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Hill JA, Agewall S, Baranchuk A, Booz GW, Borer JS, Camici PG, Chen PS, Dominiczak AF, Erol Ç, Grines CL, Gropler R, Guzik TJ, Heinemann MK, Iskandrian AE, Knight BP, London B, Lüscher TF, Metra M, Musunuru K, Nallamothu BK, Natale A, Saksena S, Picard MH, Rao SV, Remme WJ, Rosenson RS, Sweitzer NK, Timmis A, Vrints C. Medical misinformation: vet the message! European Heart Journal - Cardiovascular Pharmacotherapy 2019; 5:62-63. [PMID: 30689786 PMCID: PMC6418469 DOI: 10.1093/ehjcvp/pvz001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Tanguturi VK, Bhambhani V, Picard MH, Armstrong K, Wasfy JH. Echocardiographic Surveillance of Valvular Heart Disease in Different Sociodemographic Groups. JACC Cardiovasc Imaging 2019; 12:751-752. [PMID: 30121267 DOI: 10.1016/j.jcmg.2018.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 10/28/2022]
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Chetrit M, Roujol S, Picard MH, Timmins L, Manning WJ, Rudski LG, Levine RA, Afilalo J. Optimal Technique for Measurement of Linear Left Ventricular Dimensions. J Am Soc Echocardiogr 2019; 32:476-483.e1. [PMID: 30826223 DOI: 10.1016/j.echo.2018.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Echocardiographic assessment of the left ventricle (LV) begins with the measurement of linear dimensions that approximate its ellipsoid diameter. These linear dimensions have historically been measured at the basal level of the LV, which is not representative of its true diameter. The objective of this study was to determine the optimal level to measure LV cavity dimensions to more accurately estimate its size and mass. METHODS The derivation study included 75 patients who had a clinically indicated cardiac magnetic resonance (CMR) exam for ischemic heart disease (n = 15), nonischemic cardiomyopathy (n = 25), or normal studies (n = 35). The three-chamber bright blood cine sequence was analyzed using a custom MATLAB program to measure the LV cavity diameter and wall thickness at 15 equidistant levels from base to apex. The linear measurements from each of these levels were compared against the CMR volumetric reference standard. The validation study included 100 patients who had a clinically indicated echocardiogram and CMR within 3 days for ischemic heart disease (n = 20), nonischemic cardiomyopathy (n = 44), and normal or near-normal studies (n = 36). The parasternal long-axis cine sequence was analyzed to measure the LV cavity diameter and wall thickness at the traditional basal level and the midventricular level, which were compared against the CMR volumetric reference standard. RESULTS In both the derivation and validation studies, the midventricular linear dimensions, defined as those located at the true (maximal) diameter of the LV ellipsoid cavity, were found to be more closely correlated with the volumetric reference standard for LV mass, LV end-diastolic size, and LV ejection fraction. CONCLUSIONS Measurement of linear dimensions at the midventricular level better reflects the ellipsoid geometry of the LV cavity and provides a more accurate estimate of LV mass, size, and systolic function as compared with the traditionally recommended basal level.
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Affiliation(s)
- Michael Chetrit
- Azrieli Heart Center, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Sébastien Roujol
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom; Departments of Medicine (Cardiovascular Division) and Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Michael H Picard
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Logan Timmins
- Faculty of Sciences, Concordia University, Montreal, Quebec, Canada
| | - Warren J Manning
- Departments of Medicine (Cardiovascular Division) and Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Lawrence G Rudski
- Azrieli Heart Center, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Robert A Levine
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan Afilalo
- Azrieli Heart Center, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.
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Law TK, Bouck Z, Yin XC, Dudzinski D, Myers D, Nesbitt GC, Edwards J, Yared K, Wong B, Hansen M, Weinerman A, Shadowitz S, Farkouh M, Thavendiranathan P, Udell J, Johri A, Chow CM, Rakowski H, Picard MH, Weiner RB, Bhatia RS. Association Between Transthoracic Echocardiography Appropriateness and Echocardiographic Findings. J Am Soc Echocardiogr 2019; 32:667-673.e4. [PMID: 30846322 DOI: 10.1016/j.echo.2019.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND The association between appropriate use criteria and echocardiographic findings in patients with chronic cardiovascular diseases is unknown. METHODS As a substudy of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial, 9,230 transthoracic echocardiographic (TTE) examinations from six Ontario academic hospitals were linked to a registry of echocardiographic findings. The TTE studies were rated appropriate), rarely appropriate, or may be appropriate according to the 2011 appropriate use criteria. TTE findings of appropriately ordered examinations were compared with those of rarely appropriate examinations for specific disease subsets, including heart failure and valvular heart disease. RESULTS There were 7,574, 1,087, and 569 TTE examinations ordered for appropriate, rarely appropriate, and may be appropriate indications, and of the 7,574 appropriate studies, 6,399 were ordered for specific indications and 1,175 for general indications. TTE examinations ordered for general indications had lower rates of left ventricular dysfunction (19.6% vs 9.1%, P < .001) and moderate to severe aortic stenosis (15.5% vs 2.6%, P < .001). Of the 2,395 TTE examinations ordered for patients with heart failure, appropriately ordered studies were more likely to result in left ventricular segmental abnormality (37.0% vs 24.9%, P = .012) but similar rates of right ventricular dilatation (15.4% vs 14.7%, P = .79), right ventricular dysfunction (14.8% vs 11.3%, P = .22), and moderate to severe mitral regurgitation (12.1% vs 9.2%, P = .35). Of the 2,859 studies ordered to assess valvular heart disease, appropriately ordered studies were significantly more likely to find moderate to severe valvular pathology, including aortic stenosis (30.4% vs 24.6%, P = .008), aortic regurgitation (8.9% vs 1.6%, P < .001), mitral stenosis (6.7% vs 3.1%, P = .002), and mitral regurgitation (16.1% vs 6.1%, P < .001), but similar rates of tricuspid regurgitation (11.2% vs 13.0%, P = .60). CONCLUSIONS Overall, appropriately ordered TTE examinations for heart failure and valvular heart disease were significantly more likely to have abnormal findings than rarely appropriate examinations. TTE studies ordered for general indications had fewer, although still a significant proportion, of abnormalities compared with studies ordered for specific indications.
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Affiliation(s)
- Tamryn K Law
- Women's College Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | | | - X Cindy Yin
- Women's College Hospital, Toronto, Ontario, Canada
| | - David Dudzinski
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Dorothy Myers
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Jeremy Edwards
- Echocardiogram and Vascular Lab, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Kibar Yared
- The Scarborough Hospital, Scarborough, Ontario, Canada
| | - Brian Wong
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mark Hansen
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | | | - Michael Farkouh
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Cardiology Division, Mount Sinai Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada
| | | | - Jacob Udell
- Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada
| | - Amer Johri
- Queen's University, Kingston, Ontario, Canada
| | - Chi-Ming Chow
- Echocardiogram and Vascular Lab, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Harry Rakowski
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada
| | - Michael H Picard
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Rory B Weiner
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - R Sacha Bhatia
- Women's College Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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Hill JA, Agewall S, Baranchuk A, Booz GW, Borer JS, Camici PG, Chen PS, Dominiczak AF, Erol Ç, Grines CL, Gropler R, Guzik TJ, Heinemann MK, Iskandrian AE, Knight BP, London B, Lüscher TF, Metra M, Musunuru K, Nallamothu BK, Natale A, Saksena S, Picard MH, Rao SV, Remme WJ, Rosenson RS, Sweitzer NK, Timmis A, Vrints C. Medical Misinformation: Vet the Message! Eur Heart J 2019; 40:404-405. [PMID: 30689805 PMCID: PMC6356051 DOI: 10.1093/eurheartj/ehz009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
| | | | - Stefan Agewall
- Editor-in-Chief, European Heart Journal Cardiovascular Pharmacotherapy
| | | | - George W Booz
- Editor-in-Chief; Journal of Cardiovascular Pharmacology
| | | | | | | | | | - Çetin Erol
- Editor-in-Chief, Anatolian Journal of Cardiology
| | | | | | | | | | | | | | - Barry London
- Editor-in-Chief, Journal of the American Heart Association
| | | | - Marco Metra
- Editor-in-Chief, European Journal of Heart Failure
| | - Kiran Musunuru
- Editor-in-Chief, Circulation: Genomic and Precision Medicine
| | | | - Andrea Natale
- Editor-in-Chief, Journal of Interventional Cardiac Electrophysiology
| | - Sanjeev Saksena
- Editor-in-Chief, Journal of Interventional Cardiac Electrophysiology
| | - Michael H Picard
- Editor-in-Chief, Journal of the American Society of Echocardiography
| | - Sunil V Rao
- Editor-in-Chief, Circulation: Cardiovascular Interventions
| | | | | | | | - Adam Timmis
- Editor-in-Chief, European Heart Journal: Quality of Care and Clinical Outcomes
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Hill JA, Agewall S, Baranchuk A, Booz GW, Borer JS, Camici PG, Chen PS, Dominiczak AF, Erol Ç, Grines CL, Gropler R, Guzik TJ, Heinemann MK, Iskandrian AE, Knight BP, London B, Lüscher TF, Metra M, Musunuru K, Nallamothu BK, Natale A, Saksena S, Picard MH, Rao SV, Remme WJ, Rosenson RS, Sweitzer NK, Timmis A, Vrints C. Medical misinformation: Vet the message! Heart Rhythm 2019; 16:332-333. [PMID: 30703343 DOI: 10.1016/j.hrthm.2018.12.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Indexed: 10/27/2022]
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Hill JA, Agewall S, Baranchuk A, Booz GW, Borer JS, Camici PG, Chen PS, Dominiczak AF, Erol Ç, Grines CL, Gropler R, Guzik TJ, Heinemann MK, Iskandrian AE, Knight BP, London B, Lüscher TF, Metra M, Musunuru K, Nallamothu BK, Natale A, Saksena S, Picard MH, Rao SV, Remme WJ, Rosenson RS, Sweitzer NK, Timmis A, Vrints C. Medical Misinformation. Circ Cardiovasc Interv 2019; 12:e007796. [PMID: 30688520 DOI: 10.1161/circinterventions.119.007796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam Timmis
- European Heart Journal: Quality of Care and Clinical Outcomes
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Hill JA, Agewall S, Baranchuk A, Booz GW, Borer JS, Camici PG, Chen PS, Dominiczak AF, Erol Ç, Grines CL, Gropler R, Guzik TJ, Heinemann MK, Iskandrian AE, Knight BP, London B, Lüscher TF, Metra M, Musunuru K, Nallamothu BK, Natale A, Saksena S, Picard MH, Rao SV, Remme WJ, Rosenson RS, Sweitzer NK, Timmis A, Vrints C. Medical Misinformation. Circ Genom Precis Med 2019; 12:e002439. [PMID: 30688515 DOI: 10.1161/circgen.118.002439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Stefan Agewall
- Editor-in-Chief, European Heart Journal Cardiovascular Pharmacotherapy
| | | | - George W Booz
- Editor-in-Chief, Journal of Cardiovascular Pharmacology
| | | | | | | | | | - Çetin Erol
- Editor-in-Chief, Anatolian Journal of Cardiology
| | | | | | | | | | | | | | - Barry London
- Editor-in-Chief, Journal of the American Heart Association
| | | | - Marco Metra
- Editor-in-Chief, European Journal of Heart Failure
| | - Kiran Musunuru
- Editor-in-Chief, Circulation: Genomic and Precision Medicine
| | | | - Andrea Natale
- Editors-in-Chief, Journal of Interventional Cardiac Electrophysiology
| | - Sanjeev Saksena
- Editors-in-Chief, Journal of Interventional Cardiac Electrophysiology
| | - Michael H Picard
- Editor-in-Chief, Journal of the American Society of Echocardiography
| | - Sunil V Rao
- Editor-in-Chief, Circulation: Cardiovascular Interventions
| | | | | | | | - Adam Timmis
- Editor-in-Chief, European Heart Journal: Quality of Care and Clinical Outcomes
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Hill JA, Agewall S, Baranchuk A, Booz GW, Borer JS, Camici PG, Chen PS, Dominiczak AF, Erol Ç, Grines CL, Gropler R, Guzik TJ, Heinemann MK, Iskandrian AE, Knight BP, London B, Lüscher TF, Metra M, Musunuru K, Nallamothu BK, Natale A, Saksena S, Picard MH, Rao SV, Remme WJ, Rosenson RS, Sweitzer NK, Timmis A, Vrints C. Medical Misinformation. Circ Cardiovasc Imaging 2019; 12:e008809. [PMID: 30688516 DOI: 10.1161/circimaging.118.008809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam Timmis
- European Heart Journal: Quality of Care and Clinical Outcomes
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Hill JA, Agewall S, Baranchuk A, Booz GW, Borer JS, Camici PG, Chen PS, Dominiczak AF, Erol Ç, Grines CL, Gropler R, Guzik TJ, Heinemann MK, Iskandrian AE, Knight BP, London B, Lüscher TF, Metra M, Musunuru K, Nallamothu BK, Natale A, Saksena S, Picard MH, Rao SV, Remme WJ, Rosenson RS, Sweitzer NK, Timmis A, Vrints C. Medical Misinformation. Hypertension 2019; 73:506-507. [PMID: 30686083 DOI: 10.1161/hypertensionaha.118.12518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Stefan Agewall
- European Heart Journal: Cardiovascular Pharmacotherapy (S.A.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Barry London
- Journal of the American Heart Association (B.L.)
| | | | | | | | | | - Andrea Natale
- Journal of Interventional Cardiac Electrophysiology (A.N., S.S.)
| | - Sanjeev Saksena
- Journal of Interventional Cardiac Electrophysiology (A.N., S.S.)
| | | | - Sunil V Rao
- Circulation: Cardiovascular Interventions (S.V.R.)
| | | | | | | | - Adam Timmis
- European Heart Journal: Quality of Care and Clinical Outcomes (A.T.)
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61
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Hill JA, Agewall S, Baranchuk A, Booz GW, Borer JS, Camici PG, Chen PS, Dominiczak AF, Erol Ç, Grines CL, Gropler R, Guzik TJ, Heinemann MK, Iskandrian AE, Knight BP, London B, Lüscher TF, Metra M, Musunuru K, Nallamothu BK, Natale A, Saksena S, Picard MH, Rao SV, Remme WJ, Rosenson RS, Sweitzer NK, Timmis A, Vrints C. Medical Misinformation. Circ Heart Fail 2019; 12:e005869. [PMID: 30688079 DOI: 10.1161/circheartfailure.119.005869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam Timmis
- European Heart Journal: Quality of Care and Clinical Outcomes
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Hill JA, Agewall S, Baranchuk A, Booz GW, Borer JS, Camici PG, Chen PS, Dominiczak AF, Erol C, Grines CL, Gropler R, Guzik TJ, Heinemann MK, Iskandrian AE, Knight BP, London B, Lüscher TF, Metra M, Musunuru K, Nallamothu BK, Natale A, Saksena S, Picard MH, Rao SV, Remme WJ, Rosenson RS, Sweitzer NK, Timmis A, Vrints C. Medical Misinformation. Circ Cardiovasc Qual Outcomes 2019; 12:e005496. [PMID: 30688519 DOI: 10.1161/circoutcomes.119.005496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam Timmis
- European Heart Journal: Quality of Care and Clinical Outcomes
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Shah AB, Bechis MZ, Brown M, Finch JM, Loomer G, Groezinger E, Weiner RB, Wasfy MM, Picard MH, Fifer MA, Lewis GB, Baggish AL. Catecholamine response to exercise in patients with non-obstructive hypertrophic cardiomyopathy. J Physiol 2019; 597:1337-1346. [PMID: 30552684 DOI: 10.1113/jp277494] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/05/2018] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Intense physical activity, a potent stimulus for sympathetic nervous system activation, is thought to increase the risk of malignant ventricular arrhythmias among patients with hypertrophic cardiomyopathy (HCM). As a result, the majority of patients with HCM deliberately reduce their habitual physical activity after diagnosis and this lifestyle change puts them at risk for sequelae of a sedentary lifestyle: weight gain, hypertension, hyperlipidaemia, insulin resistance, coronary artery disease, and increased morbidity and mortality. We show that plasma catecholamine levels remain stably low at exercise intensities below the ventilatory threshold, a parameter that can be defined during cardiopulmonary exercise testing, but rise rapidly at higher intensities of exercise. These findings suggest that cardiopulmonary exercise testing may be a useful tool to provide an individualized moderate-intensity exercise prescription for patients with HCM. ABSTRACT Intense physical activity, a potent stimulus for sympathetic nervous system activation, is thought to increase the risk of malignant ventricular arrhythmias among patients with hypertrophic cardiomyopathy (HCM). However, the impact of exercise intensity on plasma catecholamine levels among HCM patients has not been rigorously defined. We conducted a prospective observational case-control study of men with non-obstructive HCM and age-matched controls. Laboratory-based cardiopulmonary exercise testing coupled with serial phlebotomy was used to define the relationship between exercise intensity and plasma catecholamine levels. Compared to controls (C, n = 5), HCM participants (H, n = 9) demonstrated higher left ventricular mass index (115 ± 20 vs. 90 ± 16 g/m2 , P = 0.03) and maximal left ventricular wall thickness (16 ± 1 vs. 8 ± 1 mm, P < 0.001) but similar body mass index, resting heart rate, peak oxygen consumption (H = 40 ± 13 vs. C = 42 ± 7 ml/kg/min, P = 0.81) and heart rate at the ventilatory threshold (H = 78 ± 6 vs. C = 78 ± 4% peak heart rate, P = 0.92). During incremental effort exercise in both groups, concentrations of adrenaline and noradrenaline were unchanged through low- and moderate-exercise intensity until reaching a catecholamine threshold (H = 82 ± 4 vs. C = 85 ± 3% peak heart rate, P = 0.86) after which levels of both molecules rose rapidly. In patients with mild non-obstructive HCM, plasma catecholamine levels remain stably low at exercise intensities below the ventilatory threshold but rise rapidly at higher intensities of exercise. Routine cardiopulmonary exercise testing may be a useful tool to provide an individualized moderate-intensity exercise prescription for patients with HCM.
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Affiliation(s)
- Ankit B Shah
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA, USA
| | - Mary Z Bechis
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA, USA
| | - Marcel Brown
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA, USA
| | - Jennifer Michaud Finch
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA, USA
| | - Garrett Loomer
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA, USA
| | - Erich Groezinger
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA, USA
| | - Rory B Weiner
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA, USA
| | - Meagan M Wasfy
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA, USA
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA, USA
| | - Michael A Fifer
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA, USA
| | - Gregory B Lewis
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA, USA
| | - Aaron L Baggish
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA, USA
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Shah AB, Zilinski J, Brown MG, Neary JH, Weiner RB, Hutter AM, Apple FS, Picard MH, Januzzi JL, Baggish AL. Endurance Exercise Training Attenuates Natriuretic Peptide Release During Maximal Effort Exercise: Biochemical Correlates of the "Athlete's Heart". J Appl Physiol (1985) 2018; 125:1702-1709. [PMID: 30307785 DOI: 10.1152/japplphysiol.00293.2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Endurance exercise training (ET) stimulates eccentric left ventricular hypertrophy (LVH) with left atrial dilation. To date, the biochemical correlates of exercise-induced cardiac remodelling (EICR) remain incompletely understood. Collegiate male rowers (n = 9) were studied with echocardiography and maximal-effort cardiopulmonary exercise testing (MECPET) before and after 90 days of ET intensification. Mid-regional pro-atrial natriuretic peptide (MR-proANP), N-terminal pro B-type natriuretic peptide (NT-proBNP), and high-sensitivity troponin T (hscTn) were measured at rest, peak MECPET, and 60 minutes post-MECPET at both study time points. ET resulted in eccentric LVH (LV mass = 102 ± 8 vs. 110 ± 11 g/m2, p=0.001; relative wall thickness = 0.36 ± 0.04 vs. 0.37 ± 0.04, p=0.103), left atrial dilation (74 ± 18 vs. 84 ± 15 mL, p<0.001), and increased exercise capacity (peak VO2 = 53.0 ± 5.9 vs. 67.3 ± 8.2 ml/kg/min, p<0.001). LV remodelling was characterized by an approximate 7% increase in LV wall thickness but only a 3% increase in LV chamber radius. The magnitude of natriuretic peptide release, examined as percent change from rest to peak exercise, was significantly lower for both MR-proANP (115 [95, 127]% vs. 78 [59, 87]%, p=0.04) and NT-proBNP (46 [31, 70]% vs. 27 [25, 37]%, p=0.02) after ET. Rowing-based ET and corollary EICR appear to result in an attenuated natriuretic peptide response to maximal effort exercise. This may occur as a function of decreased cardiac wall stress after ET as seen by disproportionally higher ventricular wall thickening compared to chamber dilation.
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Affiliation(s)
- Ankit B Shah
- Cardiovascular Performance Program, Massachusetts General Hospital, United States
| | - Jodi Zilinski
- Cardiovascular Performance Program, Massachusetts General Hospital, United States
| | - Marcel G Brown
- Cardiovascular Performance Program, Massachusetts General Hospital, United States
| | - Jennifer H Neary
- Cardiovascular Performance Program, Massachusetts General Hospital, United States
| | - Rory B Weiner
- Cardiology, Massachusetts General Hospital, United States
| | - Adolph M Hutter
- Cardiovascular Performance Program, Massachusetts General Hospital, United States
| | - Fred S Apple
- Hennepin County Medical Center, University of Minnesota School of Medicine, United States
| | - Michael H Picard
- Cardiovascular Performance Program, Massachusetts General Hospital, United States
| | - James L Januzzi
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital, United States
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, United States
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Sarma AA, Picard MH, Hung J. The Comprehensive Assessment of Left Ventricular Assist Devices by Echocardiography. Curr Cardiovasc Imaging Rep 2018. [DOI: 10.1007/s12410-018-9470-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Fiedler AG, Bhambhani V, Laikhter E, Picard MH, Wasfy MM, Tolis G, Melnitchouk S, Sundt TM, Wasfy JH. Aortic valve replacement associated with survival in severe regurgitation and low ejection fraction. Heart 2018; 104:835-840. [PMID: 29092919 DOI: 10.1136/heartjnl-2017-312024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 09/30/2017] [Accepted: 10/04/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Although guidelines support aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR) and left ventricular ejection fraction (LVEF) <50%, severe left ventricular dysfunction (LVEF <35%) is thought to confer high surgical risk. We sought to determine if a survival benefit exists with AVR compared with medical management in this high-risk, relatively rare population. METHODS A large institutional echocardiography database was queried to identify patients with severe AR and LVEF <35%. Manual chart review was performed. Due to small sample size and population heterogeneity, corrected group prognosis method was applied, which calculates the adjusted survival curve for each individual using fitted Cox proportional hazard model. Average survival adjusted for comorbidities and age was then calculated using the weighted average of the individual survival curves. RESULTS Initially, 2 54 614 echocardiograms were considered, representing 1 45 785 unique patients, of which 40 patients met inclusion criteria. Of those, 18 (45.0%) underwent AVR and 22 (55.0%) were managed medically. Absolute mortality was 27.8% in the AVR group and 91.2% in the medical management group. After multivariate adjustment, end-stage renal disease (HR=17.633, p=0.0335) and peripheral arterial disease (HR=6.050, p=0.0180) were associated with higher mortality. AVR was associated with lower mortality (HR=0.143, p=0.0490). Mean follow-up time of the study cohort was 6.58 years, and mean survival for patients undergoing AVR was 6.31 years. CONCLUSIONS Even after adjustment for clinical characteristics and patient age, AVR is associated with higher survival for patients with low LVEF and severe AR. Although treatment selection bias cannot be completely eliminated by this analysis, these results provide some evidence that surgery may be associated with prolonged survival in this high-risk patient group.
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Affiliation(s)
- Amy G Fiedler
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vijeta Bhambhani
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Laikhter
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Meagan M Wasfy
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Pedlar CR, Brown MG, Shave RE, Otto JM, Drane A, Michaud-Finch J, Contursi M, Wasfy MM, Hutter A, Picard MH, Lewis GD, Baggish AL. Cardiovascular response to prescribed detraining among recreational athletes. J Appl Physiol (1985) 2018; 124:813-820. [DOI: 10.1152/japplphysiol.00911.2017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Exercise-induced cardiac remodeling (EICR) and the attendant myocardial adaptations characteristic of the athlete’s heart may regress during periods of exercise reduction or abstinence. The time course and mechanisms underlying this reverse remodeling, specifically the impact of concomitant plasma volume (PV) contraction on cardiac chamber size, remain incompletely understood. We therefore studied recreational runners ( n = 21, age 34 ± 7 yr; 48% male) who completed an 18-wk training program (~7 h/wk) culminating in the 2016 Boston Marathon after which total exercise exposure was confined to <2 h/wk (no single session >1 h) for 8 wk. Cardiac structure and function, exercise capacity, and PV were assessed at peak fitness (10–14 days before) and at 4 wk and 8 wk postmarathon. Mixed linear modeling adjusting for age, sex, V̇o2peak, and marathon finish time was used to compare data across time points. Physiological detraining was evidenced by serial reductions in treadmill performance. Two distinct phases of myocardial remodeling and hematological adaptation were observed. After 4 wk of detraining, there were significant reductions in PV (Δ −6.0%, P < 0.01), left ventricular (LV) wall thickness (Δ −8.1%, <0.05), LV mass (Δ −10.3%, P < 0.001), and right atrial area (Δ −8.2%, P < 0.001). After 8 wk of detraining, there was a significant reduction in right ventricle chamber size (end-diastolic area Δ = −8.0%, P < 0.05) without further concomitant reductions in PV or LV wall thickness. Abrupt reductions in exercise training stimulus result in a structure-specific time course of reverse cardiac remodeling that occurs largely independently of PV contraction. NEW & NOTEWORTHY Significant reverse cardiac remodeling, previously documented among competitive athletes, extends to recreational runners and occurs with a distinct time course. Initial reductions in plasma volume and left ventricular (LV) mass, driven by reductions in wall thickness, are followed by contraction of the right ventricle. Consistent with data from competitive athletes, LV chamber volumes appear less responsive to detraining and may be a more permanent adaptation to sport.
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Affiliation(s)
- Charles R. Pedlar
- Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- School of Sport, Health and Applied Science, St Mary’s University, Twickenham, United Kingdom
| | - Marcel G. Brown
- Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert E. Shave
- Cardiff Centre for Exercise and Health, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - James M. Otto
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Aimee Drane
- Cardiff Centre for Exercise and Health, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Jennifer Michaud-Finch
- Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Miranda Contursi
- Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Meagan M. Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Adolph Hutter
- Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael H. Picard
- Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gregory D. Lewis
- Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Aaron L. Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Mihos CG, Yucel E, Capoulade R, Orencole MP, Upadhyay GA, Santana O, Singh JP, Picard MH. Effects of cardiac resynchronization therapy after inferior myocardial infarction on secondary mitral regurgitation and mitral valve geometry. Pacing Clin Electrophysiol 2018; 41:114-121. [DOI: 10.1111/pace.13255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 11/06/2017] [Accepted: 11/28/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Christos G. Mihos
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital; Harvard Medical School; Boston MA USA
- Echocardiography Laboratory, Columbia University Division of Cardiology; Mount Sinai Heart Institute; Miami Beach FL USA
| | - Evin Yucel
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Romain Capoulade
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Mary P. Orencole
- Cardiac Arrhythmia Service, Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | | | - Orlando Santana
- Echocardiography Laboratory, Columbia University Division of Cardiology; Mount Sinai Heart Institute; Miami Beach FL USA
| | - Jagmeet P. Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Michael H. Picard
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital; Harvard Medical School; Boston MA USA
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Shen T, Picard MH, Hua L, Burns SM, Andrawes MN. Assessment of Tricuspid Annular Motion by Speckle Tracking in Anesthetized Patients Using Transesophageal Echocardiography. Anesth Analg 2018; 126:62-67. [PMID: 29116970 DOI: 10.1213/ane.0000000000002614] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The perioperative assessment of right ventricular (RV) function remains a challenge. Tricuspid annular plane systolic excursion (TAPSE) using M-mode is a widely used measure of RV function. However, accurate alignment of the ultrasound beam with the direction of annular movement can be difficult with transesophageal echocardiography (TEE) to measure TAPSE, precluding effective use of M-mode to measure annular excursion. Tracking of specular reflectors in the myocardium may provide an angle-independent method to assess annular motion with TEE. We hypothesized that TEE speckle tracking of the lateral tricuspid annular motion represents a comparable measurement to the well-validated M-mode TAPSE on transthoracic echocardiogram (TTE), and may be considered as a reasonable alternative to TAPSE. METHODS This is a prospective, observational cohort study. We included all patients, who were in sinus rhythm, with a preoperative TTE within 3 months of scheduled cardiac surgery that required intraoperative TEE. Tissue motion annular displacements (TMAD) of the lateral (L), septal (S), and midpoint (M) tricuspid annulus were measured (QLAB Cardiac Motion Quantification; Philips Medical, Andover, MA) after induction of general anesthesia. This was compared to the preoperative M-mode TAPSE on TTE. RESULTS Seventy-two consecutive patients who met eligibility requirements were enrolled from September to November 2016. Twelve were excluded due to poor image quality, allowing TMAD to be analyzed in 60 patients. TMAD was analyzed offline and TMAD analysis was able to track tricuspid annular motion in all patients. The mean TMAD (L), TMAD (S), and TMAD (M) were 17.4 ± 5.2, 10.2 ± 4.8, and 14.2 ± 4.8 mm, respectively. TMAD (L) showed close correlation with M-mode TAPSE on TTE (r = 0.87, 95% confidence interval, 0.79-0.92; P < .01). All patients with a preoperative TAPSE <17 mm had a TMAD (L) <17 mm, while 71% of those with a TAPSE ≥ 17 mm had a TMAD (L) ≥ 17 mm. There was strong positive correlation between TMAD (L) and intraoperative RV fractional area change (r = 0.86, 95% confidence interval, 0.77-0.91; P < .01). Reproducibility analysis of TMAD within and across observers showed excellent correlation. CONCLUSIONS TMAD is a quick and angle-independent method to quantitatively assess RV longitudinal function by TEE. It correlates strongly with M-mode TAPSE on TTE. Because TMAD and TAPSE were not simultaneously measured in this study, their correlation is subject to differences in loading conditions, general anesthesia, and changes in the disease process. TMAD may be easily applied in routine clinical settings and its role in the perioperative environment deserves to be further explored.
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Affiliation(s)
- Tao Shen
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Michael H Picard
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lanqi Hua
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sara M Burns
- From the Department of Anesthesia, Critical Care and Pain Medicine
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Picard MH. JASE 3.0: Entering Our 4 th Decade. J Am Soc Echocardiogr 2018; 31:1-2. [DOI: 10.1016/j.echo.2017.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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71
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Wasfy MM, Bibbo CF, Brown M, DeLuca JR, Wang F, Berkstresser B, Weiner RB, Lewis GD, Hutter AM, Picard MH, Di Carli MF, Baggish AL. Myocardial Metabolism in Endurance Exercise-Induced Left Ventricular Hypertrophy. JACC Cardiovasc Imaging 2017; 11:928-930. [PMID: 29248660 DOI: 10.1016/j.jcmg.2017.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/08/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
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Lin J, Wang F, Weiner RB, DeLuca JR, Wasfy MM, Berkstresser B, Lewis GD, Hutter AM, Picard MH, Baggish AL. Blood Pressure and LV Remodeling Among American-Style Football Players. JACC Cardiovasc Imaging 2017; 9:1367-1376. [PMID: 27931524 DOI: 10.1016/j.jcmg.2016.07.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/07/2016] [Accepted: 07/29/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This study sought to determine the relationships among American-style football (ASF) participation, acquired left ventricular (LV) hypertrophy, and LV systolic function as assessed using contemporary echocardiographic parameters. BACKGROUND Participation in ASF has been associated with development of hypertension and LV hypertrophy. To what degree these processes impact LV function is unknown. METHODS This was a prospective, longitudinal cohort study evaluating National Collegiate Athletic Association Division I football athletes stratified by field position (linemen: n = 30; vs. nonlinemen, n = 57) before and after a single competitive season, using transthoracic echocardiography. LV systolic function was measured using complementary parameters of global longitudinal strain (GLS) (using 2-dimensional speckle-tracking) and ejection fraction (EF) (2-dimensional biplane). RESULTS ASF participation was associated with field position-specific increases in systolic blood pressure (SBP) (a Δ SBP of 10 ± 8 mm Hg in linemen vs. a Δ SBP of 3 ± 7 mm Hg in nonlinemen; p < 0.001) and an overall increase in incident LV hypertrophy (pre-season = 8% vs. post-season = 25%, p < 0.05). Linemen who developed LV hypertrophy had concentric geometry (9 of 11 [82%]) with decreased GLS (Δ = -1.1%; p < 0.001), whereas nonlinemen demonstrated eccentric LV hypertrophy (8 of 10 [80%]) with increased GLS (Δ = +1.4%; p < 0.001). In contrast, LV ejection fraction in the total cohort, stratified by field position, was not significantly affected by ASF participation. Among the total cohort, lineman field position, post-season weight, SBP, average LV wall thickness, and relative wall thickness were all independent predictors of post-season GLS. CONCLUSIONS ASF participation at a lineman field position may lead to a form of sport-related myocardial remodeling that is pathologic rather than adaptive. Future study will be required to determine if targeted efforts to control blood pressure, minimize weight gain, and to include an element of aerobic conditioning in this subset of athletes may attenuate this process and translate into tangible downstream health benefits.
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Affiliation(s)
- Jeffrey Lin
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Francis Wang
- Harvard University Health Services, Cambridge, Massachusetts
| | - Rory B Weiner
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts; Harvard University Health Services, Cambridge, Massachusetts
| | - James R DeLuca
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Meagan M Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Gregory D Lewis
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Adolph M Hutter
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael H Picard
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts; Harvard University Health Services, Cambridge, Massachusetts.
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Bennet CS, Abeya FC, Hoffman A, Rwebembera J, Picard MH, Wood MJ, Okello S. Performance and Interpretation Training of Transthoracic Echocardiography in Resource-Limited Settings. J Am Coll Cardiol 2017; 70:1940-1941. [PMID: 28982509 DOI: 10.1016/j.jacc.2017.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 11/17/2022]
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Mihos CG, Yucel E, Capoulade R, Orencole MP, Upadhyay GA, Santana O, Singh JP, Picard MH. Impact of cardiac resynchronization therapy on mitral valve apparatus geometry and clinical outcomes in patients with secondary mitral regurgitation. Echocardiography 2017; 34:1561-1567. [DOI: 10.1111/echo.13690] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Christos G. Mihos
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Evin Yucel
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Romain Capoulade
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Mary P. Orencole
- Cardiac Arrhythmia Service; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | | | - Orlando Santana
- Columbia University Division of Cardiology; Mount Sinai Heart Institute; Miami Beach FL USA
| | - Jagmeet P. Singh
- Cardiac Arrhythmia Service; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Michael H. Picard
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
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Safi LM, Passeri JJ, Picard MH. New considerations in the assessment of aortic stenosis. Future Cardiol 2017; 13:433-441. [PMID: 28828892 DOI: 10.2217/fca-2017-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Calcific aortic stenosis (AS) is one of the most common acquired valvular heart diseases in industrialized nations. It is a slowly progressive disease and with the aging population, the prevalence of AS is expected to increase. Doppler echocardiography is used to classify patients based on severity of stenosis. Research efforts on how to better identify and risk-assess these patients are currently underway using advanced imaging modalities and serum biomarkers. Thus far, medications for AS prevention have been unsuccessful. As technology progresses, the assessment of AS will transition from one heavily weighed on echocardiographic gradients to one of active surveillances with multimodality imaging, serum biomarkers and genetic assessment.
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Affiliation(s)
- Lucy M Safi
- Director of Interventional Echocardiography, Hackensack University Medical Center, Hackensack, NJ 07601, USA
| | - Jonathan J Passeri
- Co-Director Heart Valve Program, Director of Interventional Echocardiography, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Michael H Picard
- Cardiology Division, Massachusetts General Hospital, Professor of Medicine, Harvard Medical School, Boston, MA 02114, USA
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Tanguturi VK, Hidrue MK, Picard MH, Atlas SJ, Weilburg JB, Ferris TG, Armstrong K, Wasfy JH. Variation in the Echocardiographic Surveillance of Primary Mitral Regurgitation. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.117.006495. [PMID: 28774932 DOI: 10.1161/circimaging.117.006495] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 06/15/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Clinical outcomes after surgical treatment of mitral regurgitation are worse if intervention occurs after deterioration of left ventricular size and function. Transthoracic echocardiographic (TTE) surveillance of patients with mitral regurgitation is indicated to avoid adverse ventricular remodeling. Overly frequent TTEs can impair patient access and reduce value in care delivery. This balance between timely surveillance and overutilization of TTE in valvular disease provides a model to study variation in the delivery of healthcare services. We investigated patient and provider factors contributing to variation in TTE utilization and hypothesized that variation was attributable to provider practice even after adjustment for patient characteristics. METHODS AND RESULTS We obtained records of all TTEs from 2001 to 2016 completed at a large echocardiography laboratory. The outcome variable was time interval between TTEs. We constructed a mixed-effects linear regression model with the individual physician as the random effect in the model and used intraclass correlation coefficient to assess the proportion of outcome variation because of provider practice. Our study cohort was 55 773 TTEs corresponding to 37 843 intervals ordered by 635 providers. The mean interval between TTEs was 12.4 months, 17.0 months, 18.3 months, and 17.4 months for severe, moderate, mild, and trace mitral regurgitation, respectively, with 20% of providers deemed overutilizers of TTEs and 25% underutilizers. CONCLUSIONS We conclude that there is substantial variation in follow-up intervals for TTE assessment of mitral regurgitation, despite risk-adjustment for patient variables, likely because of provider factors.
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Affiliation(s)
- Varsha K Tanguturi
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Michael K Hidrue
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Michael H Picard
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Steven J Atlas
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Jeffrey B Weilburg
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Timothy G Ferris
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Katrina Armstrong
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.)
| | - Jason H Wasfy
- From the Division of Cardiology (V.K.T., M.H.P., J.H.W.), Department of Medicine (V.K.T., M.H.P., J.H.W., S.J.A., K.A.), Massachusetts General Hospital, Harvard Medical School, Boston; and Massachusetts General Physicians Organization, Boston (M.K.H., M.H.P., S.J.A., J.B.W., T.G.F., J.H.W.).
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Chatterjee NA, Gold MR, Waggoner AD, Picard MH, Stein KM, Yu Y, Meyer TE, Wold N, Ellenbogen KA, Singh JP. Longer Left Ventricular Electric Delay Reduces Mitral Regurgitation After Cardiac Resynchronization Therapy: Mechanistic Insights From the SMART-AV Study (SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy). Circ Arrhythm Electrophysiol 2017; 9:CIRCEP.116.004346. [PMID: 27906653 DOI: 10.1161/circep.116.004346] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 10/05/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Mitral regurgitation (MR) is associated with worse survival in those undergoing cardiac resynchronization therapy (CRT). Left ventricular (LV) lead position in CRT may ameliorate mechanisms of MR. We examine the association between a longer LV electric delay (QLV) at the LV stimulation site and MR reduction after CRT. METHODS AND RESULTS QLV was assessed retrospectively in 426 patients enrolled in the SMART-AV study (SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in CRT). QLV was defined as the time from QRS onset to the first large peak of the LV electrogram. Linear regression and logistic regression were used to assess the association between baseline QLV and MR reduction at 6 months (absolute change in vena contracta width and odds of ≥1 grade reduction in MR). At baseline, there was no difference in MR grade, LV dyssynchrony, or LV volumes in those with QLV above versus below the median (95 ms). After multivariable adjustment, increasing QLV was an independent predictor of MR reduction at 6 months as reflected by an increased odds of MR response (odds ratio: 1.13 [1.03-1.25]/10 ms increase QLV; P=0.02) and a decrease in vena contracta width (P<0.001). At 3 months, longer QLV (≥median) was associated with significant decrease in LV end-systolic volume (ΔLV end-systolic volume -28.2±38.9 versus -4.9±33.8 mL, P<0.001). Adjustment for 3-month ΔLV end-systolic volume attenuated the association between QLV and 6-month MR reduction. CONCLUSIONS In patients undergoing CRT, longer QLV was an independent predictor of MR reduction at 6 months and associated with interval 3-month LV reverse remodeling. These findings provide a mechanistic basis for using an electric-targeting LV lead strategy at the time of CRT implant.
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Affiliation(s)
| | | | | | | | | | - Yinghong Yu
- For the author affiliations, please see the Appendix
| | | | - Nicholas Wold
- For the author affiliations, please see the Appendix
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Hoffmann U, Ferencik M, Udelson JE, Picard MH, Truong QA, Patel MR, Huang M, Pencina M, Mark DB, Heitner JF, Fordyce CB, Pellikka PA, Tardif JC, Budoff M, Nahhas G, Chow B, Kosinski AS, Lee KL, Douglas PS. Prognostic Value of Noninvasive Cardiovascular Testing in Patients With Stable Chest Pain: Insights From the PROMISE Trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain). Circulation 2017; 135:2320-2332. [PMID: 28389572 PMCID: PMC5946057 DOI: 10.1161/circulationaha.116.024360] [Citation(s) in RCA: 295] [Impact Index Per Article: 42.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 03/23/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND Optimal management of patients with stable chest pain relies on the prognostic information provided by noninvasive cardiovascular testing, but there are limited data from randomized trials comparing anatomic with functional testing. METHODS In the PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), patients with stable chest pain and intermediate pretest probability for obstructive coronary artery disease (CAD) were randomly assigned to functional testing (exercise electrocardiography, nuclear stress, or stress echocardiography) or coronary computed tomography angiography (CTA). Site-based diagnostic test reports were classified as normal or mildly, moderately, or severely abnormal. The primary end point was death, myocardial infarction, or unstable angina hospitalizations over a median follow-up of 26.1 months. RESULTS Both the prevalence of normal test results and incidence rate of events in these patients were significantly lower among 4500 patients randomly assigned to CTA in comparison with 4602 patients randomly assigned to functional testing (33.4% versus 78.0%, and 0.9% versus 2.1%, respectively; both P<0.001). In CTA, 54.0% of events (n=74/137) occurred in patients with nonobstructive CAD (1%-69% stenosis). Prevalence of obstructive CAD and myocardial ischemia was low (11.9% versus 12.7%, respectively), with both findings having similar prognostic value (hazard ratio, 3.74; 95% confidence interval [CI], 2.60-5.39; and 3.47; 95% CI, 2.42-4.99). When test findings were stratified as mildly, moderately, or severely abnormal, hazard ratios for events in comparison with normal tests increased proportionally for CTA (2.94, 7.67, 10.13; all P<0.001) but not for corresponding functional testing categories (0.94 [P=0.87], 2.65 [P=0.001], 3.88 [P<0.001]). The discriminatory ability of CTA in predicting events was significantly better than functional testing (c-index, 0.72; 95% CI, 0.68-0.76 versus 0.64; 95% CI, 0.59-0.69; P=0.04). If 2714 patients with at least an intermediate Framingham Risk Score (>10%) who had a normal functional test were reclassified as being mildly abnormal, the discriminatory capacity improved to 0.69 (95% CI, 0.64-0.74). CONCLUSIONS Coronary CTA, by identifying patients at risk because of nonobstructive CAD, provides better prognostic information than functional testing in contemporary patients who have stable chest pain with a low burden of obstructive CAD, myocardial ischemia, and events. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01174550.
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Affiliation(s)
- Udo Hoffmann
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.).
| | - Maros Ferencik
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - James E Udelson
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Michael H Picard
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Quynh A Truong
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Manesh R Patel
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Megan Huang
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Michael Pencina
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Daniel B Mark
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - John F Heitner
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Christopher B Fordyce
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Patricia A Pellikka
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Jean-Claude Tardif
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Matthew Budoff
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - George Nahhas
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Benjamin Chow
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Andrzej S Kosinski
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Kerry L Lee
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
| | - Pamela S Douglas
- From Massachusetts General Hospital, Harvard Medical School, Boston (U.H., M.H.P.); Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.); Tufts University School of Medicine and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.); Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., M.H., M.P., D.B.M., C.B.F., A.S.K., K.L.L., P.S.D.); Cardiovascular Research, New York Methodist Hospital, Brooklyn (J.F.H.); Mayo Clinic, Rochester, MN (P.A.P.); Montreal Heart Institute, Université de Montréal, Canada (J.-C.T.); Los Angeles Biomedical Research Institute, Torrance, CA (M.B.); Cardiology, Beaumont Hospital-Dearborn, MI (G.N.); and Department of Medicine, Ottawa Heart Institute, Ontario, Canada (B.C.)
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Lin J, Wang F, Weiner RB, DeLuca JR, Wasfy MM, Berkstresser B, Lewis GD, Hutter AM, Picard MH, Baggish AL. The Authors Reply:. JACC Cardiovasc Imaging 2017; 10:496-497. [DOI: 10.1016/j.jcmg.2017.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/19/2017] [Indexed: 10/19/2022]
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Dudzinski DM, Bhatia RS, Mi MY, Isselbacher EM, Picard MH, Weiner RB. Effect of Educational Intervention on the Rate of Rarely Appropriate Outpatient Echocardiograms Ordered by Attending Academic Cardiologists. JAMA Cardiol 2016; 1:805-812. [DOI: 10.1001/jamacardio.2016.2232] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- David M. Dudzinski
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital, Boston
| | - R. Sacha Bhatia
- Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
| | - Michael Y. Mi
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Eric M. Isselbacher
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital, Boston
| | - Michael H. Picard
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital, Boston
| | - Rory B. Weiner
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital, Boston
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Tan TC, Zeng X, Jiao Y, Wang L, Wei Q, Thiele K, Salgo I, Mehta V, Andrawes M, Picard MH, Hung J. Three-Dimensional Field Optimization Method: Clinical Validation of a Novel Color Doppler Method for Quantifying Mitral Regurgitation. J Am Soc Echocardiogr 2016; 29:926-934. [PMID: 27405591 DOI: 10.1016/j.echo.2016.05.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Assessment of mitral regurgitation (MR) severity by echocardiography is important for clinical decision making, but MR severity can be challenging to quantitate accurately and reproducibly. The accuracy of effective regurgitant orifice area (EROA) and regurgitant volume (RVol) calculated using two-dimensional (2D) proximal isovelocity surface area is limited by the geometric assumptions of proximal isovelocity surface area shape, and both variables demonstrate interobserver variability. The aim of this study was to compare a novel automated three-dimensional (3D) echocardiographic method for calculating MR regurgitant flow using standard 2D techniques. METHODS A sheep model of ischemic MR and patients with MR were prospectively examined. Patients with a range of severity of MR were examined. EROA and RVol were calculated from 3D color Doppler acquisitions using a novel computer-automated algorithm based on the field optimization method to measure EROA and RVol. For an independent comparison group, the 3D field optimization method was compared with 2D methods for grading MR in an experimental ovine model of MR. RESULTS Fifteen 3D data sets from nine sheep (open-chest transthoracic echocardiographic data sets) and 33 transesophageal data sets from patients with MR were prospectively examined. For sheep data sets, mean 2D EROA was 0.16 ± 0.05 cm2, and mean 2D RVol was 21.84 ± 8.03 mL. Mean 3D EROA was 0.09 ± 0.04 cm2, and mean 3D RVol was 14.40 ± 5.79 cm3. There was good correlation between 2D and 3D EROA (R = 0.70) and RVol (R = 0.80). For patient data sets, mean 2D EROA was 0.35 ± 0.35 cm2, and mean 2D RVol was 58.9 ± 52.9 mL. Mean 3D EROA was 0.34 ± 0.29 cm2, and mean 3D RVol was 54.6 ± 36.5 mL. There was excellent correlation between 2D and 3D EROA (R = 0.94) and RVol (R = 0.84). Bland-Altman analysis revealed greater interobserver variability for 2D RVol measurements compared with 3D RVol using the 3D field optimization method measurements, but variability was statistically significant only for RVol. CONCLUSIONS Direct automated measurement of proximal isovelocity surface area region for EROA calculation using real-time 3D color Doppler echocardiography is feasible, with a high correlation to current 2D EROA methods but less variability. This novel automated method provides an accurate and highly reproducible method for calculating EROA.
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Affiliation(s)
- Timothy C Tan
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Xin Zeng
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yuan Jiao
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lin Wang
- St. Francis Hospital, Roslyn, New York
| | - Qifeng Wei
- Philips Healthcare, Andover, Massachusetts
| | | | - Ivan Salgo
- Philips Healthcare, Andover, Massachusetts
| | - Vipin Mehta
- Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Andrawes
- Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael H Picard
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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Afilalo J, Steele R, Manning WJ, Khabbaz KR, Rudski LG, Langlois Y, Morin JF, Picard MH. Derivation and Validation of Prognosis-Based Age Cutoffs to Define Elderly in Cardiac Surgery. Circ Cardiovasc Qual Outcomes 2016; 9:424-31. [DOI: 10.1161/circoutcomes.115.002409] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 06/02/2016] [Indexed: 11/16/2022]
Abstract
Background—
The age cutoff to define elderly is controversial in cardiac surgery, empirically ranging from ≥65 to ≥80 years. Beyond semantics, this has important implications as a starting point for clinical care pathways and inclusion in trials. We sought to characterize the relationship between age and adverse outcomes in patients undergoing cardiac surgery and to derive and validate prognosis-based age cutoffs.
Methods and Results—
Six thousand five hundred seventy one consecutive adult patients undergoing cardiac surgery at 3 hospitals in the United States and Canada were included in the cohort. Logistic regression models and generalized additive models with thin-plate splines were fit to the data. The age distribution was 50 to 59 years in 1244 (18.9%), 60 to 69 years in 2144 (32.6%), 70 to 79 years in 2000 (30.4%), ≥80 years in 1183 (18.0%) patients. After controlling for sex and type of operation, the relationship between age and 30-day operative mortality was found to be nonlinear. Receiver operating characteristic analysis showed that the optimal cutoffs to identify older patients at higher risk of operative mortality were greater than 74, 78, and 75 years for isolated coronary bypass, isolated valve surgery, and coronary bypass plus valve surgery, respectively. These age cutoffs were validated in an independent cohort.
Conclusions—
The relationship between age and operative mortality is not linear, manifesting a steeper rise after age 75 for coronary bypass and approaching octogenarian age for isolated valve surgery. Rather than using arbitrary age cutoffs to define elderly, the outcomes-based cutoff of ≥75 years should be used to identify the population of older adults that has higher risk and may benefit from preoperative geriatric evaluation and optimization.
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Affiliation(s)
- Jonathan Afilalo
- From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery,
| | - Russell Steele
- From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery,
| | - Warren J. Manning
- From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery,
| | - Kamal R. Khabbaz
- From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery,
| | - Lawrence G. Rudski
- From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery,
| | - Yves Langlois
- From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery,
| | - Jean-Francois Morin
- From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery,
| | - Michael H. Picard
- From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery,
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83
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Shaw LJ, Xie JX, Phillips LM, Goyal A, Reynolds HR, Berman DS, Picard MH, Bhargava B, Devlin G, Chaitman BR. Optimising diagnostic accuracy with the exercise ECG: opportunities for women and men with stable ischaemic heart disease. Heart Asia 2016; 8:1-7. [PMID: 27326241 DOI: 10.1136/heartasia-2016-010736] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 04/28/2016] [Indexed: 11/03/2022]
Abstract
UNLABELLED The exercise ECG is an integral part within the evaluation algorithm for diagnosis and risk stratification of patients with stable ischaemic heart disease (SIHD). There is evidence, both older and new, that the exercise ECG can be an effective and cost-efficient option for patients capable of performing at maximal levels of exercise with suitable resting ECG findings. In this review, we will highlight the major dilemmas in interpreting suspected coronary artery disease symptoms in women and identify optimal strategies for employing exercise ECG as a first-line diagnostic test in the SIHD evaluation algorithm. We will highlight current evidence as well as recent guideline statements on this subject. TRIAL REGISTRATION NUMBER NCT01471522; Pre-results.
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Affiliation(s)
- Leslee J Shaw
- Department of Medicine, Division of Cardiology , Emory University School of Medicine , Atlanta, Georgia , USA
| | - Joe X Xie
- Department of Medicine, Division of Cardiology , Emory University School of Medicine , Atlanta, Georgia , USA
| | - Lawrence M Phillips
- Cardiovascular Clinical Research Center , Leon H. Charney Division of Cardiology, Department of Medicine , New York University School of Medicine, New York , NY, USA
| | - Abhinav Goyal
- Department of Medicine, Division of Cardiology , Emory University School of Medicine , Atlanta, Georgia , USA
| | - Harmony R Reynolds
- Cardiovascular Clinical Research Center , Leon H. Charney Division of Cardiology, Department of Medicine , New York University School of Medicine, New York , NY, USA
| | - Daniel S Berman
- Department of Imaging, Cedars-Sinai Heart Institute , Cedars-Sinai Medical Center , Los Angeles, California , USA
| | - Michael H Picard
- Department of Medicine, Division of Cardiology , Massachusetts General Hospital , Boston, Massachusetts , USA
| | - Balram Bhargava
- Professor of Cardiology, Cardiothoracic Sciences Centre, and Executive Director, Stanford India Biodesign Centre , School of International Biodesign (SIB), All India Institute of Medical Sciences , New Delhi , India
| | - Gerard Devlin
- Department of Medicine, Division of Cardiology, New Zealand Heart Foundation , Waikato Hospital , Hamilton, New Zealand , USA
| | - Bernard R Chaitman
- Department of Medicine, Division of Cardiology , St Louis University School of Medicine , St Louis, Missouri , USA
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84
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Kataoka A, Scherrer-Crosbie M, Senior R, Garceau P, Valbuena S, Čelutkienė J, Hastings JL, Cheema AN, Lara A, Srbinovska-Kostovska E, Hessian R, Poggio D, Goldweit R, Saric M, Dajani KA, Kohn JA, Shaw LJ, Reynolds HR, Picard MH. Transient Ischemic Dilatation during Stress Echocardiography: An Additional Marker of Significant Myocardial Ischemia. Echocardiography 2016; 33:1202-8. [PMID: 27040889 DOI: 10.1111/echo.13222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
AIM Left ventricular (LV) transient ischemic dilatation (TID) is not clear how it relates to inducible myocardial ischemia during stress echocardiography (SE). METHODS AND RESULTS Eighty-eight SEs were examined from the site certification phase of the ISCHEMIA Trial. LV end-diastolic volume (EDV) and end-systolic volume (ESV) were measured at rest and peak stages and the percent change calculated. Moderate or greater ischemia was defined as ≥3 segments with stress-induced severe hypokinesis or akinesis. Optimum cut points in stress-induced percent EDV and ESV change that identified moderate or greater myocardial ischemia were analyzed. Analysis from percentage distribution identified a > 13% LV volume increase in EDV or a > 9% LV volume increase in ESV as the optimum cutoff points for moderate or greater ischemia. Using these definitions for TID, there were 27 (31%) with TIDESV and 12 (14%) with TIDEDV . By logistic regression analysis and receiver operating characteristic curves, the percent change in ESV had a stronger association with moderate or greater myocardial ischemia than that of EDV change. Compared to those without TIDESV , cases with TIDESV had larger extent of inducible wall-motion abnormalities, lower peak stress LVEF, and higher likelihood of moderate or grater ischemia. For moderate or greater myocardial ischemia detection, TIDESV had a sensitivity of 46%, specificity of 83%, positive predictive value of 70%, and negative predictive value of 64%. CONCLUSION Transient ischemic dilatation by SE is a marker of extensive myocardial ischemia and can be used as an additional marker of higher risk.
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Affiliation(s)
- Akihisa Kataoka
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marielle Scherrer-Crosbie
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Roxy Senior
- Department of Cardiovascular Medicine, Division of Cardiology, National Heart and Lung Institute and Imperial College, London, United Kingdom
| | - Patrick Garceau
- Department of Medicine, Montreal Heart Institute, Montreal, Canada
| | - Silvia Valbuena
- Department of Cardiology, La Paz University Hospital, Madrid, Spain
| | - Jelena Čelutkienė
- Center of Cardiology and Angiology, Vilnius University Hospital Santariskiu Clinic, Vilnius, Lithuania
| | - Jeffrey L Hastings
- Division of Cardiology, V.A. North Texas Health Care System, Dallas, Texas
| | - Asim N Cheema
- Division of Cardiology, Saint Michael's Hospital, Toronto, Canada
| | - Alfonso Lara
- Department of Medicine, Specialty Hospital, La Raza National Medical Center, Mexico City, Mexico
| | | | - Renee Hessian
- Department of Medicine, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Daniele Poggio
- Department of Medicine, Division of Cardiology, Monza Polyclinic, Monza, Italy
| | - Richard Goldweit
- Department of Medicine, Division of Cardiology, Englewood Hospital and Medical Center, Englewood, New Jersey
| | - Muhamed Saric
- Department of Medicine, Division of Cardiology, New York University Medical Center, New York, New York
| | - Khaled A Dajani
- Department of Medicine, Division of Cardiology, Loyola University Medical Center, Maywood, Illinois
| | - Jeffrey A Kohn
- Department of Medicine, New York Medical Associates, New York, New York
| | - Leslee J Shaw
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Harmony R Reynolds
- Department of Medicine, Division of Cardiology, New York University Langone Medical Center, New York, New York
| | - Michael H Picard
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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85
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Byrd BF, Abraham TP, Buxton DB, Coletta AV, Cooper JHS, Douglas PS, Gillam LD, Goldstein SA, Graf TR, Horton KD, Isenberg AA, Klein AL, Kreeger J, Martin RP, Nedza SM, Navathe A, Pellikka PA, Picard MH, Pilotte JC, Ryan TJ, Rychik J, Sengupta PP, Thomas JD, Tucker L, Wallace W, Ward RP, Weissman NJ, Wiener DH, Woodruff S. A Summary of the American Society of Echocardiography Foundation Value-Based Healthcare: Summit 2014: The Role of Cardiovascular Ultrasound in the New Paradigm. J Am Soc Echocardiogr 2016; 28:755-69. [PMID: 26140937 DOI: 10.1016/j.echo.2015.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Value-Based Healthcare: Summit 2014 clearly achieved the three goals set forth at the beginning of this document. First, the live event informed and educated attendees through a discussion of the evolving value-based healthcare environment, including a collaborative effort to define the important role of cardiovascular ultrasound in that environment. Second, publication of these Summit proceedings in the Journal of the American Society of Echocardiography will inform a wider audience of the important insights gathered. Third, moving forward, the ASE will continue to build a ‘‘living resource’’ on its website, http://www.asecho.org, for clinicians, researchers, and administrators to use in advocating for the value of cardiovascular ultrasound in the new value-based healthcare environment. The ASE looks forward to incorporating many of the Summit recommendations as it works with its members, legislators, payers, hospital administrators, and researchers to demonstrate and increase the value of cardiovascular ultrasound. All Summit attendees shared in the infectious enthusiasm generated by this proactive approach to ensuring cardiovascular ultrasound’s place as ‘‘The Value Choice’’ in cardiac imaging.
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Affiliation(s)
| | | | - Denis B Buxton
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - James H S Cooper
- Vanderbilt University Owen Graduate School of Management, Nashville, Tennessee
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | | | | | | | | | | | | | - Amol Navathe
- University of Pennsylvania and Navigant Consulting, Inc, Philadelphia, Pennsylvania
| | | | | | - John C Pilotte
- Centers for Medicare and Medicaid Services, Baltimore, Maryland
| | - Thomas J Ryan
- The Ohio State University Heart Center, Columbus, Ohio
| | - Jack Rychik
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - James D Thomas
- Bluhm Cardiovascular Institute of Northwestern University, Chicago, Illinois
| | - Leslie Tucker
- American Board of Internal Medicine and the ABIM Foundation, Philadelphia, Pennsylvania
| | | | | | - Neil J Weissman
- MedStar Health Research Institute, Washington, District of Columbia
| | | | - Sarah Woodruff
- Adult Congenital Heart Association, Philadelphia, Pennsylvania
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86
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Fazeli PK, Teoh JG, Lam EL, Gerweck AV, Wexler TL, Teo EP, Russell BM, Durst R, McCarty D, Weiner RB, Picard MH, Klibanski A, Miller KK. Effect of growth hormone treatment on diastolic function in patients who have developed growth hormone deficiency after definitive treatment of acromegaly. Growth Horm IGF Res 2016; 26:17-23. [PMID: 26774401 PMCID: PMC4716556 DOI: 10.1016/j.ghir.2015.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/04/2015] [Accepted: 12/02/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Although growth hormone (GH) replacement is prescribed for patients with hypopituitarism due to many etiologies, it is not routinely prescribed for patients with GH deficiency (GHD) after cure of acromegaly (acroGHD). This study was designed to investigate the effect of GH replacement on cardiac parameters in acroGHD. DESIGN We prospectively evaluated for 12months 23 patients with acroGHD: 15 subjects on GH replacement and eight subjects not on GH replacement. Main outcome measures included LV mass corrected for body surface area (LVM/BSA) and measures of diastolic dysfunction (E/A ratio and deceleration time), as assessed by echocardiography. RESULTS After 12months of follow-up, there were no differences between the GH-treated group and the untreated group in LVM/BSA (GH: 74.4±22.5g/m(2) vs untreated: 72.9±21.3g/m(2), p=0.89), E/A ratio (GH: 1.21±0.39 vs untreated: 1.08±0.39, p=0.50) or deceleration time (GH: 224.5±60.1ms vs untreated: 260±79.8ms, p=0.32). The overall degree of diastolic function was similar between the groups with 42.9% of untreated subjects and 50% of GH-treated subjects (p=0.76) classified as having normal diastolic function at follow-up. CONCLUSIONS There were no significant differences in LVM/BSA or parameters of diastolic function in patients with a history of acromegaly treated for GHD as compared to those who were untreated. These data are reassuring with respect to cardiovascular safety with GH use after treatment for acromegaly, although further longer term study is necessary to evaluate the safety and efficacy of GH treatment in this population.
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Affiliation(s)
- Pouneh K Fazeli
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States.
| | - Jonathan G Teoh
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States
| | - Eleanor L Lam
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States
| | - Anu V Gerweck
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Tamara L Wexler
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States
| | - Eliza P Teo
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States
| | - Brian M Russell
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Ronen Durst
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States
| | - David McCarty
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States
| | - Rory B Weiner
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States
| | - Anne Klibanski
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, United States; Harvard Medical School, Boston, MA 02115, United States
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87
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Kataoka A, Scherrer-Crosbie M, Senior R, Gosselin G, Phaneuf D, Guzman G, Perna G, Lara A, Kedev S, Mortara A, El-Hajjar M, Shaw LJ, Reynolds HR, Picard MH. The value of core lab stress echocardiography interpretations: observations from the ISCHEMIA Trial. Cardiovasc Ultrasound 2015; 13:47. [PMID: 26683627 PMCID: PMC4683787 DOI: 10.1186/s12947-015-0043-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 12/15/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stress echocardiography (SE) is dependent on subjective interpretations. As a prelude to the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) Trial, potential sites were required to submit two SE, one with moderate or severe left ventricular (LV) myocardial ischemia and one with mild ischemia. We evaluated the concordance of site and core lab interpretations. METHODS Eighty-one SE were submitted from 41 international sites. Ischemia was classified by the number of new or worsening segmental LV wall motion abnormalities (WMA): none, mild (1 or 2) or moderate or severe (3 or more) by the sites and the core lab. RESULTS Core lab classified 6 SE as no ischemia, 35 mild and 40 moderate or greater. There was agreement between the site and core in 66 of 81 total cases (81%, weighted kappa coefficient [K] =0.635). Agreement was similar for SE type - 24 of 30 exercise (80%, K = 0.571) vs. 41 of 49 pharmacologic (84%, K = 0.685). The agreement between poor or fair image quality (27 of 36 cases, 75%, K = 0.492) was not as good as for the good or excellent image quality cases (39 of 45 cases, 87%, K = 0.755). Differences in concordance were noted for degree of ischemia with the majority of discordant interpretations (87%) occurring in patients with no or mild LV myocardial ischemia. CONCLUSIONS While site SE interpretations are largely concordant with core lab interpretations, this appears dependent on image quality and the extent of WMA. Thus core lab interpretations remain important in clinical trials where consistency of interpretation across a range of cases is critical. TRIAL REGISTRATION ClinicalTrials.gov NCT01471522.
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Affiliation(s)
- Akihisa Kataoka
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street Yawkey 5E, Boston, MA, 02114, USA.
| | - Marielle Scherrer-Crosbie
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street Yawkey 5E, Boston, MA, 02114, USA.
| | - Roxy Senior
- Department of Cardiovascular Medicine, Division of Cardiology, National Heart and Lung Institute, Imperial College, Sydney Street, London, SW3 6NP, UK.
| | - Gilbert Gosselin
- Department of Medicine, Montreal Heart Institute, 5000 Belanger St, Montreal, QC H1T 1C8, Canada.
| | - Denis Phaneuf
- Department of Cardiology Research, CSSS du Sud de Lanaudiere, 911 Montee des Pionniers, Terrebonne, QC J6V 2H2, Canada.
| | - Gabriela Guzman
- Departamento de Cardiologia, Hospital Universitario La Paz, Paseo de la Castellana, 261, Madrid, 28046, Spain.
| | - Gian Perna
- Cardiologia Riabilitativa e Preventiva, Ospedali Riuniti of Ancona, via Conca 71, Ancona, Marche, 60020, Italy.
| | - Alfonso Lara
- Hospital de Especialidades, Centro Medico Nacional 'La Raza', CRC IMSS, Gabriel Mancera 222 Col. del Valle, Benito Juarez, DF, 3100, Mexico.
| | - Sasko Kedev
- Interventional Cardiology, University Clinic of Cardiology, Vodnjanska 17, Skopje, Macedonia.
| | - Andrea Mortara
- Department of Clinical Cardiology and Heart Failure, Policlinico de Monza, Via Amati 111, Monza, MB, 20900, Italy.
| | - Mohammad El-Hajjar
- Division of Cardiology, Internal Medicine, Albany Medical College and Stratton VA Medical Center, 47 New Scotland Ave. MC 44, Albany, NY, 12208, USA.
| | - Leslee J Shaw
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, 1462 Clifton Road, Atlanta, GA, 30322, USA.
| | - Harmony R Reynolds
- Department of Medicine, Division of Cardiology, New York University Langone Medical Center, 423 East 23rd Street 15150 N, New York, NY, 10010, USA.
| | - Michael H Picard
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street Yawkey 5E, Boston, MA, 02114, USA.
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88
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Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2015; 16:233-70. [PMID: 25712077 DOI: 10.1093/ehjci/jev014] [Citation(s) in RCA: 4760] [Impact Index Per Article: 528.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.
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Affiliation(s)
- Roberto M Lang
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Luigi P Badano
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Victor Mor-Avi
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Jonathan Afilalo
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Anderson Armstrong
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Laura Ernande
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Frank A Flachskampf
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Elyse Foster
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Steven A Goldstein
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Tatiana Kuznetsova
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Patrizio Lancellotti
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Denisa Muraru
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Michael H Picard
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Ernst R Rietzschel
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Lawrence Rudski
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Kirk T Spencer
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Wendy Tsang
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
| | - Jens-Uwe Voigt
- Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia; Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts
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89
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Weiner RB, DeLuca JR, Wang F, Lin J, Wasfy MM, Berkstresser B, Stöhr E, Shave R, Lewis GD, Hutter AM, Picard MH, Baggish AL. Exercise-Induced Left Ventricular Remodeling Among Competitive Athletes. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.115.003651. [DOI: 10.1161/circimaging.115.003651] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background—
Contemporary understanding of exercise-induced cardiac remodeling is based on cross-sectional data and relatively short duration longitudinal studies. Temporal progression of exercise-induced cardiac remodeling remains incompletely understood.
Methods and Results—
A longitudinal repeated-measures study design using 2-dimensional and speckle-tracking echocardiography was used to examine acute augmentation phase (AAP; 90 days) and more extended chronic maintenance phase (39 months) left ventricular (LV) structural and functional adaptations to endurance exercise training among competitive male rowers (n=12; age 18.6±0.5 years). LV mass was within normal limits at baseline (93±9 g/m
2
), increased after AAP (105±7 g/m
2
;
P
=0.001), and further increased after chronic maintenance phase (113±10 g/m
2
;
P
<0.001 for comparison to post-AAP). AAP LV hypertrophy was driven by LV dilation (ΔLV end-diastolic volume, 9±3 mL/m
2
;
P
=0.004) with stable LV wall thickness (ΔLV wall thickness, 0.3±0.1 mm;
P
=0.63). In contrast, chronic maintenance phase LV hypertrophy was attributable to LV wall thickening (Δ LV wall thickness, 1.1±0.4 mm;
P
=0.004) with stable LV chamber volumes (ΔLV end-diastolic volume, 1±1 mL/m
2
;
P
=0.48). Early diastolic peak tissue velocity increased during AAP (−11.7±1.9 versus −13.6±1.3 cm/s;
P
<0.001) and remained similarly increased after chronic maintenance phase.
Conclusions—
In a small sample of competitive endurance athletes, exercise-induced cardiac remodeling follows a phasic response with increases in LV chamber size, early diastolic function, and systolic twist in an acute augmentation phase of exercise training. This is followed by a chronic phase of adaptation characterized by increasing wall thickness and regression in LV twist. Training duration is a determinant of exercise-induced cardiac remodeling and has implications for the assessment of myocardial structure and function in athletes.
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Affiliation(s)
- Rory B. Weiner
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston (R.B.W., J.R.D., J.L., M.M.W., G.D.L., A.M.H., M.H.P., A.L.B.); Harvard University Health Services, Cambridge, MA (R.B.W., F.W., B.B., A.L.B.); and Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom (E.S., R.S.)
| | - James R. DeLuca
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston (R.B.W., J.R.D., J.L., M.M.W., G.D.L., A.M.H., M.H.P., A.L.B.); Harvard University Health Services, Cambridge, MA (R.B.W., F.W., B.B., A.L.B.); and Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom (E.S., R.S.)
| | - Francis Wang
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston (R.B.W., J.R.D., J.L., M.M.W., G.D.L., A.M.H., M.H.P., A.L.B.); Harvard University Health Services, Cambridge, MA (R.B.W., F.W., B.B., A.L.B.); and Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom (E.S., R.S.)
| | - Jeffrey Lin
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston (R.B.W., J.R.D., J.L., M.M.W., G.D.L., A.M.H., M.H.P., A.L.B.); Harvard University Health Services, Cambridge, MA (R.B.W., F.W., B.B., A.L.B.); and Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom (E.S., R.S.)
| | - Meagan M. Wasfy
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston (R.B.W., J.R.D., J.L., M.M.W., G.D.L., A.M.H., M.H.P., A.L.B.); Harvard University Health Services, Cambridge, MA (R.B.W., F.W., B.B., A.L.B.); and Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom (E.S., R.S.)
| | - Brant Berkstresser
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston (R.B.W., J.R.D., J.L., M.M.W., G.D.L., A.M.H., M.H.P., A.L.B.); Harvard University Health Services, Cambridge, MA (R.B.W., F.W., B.B., A.L.B.); and Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom (E.S., R.S.)
| | - Eric Stöhr
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston (R.B.W., J.R.D., J.L., M.M.W., G.D.L., A.M.H., M.H.P., A.L.B.); Harvard University Health Services, Cambridge, MA (R.B.W., F.W., B.B., A.L.B.); and Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom (E.S., R.S.)
| | - Rob Shave
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston (R.B.W., J.R.D., J.L., M.M.W., G.D.L., A.M.H., M.H.P., A.L.B.); Harvard University Health Services, Cambridge, MA (R.B.W., F.W., B.B., A.L.B.); and Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom (E.S., R.S.)
| | - Gregory D. Lewis
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston (R.B.W., J.R.D., J.L., M.M.W., G.D.L., A.M.H., M.H.P., A.L.B.); Harvard University Health Services, Cambridge, MA (R.B.W., F.W., B.B., A.L.B.); and Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom (E.S., R.S.)
| | - Adolph M. Hutter
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston (R.B.W., J.R.D., J.L., M.M.W., G.D.L., A.M.H., M.H.P., A.L.B.); Harvard University Health Services, Cambridge, MA (R.B.W., F.W., B.B., A.L.B.); and Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom (E.S., R.S.)
| | - Michael H. Picard
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston (R.B.W., J.R.D., J.L., M.M.W., G.D.L., A.M.H., M.H.P., A.L.B.); Harvard University Health Services, Cambridge, MA (R.B.W., F.W., B.B., A.L.B.); and Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom (E.S., R.S.)
| | - Aaron L. Baggish
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston (R.B.W., J.R.D., J.L., M.M.W., G.D.L., A.M.H., M.H.P., A.L.B.); Harvard University Health Services, Cambridge, MA (R.B.W., F.W., B.B., A.L.B.); and Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom (E.S., R.S.)
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90
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Mehrotra P, Flynn AW, Jansen K, Tan TC, Mak G, Julien HM, Zeng X, Picard MH, Passeri JJ, Hung J. Differential Left Ventricular Outflow Tract Remodeling and Dynamics in Aortic Stenosis. J Am Soc Echocardiogr 2015; 28:1259-66. [DOI: 10.1016/j.echo.2015.07.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Indexed: 10/23/2022]
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91
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Tan TC, Flynn AW, Chen-Tournoux A, Rudski LG, Mehrotra P, Nunes MC, Rincon LM, Shahian DM, Picard MH, Afilalo J. Risk Prediction in Aortic Valve Replacement: Incremental Value of the Preoperative Echocardiogram. J Am Heart Assoc 2015; 4:e002129. [PMID: 26504147 PMCID: PMC4845123 DOI: 10.1161/jaha.115.002129] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Risk prediction is a critical step in patient selection for aortic valve replacement (AVR), yet existing risk scores incorporate very few echocardiographic parameters. We sought to evaluate the incremental predictive value of a complete echocardiogram to identify high‐risk surgical candidates before AVR. Methods and Results A cohort of patients with severe aortic stenosis undergoing surgical AVR with or without coronary bypass was assembled at 2 tertiary centers. Preoperative echocardiograms were reviewed by independent observers to quantify chamber size/function and valve function. Patient databases were queried to extract clinical data. The cohort consisted of 432 patients with a mean age of 73.5 years and 38.7% females. Multivariable logistic regression revealed 3 echocardiographic predictors of in‐hospital mortality or major morbidity: E/e’ ratio reflective of elevated left ventricular (LV) filling pressure; myocardial performance index reflective of right ventricular (RV) dysfunction; and small LV end‐diastolic cavity size. Addition of these echocardiographic parameters to the STS risk score led to an integrated discrimination improvement of 4.1% (P<0.0001). After a median follow‐up of 2 years, Cox regression revealed 5 echocardiographic predictors of all‐cause mortality: small LV end‐diastolic cavity size; LV mass index; mitral regurgitation grade; right atrial area index; and mean aortic gradient <40 mm Hg. Conclusions Echocardiographic measures of LV diastolic dysfunction and RV performance add incremental value to the STS risk score and should be integrated in prediction when evaluating the risk of AVR. In addition, findings of small hypertrophied LV cavities and/or low mean aortic gradients confer a higher risk of 2‐year mortality.
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Affiliation(s)
- Timothy C Tan
- Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.)
| | - Aidan W Flynn
- Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.) Hartford Hospital, University of Connecticut, Hartford, CT (A.W.F.)
| | - Annabel Chen-Tournoux
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada (A.C.T., L.G.R., J.A.)
| | - Lawrence G Rudski
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada (A.C.T., L.G.R., J.A.)
| | - Praveen Mehrotra
- Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.) Thomas Jefferson University Hospital, Jefferson Medical College, Philadelphia, PA (P.M.)
| | - Maria C Nunes
- Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.) Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil (M.C.N.)
| | - Luis M Rincon
- Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.)
| | - David M Shahian
- Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.)
| | - Michael H Picard
- Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.)
| | - Jonathan Afilalo
- Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.) Jewish General Hospital, McGill University, Montreal, Quebec, Canada (A.C.T., L.G.R., J.A.) Centre for Clinical Epidemiology, Lady Davis Institute, Montreal, Quebec, Canada (J.A.)
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92
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Wasfy MM, Weiner RB, Wang F, Berkstresser B, Lewis GD, DeLuca JR, Hutter AM, Picard MH, Baggish AL. Endurance Exercise-Induced Cardiac Remodeling: Not All Sports Are Created Equal. J Am Soc Echocardiogr 2015; 28:1434-40. [PMID: 26361851 DOI: 10.1016/j.echo.2015.08.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND The term endurance sport (ES) is broadly used to characterize any exercise that requires maintenance of high cardiac output over extended time. However, the relative amount of isotonic (volume) versus isometric (pressure) cardiac stress varies across ES disciplines. To what degree ES-mediated cardiac remodeling varies, as a function of superimposed isometric stress, is uncertain. The aim of this study was to compare the cardiac remodeling characteristics associated with two common yet physiologically distinct forms of ES. METHODS Healthy competitive male long-distance runners (high isotonic, low isometric stress; n = 40) and rowers (high isotonic, high isometric stress; n = 40) were comparatively studied after 3 months of sport-specific exercise training with conventional and speckle-tracking two-dimensional echocardiography. RESULTS Rowers demonstrated dilated left ventricular (LV) volumes and elevated LV mass (i.e., eccentric LV hypertrophy), whereas runners demonstrated normal LV mass (runners, 88 ± 11 g/m(2); rowers, 108 ± 13 g/m(2); P < .001) despite comparatively larger LV volumes (runners, 101 ± 10 mL/m(2); rowers, 89 ± 13 mL/m(2); P < .001) consistent with eccentric LV remodeling. Increasing LV mass was associated with increased reliance on early diastolic filling (LV mass vs E'/A' ratio, R = 0.47, P < .001) indicating "mass-dependent" diastolic function. Right ventricular dilation of similar magnitude and LV systolic function, as assessed by numerous complementary indices, were similar in both groups. CONCLUSIONS Cardiac adaptations differ significantly as a function of ES discipline. Further work is required to determine the mechanisms for this differential adaptation, to develop definitive ES discipline-specific normative values, and to evaluate the optimal therapeutic use of specific ES disciplines among patients with common cardiovascular diseases.
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Affiliation(s)
- Meagan M Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Rory B Weiner
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Francis Wang
- Harvard University Health Services, Cambridge, Massachusetts
| | | | - Gregory D Lewis
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - James R DeLuca
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Adolph M Hutter
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael H Picard
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts; Harvard University Health Services, Cambridge, Massachusetts.
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93
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Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28:1-39.e14. [PMID: 25559473 DOI: 10.1016/j.echo.2014.10.003] [Citation(s) in RCA: 7981] [Impact Index Per Article: 886.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.
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Affiliation(s)
| | | | | | - Jonathan Afilalo
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Laura Ernande
- INSERM U955 and Hôpital Henri Mondor, Créteil, France
| | | | - Elyse Foster
- University of California, San Francisco, California
| | | | | | | | | | - Michael H Picard
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Lawrence Rudski
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Wendy Tsang
- University of Toronto, Toronto, Ontario, Canada
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94
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Wang L, Tan TC, Halpern EF, Neilan TG, Francis SA, Picard MH, Fei H, Hochberg EP, Abramson JS, Weyman AE, Kuter I, Scherrer-Crosbie M. Major Cardiac Events and the Value of Echocardiographic Evaluation in Patients Receiving Anthracycline-Based Chemotherapy. Am J Cardiol 2015; 116:442-6. [PMID: 26071994 DOI: 10.1016/j.amjcard.2015.04.064] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 04/30/2015] [Accepted: 04/30/2015] [Indexed: 11/15/2022]
Abstract
Anthracyclines are an important component of cancer treatments; however, their use is limited by the occurrence of cardiotoxicity. There are limited data on the occurrence of heart failure and the value of baseline and follow-up measurements of left ventricular (LV) ejection fraction (EF) in the current era. Therefore, the objectives of the present study were twofold: (1) to characterize the occurrence of and risk factors for major adverse cardiac events (MACEs: symptomatic heart failure and cardiac death) in a large contemporaneous population of adult patients treated with anthracyclines and (2) to test the value of LVEF and LV dimensions obtained using echocardiography in the prediction of MACE. Five thousand fifty-seven patients were studied, of whom 124 (2.4%) developed MACE. Of the total cohort, 2,285 patients had an available echocardiogram pre-chemotherapy. Patients with MACE were older (p <0.0001), predominantly men (p = 0.03), and with a higher incidence of cardiovascular risk factors and cardiac treatments. Patients with hematologic cancers had a higher incidence of cardiac events than patients with breast cancer (4.2% vs 0.7%, p <0.0001). Baseline LVEF, LVEF ≤5 points above the lower limits of normal, and LV internal diameter were predictive of the rate of occurrence of MACE. In conclusion, older patients with hematologic cancers and patients with a baseline LVEF ≤5 points above the lower limit of normal have higher incidence of MACE and should be closely monitored.
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Affiliation(s)
- Lin Wang
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy C Tan
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elkan F Halpern
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sanjeev A Francis
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael H Picard
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hongwen Fei
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ephraim P Hochberg
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Jeremy S Abramson
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Arthur E Weyman
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Irene Kuter
- Center for Breast Cancer, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Marielle Scherrer-Crosbie
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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95
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Putt M, Hahn VS, Januzzi JL, Sawaya H, Sebag IA, Plana JC, Picard MH, Carver JR, Halpern EF, Kuter I, Passeri J, Cohen V, Banchs J, Martin RP, Gerszten RE, Scherrer-Crosbie M, Ky B. Longitudinal Changes in Multiple Biomarkers Are Associated with Cardiotoxicity in Breast Cancer Patients Treated with Doxorubicin, Taxanes, and Trastuzumab. Clin Chem 2015. [PMID: 26220066 DOI: 10.1373/clinchem.2015.241232] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Biomarkers may play an important role in identifying patients at risk for cancer therapy cardiotoxicity. Our objectives were to define the patterns of change in biomarkers with cancer therapy and their associations with cardiotoxicity. METHODS In a multicenter cohort of 78 breast cancer patients undergoing doxorubicin and trastuzumab therapy, 8 biomarkers were evaluated at baseline and every 3 months over a maximum follow-up of 15 months. These biomarkers, hypothesized to be mechanistically relevant to cardiotoxicity, included high-sensitivity cardiac troponin I (hs-cTnI), high-sensitivity C-reactive protein (hsCRP), N-terminal pro-B-type natriuretic peptide (NT-proBNP), growth differentiation factor 15 (GDF-15), myeloperoxidase (MPO), placental growth factor (PlGF), soluble fms-like tyrosine kinase receptor-1 (sFlt-1), and galectin 3 (gal-3). We determined if biomarker increases were associated with cardiotoxicity at the same visit and the subsequent visit over the entire course of therapy. Cardiotoxicity was defined by the Cardiac Review and Evaluation Criteria; alternative definitions were also considered. RESULTS Across the entire cohort, all biomarkers except NT-proBNP and gal-3 demonstrated increases by 3 months; these increases persisted for GDF-15, PlGF, and hs-cTnI at 15 months. Increases in MPO, PlGF, and GDF-15 were associated with cardiotoxicity at the same visit [MPO hazard ratio 1.38 (95% CI 1.10-1.71), P = 0.02; PlGF 3.78 (1.30-11.0), P = 0.047; GDF-15 1.71 (1.15-2.55), P = 0.01] and the subsequent visit. MPO was robust to alternative outcome definitions. CONCLUSIONS Increases in MPO are associated with cardiotoxicity over the entire course of doxorubicin and trastuzumab therapy. Assessment with PlGF and GDF-15 may also be of value. These findings motivate validation studies in additional cohorts.
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Affiliation(s)
- Mary Putt
- University of Pennsylvania, Philadelphia, PA
| | | | - James L Januzzi
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Heloisa Sawaya
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Igal A Sebag
- Sir Mortimer B. Davis-Jewish General Hospital and McGill University, Montreal, CA
| | | | - Michael H Picard
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Elkan F Halpern
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Irene Kuter
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Jonathan Passeri
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Victor Cohen
- Sir Mortimer B. Davis-Jewish General Hospital and McGill University, Montreal, CA
| | | | | | - Robert E Gerszten
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Bonnie Ky
- University of Pennsylvania, Philadelphia, PA;
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96
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Afilalo J, Grapsa J, Nihoyannopoulos P, Beaudoin J, Gibbs JSR, Channick RN, Langleben D, Rudski LG, Hua L, Handschumacher MD, Picard MH, Levine RA. Leaflet area as a determinant of tricuspid regurgitation severity in patients with pulmonary hypertension. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.114.002714. [PMID: 25977303 DOI: 10.1161/circimaging.114.002714] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tricuspid regurgitation (TR) is a risk factor for mortality in pulmonary hypertension (PH). TR severity varies among patients with comparable degrees of PH and right ventricular remodeling. The contribution of leaflet adaptation to the pathophysiology of TR has yet to be examined. We hypothesized that tricuspid leaflet area (TLA) is increased in PH, and that the adequacy of this increase relative to right ventricular remodeling determines TR severity. METHODS AND RESULTS A prospective cohort of 255 patients with PH from pre and postcapillary pathogeneses was assembled from 2 centers. Patients underwent a 3-dimensional echocardiogram focused on the tricuspid apparatus. TLA was measured with the Omni 4D software package. Compared with normal controls, patients with PH had a 2-fold increase in right ventricular volumes, 62% increase in annular area, and 49% increase in TLA. Those with severe TR demonstrated inadequate increase in TLA relative to the closure area, such that the ratio of TLA:closure area <1.78 was highly predictive of severe TR (odds ratio, 68.7; 95% confidence interval, 16.2-292.7). The median vena contracta width was 8.5 mm in the group with small TLA and large closure area as opposed to 4.8 mm in the group with large TLA and large closure area. CONCLUSIONS TLA plays a significant role in determining which patients with PH develop severe functional TR. The ratio of TLA:closure area, reflecting the balance between leaflet adaptation versus annular dilation and tethering forces, is an indicator of TR severity that may identify which patients stand to benefit from leaflet augmentation during tricuspid valve repair.
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Affiliation(s)
- Jonathan Afilalo
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
| | - Julia Grapsa
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Petros Nihoyannopoulos
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Jonathan Beaudoin
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - J Simon R Gibbs
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Richard N Channick
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - David Langleben
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Lawrence G Rudski
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Lanqi Hua
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Mark D Handschumacher
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Michael H Picard
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Robert A Levine
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
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Reynolds HR, Picard MH, Hochman JS. Does ischemia burden in stable coronary artery disease effectively identify revascularization candidates? Ischemia burden in stable coronary artery disease does not effectively identify revascularization candidates. Circ Cardiovasc Imaging 2015; 8:discussion p 9. [PMID: 25977302 DOI: 10.1161/circimaging.113.000362] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Harmony R Reynolds
- From the Cardiovascular Clinical Research Center, Leon Charney Division of Cardiology and Department of Medicine, NYU Langone Medical Center, New York, NY (H.R.R., J.S.H.); and Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (M.H.P.).
| | - Michael H Picard
- From the Cardiovascular Clinical Research Center, Leon Charney Division of Cardiology and Department of Medicine, NYU Langone Medical Center, New York, NY (H.R.R., J.S.H.); and Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (M.H.P.)
| | - Judith S Hochman
- From the Cardiovascular Clinical Research Center, Leon Charney Division of Cardiology and Department of Medicine, NYU Langone Medical Center, New York, NY (H.R.R., J.S.H.); and Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (M.H.P.)
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Afilalo J, Grapsa J, Nihoyannopoulos P, Beaudoin J, Gibbs JSR, Channick RN, Langleben D, Rudski LG, Hua L, Handschumacher MD, Picard MH, Levine RA. Leaflet Area as a Determinant of Tricuspid Regurgitation Severity in Patients With Pulmonary Hypertension. Circ Cardiovasc Imaging 2015. [DOI: 10.1161/circimaging.114.002714 e002714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Background—
Tricuspid regurgitation (TR) is a risk factor for mortality in pulmonary hypertension (PH). TR severity varies among patients with comparable degrees of PH and right ventricular remodeling. The contribution of leaflet adaptation to the pathophysiology of TR has yet to be examined. We hypothesized that tricuspid leaflet area (TLA) is increased in PH, and that the adequacy of this increase relative to right ventricular remodeling determines TR severity.
Methods and Results—
A prospective cohort of 255 patients with PH from pre and postcapillary pathogeneses was assembled from 2 centers. Patients underwent a 3-dimensional echocardiogram focused on the tricuspid apparatus. TLA was measured with the Omni 4D software package. Compared with normal controls, patients with PH had a 2-fold increase in right ventricular volumes, 62% increase in annular area, and 49% increase in TLA. Those with severe TR demonstrated inadequate increase in TLA relative to the closure area, such that the ratio of TLA:closure area <1.78 was highly predictive of severe TR (odds ratio, 68.7; 95% confidence interval, 16.2–292.7). The median vena contracta width was 8.5 mm in the group with small TLA and large closure area as opposed to 4.8 mm in the group with large TLA and large closure area.
Conclusions—
TLA plays a significant role in determining which patients with PH develop severe functional TR. The ratio of TLA:closure area, reflecting the balance between leaflet adaptation versus annular dilation and tethering forces, is an indicator of TR severity that may identify which patients stand to benefit from leaflet augmentation during tricuspid valve repair.
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Affiliation(s)
- Jonathan Afilalo
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Julia Grapsa
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Petros Nihoyannopoulos
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Jonathan Beaudoin
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - J. Simon R. Gibbs
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Richard N. Channick
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - David Langleben
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Lawrence G. Rudski
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Lanqi Hua
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Mark D. Handschumacher
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Michael H. Picard
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Robert A. Levine
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
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Tan TC, Bouras S, Sawaya H, Sebag IA, Cohen V, Picard MH, Passeri J, Kuter I, Scherrer-Crosbie M. Time Trends of Left Ventricular Ejection Fraction and Myocardial Deformation Indices in a Cohort of Women with Breast Cancer Treated with Anthracyclines, Taxanes, and Trastuzumab. J Am Soc Echocardiogr 2015; 28:509-14. [DOI: 10.1016/j.echo.2015.02.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Indexed: 02/07/2023]
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Douglas PS, Hoffmann U, Patel MR, Mark DB, Al-Khalidi HR, Cavanaugh B, Cole J, Dolor RJ, Fordyce CB, Huang M, Khan MA, Kosinski AS, Krucoff MW, Malhotra V, Picard MH, Udelson JE, Velazquez EJ, Yow E, Cooper LS, Lee KL. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med 2015; 372:1291-300. [PMID: 25773919 PMCID: PMC4473773 DOI: 10.1056/nejmoa1415516] [Citation(s) in RCA: 1004] [Impact Index Per Article: 111.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Many patients have symptoms suggestive of coronary artery disease (CAD) and are often evaluated with the use of diagnostic testing, although there are limited data from randomized trials to guide care. METHODS We randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). The composite primary end point was death, myocardial infarction, hospitalization for unstable angina, or major procedural complication. Secondary end points included invasive cardiac catheterization that did not show obstructive CAD and radiation exposure. RESULTS The mean age of the patients was 60.8±8.3 years, 52.7% were women, and 87.7% had chest pain or dyspnea on exertion. The mean pretest likelihood of obstructive CAD was 53.3±21.4%. Over a median follow-up period of 25 months, a primary end-point event occurred in 164 of 4996 patients in the CTA group (3.3%) and in 151 of 5007 (3.0%) in the functional-testing group (adjusted hazard ratio, 1.04; 95% confidence interval, 0.83 to 1.29; P=0.75). CTA was associated with fewer catheterizations showing no obstructive CAD than was functional testing (3.4% vs. 4.3%, P=0.02), although more patients in the CTA group underwent catheterization within 90 days after randomization (12.2% vs. 8.1%). The median cumulative radiation exposure per patient was lower in the CTA group than in the functional-testing group (10.0 mSv vs. 11.3 mSv), but 32.6% of the patients in the functional-testing group had no exposure, so the overall exposure was higher in the CTA group (mean, 12.0 mSv vs. 10.1 mSv; P<0.001). CONCLUSIONS In symptomatic patients with suspected CAD who required noninvasive testing, a strategy of initial CTA, as compared with functional testing, did not improve clinical outcomes over a median follow-up of 2 years. (Funded by the National Heart, Lung, and Blood Institute; PROMISE ClinicalTrials.gov number, NCT01174550.).
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Affiliation(s)
- Pamela S Douglas
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (P.S.D., M.R.P., D.B.M., H.R.A.-K., R.J.D., C.B.F., M.H., A.S.K., M.W.K., E.J.V., E.Y., K.L.L.); Massachusetts General Hospital, Harvard Medical School (U.H., M.H.P.), and Tufts Medical Center, Tufts University School of Medicine (J.E.U.) - both in Boston; New Mexico Heart Institute, Albuquerque (B.C.); Cardiology Associates, Mobile, AL (J.C.); North Dallas Research Associates, Dallas (M.A.K.); Cardiac Study Group, Puyallup, WA (V.M.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
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