Left ventricular diastolic function in mitral stenosis.

The assessment of left ventricular (LV) function in the setting of mitral stenosis (MS) has been critically examined for decades. Accurate assessment of aberrations in diastolic function is important as these subjects often present with signs and symptoms of heart failure and pulmonary congestion that cannot be solely explained by the severity of mechanical obstruction. Echocardiographic evaluation of diastolic dysfunction includes an evaluation of reduced LV compliance, diminished restoring forces, and enhanced stiffness, which are challenging in the setting of MS owing to altered hemodynamic loading. Conventional echocardiographic and Doppler measures offer limited information. Novel assessments employing speckle tracking echocardiography are relatively less studied. A more comprehensive assessment including clinical evaluation, identification of concomitant disorders, and comorbidities is particularly warranted in older subjects with degenerative MS to suspect diastolic dysfunction and arrive at optimal medical therapy or intervention. This review provides an overview of etiological, pathophysiological, echocardiographic, and invasive assessment of diastolic dysfunction in the setting of MS, with specific focus on strengths and limitations of available echocardiographic and Doppler techniques.

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.

Transcatheter para mitral annular ring leak device closure - A case report.

Para mitral annular ring leakage can occur following ring dehiscence after mitral annuloplasty. Percutaneous device closure of para-annular ring leakage can be performed successfully to treat such regurgitations with good transesophageal echocardiography guidance and patient selection. While para valvular device closure has been described in the medical literature, there have been few anecdotal reports published on para ring leak device closures. In this case, we highlight our experience from the successful closure of a para mitral annular ring closure with an AVP III device. The patient had a para annular ring regurgitation post coronary artery bypass grafting with mitral ring annuloplasty presenting with hemolytic anemia and acute renal failure, successfully treated by percutaneous device closure. Learning objective: This report describes the safety and effectiveness of a transcatheter para ring leak closure with an AVP III device. We applied the principles of device closure of paravalvular leak from our experience and related data from literature for this case and describe various hardware and techniques used for a successful closure of a para mitral ring leak.

Transcatheter Aortic Valve Implantation in the Descending Aorta: History Revisited!

An elderly patient with significant aortic regurgitation presented with heart failure. Dilation of the aortic root precluded a transcatheter anatomic site valve implantation, and prohibitive operative risk ruled against surgical implantation. A bail-out transcatheter implantation of the aortic valve in the descending aorta was successfully carried out with satisfactory outcomes.

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.

Study of left ventricular rotation and torsion in the acute phase of ST-elevation myocardial infarction by speckle tracking echocardiography.

BACKGROUND: The mechanics of the complex left ventricular (LV) myocardial fiber architecture may accurately be assessed by speckle tracking echocardiography (STE). The role of STE to assess LV mechanical dysfunction in the setting of ST segment elevation myocardial infarction (AMI) is still poorly studied. PATIENTS AND METHODS: 29 consecutive patients (55 +/- 13 years) presenting with AMI underwent STE within 72 hours of admission. Reperfusion was achieved with thrombolysis in 15 patients and with primary percutaneous coronary intervention in 14. LV rotational and torsion data were registered during peak systole. Standard Doppler data included LV ejection fraction (EF), mitral inflow deceleration time (DT), and conventional E/A ratio. E/E' ratio (mitral inflow E velocity/tissue Doppler E velocity) was calculated as a marker of LV filling pressure. Twelve subjects with clinically indicated but negative dobutamine stress echocardiogram served as Controls. RESULTS: Peak systolic torsion was not only significantly lower in AMI compared with Controls (13.3 +/- 7.6 vs. 21.8 +/- 6.1; P < 0.01), it was also lower in subjects with LVEF <40% (5.0 +/- 2.9) compared with those who had LVEF >40% (10.6 +/- 6.6; P < 0.02). Torsion had a modest but significantly positive linear relation (R = 0.6; P < 0.05) with DT, not with E/E' or LVEF. CONCLUSION: LV systolic torsion is decreased in AMI and more markedly decreased in patients with LVEF <40%. The most significant linear relationship between DT and torsion may possibly indicate that the LV mechanical dysfunction is also associated with altered filling dynamics.

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.

Acute administration of a single dose of valsartan improves left ventricular functions: a pilot study to assess the role of tissue velocity echocardiography in patients with systemic arterial hypertension in the TVE-valsartan study I.

BACKGROUND: The advent of colour-coded tissue velocity echocardiography (TVE) has now made it possible to quantify left ventricular (LV) functions in patients with systemic arterial hypertension (HTN). Hypothesis In this project, we have studied the cardiac effects of a single dose of orally administered valsartan in patients with known HTN. METHODS: Fifty-five patients with HTN with a mean age of 56 +/- 10 years were given an early morning dose of 80 mg valsartan withholding regular antihypertensive medications on the day of investigation. TVE images, acquired on VIVID systems were digitized for postprocessing of longitudinal and radial peak systolic velocities, strain rate, and systolic and diastolic time intervals before (pre) and 5 h after (post) administration of the drug. RESULTS: Blood pressure (mmHg) pre and post, respectively, were 147 +/- 15 versus 137 +/- 14 systolic and 90 +/- 7 versus 86 +/- 7 diastolic (all P<0.01). LV longitudinal systolic velocities (cm s(-1)) were significantly higher post in LV septum (5.7 +/- 1.1 versus 6.4 +/- 1.6; P<0.001) with similar results obtained in other LV walls. Radial strain rate (1 s(-1)) was significantly higher post compared with pre valsartan (2.1 +/- 0.6 versus 2.3 +/- 0.9; P<0.01). Regional diastolic filling and ejection times (ms) were significantly shorter post (390 +/- 122 versus 370 +/- 120 and 275 +/- 32 versus 163 +/- 36 respectively; all P<0.05). CONCLUSIONS: Within 5 h after oral administration of valsartan, improvement in regional myocardial systolic functions could be registered. Although the changes could well be secondary to afterload reduction, additional effects of the drug, evidenced by improved strain rate that is relatively load-independent, may have contributed in this improvement.

Quality metric for Parasternal Long AXis B-mode echocardiograms.

This paper presents a method for automatically estimating the quality of Parasternal Long AXis (PLAX) B-mode echocardiograms. The purpose of the algorithm is to provide live feedback to the user on the quality of the acquired image. The proposed approach uses Generalized Hough Transform to compare the structures derived from the incoming image to a representative atlas, thereby providing a quality metric (PQM). On 133 PLAX images from 35 patients, we show: 1) PQM has high correlation with manual ratings from an expert echocardiographer 2) PQM has high correlation with contrast-to-noise ratio, a traditional indicator of image quality 3) on images with high PQM, error in automatic septal wall thickness measurement is low, and vice versa.

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.

Microalbuminuria and left ventricular function in type 2 diabetes: a quantitative assessment by stress echocardiography in the Myocardial Doppler in Diabetes (MYDID) Study III.

BACKGROUND: Left ventricular (LV) function might be altered in type 2 diabetes (DM) and microalbuminuria (MA) may accentuate the abnormalities. We sought to investigate whether additional LV dysfunction could be unmasked using tissue Doppler (TVE)-enhanced dobutamine stress echocardiography (TVE-DSE) in patients with DM + MA. METHODS: Twenty seven DM subjects with MA, (DM + MA), 31 DM subjects without MA (DM - MA), and 13 Controls were evaluated using TVE-DSE. LV basal peak systolic (PSV), early (E') and late (A') diastolic velocities (cm/sec) at rest and peak stress were post-processed. LV filling pressure was assessed using E/E'ratio. RESULTS: PSV and E'velocity at peak stress in the respective three groups were 13.7 +/- 1.0, 10.1 +/- 1.1, 10.0 +/- 1.2 for PSV; and 10.0 +/- 1.6, 5.0 +/- 1.4, 4.8 +/- 1.4 for E' (p < 0.001 for controls vs. both groups). E/E' at rest was 7.9 +/- 0.7 in the controls, 10.8 +/- 2.4 in DM - MA, and 11.0 +/- 2.2 in DM + MA (p < 0.01 Controls vs. both the DM groups). CONCLUSIONS: Patients with DM + MA do not have additional LV regional systolic and diastolic dysfunctions compared with DM -MA, as revealed by TVE-DSE, when controlled for glycemia levels, lipids, and treatment strategies.