral (+45%). VVI parameters increased (Sv, +36%; strain, +81%; and strain rate, +67%; P < .05), unlike tissue Doppler systolic velocities (+2%; P = NS). Whatever the ECLS flow, Sa was higher in patients who survived. CONCLUSIONS: VVI parameters are not useful in characterizing the failed left ventricle with rapidly varying load conditions. Tissue Doppler systolic velocities appear to be load independent and thus could help in the management of ECLS patients.

Predictors of successful extracorporeal membrane oxygenation (ECMO) weaning after assistance for refractory cardiogenic shock.

PURPOSE: Detailed extracorporeal membrane oxygenation (ECMO) weaning strategies and specific predictors of ECMO weaning success are lacking. This study evaluated a weaning strategy following support for refractory cardiogenic shock to identify clinical, hemodynamic, and Doppler echocardiography parameters associated with successful ECMO removal. METHODS: Hemodynamically stable patients underwent ECMO flow reduction trials to <1.5 L/min under clinical and Doppler echocardiography monitoring. When a patient had partially or fully recovered from severe cardiac dysfunction, tolerated the weaning trial, and had left ventricular ejection fraction (LVEF) >20-25% and aortic time-velocity integral (VTI) >10 cm under minimal ECMO support, device removal was considered. RESULTS: Among the 51 patients (34 males, aged 54 ± 14 years) who received ECMO for medical (n = 27), postcardiotomy (n = 11), or posttransplantation (n = 5) cardiogenic shock, 38 tolerated at least one ECMO flow reduction trial and 20 were ultimately weaned. Compared with the 13 patients who tolerated the trial but were not deemed weanable, those successfully weaned had, at each ECMO flow level, higher arterial systolic and pulse pressures, VTI, LVEF, and lateral mitral annulus peak systolic velocity (TDSa). All weaned patients had aortic VTI ≥10 cm, LVEF >20-25%, and TDSa ≥6 cm/s at minimal ECMO flow support. These Doppler echocardiography parameters better separated weaned and nonweaned patients than any other parameters tested. CONCLUSIONS: Patients who tolerated a full ECMO weaning trial and had aortic VTI ≥10 cm, LVEF >20-25%, and TDSa ≥6 cm/s at minimal ECMO flow were all successfully weaned. However, further studies are needed to validate these simple and easy-to-acquire Doppler echocardiography parameters as predictors of subsequent ECMO weaning success in patients recovering from severe cardiogenic shock.

How to calculate left ventricular mass in routine practice? An echocardiographic versus cardiac magnetic resonance study.

BACKGROUND: An accurate assessment of left ventricular (LV) mass is important for the detection of LV hypertrophy. AIMS: To assess the accuracy of four echocardiographic imaging modalities for assessing LV mass compared with cardiac magnetic resonance (CMR). METHODS: We prospectively studied 40 consecutive patients, who underwent an echocardiographic examination using four imaging modalities (M-mode fundamental imaging [FI], M-mode harmonic imaging [HI], two-dimensional [2D] FI and 2D HI) and CMR (our gold standard for LV mass measurement). All echocardiographic measurements were performed by two independent observers. RESULTS: All echocardiographic modes significantly overestimated LV mass compared with CMR (P≤0.04), except 2D FI (P=0.25). This overestimation was significantly higher with HI (up to 15.5%) compared with FI (up to 5.7%; P≤0.04). Significant correlations were observed between the different echocardiographic methods and the two observers. The interobserver agreement over LV mass measurement was lower with FI (intraclass coefficient [ICC] range, 0.66-0.73) than with HI (ICC range, 0.72-0.82), and the best agreement was obtained with 2D HI (ICC, 0.82). Good agreement between CMR and all echocardiographic methods was observed among the smallest LV diameters (ICC range, 0.62-0.85), but not among the largest LV diameters (ICC range, 0-0.22). CONCLUSIONS: HI overestimates LV mass compared with FI and CMR; this leads to overestimation of prevalence of LV hypertrophy in a population of hypertensive patients. HI improves interobserver reproducibility of LV mass measurement compared with FI, leading to a significant decrease in the number of patients required for clinical trials evaluating LV mass regression. Accuracy of LV mass measurement by echocardiography is affected by LV geometry.