Preoperative aortic annulus size assessment by transthoracic echocardiography compared to the size of surgically implanted aortic prostheses.

OBJECTIVES: The aortic annulus diameter measured by transthoracic echocardiography yields lower values than by computed tomography, and echo-based selection of transcatheter aortic valve prosthesis size has been implied to result in more frequent paravalvular leakage. We investigated the relation of preoperative annulus diameter by echo with the ring size of the aortic prosthesis chosen by direct assessment during open-heart aortic valve replacement. METHODS: Preoperative annulus diameter by echo (from parasternal long-axis cross-sections of the left ventricular outflow tract and aortic valve) and implanted prosthetic diameter (tissue annulus diameter, determined intraoperatively using a sizing instrument) were compared retrospectively in 285 consecutive patients undergoing open-heart aortic valve replacement. RESULTS: A total of 285 prostheses (240 biologic and 45 mechanical) were implanted, with prosthetic diameter ranging between 19 and 27 mm. There was a significant linear correlation (P < 0.0001) with r = 0.51, between preoperative annulus diameter by echo (mean 21.8 ± 2.8 mm) and prosthetic diameter (22.9 ± 1.7 mm). Preoperative annulus diameter of patients receiving prostheses no. 21, 23 and 25 mm aortic prostheses (the most frequent prosthesis sizes) were significantly different (P < 0.001) from each other. On average, preoperative annulus diameter by echo underestimated prosthetic diameter by a bias of 1.07 mm. CONCLUSION: Our data confirm that preoperative echo assessment of the aortic valve may slightly underestimates the optimal surgical prosthesis diameter for the aortic valve annulus.

Cardiac function after hematopoietic cell transplantation: an echocardiographic cross-sectional study in young adults treated in childhood.

BACKGROUND: Hematopoietic cell transplantation (HCT) including preparative regimens with chemotherapy and total body irradiation (TBI) is an accepted treatment for many malignant disorders but may have side-effects for several organs, including the cardiovascular system. The aim of this study was to study very long-term consequences on cardiac function after childhood HCT. PROCEDURE: Cardiac function was evaluated using echocardiography and levels of NT-proBNP and growth hormone (GHmax) in 18 patients, at a median of 18 years after HCT including TBI, and in 18 matched controls. RESULTS: Patients after HCT had cardiac dimensions, volumes, and left ventricular ejection fractions within normal range after correction for body size. However, compared with the control group, patients after HCT had significantly lower E/A ratio, as a measure of left ventricular diastolic function, significantly lower fractional shortening and mitral annular plane systolic excursion, as measures of left ventricular systolic function, significantly lower tricuspid annular plane systolic excursion, as a measure of right ventricular function, and significantly higher NT-proBNP, as a measure of total cardiac function. Also, pulmonary flow acceleration time was shorter in the group after HCT, indicating possible pulmonary involvement. Heart rate was significantly higher and GHmax significantly lower in patients after HCT. CONCLUSIONS: Almost two decades after HCT, including preparative regimens with TBI, cardiac function in patients was found to be within normal range. However, when compared with a healthy control group, patients after HCT showed lower systolic and diastolic left ventricular function as well as lower right ventricular function.

The most important publications of the past year in echocardiography.

We review the published literature on clinical echocardiography of the past year. Key topics were valvular heart disease, in particular aortic stenosis, and the imaging requirements for transcatheter aortic valve implantation. Three-dimensional echocardiography and deformation imaging have yielded important new insights in valvular heart disease. Other key fields have been assessment of heart failure, in particular heart failure with preserved ejection fraction, and the relationship of this condition with diastolic dysfunction and left atrial function. Functional imaging of cardiomyopathies was also an important topic.

Recommendations for transoesophageal echocardiography: update 2010.

Transoesophageal echocardiography (TOE) is a standard and indispensable technique in clinical practice. The present recommendations represent an update and extension of the recommendations published in 2001 by the Working Group on Echocardiography of the European Society of Cardiology. New developments covered include technical advances such as 3D transoesophageal echo as well as developing applications such as transoesophageal echo in aortic valve repair and in valvular interventions, as well as a full section on perioperative TOE.

[A patient with aortic valve stenosis and severe obstruction of the left ventricular outflow tract: a diagnostic challenge]. / Ein Patient mit Aortenstenose und schwerer Ausflussbahn-Obstruktion: Eine diagnostische Herausforderung.

HISTORY AND ADMISSION FINDINGS: A 83-year-old male patient was admitted with dyspnoe and paroxysmal atrial fibrillation. A severe aortic stenosis was diagnosed 9 months before. INVESTIGATIONS: Echocardiography now revealed severe obstruction of the left ventricular outflow tract, as part of an obstructive cardiomyopathy, mild aortic valve stenosis and mark4d left atrial dilatation. THERAPY AND COURSE: After spontaneous conversion into sinus rhythm the patient remained asymptomatic and continuing conservative treatment was recommended. CONCLUSION: It may be difficult to diagnose the correct components of systolic obstruction when there is both obstructive cardiomyopathy and aortic valve stenosis and thus decide on the optimal management of such a case.

Sequential changes in myocardial function after valve replacement for aortic stenosis by speckle tracking echocardiography.

AIMS: Regional myocardial function may change differently in different pathology. Speckle tracking echocardiography (STE) was applied to evaluate longitudinal, radial, and circumferential function in patients with aortic stenosis (AS) before, within 1 week, and 6 months after aortic valve replacement (AVR). METHODS AND RESULTS: In 40 consecutive patients with severe AS, we acquired apical four-, three-, and two-chamber views and standard short-axis view pre- and post-AVR and after 6 months. Longitudinal, radial, and circumferential (LS, RS, and CS) were calculated by commercial STE software. Further, we analysed diastolic myocardial function by measuring E/e' ratio. With AVR, valve area increased and remained stable at 6 months follow-up. Left ventricular mass was unchanged 1 week after AVR (270 +/- 58 g vs. 267 +/- 58 g, n.s.) but decreased significantly during the next 6 months (219 +/- 50 g, P < 0.05). Left ventricular ejection fraction remained unchanged. Strain values did not change significantly within 1 week after AVR but increased significantly after 6 months (LS by 16%, RS by 21%, and CS by 28% of baseline values). E/e' ratio was highly augmented before AVR (26.1 +/- 12.5) and decreased significantly 6 months after AVR (15.9 +/- 5.9). CONCLUSION: Myocardial function significantly recovers after replacing the stenosed aortic valve. However, there is a considerable difference between the response of longitudinal, radial, and circumferential function. Our data suggest that echocardiographic assessment of regional function is feasible and of potential clinical importance.

[Congenital aortic valve stenosis with very high pressure gradient in a pregnant patient]. / Kongenitale Aortenklappenstenose mit sehr hohem Druckgradienten bei einer schwangeren Patientin.

HISTORY AND CLINICAL FINDINGS: A 34-year-old woman was in her 24th week of her second pregnancy when she suffered a recurrence of her congenital aortic valve stenosis (CAS), previously treated by surgical commissurotomy. She was dyspneic on only mild exertion. The first pregnancy had been uneventful. INVESTIGATIONS: RR was 110/70 mmHg. The electrocardiogram showed left ventricular hypertrophy and myocardial damage. Echocardiography revealed a maximal systolic gradient of 155 mm Hg (mean gradient 104 mm Hg). The blood picture showed a pregnancy-related mild anemia and haemodilution. TREATMENT AND COURSE: The patient was hospitalized as a precaution from the 31st week of pregnancy onwards. An elective section was performed under intubation aneasthesia in the 36th week of pregnancy. The aortic valve was electively replaced 13 weeks after delivery. CONCLUSION: Patients with a CAS who had been treated palliatively with a commissurotomy should be carefully and regularly monitored to avoid recurrent stenosis. Close collaboration with the delivery team is essential.

Fatal methanol intoxication with different survival times--morphological findings and postmortem methanol distribution.

Three corresponding cases of fatal methanol intoxication with different survival times were investigated ante-mortem and postmortem. Ante-mortem serum methanol concentrations were determined during treatment in hospital for 4 days. Furthermore, postmortem distribution of methanol in various tissues and fluids was measured after autopsy. Morphological and toxicological findings are discussed based on the literature. The morphological findings correlated with the different survival times. The results of the toxicological analyses were partly in keeping with previously published data. Interestingly, very high methanol levels were determined in brain with very low concentrations in femoral venous blood. These results may have implications for postmortem toxicological analysis, brain death diagnosis and organ explanation for transplantation.

[Mitral regurgitation]. / Mitralinsuffizienz.

Mitral regurgitation is the second most frequent reason for valve surgery. The most important causes of mitral regurgitation are degenerative valve disease (mitral valve prolapse), left ventricular impairment and dilatation (in coronary artery disease or dilated cardiomyopathy), and infective endocarditis. The regurgitation of blood from the left ventricle into the left atrium leads to dilatation of the left atrium, increase in pulmonary capillary pressure and pulmonary congestion. In chronic severe mitral regurgitation, the left ventricle dilates and becomes impaired over time. Key symptoms are fatigue and dyspnea on exertion. The most prominent physical sign is the characteristic systolic murmur. Echocardiography identifies severity, delineates morphology, and estimates the impact of mitral regurgitation on left ventricular function. Importantly, echocardiography identifies candidates for mitral valve repair. Symptomatic patients and asymptomatic patients with impaired left ventricular function should be operated. If possible, valve repair is preferred over valve replacement to better preserve left ventricular function and to avoid the need for postoperative anticoagulation (except if atrial fibrillation persists).

[Diagnostic algorithm in heart failure]. / Verdacht auf Herzinsuffizienz. So sichern Sie die Diagnose.

Chronic heart failure has a multitude of cardiological causes the most common being coronary artery disease, dilatory cardiomyopathy or arterial hypertension. Clinical examination, ECG and radiography can support the suspected diagnosis of heart failure. Confirmation of the diagnosis and clarification of the etiology is done largely with echocardiography. Depending upon the etiology, further investigations are necessary, in particular in the case of coronary artery disease. In doubtful cases, low levels of natriuretic peptide can exclude heart failure.

The interventricular septum is functionally bilayered: a fresh look at a well known structure.

Increasingly sophisticated echocardiographic procedures are revealing previously unknown details of well known structures such as the interventricular septum.

Dose-dependent disintegration of human endothelial monolayers by contrast echocardiography.

Biological effects on endothelium induced by contrast ultrasound (US) may be relevant for transferring drugs into the tissue. An in vitro tissue-mimicking phantom was developed to simulate clinical precordial echocardiography of three modalities (two-dimensional (2DE), pulsed wave (PW), and Power Doppler echocardiography) with gradual increases of acoustic output (mechanical index (MI) 0.0-1.6 and thermal index soft tissue (TIS) 0.0-1.3, respectively; transmit-frequency 1.8 MHz in second harmonic mode (SHI) by 2DE, 1.8 MHz for PW-Doppler, and 3.2 MHz for Power Doppler) as well as contrast agent (CA) concentrations (0.002-4 mg/mL Levovist). Disintegration of the endothelial monolayer was quantitatively analyzed by counting intercellular gaps in light microscopy. No gaps were observed in CA application without sonication. Only few gaps appeared at sonication without CA application in 2DE at MI=1.6 and in PW- and Power Doppler at TIS > or =0.4 and MI > or =0.4. The number of gaps increased significantly with the gradual increase of US output and to a comparably lesser but also significant extent with CA concentrations. Diagnostic contrast echocardiography may induce endothelial disintegrations dependent on US output as well as on CA concentrations. This aspect might be helpful in further in vivo series on local drug delivery.