Global Longitudinal Strain at Rest as an Independent Predictor of Mortality in Liver Transplant Candidates: A Retrospective Clinical Study.

Speckle tracking echocardiography enables the detection of subclinical left ventricular dysfunction at rest in many heart diseases and potentially in severe liver diseases. It could also possibly serve as a predictor for survival. In this study, 117 patients evaluated for liver transplantation in a single center between May 2010 and April 2016 with normal left ventricular ejection fraction were included according to clinical characteristics of their liver disease: (1) compensated (n = 29), (2) clinically significant portal hypertension (n = 49), and (3) decompensated (n = 39). Standard echocardiography and speckle tracking echocardiography were performed at rest and during dobutamine stress. Follow-up amounted to three years to evaluate survival and major cardiac events. Altogether 67% (78/117) of the patients were transplanted and 32% (31/96 patients) died during the three-year follow-up period. Global longitudinal strain (GLS) at rest was significantly increased (became more negative) with the severity of liver disease (p < 0.001), but reached comparable values in all groups during peak stress. Low (less negative) GLS values at rest (male: >-17/female: >-18%) could predict patient survival in a multivariate Cox regression analysis (p = 0.002). GLS proved valuable in identifying transplant candidates with latent systolic dysfunction.

Use of two-dimensional speckle tracking echocardiography to predict cardiac events: Comparison of patients with acute myocardial infarction and chronic coronary artery disease.

BACKGROUND: Two-dimensional speckle strain (2D STE) echocardiography can aid in the prognosis of acute myocardial infarction (AMI) and chronic coronary artery disease (CAD). HYPOTHESIS: Differences occur in the prediction of cardiac events using 2D STE in AMI vs CAD patients. METHODS: In this prospective study, 94 patients with a first AMI and successful revascularization, and 137 patients with stable CAD after complete revascularization were included. In all patients, we performed echocardiography and myocardial deformation analysis for layer-specific global circumferential strain (GCS) and longitudinal strain. Receiver operating characteristic (ROC) curve analysis was used to predict the presence of a cardiac event using strain values and baseline characteristics in different regression models. RESULTS: Patients were followed for 3.6 ± 0.8 years. Strain parameters in AMI and CAD patients were significantly different with respect to the occurrence of a cardiac event. Frequency of diabetes and hypertension was associated with the presence of a cardiac event in CAD patients. Furthermore, in CAD patients, ROC analysis demonstrated that the addition of endocardial GCS to baseline characteristics and ejection fraction to a regression model significantly improved the prediction of cardiac events (area under curve = 0.86, cutoff value: 20%, sensitivity: 79%, specificity: 84%). In contrast, the addition of strain parameters in AMI patients did not increase the prediction power for cardiac events. CONCLUSIONS: Global strain parameters by 2D STE may be useful for the prediction of cardiac events in patients with CAD but add no supplemental information to baseline characteristic and ejection fraction in patients with AMI.

Right ventricular outflow tract dimensions in arrhythmogenic right ventricular cardiomyopathy/dysplasia-a multicentre study comparing echocardiography and cardiovascular magnetic resonance.

Aims: Right ventricular outflow tract (RVOT) dilation is one of the echocardiographic criteria in the 2010 revised Task Force Criteria (TFC) of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). However, studies comparing cardiac magnetic resonance (CMR) and transthoracic echocardiography (TTE) suggest a lower diagnostic accuracy of TTE due to its operator dependence and limited reproducibility. The goal of this study was to compare the 2010 TFC measures of RVOT dilation with three alternative measures for improving the echocardiographic assessment of RVOT in patients with ARVC/D. Methods and results: In this multicentre study, CMR and TTE were performed in 38 patients with a definite, borderline, or possible ARVC/D diagnosis and in 10 healthy controls. Besides the echocardiographic RVOT measurements listed by the 2010 TFC, we assessed three additional end-diastolic RVOT diameters. These included the RVOT diameter defined by the parasternal long axis M-mode of the aortic sinus portion (RVOT3), that defined by the parasternal long axis M-mode of the left ventricle (RVOT4), and that obtained by the parasternal short axis view of the distal RVOT proximal to the pulmonary valve (RVOT5). RVOT4 provided the best correlation between CMR and TTE (r = 0.92, [95% confidence interval (CI): 0.84-0.96; P < 0.0001]) and enhanced diagnostic accuracy for diagnosing ARVC/D (area under the curve 0.92 [95% CI, 0.78-0.98]). Conclusion: Among all RVOT diameters examined, that defined by the parasternal long axis M-mode of the left ventricle (RVOT4) provides the best agreement between CMR and TTE and exhibits the best diagnostic accuracy for ARVC/D. This novel RVOT4 measurement carries the potential for improving the echocardiographic diagnosis of ARVC/D.

Fusion of CT coronary angiography and whole-heart dynamic 3D cardiac MR perfusion: building a framework for comprehensive cardiac imaging.

The purpose of this work was to develop a framework for 3D fusion of CT coronary angiography (CTCA) and whole-heart dynamic 3D cardiac magnetic resonance perfusion (3D-CMR-Perf) image data-correlating coronary artery stenoses to stress-induced myocardial perfusion deficits for the assessment of coronary artery disease (CAD). Twenty-three patients who underwent CTCA and 3D-CMR-Perf for various indications were included retrospectively. For CTCA, image quality and coronary diameter stenoses > 50% were documented. For 3D-CMR-Perf, image quality and stress-induced perfusion deficits were noted. A software framework was developed to allow for 3D image fusion of both datasets. Computation steps included: (1) fully automated segmentation of coronary arteries and heart contours from CT; (2) manual segmentation of the left ventricle in 3D-CMR-Perf images; (3) semi-automatic co-registration of CT/CMR datasets; (4) projection of the 3D-CMR-Perf values on the CT left ventricle. 3D fusion analysis was compared to separate inspection of CTCA and 3D-CMR-Perf data. CT and CMR scans resulted in an image quality being rated as good to excellent (mean scores 3.5 ± 0.5 and 3.7 ± 0.4, respectively, scale 1-4). 3D-fusion was feasible in all 23 patients, and perfusion deficits could be correlated to culprit coronary lesions in all but one case (22/23 = 96%). Compared to separate analysis of CT and CMR data, coronary supply territories of 3D-CMR-Perf perfusion deficits were refined in two cases (2/23 = 9%), and the relevance of stenoses in CTCA was re-judged in four cases (4/23 = 17%). In conclusion, 3D fusion of CTCA/3D-CMR-Perf facilitates anatomic correlation of coronary lesions and stress-induced myocardial perfusion deficits thereby helping to refine diagnostic assessment of CAD.

In vivo quantification of amyloid burden in TTR-related cardiac amyloidosis.

Cardiac transthyretin-related (ATTR) amyloidosis is a severe cardiomyopathy for which therapeutic approaches are currently under development. Because non-invasive imaging techniques such as cardiac magnetic resonance imaging and echocardiography are non-specific, the diagnosis of ATTR amyloidosis is still based on myocardial biopsy. Thus, diagnosis of ATTR amyloidosis is difficult in patients refusing myocardial biopsy. Furthermore, myocardial biopsy does not allow 3D-mapping and quantification of myocardial ATTR amyloid. In this report we describe a 99mTc-DPD-based molecular imaging technique for non-invasive single-step diagnosis, three-dimensional mapping and semiquantification of cardiac ATTR amyloidosis in a patient with suspected amyloid heart disease who initially rejected myocardial biopsy. This report underlines the clinical value of SPECT-based nuclear medicine imaging to enable non-invasive diagnosis of cardiac ATTR amyloidosis, particularly in patients rejecting biopsy.

Multi-centre study of whole-heart dynamic 3D cardiac magnetic resonance perfusion imaging for the detection of coronary artery disease defined by fractional flow reserve: gender based analysis of diagnostic performance.

AIMS: Coronary artery disease (CAD) is a leading cause of morbidity and mortality in women and non-invasive testing for CAD in women can be more challenging than in men. This study compared the diagnostic performance of whole-heart dynamic 3D cardiovascular magnetic resonance (CMR) stress perfusion imaging in female and male patients with quantitative coronary angiography (QCA) and fractional flow reserve (FFR) as reference tests. METHODS AND RESULTS: Four hundred sixteen patients with suspected or known CAD were enrolled in five European centres. CMR imaging was performed prior to clinically indicated coronary angiography. QCA was performed in all patients and FFR in 357 of 416 patients. Whole-heart dynamic 3D CMR first-pass perfusion imaging was conducted at rest and during adenosine stress. All CMR analyses were operated by experienced investigators blinded to all clinical data. One hundred nineteen female and 297 male patients were included and successfully examined (mean age 65 ± 11 and 63 ± 11 years, respectively). FFR was performed in 106 female and 251 male patients. Sensitivity and specificity of whole-heart dynamic 3D CMR stress perfusion imaging were 89% (95% CI: 77-96) and 82% (95% CI: 70-90) in the female population and 83% (95% CI: 77-86) and 79% (95% CI: 71-86) in the male population relative to QCA (P = 0.474 and P = 0.83, P-values for comparison between genders). Sensitivity and specificity were 95% (95% CI: 82-99) and 84% (95% CI: 73-92) in the female population and 83% (95% CI: 76-89) and 82% (95% CI: 74-88) in the male population when using FFR as the reference (P = 0.134 and P = 0.936, P-values for comparison between genders). Diagnostic accuracy in females was 92% (95% CI: 85-96) and 86% (95% CI: 81-90) in males when using FFR as the reference. The prevalence of CAD as defined by FFR (<0.8) was 36% in females and 53% in males. CONCLUSION: Whole-heart dynamic 3D CMR stress perfusion imaging has a high diagnostic accuracy for the detection of significant CAD irrespective of gender and is therefore a suitable non-invasive testing tool to detect myocardial ischaemia in both genders.

3D fusion of coronary CT angiography and CT myocardial perfusion imaging: Intuitive assessment of morphology and function.

BACKGROUND: The objective of this work was to support three-dimensional fusion of coronary CT angiography (coronary CTA) and CT myocardial perfusion (CT-Perf) data visualizing coronary artery stenoses and corresponding stress-induced myocardial perfusion deficits for diagnostics of coronary artery disease. METHODS: Twelve patients undergoing coronary CTA/CT-Perf after heart transplantation were included (56 ± 12 years, all males). CT image quality was rated. Coronary diameter stenoses >50% were documented for coronary CTA. Stress-induced perfusion deficits were noted for CT-Perf. A software was implemented facilitating 3D fusion imaging of coronary CTA/CT-Perf data. Coronary arteries and heart contours were segmented automatically. To overcome anatomical mismatch of coronary CTA/CT-Perf image acquisition, perfusion values were projected on the left ventricle as visualized in coronary CTA. Three resulting datasets (coronary tree/heart contour/perfusion values) were fused for combined three-dimensional rendering. 3D fusion was compared with conventional analysis of coronary CTA/CT-Perf data and to results from catheter coronary angiography. RESULTS: CT image quality was rated good-excellent (3.5 ± 0.5, scale 1-4). 3D fusion imaging of coronary CTA/CT-Perf data was feasible in 11/12 patients (92%). One patient (8%) was excluded from further analysis due to severe motion artifacts. 2 of 11 remaining patients (18%) showed both stress-induced perfusion deficits and relevant coronary stenoses. Using 3D fusion imaging, the ischemic region could be correlated to a culprit coronary lesion in one case (1/2 = 50%) and diagnostic findings could be rectified in the other case (1/2 = 50%). Coronary CTA was in full correspondence with catheter coronary angiography. CONCLUSION: A method for 3D fusion of coronary CTA/CT-Perf is introduced correlating relevant coronary lesions and corresponding stress-induced myocardial perfusion deficits.

Impact of stroke volume assessment by integrating multi-detector computed tomography and Doppler data on the classification of aortic stenosis.

BACKGROUND: The prevalence of low flow low gradient (LFLG) severe aortic stenosis (AS) may be overrated due to underestimation of stroke volume in two-dimensional (2D) echocardiography. The implications of 3D imaging on stroke volume calculation for AS classification have not been elucidated. Integrating multi-detector computed tomography (MDCT) and Doppler data may improve diagnostic accuracy in patients with LFLG AS. METHODS: A total of 186 patients with severe AS evaluated for transcatheter aortic valve replacement were classified according to indexed stroke volume (SVI, cut-off 35mL/m2) and mean transaortic pressure gradient (cut-off 40mmHg). SVI was calculated using a) the biplane Simpson's method, b) left ventricular outflow tract (LVOT) velocity time integral (VTI) and LVOT diameter determined by 2D echocardiography, or c) LVOT VTI and LVOT area planimetered by MDCT. RESULTS: SVI assessed by the biplane Simpson's method was smaller than that obtained from 2D echocardiography LVOT diameter (29.5±0.6 vs 34.9±0.8mL/m2, p<0.001). The latter was smaller than SVI calculated by integrating MDCT and Doppler data (47.5±1.4mL/m2, p<0.001). LFLG and paradoxical LFLG severe AS were diagnosed in 42.5% and 27.4% of patients using the biplane Simpson's method, in 30.1% and 16.7% using 2D echocardiography LVOT diameter, and in 17.2% and 8.1% when integrating MDCT and Doppler data. CONCLUSIONS: The prevalence of LFLG and paradoxical LFLG severe AS was overestimated by 2.5- and 3.4-fold based on 2D echocardiography alone. Integration of MDCT and Doppler data should be considered for stroke volume assessment in the classification of severe AS.

Detection of Acute Changes in Left Ventricular Function by Myocardial Deformation Analysis after Excessive Alcohol Ingestion.

BACKGROUND: The effects of acute excessive alcohol ingestion on echocardiographic parameters of left ventricular (LV) function are unclear. METHODS: One hundred ninety-nine healthy subjects (44 ± 5 years, 71% male) were prospectively examined within 6 hours after excessive alcohol ingestion as well as after 4 weeks with strict alcohol abstinence. Echocardiography was performed at baseline and follow-up for conventional parameters (left ventricular ejection fraction [LVEF], transmitral E and A Doppler flow velocities, E/A ratio, tissue Doppler velocity lateral and septal (é), E/é ratio, deceleration time of E, and isovolumic relaxation time) and myocardial deformation data (such as global radial and global and layer-specific circumferential [endo and epi global CS] and longitudinal [endo and epi global LS] strain). Multivariate regression was used to assess the impact of independent variables on echocardiographic parameters. RESULTS: Alcohol levels were 1.2 ± 0.3 g/L at the time of drinking cessation. After alcohol ingestion endo CS (30% ± 2% vs 37% ± 3%, P = .008) and endo LS (27% ± 4% vs 33% ± 3%, P = .002) were significantly lower at baseline versus follow-up. Blood pressure, LVEF and heart rate, and other echocardiographic parameters did not differ between the two examinations. Alcohol levels were modestly, negatively associated with change in endo CS and endo LS (r = -0.54, 95% CI, -0.63 to -0.43, P < .001; and r = -0.26, 95% CI, -0.39 to -0.14; P < .003, respectively). Alcohol levels were the strongest predictor for endo CS (ß = -4.84; 95% CI, -6.31 to -3.37) and endo LS (ß = -2.50; 95% CI, -4.32 to -0.68). CONCLUSIONS: Acute alcohol ingestion effects endocardial CS and LS, suggesting an acute and transient toxic effect on myocardial deformation, an effect that remains undetected by conventional echocardiographic parameters. The current findings may help clinicians to gain more understanding into the mechanism of developing an alcohol cardiomyopathy and to detect early persistent alcohol-induced myocardial disturbances for an effective therapy in time to prevent harm.

Intra-procedural determination of viability by myocardial deformation imaging: a randomized prospective study in the cardiac catheter laboratory.

BACKGROUND: The benefit of revascularization for functional recovery depends on the presence of viable myocardial tissue. OBJECTIVE: Myocardial deformation imaging allows determination of myocardial viability. METHODS: In a first approach, we assessed the optimal cutoff value to determine preserved viability by layer-specific echocardiographic myocardial deformation imaging at rest and low-dose dobutamine (DSE) echocardiography: regional endocardial circumferential strain (eCS) <-19% at rest was as accurate as eCS at DSE. In a main study, 123 patients (66% men, age 59 ± 6 years) with relevant coronary stenoses and corresponding severe regional myocardial dysfunction were included and randomized in 2 groups after coronary angiography: group A: intra-procedural myocardial deformation imaging in the cardiac catheter laboratory (CLab), determination of myocardial viability by regional eCS <-19%, in case of positive viability immediate coronary intervention in the same session. Group B: two-step determination of myocardial viability by cardiovascular magnetic resonance (CMR), in case of positive viability coronary intervention. After 18 months follow-up an analysis of the endpoints regarding cardiovascular events, left ventricular (LV) function, and comparison of cost was performed. RESULTS: Group A (N = 61) and group B (N = 62) showed no differences concerning localization of the coronary stenosis, comorbidities, or medical therapy. Cardiovascular events at 18-month follow-up were as follows: group A 13% (N = 10) vs. group B 14% (N = 9, p = 0.288); improvement of LV function: group A: +7 ± 2% vs. group B: +7 ± 3%, p = 0.963; costs: group A: 3096 Dollar vs. group B: 6043 Dollar, p < 0.001. CONCLUSION: Intra-procedural determination of myocardial viability by myocardial deformation imaging in the CLab is feasible, safe, and cost effective and may become an emerging alternative to the current practice of two-stage viability diagnostics.

Analysis of spatiotemporal fidelity in quantitative 3D first-pass perfusion cardiovascular magnetic resonance.

BACKGROUND: Whole-heart first-pass perfusion cardiovascular magnetic resonance (CMR) relies on highly accelerated image acquisition. The influence of undersampling on myocardial blood flow (MBF) quantification has not been systematically investigated yet. In the present work, the effect of spatiotemporal scan acceleration on image reconstruction accuracy and MBF error was studied using a numerical phantom and validated in-vivo. METHODS: Up to 10-fold scan acceleration using k-t PCA and k-t SPARSE-SENSE was simulated using the MRXCAT CMR numerical phantom framework. Image reconstruction results were compared to ground truth data in the k-f domain by means of modulation transfer function (MTF) analysis. In the x-t domain, errors pertaining to specific features of signal intensity-time curves and MBF values derived using Fermi model deconvolution were analysed. In-vivo first-pass CMR data were acquired in ten healthy volunteers using a dual-sequence approach assessing the arterial input function (AIF) and myocardial enhancement. 10x accelerated 3D k-t PCA and k-t SPARSE-SENSE were compared and related to non-accelerated 2D reference images. RESULTS: MTF analysis revealed good recovery of data upon k-t PCA reconstruction at 10x undersampling with some attenuation of higher temporal frequencies. For 10x k-t SPARSE-SENSE the MTF was found to decrease to zero at high spatial frequencies for all temporal frequencies indicating a loss in spatial resolution. Signal intensity-time curve errors were most prominent in AIFs from 10x k-t PCA, thereby emphasizing the need for separate AIF acquisition using a dual-sequence approach. These findings were confirmed by MBF estimation based on AIFs from fully sampled and undersampled simulations. Average in-vivo MBF estimates were in good agreement between both accelerated and the fully sampled methods. Intra-volunteer MBF variation for fully sampled 2D scans was lower compared to 10x k-t PCA and k-t SPARSE-SENSE data. CONCLUSION: Quantification of highly undersampled 3D first-pass perfusion CMR yields accurate MBF estimates provided the AIF is obtained using fully sampled or moderately undersampled scans as part of a dual-sequence approach. However, relative to fully sampled 2D perfusion imaging, intra-volunteer variation is increased using 3D approaches prompting for further developments.

Prediction of Outcomes in Patients with Chronic Ischemic Cardiomyopathy by Layer-Specific Strain Echocardiography: A Proof of Concept.

BACKGROUND: Cardiac magnetic resonance imaging (CMR) has been established as a powerful tool for predicting mortality. However, its application is limited by availability and various contraindications. The aim of this study was to evaluate the predictive value of layer-specific myocardial deformation analysis as assessed by strain echocardiography for cardiac events in patients with chronic ischemic left ventricular dysfunction in comparison with CMR. METHODS: Three hundred ninety patients (mean age, 63 ± 4 years; 69% men; mean left ventricular ejection fraction [LVEF], 41 ± 7%) with chronic ischemic cardiomyopathy were prospectively enrolled and underwent strain echocardiography and CMR within 3 ± 1 days. LVEF, wall motion score index, and circumferential strain (CS), longitudinal strain, and radial strain for total wall thickness and for three myocardial layers (endocardial, midmyocardial, and epicardial) were determined by echocardiography. The extent of total myocardial scar (TMS) was determined by CMR. Follow-up was obtained for a mean of 4.9 ± 2.2 years. Cardiac events were defined as readmission for worsening of heart failure, ventricular arrhythmias, or death of any cause. The incremental value of LVEF, strain parameters, and TMS to relevant clinical variables was determined in nested Cox models. RESULTS: There were 133 cardiac events (34%). Baseline clinical data associated with outcomes were age (hazard ratio [HR], 1.27; P = .04), diabetes mellitus (HR, 1.52; P = .001), and renal insufficiency (HR, 1.77; P = .001) by multivariate analysis. The addition of LVEF, global and endocardial strain parameters, and TMS increased the predictive power, but endocardial CS (HR, 1.52; P < .01) caused the greatest increment in model power (χ(2) = 39.2, P < .001). Endocardial CS < -20% was found to be the optimal predictor of prognosis. CONCLUSIONS: Endocardial CS is a powerful predictor of cardiac events and appears to be a better parameter than LVEF, TMS by CMR, and other strain variables by echocardiography.

Myocardial deformation by strain echocardiography identifies patients with acute coronary syndrome and non-diagnostic ECG presenting in a chest pain unit: a prospective study of diagnostic accuracy.

OBJECTIVE: Clinical assessment often cannot risk stratify patients hospitalized with chest pain and non-diagnostic electrocardiography (ECG) or myocardial enzymes. An inappropriate admission of patients with non-cardiac chest pain is an enormous cost factor. METHODS: 2315 patients who presented in the chest pain unit (CPU) with symptoms suggestive of acute coronary syndrome (ACS) were screened. All patients with relevant changes in ECG or myocardial enzymes were excluded. 268 consecutive patients (mean 58 ± 7 years, 88 men) were prospectively included and underwent echocardiography for left ventricular ejection fraction (LVEF), wall motion score index (WMSI) and strain parameter and a coronary angiography (CA) within 2 ± 1 days after admission. RESULTS: Anatomically obstructive coronary artery disease (CAD) (≥70 % diameter stenosis) was present in 110 patients (41 %). The incremental value of LVEF, WMSI, and strain parameters to relevant clinical variables was determined in nested Cox models. Baseline clinical data associated with relevant CAD were age [hazard ratio (HR) 1.31, p = 0.03], arterial hypertension (HR 1.39, p = 0.03) and diabetes (HR 1.46, p = 0.001). The addition of endocardial global circumferential strain (GCS) (HR 1.57, p < 0.001) caused the greatest increment in model power (χ (2) = 43.4, p < 0.001). Optimal cut-off value was calculated as -21.7 % for GCS (sensitivity 87 %, specificity 76 %) to differentiate between these patients. CONCLUSIONS: In patients with suspected ACS but without ECG changes or myocardial enzyme abnormalities, myocardial deformation imaging can identify patients at risk. This approach may be applied to improve decision guidance at the CPU for fast discharge of patients with non-cardiac chest pain or prompt cardiological allocation of patients with CAD. CLINICAL TRIAL REGISTRATION: NCT 02357641.

Analysis of procedural effects of percutaneous edge-to-edge mitral valve repair by 2D and 3D echocardiography.

BACKGROUND: Analysis of procedural effects in patients undergoing percutaneous mitral valve repair (PMVR) using the edge-to-edge technique is complex, and common methods to define mitral regurgitation severity based on 2-dimensional (2D) echocardiography are not validated for postprocedural double-orifice mitral valve. This study used 3D transesophageal echocardiography (TEE) to determine the functional and morphological effects of PMVR. METHODS AND RESULTS: In 39 high-risk surgical patients with moderate to severe functional mitral valve regurgitation, 3D TEE with and without color Doppler as well as 2D transthoracic and TEE was performed before and after PMVR (MitraClip device). Mitral valve regurgitant volume by color Doppler 3D TEE was determined as the product of vena contracta areas defined by direct planimetry and velocity time integral using continuous-wave Doppler. Regurgitant volume was reduced from 84.1±38.3 mL preintervention to 35.6±25.6 mL postintervention. Patients in whom vena contracta area could be reduced >50% had a smaller preprocedural mitral annulus area compared with patients with ≤50% reduction (11.9±3.9 versus 16.1±8.5 cm(2), respectively; P=0.036) and tended to have a smaller mitral annulus circumference (13.0±2.0 versus 14.8±4.1 cm, respectively; P=0.112). At 6 months follow-up, left atrial and left ventricular end-diastolic volumes were significantly more reduced in patients in whom regurgitant vena contracta area was reduced by >50% compared with those with less reduction (-11.4±5.2 versus -4.8±7.7%; P=0.005, and -11.0±7.2 versus -4.5±9.3%; P=0.028). The maximum diastolic mitral valve area decreased from 6.0±2.0 to 2.9±0.9 cm(2) (P<0.0001). CONCLUSIONS: Three dimensional TEE demonstrates significant reduction of regurgitant volume after PMVR. The unique visualization of the mitral valve by 3D TEE allows improved understanding of the morphological and functional changes induced by PMVR.

Comparison of accuracy of mitral valve regurgitation volume determined by three-dimensional transesophageal echocardiography versus cardiac magnetic resonance imaging.

Direct planimetry of anatomic regurgitation orifice area (AROA) using 3-dimensional transesophageal echocardiography (TEE) has been described. This study sought to (1) compare mitral valve regurgitant volume (RV) derived by AROA using 3-dimensional TEE with RV obtained by cardiac magnetic resonance (CMR) imaging and (2) determine the impact of AROA and flow velocity changes throughout systole on the dynamic variation in mitral regurgitation. In 43 patients (71 ± 11 years old) with mild to severe mitral regurgitation, 3-dimensional TEE and CMR were performed. Mitral valve RV was determined based on (1) AROA at 5 subintervals of systole and analysis of the regurgitant continuous-wave Doppler signal at equal durations of systole, (2) effective regurgitation orifice area (EROA) using the proximal isovelocity surface area method, (3) CMR with subtraction of aortic outflow volume from left ventricular stroke volume. RV calculated by AROA tended to overestimate RV less than RV calculated by EROA compared to RV by CMR (average bias +20 ml, 95% confidence interval [CI] -41 to +81, vs +13 ml, 95% CI -22 to 47). In patients with RV >30 ml by CMR, overestimation of RV using the AROA method was less than using the EROA method (difference in means +18 ml, 95% CI 4 to 32, p <0.001). AROA determined by 3-dimensional TEE varied by only 18% among the 5 subintervals of systole, and the velocity time integral of the subinterval with the highest flow was 120% of the subinterval with the lowest flow. In conclusion, 3-dimensional TEE allows accurate analysis of mitral valve RV. In the clinically relevant group of patients with RV >30 ml as defined by CMR, the AROA method results in less overestimation of RV than the EROA method. Changes in AROA during systole contribute much less to dynamic variation in mitral regurgitation severity than changes in regurgitant flow velocity.

Comparison of two-dimensional and three-dimensional imaging techniques for measurement of aortic annulus diameters before transcatheter aortic valve implantation.

AIMS: Different two-dimensional (2D) and three-dimensional (3D) imaging techniques are used for procedure planning and selection of prosthesis size before transcatheter aortic valve implantation. This study sought to compare different 2D and 3D imaging techniques and determine the accuracy of 3D transoesophageal echocardiography (TEE) for accurate analysis of aortic annulus dimensions. METHODS: In 49 consecutive patients with severe aortic stenosis undergoing transcatheter aortic valve implantation angiography, 2D transthoracic echocardiography (TTE), 2D and 3D TEE, and dual-source CT (DSCT) were performed to determine aortic annulus diameters. TTE and 2D TEE provided only one diameter of the aortic annulus. Angiography, DSCT and 3D TEE allowed measurement of diameters in sagittal and coronal views. The distance between aortic annulus and left main coronary artery ostium was measured by angiography, DSCT and 3D TEE. RESULTS: Sagittal diameters determined by angiography, TTE, 2D TEE, 3D TEE and DSCT were smaller than coronal diameters determined by angiography, 3D TEE and DSCT. Coronal and sagittal diameters determined by 3D TEE were in high agreement with corresponding measurements by DSCT (23.60±1.89 vs 23.46±2.07 mm and 22.19±1.96 vs 22.27±2.01 mm, respectively; mean±SD). There was a high correlation between DSCT and 3D TEE for the definition of coronal and sagittal aortic annulus diameters (r=0.88, SEE=0.89 mm and r=0.77, SEE=1.26 mm, respectively). Correlation of 3D TEE (13.47±1.67 mm) and DSCT (13.64±1.82 mm) in the analysis of the distance between aortic annulus and left main coronary artery ostium was better (r=0.54, SEE=1.55 mm) than between angiography (14.85±3.84 mm) and DSCT (r=0.35, SEE=1.77 mm). CONCLUSIONS: 3D imaging techniques should be used to evaluate aortic annulus diameters, as 2D imaging techniques, providing only a sagittal view, underestimate them. 3D TEE provides measurements of aortic annulus diameters similar to those obtained by DSCT.