EACVI survey on radiation exposure in interventional echocardiography.

AIMS: The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey on radiation exposure in interventional echocardiography. The survey aimed to collect data on local practices for radioprotection in interventional echocardiography and to assess the awareness of echocardiography operators about radiation-related risks. METHODS AND RESULTS: A total of 258 interventional echocardiographers from 52 different countries (48% European) responded to the survey. One hundred twenty-two (47%) participants were women. Two-thirds (76%) of interventional echocardiographers worked in tertiary care/university hospitals. Interventional echocardiography was the main clinical activity for 34% of the survey participants. The median time spent in the cath-lab for the echocardiographic monitoring of structural heart procedures was 10 (5-20) hours/month. Despite this, only 28% of interventional echocardiographers received periodic training and certification in radioprotection and 72% of them did not know their annual radiation dose. The main adopted personal protection devices were lead aprons and thyroid collars (95% and 92% of use, respectively). Dedicated architectural protective shielding was not available for 33% of interventional echocardiographers. Nearly two-thirds of responders thought that the radiation exposure of interventional echocardiographers was higher than that of interventional cardiologists and 72% claimed for an improvement in the radioprotection measures. CONCLUSION: Radioprotection measures for interventional echocardiographers are widely variable across centres. Radioprotection devices are often underused by interventional echocardiographers, portending an increased radiation-related risk. International scientific societies working in the field should collaborate to endorse radioprotection training, promote reliable radiation dose assessment, and support the adoption of radioprotection shielding dedicated to interventional echocardiographers.

Cardiovascular magnetic resonance in autoimmune rheumatic diseases: a clinical consensus document by the European Association of Cardiovascular Imaging.

Autoimmune rheumatic diseases (ARDs) involve multiple organs including the heart and vasculature. Despite novel treatments, patients with ARDs still experience a reduced life expectancy, partly caused by the higher prevalence of cardiovascular disease (CVD). This includes CV inflammation, rhythm disturbances, perfusion abnormalities (ischaemia/infarction), dysregulation of vasoreactivity, myocardial fibrosis, coagulation abnormalities, pulmonary hypertension, valvular disease, and side-effects of immunomodulatory therapy. Currently, the evaluation of CV involvement in patients with ARDs is based on the assessment of cardiac symptoms, coupled with electrocardiography, blood testing, and echocardiography. However, CVD may not become overt until late in the course of the disease, thus potentially limiting the therapeutic window for intervention. More recently, cardiovascular magnetic resonance (CMR) has allowed for the early identification of pathophysiologic structural/functional alterations that take place before the onset of clinically overt CVD. CMR allows for detailed evaluation of biventricular function together with tissue characterization of vessels/myocardium in the same examination, yielding a reliable assessment of disease activity that might not be mirrored by blood biomarkers and other imaging modalities. Therefore, CMR provides diagnostic information that enables timely clinical decision-making and facilitates the tailoring of treatment to individual patients. Here we review the role of CMR in the early and accurate diagnosis of CVD in patients with ARDs compared with other non-invasive imaging modalities. Furthermore, we present a consensus-based decision algorithm for when a CMR study could be considered in patients with ARDs, together with a standardized study protocol. Lastly, we discuss the clinical implications of findings from a CMR examination.

Renal function in patients with significant tricuspid regurgitation: pathophysiological mechanisms and prognostic implications.

BACKGROUND: The pathophysiological mechanisms linking tricuspid regurgitation (TR) and chronic kidney disease (CKD) remain unknown. This study aimed to determine which pathophysiological mechanisms related to TR are independently associated with renal dysfunction and to evaluate the impact of renal impairment on long-term prognosis in patients with significant (≥ moderate) secondary TR. METHODS: A total of 1234 individuals (72 [IQR 63-78] years, 50% male) with significant secondary TR were followed up for the occurrence of all-cause mortality and the presence of significant renal impairment (eGFR of <60 mL min-1  1.73 m-2 ) at the time of baseline echocardiography. RESULTS: Multivariable analysis demonstrated that severe right ventricular (RV) dysfunction (TAPSE < 14 mm) was independently associated with the presence of significant renal impairment (OR 1.49, 95% CI 1.11 to 1.99, P = 0.008). Worse renal function was associated with a significant reduction in survival at 1 and 5 years (85% vs. 87% vs. 68% vs. 58% at 1 year, and 72% vs. 64% vs. 39% vs. 19% at 5 years, for stage 1, 2, 3 and 4-5 CKD groups, respectively, P < 0.001). The presence of severe RV dysfunction was associated with reduced overall survival in stage 1-3 CKD groups, but not in stage 4-5 CKD groups. CONCLUSIONS: Of the pathophysiological mechanisms identified by echocardiography that are associated with significant secondary TR, only severe RV dysfunction was independently associated with the presence of significant renal impairment. In addition, worse renal function according to CKD group was associated with a significant reduction in survival.

Physical activity in patients with systemic sclerosis.

OBJECTIVES: To compare self-reported levels of physical activity (PA) of systemic sclerosis (SSc) patients with the general population. To evaluate in SSc patients factors associated with PA levels and needs and preferences regarding PA. METHODS: Fifty nine SSc patients completed the Short QUestionnaire to ASsess Health-Enhancing PA. The proportion of patients meeting the Dutch Recommendation for PA (= moderate PA for 30 min on ≥ 5 days/week) and total minutes of PA per week were calculated and compared with similar data from the Dutch population. Characteristics were univariately and multivariately compared between patients with low and high PA levels (either ≤ or > mean minutes/week of the Dutch population). Needs and preferences regarding PA promotion and guidance related to exercise were assessed by questionnaires. RESULTS: Stratified for age (< 55 or ≥ 55 years) and gender, the proportion SSc patients meeting the Dutch recommendation for PA was not significantly different from the Dutch population. The total minutes of PA per week was significantly lower among SSc patients (1704 vs. 2614, P < 0.001). Multivariable analyses showed that in SSc patients the male gender, scleroderma health assessment questionnaire (SHAQ) and lack of energy were significantly associated with lower PA levels (P = 0.007; P = 0.042; P = 0.025). Two-third of patients required more information about PA. CONCLUSION: In SSc patients, the total minutes of PA per week are significantly lower compared to the general population. The male gender, functional ability as reflected by SHAQ and lack of energy seem to interfere with PA. These results might guide health professionals in providing their patients with appropriate information on PA.

Detection of pulmonary vasculopathy by novel analysis of oxygen uptake in patients with systemic sclerosis: association with pulmonary arterial pressures.

OBJECTIVES: During cardiopulmonary exercise testing (CPET) compromised pulmonary vasculature in patients with systemic sclerosis (SSc) may lead to increases in pulmonary arterial pressures (PAP) and decreased oxygen uptake. We hypothesised that this may lead into a disproportional heart rate (HR) increase with a corresponding V'O2/HR breakpoint and relates to systolic PAP at rest. METHODS: In a prospective design we evaluated V'O2/HR slopes for breakpoints. To understand its physiological meaning, we evaluated V'O2/HR and V'O2/mPAP slopes for breakpoints in a historic data set of SSc patients, in which CPET and right heart catheterisation was performed simultaneously. V'O2/HR slopes with a peak oxygen uptake outside the normal range were defined as pathologic. RESULTS: A breakpoint occurred in both V'O2/mPAP and V'O2/HR slope in 16/34 patients in the historic dataset and occurred in the V'O2/mPAP slope at a lower V'O2in 15 patients. In the prospective dataset, 73/121 patients showed a V'O2/HR breakpoint and achieved a significantly lower peak oxygen uptake compared to 48/121 patients without a V'O2/HR breakpoint (p=0.036). Mean systolic PAP in 41/121 patients with a pathologic V'O2/HR slope differed significantly from patients without a pathologic V'O2/HR slope (p=0.027). In 27/121 patients with a systolic PAP < 35 mmHg a pathologic V'O2/HR slope was observed. CONCLUSIONS: SSc patients with a V'O2/HR breakpoint are characterised by a decreased oxygen uptake, likely caused by sudden PAP increases during exercise. Importantly, in patients with normal resting SPAP pathologic V'O2/HR slopes were observed. This suggests that these patients are at risk for developing pulmonary hypertension.

ST-segment elevation associated with allergic reaction to echocardiographic contrast agent administration.

We report a case of an allergic reaction after the administration of an echocardiographic contrast agent which resulted in ST-segment elevation. Hypersensitivity and allergic reactions are known causes of acute cardiovascular events. However, only limited reports are available which suggest the exact mechanism of the occurrence of angina or myocardial infarction during severe allergic reactions. In our case, through invasive imaging (coronary angiography and IVUS) we have shown for the first time a transient coronary spasm in the absence of intra-coronary thrombus and only minimal neointimal hyperplasia.

Echocardiography and non-invasive imaging in cardiac resynchronization therapy.

The beneficial effects of cardiac resynchronization therapy (CRT) on morbidity and mortality in advanced heart failure patients have been extensively demonstrated. However, previous single- and multicenter studies demonstrated that approximately 30-40% of CRT patients do not show significant clinical improvement or LV reverse remodeling despite fulfilling current inclusion criteria. In search of novel indices that may help to improve the selection of responders to CRT, non-invasive multimodality imaging has provided further insight into the mechanisms underlying CRT response. LV dyssynchrony, extent and location of myocardial scar and LV lead position have shown to be independent determinants of CRT response. An integrated evaluation of these three pathophysiological mechanisms may provide a more accurate selection of heart failure patients who will benefit from CRT and may maximize the cost-effectiveness of this therapy. The present review article provides a critical appraisal of the role of multimodality imaging in the selection of heart failure patients who are candidates for CRT with special focus on the assessment of LV mechanical dyssynchrony, LV myocardial scar tissue extent and LV lead position.

Advanced applications of 3-dimensional echocardiography.

Over the last few decades, advancements in ultrasound, electronic and computing technologies have permitted current second generation 3-dimensional (3D) echocardiography to display on-line 3D rendered images of the heart. Since various studies demonstrated its superiority over 2-dimensional echocardiography, there is growing enthusiasm to embrace this new 3D echocardiographic technology. With its increasing widespread clinical availability, 3D echocardiography is getting closer to routine clinical use. However, as with any new emerging technologies, clinical applications of 3D echocardiography should be based on current evidence. This review will focus on the evidence from clinical studies that form the scientific basis for the advanced applications of 3D echocardiography, from cardiac chamber volume assessments, left ventricular dyssynchrony assessments, quantifications of valvular abnormalities, to the role of 3D echocardiography during cardiac interventions.

Effect of intramyocardial bone marrow cell injection on left ventricular dyssynchrony and global strain.

OBJECTIVE: To evaluate the effect of bone marrow cell injection on global strain and left ventricular (LV) dyssynchrony. METHODS: In 14 patients with severe postinfarction heart failure, 93 (14) x 10(6) autologous bone marrow cells were percutaneously injected in the infarction border zone. LV ejection fraction (LVEF), LV dyssynchrony and echocardiographic global strain were assessed at baseline and 3 months in patients and in a non-randomised control group of 10 patients with a history of infarction who developed heart failure and were treated medically. RESULTS: No periprocedural complications occurred during bone marrow cell injection. At 3 months mean (SD) LVEF increased from 23 (8)% to 27 (9)% (p = 0.02) and global strain improved from -7.7 (4.7)% to -8.5 (4.9)% (p = 0.04). In patients with > or =5% improvement in LVEF after bone marrow cell injection, global strain improved from -8.7 (4.6)% to -10.6 (4.5)% (p<0.01). Global strain remained unchanged in patients with <5% improvement in LVEF (-6.6 (4.9)% vs -6.4 (4.5)%, p = NS). The relation between the increase in LVEF and improvement in global strain was significant (r = 0.84, p<0.01). In patients with > or =5% improvement in LVEF, LV dyssynchrony decreased from 173 (64) ms to 116 (64) ms (p = 0.01). In patients with <5% improvement in LVEF, LV dyssynchrony remained unchanged (155 (67) ms vs 177 (81) ms, p = NS). The correlation between improvement in LVEF and reduction in LV dyssynchrony was good (r = -0.77, p<0.01). In the control group, LVEF, global strain and LV dyssynchrony did not improve. CONCLUSIONS: Bone marrow cell injection improves LVEF in patients with severe postinfarction heart failure. The improvement in LVEF was related to reduced LV dyssynchrony and increased global strain.

Triplane tissue Doppler imaging: a novel three-dimensional imaging modality that predicts reverse left ventricular remodelling after cardiac resynchronisation therapy.

BACKGROUND: Several two-dimensional (2-D) tissue Doppler imaging (TDI) echocardiographic techniques have proved useful to identify responders to cardiac resynchronisation therapy (CRT). Recently a 3-D probe allowing simultaneous acquisition of TDI data in three imaging planes became available. OBJECTIVE: To evaluate the value of triplane TDI to predict reverse left ventricular (LV) remodelling after CRT. METHODS: Sixty patients with heart failure, scheduled for CRT, underwent triplane echocardiography with simultaneous TDI acquisition before and 6 months after implantation. From the triplane dataset a 3-D LV volume was generated and LV volumes and ejection fraction were calculated. Intraventricular dyssynchrony was quantitatively analysed by evaluating time from onset of the QRS complex to peak myocardial systolic velocity in 12 LV segments from the triplane dataset and calculation of the standard deviation (Ts-SD-12). Clinical response was defined as an improvement of at least one New York Heart Association class. Reverse LV remodelling was defined as >/=15% decrease of LV end-systolic volume at 6 months' follow-up. RESULTS: Responders to CRT had significantly more LV dyssynchrony at baseline than non-responders (mean (SD) Ts-SD-12: 42 (14) vs 22 (12), p<0.001). A cut-off value of 33 ms for baseline Ts-SD-12, acquired from the triplane TDI dataset, yielded a sensitivity of 89% with a specificity of 82% to predict clinical response to CRT; sensitivity and specificity to predict reverse LV remodelling were 90% and 83%, respectively. CONCLUSION: Triplane TDI echocardiography predicts clinical response and reverse LV remodelling 6 months after CRT implantation.