Prognostic Value of Late Gadolinium Enhancement Cardiovascular Magnetic Resonance in Cardiac Amyloidosis

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The prognosis and treatment of the 2 main types of cardiac amyloidosis, immunoglobulin light chain (AL) and transthyretin (ATTR) amyloidosis, are substantially influenced by cardiac involvement. Cardiovascular magnetic resonance with late gadolinium enhancement (LGE) is a reference standard for the diagnosis of cardiac amyloidosis, but its potential for stratifying risk is unknown.

Abnormal septal convexity into the left ventricle occurs in subclinical hypertrophic cardiomyopathy

BACKGROUND

Sarcomeric gene mutations cause hypertrophic cardiomyopathy (HCM). In gene mutation carriers without left ventricular (LV) hypertrophy (G + LVH-), subclinical imaging biomarkers are recognized as predictors of overt HCM, consisting of anterior mitral valve leaflet elongation, myocardial crypts, hyperdynamic LV ejection fraction, and abnormal apical trabeculation. Reverse curvature of the interventricular septum (into the LV) is characteristic of overt HCM. We aimed to assess LV septal convexity in subclinical HCM.

METHODS

Cardiovascular magnetic resonance was performed on 36 G + LVH- individuals (31 ± 14 years, 33 % males) with a pathogenic sarcomere mutation, and 36 sex and age-matched healthy controls (33 ± 12 years, 33 % males). Septal convexity (SCx) was measured in the apical four chamber view perpendicular to a reference line connecting the mid-septal wall at tricuspid valve insertion level and the apical right ventricular insertion point.

RESULTS

Septal convexity was increased in G + LVH- compared to controls (maximal distance of endocardium to reference line: 5.0 ± 2.5 mm vs. 1.6 ± 2.4 mm, p ≤ 0.0001). Expected findings occurred in G + LVH- individuals: longer anterior mitral valve leaflet (23.5 ± 3.0 mm vs. 19.9 ± 3.1 mm, p ≤ 0.0001), higher relative wall thickness (0.31 ± 0.05 vs. 0.29 ± 0.04, p ≤ 0.05), higher LV ejection fraction (70.8 ± 4.3 % vs. 68.3 ± 4.4 %, p ≤ 0.05), and smaller LV end-systolic volume index (21.4 ± 4.4 ml/m(2) vs. 23.7 ± 5.8 ml/m(2), p ≤ 0.05). Other morphologic measurements (LV angles, sphericity index, and eccentricity index) were not different between G + LVH- and controls.

CONCLUSIONS

Septal convexity is an additional previously undescribed feature of subclinical HCM.

Early detection of left ventricular systolic dysfunction using two-dimensional speckle tracking strain evaluation in healthy subjects after acute alcohol intoxication

Objectives: We evaluated the ability of two-dimensional speckle tracking strain echocardiography to detect left ventricular (LV) systolic dysfunction as compared with LV ejection fraction (EF) in healthy subjects following acute alcohol intoxication. Methods and Results: In total, 25 healthy subjects were investigated using echocardiography 4–6 hours after the onset of alcohol intoxication at a regional festive gathering, and then compared to 23 healthy control subjects without alcohol consumption. Heart rate, blood pressure, blood alcohol level, LV volumes, EF, shortening fraction, E/A ratio, as well as global longitudinal strain (LS) were recorded. Mean blood alcohol level was 1.3 ± 0.3 g.L⁻¹. Mean systolic blood pressure and heart rate were slightly increased in the alcohol group compared to controls (147.5 ± 21.8 mmHg vs 127.0 ± 9.9 mmHg, P = 0.003, and 79.7 ± 10.7 bpm vs 70.6 ± 7.6 bpm, P < 0.001, respectively). While there was no significant difference in terms of LVEF (62.9 ± 4.4% vs 64.8 ± 5.9%, P = 0.18) or shortening fraction (34.7 ± 5.9% vs 36.0 ± 4.3%, P = 0.54), global LS was significantly impaired (–17.8 ± 2.0% vs −21.2 ± 1.8%, P < 0.001). In addition, subjects who consumed alcohol had increased LV end-diastolic (108.3 ± 20.1 mL vs 95.5 ± 14.6 mL, P = 0.037) and end-systolic volumes (41.6 ± 11.4 mL vs 33.7 ± 6.9 mL, P = 0.024), along with depressed aortic time-velocity integral (19.9 ± 3.2 mL vs 21.9 ± 2.5 mL, P = 0.034). According to multivariate linear regression analyses, blood alcohol level was the only factor significantly associated with global LS (β=−3.6 ± 1.0, P = 0.005). Conclusion: Alcohol intoxication around festive days induces acute LV contraction abnormalities, which may be detected using global LS by speckle tracking at an earlier stage and more accurately than LVEF decreases.

Evaluation of global left ventricular systolic function using three-dimensional echocardiography speckle-tracking strain parameters

BACKGROUND

The aim of this study was to evaluate the capacity and reproducibility of three-dimensional echocardiographic (3DE) strain parameters in the assessment of global left ventricular (LV) systolic function.

METHODS

A total of 128 subjects with differing LV ejection fractions were investigated using two-dimensional echocardiographic (2DE) and 3DE strains. Three-dimensional echocardiographic strain allows obtaining longitudinal, circumferential, radial, and area strains. First, values of global longitudinal strain (GLS) by 2DE and 3DE speckle-tracking analyses were compared. Thereafter, 3DE strain parameters were correlated with LV ejection fraction and indexed output. Last, the variability of 3DE versus 2DE strain measurements as well as recorded time of analysis were assessed.

RESULTS

After excluding 21 patients for insufficient image quality, four for arrhythmia, two for severe valvular disease, and one for severe dyspnea, the final population consisted of 100 patients. Comparison between 2DE and 3DE GLS revealed high correspondence (r = 0.91, y = 1.04x - 0.71) and mean error measurement of -1.3% (95% confidence interval, -5.7 to 3.2). Among strain parameters, global area strain exhibited the highest correlation with LV ejection fraction (y = -1.65 + 10.4, r = -0.92, P < .001). Intraobserver measurement variability proved acceptable: 8% for GLS (vs 6% on 2DE analysis), 7% for circumferential strain (vs 15% on 2DE analysis), 7% for radial strain (vs 33% on 2DE analysis), and 5% for global area strain. The mean error between two measurements was lower with 3DE than 2DE analysis for circumferential and radial strains but similar for GLS. The mean time of analysis was of 117 ± 16 sec for 3DE analysis, which was 25% less than for 2DE analysis (P < .001).

CONCLUSIONS

Of all strain parameters, new 3DE area strain correlated best with common LV systolic function parameters and is thus the most promising approach, while all 3DE strain markers exhibited good reproducibility.

Validation of the smallest pocket echoscopic device's diagnostic capabilities in heart investigation

We hypothesized that, based on greyscale imaging and color Doppler capabilities, a new pocket ultrasound device (PUD) could accurately record cardiologic diagnostic findings. One hundred patients referred for conventional clinical indications underwent a standard echocardiography. Subsequently, a second physician blinded to the results performed an evaluation using the PUD on the same patients. Study end-points were echocardiographic window quality; left ventricular (LV) morphology; function; hypertrophy; right ventricular, atrial and vena caval morphologies; aortic and mitral valvulopathies; and pericardial structure. Using a scale of three grades, concordance in image quality proved good with a kappa coefficient (κ) of 0.71. Concordances between systems were excellent for LV function and morphology (κ = 0.91 and 0.96). Concordance for LV hypertrophy was good (κ = 0.74). Concordances for mitral regurgitation grades were 0.90, 0.95 and 1.00, respectively. In conclusion, a new PUD enabled scanning examinations, which showed good concordance of basic and qualitative diagnostic capability to standard echocardiographic instruments.

Spontaneous fistulization of a caseous calcification of the mitral annulus: an exceptional cause of stroke

We present the case of a caseous calcification of the mitral annulus, responsible for two strokes, in a 72-year-old female patient. The brain computed tomography (CT) scan confirmed the presence of a calcific embolus. The echocardiography showed a liquidy, pseudotumoral mass combined with numerous calcifications located in the posterior part of the mitral annulus and extending toward the inferior surface of the left ventricle. During surgery, we found a direct communication between the caseous necrosis and the lumen of the left ventricle at the level of its inferior wall. We performed a valve repair procedure and excision of the caseous necrosis, combined with injection of bioglue into the cavity, to avoid recurrence. Six months after the procedure, the patient was in good health, and had no recurrence of stroke with a satisfactory echocardiography. This is the first description of spontaneous fistulization of a caseous necrosis in the lumen of the left ventricle, explaining a new mechanism for cerebral embolism during the course of calcifying diseases of the mitral annulus.

Relationship between left ventricular stimulation characteristics at implantation and echocardiographic response after 6 months of cardiac resynchronization therapy

AIMS

Although the electrical stimulation of an ischaemic tissue adversely affects the left ventricular (LV) systolic function, the optimal stimulation site in patients with non-ischaemic cardiomyopathy has not been systematically studied. We hypothesized that the local stimulation characteristics at the time of device implantation predict the response to cardiac resynchronization therapy (CRT).

METHODS AND RESULTS

We measured the impedance, sensing, and capture threshold of a bipolar LV lead in 138 patients with non-ischaemic cardiomyopathy undergoing first implantation of CRT device for drug refractory heart failure. All patients underwent echocardiography at baseline and at 6 months post-implantation. An absence of favourable response to CRT was defined as <15% decrease in echocardiographic LV end-systolic volume (LVESV) at 6 months. Echocardiographic response to CRT was observed in 70% of patients. The LV lead measurements predicted neither the optimal stimulation site nor the response to CRT. Left ventricular capture threshold (1.50 ± 1.1 vs. 1.32 ± 0.8 V) and impedance (725 ± 287 vs. 720 ± 261 Ω) were similar between the responders and the non-responders. Independent of baseline LV ejection fraction or ESV, the LV R-wave amplitude at implantation was significantly higher (P = 0.0038) in responders (12.7 ± 5.2 mV) than in non-responders (9.7 ± 6.3 mV), with an area under the receiver operating characteristic curve of 0.7.

CONCLUSION

Response to CRT, as determined by decrease in LVESV at 6 months, was associated with significantly higher LV R-wave amplitude at the time of device implantation.

Systolic time intervals as simple echocardiographic parameters of left ventricular systolic performance: correlation with ejection fraction and longitudinal two-dimensional strain

AIMS

Conventionally, the evaluation of left ventricular (LV) systolic function is based on ejection fraction assessment, which may be supplemented by other echocardiographic techniques, such as tissue Doppler imaging, 3D evaluation, and speckle tracking strains. However, these imaging modalities have a high technicity and are time-consuming, while being associated with reproducibility limitations. In this context, the usefulness of simpler measurements such as systolic time intervals (STI) by pulsed Doppler echocardiography must be emphasized.

METHODS AND RESULTS

In this multicentre study, left ventricular ejection fraction (LVEF), dP/dt(max), LV stroke volume, myocardial longitudinal deformation, aortic pre-ejectional period (PEP, ms), and left ventricular ejection time (LVET, ms) were prospectively investigated and compared in 134 consecutive heart failure (HF) patients and 43 control subjects. Feasibility of STI measurements was 100%. Intra-observer reproducibility was 98% for PEP, 96% for LVET, 87% for LVEF, and 93% for global longitudinal strain (GLS). By subgroup analyses, with increasingly altered LVEF or GLS, PEP significantly increased, whereas significantly LVET decreased, resulting in a significantly increased PEP/LVET ratio (P < 0.001). In the HF patients group, a correlation between LVEF and PEP/LVET was found, with r = 0.55 (y = -0.0083x + 0.75, P < 0.001). Based on receiver operating curve analyses, the area under the curve was 0.91 for PEP/LVET > 0.43, which allowed us to detect LVEF < 35% with a sensitivity of 87%, and a specificity of 84%.

CONCLUSION

STI can be easily and accurately measured in clinical practice, and may be used for detecting alterations in LV systolic function. Moreover, this method is likely to have potential applications in the management of HF patients.