Biatrial and right ventricular deformation imaging: Implications of the recent EACVI consensus document in the clinics and beyond.

In this review, right ventricular (RV), right atrial (RA), and left atrial (LA) strain in some selected clinical situations has been discussed in light of the current literature. To exemplify the significance of the use of multichamber strain, we have provided some illustrations of common cardiac problems. The recently published European Association of Cardiovascular Imaging (EACVI) consensus document for standardization of RV, RA, and LA strain, using the currently available software, has fulfilled the aspirations of investigators world over who have been studying atrial strain using a bailed-out algorithm designed principally to quantify left ventricular deformation. The purpose of this review was to reiterate the value of the application of RV and biatrial strain imaging in research and day-to-day clinical practice, using the 2-dimensional speckle tracking echocardiography (2D-STE). Also, we present a short report on how RA strain may remain coupled to pulmonary hemodynamics. Besides, we have highlighted the technical challenges of atrial strain quantification. We have not used the nomenclature of chamber deformation proposed by the EACVI document as the publications cited in this review have used different sets of nomenclature.

Deformation imaging of the atria using 2D strain: A noninvasive modality to characterize operating compliance?

This viewpoint with two illustrated case summaries of biventricular and biatrial mechanical function/dysfunction emphasizes the importance of continued research in deformation imaging beyond the left ventricle, as there are no Cinderellas in the heart and we just cannot afford to be nonchalant toward the atria, particularly the right atrium.

Incremental prognostic value of multichamber deformation imaging and renal function status to predict adverse outcome in heart failure with reduced ejection fraction.

AIMS: Deformation imaging, particularly of left-sided heart, is fast becoming an essential tool in clinical cardiology. However, data are scant regarding the value of biventricular and bi-atrial deformation in association with comorbidities in heart failure with reduced left ventricular ejection fraction (HFREF). METHODS AND RESULTS: Forty-nine subjects (72 ± 13 years; 28 male) with HFREF and 14 age-matched controls underwent deformation imaging including LV global longitudinal strain (LVGLS%), right ventricular strain (RVS%), and left atrial reservoir strain (LARS%). Standard echo parameters included LVEF%, E/E' ratio, and pulmonary artery systolic pressure (PASP). Mean ± SD of LVEF, LVGLS%, and RVS% were 31% ± 8%, 7% ± 3%, and 17% ± 7%, respectively, and were significantly lower compared with controls (all P < .0001). Over a follow-up period of 4.2 years, 24% of patients died and 48% had a composite outcome of death and heart failure hospitalization. In the logistic regression model, taking the composite of death and heart failure hospitalization as a dichotomous variable, RVS%, E/E' ratio, and PASP were the only significant univariate predictors of adverse outcome (R2  = .68, all P < .05). In the multivariate model, however, only PASP predicted adverse outcome. PASP also had the largest AUC (0.8) in the ROC analysis. A creatinine level of >88 µmol/L (SCREAT) and a cutoff value of LA reservoir strain (LARS %) at <16.7% provided the best sensitivity (86%) and specificity (40%) with an odds ratio of 3.8. In the Kaplan-Meier survival estimate, LARS%-SCREAT predicted all-cause mortality and HF hospitalization. CONCLUSION: Multichamber deformation imaging along with renal function and PASP could best predict adverse outcome in HFREF.

Value of two-dimensional speckle tracking and real time three-dimensional echocardiography for the identification of subclinical left ventricular dysfunction in patients referred for routine echocardiography.

BACKGROUND: While speckle tracking echocardiography (2DSTE) can be used to study longitudinal, circumferential, and radial function, real time 3D echocardiography (3DE) generates dynamic time-volume curves, offering a wide array of new parameters for characterizing mechanical and volumetric properties of the left ventricle (LV). Our aim was to investigate the merit of these new techniques to separate normal from abnormal echocardiograms as well as to identify subclinical disease in reportedly normal subjects. METHODS: Eighty-one patients (mean age 61 ± 16 years) underwent standard 2D echocardiography (2DE) enhanced by 2DSTE and 3DE. The data included LV volumes and ejection fraction (EF), velocities, strain/strain rate, and peak ejection/filling rates. The patients were divided into Group 1: normal (n = 42) and Group 2: abnormal (n = 39) on the basis of an expert interpretation of the resting 2DE. RESULTS: Global longitudinal strain (%) was 17 ± 4 in Group1 and 14 ± 4 in Group2 (P < 0.002). Strain rates (SR, 1/sec) at peak systole (1.1 ± 0.2 vs 0.9 ± 0.3, P < 0.001) and early diastole (1.3 ± 0.3 vs 0.9 ± 0.3, P < 0.001) were also higher in Group1. Three-dimensional peak ejection and filling rates (EDV/sec) were significantly higher in Group1 (-2.5 ± 0.4 vs -2.1 ± 0.7, and 1.8 ± 0.2 vs 1.5 ± 0.5, P < 0.002, P < 0.001, respectively). The best discriminatory power for predicting a normal 2DE was systolic SR with a sensitivity of 82% and a specificity of 54% using a cutoff value of 1.09. Interestingly, 19/41 (46%) of Group1 patients had systolic SR < 1.09, suggesting subclinical disease. CONCLUSIONS: 2DSTE and 3DE can discriminate between normal and abnormal echocardiograms and have the potential to detect subclinical LV dysfunction.

Principles and clinical applications of strain imaging.

M-Mode echocardiography, 2-D grey scale imaging and standard Doppler that constitute conventional echocardiography has been used for over many decades now. Although these modalities form the backbone in routine clinical echocardiography, its inability to objectively quantify left ventricular function at regional and global levels as well as its loading and heart rate dependency make conventional echocardiography an incomplete tool in clinical situations. Tissue Doppler imaging (which includes myocardial velocity, displacement and strain) has been successfully used in a variety of clinical situations, from investigations of diastolic function to implantation of bi-ventricular pacing for cardiac resynchronization therapy and even in preclinical diagnosis of genetic diseases such as hypertrophic cardiomyopathy. Strain imaging has been found to be superior to velocity in a variety of clinical conditions and enables us to quantify deformation as a measurable number in terms of regional myocardial deformation. Strain and strain rate have to be assessed together since they provide complementary information somewhat analogous to ejection fraction and contraction. This article has tried to simplify its principles, understand its limitations and know its utility to ensure having a better knowledge of this promising tool before one starts to actively use it. In this review, focus has been made on the physical, technical and also clinical aspects of strain imaging. In the new world of multi-modality imaging, cardiac magnetic resonance imaging (CMR) and nuclear perfusion scintigraphy (NPS) are the competitors of echocardiography, but it would be of interest to note that even these modalities are also adapting concepts of strain imaging (in CMR) and left ventricular synchronicity (in NPS). This only emphasizes the role of advanced echocardiography as a more economical and stand-alone modality visa vis the other two related technologies. The sooner we adapt to these advanced applications, stronger would be the ground to resolve technical and clinical issues. Strain imaging in its present form cannot win the game alone in this era of multi-modality imaging, but it is almost certain that with continued advancement, tissue Doppler and speckle tracking echocardiography based strain could play a pivotal role in a variety of clinical situations providing much needed incremental information.

Quantification of low-dose dobutamine stress using speckle tracking echocardiography in coronary artery disease.

AIMS: We sought to evaluate the utility of speckle tracking echocardiography (STE) for detecting left ventricular (LV) mechanical abnormalities during low-dose (20 microg) dobutamine stress (DSE). METHODS AND RESULTS: Twenty-nine patients (56 +/- 12 years) with a history of recent acute coronary events (ACE) underwent STE-DSE. Left ventricular images, sampled at frame rates 70-100 Hz, were analysed off-line (Echopac BT 6.0.0). Velocity, strain, and rotational imaging were performed. Twenty patients had LV ejection fraction (EF) >40% (Group 1) whereas nine patients had LVEF <40% (Group 2). Average heart and frame rates were identical during DSE in the two groups (P = ns). Global circumferential strain (%) was significantly lower in Group 2 compared with Group 1 (10.65 +/- 5.30 vs. 16.82 +/- 6.61; P < 0.05) at rest and during peak stress (14.72 +/- 6.51 vs. 21.13 +/- 7.2; P < 0.05). The global peak rotation rate (degree/s) was, however, higher at rest in Group 2 (70 +/- 97 vs. 19 +/- 67; P < 0.05) and 20 microg stress. Peak systolic velocity increased in three of the four LV walls at 20 microg (in Groups 1 and 2). A global rotational rate increased significantly at 20 microg during systole in both the groups, but was unchanged in Group 2 during diastole. CONCLUSIONS: Speckle tracking echocardiography dobutamine stress appears to provide comprehensive information on LV mechanical status in the aftermath of ACE. The modality may help risk stratify such patients.

3D and 4D Ultrasound: Current Progress and Future Perspectives.

PURPOSE OF REVIEW: Three-dimensional (3D) echocardiography (3DE) and 4-dimensional echocardiography (4DE), also known as real-time (RT) 3DE (RT3DE), are rapidly emerging technologies which have made significant impact in the clinical arena over the years. This review will discuss the recent applications of 3DE in diagnosing and treating different types of cardiovascular disease. RECENT FINDINGS: Recent studies using 3DE expanded on prior findings and introduced additional applications to different cardiac conditions. Some studies have used 3D parameters to prognosticate long-term outcomes. Numerous innovative software designs including fully automated algorithms have been introduced to better evaluate valvular heart disease and cardiac function. SUMMARY: With further evolution of 3DE technologies, this imaging modality will emerge as a powerful tool and likely become the imaging modality of choice in the diagnosis and management of various cardiac disorders.

Prevalence of Congenital Heart Disease and Pulmonary Hypertension in Down's Syndrome: An Echocardiographic Study.

BACKGROUND: Down's syndrome (DS) is a genetic anomaly, which undergoes increased morbidity and mortality when associated with congenital heart disease (CHD). The aims of the study were to determine the prevalence of CHD and pulmonary hypertension (PH) in DS. METHODS: One hundred twenty-seven patients with DS living in Mexico City were evaluated by physical exam, electrocardiogram and echocardiogram. RESULTS: CHD was found in 40%. In 80% (n = 102) PH was present [systolic pulmonary artery pressure (SPAP) of 47 ± 19 mm Hg and mean pulmonary artery pressure (MPAP) of 32 ± 11 mm Hg]. Patients with CHD and PH were classified as having 1) no shunt (n = 18) with SPAP of 37 ± 9 mm Hg and MPAP of 25 ± 6 mm Hg and 2) with shunt (n = 26) with PASP of 57 ± 29 mm Hg and MPAP of 38 ± 19 mm Hg (p ≤ 0.001). In those without CHD or with CHD without shunt (n = 76), SPAP was 37 ± 19 mm Hg and the MPAP 25 ± 6 mm Hg. The prevalence of PH in DS was 5.9% at one year and 15% at 10 years. The odds ratio of PH in DS with CHD was 7.3 vs. 3 without CHD. CONCLUSION: DS has a high prevalence of CHD and PH. PH prevalence increases when it is associated with CHD. The pathophysiology of PH in DS without CHD should be studied in the near future. Echocardiography is an indispensible tool for evaluation of DS.

Role of N-terminal pro-brain natriuretic peptide in ST-segment elevation myocardial infarction: experience from a tertiary centre in India.

BACKGROUND: Role of biomarkers in ST-segment elevation myocardial infarction (STEMI) is paramount, as they aid in diagnosis and gauge prognosis of the disease. In this project, we sought to study the short-term outcome and clinical associates of N-terminal pro-brain natriuretic peptide (NT-proBNP) in the setting of STEMI at a tertiary center in India. METHODS: In all, 173 STEMI patients (mean age: 57 ± 12 years, 38 women) had their NT-proBNP assayed in addition to troponins and high-sensitive C-reactive protein. Subjects were divided according to NT-proBNP levels into 2 groups: group 1 (NT-proBNP ≤100 pg/mL) and group 2 (NT-proBNP >100 pg/mL). RESULTS: NT-proBNP values (pg/mL) were elevated in group 2 (group 1: 61.7 ± 6.2; group 2: 1006.5 ± 990.6, P < 0.0001). Significantly greater number of females had elevated NT-proBNP (P < 0.05) that could be predicted by the duration of chest pain related to STEMI (area under the curve: 0.72), and age at presentation (area under the curve: 0.66). Multiple regression analysis showed a strong inverse association between NT-proBNP and left ventricular ejection fraction and a strong positive association between the peptide and high-sensitive C-reactive protein. A significant positive association was also noted between NT-proBNP and troponin I (all P < 0.05, Global R = 0.47). Diabetes mellitus and/or hypertension, and infarction localization showed no effect on NT-proBNP levels along with death, primary coronary intervention-related bleeding, and arrhythmias, (χ, P = ns). CONCLUSIONS: The data suggest that women are more likely to have increased NT-proBNP while presenting with STEMI. Duration of chest pain and age at presentation are the best predictors of elevated NT-proBNP, though without much bearing on short-term morbidity and mortality.

Relative importance of errors in left ventricular quantitation by two-dimensional echocardiography: insights from three-dimensional echocardiography and cardiac magnetic resonance imaging.

BACKGROUND: The accuracy of left ventricular (LV) volumes and ejection fraction (EF) on two-dimensional echocardiography (2DE) is limited by image position (IP), geometric assumption (GA), and boundary tracing (BT) errors. METHODS: Real-time three-dimensional echocardiography (RT3DE) and cardiac magnetic resonance imaging (CMR) were used to determine the relative contribution of each error source in normal controls (n = 35) and patients with myocardial infarctions (MIs) (n = 34). LV volumes and EFs were calculated using (1) apical biplane disk summation on 2DE (IP + GA + BT errors), (2) biplane disk summation on RT3DE (GA + BT errors), (3) 4-multiplane to 8-multiplane surface approximation on RT3DE (GA + BT errors), (4) voxel-based surface approximation on RT3DE (BT error alone) and (5) CMR. By comparing each method with CMR, the absolute and relative contributions of each error source were determined. RESULTS: IP error predominated in LV volume quantification on 2DE in normal controls, whereas GA error predominated in patients with MIs. Underestimation of volumes on 2DE was overcome by increasing the number of imaging planes on RT3DE. Although 4 equidistant image planes were acceptable, the best results were achieved with voxel-based RT3DE. For EF estimation, IP error predominated in normal controls, whereas BT error predominated in patients with MIs. Nevertheless, one third of the EF estimation error in patients with MIs was due to a combination of IP and GA errors, both of which may be addressed using RT3DE. CONCLUSIONS: The relative contribution of each source of LV quantitation error on 2DE was defined and quantified. Each source of error differed depending on patient characteristics and LV geometry.

Normal values of right ventricular size and function by real-time 3-dimensional echocardiography: comparison with cardiac magnetic resonance imaging.

BACKGROUND: Assessment of right ventricular function by 2-dimensional echocardiography (2DECHO) is difficult because of its complex shape. Real-time 3-dimensional echocardiography (RT3DECHO) may be superior. METHODS: End-diastolic volume, end-systolic volume, stroke volume, and ejection fraction obtained by 2DECHO, RT3DECHO short-axis disk summation (DS), and RT3DECHO apical rotation were compared with cardiac magnetic resonance imaging in 71 healthy individuals. RESULTS: RT3DECHO DS showed less volume underestimation compared with 2DECHO and RT3DECHO apical rotation. Test-retest variability for RT3DECHO DS end-diastolic volume, end-systolic volume, stroke volume, and ejection fraction were 3.3%, 8.7%, 10%, and 10.3%, respectively. Normal reference ranges of indexed volumes (mean +/- 2SD) for right ventricular end-diastolic volume, end-systolic volume, stroke volume, and ejection fraction were 38.6 to 92.2 mL/m(2), 7.8 to 50.6 mL/m(2), 22.5 to 42.9 mL/m(2), and 38.0% to 65.3%, respectively, for women and 47.0 to 100 mL/m(2), 23.0 to 52.6 mL/m(2), 14.2 to 48.4 mL/m(2), and 29.9% to 58.4%, respectively, for men. CONCLUSIONS: RT3DECHO DS is superior to RT3DECHO apical rotation and 2DECHO for right ventricular quantification, and performs acceptably when compared with cardiac magnetic resonance imaging in healthy individuals.

Primary large B-cell cardiac lymphoma.

Primary cardiac lymphomas are rare. They can be detected incidentally during echocardiography or cardiac operation. They can have various clinical manifestations. We report a case of primary cardiac large B-cell lymphoma in a 66-year-old man with symptoms of chest pain and light-headedness who was found to have a right atrial mass with echocardiography and without right ventricular outflow tract obstruction or pericardial involvement.

Evaluation of the electrocardiographic criteria for left ventricular hypertrophy with use of three-dimensional echocardiography.

BACKGROUND: Left ventricular hypertrophy (LVH) is a common condition that carries an increased risk of cardiovascular events. Use of ECG in detection of LVH is limited because of the reported low sensitivity. Conventional echocardiographic techniques used as the standard for estimating left ventricular (LV) mass have limitations related to the position of the image plane and shape of the ventricle. Three-dimensional echocardiography is free of these limitations and therefore is more accurate. We hypothesized that accuracy of ECG criteria for LVH would improve when LV mass was assessed by three-dimensional echocardiography. RESULTS: For most of the criteria, sensitivity, specificity and accuracy improved when LV mass was assessed by three-dimensional echocardiography. Two-dimensional echocardiography significantly overestimated LV mass as compared with the three-dimensional method. CONCLUSIONS: Sensitivity, specificity, and accuracy of the ECG criteria improved when LV mass was estimated by three-dimensional echocardiography. This improvement may be attributed at least in part to superior accuracy of three-dimensional measurements.

Relationship of mitral annular remodeling to severity of chronic mitral regurgitation.

HYPOTHESES: (1) Mitral regurgitation (MR) severity is directly associated with mitral annular remodeling as evidenced by mitral annular enlargement. (2) Increasing severity of chronic MR will result in symmetric enlargement of the mitral annulus as measured by annular shape indices. BACKGROUND: Limited data exist on mitral annular remodeling for patients with MR. Identification of annular changes may be important in aiding surgical repair. METHODS: The mitral annulus was measured in several planes using transthoracic echocardiography in 173 patients: trace to no MR (34), mild MR (48), moderate MR (45), and severe MR (46). Patients were subgrouped by mechanism of MR and annular shape indices were determined. RESULTS: With increasing MR severity, there was a corresponding symmetric increase in all systolic and diastolic measurements, but no significant differences in annular shape indices between subgroups by MR severity or by MR mechanism. CONCLUSIONS: Mitral annular remodeling is symmetric, regardless of degree or mechanism of MR.

Intraoperative assessment of mitral regurgitation: role of phenylephrine challenge.

OBJECTIVES: We defined the effects of the operative (OP) state and phenylephrine challenge on the assessment of mitral regurgitation (MR) severity. METHODS: In all, 57 patients underwent transesophageal echocardiographic assessment of MR severity pre-OP (PREOP) and intra-OP. MR severity was assessed PREOP under conscious sedation and intra-OP with general anesthesia, before and after hemodynamic manipulation with vasoactive agents, to match intra-OP and PREOP transesophageal echocardiographic mean arterial blood pressures. RESULTS: Intra-OP MR and mean arterial pressure were less than PREOP in 27 patients (both P < .001). When PREOP and OP blood pressures were matched using phenylephrine, there was no significant difference in MR severity between the two states (P = 1.0). Nonetheless, MR severity was still underestimated in 6 patients and overestimated in 7 patients intra-OP. CONCLUSIONS: Intra-OP transesophageal echocardiography underestimates MR severity. Phenylephrine reduces, yet does not eliminate, intra-OP underestimation of MR severity.