True mitral annulus diameter is underestimated by two-dimensional echocardiography as evidenced by real-time three-dimensional echocardiography and magnetic resonance imaging

Use of speckle tracking echocardiography in evaluating cardiac dysfunction in patients with acromegaly: an update

In recent years, cardiovascular disease has garnered increasing attention as the second leading cause of death in individuals with acromegaly, following malignancy. Identifying cardiac dysfunction early in acromegaly patients for timely intervention has become a focal point of clinical research. Speckle tracking echocardiography, a well-established ultrasound technique, surpasses conventional Doppler ultrasound in its sensitivity to assess both local and global cardiac mechanics. It can accurately detect subclinical and clinical myocardial dysfunction, including myocardial ischemia, ventricular hypertrophy, and valvular changes. Over the past five years, the use of speckle tracking echocardiography in acromegaly patients has emerged as a novel approach. Throughout the cardiac cycle, speckle tracking echocardiography offers a sensitive evaluation of the global and regional myocardial condition by quantifying the motion of myocardial fibres in distinct segments. It achieves this independently of variations in ultrasound angle and distance, effectively simulating the deformation of individual ventricles across different spatial planes. This approach provides a more accurate description of changes in cardiac strain parameters. Importantly, even in the subclinical stage when ejection fraction remains normal, the strain parameters assessed by speckle tracking echocardiography hold a good predictive value for the risk of cardiovascular death and hospitalization in acromegaly patients with concomitant cardiovascular disease. This information aids in determining the optimal timing for interventional therapy, offering important insights for cardiac risk stratification and prognosis. In the present study, we comprehensively reviewed the research progress of speckle tracking echocardiography in evaluating of cardiac dysfunction in acromegaly patients, to pave the way for early diagnosis of acromegaly cardiomyopathy.

3D echocardiography in mitral valve prolapse

Mitral valve prolapse (MVP) is the leading cause of mitral valve surgery. Echocardiography is the principal imaging modality used to diagnose MVP, assess the mitral valve morphology and mitral annulus dynamics, and quantify mitral regurgitation. Three-dimensional (3D) echocardiographic (3DE) imaging represents a consistent innovation in cardiovascular ultrasound in the last decades, and it has been implemented in routine clinical practice for the evaluation of mitral valve diseases. The focus of this review is the role and the advantages of 3DE in the comprehensive evaluation of MVP, intraoperative and intraprocedural monitoring.

Normal reference values of three-dimensional speckle-tracking echocardiography-derived mitral annular dimensions and functional properties in healthy adults: Insights from the MAGYAR-Healthy Study

INTRODUCTION

There is a limited number of echocardiographic studies determining mitral annular (MA) dimensions in healthy subjects. The present study aimed to establish normal reference values of three-dimensional speckle-tracking echocardiography-derived MA dimensions and functional properties in healthy adults in relation with age and gender.

METHODS

The present study comprised 298 healthy adult subjects. From this population, 94 subjects were excluded due to inadequate image quality. Therefore the remaining group consisted of 204 subjects with the mean age of 33.88 ± 12.97 years (107 males). The population sample was further divided into age categories: 18-29 years (n = 105; mean age: 24.11 ± 2.98 years, 51 males), 30-39 years (n = 44; mean age: 33.80 ± 2.39 years, 31 males), 40-49 years (n = 19; mean age: 43.47 ± 3.18 years, 11 males) and ≥50 years of age (n = 36, mean age: 57.42 ± 6.11 years, 14 males).

RESULTS

End-diastolic MA dimensions did not change significantly during the decades. End-systolic MA diameter, area, and perimeter were larger over the age of 50 years than in the 18-29 year-old group. MA fractional area change was found smaller over the age of 50 years than in 18-29-year-old group. While end-diastolic MA variables did not show gender-differences, end-systolic MA area and perimeter were lower in females in the 18-29-year-old group.

CONCLUSIONS

End-systolic MA dimensions change over decades, resulting in a special pattern of MA functional properties with significant reduction over the age of 50 years.

Mitral annulus is dilated with preserved function in acromegaly regardless of its activity: Insights from the three-dimensional speckle-tracking echocardiographic MAGYAR-Path Study

INTRODUCTION AND OBJECTIVE

Acromegaly is a rare, chronic and slowly developing endocrine disorder caused by hypersecretion of human growth hormone and consequently of insulin-like growth factor-1 during adulthood. The present study was conducted to assess mitral annular (MA) size and function between acromegalic patients and age- and gender-matched healthy controls by three-dimensional speckle-tracking echocardiography (3D-STE). It also aimed to examine whether activity of the disease has any effect on MA parameters.

METHODS

This study included 27 patients with acromegaly, three of whom were excluded due to inferior image quality. The mean age of the remaining 24 patients was 55.7±14.0 years and seven were male. Complete two-dimensional Doppler echocardiography and 3D-STE were performed in all cases.

RESULTS

Significantly increased end-diastolic and end-systolic MA diameter (2.81±0.36 cm vs. 2.44±0.34 cm and 2.00±0.32 cm vs. 1.65±0.37 cm, respectively), area (9.67±2.33 cm² vs. 7.38±1.93 cm² and 5.14±1.62 cm² vs. 3.74±1.19 cm², respectively) and perimeter (11.76±1.42 cm vs. 10.27±1.33 cm and 8.61±1.23 cm vs. 7.36±1.10 cm, respectively) were demonstrated in acromegalic patients compared with control subjects. MA functional parameters were not significantly altered compared to those of healthy individuals.

CONCLUSIONS

MA dilation could be seen in acromegaly regardless of its activity. Acromegaly is not associated with MA functional impairment.

Predicting clinical outcome by indexed mitral valve tenting in functional mitral valve regurgitation

OBJECTIVES

Mitral valve (MV) tenting parameters are indicators of left ventricular remodelling severity and may predict outcome in functional mitral regurgitation (FMR). We hypothesised that indexing of MV tenting area to body surface area (BSA), to mitral annulus diameter or gender-adjusted analysis of tenting parameters may improve their prognostic value.

METHODS

We identified retrospectively 240 patients with consecutive FMR (mean age 68±10 years; men=135) from our institutional database who underwent isolated MV annuloplasty during a period of 7 years (2010-2016). Using preoperative two-dimensional transthoracic echocardiographic images, MV tenting parameters including tenting area, tenting height and annulus diameter were systematically assessed. Follow-up protocol consisted of chart review and structured clinical questionnaire. Primary study endpoint was the composite of death and adverse cardiac events (ie, MV reoperation, cardiac resynchronisation therapy implantation, ventricular assist device implantation or heart transplantation).

RESULTS

BSA-indexed MV tenting area was identified as independent predictor of primary study endpoint (HR 1.9; 95% CI 1.1 to 3.5; p=0.02). After cut-off point analysis, BSA-indexed MV tenting area >1.35 cm²/m² was significantly associated with primary study outcome (HR 2.3; 95% CI 1.3 to 4.0; p=0.003). Annulus-indexed MV tenting area showed only a tendency towards primary study endpoint prediction (HR 2.8; 95% CI 0.6 to 12.6; p=0.17). Between female and male patients, BSA-indexed MV tenting area was similar (1.42±0.4 cm²/m² vs 1.45±0.4cm²/cm²; p=0.6) and gender was not associated with primary study outcome (HR 0.8; 95% CI 0.5 to 1.4; p=0.5).

CONCLUSION

In our FMR cohort, BSA-indexed MV tenting area showed the strongest association with negative outcomes following isolated MV annuloplasty. Patients with BSA-indexed MV tenting area >1.35cm²/m² could potentially benefit from additional surgical maneuvers addressing left ventricular remodelling.

The Application of Transesophageal Echocardiography in Mitral Valve Repair With Tendon Reconstruction

Objective: To investigate whether tendon reconstruction during mitral valve repair can be effectively guided by transesophageal echocardiography (TEE), using the mid-esophageal bi-commissure view, bicaval view and the aortic valve–mitral valve transition short-axis view.

Methods: A total of 40 patients that underwent mitral valve repair with artificial tendineae were recruited. Before the operation, conventional transthoracic echocardiography was used to determine whether mitral valve repair would be possible. Following intraoperative anesthesia, two-dimensional and three-dimensional TEE reconstructions were used to assess the state of the valve and tendon and to make a repair plan.

Results: TEE accurately diagnosed single functional tendon rupture and predicted single artificial tendon implantation in 88% of cases (23/26). TEE accurately diagnosed single functional tendon rupture and predicted the implantation of two artificial tendons in 100% of cases (4/4). TEE accurately diagnosed two or more functional tendon ruptures and predicted the implantation of two artificial tendons in 100% of cases (5/5). The length of the tendon cord predicted by TEE (2.45 ± 0.15 mm) was not significantly different (P > 0.05) from the length of the cord that was actually implanted (2.31 ± 0.11 mm). TEE also accurately predicted the size of the annuloplasty ring in 86% of cases (33/38), with differences of 2 mm or less compared to the size of the ring that was actually implanted.

Conclusion: Both the mid-esophageal bi-commissure view, bicaval view and the short-axis view of the aortic valve–mitral valve transition can reduce the difficulty of tendon reconstruction by helping to determine what length of tendon and what size of artificial annulus are required.

The impact of different geometric assumption of mitral annulus on the assessment of mitral regurgitation volume by Doppler method

Background

Mitral regurgitation volume (MRvol) by quantitative pulsed Doppler (QPD) method previously recommended suffers from geometric assumption error because of circular geometric assumption of mitral annulus (MA). Therefore, the aim of this study was to evaluate the impact of different geometric assumption of MA on the assessment of MRvol by two-dimensional transthoracic echocardiographic QPD method.

Methods

This study included 88 patients with varying degrees of mitral regurgitation (MR). The MRvol was evaluated by QPD method using circular or ellipse geometric assumption of MA. MRvol derived from effective regurgitant orifice area by real time three-dimensional echocardiography (RT3DE) multiplied by MR velocity-time integral was used as reference method.

Results

Assumption of a circular geometry of MA, QPD-MA_A4C and QPD-MA_PLAX overestimated the MRvol by a mean difference of 10.4 ml (P < 0.0001) and 22.5 ml (P < 0.0001) compared with RT3DE. Assumption of an ellipse geometry of MA, there was no significant difference of MRvol (mean difference = 1.7 ml, P = 0.0844) between the QPD-MA_{A4C + A2C} and the RT3DE.

Conclusions

Assuming that the MA was circular geometry previously recommended, the MRvol by QPD-MA_A4C was overestimated compared with the reference method. However, assuming that the MA was ellipse geometry, the MRvol by the QPD-MA_{A4C + A2C} has no significant difference with the reference method.

Quantitative assessment of two- and three-dimensional transthoracic and two-dimensional transesophageal echocardiography, computed tomography, and magnetic resonance imaging in normal canine hearts

INTRODUCTION

The objective of the study was to evaluate the accuracy of two- and three-dimensional (2D, 3D) transthoracic echocardiography (TTE), 2D transesophageal echocardiography, and computed tomography angiography (CTA) compared with cardiac magnetic resonance imaging (CMR) in normal dogs and to assess repeatability of 2D and 3D TTE for the assessment of left ventricular (LV) and left atrial (LA) dimensions.

ANIMALS

The study was performed on six healthy dogs.

MATERIALS AND METHODS

Transthoracic echocardiography, transesophageal echocardiography, CTA, and CMR were performed on each dog. Right ventricular (RV) and LV volumes (in systole and diastole), ejection fraction (EF), and LA and right atrial (RA) volumes were assessed. Repeatability and intrarater and interrater measurements of variability were quantified by average coefficient of variation (CV) for 2D and 3D TTE.

RESULTS

No clinically relevant differences in LV volume were detected between CMR and all modalities. Importantly, 3D TTE had the lowest CV (6.45%), correlated with (r_s = 0.62, p = 0.01), and had the highest overlap in distribution with CMR (OVL >80%). Left ventricular EF and LA size via CTA compared best with CMR and RV and RA volumes were best estimated by 3D TTE. Assessment of LV and LA volumes via 3D TTE had moderate repeatability (15-21%) compared with LV M-mode measurements and 2D LA-to-aortic ratio (<10%), respectively. For LV size, interrater CV for 3D TTE (19.4%) was lower than 2D TTE (23.1%).

CONCLUSIONS

Measurements of LV, RV, and RA volumes via 3D TTE and LA volume and LV EF assessed by CTA compared best with CMR. Three-dimensional echocardiography had lower interrater and intrarater CV compared with 2D TTE.

Changes in mitral annular morphology and function in young patients with type 1 diabetes mellitus-results from the three-dimensional speckle tracking echocardiographic MAGYAR-Path Study

BACKGROUND

Alterations in mitral annular size and function could be demonstrated in cardiomyopathies and ischaemic heart disease. The present study was designed to evaluate mitral annulus (MA) morphology and function in young type 1 diabetes mellitus (T1DM) patients by three-dimensional speckle tracking echocardiography (3DSTE) and to compare their results to matched healthy controls.

METHODS

The study comprised 18 patients with T1DM (mean age: 33.0±8.0 years). Their results were compared to that of 20 age- and gender-matched healthy controls (mean age: 37.8±10.9 years). Complete two-dimensional (2D) Doppler echocardiography and 3DSTE have been performed in all cases.

RESULTS

No significant differences could be demonstrated in demographic and standard echocardiographic parameters between the groups. Significantly enlarged diastolic MA diameter (2.87±0.27 mm vs. 2.58±0.32 mm, P=0.01), MA diameter index 1.61±0.20 cm/m(2) vs. 1.30±0.39 cm/m(2), P=0.008, and MA area index (4.81±0.88 cm(2)/m(2) vs. 3.91±1.35 cm(2)/m(2), P=0.03) could be demonstrated in T1DM together with augmented MA fractional shortening (28.64±9.63% vs. 20.35±12.50%, P=0.05).

CONCLUSIONS

Early alterations in MA size and function could be demonstrated in young patients with T1DM by 3DSTE.

Mitral valve anatomy: implications for transcatheter mitral valve interventions

Mitral regurgitation is a common valvular heart disease and its prevalence is expected to increase with population ageing. Percutaneous techniques for the treatment of mitral regurgitation are emerging as an alternative therapeutic option. However, the mitral valve is a complex structure, and a comprehensive understanding of the anatomy of the mitral valve apparatus and its surrounding structures is crucial for a correct selection of patients and the success of transcatheter mitral valve interventions.

Reference values for mitral and tricuspid annular dimensions using two-dimensional echocardiography

Only limited data are available from which normal ranges of mitral annular (MA) and tricuspid annular (TA) dimensions have been established. Normative data are important to assist the echocardiographer in defining the mechanism of atrioventricular valve regurgitation and to inform surgical planning. This study was conceived to establish normal MA and TA dimensions. Consecutive healthy subjects over the age of 60 were randomly recruited from the community as part of a screening project within South Birmingham. MA and TA dimensions in end-systole and end-diastole were evaluated in the parasternal and apical acoustic windows views using transthoracic echocardiography. Gender (males (M) and females (F))-specific dimensions were then assessed. A total of 554 subjects were screened and 74 with pathology considered to have an effect on annular dimensions were excluded from analysis. The mean age of the remaining 480 subjects was 70±7 years and the majority were female (56%). Dimensions were larger in men than in women and greater at end-diastole than end-systole (both P<0.05). Mean MA diameters at end-systole in the parasternal long axis view (cm) were 3.44 cm (M) and 3.11 cm (F) and at end-diastole 3.15 cm (M) and 2.83 cm (F) respectively. Mean TA diameters (cm) at end-systole in the apical 4 chamber view were 2.84 (M) and 2.80 (F) and at end-diastole 3.15 (M) and 3.01 (F) respectively. The reference ranges derived from this study differ from current published standards and should help to improve distinction of normal from pathological findings, in identifying aetiology and defining the mechanism of regurgitation.

[Correlations between mitral annular and left atrial function as assessed by three-dimensional speckle-tracking echocardiography in healthy volunteers. Results from the MAGYAR-Healthy Study]

INTRODUCTION

Left atrium is a heart chamber with dinamic motion communicating with left ventricle through the mitral valve and its annulus.

AIM

The aim of the present study was to analyse whether relationships could exist between three-dimensional speckle-tracking echocardiography-derived morphologic and functional parameters of the left atrium and mitral annulus in healthy subjects.

METHOD

The present study comprised 35 healthy volunteers. Maximum (Vmax) and minimum (Vmin) left atrial volumes and left atrial volume before atrial contraction (VpreA) were measured, and several functional parameters based on these volumes were calculated in all cases. Morphologic and functional characteristics of the mitral annulus were also determined.

RESULTS

While Vmax showed correlations with both systolic and diastolic mitral annulus parameters, Vmin-VpreA correlated with only systolic ones. While total left atrial stroke volume correlated with both systolic and diastolic mitral annular parameters, passive left atrial stroke volume showed correlations only with diastolic ones.

CONCLUSIONS

Correlations exist between left atrial and mitral annular morphological and functional characteristics in healthy subjects.

Vortex formation time-to-left ventricular early rapid filling relation: model-based prediction with echocardiographic validation

During early rapid filling, blood aspirated by the left ventricle (LV) generates an asymmetric toroidal vortex whose development has been quantified using vortex formation time (VFT), a dimensionless index defined by the length-to-diameter ratio of the aspirated (equivalent cylindrical) fluid column. Since LV wall motion generates the atrioventricular pressure gradient resulting in the early transmitral flow (Doppler E-wave) and associated vortex formation, we hypothesized that the causal relation between VFT and diastolic function (DF), parametrized by stiffness, relaxation, and load, can be elucidated via kinematic modeling. Gharib et al. (Gharib M, Rambod E, Kheradvar A, Sahn DJ, Dabiri JO. Proc Natl Acad Sci USA 103: 6305–6308, 2006) approximated E-wave shape as a triangle and calculated VFTGharib as triangle (E-wave) area (cm) divided by peak (Doppler M-mode derived) mitral orifice diameter (cm). We used a validated kinematic model of filling for the E-wave as a function of time, parametrized by stiffness, viscoelasticity, and load. To calculate VFTkinematic, we computed the curvilinear E-wave area (using the kinematic model) and divided it by peak effective orifice diameter. The derived VFT-to-LV early rapid filling relation predicts VFT to be a function of peak E-wave-to-peak mitral annular tissue velocity (Doppler E′-wave) ratio as (E/E′)3/2. Validation utilized 262 cardiac cycles of simultaneous echocardiographic high-fidelity hemodynamic data from 12 subjects. VFTGharib and VFTkinematic were calculated for each subject and were well-correlated ( R2 = 0.66). In accordance with prediction, VFTkinematic to (E/E′)3/2 relationship was validated ( R 2 = 0.63). We conclude that VFTkinematic is a DF index computable in terms of global kinematic filling parameters of stiffness, viscoelasticity, and load. Validation of the fluid mechanics-to-chamber kinematics relation unites previously unassociated DF assessment methods and elucidates the mechanistic basis of the strong correlation between VFT and (E/E′)3/2.

[Evaluation of the mitral valve by transthoracic real-time three-dimensional echocardiography]

Recently, echocardiography is the most widely used routine non-invasive diagnostic method, with which morphology and function of the mitral valve can be characterized. The aim of this review is to demonstrate the role of one of the newest echocardiographic developments, the transthoracic real-time three-dimensional echocardiography in the evaluation of mitral valve.

Advances in echocardiography

Echocardiography remains the main tool for noninvasive cardiac evaluation. Advances in echo technology and techniques offer new information, which will impact both the timing and method of surgical intervention. Three-dimensional echocardiography, in particular, provides improved tools for quantification both of volumes and of flows. Geometrical relations necessary for understanding functional abnormalities are also preserved with three-dimensional (3D) echocardiography. Finally 3D echocardiography also provides a unique tool for guiding minimally invasive interventions.

Real-time 3-dimensional echocardiography – can there be one more dimension?

A kardiológiai betegek ellátásában a noninvazív vizsgáló módszereknek alapvető jelentőségük van. Elméletileg a szív akkor vizsgálható tökéletesen, ha természetének megfelelően három dimenzióban rögzítjük a szívciklus szerint. A második generációs, immár real-time (vagyis valós idejű) háromdimenziós echokardiográfok elméletileg optimális lehetőséget nyújtanak a cardialis struktúrák háromdimenziós elemzésére. Real-time 3-dimenziós echokardiográfia során pontosan mérhetők a kamrai és pitvari térfogatok, valamint a kamrai izomtömeg. A billentyűk és a congenitalis abnormalitások ‘en-face’ vizsgálhatók. Használhatóságát terheléses protokollok alkalmazása mellett igazolták. A jelen összefoglaló közlemény célja a módszer bemutatása, lehetséges előnyeinek tisztázása a jelenleg még fennálló technológiai korlátok bemutatásával együtt.

Evaluation of left atrial systolic function in noncompaction cardiomyopathy by real-time three-dimensional echocardiography

BACKGROUND

Noncompaction cardiomyopathy (NCCM) is a rare disorder with persistance of the embryonic pattern of myoarchitecture. NCCM is characterized by loosened, spongy myocardium associated with a high incidence of systolic and diastolic left ventricular (LV) dysfunction and heart failure (HF). It is known that LV dysfunction contributes to elevated left atrial (LA) and pulmonary vascular pressures, however atrial function has not been examined in NCCM. The objective of the present study was to assess LA systolic function characterized by LA ejection force (LAEF) in NCCM patients using real-time three-dimensional echocardiography (RT3DE) and to compare to control subjects.

METHODS

The study comprised 17 patients with an established diagnosis of NCCM and their results were compared to 17 healthy age-matched controls with no evidence of cardiovascular disease. Forty-one percent of NCCM patients were in NYHA functional class II / III HF. Previously proposed echocardiographic diagnostic criteria for NCCM were used. All patients underwent conventional two-dimensional echocardiography and RT3DE. LAEF was measured based on MA annulus diameter (LAEF 3D-MAD) and area (LAEF 3D-MAA) using RT3DE.

RESULTS

The presence and severity of mitral regurgitation were more frequent in NCCM patients than in control subjects. LV diameters and mitral annulus were significantly increased in NCCM patients. Compared with control subjects, both LAEF 3D-MAD (3.8 +/- 2.2 vs 2.3 +/- 1.0 kdyne, P < 0.05) and LAEF 3D-MAA (12.7 +/- 7.6 vs 4.9 +/- 2.1 kdyne, P < 0.01) were significantly increased in NCCM patients.

CONCLUSIONS

LAEF as a characteristic of LA systolic function is increased in NCCM patients compared to normal individuals. These results can suggest compensating left atrial work against the dysfunctional LV in NCCM patients.