Usefulness of real-time three-dimensional echocardiography to identify right ventricular dysfunction in patients with congenital heart disease

Mid-term follow-up by speckle tracking and cardiac MRI of children post-transcatheter closure of large atrial septal defects

This is a case-control study of our experience of mid-term follow-up of 40 children who had a transcatheter closure of very large atrial septal defects group (1). All cases had an atrial septal defect device size more than 1.5 times their weight, a ratio considered a contraindication for trans catheter closure (TCC) in some previous reports. The aim of this study is to report the outcomes and mid-term follow-up of transcatheter closure of large atrial septal defects using two-dimensional conventional echocardiography, tissue Doppler imaging, and four-dimensional speckle tracking imaging, and as such to compare results of same echocardiographic examination of age-matched control group of 40 healthy children group (2). Cardiac MRI was performed on cases group (1) only to detect right ventricle and left ventricle volumes and function and early signs of complications. There was no difference between cases and matched healthy controls in terms of the assessment of left ventricle and right ventricle by two-dimensional echocardiography, tissue Doppler imaging, and four-dimensional speckle tracking imaging. Similarly, there was no statistically significant difference between four-dimensional echocardiography and cardiac MRI in their respective assessment of both left ventricle and right ventricle volumes and function. We also detected no complications by echo or by cardiac MRI after a median follow-up period of 2 years and recorded a complete remodelling of right ventricle volumes in all children studied. This points to the safety and efficiency of transcatheter closure of large atrial septal defects in children on mid-term follow-up.

Three-Dimensional Echocardiography Assessment of Right Ventricular Volumes and Function: Technological Perspective and Clinical Application

Right ventricular (RV) function has important prognostic value in a variety of cardiovascular diseases. Due to complex anatomy and mode of contractility, conventional two-dimensional echocardiography does not provide sufficient and accurate RV function assessment. Currently, three-dimensional echocardiography (3DE) allows for an excellent and reproducible assessment of RV function owing to overcoming these limitations of traditional echocardiography. This review focused on 3DE and discussed the following points: (i) acquisition of RV dataset for 3DE images, (ii) reliability, feasibility, and reproducibility of RV volumes and function measured by 3DE with different modalities, (iii) the clinical application of 3DE for RV function quantification.

Reference Values of Right Ventricular Volumes and Ejection Fraction by Three-Dimensional Echocardiography in Adults: A Systematic Review and Meta-Analysis

Objective: This study was conducted in order to determine the reference values for right ventricular (RV) volumes and ejection fraction (EF) using three-dimensional echocardiography (3DE) and to identify sources of variance through a systematic review and meta-analysis.

Methods: This systematic review was preregistered with the International Prospective Register of Systematic Reviews (https://www.crd.york.ac.uk/PROSPERO/) (CRD42020211002). Relevant studies were identified by searches of the PubMed, Embase, and Cochrane Library databases through October 12, 2020. Pooled reference values were calculated using the random-effects model weighted by inverse variance. Meta-regression analysis and Egger's test were used to determine the source of heterogeneity. A subgroup analysis was performed to evaluate the reference values across different conditions.

Results: The search identified 25 studies of 2,165 subjects. The mean reference values were as follows: RV end-diastolic volume, 100.71 ml [95% confidence interval (CI), 90.92–110.51 ml); RV end-systolic volume, 44.19 ml (95% CI, 39.05–49.33 ml); RV end-diastolic volume indexed, 57.01 ml/m² (95% CI, 51.93–62.08 ml/m²); RV end-systolic volume indexed, 25.41 ml/m² (95% CI, 22.58–28.24 ml/m²); and RVEF, 56.20% (95% CI, 54.59–57.82%). The sex- and age-specific reference values were assessed according to the studies reporting the values of different sexes and age distributions, respectively. In addition, the vendor- and software-specific reference values were analyzed. The meta-regression analysis revealed that sex, frame rate, pulmonary artery systolic pressure, and software packages were associated with variations in RV volumes (P < 0.05). Inter-vendor and inter-software discrepancies may explain the variability of RVEF.

Conclusions: The reference values for RV volumes and RVEF using 3DE were assessed. The confounders that impacted the variability in RV volumes or RVEF contained the sex, frame rate, pulmonary artery systolic pressure, inter-vendor discrepancies, and inter-software discrepancies.

Stereoscopic Display Is Superior to Conventional Display for Three-Dimensional Echocardiography of Congenital Heart Anatomy

BACKGROUND

Three-dimensional echocardiography (3DE) improves visualization of cardiac lesions. Current viewing of 3DE studies on a conventional display diminishes the encoded stereoscopic (stereo) information for depth perception. This study aims to evaluate clinician subjective and objective experience of stereo display compared with nonstereo display of 3DE in congenital heart disease.

METHODS

In this prospective study, 22 cardiologists, advanced cardiology trainees, and cardiothoracic surgeons used a commercially available stereo display system with proprietary software to view 10 3DE data sets, alternating between simple and complex lesions. In part A, participants viewed each data set, randomized to 1 minute of stereo display followed by 1 minute of nonstereo display, or vice versa. In part B, participants could freely toggle between stereo and nonstereo display for an additional 90 seconds per data set. Participants answered a series of questions and rated their subjective experience using stereo versus nonstereo display mode on a Likert scale. Objective data on time spent in each display mode during part B and duration of interaction and degree of movement of the 3DE data set in parts A and B were also collected.

RESULTS

All clinician groups found stereo display preferable to nonstereo display of 3DE (P < .0001). Viewing complex lesions was rated lower than simple lesions when using nonstereo display (P < .01). Simple and complex lesions were equally well rated when using stereo display (P = .14). When given a choice of display modes in part B, participants spent more time in stereo display (P < .0001) and interacted more with the 3DE data sets in stereo display (P < .0001).

CONCLUSIONS

Interactive stereoscopic display of 3DE was preferred over conventional nonstereo display by all clinician groups for viewing both simple and complex lesions. This preference is especially true for viewing complex lesions.

[Update on pediatric cardiology and congenital heart disease: imaging techniques, pulmonary arterial hypertension, hybrid treatment, and surgical treatment]

This article contains a review of the most significant contributions to pediatric cardiology and congenital heart disease reported in publications between September 2009 and August 2010. The review focuses on imaging techniques, new treatment for pulmonary arterial hypertension in pediatric patients, and therapy in general (e.g. hybrid treatment and surgical treatment). With regard to imaging techniques, the review highlights the increasing application of congenital heart disease diagnosis during fetal life, the introduction of new echocardiographic techniques (e.g. tissue Doppler imaging, two-dimensional speckle-tracking imaging and three-dimensional echocardiography) into routine clinical practice, and the growing use of cardiac CT and magnetic resonance imaging in diagnosis and the assessment of cardiac function, respectively. The role played by cardiac interventions continues to increase and cardiac surgery is becoming more advanced and has, in some cases, been combined with hybrid techniques. However, there are still a number of controversial issues in cardiac surgery that have not yet been resolved, such as whether or not fenestration should be used with Fontan surgery, the optimum type of correction for hypoplastic left heart syndrome, and the best conduit for pulmonary artery replacement.

A pilot study of systolic dyssynchrony index by real-time three-dimensional echocardiography predicting clinical outcomes to surgical ventricular reconstruction in patients with left ventricular aneurysm

OBJECTIVES

The aim of the study was to detect whether the systolic dyssynchrony index (SDI) assessed by real-time 3D echocardiography (RT3DE) could predict clinical outcomes of patients with ventricular aneurysm in response to surgical ventricular reconstruction (SVR).

METHODS

In total, 120 individuals underwent RT3DE, including 30 healthy volunteers and 90 patients with ventricular aneurysm. All patients underwent clinical and echocardiographic assessments at baseline and at 12 months after SVR. The SDI was defined as the SD of time to minimum systolic volume of the 16 left ventricular (LV) segments, expressed in percent RR duration. SVR responder was defined as a >15% decrease in LV end-systolic volume, reduction in NYHA functional class or 20% relative increase in the LV ejection fraction (LVEF).

RESULTS

The SDI was significantly higher in patients with aneurysm, at 14.3% compared with 2.0% in healthy volunteers (P <0.047). The SDI was negatively correlated with the LVEF. After SVR, 86 patients were responders. In this patient subgroup, the SDI exhibited an immediate significant decrease (to 7.7%; P <0.034) and a progressive decrease during 12 months of follow-up (to 4.9%; P <0.044). The SDI can discriminate SVR responders. Receiver-operating characteristic curve analysis yielded cut-off values of SDI 14.3% best associated with SVR response; area under the curve was 0.79 with reduction in NYHA class, 0.86 with increase in EF and 0.66 with decrease in the end-systolic volume.

CONCLUSIONS

RT3DE can be used to assess LV mechanical dyssynchrony in patients with aneurysm. SVR produces a mechanical intraventricular resynchronization and SDI can predict improvement following SVR.

Advanced echocardiographic imaging of the congenitally malformed heart

There have been significant advancements in the ability of echocardiography to provide both morphological and functional information in children with congenitally malformed hearts. This progress has come through the development of improved technology such as matrix array probes and software which allows for the off line analysis of images to a high standard. This article focuses on these developments and discusses some newer concepts in advanced echocardiography such is multi-planar reformatting [MPR] and tissue motion annular displacement [TMAD].

Our aim is to discuss important aspects related to the quality and reproducibility of data, to review the most recent published data regarding advanced echocardiography in the malformed heart and to guide the reader to appropriate text for overcoming the technical challenges of using these methods. Many of the technical aspects of image acquisition and post processing have been discussed in recent reviews by the authors and we would urge readers to study these texts to gain a greater understanding [1]. The quality of the two dimensional image is paramount in both strain analysis and three dimensional echocardiography. An awareness of how to improve image quality is vital to acquiring accurate and usable data.

Three dimensional echocardiography (3DE) is an attempt to visualise the dynamic morphology of the heart. Although published media is the basis for theoretical knowledge of how to practically acquire images, electronic media [eg.www.3dechocardiography.com] is the only way of visualising the advantages of this technology in real time.

It is important to be aware of the limitations of this technology and that much of the data gleaned from using these methods is at a research stage and not yet in regular clinical practice.

Echocardiography in pediatric pulmonary hypertension

Pulmonary hypertension (PH) can be a rapidly progressive and fatal disease. Although right heart catheterization remains the gold standard in evaluation of PH, echocardiography remains an important tool in screening, diagnosing, evaluating, and following these patients. In this article, we will review the important echocardiographic parameters of the right heart in evaluating its anatomy, hemodynamic assessment, systolic, and diastolic function in children with PH.

Quantifying pulmonary regurgitation and right ventricular function in surgically repaired tetralogy of Fallot: a comparative analysis of echocardiography and magnetic resonance imaging

BACKGROUND

Patients with repaired tetralogy of Fallot are monitored for pulmonary regurgitation (PR) and right ventricular (RV) function. We sought to compare measures of PR and RV function on echocardiogram to those on cardiac magnetic resonance (CMR) and to develop a new tool for assessing PR by echocardiogram.

METHODS AND RESULTS

Patients with repaired tetralogy of Fallot (n=143; 12.5±3.2 years) had an echocardiogram and CMR within 3 months of each other. On echocardiogram, RV function was assessed by (1) Doppler tissue imaging of the RV free wall and (2) myocardial performance index. The ratio of diastolic and systolic time-velocity integrals measured by Doppler of the main pulmonary artery was calculated. CMR variables included RV ejection fraction, RV volumes, and pulmonary regurgitant fraction (RF). Pulmonary regurgitation was graded as mild (RF<20%), moderate (RF=20-40%), and severe (RF>40%). On CMR, RF was 34+17% and RV ejection fraction was 61+8%. Echocardiography had good sensitivity identifying cases with RF>20% (sensitivity 97%; 95% CI: 92-99%) but overestimated the amount of PR when RF<20% (false-positive rate 36%; 95% CI: 18-57%). The diastolic and systolic time-velocity integrals on echocardiogram showed moderate correlation with RF on CMR (R=0.60; P<0.0001). On CMR, RF of 20% and 40% corresponded with a diastolic and systolic time-velocity integral of 0.49 (95% CI: 0.44-0.56) and 0.72 (95% CI: 0.68-0.76), respectively. RV myocardial performance index correlated modestly with RV ejection fraction (r=-0.33; P<0.001).

CONCLUSIONS

This study suggests that the diastolic and systolic time-velocity integrals ratio may make a modest contribution to the overall assessment of PR in patients with repaired tetralogy of Fallot and warrants further investigation. However, echocardiography continues to have a limited ability to quantify PR and RV function as compared with CMR.

Current clinical applications of transthoracic three-dimensional echocardiography

The advent of three-dimensional echocardiography (3DE) has significantly improved the impact of non-invasive imaging on our understanding and management of cardiac diseases in clinical practice. Transthoracic 3DE enables an easier, more accurate and reproducible interpretation of the complex cardiac anatomy, overcoming the intrinsic limitations of conventional echocardiography. The availability of unprecedented views of cardiac structures from any perspective in the beating heart provides valuable clinical information and new levels of confidence in diagnosing heart disease. One major advantage of the third dimension is the improvement in the accuracy and reproducibility of chamber volume measurement by eliminating geometric assumptions and errors caused by foreshortened views. Another benefit of 3DE is the realistic en face views of heart valves, enabling a better appreciation of the severity and mechanisms of valve diseases in a unique, noninvasive manner. The purpose of this review is to provide readers with an update on the current clinical applications of transthoracic 3DE, emphasizing the incremental benefits of 3DE over conventional two-dimensional echocardiography.

Imaging the right heart: the use of integrated multimodality imaging

During recent years, right ventricular (RV) structure and function have been found to be an important determinant of outcome in different cardiovascular and also pulmonary diseases. Currently, echocardiography and cardiac magnetic resonance (CMR) imaging are the two imaging modalities most commonly used to visualize the RV. Most structural abnormalities of the RV can be reliably described by echocardiography but due its complex geometrical shape, echocardiographic assessment of RV function is more challenging. Newer promising echocardiographic techniques are emerging but lack of validation and limited normal reference data influence their routine clinical application. Cardiac magnetic resonance is generally considered the clinical reference technique due to its unlimited imaging planes, superior image resolution, and three-dimensional volumetric rendering. The accuracy and reliability of CMR measurements make it the ideal tool for serial examinations of RV function. Multidetector computed tomography (MDCT) plays an important role in the diagnosis of pulmonary emboli but can also be used for assessing RV ischaemic disease or as an alternative for CMR if contra-indicated. Radionuclide techniques have become more obsolete in the current era. The different imaging modalities should be considered complimentary and each plays a role for different indications.

[Pediatric cardiology and congenital heart disease: from fetus to adult]

This article contains a review of some of the most important publications on congenital heart disease and pediatric cardiology that appeared in 2010 and up until September 2011. Of particular interest were studies on demographic changes reported in this patient population and on the need to manage the patients' transition from the pediatric to the adult cardiology department. This transition has given rise to the appearance of new areas of interest: for example, pregnancy in women with congenital heart disease, and the effect of genetic factors on the etiology and transmission of particular anomalies. In addition, this review considers some publications on fetal cardiology from the perspective of early diagnosis and, if possible, treatment. There follows a discussion on new contributions to Eisenmenger's syndrome and arrhythmias, as well as on imaging techniques, interventional catheterization and heart transplantation. Finally, there is an overview of the new version of clinical practice guidelines on the management of adult patients with congenital heart disease and of recently published guidelines on pregnancy in women with heart disease, both produced by the European Society of Cardiology.

Manual correction of semi-automatic three-dimensional echocardiography is needed for right ventricular assessment in adults; validation with cardiac magnetic resonance

BACKGROUND

Three-dimensional echocardiography (3DE) and semi-automatic right ventricular delineation has been proposed as an appropriate method for right ventricle (RV) evaluation. We aimed to examine how manual correction of semi-automatic delineation influences the accuracy of 3DE for RV volumes and function in a clinical adult setting using cardiac magnetic resonance (CMR) as the reference method. We also examined the feasibility of RV visualization with 3DE.

METHODS

62 non-selected patients were examined with 3DE (Sonos 7500 and iE33) and with CMR (1.5T). Endocardial RV contours of 3DE-images were semi-automatically assessed and manually corrected in all patients. End-diastolic (EDV), end-systolic (ESV) volumes, stroke volume (SV) and ejection fraction (EF) were computed.

RESULTS

53 patients (85%) had 3DE-images feasible for examination. Correlation coefficients and Bland Altman biases between 3DE with manual correction and CMR were r = 0.78, -22 ± 27 mL for EDV, r = 0.83, -7 ± 16 mL for ESV, r = 0.60, -12 ± 18 mL for SV and r = 0.60, -2 ± 8% for EF (p < 0.001 for all r-values). Without manual correction r-values were 0.77, 0.77, 0.70 and 0.49 for EDV, ESV, SV and EF, respectively (p < 0.001 for all r-values) and biases were larger for EDV, SV and EF (-32 ± 26 mL, -21 ± 15 mL and - 6 ± 9%, p ≤ 0.01 for all) compared to manual correction.

CONCLUSION

Manual correction of the 3DE semi-automatic RV delineation decreases the bias and is needed for acceptable clinical accuracy. 3DE is highly feasible for visualizing the RV in an adult clinical setting.

Multimodality Imaging in Congenital Heart Disease: an Update

The increasing number of survivors of congenital heart disease (CHD) has been paralleled by advancement of imaging modalities used for the ongoing assessment of these patients. There has been a large body of literature describing new approaches to non-invasive assessment of CHD. We will review new applications of well established as well as novel techniques for the management and understanding of CHD.

Non-Invasive Imaging for Congenital Heart Disease: Recent Innovations in Transthoracic Echocardiography

Transthoracic echocardiography (TTE) is an important tool for diagnosis and follow-up of patients with congenital heart disease (CHD). Appropriate use of TTE can reduce the need for more invasive and complex modalities, such as cardiac catheterization and cardiac magnetic resonance imaging. New echocardiographic techniques have emerged for the assessment of ventricular systolic and diastolic function: Tissue Doppler imaging, tissue tracking, strain and strain rate imaging, vector velocity imaging (VVI), myocardial performance index, myocardial acceleration during isovolumic contraction (IVA), the ratio of systolic to diastolic duration (S/D ratio), and other measurements of systolic right ventricular (RV) function like tricuspid annular plane systolic excursion (TAPSE). These modalities may become valuable indicators of ventricular performance, compliance and disease progression, with the caveat of preload-dependency of the variables measured. In addition, three-dimensional (3D) echocardiography for the assessment of cardiac anatomy, valvular function, device position, ventricular volumes and ejection fraction is integrated into routine clinical care. In this review, we discuss the potential use and limitations of these new echocardiographic techniques in patients with CHD. A particular focus is on the echocardiographic assessment of right ventricular (RV) function by means of tissue Doppler imaging, tissue tracking, and three-dimensional imaging, in conditions associated with increased right ventricular volume or pressure load.

Echocardiographic evaluation of the single right ventricle in congenital heart disease: results of new techniques

Right ventricular (RV) function is increasingly recognized as having prognostic significance in various disease processes. The current gold standard for noninvasive measurement of RV function is cardiac magnetic resonance imaging; however, because of practical considerations, echocardiography remains the most often used modality for evaluating the RV. In the past, because of its complex morphology, echocardiographic assessment of the RV was usually qualitative in nature. Current advances in echocardiographic techniques have been able to overcome some of the previous limitations and thus quantification of RV function is increasingly being performed. In addition, recent echocardiographic guidelines for evaluating the RV have been published to aid in standardizing practice. The evaluation of RV function almost certainly has no greater importance than in the congenital heart population, especially in those patients that have a single RV acting as the systemic ventricle. As this complex population continues to increase in number, accurate and precise evaluation of RV function will be a major issue in determining clinical care.

Recent advances in adult congenital heart disease

As a result of major achievements in pediatric cardiac care, a growing number of patients with congenital heart disease (CHD) are flourishing well into adulthood. This heterogeneous and aging population of patients, many of whom represent the first generation of middle-age survivors, faces unique issues and challenges. As a field, adult CHD has evolved markedly during the past decade on several fronts, including imaging, arrhythmia management, percutaneous interventions, surgical techniques, research, and multidisciplinary care that extends beyond the cardiac realm. This review highlights recent advances across the wide spectrum of key issues encountered by adults with CHD.