Unmasking Myocardial Dysfunction in Patients Hospitalized for Community-Acquired Pneumonia Using a 4-Chamber 3-Dimensional Volume/Strain Analysis.

Lower respiratory infection was reported as the most common fatal infectious disease. Community-acquired pneumonia (CAP) and myocardial injury are associated; yet, true prevalence of myocardial injury is probably underestimated. We assessed the rate and severity of myocardial dysfunction in patients with CAP. Admitted patients diagnosed with CAP were prospectively recruited. All the patients had C-reactive protein (CRP), brain natriuretic peptide (BNP), and high-sensitivity cardiac troponin (hs-cTnl) tests added to their routine workup. 2D/3D Doppler echocardiography was done on a Siemens Acuson SC2000 machine ≤ 24 h of diagnosis. 3D datasets were blindly analyzed for 4-chamber volumes/strains using EchobuildR 3D-Volume Analysis prototype software, v3.0 2019, Siemens-Medical Solutions. Volume/strain parameters were correlated with admission clinical and laboratory findings. The cohort included 34 patients, median age 60 years (95% CI 55-72). The cohort included 18 (53%) patients had hypertension, 9 (25%) had diabetes mellitus, 7 (21%) were smokers, 7 (21%) had previous myocardial infarction, 4 (12%) had chronic renal failure, and 1 (3%) was on hemodialysis treatment. 2D/Doppler echocardiography findings showed normal ventricular size/function (LVEF 63 ± 9%), mild LV hypertrophy (104 ± 36 g/m2), and LA enlargement (41 ± 6 mm). 3D volumes/strains suggested bi-atrial and right ventricular dysfunction (global longitudinal strain RVGLS = - 8 ± 4%). Left ventricular strain was normal (LVGLS = - 18 ± 5%) and correlated with BNP (r = 0.40, p = 0.024). The patients with LVGLS > - 17% had higher admission blood pressure and lower SaO2 (144 ± 33 vs. 121 ± 20, systolic, mmHg, p = 0.02, and 89 ± 4 vs. 94 ± 4%, p = 0.006, respectively). hs-cTnl and CRP were not different. Using novel 3D volume/strain software in CAP patients, we demonstrated diffuse global myocardial dysfunction involving several chambers. The patients with worse LV GLS had lower SaO2 and higher blood pressure at presentation. LV GLS correlated with maximal BNP level and did not correlate with inflammation or myocardial damage markers.

Tricuspid and mitral remodelling in atrial fibrillation: a three-dimensional echocardiographic study.

AIMS: Atrial fibrillation (AF) is associated with atrial enlargement, mitral annulus (MA) and tricuspid annulus (TA) dilation, and atrial functional regurgitation (AFR). However, less is known about the impact of AF on both atrioventricular valves in those with normal and abnormal ventricular function. We aimed to compare the remodelling of the TA and MA in patients with non-valvular AF without significant AFR. METHODS AND RESULTS: Ninety-two patients referred for transoesophageal echocardiography were included and categorized into three groups: (i) AF with normal left ventricular (LV) function (Normal LV-AF), n = 36; (ii) AF with LV systolic dysfunction (LVSD-AF), n = 29; and (iii) Controls in sinus rhythm, n = 27. Three-dimensional MA and TA geometry were analysed using automated software. In patients with AF regardless of LV function, the MA and TA areas were larger compared with controls (LVSD-AF vs. Normal LV-AF vs. Controls, end-systolic MA: 5.2 ± 1.1 vs. 4.5 ± 0.7 vs. 3.9 ± 0.7 cm2/m2; end-systolic TA: 5.6 ± 1.3 vs. 5.3 ± 1.3 vs. 4.1 ± 0.7 cm2/m2; P < 0.05 for each comparison with Controls). TA and MA areas were not statistically different between the two AF groups. The TA increase over controls was greater than that of the MA in the Normal LV-AF group (27.7% vs. 15.6%, P = 0.041). Conversely, in the LVSD-AF group, MA and TA increased similarly (35.9% vs. 32.4%, P = 0.660). CONCLUSION: Patients with AF showed dilation of both TA and MA compared with patients in sinus rhythm. In patients with normal LV function, AF was associated with greater TA dilation than MA dilation whereas in patients with LVSD the TA and MA were equally dilated.

Systematic Comparison of Left Ventricular Geometry Between 3D-Echocardiography and Cardiac Magnetic Resonance Imaging.

Aims: Left ventricular (LV) volumes estimated using three-dimensional echocardiography (3D-echo) have been reported to be smaller than those measured using cardiac magnetic resonance (CMR) imaging, but the underlying causes are not well-understood. We investigated differences in regional LV anatomy derived from these modalities and related subsequent findings to image characteristics. Methods and Results: Seventy participants (18 patients and 52 healthy participants) were imaged with 3D-echo and CMR (<1 h apart). Three-dimensional left ventricular models were constructed at end-diastole (ED) and end-systole (ES) from both modalities using previously validated software, enabling the fusion of CMR with 3D-echo by rigid registration. Regional differences were evaluated as mean surface distances for each of the 17 American Heart Association segments, and by comparing contours superimposed on images from each modality. In comparison to CMR-derived models, 3D-echo models underestimated LV end-diastolic volume (EDV) by -16 ± 22, -1 ± 25, and -18 ± 24 ml across three independent analysis methods. Average surface distance errors were largest in the basal-anterolateral segment (11-15 mm) and smallest in the mid-inferoseptal segment (6 mm). Larger errors were associated with signal dropout in anterior regions and the appearance of trabeculae at the lateral wall. Conclusions: Fusion of CMR and 3D-echo provides insight into the causes of volume underestimation by 3D-echo. Systematic signal dropout and differences in appearances of trabeculae lead to discrepancies in the delineation of LV geometry at anterior and lateral regions. A better understanding of error sources across modalities may improve correlation of clinical indices between 3D-echo and CMR.

Understanding tricuspid valve remodelling in atrial fibrillation using three-dimensional echocardiography.

AIMS: Atrial fibrillation (AF) has been associated with tricuspid annulus (TA) dilation in patients with severe functional tricuspid regurgitation (TR); however, the impact of AF is less clear in patients without severe TR. Our aim was to characterize TA remodelling in patients with AF in the absence of severe TR using 3D transoesophageal echocardiography (TOE). METHODS AND RESULTS: Ninety patients underwent clinically indicated transthoracic and TOE: non-structural (NS)-AF (n = 30); AF with left heart disease (LHD) (n = 30), and controls in sinus rhythm (n = 30). Three-dimensional TOE datasets were analysed to measure TA dimensions using novel dedicated tricuspid valve software. The NS-AF group showed biatrial dilatation and normal right ventricular (RV) size with decreased longitudinal function compared to controls, whereas the LHD-AF group showed biatrial dilatation, RV enlargement, decreased biventricular function, and higher systolic pulmonary artery pressure compared with the other groups. Indexed TA area, minimum diameter, maximum diameter, and total perimeter were significantly larger in the NS-AF group than in controls (measurements in end-diastole: 6.4 ± 1.1 vs. 5.0 ± 0.6 cm2/m2, 1.8 ± 0.3 vs. 1.6 ± 0.2 cm/m2, 2.1 ± 0.3 vs. 1.9 ± 0.2 cm/m2, and 6.6 ± 0.9 vs. 5.9 ± 0.7 cm/m2, respectively, all P < 0.05). There was no significant difference in any indexed TA parameter between AF groups. TA circularity index (ratio between minimum and maximal diameters) and TA fractional area change between end-diastole and end-systole were no different among the three groups. CONCLUSION: AF is associated with right atrial and tricuspid annular remodelling independent of the presence of LHD in patients with intrinsically normal tricuspid leaflets without severe TR.

Automated 3-Dimensional Single-Beat Real-Time Volume Colour Flow Doppler Echocardiography in Children: A Validation Study of Right and Left Heart Flows.

BACKGROUND: Novel quantification of stroke volume according to mitral inflow and aortic outflow using automated real-time 3-dimensional volume colour flow Doppler echocardiography (3D-RT-VCFDE) is more accurate than 2-dimensional echocardiography and has excellent correlation with cardiac magnetic resonance imaging-based flows in adults. This technology is applied for the first time to the right heart and in children. METHODS: 3D-RT-VCFDE was performed in 61 image sets of flow through the aortic (AV), mitral (MV), pulmonary (PV), and tricuspid (TV) valves of 34 children. These were compared with stroke volumes of the right (RV) and left (LV) ventricles and ratio of pulmonary to systemic blood flow determined using the Fick method in 31 children with atrial shunts. RESULTS: The mean age was 8.0 ± 3.3 years, and the mean weight was 27.8 ± 10.0 kg. The mean temporal resolution for flow analyses was ≥ 22 volumes per second. In conditions with no shunt, the correlations were: AV with MV flows (r = 0.98), PV with TV flows (r = 0.96), RV stroke volume with PV flow (r = 0.95), and with TV flow (r = 0.93), LV stroke volume with AV flow (r = 0.87), and with MV flow (r = 0.89). Fick ratio of pulmonary to systemic blood flow correlations were: PV/AV ratio (r = 0.84), TV/MV ratio (r = 0.87), and RV/LV ratio (r = 0.70). CONCLUSIONS: Stroke volume determined using automated 3D-RT-VCFDE is feasible in children and in the right side of the heart. This technique potentially provides a noninvasive alternative to historically invasively acquired hemodynamic data and to cardiac magnetic resonance imaging.

Left Ventricular Systolic Myocardial Deformation: A Comparison of Two- and Three-Dimensional Echocardiography in Children.

BACKGROUND: The clinical applicability and reliability of three-dimensional (3D) speckle-tracking echocardiography has not been well studied in pediatric patients. The aim of this study was to compare two-dimensional (2D) echocardiography and 3DE real-time full-volume-derived strain and rotation indices in healthy children and patients with dilated cardiomyopathy (DCM). METHODS: Children with either normal function or DCM were prospectively recruited in an outpatient setting, and deformation indices, including circumferential, radial, and longitudinal strain and torsion, were measured by 2D and 3D echocardiography. Control subjects were compared with patients using the Mann-Whitney U test, correlations between 2D and 3D measurements were analyzed using Spearman correlation analysis, and reproducibility analyses are reported using intraclass correlation coefficients and coefficient of variations. RESULTS: The study cohort consisted of 15 patients (47%) with DCM and 17 control subjects (53%). The median age of the cohort was 13.4 years (range, 5.7-19.3 years). By both 2D and 3D analysis, magnitudes of global longitudinal (P = .01), circumferential (P = .007), and radial (P = .004) strain were significantly lower in patients with DCM in comparison with control subjects. Using receiver operating characteristic curves, lower values of absolute circumferential (area under the curve = 0.95, P < .0001) and longitudinal (area under the curve = 0.93, P < .0001) strain were associated with left ventricular dysfunction. No difference was noted in torsion between control subjects and patients. Three-dimensional analysis was superior to 2D analysis in terms of intraobserver, interobserver, and test-retest reliability. CONCLUSIONS: Left ventricular deformation shows significant changes while torsion is preserved in outpatients with DCM compared with control subjects. Three-dimensional global strain can discriminate subtle left ventricular dysfunction and has better reproducibility in comparison with 2D echocardiography. High-resolution 3D imaging is a useful clinical assessment tool for cardiac performance and may overcome some of the limitations of 2D analysis.

Feasibility of Automated Three-Dimensional Rotational Mechanics by Real-Time Volume Transthoracic Echocardiography: Preliminary Accuracy and Reproducibility Data Compared with Cardiovascular Magnetic Resonance.

BACKGROUND: Three-dimensional (3D) speckle-tracking echocardiography (STE) for myocardial strain imaging may be superior to two-dimensional STE, especially with respect to rotational mechanics. Automated strain measurements from nonstitched 3D STE may improve work flow and clinical utility. The aim of this study was to test the feasibility of model-based 3D STE for the automated measurement of voxel circumferential strain (Ecc) and myocardial rotation. METHODS: Thirty-five individuals (12 healthy volunteers, 12 patients with dilated cardiomyopathy, and 11 patients with hypertensive left ventricular [LV] hypertrophy) were prospectively studied. The latter two groups did not have significant coronary artery disease on coronary arteriography. Tagged cardiovascular magnetic resonance (CMR) and feature-tracking CMR were used as reference standards. Regional (apex and mid left ventricle) and slice (within a region) Ecc and rotation were measured by real-time volume transthoracic echocardiography (nonstitched) using an automated algorithm. RESULTS: Compared with both CMR techniques, apical and mid-LV Ecc (concordance correlation coefficients [CCCs], 0.84-0.95 and 0.48-0.68) and rotation (CCCs, 0.70-0.95 and 0.42-0.68) showed excellent, good, and moderate agreement, respectively. At the LV base, rotation showed poor agreement with CMR methods (CCC, 0.04-0.21), consistent with previous descriptions, but calculated LV twist showed moderate to good correlation with CMR techniques (CCC, 0.61-0.84). However, the 95% CI for measurements between techniques was wide, emphasizing the challenges in comparing voxel deformation by 3D echocardiography with CMR, compounded by differences in approaches to measuring deformation, and matching regional and slice measurements between techniques. Reproducibility (n = 10, including test-retest variability) of automated 3D strain and rotation measurements was good to excellent (coefficient of variation < 10%) and was comparable with that of CMR methods (coefficient of variation < 10%) in the same patients. CONCLUSIONS: The data from this study show that automated measurements of voxel rotational mechanics by real-time volume transthoracic echocardiography is feasible and comparable with tagged CMR and feature-tracking CMR strain measurements, albeit with wide limits of agreement, emphasizing the differences between the modalities. Furthermore, this automated 3D speckle-tracking echocardiographic approach shows excellent reproducibility, including test-retest variability, comparable with that of the CMR methods.

Differences in aortic vortex flow pattern between normal and patients with stroke: qualitative and quantitative assessment using transesophageal contrast echocardiography.

The flow in the aorta forms a vortex, which is a critical determinant of the flow dynamics in the aorta. Arteriosclerosis can alter the blood flow pattern of the aorta and cause characteristic alterations of the vortex. However, this change in aortic vortex has not yet been studied. This study aimed to characterize aortic vortex flow pattern using transesophageal contrast echocardiography in normal and stroke patients. A total of 85 patients who diagnosed with ischemic stroke and 16 normal controls were recruited for this study. The 16 normal control subjects were designated as the control group, and the 85 ischemic stroke patients were designated as the stroke group. All subjects underwent contrast transesophageal echocardiography (TEE), and particle image velocimetry was used to assess aortic vortex flow. Qualitative and quantitative analyses of vortex flow morphology, location, phasic variation, and pulsatility were undertaken and compared between the groups. In the control group, multiple irregularly-shaped vortices were observed in a peripheral location in the descending thoracic aorta. In contrast, the stroke group had a single, round, merged, and more centrally located aortic vortex flow. In the quantitative analysis of vortex, vortex depth, which represents the location of the major vortex in the aorta, was significantly higher in the control group than in the stroke group (0.599 ± 0.159 vs. 0.522 ± 0.101, respectively, P = 0.013). Vortex relative strength, which is the pulsatility parameter of the vortex itself, was significantly higher in the stroke group than in the control group (0.367 ± 0.148 vs. 0.304 ± 0.087, respectively, P = 0.025). It was feasible to visualize and quantify the characteristic morphology and pulsatility of the aortic vortex flow using contrast TEE, and aortic vortex pattern significantly differed between normal and stroke patients.

Two-dimensional speckle tracking echocardiography: standardization efforts based on synthetic ultrasound data.

AIMS: Speckle tracking echocardiography has already demonstrated its clinical potential. However, its use in routine practice is jeopardized by recent reports on high inter-vendor variability of the measurements. As such, the European Association of CardioVascular Imaging (EACVI) and the American Society of Echocardiography (ASE) set up a standardization task force, which was joined by all manufacturers of echocardiographic equipment as well as by companies offering software solutions only, with the ambition to tackle this problem by standardization and quality assurance (QA). METHODS AND RESULTS: In this study, a first step towards QA of all commercially available tracking solutions based on computer-generated ultrasound images is presented. The accuracy of the products was acceptable with relative errors below 10% and intra-vendor reproducibility within 5%. CONCLUSION: Whether these results can be extrapolated to the clinical setting is the topic of an ongoing study of the EACVI/ASE/Industry Task Force to standardize deformation imaging. This study was an important first step in the development of generally accepted tools for QA of speckle tracking echocardiography.

Clinical impact of quantitative left atrial vortex flow analysis in patients with atrial fibrillation: a comparison with invasive left atrial voltage mapping.

Recently, left atrial (LA) vortex flow analysis using contrast transesophageal echocardiography (TEE) has been shown to be feasible and has demonstrated significant differences in vortex flow morphology and pulsatility between normal subjects and patients with atrial fibrillation (AF). However, the relationship between LA vortex flow and electrophysiological properties and the clinical significance of LA vortex flow are unknown. The aims of this study were (1) to compare LA vortex flow parameters with LA voltage and (2) to assess the predictive value of LA vortex flow parameters for the recurrence of AF after radiofrequency catheter ablation (RFCA). Thirty-nine patients with symptomatic non-valvular AF underwent contrast TEE before undergoing RFCA for AF. Quantitative LA vortex flow parameters were analyzed by Omega flow (Siemens Medical Solution, Mountain View, CA, USA). The morphology and pulsatility of LA vortex flow were compared with electrophysiologic parameters that were measured invasively. Hemodynamic, electrophysiological, and vortex flow parameters were compared between patients with and without early recurrence of AF after RFCA. Morphologic parameters, including LA vortex depth, length, width, and sphericity index were not associated with LA voltage or hemodynamic parameters. The relative strength (RS), which represents the pulsatility power of LA, was positively correlated with LA voltage (R = 0.53, p = 0.01) and LA appendage flow velocity (R = 0.73, p < 0.001) and negatively correlated with LA volume index (R = -0.56, p < 0.001). Patients with recurrent AF after RFCA showed significantly lower RS (1.7 ± 0.2 vs 1.9 ± 0.4, p = 0.048) and LA voltage (0.9 ± 0.7 vs 1.7 ± 0.8, p = 0.004) than patients without AF recurrence. In the relatively small LA dimension group (LA volume index ≤ 33 ml/m(2)), RS was significantly lower (2.1 ± 0.3 vs 1.7 ± 0.1, p = 0.029) in patients with the recurrent AF. Quantitative LA vortex flow analysis, especially RS, correlated well with LA voltage. Decreased pulsatility strength in the LA was associated with recurrent AF. LA vortex may have incremental value in predicting the recurrence of AF.

Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging.

Recognizing the critical need for standardization in strain imaging, in 2010, the European Association of Echocardiography (now the European Association of Cardiovascular Imaging, EACVI) and the American Society of Echocardiography (ASE) invited technical representatives from all interested vendors to participate in a concerted effort to reduce intervendor variability of strain measurement. As an initial product of the work of the EACVI/ASE/Industry initiative to standardize deformation imaging, we prepared this technical document which is intended to provide definitions, names, abbreviations, formulas, and procedures for calculation of physical quantities derived from speckle tracking echocardiography and thus create a common standard.

Three-dimensional transesophageal echocardiographic study of aortic-mitral valve coupling after coronary artery bypass grafting.

AIMS: To observe the geometric changes in aortic-mitral valve coupling (AMC) on three-dimensional transesophageal echocardiography and the factors leading to decreased mitral regurgitation (MR) after coronary artery bypass grafting (CABG). METHODS AND RESULTS: This study included 23 patients undergoing CABG for coronary artery disease. Fifteen patients with moderate to severe MR were separately analyzed to determine whether the severity of MR influences the geometric change in AMC. Echocardiographic examinations were performed pre- and post-CABG, and the studied parameters were obtained using Siemens Auto Valve Analysis software. The effective mitral regurgitant orifice area, left ventricular ejection fraction (LVEF), end-diastolic volume (EDV), and end-systolic volume (ESV) were measured pre- and post-CABG using Philips QLAB software. Ischemic MR, EDV, and ESV significantly decreased (all P < 0.05) and LVEF significantly improved (P < 0.05) after CABG. There were no significant differences between the pre- and post-CABG mitral valve (MV) parameters, aortic valve parameters, aortic-mitral annular angle, or centroid distance (all P > 0.05). Patients with moderate to severe MR exhibited the same results. CONCLUSION: The results of this study show that CABG does not cause an acute change in the geometry of AMC. Improved left ventricular function might increase the closing force of the MV, leading to decreased MR after CABG alone. MR significantly improved after CABG alone without MV treatment in the present study. This result may help to guide surgeons in choosing the optimal surgical methods for individual patients.

Four-dimensional modelling of the mitral valve by real-time 3D transoesophageal echocardiography: proof of concept.

OBJECTIVES: The complexity of the mitral valve (MV) anatomy and function is not yet fully understood. Assessing the dynamic movement and interaction of MV components to define MV physiology during the complete cardiac cycle remains a challenge. We herein describe a novel semi-automated 4D MV model. METHODS: The model applies quantitative analysis of the MV over a complete cardiac cycle based on real-time 3D transoesophageal echocardiography (RT3DE) data. RT3DE data of MVs were acquired for 18 patients. The MV annulus and leaflets were semi-automatically reconstructed. Dimensions of the mitral annulus (anteroposterior and anterolateral-posteromedial diameter, annular circumference, annular area) and leaflets (MV orifice area, intercommissural distance) were acquired. Variability and reproducibility (intraclass correlation coefficient, ICC) for interobserver and intraobserver comparison were quantified at 4 time points during the cardiac cycle (mid-systole, end-systole, mid-diastole and end-diastole). RESULTS: Mitral annular dimensions provided highly reliable and reproducible measurements throughout the cardiac cycle for interobserver (variability range, 0.5-1.5%; ICC range, 0.895-0.987) and intraobserver (variability range, 0.5-1.6%; ICC range, 0.827-0.980) comparison, respectively. MV leaflet parameters showed a high reliability in the diastolic phase (variability range, 0.6-9.1%; ICC range, 0.750-0.986), whereas MV leaflet dimensions showed a high variability and lower correlation in the systolic phase (variability range, 0.6-22.4%; ICC range, 0.446-0.915) compared with the diastolic phase. CONCLUSIONS: This 4D model provides detailed morphological reconstruction as well as sophisticated quantification of the complex MV structure and dynamics throughout the cardiac cycle with a precision not yet described.

Quantitative assessment of mitral inflow and aortic outflow stroke volumes by 3-dimensional real-time full-volume color flow doppler transthoracic echocardiography: an in vivo study.

OBJECTIVES: Noninvasive quantification of left ventricular (LV) stroke volumes has an important clinical role in assessing circulation and monitoring therapeutic interventions for cardiac disease. This study validated the accuracy of a real-time 3-dimensional (3D) color flow Doppler method performed during transthoracic echocardiography (TTE) for quantifying volume flows through the mitral and aortic valves using a dedicated offline 3D flow computation program compared to LV sonomicrometry in an open-chest animal model. METHODS: Forty-six different hemodynamic states in 5 open-chest pigs were studied. Three-dimensional color flow Doppler TTE and 2-dimensional (2D) TTE were performed by epicardial scanning. The dedicated software was used to compute flow volumes at the mitral annulus and the left ventricular outflow tract (LVOT) with the 3D color flow Doppler method. Stroke volumes by 2D TTE were computed in the conventional manner. Stroke volumes derived from sonomicrometry were used as reference values. RESULTS: Mitral inflow and LVOT outflow derived from the 3D color flow Doppler method correlated well with stroke volumes by sonomicrometry (R = 0.96 and 0.96, respectively), whereas correlation coefficients for mitral inflow and LVOT outflow computed by 2D TTE and stroke volumes by sonomicrometry were R = 0.84 and 0.86. Compared to 2D TTE, the 3D method showed a smaller bias and narrower limits of agreement in both mitral inflow (mean ± SD: 3D, 2.36 ± 2.86 mL; 2D, 10.22 ± 8.46 mL) and LVOT outflow (3D, 1.99 ± 2.95 mL; 2D, 4.12 ± 6.32 mL). CONCLUSIONS: Real-time 3D color flow Doppler quantification is feasible and accurate for measurement of mitral inflow and LVOT outflow stroke volumes over a range of hemodynamic conditions.

Effects of right ventricular hemodynamic burden on intraventricular flow in tetralogy of fallot: an echocardiographic contrast particle imaging velocimetry study.

BACKGROUND: The purpose of this investigation was to test the hypothesis that flow patterns in the right ventricle are abnormal in patients with repaired tetralogy of Fallot (TOF). High-resolution echocardiographic contrast particle imaging velocimetry was used to investigate rotation intensity and kinetic energy dissipation of right ventricular (RV) flow in patients with TOF compared with normal controls. METHODS: Forty-one subjects (16 with repaired TOF and varying degrees of RV dilation and 25 normal controls) underwent prospective contrast imaging using the lipid-encapsulated microbubble (Definity) on Sequoia systems. A mechanical index of 0.4, three-beat high-frame rate (>60 Hz) captures, and harmonic frequencies were used. Rotation intensity and kinetic energy dissipation of flow in the right and left ventricles were studied (Hyperflow). Ventricular volumes and ejection fractions in all subjects were derived from same-day cardiac magnetic resonance (CMR). RESULTS: Measurable planar maps were obtained for the left ventricle in 14 patients and the right ventricle in 10 patients among those with TOF and for the left ventricle in 23 controls and the right ventricle in 21 controls. Compared with controls, the TOF group had higher RV indexed end-diastolic volumes (117.8 ± 25.5 vs 88 ± 15.4 mL/m(2), P < .001) and lower RV ejection fractions (44.6 ± 3.6% vs 51.8 ± 3.6%, P < .001). Steady-streaming (heartbeat-averaged) flow rotation intensities were higher in patients with TOF for the left ventricle (0.4 ± 0.13 vs 0.29 ± 0.08, P = .012) and the right ventricle (0.53 ± 0.15 vs 0.26 ± 0.12, P < .001), whereas kinetic energy dissipation in TOF ventricles was lower (for the left ventricle, 0.51 ± 0.29 vs 1.52 ± 0.69, P < .001; for the right ventricle, 0.4 ± 0.24 vs 1.65 ± 0.91, P < .001). CONCLUSIONS: It is feasible to characterize RV and left ventricular flow parameters and planar maps in adolescents and adults with repaired TOF using echocardiographic contrast particle imaging velocimetry. Intraventricular flow patterns in the abnormal and/or enlarged right ventricle in patients with TOF differ from those in normal young adults. The rotation intensity and energy dissipation trends in this investigation suggest that they may be quantitative markers of RV and left ventricular compliance abnormalities in patients with repaired TOF. This hypothesis merits further investigation.

Two- and three-dimensional speckle tracking echocardiography: clinical applications and future directions.

Two-dimensional speckle tracking echocardiography (2D STE) is a novel technique of cardiac imaging for quantifying complex cardiac motion based on frame-to-frame tracking of ultrasonic speckles in gray scale 2D images. Two-dimensional STE is a relatively angle independent technology that can measure global and regional strain, strain rate, displacement, and velocity in longitudinal, radial, and circumferential directions. It can also quantify rotational movements such as rotation, twist, and torsion of the myocardium. Two-dimensional STE has been validated against hemodynamics, tissue Doppler, tagged magnetic resonance imaging, and sonomicrometry studies. Two-dimensional STE has been found clinically useful in the assessment of cardiac systolic and diastolic function as well as providing new insights in deciphering cardiac physiology and mechanics in cardiomyopathies, and identifying early subclinical changes in various pathologies. A large number of studies have evaluated the role of 2D STE in predicting response to cardiac resynchronization therapy in patients with severe heart failure. However, the clinical utility of 2D STE in the above mentioned conditions remains controversial because of conflicting reports from different studies. Emerging areas of application include prediction of rejection in heart transplant patients, early detection of cardiotoxicity in patients receiving chemotherapy for cancer, and effect of intracoronary injection of bone marrow stem cells on left ventricular function in patients with acute myocardial infarction. The emerging technique of three-dimensional STE may further extend its clinical usefulness.

Characterization of the left atrial vortex flow by two-dimensional transesophageal contrast echocardiography using particle image velocimetry.

This article is the first clinical investigation of the quantitative left atrial (LA) vortex flow by two-dimensional (2-D) transesophageal contrast echocardiography (2-D-TECE) using vector particle image velocimetry (PIV). The aims of this study were to assess the feasibility of LA vortex flow analysis and to characterize and quantify the LA vortex flow in controls and in patients with atrial fibrillation (AF). Thirty-five controls and 30 patients with AF underwent transesophageal contrast echocardiography. The velocity vector was estimated by particle image velocimetry. The morphology and pulsatility of the LA vortex flow were compared between the control and AF groups. In all patients, quantitative LA vortex flow analysis was feasible. In the control group, multiple, pulsatile, compact and elliptical-shaped vortices were seen in the periphery of the LA. These vortices were persistently maintained and vectors were directed toward the atrioventricular inflow. In the AF group, a large, merged, lower pulsatile and round-shaped vortex was observed in the center of the LA. In comparisons of vortex parameters, the relative strength was significantly lower in the AF group (1.624 ± 0.501 vs. 2.105 ± 0.226, p < 0.001). It is feasible to characterize and quantify the LA vortex flow by transesophageal contrast echocardiography in patients with AF, which offers a new method to obtain additional information on LA hemodynamics. The approach has the potential for early detection of the LA dysfunction and in decisions regarding treatment strategy and guiding anticoagulation treatment in patients with AF.

Automated quantitative 3-dimensional modeling of the aortic valve and root by 3-dimensional transesophageal echocardiography in normals, aortic regurgitation, and aortic stenosis: comparison to computed tomography in normals and clinical implications.

BACKGROUND: We tested the ability of a novel automated 3-dimensional (3D) algorithm to model and quantify the aortic root from 3D transesophageal echocardiography (TEE) and computed tomographic (CT) data. METHODS AND RESULTS: We compared the quantitative parameters obtained by automated modeling from 3D TEE (n=20) and CT data (n=20) to those made by 2D TEE and targeted 2D from 3D TEE and CT in patients without valve disease (normals). We also compared the automated 3D TEE measurements in severe aortic stenosis (n=14), dilated root without aortic regurgitation (n=15), and dilated root with aortic regurgitation (n=20). The automated 3D TEE sagittal annular diameter was significantly greater than the 2D TEE measurements (P=0.004). This was also true for the 3D TEE and CT coronal annular diameters (P<0.01). The average 3D TEE and CT annular diameter was greater than both their respective 2D and 3D sagittal diameters (P<0.001). There was no significant difference in 2D and 3D measurements of the sinotubular junction and sinus of valsalva diameters (P>0.05) in normals, but these were significantly different (P<0.05) in abnormals. The 3 automated intercommissural distance and leaflet length and height did not show significant differences in the normals (P>0.05), but all 3 were significantly different compared with the abnormal group (P<0.05). The automated 3D annulus commissure coronary ostia distances in normals showed significant difference between 3D TEE and CT (P<0.05); also, these parameters by automated 3D TEE were significantly different in abnormal (P<0.05). Finally, the automated 3D measurements showed excellent reproducibility for all parameters. CONCLUSIONS: Automated quantitative 3D modeling of the aortic root from 3D TEE or CT data is technically feasible and provides unique data that may aid surgical and transcatheter interventions.