Discongruence Index　- Simple Indicator to Predict Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement.

BACKGROUND: Prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) remains an important issue. The aim of this study was to assess the value of a new discongruence index, to predict PPM after TAVR.Methods and Results: A total of 185 patients with severe aortic stenosis who underwent TAVR with the Edwards Sapien prosthesis or CoreValve Revalving system were included (Edwards valve, n=119; Core Valve Revalving system, n=66). Discongruence index was calculated pre-procedurally as the ratio of selected transcatheter valve size (mm) to body surface area (cm2). PPM was defined as effective orifice area (EOA) ≤0.85 cm2/m2 on transthoracic echocardiography before hospital discharge. Mean age was 82±5 years and 72 patients (38.9%) were men. The overall incidence of post-TAVR PPM was 35.1% (n=65). Discongruence index correlated with post-TAVR indexed EOA (y=0.18+0.057x; P<0.001). On multivariate logistic regression analysis, discongruence index was the only independent predictor of post-TAVR PPM (OR, 0.15; 95% CI: 0.03-0.66; P=0.012), and the area under the receiver operating characteristic curve was 0.62 (95% CI: 0.54-0.70, P=0.003), with an optimal cut-off point of 15.02 (sensitivity, 86.2%; specificity, 72.5%; positive predictive value, 74.3%; negative predictive value, 83.4%). CONCLUSIONS: The new discongruence index may be useful tool to predict PPM after TAVR.

Mitral valve navigator. A new diagnostic tool for effective regurgitant orifice quantification in mitral regurgitation.

INTRODUCTION: Mitral regurgitation severity assessment is usually carried out using qualitative, semiquantitative, and quantitative parameters. The mitral valve navigation (MVN) tool allows to measure the mitral effective regurgitant orifice (MERO) from 3D echo datasets. Our aim was to validate the MVN as a new tool to quantify MERO. A secondary aim was to assess the intra- and interobserver variability. METHODS: This is a retrospective study in which consecutive subjects undergoing a transoesophageal echocardiogram for more than mild mitral regurgitation evaluation were included. MERO measurement obtained by means of 3D color Doppler was used as the gold standard method for comparison. In every patient, MERO was also obtained using the MVN tool. RESULTS: Fifty-nine consecutive patients were analyzed (47.5% female; mean age 50.8 years). Mitral regurgitation was moderate in 23 (39%) and severe in 36 (61%) patients. Forty patients (67.8%) had a primary and 19 (32.2%) a secondary mitral regurgitation. The intraclass correlation coefficient (ICC) between 3D color Doppler and MVN was excellent (ICC: 0.95; 95% CI: 0.82 to 0.98; P < 0.001) in the total group and for patients with primary and secondary mitral regurgitation. Intra- and interobserver agreements were also good. CONCLUSIONS: Mitral valve navigator shows an excellent accuracy for measuring MERO when the transoesophageal 3D color Doppler is used as the reference method, either primary or secondary mitral regurgitation. Intraobserver reproducibility and interobserver reproducibility are also excellent. These findings make this software a good alternative method to measure mitral regurgitation severity.

Development and Clinical Application of Left Ventricular-Arterial Coupling Non-Invasive Assessment Methods.

The constant and dynamic interaction between ventricular function and arterial afterload, known as ventricular-arterial coupling, is key to understanding cardiovascular pathophysiology. Ventricular-arterial coupling has traditionally been assessed invasively as the ratio of effective arterial elastance over end-systolic elastance (Ea/Ees), calculated from information derived from pressure-volume loops. Over the past few decades, numerous invasive and non-invasive simplified methods to estimate the elastance ratio have been developed and applied in clinical investigation and practice. The echocardiographic assessment of left ventricular Ea/Ees, as proposed by Chen and colleagues, is the most widely used method, but novel echocardiographic approaches for ventricular-arterial evaluation such as left ventricle outflow acceleration, pulse-wave velocity, and the global longitudinal strain or global work index have arisen since the former was first published. Moreover, multimodal imaging or artificial intelligence also seems to be useful in this matter. This review depicts the progressive development of these methods along with their academic and clinical application. The left ventricular-arterial coupling assessment may help both identify patients at risk and tailor specific pharmacological or interventional treatments.

Valvulitis: a new echocardiographic criterion for the diagnosis of bioprosthetic aortic valve infective endocarditis.

INTRODUCTION AND OBJECTIVES: Diffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE. METHODS: From 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis. RESULTS: The prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy. CONCLUSIONS: Valvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

Right atrial indexed volume in healthy adult population: reference values for two-dimensional and three-dimensional echocardiographic measurements.

BACKGROUND: Current guidelines do not recommend routine assessment of right atrial volume due to the lack of standardized data. Three-dimensional wall-motion tracking (3D-WMT) is a new technology that allows us to calculate volumes without any geometric assumptions. The aim of this study was to define the indexed reference values for two-dimensional echocardiography (2D-echo) and 3D-WMT in adult healthy population and to assess the intermethod, intra- and interobserver agreement. METHODS: Prospective study. Nonselected healthy subjects were enrolled. Every patient underwent a 2D-echo and a 3D-WMT examination. 2D-echo right atrial volume was obtained by using the area-length method (A-L) from four- and two-chamber view. 3D-echo volumes were assessed by 3D-WMT. Values were indexed by the patient's body surface area. RESULTS: Sixty consecutive healthy subjects were enrolled. Mean age was 57 ± 12-years old and 27 patients (45%) were male. Average indexed right atrial volume obtained by 2D-echo and 3D-echo was 16.76 ± 8.15 mL/m(2) and 19.05 ± 6.87 mL/m(2) , respectively. Univariate linear regression analysis between 2D-echo and 3D-echo right atrial volumes shows a weak correlation between right atrial volume obtained with 2D-echo compared with 3D-WMT (r = 0.29, CI 95% 0.029-0.66, P = 0.033). The agreement analysis shows a similar result (intraclass correlation coefficient [ICC] = 0.28). The intra- and interobserver agreement analysis showed a better agreement when using 3D-WMT. CONCLUSIONS: This is the first study that reports the reference indexed right atrial volume values by means of 2D-echo and 3D-echo in healthy population. 3D-WMT is a feasible and reproducible method to determine right atrial volume.

Redefining cardiac damage staging in aortic stenosis: the value of GLS and RVAc.

AIMS: Cardiac damage staging has been postulated as a prognostic tool in patients undergoing transcatheter aortic valve replacement (TAVR). The aims of our study are (i) to validate cardiac damage staging systems previously described to stratify patients with aortic stenosis (AS), (ii) to identify independent risk factors for 1-year mortality in patients with severe AS undergoing TAVR, and (iii) to develop a novel staging model and compare its predictive performance to that of the above mentioned. METHODS AND RESULTS: Patients undergoing TAVR from 2017 to 2021 were included in a single-centre prospective registry. Transthoracic echocardiography was performed in all patients before TAVR. Logistic and Cox's regression analysis were used to identify predictors of 1-year all-cause mortality. In addition, patients were classified based on previously published cardiac damage staging systems, and the predictive performance of the different scores was measured.Four hundred and ninety-six patients (mean age 82.1 ± 5.9 years, 53% female) were included. Mitral regurgitation (MR), left ventricle global longitudinal strain (LV-GLS) and right ventricular-arterial coupling (RVAc) were independent predictors of all-cause 1-year mortality. A new classification system with four different stages was developed using LV-GLS, MR, and RVAc. The area under the receiver operating characteristic curve was 0.66 (95% confidence interval 0.63-0.76), and its predictive performance was superior compared with the previously published systems (P < 0.001). CONCLUSION: Cardiac damage staging might have an important role in patients' selection and better timing for TAVR. A model that includes LV-GLS, MR, and RVAc may help to improve prognostic stratification and contribute to better selection of patients undergoing TAVR.

Determinants of Tricuspid Regurgitation Progression and Its Implications for Adequate Management.

BACKGROUND: Tricuspid regurgitation (TR) is associated with an increased mortality. Previous studies have analyzed predictors of TR progression and the clinical impact of baseline TR. However, there is a lack of evidence regarding the natural history of TR: the pattern of change and clinical impact of progression. OBJECTIVES: The authors sought to evaluate predictors of TR progression and assess the prognostic impact of TR progression. METHODS: A total of 1,843 patients with at least moderate TR were prospectively followed up with consecutive echocardiographic studies and/or clinical evaluation. All patients with less than a 2-year follow-up were excluded. Clinical and echocardiographic features, hospitalizations for heart failure, and cardiovascular death and interventions were recorded to assess their impact in TR progression. RESULTS: At a median 2.3-year follow-up, 19% of patients experienced progression. Patients with baseline moderate TR presented a rate progression of 4.9%, 10.1%, and 24.8% 1 year, 2 years, and 3 years, respectively. Older age (HR: 1.03), lower body mass index (HR: 0.95), chronic kidney disease (HR: 1.55), worse NYHA functional class (HR: 1.52), and right ventricle dilation (HR: 1.33) were independently associated with TR progression. TR progression was associated with an increase in chamber dilation as well as a decrease in ventriculoarterial coupling and in left ventricle ejection fraction (P < 0.001). TR progression was associated with an increased cardiovascular mortality and hospitalizations for heart failure (P < 0.001). CONCLUSIONS: Marked individual variability in TR progression hindered accurate follow-up. In addition, TR progression was a determinant for survival regardless of initial TR severity.

Validation of the TRI-SCORE in patients undergoing surgery for isolated tricuspid regurgitation.

INTRODUCTION: Estimation of peri-procedural risk in patients with tricuspid regurgitation (TR) undergoing isolated tricuspid valve surgery (ITVS) is of paramount importance. The TRI-SCORE is a new surgical risk scale specifically developed for this purpose, which ranged from 0 to 12 points and included eight parameters: right-sided heart failure signs, daily dose of furosemide ≥125 mg, glomerular filtration rate <30 mL/min, elevated bilirubin (with a value of 2 points), age ≥70 years, New York Heart Association Class III-IV, left ventricular ejection fraction <60% and moderate/severe right ventricular dysfunction (with a value of 1 point). The objective of the study was to evaluate the performance of the TRI-SCORE in an independent cohort of patients undergoing ITVS. METHODS: A retrospective observational study was performed in four centres, including consecutive adult patients undergoing ITVS for TR between 2005 and 2022. The TRI-SCORE and the traditional risk scores used in cardiac surgery (Logistic EuroScore (Log-ES) and EuroScore-II (ES-II)) were applied for each patient, and discrimination and calibration of the three scores were evaluated in the entire cohort. RESULTS: A total of 252 patients were included. The mean age was 61.5±11.2 years, 164 (65.1%) patients were female, and TR mechanism was functional in 160 (63.5%) patients. The observed in-hospital mortality was 10.3%. The estimated mortality by the Log-ES, ES-II and TRI-SCORE was 8.7±7.3%, 4.7±5.3% and 11.0±16.6%, respectively. Patients with a TRI-SCORE ≤4 and >4 had an in-hospital mortality of 1.3% and 25.0%, p=0.001, respectively. The discriminatory capacity of the TRI-SCORE had a C-statistic of 0.87 (0.81-0.92), which was significantly higher than both the Log-ES (0.65 (0.54-0.75)) and ES-II (0.67 (0.58-0.79)), p=0.001 (for both comparisons). CONCLUSION: This external validation of the TRI-SCORE demonstrated good performance to predict in-hospital mortality in patients undergoing ITVS, which was significantly better than the Log-ES and ES-II, which underestimated the observed mortality. These results support the widespread use of this score as a clinical tool.

Non-invasive electromechanical assessment during atrial fibrillation identifies underlying atrial myopathy alterations with early prognostic value.

Electromechanical characterization during atrial fibrillation (AF) remains a significant gap in the understanding of AF-related atrial myopathy. This study reports mechanistic insights into the electromechanical remodeling process associated with AF progression and further demonstrates its prognostic value in the clinic. In pigs, sequential electromechanical assessment during AF progression shows a progressive decrease in mechanical activity and early dissociation from its electrical counterpart. Atrial tissue samples from animals with AF reveal an abnormal increase in cardiomyocytes death and alterations in calcium handling proteins. High-throughput quantitative proteomics and immunoblotting analyses at different stages of AF progression identify downregulation of contractile proteins and progressive increase in atrial fibrosis. Moreover, advanced optical mapping techniques, applied to whole heart preparations during AF, demonstrate that AF-related remodeling decreases the frequency threshold for dissociation between transmembrane voltage signals and intracellular calcium transients compared to healthy controls. Single cell simulations of human atrial cardiomyocytes also confirm the experimental results. In patients, non-invasive assessment of the atrial electromechanical relationship further demonstrate that atrial electromechanical dissociation is an early prognostic indicator for acute and long-term rhythm control.

Importance of cardiac imaging assessment of epicardial adipose tissue after a first episode of myocardial infarction.

Background: Over the past years, information about the crosstalk between the epicardial adipose tissue (EAT) and the cardiovascular system has emerged. Notably, in the context of acute myocardial infarction (AMI), EAT might have a potential role in the pathophysiology of ventricular structural changes and function, and the clinical evolution of patients. This study aims to assess the impact of EAT on morpho-functional changes in the left ventricle (LV) and the outcome of patients after an AMI. Methods: We studied prospectively admitted patients to our hospital with a first episode of AMI. All patients underwent percutaneous coronary intervention (PCI) during admission. Transthoracic echocardiography (TTE) was performed within 24-48 h after PCI, as well as blood samples to assess levels of galectin-3 (Gal-3). Cardiac magnetic resonance (CMR) was performed 5-7 days after PCI. Clinical follow-up was performed at 1 and 5 years after MI. Results: Mean age of our cohort (n = 41) was 57.5 ± 10 years, and 38 (93%) were male. Nine patients had normal BMI, 15 had overweight (BMI 25-30), and 17 were obese (BMI > 30). Twenty three patients (56%) had ≥ 4 mm thickness of EAT measured with echo. In these patients, baseline left ventricular ejection fraction (LVEF) after AMI was significantly lower, as well as global longitudinal strain. EAT thickness ≥ 4 m patients presented larger infarct size, higher extracellular volume, and higher T1 times than patients with EAT < 4 mm. As for Gal-3, the median was 16.5 ng/mL [12.7-25.2]. At five-year follow-up 5 patients had major cardiac events, and all of them had EAT ≥ 4 mm. Conclusions: Patients with EAT >4 mm have worse LVEF and GLS, larger infarct size and longer T1 values after a MI, and higher levels of Gal-3. EAT >4 mm was an independent predictor of MACE at 5-year follow-up. EAT thickness is a feasible, noninvasive, low-cost parameter that might provide important information regarding the chronic inflammatory process in the myocardium after an infarction.

Correlation of Intraprocedural and Follow Up Parameters for Mitral Regurgitation Grading after Percutaneous Edge-to-Edge Repair.

Background: There is no consensus on the best intraprocedural parameter to evaluate residual mitral regurgitation (MR) after transcatheter edge-to-edge mitral repair (TEER). Thus, our aim was to evaluate the predictive value of different MR parameters from intraprocedural transesophageal echocardiogram (TEE) for grading in consecutive transthoracic echocardiogram (TTE) during the follow up. Methods: All the consecutive patients who underwent TEER with MitraClip between 2010 and 2020 in our center were considered. TEE-derived immediate postprocedural MR parameters were reassessed to blindly compare them with follow up MR grading in sequential TTE. Results: We finally included 88 patients (64.8% males; 76 ± 10 years-old). Significant MR was detected in 14.3% of the cases at 6 months, in similar proportion than at postprocedural at 1 month. Among all the intraprocedural TEE quantitative parameters only additive and maximum VC were associated with significant MR persistence. Moreover, on ROC analysis maximum VC demonstrated an excellent discriminatory power (AUC 0.96; p < 0.001) to identify MR ≥ III at 6 months. Thus, a cut-off point of 0.45 cm demonstrated 88% sensitivity and 89% specificity. Conclusion: Among intraprocedural TEE parameters to evaluate residual MR in TEER, maximum and additive VC were the most reliable to predict persistence of significant insufficiency.

Usefulness of real-time three-dimensional transoesophageal echocardiography in the assessment of chronic aortic dissection.

AIMS: To assess the usefulness of three-dimensional transoesophageal echocardiography (3D-TOE) vs. two-dimensional (2D)-TOE in the evaluation of morphological and dynamic findings of aortic dissection, and compare the results with those obtained by multi-slice computed tomography (CT). METHODS AND RESULTS: Twenty-six patients (21 men and 5 women, median age: 67 years, range: 28-74 years) diagnosed of chronic aortic dissection with patent false lumen were studied. A comprehensive 2D-TOE and a real-time 3D-TOE study targeted at assessing dissection variables were performed and compared with CT within 3 months. Both 3D-TOE and 2D-TOE visualized the intimal flap extension and presence of flow in aortic dissection lumina in the same aortic segments. Three-dimensional TOE correctly identified true lumen in all cases, being superior to 2D-TOE in three cases with a spiroidal course of the dissection in descending aorta. Maximum entry tear diameter measured by 3D-TOE showed a better correlation with CT than 2D-TOE (0.96 and 0.87, P< 0.001, respectively). Compared with CT, 2D-TOE underestimated maximum entry tear diameter (-1.75 ± 3.28 mm, P< 0.01) but 3D-TOE did not (-0.20 ± 1.92 mm, P: n.s.). However, entry tear area measured by 3D-TOE and CT showed the best correlation (r: 0.97) and agreement (0.05 ± 0.20 cm(2), P: n.s.). CONCLUSION: Three-dimensional TOE provides additional information to 2D-TOE in aortic dissection assessment, particularly in entry tear size quantification. Agreement between entry tear area defined by 3D-TOE and CT was excellent. Three-dimensional TOE permits better morphological and dynamic understanding of aortic dissection when the flap is spiroidal.

Impact of contrast-enhanced echocardiography on the diagnostic algorithm of acute aortic dissection.

AIMS: To determine the usefulness of contrast echocardiography in the diagnosis of aortic dissection (AD) and in the assessment of findings necessary for adequate patient management. METHODS AND RESULTS: Conventional and contrast-enhanced transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) were performed in 128 consecutive patients with clinically suspected acute AD. Results were validated independently against intraoperative findings in 45 patients and computed tomography information in 83. Sensitivity and specificity of conventional TTE increased after contrast enhancement from 73.7 to 86.8% (P< 0.005) and 71.2 to 90.4% (P < 0.05), respectively. Sensitivity and specificity of enhanced TTE were similar to conventional TOE in ascending aorta (93.3 vs. 95.6% and 97.6 vs. 96.4%, respectively) and in the arch (88.4 vs. 93.0% and 95.3 vs. 98.82%, respectively). Contrast-enhanced TOE permitted the location of non-visualized entry tear in seven cases (10.6%), helped to correctly identify the true lumen in six (9.1%), and diagnosed retrograde dissection in nine (13.6%). CONCLUSION: Contrast enhancement substantially improves TTE in the diagnosis of AD and should be considered as the initial imaging modality in the emergency setting. Contrast enhancement also has significant value for obtaining critical morphological and haemokinetic information by TOE useful for adequate patient management.

New insights of tricuspid regurgitation: a large-scale prospective cohort study.

AIMS: To evaluate the burden of tricuspid regurgitation (TR) in a large cohort, determine the right ventricle involvement of patients with TR and determine the characteristics of isolated TR. METHODS AND RESULTS: Prospective study where consecutive patients undergoing an echocardiographic study in 10 centres were included. All studies with significant TR (at least moderate) were selected. We considered that patients with one of pulmonary systolic hypertension >50 mmHg, left ventricular ejection fraction <35%, New York Heart Association III-IV, or older than 85 years, had a high surgical risk. A total of 35 088 echocardiograms were performed. Significant TR was detected in 6% of studies. Moderate TR was found in 69.6%, severe in 25.5%, massive in 3.9%, and torrential in 1.0% of patients. Right ventricle was dilated in 81.7% of patients with massive/torrential TR, in 55.9% with severe TR, and in 29.3% with moderate TR (P < 0.001). Primary TR was present in 7.4% of patients whereas secondary TR was present in 92.6%. Mitral or aortic valve disease was the most common aetiology (54.6%), following by isolated TR (16%). Up to 51.9% of patients with severe, massive, or torrential primary TR and 57% of patients with severe, massive, or torrential secondary TR had a high surgical risk. CONCLUSION: Significant TR is a prevalent condition and a high proportion of these patients have an indication for valve intervention. More than a half of patients with severe, massive, or torrential TR had a high surgical risk. Massive/torrential TR may have implications regarding selection and monitoring patients for percutaneous treatment.

Myocardial strain in nonischemic dilated cardiomyopathy with feature tracking. Feasibility and prognostic implications.

INTRODUCTION AND OBJECTIVES: Myocardial strain analysis could provide additional information to left ventricular ejection fraction (LVEF) in nonischemic dilated cardiomyopathy (NIDC). Our aim was to analyze the feasibility of left ventricular strain evaluation using cardiac magnetic resonance feature tracking (FT) in NIDC, and to determine its clinical and prognostic impact. METHODS: We retrospectively included consecutive patients with NIDC who underwent cardiac magnetic resonance. Left ventricular global longitudinal, circumferential and radial strain were obtained from standard cine sequences using FT analysis software. We evaluated their association with a composite endpoint (heart failure, implantable cardioverter-defibrillator in secondary prevention, or death). RESULTS: FT analysis could be performed in all of the 98 patients (mean age 68±13 years, 72% men). Intra- and interobserver concordance was good for global longitudinal and circumferential strain but was worse for radial strain. Global circumferential strain was independently associated (OR, 1.16; P=.045) with LVEF normalization during follow-up and was the only morphological parameter independently associated with the composite endpoint (OR, 1.15; P=.038). A cutoff value <-8.2% was able to predict the incidence of this event during follow-up (log-rank 4.6; P=.032). CONCLUSIONS: Left ventricular strain analysis with FT is feasible and reproducible in NIDC. Global circumferential strain was able to predict LVEF recovery and the appearance of major cardiovascular events during follow-up.

Three-dimensional Tricuspid Area. A New Criterion to Improve Patient Selection for Annuloplasty in Tricuspid Regurgitation.

INTRODUCTION AND OBJECTIVES: Late functional tricuspid regurgitation after rheumatic left-sided valve surgery is an important predictor of poor prognosis. This study investigated the usefulness and accuracy of 3-dimensional transthoracic echocardiography tricuspid area compared with conventional 2-dimensional diameter (2DD) for assessing significant tricuspid annulus dilatation, providing cutoff values that could be used in clinical practice to improve patient selection for surgery. METHODS: We prospectively included 109 patients with rheumatic heart disease in the absence of previous valve replacement. Tricuspid regurgitation was divided into 3 groups: mild, moderate, and severe. Optimal 3-dimensional area (3DA) and 2DD cutoff points for identification of significant tricuspid annulus dilatation were obtained and compared with current guideline thresholds. Predictive factors for 3DA dilatation were also assessed. RESULTS: Optimal cutoff points for both absolute and adjusted to body surface area (BSA) tricuspid annulus dilatation were identified (3DA: 10.4 cm2, 6.5 cm2/m2; 2DD: 35 mm, 21 mm/m2); 3DA/BSA had the best diagnostic performance (AUC=0.83). Three-dimensional transthoracic echocardiography tricuspid area helped to reclassify surgical indication in 14% of patients with mild tricuspid regurgitation (95%CI, 1%-15%; P=.03) and 37% with moderate tricuspid regurgitation (95%CI, 22%-37%; P<.0001), whereas 3DA/BSA changed surgery criteria in cases of mild tricuspid regurgitation (17%; 95%CI, 3%-17%; P=.01) compared with 2DD/BSA. On multivariable analysis, right and left atrial volumes and basal right ventricle diameter were independently correlated with 3DA. CONCLUSIONS: The current 40 mm threshold underestimates tricuspid annulus dilatation. Although 21 mm/m2 seems to be a reasonable criterion, the combination with 3DA assessment improves patient selection for surgery.

No-reflow phenomenon in cardiac MRI: diagnosis and clinical implications.

OBJECTIVE: The purposes of this study were to depict the first-pass, delayed contrast enhancement and regional myocardial wall motion abnormalities of no-reflow phenomenon MRI and to review the major mechanisms and significance of this phenomenon in the clinical setting. CONCLUSION: Contrast-enhanced MRI is a useful noninvasive technique for determining the presence of microvascular obstruction. No-reflow phenomenon has important prognostic implications, and knowledge of the physiologic mechanism is important to understanding the distribution patterns of enhancement in correlation with the underlying pathologic process.

Impact of Calcium Score on Agreement Between Multidetector Computed Tomography and Invasive Coronary Angiography.

INTRODUCTION AND OBJECTIVES: Multidetector computed tomography (MDCT) has been demonstrated as a feasible alternative to invasive coronary angiography (ICA). However, contradictory results have been reported regarding the effect of coronary artery calcium score (CS) on the diagnostic accuracy of MDCT. Our aim was to assess the agreement of MDCT and ICA and to evaluate the influence of CS on this agreement. METHODS: We enrolled 266 consecutive patients who underwent evaluation with 64-slice MDCT and ICA. Standard CS software tools were used to calculate the Agatston score. Stenosis was qualitatively classified as mild, moderate, or severe by 1 blinded observer and the results were compared with those of ICA, which was used as the gold standard. RESULTS: The mean age of the patients was 65.4 ± 11.2 years, and 188 patients (70.3%) were men. A total of 484 segments with coronary stenosis ≥ mild were qualitatively evaluated and quantified with MDCT. Noninvasive measurements were concordant with ICA in 402 stenoses (83.05%; Kappa, 0.684), with no significant differences between vessels and with no statistically significant influence of CS on this agreement (OR, 0.93; 95%CI, 0.76-1.09; P = .21). Multidetector computed tomography had high sensitivity, specificity, positive predictive value, and negative predictive value on a per-segment, per-vessel, and per-patient basis. CONCLUSIONS: Non-ICA using MDCT showed good agreement with ICA in the qualitative quantification coronary stenosis and CS had no significant impact on this agreement.

Radial versus longitudinal myocardial deformation from gray-scale echocardiography.

The objectives of this work are to evaluate a novel non-Doppler-based echocardiographic method that makes it possible to simultaneously obtain the radial and longitudinal components of myocardial velocity (V) and strain (S), and to assess whether left ventricular fiber architecture affects the net function of the myocardium. Previous reports state that differences in the estimation of regional function between septum and lateral walls can be related to the anatomic disposition of myocardial fibers. In this work we measure and compare in 21 healthy volunteers longitudinal and radial peak systolic velocity V (V(long), V(rad): cm/s), peak systolic strain S (S(long), S(rad): %) and time-to-peak S and V (T-Smax, T-V(max): ms) at the midsegments of the septal and lateral walls. Results show that V was higher, both in the radial and longitudinal components, in the lateral wall than in the septum (V(rad): 4.77 +/- 0.26 cm/s vs. 3.77 +/- 0.20 cm/s, p = 0.007; V(long): 5.60 +/- 0.48 cm/s vs. 4.13 +/- 0.11 cm/s, p = 0.01). Radial strain was higher in the septum (S(rad): 28.63 +/- 2.25% vs. 22.54 +/- 1.5%, p = 0.015), and longitudinal strain, in the lateral wall (S(long): -25.89 +/- 1.43% vs. -22.20 +/- 0.87%, p = 0.02). There was a significant delay in longitudinal T-Smax between the lateral and septal medial segments (mean: 14.5 ms; CI 95%: 0.3-28.6 ms; p = 0.04), with no difference in radial T-Smax (277.1 +/- 8.6 ms vs. 277.2 +/- 12.4 ms, p = 0.93). The assessment of regional myocardial function by this new method enables the simultaneous analysis of its radial and longitudinal components. These measurements correlate well with previous anatomical knowledge of the architecture of myocardial fibers, emphasizing its functional significance in regional myocardial function analysis.