Prognostic Value of the Right Ventricular Ejection Fraction, Assessed by Fully Automated Three-Dimensional Echocardiography: A Direct Comparison of Analyses Using Right Ventricular-Focused Views versus Apical Four-Chamber Views.

BACKGROUND: Right ventricular (RV) three-dimensional echocardiographic (3DE) data sets are acquired from either the RV-focused view (RVFV) or the apical four-chamber view (4CV). The prognostic value of 3DE RV ejection fraction (RVEF) was investigated using fully automated RV quantification software, and how measurement values with 3DE data sets from the RVFV compare with those from the 4CV was determined. METHODS: One hundred seventy-four patients who had undergone both cardiac magnetic resonance (CMR) and 3DE imaging were retrospectively selected. RV 3DE data sets were acquired from both the RVFV and the 4CV and were analyzed separately using fully automated RV quantification software. Primary end points were cardiac events, including cardiac death, heart failure requiring hospitalization, nonfatal myocardial infarction, and ventricular tachyarrhythmia. RESULTS: The feasibility of RVEF measurements on 3DE imaging from the RVFV and 4CV was 92% and 92%, respectively. There was good correlation (r = 0.83) and small bias (0.3%) between RVEF from the RVFV and that from the 4CV. Similar results were obtained when only data from patients whose echocardiograms had poor image quality in one or both views were analyzed (r = 0.83, bias = 1.7%, n = 78). Although fully automated analysis in both the RVFV and 4CV significantly underestimated RV volumes compared with CMR, neither measurement differed significantly for RVEF compared with CMR. During a median follow-up period of 12.5 months, 21 patients experienced primary end points. RVEF assessed by CMR and 3DE imaging was significantly associated with cardiac events. RVEF using fully automated analysis had a significant association with cardiac events, even in patients with poor image quality (RVFV: hazard ratio, 0.90 [P = .009, n = 44]; 4CV: hazard ratio, 0.90 [P = .009, n = 68]). CONCLUSIONS: RV 3DE data sets from the RVFV and 4CV yielded similar RVEF values using fully automated software. RVEFs from both approaches had significant association with outcomes. Thus, both provide accurate information regarding RV function and risk for adverse outcomes.

Impact of a training program incorporating cardiac magnetic resonance imaging on the accuracy and reproducibility of two-dimensional echocardiographic measurements of left ventricular volumes and ejection fraction.

BACKGROUND: Left ventricular (LV) ejection fraction (LVEF) assessed by two-dimensional echocardiography (2DE) is the most widely used parameter for clinical decision-making, but reproducibility and accuracy problems remain. We evaluated the usefulness of a novel training program based on cardiac magnetic resonance (CMR) imaging to obtain more reliable values of 2DE-derived LVEF and LV volumes. METHODS: Fifty-four sonographers from five hospitals independently measured LV volumes and LVEF using the same 2DE images from 15 patients who underwent CMR and 2DE. After receiving a lecture from an expert on how to properly trace the LV endocardium, each sonographer voluntary performed the measurements using the same datasets, and was invited to perform the same analysis for additional patients. The effect of the training intervention was evaluated using the coefficient of variation (CV) and coverage probability (CP). RESULTS: Before the intervention, the LV volumes were significantly underestimated and the LVEF was significantly overestimated compared to the CMR results; however, these differences were reduced after the intervention. In particular, the CP (0.52 vs. 0.76, p < 0.001) for the LVEF showed significant improvement. However, the degree of improvement differed among institutions, and the CV actually became worse in two hospitals after the intervention. Level of experience and self-practice was associated with the reproducibility after the intervention. CONCLUSIONS: A training program using CMR as a reference improved the accuracy of 2DE-determined LV measurements. Since the degree of improvements differed among hospitals, individualization of training programs and periodical objective evaluation may be required to reduce inter-institutional variability.

Symptomatic paradoxical low gradient severe aortic stenosis: A possible link to heart failure with preserved ejection fraction.

BACKGROUND: There is an ongoing debate regarding optimal management of patients with paradoxical low gradient severe aortic stenosis (PLG-SAS). We hypothesized that the presence of symptoms is closely associated with future adverse outcome. We aimed to determine the relation between symptoms and outcome in patients with PLG-SAS. METHODS: We prospectively enrolled 222 patients with PLG-SAS. Left ventricular (LV) volumes, mass, and strain were measured by three-dimensional echocardiography. The primary end-point was cardiac events including cardiac death, ventricular fibrillation, and heart failure leading to hospitalization. RESULTS: There were 65 cases of symptomatic PLG-SAS and 157 cases of asymptomatic PLG-SAS. Patients with symptomatic PLG-SAS received beta-blockers, angiotensin blockers, and diuretics more frequently and showed higher levels of B-type natriuretic peptide than patients with asymptomatic PLG-SAS. Although LV chamber parameters were not different, patients with symptomatic PLG-SAS had significantly higher E-wave velocity and E/A ratio than patients with asymptomatic PLG-SAS. During the median follow-up of 18 months, 20 patients reached the primary end-point. Patients with symptomatic PLG-SAS had significantly worse prognosis than patients with asymptomatic PLG-SAS. A similar trend was observed while comparing with the propensity-score-matched cohort after adjusting for age, sex, stroke volume index, and severity of AS. CONCLUSIONS: Symptomatic PLG-SAS is associated with poorer prognosis even after adjusting for flow status and severity of AS. Therefore, presence of symptoms is not always related to the severity of AS itself but might be related to the underlying comorbidities. Our results suggest a possible link between PLG-SAS and heart failure with preserved ejection fraction in some symptomatic patients.

Congenital absence of inferior vena cava with azygos continuation revealed by vascular echo in a patient with pulmonary thromboembolism and deep vein thrombosis: a case report.

A 44-year-old man with an isolated anomaly of azygos continuation of the inferior vena cava (IVC) presented with dyspnea due to pulmonary thromboembolism (PTE) and deep-vein thrombosis (DVT). Sono-graphic examination disclosed not only pulmonary hypertension and DVT, but also infrahepatic interruption of the IVC with azygos continuation. A rare anomaly of azygos continuation of IVC could cause DVT and PTE. Vascular echo could play an important role in the examination of DVT and/or venous anomalies.