3151The prognostic meaning of a reduced reserve of left ventricular force during exercise in hypertrophic cardiomyopathy
M G D'AlfonsoJesús PeteiroClarissa Carmona de Azevedo BellagambaMarco Antônio Rodrigues TorresFederica ReMilorad TešićLorenzo MonserratAna Djordjevic‐DikicB BeleslinXusto FernándezCarlos CotrimJ. OlivottoQuirino CiampiFabio MoriEugenio Picaño
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Abstract Background Hypertrophic cardiomyopathy (HCM) patients with blunted force-frequency relationship assessed with pacing during cardiac catheterization are at greater risk of adverse events. Left ventricular contractile reserve (LVCR) based on force can be obtained noninvasively during exercise stress echocardiography (ESE). Purpose To evaluate the prognostic correlates of force-based LVCR during ESE in HCM. Methods We enrolled 332 HCM patients (age 51±15 years, 193 males, New York Heart Association, NYHA, Class I-III, EF 68±9%, maximal wall thickness 20±5 mm, left ventricular outflow tract gradient, LVOTG, present at rest in 34 pts, 10%) referred for ESE in 7 quality-controlled labs. SE assessment included LVOTG (mm Hg), LV Force (systolic blood pressure by cuff sphygmomanometer + LVOTG/LV end-systolic volume assessed with 2-D, mmHg/ml) and LVCR (peak/rest ratio of LV Force). LV volumes were measured from apical biplane (4- and 2-chamber) views with Simpson method when feasible (n=290) or with linear Teichholz (T) method from parasternal (long- or short-axis) view (n=42). All patients were followed-up. Results Force values were 8.5±6.7 at rest and 15.0±13.7 mmHg/mL at peak stress (P<0.001). During a median follow-up time of 58 months, 50 patients experienced at least one event: 19 deaths (10 cardiac), 9 hospitalizations for acute heart failure, 16 myotomy/myectomy and 22 atrial fibrillations. The event-free survival was lower in the 195 patients with LVCR <1.77 (identified with Receiver-Operator Characteristic analysis) compared to the 137 with LVCR ≥1.77: see figure. Multivariate analysis identified LVCR (Hazard ratio, HR, 2.032, 95% confidence intervals, CI, 1.042–3.964, P=0.037), age (HR, 1.033, 95% CI 1.009–1.058, P=0.007) and NYHA class (HR 2.204, 95% CI 1.161–4.185, P<0.016) as independent predictors of events. Figure 1. HCM-LVCR Conclusion A non-invasive evaluation of LVOTG, systolic blood pressure and LV end-systolic volume during ESE allows to assess force-based LVCR in HCM. Lower LVCR is associated with greater risk of events at follow-up.Keywords:
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Ventricular outflow tract
Interventricular septum
Doppler tissue imaging is a new technique of measuring the velocities of myocardial wall motion. In order to assess its value in the diagnosis of acute rejection, the velocities of the interventricular septum and left ventricular posterior wall were measured in systole and early diastole in 34 cardiac transplant patients at the time of their endomyocardial biopsy, using an M mode left parasternal short axis view. During 40 episodes of acute rejection (26 mild and/or moderate, 10 sub-severe and 4 severe), the wall velocities decreased significantly (p < 0.001) both in the interventricular septum and endocardium of the posterior wall. Myocardial velocities were significantly slower in sub-severe or severe rejection than in mild or moderate rejection. The most sensitive criterion was the measurement of posterior wall endocardial velocity in early diastole, a decrease of 10% having a sensitivity of 92% whereas the sensitivity of usual Doppler echocardiographic parameters is only 73%. Acute rejection, even mild cases, can be diagnosed with excellent sensitivity by measuring myocardial velocities by Doppler tissue imaging. This technique has the advantage of being non-invasive, reproducible and reliable in the follow-up of cardiac transplant patients.
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Interventricular septum
Endocardium
Posterior wall
Doppler imaging
Systole
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The aim of this study was to improve the accuracy of transthoracic echo- cardiographic (TTE) assessment of the aortic valve area (AVA) in patients with aortic stenosis (AS). The traditional continuity equation (CE) for determining AVA requires a measurement of left ventricular outflow tract (LVOT) area, which is calculated from a linear LVOT dimension using the parasternal long axis view, assuming circular geometry. However, routine use of multidetector computed tomography (MDCT) in patients undergoing evaluation for transcatheter aortic valve replacement (TAVR) has shown that the LVOT is elliptical rather than round. Assumption of circular geometry may introduce inaccuracies into AVA assessment. A total of 61 patients (76 ± 11 years of age, 61% men) with isolated calcific AS (mean gradient 42 ± 9 mm Hg; ejection fraction 56 ± 11%) underwent Doppler TTE as part of pre TAVR or aortic valvuloplasty evaluation. AVA was calculated by TTE using two near- perpendicular planes (parasternal long axis and apical five chamber view) to evaluate the LVOT. A modified CE was used to calculate AVA (cm2) = (π((D1 x D2)/4)x LVOT VTI)/(AV VTI) in order to account for the elliptical rather than round shape of the LVOT. AVA measurements from the traditional and modified CE were compared to invasive AVA assessment. Biplane (Figure, Panel B+D) vs. traditional single plane (Panel A+C) TTE measurement of the LVOT yielded a significantly improved positive correlation between TTE and invasive AVA assessment (r2=0.861 vs. 0.296) and a markedly reduced mean error (0.07 cm2 vs. 0.18 cm2), p<0.001. Utilizing the proposed modified continuity equation greatly improves the accuracy of TTE guided AVA measurements. This simple calculation can be performed using standard TTE without additional costly equipment (ie, biplane transducers), without additional echo views (ie, more sonographer time), and without the need to subject patients to further invasive or non- invasive testing (ie, TEE or MDCT).
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We report a challenging case of a 81-year-old male with history of severe calcific aortic valve stenosis and aneurysmal membranous interventricular septum. The presence of anomalies in the sub-annular area can lead to valve malpositioning and its consequences. transcatheter aortic valve implantation (TAVR) in patients with aneurysm of the perimembranous interventricular septum extending into the left ventricular outflow tract has not been previously reported. This case describes a successful transfemoral TAVR with an Edwards SAPIEN XT valve (Edwards Lifesciences, Irvine, CA, United States) with such anomaly.
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Valve replacement
Outflow
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Intercostal space
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Background: The Area of left ventricular outflow tract (LVOT) is now calculated with LVOT diameter on the assumption that it's shape is a circle. The latest development of three dimensional echocardiography (3DE) can visualize LVOT directly. The morphological change of LVOT by aging is not clear. Methods: we evaluated 50 cases (mean age 61 years, 24 male ) which have normal left ventricular ejection fraction with transthoracic echocardiography. We recorded conventional left ventricular morphology with two dimensional echocardiography and recorded 3DE of parasternal long axis view and analyzed LVOT area (LVOT-A) and long (D1) and short axis (D2) of LVOT diameter at end diastole. Results: LVOT showed elliptical shape and LVOT-A obtained with 3DE was larger than the LVOT-A calculated with LVOT diameter (3.9±0.6cm2 v.s.3.1±0.6cm2;p<0.01). We divided these study population into 2 groups according with age. GroupIwas composed with less than 60 years (mean age 45 years n=21), GroupII was more than 60 years ( mea...
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Sixty three patients with complete transposition of the great arteries (d-TGA) were studied by two dimensional echocardiography in order to assess: great artery relationships; ventriculo-arterial connections; presence and nature of the left ventricular outflow obstruction (LVOTO). From the parasternal short axis view at the great arteries level, four different relationships were imaged: the aorta was anterior and to the right in 35 patients, the two vessels were in a direct anterior-posterior position in 15 or side by side in 3 and the aorta was anterior and to the left in 10. Differently from normals, early pulmonary bifurcation of the artery arising from the left ventricle was imaged in 42 patients (84%) from the apical approach and in 36 (72%) from the subcostal longitudinal view. Left ventricular outflow tract obstruction was diagnosed in 29 patients (46%) and two distinct types of obstruction were differentiated: fixed and dynamic. We conclude that information derived from two-dimensional echocardiography is a valuable tool for the medical management, cardiac catheterization and surgical treatment of infants and children with d-TGA.
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Cardiac catheterization
Transposition (logic)
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Abstract Background Echocardiography and intra-cardiac dimensions have not previously been reported in adult camels despite its potential application for medical purpose. The aim of this study was to describe the results of a prospective study, aiming to report normal cardiac appearance and normal chamber dimensions in adult camels ( Camelus dromedarius) . Results On the right side, when the probe was placed in the 5 th or 4 th intercostal space (ICS), the caudal long-axis four-chamber view of the ventricles, atria, and the interventricular septum was obtained. Placing the probe slightly more cranially in the 4 th ICS, the caudal long-axis four-chamber view and the caudal long-axis view of the left ventricular outflow tract (LVOT) were imaged. In 7 camels, a hybrid view between a “four-chamber” and “LVOT view” was imaged from the same position. The short-axis view of the ventricles was obtained in the 4 th ICS where the transducer was rotated between 0° and 25°. Placement of the transducer in the 3 rd ICS allowed visualisation of the right ventricular outflow tract (RVOT). On the left side, when the probe was placed in the 5 th or 4 th ICS, a four-chamber view was obtained. The LVOT is imaged in the 4 th ICS and the RVOT was seen from the 3 rd ICS. Conclusions This study showed that it is possible to obtain good-quality echocardiograms in adult camels and provide normal cardiac dimensions. This study could be used as a reference for further studies concerning camels with cardiac diseases.
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Interventricular septum
Intercostal space
Left Ventricles
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Aims Left ventricular outflow tract obstruction (LVOTO) is associated with reduced survival in patients with hypertrophic cardiomyopathy (HCM). The influence of LVOTO on survival from SD in relation to other recognized clinical risk markers is unknown.
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Sudden Death
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Doxorubicin (DXR) is one of the most effective antineoplastic agents, but its use is limited by its myocardial toxicity. Myocardial injury reduces the cyclic variation of integrated backscatter (CV-IBS) and so the present study was designed to investigate whether CV-IBS can be used to detect the early phase of myocardial damage in patients receiving DXR. Thirty-four subjects constituted the study population, none of whom showed clinically evident heart failure. CV-IBS was obtained for both the interventricular septum and the left ventricular posterior wall in the parasternal short-axis view. Standard echographic measures of left ventricular function were also made. Subjects without DXR exposure or evident cardiac diseases served as controls. The total dose of DXR administered per patient was 339+/-164 mg/m2 (range: 95-680 mg/m2). Conventional echographic parameters, including left ventricular wall thickness, dimensions, fractional shortening, and ejection fraction, showed no significant differences between the 2 groups. In contrast, CV-IBS was significantly decreased in the DXR group compared with the control group (septum: 4.7+/-1.7 vs 7.2+/-1.9 dB, p<0.0001; posterior wall: 6.7 +/-2.2 vs 8.0+/-1.6 dB, p<0.05). CV-IBS can be used as an early indicator of DXR-induced myocardial damage in patients demonstrating normal left ventricular systolic function.
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Cardiotoxicity
Fractional shortening
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Objectives The purpose of this study was to systematically investigate the feasible echocardiographic views for human transthoracic cardiac shear wave elastography (SWE) and the impact of myocardial anisotropy on myocardial stiffness measurements. Methods A novel cardiac SWE technique using pulse inversion harmonic imaging and time‐aligned sequential tracking was developed for this study. The technique can measure the quantitative local myocardial stiffness noninvasively. Ten healthy volunteers were recruited and scanned by the proposed technique 3 times on 3 different days. Results Seven combinations of echocardiographic views and left ventricular (LV) segments were found to be feasible for LV diastolic stiffness measurements: basal interventricular septum under parasternal short‐ and long‐axis views; mid interventricular septum under parasternal short‐ and long‐axis views; anterior LV free wall under parasternal short‐ and long‐axis views; and posterior LV free wall under a parasternal short‐axis view. Statistical analyses showed good repeatability of LV diastolic stiffness measurements among 3 different days from 70% of the participants for the basal interventricular septum and posterior LV free wall short‐axis views. On the same LV segment, the mean diastolic shear wave speed measurements from the short‐axis view were statistically different from the long‐axis measurements: 1.82 versus 1.29 m/s for the basal interventricular septum; 1.81 versus 1.45 m/s for mid interventricular septum; and 1.96 versus 1.77 m/s for the anterior LV free wall, indicating that myocardial anisotropy plays a substantial role in LV diastolic stiffness measurements. Conclusions These results establish the preliminary normal range of LV diastolic stiffness under different scan views and provide important guidance for future clinical studies using cardiac SWE.
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