Incremental diagnostic and prognostic utility of left atrial deformation in heart failure using speckle tracking echocardiography.

Left atrium (LA) is a very important component of cardiovascular performance. The assessment of LA function has gathered the interest with expanding research supporting the utility as a biomarker for outcomes in heart failure (HF). Echocardiography is the main imaging modality which helps in a qualitative and quantitative assessment of the LA size and function. Recent advances in probe technology and software analysis have provided a better understanding of LA anatomy, physiology, pathology, and function. A variety of parameters have been defined as markers of LA function but there is no single parameter that best defines LA function. Speckle tracking echocardiography-derived analysis of LA deformation provides a window on all phases of LA function (reservoir, conduit, and booster pump). There is accumulative published data that supported the diagnostic and prognostic values of LA deformation integration during echo assessment of LA in HF. This review article summarized the clinical utility of LA deformation that may help in prediction, diagnosis, categorization, risk stratification, and guiding the proper selection of therapy in HF patients in daily practice.

Assessment of suitability for percutaneous mitral commissurotomy: a contemporary review of key anatomical criteria and predictive models.

The immediate result of percutaneous balloon mitral commissurotomy is largely determined by the anatomy of the mitral valve complex. Several scores and models have been developed to assess anatomical suitability for percutaneous balloon mitral commissurotomy. Although none has an optimal predictive power, these models look at the valvular apparatus from different perspectives bearing the potential for a complementary role.

Echocardiographic evaluation of hypertrophic cardiomyopathy: A review of up-to-date knowledge and practical tips.

Hypertrophic cardiomyopathy (HCM) is the most frequent cardiac disease with genetic substrate, affecting about .2%-.5% of the population. The proper diagnosis is important for optimal management and follow-up. Echocardiography plays an essential role in the assessment of patients with HCM including diagnosis, screening, management formulation, prognosis, and follow up. It also helps to differentiate HCM from other diseases. The advancement of software and probe technology added many echo modalities and techniques that helped in refining the diagnostic and assessing the prognosis of patients with HCM. In this review, we briefly summarize how to integrate the different echocardiographic modalities to obtain comprehensive assessment supported by an updated knowledge of the latest guidelines and recently published articles. Many practical tips and tricks are included in this review to improve the diagnostic accuracy of echocardiography and minimize errors during interpretation.

Value of Three-Dimensional Echocardiography in Assessing Double-Orifice Mitral Valve in an Asymptomatic Patient.

Double-orifice mitral valve (DOMV) is a rare congenital anomaly consisting of an accessory bridge of fibrous tissue, which divides the mitral valve (MV) into two orifices. The mitral leaflets are essentially normal in most cases, but they can be regurgitant or stenotic. It is most commonly associated with a variety of other cardiac anomalies. Isolated DOMV with normal MV function is very rare. We present here a rare case of congenital DOMV in a 25-year-old female diagnosed by real-time three-dimensional echocardiography (RT3DE). RT3DE enabled complete anatomical and functional assessment of MV apparatus. It added much valuable information over conventional 2DE that helped in establishment of the diagnosis, identification of the anatomical type, and selection of the proper management.

Stepwise Protocols for Scoring of Mitral Valve using Three-Dimensional Transthoracic Echocardiography in Mitral Stenosis.

AIM: This study aims to propose protocols that enable scoring of mitral valve (MV) in mitral stenosis using the three-dimensional (3D) scoring system. METHODS: A two-staged study was conducted. The first stage was designed to select the best 3D images of MV leaflets and chordae through analysis of 471 images. The second stage was designed to organize the best 3D images into protocols for complete scoring of MV. It included 35 consecutive patients; 23 had sinus rhythm (SR) and 12 had atrial fibrillation (AF). Both single- and multi-beat 3D acquisition from apical and parasternal windows were focused on MV leaflets and chordae using all 3D modalities (live, zoom, and full volume). To propose the protocols, 1563 images were analyzed. RESULTS: In SR with good apical window, 2 protocols were recommended for complete scoring of leaflets and chordae (4 zoom 3D images [1 image for leaflets and 3 images for chordae] and 1 full-volume 3D image) using single- and multi-beat acquisition. In AF, the same 2 protocols using single-beat acquisition were recommended. From parasternal window, complete scoring of leaflets was obtained by 3 recommended protocols (single- or multi-beat zoom 3D images from parasternal short axis [PSAX], multibeat live 3D images from PSAX, and single- or multi-beat full-volume 3D images from parasternal long axis) in SR and 1 protocol in AF (single-beat zoom 3D images from PSAX). Scoring of chordae was incomplete in all patients by all 3D modalities. CONCLUSIONS: The proposed 3D-transthoracic echocardiography protocols suit all patients regardless of echo window and heart rhythm and enabled complete MV scoring.

A Proposed Maneuver to Guide Transseptal Puncture Using Real-Time Three-Dimensional Transesophageal Echocardiography: Pilot Study.

Aim of Study. To assess the feasibility of a new proposed maneuver "RATLe-90" using real-time three-dimensional transesophageal echocardiography (RT-3DTEE) for anatomically oriented visualization of the interatrial septum (IAS) in guiding the transseptal puncture TSP. Methods. The study included 20 patients (mean age, 60.2 ± 6.7 years; 60% males) who underwent TSP for different indications. RT-3DTEE was used to guide TSP. The proposed maneuver RATLe-90 (Rotate-Anticlockwise-Tilt-Left-90) was applied in all cases to have the anatomically oriented en face view of the IAS from the right atrial (RA) aspect. Having this anatomically oriented view, we guided the TSP catheter towards the proper puncture site according to the planned procedure. Results. Using the RATLe-90 maneuver, the anatomically oriented en face view of the IAS from the RA was obtained in all patients. We were able to guide the puncture catheter to the proper puncture site on the IAS. The 3D images obtained were clearly understood by both echocardiographers and interventionists. The RATLe-90 maneuver acquisition time was 19.9 ± 1.6 seconds. The time-to-tent was 64.8 ± 16.3 seconds. Less TEE probe manipulations were needed while guiding the TSP. Conclusions. Application of RT3D-TEE during TSP using RATLe-90 maneuver is feasible with shorter fluoroscopy time and minimizing TEE probe manipulations.

Real time three-dimensional transesophageal echocardiography: a novel approach for the assessment of prosthetic heart valves.

OBJECTIVES: To explore our initial experience with real time three-dimensional transesophageal echocardiography (RT3DTEE) for the assessment of prosthetic valves (PV). METHODS: The study included 40 patients (mean age 35 ± 8.5 years, 68% male) who underwent PV implant. Fifty PV (34 bioprosthetic and 16 mechanical) were evaluated using two-dimensional (2D)TEE and RT3DTEE to rule out PV dysfunction. RESULTS: In all patients, RT3DTEE allowed good and simultaneous visualization of PV leaflets. Ten patients had normal functioning PV (5 in mitral, 3 in aortic, and 2 in tricuspid positions). Infective endocarditis was evident in 13 patients (20 PV) by repeated 2DTEE. RT3DTEE confirmed the 2DTEE diagnosis of endocarditis in same patients. Clear delineation of vegetations (size, site, and number) was obtained from RT3DTEE full volume while the vegetation attachment, consistency, mobility and its relation to valve structure were obtained using zoom 3D. Paraaortic abscesses size, site, extension, wall thickness of the abscess could be identified by RT3DTEE in 7 PV. Through cropping of the full-volume 3D images, the orifice of communication between the abscess cavity and aorta could be visualized well in en face view. Color full-volume allowed the detection of paravalvular regurgitation (size, location, direction, and extent) in 8 patients. In the 18 PV who underwent redo surgery, the intra-operative findings confirmed the RT3DTEE description of PV lesions. CONCLUSION: Real time 3DTEE improved the anatomical and functional assessment of PV with better understanding of the underlying causes of PV dysfunction; hence, it could improve the management planning for such patients.

Accuracy of two-dimensional speckle tracking echocardiography for the detection of significant coronary stenosis.

BACKGROUND: Visual assessment of wall motion abnormalities (WMA) by 2-dimensional echocardiography (2DE) is the most semi-quantitative method used to detect coronary artery disease (CAD), but it carries many limitations. Speckle tracking echocardiography (STE) overcomes these limitations and allows an objective quantification of myocardial deformation. The aim of the study to examine the accuracy of global and segmental longitudinal strain (LS) for the detection of CAD compared with visual assessment of WMA using coronary angiography as a golden standard. METHODS: The study enrolled 25 patients (mean age 51.0 ± 8.7, 64% are male) referred to coronary angiography with clinical suspicion of CAD. 2DE assessment of WMA and evaluation of LS using STE were performed using left ventricular 17-segments models. Significant CAD was defined as ≥ 50% stenosis in one or more major coronary arteries by angiography. RESULTS: Patients were classified into 2 groups: group I included 15 patients with significant CAD and group II included 10 patients with insignificant and/or absence of CAD. WM score was strongly correlated with the global LS in group I and II (R = 0.80, p < 0.0001 and R = 0.88, p < 0.0001 respectively). In all patients, 425 segments were analyzed. WMA was detected in 163 segments of 425 (38.3%) while abnormal LS was detected in 214 segments (50.3%). Compared with coronary angiography, the total sensitivity, specificity and accuracy for visual analysis and STE were (56%, 88.2%, and 60% vs. 68.6%, 77%, and 81.8% respectively). CONCLUSION: Segmental LS is more accurate for the detection of ischemic myocardial segment corresponding to functionally relevant coronary anatomy than visual assessment of WM.

Global and segmental myocardial deformation by 2D speckle tracking compared to visual assessment.

AIM: To examine the feasibility and reliability of measuring global and segmental longitudinal strain (LS) compared to visual assessment of wall motion (WM). METHODS: Assessment of segmental (17 left ventricular segments) LS using automatic function imaging (AFI) in 55 patients (60.0 ± 8.7 years, 73% male) divided into 2 groups: group I included 35 patients with WM abnormalities and/or impaired ejection fraction and group II included 20 patients with normal WM and ejection fraction. Visual analysis of WM abnormalities was performed using 2-dimensional echocardiography (2DE) and WM score was calculated. Both modalities were analyzed by one expert reader at 2 different sessions. RESULTS: Analysis of 935 left ventricular segments was completed in 94.1% and 96.3% by visual assessment and AFI, respectively. There was a strong positive linear relationship between the WM score and global LS in all patients. Intra-observer agreement for calculation of WM score was excellent for group I patients (kappa: 0.97) and very good for group II patients (kappa: 0.92). Intra-observer agreement for AFI showed excellent agreement with very small mean difference in both group I and II (-0.0 ± 2.3 and -0.0 ± 1.9, respectively). CONCLUSION: The interpretation of global and segmental LS using AFI is a more feasible and reliable technique for the quantification of myocardial deformation than visual assessment of WM scores.

Incremental utility of real time three-dimensional tranthoracic echocardiography in the assessment of congenitally malformed aortic valve.

OBJECTIVES: To study the feasibility and additional value of real time three-dimensional transthoracic echocardiography (RT3D-TTE) for anatomical and functional assessment of malformed aortic valve (AV) compared to conventional two-dimensional TTE (2D-TTE). METHODS: Malformed AV was evaluated in 35 patients (mean age 18 ± 9.5 years, 70% male) by both 2D-TTE and RT3D-TTE. The anatomical definition of aortic cusps (number, direction, and commissures) was evaluated by a 3-point visualization score (1: nonvisualized, 2: inadequate, 3: adequate). 2D-TTE and RT3D-TTE measurements included AV area and maximum diameters of both AV annulus and left ventricular outflow tract (LVOT). RESULTS: Adequate visualization of AV cusps was achieved in 86% of patients by RT3D-TTE compared to 63% by 2D-TTE. The mean and median visualization score obtained by RT3D-TTE were higher than that by 2D-TTE. The opening of commissures was detected in (80%) of patients by RT3D-TTE compared to (34%) by 2D-TTE. AV area planimetry could be obtained in 77% of patients by RT3D-TTE compared to 43% by 2D-TTE. RT3D-TTE visualization score of AV cusps and commissures showed better interobserver agreement (Kappa: 0.62 and 0.72, respectively) than 2D-TTE (0.58 and 0.69, respectively). RT3D-TTE and 2D-TTE measurements of AV annulus and LVOT were well correlated (r = 0.85; P < 0.001) but the RT3D-TTE measurements were significantly larger than that obtained by 2D-TTE (2.05 ± 0.7 cm and 2.5 ± 0.86 cm vs 1.94 ± 0.67 cm and 1.98 ± 0.74 cm; P < 0.01). CONCLUSION: RT3D-TTE is a feasible technique that allows comprehensive quantitative and qualitative assessment of malformed AV.

Real-time three-dimensional transthoracic echocardiography in daily practice: initial experience.

AIM OF THE WORK: To evaluate the feasibility and possible additional value of transthoracic real-time three-dimensional echocardiography (RT3D-TTE) for the assessment of cardiac structures as compared to 2D-TTE. METHODS: 320 patients (mean age 45 ± 8.4 years, 75% males) underwent 2D-TTE and RT3D-TTE using 3DQ-Q lab software for offline analysis. Volume quantification and functional assessment was performed in 90 patients for left ventricle and in 20 patients for right ventricle. Assessment of native (112 patients) and prosthetic (30 patients) valves morphology and functions was performed. RT3D-TTE was performed for evaluation of septal defects in 30 patients and intracardiac masses in 52 patients. RESULTS: RT3D-TTE assessment of left ventricle was feasible and reproducible in 86% of patients while for right ventricle, it was (55%). RT3D-TTE could define the surface anatomy of mitral valve optimally (100%), while for aortic and tricuspid was (88% and 81% respectively). Valve area could be planimetered in 100% for the mitral and in 80% for the aortic. RT3D-TTE provided a comprehensive anatomical and functional evaluation of prosthetic valves. RT3D-TTE enface visualization of septal defects allowed optimal assessment of shape, size, area and number of defects and evaluated the outcome post device closure. RT3D-TTE allowed looking inside the intracardiac masses through multiple sectioning, valuable anatomical delineation and volume calculation. CONCLUSION: Our initial experience showed that the use of RT3D-TTE in the assessment of cardiac patients is feasible and allowed detailed anatomical and functional assessment of many cardiac disorders.

Importance of accurate diagnosis using real-time three-dimensional echocardiography in the surgical treatment of congenital intramitral ring in infants.

Congenital mitral ring is a rare type of congenital mitral stenosis. There are two types of mitral ring: the intramitral ring and the supramitral ring. Intramitral rings are often associated with complex valve pathology, and therefore have a worse prognosis than supramitral rings, in which the mitral apparatus is usually normal. The role of echocardiography in the evaluation of the mitral valve apparatus is crucial, because it allows an identification of the types of malformation, their hemodynamic repercussion and early predictors of the outcome. We describe two cases of intramitral ring, the diagnostic challenge they provided, and the value of the information obtained using real-time three-dimensional echocardiography in such cases.

New Scores for the Assessment of Mitral Stenosis Using Real-Time Three-Dimensional Echocardiography.

Nonsurgical management of patients with symptomatic mitral valve stenosis has been established as the therapeutic modality of choice for two decades. Catheter-based balloon dilation of the stenotic valvular area has been shown, at least, as effective as surgical interventions. Unfavorable results of catheter-based interventions are largely due to unfavorable morphology of the valve apparatus, particularly leaflets calcification and subvalvular apparatus involvement. A mitral valve score has been proposed in Boston, MA, about two decades ago, based on morphologic assessment of mitral valve apparatus by two-dimensional (2D) echocardiography to predict successful balloon dilation of the mitral valve. Several other scores have been developed in the following years in order to more successfully predict balloon dilatation outcome. However, all those scores were based on 2D echocardiography, which is limited by ability to distinguish calcification and subvalvular involvement. The introduction of new matrix-based ultrasound probe has allowed 3D echocardiography (3DE) to provide more detailed morphologic analysis of mitral valve apparatus including calcification and subvalvular involvement. Recently, a new 3DE scoring system has been proposed by our group, which represents an important leap into refinement of the use of echocardiography guiding mitral valve interventions.

Organized intrapericardial haematoma: a rare cause of heart failure after 2 years of trauma.

Intrapericardial organized haematoma secondary to blunt chest trauma is an extremely rare cause of constrictive pericarditis. We report a 30-year-old male who presented with heart failure for 12 months and was found to have an organized intrapericardial haematoma secondary to blunt chest trauma in a road traffic accident 2 years prior. The use of multiple imaging modalities including two-dimensional (transthoracic and transoesophageal) echocardiogram and cardiac magnetic resonance imaging established the diagnosis. Surgical excision of the haematoma and removal of the constricting pericardium relieved his symptoms.

Aspergillus cyst of aortic valve bioprosthesis.

Aspergillus endocarditis (AE) is an ominous complication of cardiac surgery with a dismal prognosis. We present a 35-year-old female who developed AE 4 months after her aortic and mitral valve replacement. Transesophageal echocardiography revealed an aortic root abscess and a cystic mass attached to the aortic bioprosthesis. Intraoperatively, the cyst was filled with fungal material. The aortic bioprosthesis was replaced and the patient was treated with amphotericin B. Six weeks later her condition suddenly deteriorated and she died on the same day. Early performance of transesophageal echocardiography and extended blood culture is mandatory in suspected cases of AE.

An incidental finding of mitral valve network.

A 63-year-old male presented with a 6-month history of worsening exertional dyspnea and was found to have three-vessel coronary artery disease. Transesophageal echocardiography revealed a filamentous structure attached to the anterior mitral valve leaflet, which was confirmed during surgery as filamentous network. To our knowledge, this is the first report to describe such a network attached to the mitral valve.

Validation of a new score for the assessment of mitral stenosis using real-time three-dimensional echocardiography.

BACKGROUND: The aim of this study was to validate a new real-time three-dimensional echocardiography (RT3DE) score for evaluating patients with mitral stenosis (MS). METHODS: A two-staged study was conducted. In the first stage, the feasibility of a new RT3DE score was assessed in 17 patients with MS. The second stage was planned to validate the RT3DE score in 74 consecutive patients undergoing percutaneous mitral valvuloplasty. The new RT3DE score was constructed by dividing each mitral valve (MV) leaflet into 3 scallops and was composed of 31 points (indicating increasing abnormality), including 6 points for thickness, 6 for mobility, 10 for calcification, and 9 for subvalvular apparatus involvement. The total RT3DE score was calculated and defined as mild (<8), moderate (8-13), or severe (>or=14). MV morphology was assessed using Wilkins's score and compared with the new RT3DE score. RESULTS: In the first stage, the RT3DE score was feasible and easily applied to all patients, with good interobserver and intraobserver agreement. In the second stage, RT3DE improved MV morphologic assessment, particularly for the detection of calcification and commissural splitting. Both scores were correlated for assessment of thickness and calcification (r = 0.63, P < .0001, and r = 0.44, P < .0001, respectively). Predictors of optimal percutaneous mitral valvuloplasty success by Wilkins's score were leaflet calcification and subvalvular apparatus involvement, and those by RT3DE score were leaflet mobility and subvalvular apparatus involvement. The incidence and severity of mitral regurgitation were associated with high-calcification RT3DE score. CONCLUSION: The new RT3DE score is feasible and highly reproducible for the assessment of MV morphology in patients with MS. It can provide incremental prognostic information in addition to Wilkins's score.

Right atrial metastasis mimicking myxoma in advanced hepatocellular carcinoma.

Hepatocellular carcinoma is the most common primary tumor of the liver accounting for 4.6% of all new human cancers. Cardiac metastasis in hepatocellular carcinoma is an uncommon secondary cardiac malignancy. We described two cases of advanced hepatocellular carcinoma with large masses in the right atrium mimicking atrial myxoma. The RA masses were incidentally detected during two-dimensional echocardiographic examination.

[The role of real-time three-dimensional echocardiography in the evaluation of hypertrophic cardiomyopathy]. / A real-time háromdimenziós echokardiográfia szerepe a hypertrophiás cardiomyopathia vizsgálatában.

Hypertrophic cardiomyopathy is a relatively common hereditary disorder, which is associated with cardiac morphologic and functional alterations. Echocardiography is a non-invasive, simple and easy-to-learn method to evaluate patients with cardiomyopathy. The aim of this review paper is to demonstrate the possible diagnostic role of one of the newest echocardiographic development, the real-time 3-dimensional echocardiography in the evaluation of hypertrophic cardiomyopathy.