Mitral E point septal separation: a reliable index of left ventricular performance in coronary artery disease

Emergency medicine updates: Sympathetic crashing acute pulmonary edema

INTRODUCTION

Patients with heart failure exacerbation can present in a variety of ways, including sympathetic crashing acute pulmonary edema (SCAPE). Emergency physicians play a key role in the diagnosis and management of this condition.

OBJECTIVE

This narrative review evaluates key evidence-based updates concerning the diagnosis and management of SCAPE for the emergency clinician.

DISCUSSION

SCAPE is a subset of acute heart failure, defined as a patient with sudden, severe pulmonary edema and hypertension, resulting respiratory distress, and hypoxemia. This is associated with significantly elevated afterload with fluid maldistribution into the pulmonary system. Evaluation and resuscitation should occur concurrently. Laboratory assessment, electrocardiogram, and imaging should be obtained. Point-of-care ultrasound is a rapid and reliable means of confirming pulmonary edema. Management focuses on respiratory support and vasodilator administration. Noninvasive positive pressure ventilation (NIPPV) with oxygen support is associated with reduced need for intubation, improved survival, and improved respiratory indices. If the patient does not improve or decompensates on NIPPV, endotracheal intubation is recommended. Rapid reduction in afterload is necessary, with the first-line medication including nitroglycerin. High-dose bolus nitroglycerin is safe and effective, followed by an infusion. If hypertension is refractory to NIPPV and high-dose nitroglycerin, other agents may be administered including clevidipine or nicardipine. Angiotensin-converting enzyme inhibitors such as enalaprilat are an option in those with normal renal function and resistant hypertension. Diuretics may be administered in those with evidence of systemic volume overload (e.g., cardiomegaly, peripheral edema, weight gain), but should not be routinely administered in patients with SCAPE in the absence of fluid overload. Caution is recommended in utilizing opioids and beta blockers in those with SCAPE.

CONCLUSION

An understanding of the current literature concerning SCAPE can assist emergency clinicians and improve the care of these patients.

Cardiac Point-Of-Care Ultrasound: An Emergency Medicine Review

Cardiac point-of-care ultrasound (POCUS) can make critical diagnoses and monitor the response to interventions. In contrast with consultative echocardiography, cardiac POCUS serves to answer a specific clinical question. This imaging modality can be used to evaluate for left ventricular systolic and diastolic dysfunction, pericardial effusion and tamponade, acute and chronic right ventricular dysfunction, valvular dysfunction, and cardiac activity in cardiac arrest.

A Pilot Study Evaluating LV Diastolic Function with M-Mode Measurement of Mitral Valve Movement in the Parasternal Long Axis View

This pilot study aimed to develop a new, reliable, and easy-to-use method for the evaluation of diastolic function through the M-mode measurement of mitral valve (MV) movement in the parasternal long axis (PSLA), similar to E-point septal separation (EPSS) used for systolic function estimation. Thirty healthy volunteers from a tertiary emergency department (ED) underwent M-mode measurements of the MV anterior leaflet in the PSLA view. EPSS, A-point septal separation (APSS), A-point opening length (APOL), and E-point opening length (EPOL) were measured in the PSLA view, along with the E and A velocities and e' velocity in the apical four-chamber view. Correlation analyses were performed to assess the relationship between M-mode and Doppler measurements, and the measurement time was evaluated. No significant correlations were found between M-mode and Doppler measurements in the study. However, M-mode measurements exhibited high reproducibility and faster acquisition, and the EPOL value consistently exceeded the APOL value, resembling the E and A pattern. These findings suggest that visually assessing the M-mode pattern on the MV anterior leaflet in the PSLA view may be a practical approach to estimating diastolic function in the ED. Further investigations with a larger and more diverse patient population are needed to validate these findings.

Utility of E point septal separation as screening tool for left ventricular ejection fraction in perioperative settings by anesthetists

Background and Aims

Left ventricular (LV) systolic dysfunction is a common cause of hemodynamic disturbance perioperatively and is associated with increased morbidity and mortality. Echocardiographic evaluation of left ventricular systolic function (LVSF) has great clinical utility. This study was aimed to test the hypothesis that LVSF assessed by an anesthetist using mitral valve E Point Septal Separation (EPSS) has a significant correlation with that assessed using modified Simpson's method perioperatively.

Methods

This prospective observational study included 100 patients scheduled for elective surgeries. Transthoracic echocardiography (TTE) was performed preoperatively within 24 hours of surgery by an anesthetist as per American Society of Echocardiography (ASE) guidelines. EPSS measurements were obtained in parasternal long-axis view while volumetric assessment of LV ejection fraction (EF) used apical four-chamber view. Bivariate analysis of EPSS and LV EF was done by testing Pearson correlation coefficient. Receiver Operating Characteristic (ROC) curve constructed to obtain area under curve (AUC) and Youden's Index.

Results

The mean value of mitral valve EPSS was 7.18 ± 3.95 mm. The calculated mean LV EF value using volumetric analysis was 56.31 ± 11.92%. LV dysfunction as per ASE guidelines is present in 28% of patients. EPSS was statistically significantly related to LV EF negatively with a Pearson coefficient of -0.74 (P < 0.0001). AUC of ROC curve 0.950 (P < 0.0001) suggesting a statistically significant correlation between EPSS and LV EF. Youden's index of EPSS value 7 mm was obtained to predict LV systolic dysfunction.

Conclusion

Mitral valve EPSS shows a significant negative correlation with gold standard LVEF measurement for LVSF estimation. It can very well be used to assess LVSF perioperatively by anesthetists with brief training.

Myocarditis Following mRNA COVID-19 Vaccine

ABSTRACT

A growing number of adolescents are being diagnosed with acute myocarditis following mRNA COVID-19 vaccinations. This case describes an adolescent who presented to the emergency department with chest pain and tachycardia following the Pfizer-BioNTech COVID-19 vaccination. Point-of-care ultrasound was performed prior to the return of laboratory studies and revealed depressed left ventricular systolic function. Point-of-care ultrasound may be a tool used to rapidly diagnose or risk stratify patients with potential post-COVID-19 vaccine myocarditis.

Left Ventricular Ejection Fraction Assessment by Emergency Physician-Performed Bedside Echocardiography: A Prospective Comparative Evaluation of Multiple Modalities

BACKGROUND

Although there is some support for visual estimation (VE) as an accurate method to estimate left ventricular ejection fraction (LVEF), it is also scrutinized for its subjectivity. Therefore, more objective assessments, such as fractional shortening (FS) or e-point septal separation (EPSS), may be useful in estimating LVEF among patients in the emergency department (ED).

OBJECTIVE

Our aim was to compare the real-world accuracy of VE, FS, and EPSS using a sample of point-of-care cardiac ultrasound transthoracic echocardiography (POC-TTE) images acquired by emergency physicians (EPs) with the gold standard of Simpson's method of discs, as measured by comprehensive cardiology-performed echocardiography.

METHODS

We conducted a single-site prospective observational study comparing VE, FS, and EPSS to assess LVEF. Adult patients in the ED receiving both POC-TTE and comprehensive cardiology TTE were included. EPs acquired POC-TTE images and videos that were then interpreted by 2 blinded EPs who were fellowship-trained in emergency ultrasound. EPs estimated LVEF using VE, FS, and EPSS. The primary outcome was accuracy.

RESULTS

Between April and May 2018, 125 patients were enrolled and 113 were included in the final analysis. EP1 and EP2 had a κ of 0.94 (95% confidence interval [CI] 0.87-1.00) and 0.97 (95% CI 0.91-1.00), respectively, for VE compared with gold standard, a κ of 0.40 (95% CI 0.23-0.57) and 0.38 (95% CI 0.18-0.57), respectively, for EPSS compared with gold standard, and a κ of 0.70 (95% CI 0.54-0.85) and 0.66 (95% CI 0.50-0.81), respectively, for FS compared with gold standard. Sensitivity of severe dysfunction was moderate to high in VE (EP1 85% and EP2 93%), poor to moderate in FS (EP1 73% and EP2 50%), and poor in EPSS (EP1 11% and EP2 18%).

CONCLUSIONS

Using a real-world sample of POC-TTE images, the quantitative measurements of EPSS and FS demonstrated poor accuracy in estimating LVEF, even among experienced sonographers. These methods should not be used to determine cardiac function in the ED. VE by experienced physicians demonstrated reliable accuracy for estimating LVEF compared with the gold standard of cardiology-performed TTE.

Preoperative Point-of-Care Assessment of Left Ventricular Systolic Dysfunction With Transthoracic Echocardiography

BACKGROUND

Left ventricular (LV) systolic dysfunction is an acknowledged perioperative risk factor and should be identified before surgery. Conventional echocardiographic assessment of LV ejection fraction (LVEF) obtained by biplane LV volumes is the gold standard to detect LV systolic dysfunction. However, this modality needs extensive training and is time consuming. Hence, a feasible point-of-care screening method for this purpose is warranted. The aim of this study was to evaluate 3 point-of-care echocardiographic methods for identification of LV systolic dysfunction in comparison with biplane LVEF.

METHODS

One hundred elective surgical patients, with a mean age of 63 ± 12 years and body mass index of 27 ± 4 kg/m2, were consecutively enrolled in this prospective observational study. Transthoracic echocardiography was conducted 1-2 hours before surgery. LVEF was obtained by automatic two-dimensional (2D) biplane ejection fraction (EF) software. We evaluated if Tissue Doppler Imaging peak systolic myocardial velocities (TDISm), anatomic M-mode E-point septal separation (EPSS), and conventional M-mode mitral annular plane systolic excursion (MAPSE) could discriminate LV systolic dysfunction (LVEF <50%) by calculating accuracy, efficiency, correlation, positive (PPV) respective negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC) for each point-of-care method.

RESULTS

LVEF<50% was identified in 22% (21 of 94) of patients. To discriminate an LVEF <50%, AUROC for TDISm (mean <8 cm/s) was 0.73 (95% confidence interval [CI], 0.62-0.84; P < .001), with a PPV of 47% and an NPV of 90%. EPSS with a cutoff value of >6 mm had an AUROC 0.89 (95% CI, 0.80-0.98; P < .001), with a PPV of 67% and an NPV of 96%. MAPSE (mean <12 mm) had an AUROC 0.80 (95% CI, 0.70-0.90; P < 0.001) with a PPV of 57% and an NPV of 98%.

CONCLUSIONS

All 3 point-of-care methods performed reasonably well to discriminate patients with LVEF <50%. The clinician may choose the most suitable method according to praxis and observer experience.

Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era

Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to "collateral damage" in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.

Diagnosis of Acute Heart Failure in the Emergency Department: An Evidence-Based Review

Heart failure is a common presentation to the emergency department (ED), which can be confused with other clinical conditions. This review provides an evidence-based summary of the current ED evaluation of heart failure. Acute heart failure is the gradual or rapid decompensation of heart failure, resulting from either fluid overload or maldistribution. Typical symptoms can include dyspnea, orthopnea, or systemic edema. The physical examination may reveal pulmonary rales, an S3 heart sound, or extremity edema. However, physical examination findings are often not sensitive or specific. ED assessments may include electrocardiogram, complete blood count, basic metabolic profile, liver function tests, troponin, brain natriuretic peptide, and a chest radiograph. While often used, natriuretic peptides do not significantly change ED treatment, mortality, or readmission rates, although they may decrease hospital length of stay and total cost. Chest radiograph findings are not definitive, and several other conditions may mimic radiograph findings. A more reliable modality is point-of-care ultrasound, which can facilitate the diagnosis by assessing for B-lines, cardiac function, and inferior vena cava size. These modalities, combined with clinical assessment and gestalt, are recommended.

Resuscitative Cardiopulmonary Ultrasound and Transesophageal Echocardiography in the Emergency Department

Resuscitative ultrasound describes point-of-care applications that provide diagnostic information, physiologic monitoring, and procedural guidance in critically ill patients. This article reviews the evaluation of ventricular function, identification of pericardial effusion and tamponade, evaluation of preload and fluid responsiveness, and hemodynamic monitoring, as some of the main applications where this modality can help emergency physicians during resuscitation of critically ill patients.

Estimation of Cardiac Systolic Function Based on Mitral Valve Movements: An Accurate Bedside Tool for Emergency Physicians in Dyspneic Patients

OBJECTIVES

The purpose of this study was to determine the success of mitral valve movements in the estimation of left ventricular ejection fraction (LVEF).

METHODS

Adult patients whose principal symptom was dyspnea were included in this prospective observational study. The distance from the anterior mitral valve (AMV) to the interventricular septum (IVS) during early diastole was measured first in B-mode in the parasternal long axis (PLAX) named parasternal long axis-anterior leaflet septal separation. Second, the AMV-IVS distance was measured in M-mode in the PLAX named E-point septal separation. Third, AMV-IVS distance was measured in B-mode in the apical 4-chamber view named apical 4-chamber view-anterior leaflet septal separation. Finally, maximum distance between the 2 mitral leaflets in the apical 4-chamber view was measured and named mitral valve leaflet separation. Comprehensive echocardiography was performed by an experienced cardiologist. Correlation was calculated between mitral valve measurements and LVEF. Cutoff values were determined using receiver operating characteristic curves and the chi-square test.

RESULTS

A total of 118 patients were included in the study. Parasternal long axis-anterior leaflet septal separation, E-point septal separation, and apical 4-chamber view-anterior leaflet septal separation were highly correlated with LVEF (correlation coefficient, -0.848, -0.833, and-0.822 [P < .001]). Parasternal long axis-anterior leaflet septal separation values less than 2.30 mm, E-point septal separation values less than 2 mm, and mitral valve leaflet separation values greater than 25.15 mm exhibited a 100% negative predictive value in excluding reduced LVEF. Parasternal long axis-anterior leaflet septal separation values less than 4.95 mm, EPSS values less than 5.85 mm, apical 4-chamber view-anterior leaflet septal separation values less than 6.95 mm, and mitral valve leaflet separation values greater than 24.05 mm exhibited a 100% negative predictive value in excluding severe reduced LVEF.

CONCLUSIONS

Mitral valve measurement methods may be useful in predicting LVEF or values thereof as a complementary method of diagnosing challenging patients on echocardiographic images.

Echocardiographic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care

Proficiency in echocardiography and lung ultrasound has become essential for anesthesiologists and critical care physicians. Nonetheless, comprehensive echocardiography measurements often are time-consuming and technically challenging, and conventional 2-dimensional images do not permit evaluation of specific conditions (eg, systolic anterior motion of the mitral valve, pneumothorax), which have important clinical implications in the perioperative setting. M-mode (motion-based) ultrasonographic imaging, however, provides the most reliable temporal resolution in ultrasonography. Hence, M-mode can provide clinically relevant information in echocardiography and lung ultrasound-driven approaches for diagnosis, monitoring, and interventional procedures performed by anesthesiologists and intensivists. Although M-mode is feasible, this imaging modality progressively has been abandoned in echocardiography and is often underutilized in lung ultrasound. This article aims to comprehensively illustrate contemporary applications of M-mode ultrasonography in the anesthesia and critical care medicine practice. Information presented for each clinical application will include image acquisition and interpretation, evidence-based clinical implications in the critically ill and surgical patient, and limitations. The present article focuses on echocardiography and reviews left ventricular function (mitral annular plane systolic excursion, E-point septal separation, fractional shortening, and transmitral propagation velocity); right ventricular function (tricuspid annular plane systolic excursion, subcostal echocardiographic assessment of tricuspid annulus kick, outflow tract fractional shortening, ventricular septal motion, wall thickness, and outflow tract obstruction); volume status and responsiveness (inferior vena cava and superior vena cava diameter and respiratory variability [collapsibility and distensibility indexes]); cardiac tamponade; systolic anterior motion of the mitral valve; and aortic dissection.

Cardiac echocardiography

Focused cardiac echocardiography has become a critical diagnostic tool for the emergency physician and critical care physician caring for patients in shock and following trauma to the chest, and those presenting with chest pain and shortness of breath,. Cardiac echocardiography allows for immediate diagnosis of pericardial effusions and cardiac tamponade, evaluation of cardiac contractility and volume status, and detection of right ventricular strain possibly seen with a significant pulmonary embolus. This article addresses how to perform cardiac echocardiography using the standard windows, how to interpret a focused goal-directed examination, and how to apply this information clinically at the bedside.

The role of the emergency department in the patient with acute heart failure

The diagnosis and management of the patient with acute decompensated heart failure (ADHF) presents a unique challenge to the emergency medicine (EM) physician. ADHF is one of the most common cardiac emergencies managed in the emergency department (ED). ED presentations for ADHF will grow as survival rates after myocardial infarction continue to increase and thus, the incidence and prevalence of heart failure (HF) increases. There are very little data to aid EM physicians when trying to identify low-risk patients who are safe for ED discharge and observation units are not yet universally utilized. This results in 80% of patients with ADHF getting admitted to the hospital. The aim of this review is to evaluate current strategies for diagnosis, treatment, and disposition of the ADHF patient in the ED while highlighting new approaches for treatment and disposition, and areas in need of additional research.

Initial management of patients with acute heart failure

Pressure exists to manage patients with acute decompensated heart failure (ADHF) efficiently in the acute-care environment. Although most patients present with worsening of chronic heart failure, some may present with undifferentiated dyspnea and new-onset heart failure. Others have significant comorbidities that complicate both the diagnosis and treatment. The treatment of patients with ADHF is prioritized based on vital signs and presenting phenotype. The risk stratification of patients is the subject of ongoing evaluation. The disposition of patients to areas other than a monitored inpatient bed, such as an emergency department-based observation unit, may prove effective.

Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol

Assessment of hemodynamic status in a shock state remains a challenging issue in Emergency Medicine and Critical Care. As the use of invasive hemodynamic monitoring declines, bedside-focused ultrasound has become a valuable tool in the evaluation and management of patients in shock. No longer a means to simply evaluate organ anatomy, ultrasound has expanded to become a rapid and noninvasive method for the assessment of patient physiology. Clinicians caring for critical patients should strongly consider integrating ultrasound into their resuscitation pathways.

Can junior emergency physicians use E-point septal separation to accurately estimate left ventricular function in acutely dyspneic patients?

OBJECTIVES

The authors determined if E-point septal separation (EPSS) as measured by junior emergency physicians (EPs) correlated with visual estimation of left ventricle ejection fraction (LVEF) by senior EPs and cardiologists in acutely dyspneic patients presenting to an adult emergency department (ED).

METHODS

Acutely dyspneic patients were enrolled in a prospective, observational study. EPSS was measured using bedside ultrasonography by junior EPs (PGY 3 and PGY 4 residents) with variable ultrasound experience. M-mode measurements of EPSS were recorded in the parasternal long-axis orientation and were calculated during diastole by measuring distance from the tip of the anterior mitral valve leaflet to the septal wall. LVEF was visually estimated at the bedside by emergency medicine (EM) ultrasound fellows and an EM ultrasound fellowship-trained attending physician and was subsequently visually estimated by two cardiologists reviewing video clips obtained by the junior EPs. The correlation between EPSS and visually estimated LVEF was calculated.

RESULTS

Of the 58 patients, the median age was 63 years (range = 28 to 90 years) and 66% were women. Interobserver reliability between EPs and cardiologists for the visual estimation of LVEF was excellent (κ = 0.75). The correlation between measurements of EPSS by junior EPs and visual estimations of LVEF by the senior EPs was ρ = -0.844 (p < 0.001).

CONCLUSIONS

In this study, junior EPs were able to obtain measurements of EPSS that correlated closely with visual estimates of LVEF by clinicians with extensive point-of-care and comprehensive echocardiography experience.

Estimation of left ventricular systolic function by nonvolumetric echocardiographic analysis in subjects with poor left ventricular visualization: a pilot study

BACKGROUND

Accurate assessment of left ventricular (LV) systolic function is an essential requirement in clinical cardiology. Several echocardiographic methods provide quantitative analysis of LV volumes and ejection fraction (EF) based on the precise tracing of endocardial borders. Often, however, technically limited studies prohibit such direct analysis, and alternative techniques must be applied.

HYPOTHESIS

Nonvolumetric echocardiographic methods which do not require endocardial edge definition and tracing may accurately provide quantitative LV systolic function data.

METHODS

A pilot study was conducted to validate and compare two recently described indirect echocardiographic methods of LV systolic function analysis, with LVEF by radionuclear cardiac angiography (RNCA). Thirty-two consecutive patients undergoing RNCA for clinical indications also underwent echocardiography within 24 h, with LV analysis performed by the techniques of (1) atrioventricular plane displacement (AVPD) and (2) mitral valve leaflet coaptation point to interventricular septum distance at end-systole (MVC-IVS).

RESULTS

Thirteen patients had an echocardiogram with poor two-dimensional visualization of LV endocardial borders. One patient could not be evaluated by the MVC-IVS method and two others by the AVPD method because of technical limitations. Chi-square analysis to compare how each method could discriminate between an RNCA LVEF of < or > or = 50% demonstrated high correlations for the AVPD method (r = 0.6530, p < 0.0005) and the MVC-IVS method (r = -0.7029, p < 0.0001). Sensitivity, specificity, positive and negative predictive values, and test accuracy for the AVPD and MVC-IVS methods were 85 and 80%, 88 and 94%, 85 and 92%, 82 and 83%, and 83 and 87%, respectively.

CONCLUSION

This pilot study demonstrates that both alternative echocardiographic methods may be useful in the assessment of LV systolic performance, even in the setting of poor LV endocardial border visualization. A larger study is warranted to apply and contrast these methods in different patient subsets.

Quantitative estimation of left ventricular ejection fraction from mitral valve E-point to septal separation and comparison to magnetic resonance imaging

This study tested the hypothesis that the mitral valve E point-to-septal separation (EPSS) can be used to quantify the left ventricular (LV) ejection fraction (EF) on a continuous scale rather than simply as "normal" or "reduced." After excluding 5 patients with mitral valve prostheses, asymmetric septal hypertrophy, or significant aortic insufficiency, EPSS was measured in 42 patients by 3 independent observers on a cardiac magnetic resonance image identical to the echocardiographic parasternal long-axis view. In each patient, the reference standard LVEF was calculated from the magnetic resonance short-axis cross-sectional stack images by Simpson's rule and ranged from 11% to 72%. For all 42 patients, linear regression revealed the relation magnetic resonance imaging (MRI) LVEF = 75.5 - 2.5. EPSS (millimeters). Correlation between EPSS and the MRI LVEF for the 3 observers agreed closely, ranging from r = 0.78 to r = 0.82 (SEE 9 to 10), with similar regression coefficients. After blinded segmental wall motion scoring of the gated magnetic resonance cine images of the left ventricle in each patient, correlations, SEEs, and regression coefficients were found to be very similar in the 21 patients with the most homogenous wall motion, compared with the 21 patients with the most heterogenous wall motion. In conclusion, clinically useful quantitative prediction of the LVEF as a continuous variable can be obtained from the EPSS with a simple linear regression equation in a substantial portion of patients and may be a useful adjunct for assessment of LV function.

Restricted diastolic opening of the mitral leaflets in patients with left ventricular dysfunction: evidence for increased valve tethering

OBJECTIVES

We tested the hypothesis that patients with incomplete systolic mitral leaflet closure (IMLC: apically displaced coaptation) also have restricted diastolic leaflet opening that is independent of mitral inflow volume and provides evidence supporting increased leaflet tethering.

BACKGROUND

Competing hypotheses for functional mitral regurgitation (MR) with IMLC include global left ventricular (LV) dysfunction per se (reduced leaflet closing force) versus geometric distortion of the mitral apparatus by LV dilation (augmented leaflet tethering). These are inseparable in systole, but restricted leaflet motion has also been observed in diastole, and attributed to reduced mitral inflow.

METHODS

Diastolic mitral leaflet excursion and orifice area were measured by two-dimensional echocardiography in 58 patients with global LV dysfunction, 36 with and 22 without IMLC, compared with 21 normal subjects. The biplane Simpson's method was used to calculate LV ejection volume, which equals mitral inflow volume in the absence of aortic regurgitation.

RESULTS

The diastolic mitral leaflet excursion angle was markedly reduced in patients with IMLC compared with those without IMLC, whose ventricles were smaller, and normal subjects (17 +/- 10 degrees vs. 58 +/- 13 degrees vs. 67 +/- 8 degrees, p < 0.0001). Excursion angle was dissociated from mitral inflow volume (r2 = 0.04); excursion was reduced in patients with IMLC despite a normal inflow volume in the larger ventricles with MR (60 +/- 25 vs. 61 +/- 12 ml in normal subjects, p = NS), and excursion was nearly normal in patients without IMLC despite reduced inflow volume (40 +/- 10 ml, p < 0.001 vs. normal subjects). The anterior leaflet when maximally open coincided well with the line connecting its attachments to the anterior annulus and papillary muscle tip (angular difference = 3 +/- 7 degrees vs. 25 +/- 9 degrees vs. 32 +/- 10 degrees in patients with and without IMLC vs. normal subjects, p < 0.0001). In patients with IMLC, the leaflet tip orifice was smaller in an anteroposterior direction but wider than in the other groups, giving a normal total area (6.8 +/- 1.8 vs. 7.1 +/- 1.2 vs. 6.9 +/- 0.8 cm2, p = NS).

CONCLUSIONS

Patients with LV dysfunction and systolic IMLC also have restricted diastolic leaflet excursion that is independent of inflow volume, coincides with the tethering line connecting the annulus and papillary muscle and reflects limitation of anterior motion relative to the posteriorly placed papillary muscles without a decrease in total orifice area. These observations are consistent with increased tethering by displaced mitral leaflet attachments in the dilated ventricles of patients with IMLC that can restrict both diastolic opening and systolic closure.

Noninvasive Doppler-derived myocardial performance index: correlation with simultaneous measurements of cardiac catheterization measurements

A simple, reproducible, noninvasive Doppler index for the assessment of overall cardiac function has been described previously. The purpose of this study was to correlate the Doppler index with accepted indexes of cardiac catheterization of left ventricular performance. Thirty-four patients with ischemic heart disease or idiopathic dilated cardiomyopathy prospectively underwent a simultaneous cardiac catheterization and Doppler echocardiographic study. Invasive measurements of peak +dP/dt, peak -dP/dt, and tau were obtained from the high-fidelity left ventricular pressures. A Doppler index of myocardial performance was defined as the summation of isovolumetric contraction and relaxation time divided by ejection time. There was a correlation between Doppler measurement of isovolumetric contraction time and peak +dP/dt (r = 0.842; p < 0.0001) and Doppler measurement of isovolumetric relaxation time and peak -dP/dt (r = 0.638; p < 0.001). Left ventricular ejection time correlated with both peak +dP/dt (r = 0.539; p < 0.001) and peak -dP/dt (r = 0.582; p < 0.001). The Doppler index correlated with simultaneously recorded systolic peak +dP/dt (r = 0.821; p < 0.0001) and diastolic peak -dP/dt (r = 0.833; p < 0.001) and tau (r = 0.680; p < 0.0001). This study documents that a simple, easily recordable, noninvasive Doppler index of myocardial performance correlates with invasive measurement of left ventricular systolic and diastolic function and appears to be a promising noninvasive measurement of overall cardiac function.

Reduction of left ventricular spontaneous echo contrast in cardiomyopathy by acute inotropic intervention or aggressive therapy

The purpose of this study was to determine whether improvement of left ventricular (LV) systolic function could reduce the severity or eliminate LV spontaneous echo contrast found with transthoracic echocardiography in a group of patients with advanced cardiomyopathy. A successful reduction of this by hemodynamic means might indicate an additional beneficial method of helping prevent thromboembolism in advanced cardiomyopathy. Six patients with advanced cardiomyopathy and demonstrating spontaneous echo contrast on transthoracic echocardiography were treated with acute inotropic drug infusions or aggressive medical therapy to improve LV systolic function to determine whether reduction in spontaneous contrast could be achieved by such means. A spontaneous echo contrast scoring system was devised: 0 to 4, indicating absent to severe. Six observers, unacquainted with the study plan, were blinded as to the source of the 12 pre- and post-therapy two-dimensional echocardiograms obtained and re-recorded in a random sequence, and were asked to grade the degree of spontaneous echo contrast. In all six patients, LV spontaneous echo contrast was reduced by improvement in LV systolic function (average score lowered from 2.94 to 1.25, p < 0.005). Among patients with cardiomyopathy at high risk for LV thromboembolism, as indicated by the presence of LV spontaneous echo contrast, improvement in LV systolic function may serve as an adjunct to anticoagulation or, in some cases, as a substitute when the latter is contraindicated in the prevention of thromboembolism. The results obtained suggest merit in prospective, long-term studies of a larger group of such patients.

Mitral-septal angle: a new two-dimensional echocardiographic index of left ventricular performance

The diagnostic value of a new two-dimensional echocardiographic measurement, the mitral septal angle, was evaluated as an index of left ventricular (LV) function in 122 patients. Their mean age was 56.5 years and the majority (80%) suffered from coronary artery disease, 46 with an acute myocardial infarction. Mitral septal angle was easily and reproducibly measured. An ejection fraction (EF) of greater than or equal to 50% and an angle less than or equal to 30 degrees were used as normal cut-off values. A strong negative correlation was found between the angle and radionuclide EF (-0.821) and angiographic EF (-0.82) in patients without acute myocardial infarction. For patients with acute myocardial infarction, the correlation was -0.722. For the entire group, the correlation coefficient was -0.742. In patients without acute infarction, the sensitivity, specificity, and predictive accuracy of the mitral septal angle were 92%, 86%, and 89%, respectively. In acute infarction, sensitivity dropped to 70% without change in specificity (89%). We conclude that mitral septal angle is a simple index of LV function which relates well to EF, particularly in patients with chronic heart disease.

Sensitivity of cross-sectional echocardiography in detection of impaired global and regional left ventricular function: prospective study

In order to establish the sensitivity and specificity of cross-sectional echocardiography for detection of global and regional left ventricular function a prospective study was performed in 80 patients suspected of having coronary artery disease. Twenty four hours before heart catheterization, cross-sectional echocardiograms were recorded in the apical RAO-equivalent view and high quality echocardiograms were obtained in 71/80 patients (89%). M-mode echocardiograms of the left ventricle could be performed in 56/71 patients (79%). Based on normal values sensitivity and specificity of cross-sectional echocardiography were calculated in comparison to cineventriculography. For fractional shortening (normal value greater than 25%) sensitivity measured 46% and specificity 93%, and when the E-point septal separation was measured (normal value less than 7 mm), sensitivity increased to 73% and specificity was 84%. For detection of increased end-diastolic volume (less than 155 ml) sensitivity reached 84% and specificity 98% and for increased end-systolic (less than 70 ml) volume it was 86 and 97%, respectively. A depressed left ventricular ejection fraction (greater than 49%) was found with a sensitivity of 93% and specificity of 100%. Regional left ventricular wall motion, analyzed by an area method, revealed for anterior wall motion a sensitivity of 68% and a specificity of 94%, whereas for posterior wall motion sensitivity reached 80% and specificity 96%. Regression equation between the number of pathological segments and left ventricular ejection fraction for cineventriculography was given by Y = -4.06 X + 73.4, r = 0.93 and for cross-sectional echocardiography by Y = -3.69 X + 62.6, r = 0.85. We conclude that cross-sectional echocardiography can be used as a screening method to detect impaired left ventricular function. It is superior to M-mode echocardiography. Reduced regional function of the posterior wall can be found with high sensitivity, but depressed motion of the anterior wall may be overlooked.

Widened E point septal separation in a normal pediatric population

To determine the age and gender distribution of the E point septal separation (EPSS), M-mode echocardiograms were obtained from 121 normal subjects aged four months to 82 years. A small but consistent age factor was found. In subjects less than age 20, EPSS was 3.0 +/- 2.6 mm, whereas in those greater than 20 years, EPSS was 1.4 +/- 1.8 (p less than .001). In females EPSS did not vary appreciably at different ages. By contrast, in males EPSS increased with age, peaking between ages 15 and 19 and then decreasing. Between ages 10 and 19, EPSS was significantly wide in males than in females. Thus, EPSS is wide in male adolescents than in adults. The cause for this phenomenon is unclear, but judging from its age and gender distribution, it may be related to the effect of androgens on the myocardium.