Advanced heart failure and management strategies.

The global healthcare burden attributable to heart failure is ever increasing. Patients presenting with refractory heart failure should be evaluated for compliance with medical regimens and sodium and/or fluid restriction, and every attempt should be made to optimize conventional strategies. Reversible causes such as ischemia should be identified and revascularization considered in persistently symptomatic patients, particularly those with a viable myocardium. Carefully selected patients who continue to deteriorate clinically in spite of optimization of medical therapy may be considered for advanced treatment strategies, such as continuous inotropic infusions, mechanical circulatory support devices, cardiac transplantation, or referral to hospice care. We discuss the clinical presentation and management of patients with advanced/refractory (Stage D) heart failure.

Live/real time three-dimensional transthoracic echocardiographic assessment of pulmonary regurgitation.

There is no gold standard for the measurement of pulmonary regurgitation (PR) severity. Two-dimensional (2D) transthoracic echocardiography is most commonly used to quantify PR severity using color Doppler criteria for aortic regurgitation. However, this method is limited by visualization of only one or two dimensions of the proximal PR jet or vena contracta (VC) precluding accurate assessment of its shape or size. This limitation would be expected to be obviated by three-dimensional (3D) transthoracic echocardiography, which could provide a more accurate quantitative assessment of PR severity. This study evaluated 82 adult patients with PR using 2D and 3D. PR VC area by 3D was obtained by planimetry by positioning the cropping plane exactly parallel to the VC, which was viewed en face by cropping of the 3D data set. Regurgitant volumes were calculated by 2D (assuming a circular VC) and by 3D as a product of the VC and velocity time integral obtained by color Doppler-guided conventional Doppler interrogation of the PR jet.The 3D VC area correlated with 2D jet width (JW)/right ventricular outflow tract (RVOT) width (r = 0.71) and 2D VC area (r = 0.79). 3D JW/RVOT width correlated with 2D JW/RVOT (r = 0.87). 3D regurgitant volumes also correlated with 2D regurgitant volumes (r = 0.76). The 3D VC values of <0.20, 0.20-0.45, 0.46-1.15, and >1.15 cm(2) and regurgitant volumes of <15 ml, 15-50 ml, 51-115 ml, and >115 ml were effective as cutoffs for grades 1, 2, 3, and 4 PR, respectively. In conclusion, quantification of 3D VC area and regurgitant volumes correlate reasonably well with the current 2D methods for measurement of PR. Since 3D visualizes PR VC in three dimensions, it would be expected to provide a more accurate and more quantitative assessment of PR severity as compared to 2D.

Superior vena cava, right pulmonary artery or both: real time two- and three-dimensional transthoracic contrast echocardiographic identification of the echo-free space posterior to the ascending aorta.

We describe the usefulness of contrast echocardiography and live/real time three-dimensional transthoracic echocardiography in characterizing the normal structures imaged posterior to the proximal ascending aorta as superior vena cava, right pulmonary artery, or both.

Live/real time three-dimensional transthoracic echocardiographic assessment of tricuspid valve pathology: incremental value over the two-dimensional technique.

Twenty-nine patients with different tricuspid valve (TV) pathologies were studied by both two-dimensional transthoracic (2DTTE) and live/real time three-dimensional transthoracic echocardiography (3DTTE). A major contribution of 3DTTE over 2DTTE was the en face visualization of all three leaflets of the TV in all patients. This allowed accurate assessment of TV orifice area in patients with TV stenosis and carcinoid disease. Loss of TV leaflet tissue, defects in TV leaflets and size of TV systolic non-coaptation could also be delineated and resulted in identifying the mechanism of tricuspid regurgitation (TR) in patients with Ebstein's anomaly and rheumatic heart disease. Prolapse of TV leaflets could also be well visualized and enabled us to develop a schema for systematic assessment of individual segment prolapse which could help in surgical planning. The exact sites of chordae rupture in patients with flail TV as well as right ventricular papillary muscle rupture could be well seen by 3DTTE. 3DTTE also permitted sectioning of various TV masses for more specific diagnosis of their nature. In addition, color Doppler 3DTTE provided an estimate of quantitative evaluation of TR severity, since the exact shape and size of the vena contracta could be accurately assessed. In conclusion, our preliminary experience with 3DTTE has demonstrated substantial incremental value over 2DTTE in the assessment of various TV pathologies.

Live/real time three-dimensional transthoracic echocardiographic assessment of left ventricular volumes, ejection fraction, and mass compared with magnetic resonance imaging.

Due to reliance upon geometric assumptions and foreshortening issues, the traditionally utilized transthoracic two-dimensional echocardiography (2DTTE) has shown limitations in assessing left ventricular (LV) volume, mass, and function. Cardiac magnetic resonance imaging (MRI) has shown potential in accurately defining these LV characteristics. Recently, the emergence of live/real time three-dimensional (3D) TTE has demonstrated incremental value over 2DTTE and comparable value with MRI in assessing LV parameters. Here we report 58 consecutive patients with diverse cardiac disorders and clinical characteristics, referred for clinical MRI studies, who were evaluated by cardiac MRI and 3DTTE. Our results show good correlation between the two modalities.

Left ventricular function in male patients with secondary hypogonadism.

BACKGROUND: In addition to the effects on ventricular repolarization, testosterone could also affect left ventricular performance. The enhancement of left ventricular contractility in testosterone-deficient rats following testosterone replacement implies to the possible testosterone effect. OBJECTIVES: The aim of the current study is to reveal the alterations of left ventricular functions, if any, in secondary hypogonadal male patients. METHODS: Thirty-four males with secondary hypogonadism comprised the study group. The control group consisted of 30 healthy subjects. Echocardiographic measurements including left ventricular dimensions, ejection fraction, mitral inflow, and left ventricular outflow parameters were obtained from all subjects. Tissue Doppler parameters were also measured from left ventricular lateral wall and interventricular septum. RESULTS: Left ventricular diameters, wall thicknesses, and performance parameters were similar in both groups. Mitral inflow parameters showed a statistically insignificant difference. Pulse-wave tissue Doppler interpretation of hypogonadal and healthy subjects were similar in terms of lateral and septal basal segment Sm, Em, and Am wave velocities. CONCLUSIONS: Regarding the findings of previous studies that showed impaired myocardial contractility and lusitropy in testosterone deficient rats and our study results, further studies are needed for better understanding of testosterone's effects on human myocardium.

Identification of tricuspid valve vegetation by computed tomography scan.

We report a patient with disseminated sepsis in whom a large vegetation involving the tricuspid valve was seen on a routine nongated computed tomography (CT) study emphasizing the potential role of CT scan in endocarditis.

Quantification of tricuspid regurgitation by live three-dimensional transthoracic echocardiographic measurements of vena contracta area.

We evaluated tricuspid regurgitation (TR) by multiple echocardiographic techniques in 93 consecutive patients who underwent standard two-dimensional (2D) and live three-dimensional (3D) transthoracic echocardiography (TTE). TR vena contracta (VC) area was obtained by 3D TTE by systematic and sequential cropping of the acquired 3D TTE dataset. Assessment of VC area by 3D TTE was compared to 2D TTE measurements of the ratio of TR regurgitant jet area to right atrial area (RJA/RAA), RJA alone, VC width, and calculated VC area. VC area from 3D TTE closely correlated with RJA/RAA and RJA alone as determined from 2D TTE measurements. Live 3D TTE color Doppler measurements of VC area can be used for quantitative assessment of TR and offer incremental value for quantification of particularly severe regurgitant lesions.

Cor triatriatum sinister: assessment by live/real time three-dimensional transthoracic echocardiography.

We report a 49-year-old morbidly obese female with a poor acoustic window in whom live/real time three-dimensional transthoracic echocardiography was able to make a confident diagnosis of cor triatriatum sinister. En face views of the membrane facilitated accurate assessment of the size and shape of the large nonobstructing opening in the membrane. Maximum dimensions of the opening were 3.06 x 1.03 cm and area was 2.3 cm(2).

Live/real time three-dimensional echocardiographic demonstration of left ventricular noncompaction and thrombi.

We describe two adult patients with left ventricular noncompaction in whom live/real time three-dimensional transthoracic echocardiography (3DTTE) supplemented two-dimensional transthoracic echocardiography in making a definitive diagnosis of clots coexisting with trabeculations in the left ventricle. Mobility of clots and the presence of central echolucencies consistent with clot lysis were best demonstrated by 3DTTE and served to confidently differentiate clots from adjacent trabeculations.

Usefulness of live/real time three-dimensional transthoracic echocardiography in the identification of individual segment/scallop prolapse of the mitral valve.

In this report, we present 34 patients in whom surgical intervention was undertaken for severe mitral insufficiency due to mitral valve prolapse (MVP). Location and severity of MVP and regurgitation were assessed preoperatively by live/real time three-dimensional transthoracic echocardiography and closely agreed with the surgical findings.

Live/real time three-dimensional transthoracic echocardiographic assessment of mycotic pseudoaneurysm involving the descending thoracic aorta.

We describe a patient in whom a mycotic aneurysm involving the distal descending thoracic aorta could be definitively diagnosed by live/real time three-dimensional transthoracic echocardiography.

Two-dimensional transthoracic contrast echocardiographic assessment of metastatic left ventricular tumors.

To illustrate the usefulness of contrast echocardiography in the assessment of cardiac tumors, we present an 81-year-old female with pathological fracture of the right clavicle in whom biopsy showed poorly differentiated carcinoma. Two-dimensional transthoracic echocardiography found two masses in the left ventricle attached to mid-ventricular septum consistent with metastases. Echo contrast study with octafluoropropane (Optison) showed contrast enhancement of both the masses consistent with high vascularity seen in a malignant tumor.

Definitive diagnosis of descending thoracic aortic dissection by real time/live three-dimensional transthoracic echocardiography.

We describe a patient with descending thoracic aortic dissection in whom three- dimensional transthoracic echocardiography was able to clearly visualize the dissection flap en face as a sheet of tissue, as well as demonstrate a large communication between the true and false lumen in three dimensions, enabling a definitive diagnosis of dissection.