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Tomaselli M, Badano LP, Oliverio G, Curti E, Pece C, Springhetti P, Milazzo S, Clement A, Penso M, Gavazzoni M, Hădăreanu DR, Mihaila SB, Pugliesi GM, Delcea C, Muraru D. Clinical Impact of the Volumetric Quantification of Ventricular Secondary Mitral Regurgitation by Three-Dimensional Echocardiography. J Am Soc Echocardiogr 2024; 37:408-419. [PMID: 38244817 DOI: 10.1016/j.echo.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND The assessment of ventricular secondary mitral regurgitation (v-SMR) severity through effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) calculations using the proximal isovelocity surface area (PISA) method and the two-dimensional echocardiography volumetric method (2DEVM) is prone to underestimation. Accordingly, we sought to investigate the accuracy of the three-dimensional echocardiography volumetric method (3DEVM) and its association with outcomes in v-SMR patients. METHODS We included 229 patients (70 ± 13 years, 74% men) with v-SMR. We compared EROA and RegVol calculated by the 3DEVM, 2DEVM, and PISA methods. The end point was a composite of heart failure hospitalization and death for any cause. RESULTS After a mean follow-up of 20 ±11 months, 98 patients (43%) reached the end point. Regurgitant volume and EROA calculated by 3DEVM were larger than those calculated by 2DEVM and PISA. Using receiver operating characteristic curve analysis, both EROA (area under the curve, 0.75; 95% CI, 0.68-0.81; P = .008) and RegVol (AUC, 0.75; 95% CI, 0.68-0.82; P = .02) measured by 3DEVM showed the highest association with the outcome at 2 years compared to PISA and 2DEVM (P < .05 for all). Kaplan-Meier analysis demonstrated a significantly higher rate of events in patients with EROA ≥ 0.3 cm2 (cumulative survival at 2 years: 28% ± 7% vs 32% ± 10% vs 30% ± 11%) and RegVol ≥ 45 mL (cumulative survival at 2 years: 21% ± 7% vs 24% ± 13% vs 22% ± 10%) by 3DEVM compared to those by PISA and 2DEVM, respectively. In Cox multivariable analysis, 3DEVM EROA remained independently associated with the end point (hazard ratio, 1.02, 95% CI, 1.00-1.05; P = .02). The model including EROA by 3DEVM provided significant incremental value to predict the combined end point compared to those using 2DEVM (net reclassification index = 0.51, P = .003; integrated discrimination index = 0.04, P = .014) and PISA (net reclassification index = 0.80, P < .001; integrated discrimination index = 0.06, P < .001). CONCLUSIONS Effective regurgitant orifice area and RegVol calculated by 3DEVM were independently associated with the end point, improving the risk stratification of patients with v-SMR compared to the 2DEVM and PISA methods.
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Affiliation(s)
- Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Giorgio Oliverio
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Emanuele Curti
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Cinzia Pece
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Paolo Springhetti
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Salvatore Milazzo
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
| | - Alexandra Clement
- Internal Medicine Department, "Grigore T. Popa", University of Medicine and Pharmacy, Iasi, Romania
| | - Marco Penso
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Diana R Hădăreanu
- Department of Cardiology, Clinical Emergency County Hospital of Craiova, Craiova, Romania
| | - Sorina Baldea Mihaila
- Cardiology Department, Carol Davila, University of Medicine and Pharmacy, Bucharest, Romania
| | - Giordano M Pugliesi
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Caterina Delcea
- Cardiology Department, Carol Davila, University of Medicine and Pharmacy, Bucharest, Romania
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Passive Leg Raise Stress Echocardiography in Severe Paradoxical Low-Flow, Low-Gradient Aortic Stenosis. J Am Soc Echocardiogr 2022; 35:1123-1132. [PMID: 35863544 DOI: 10.1016/j.echo.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Dobutamine stress echocardiography (DSE) is used to increase the transvalvular flow in patients with low-flow, low-gradient aortic stenosis. Dobutamine fails to increase the stroke volume index (SVI) in a third of patients. In this study, we tested whether passive leg raise (PLR) added to dobutamine could increase SVI and transvalvular flow in patients with severe paradoxical low-flow, low-gradient aortic stenosis. METHODS Forty-five patients with apparent severe low-flow, low-gradient AS based on traditional measurements were included. Twenty-five were categorized as belonging to the "Paradox"-Group (LVEF≥50%), and twenty to the "LowEF"-Group (LVEF<50% or "classical" low-flow, low-gradient AS) for comparison. A four-step stress echocardiographic exam was performed: resting conditions ("Rest"), PLR alone ("PLR"), maximal dobutamine infusion rate ("Dmax"), and combination of Dmax and PLR ("Dmax+PLR"). AVA, (aortic valve area, cm2) SVI (ml/m2) and mean transvalvular flow (ml/s) were calculated using both, velocity-time-integral (VTI) of LV outflow tract and the Simpson-method. Changes compared to "Rest" and between the stress maneuvers were analysed. RESULTS In the "Paradox"-Group, compared to "Rest", LV end-diastolic volume significantly decreased under "Dmax" but was completely restored with "Dmax+PLR" ("Rest", "Dmax", "Dmax+PLR": 61±15 vs 49±18 (p<0.001) vs 61±18 ml (ns)). The smallest SVI-increase in the "Paradox"-Group was observed during "Dmax" ("PLR", "Dmax", "Dmax+PLR": VTI: 38±4 (p<0.001), 36±7 (p=0.019), 41±7 (p<0.001); Simpson: 28±6 (p<0.001), 21±7 (ns), 27±7 ml/m2 (ns)). Compared to "Dmax", "Dmax+PLR" was able to achieve a higher SVI (VTI: 36±7 vs 41±7, p<0.001, Simpson: 21±7 vs 27±7 ml/m2, p<0.001), and transvalvular flow in the Simpson-method only (179±56 vs 219±56 ml/s, p<0.001) as well as, additionally, a higher mean gradient (34±10 vs 39±12 mmHg, p=0.003) and AVA in the Simpson-method (0.64±0.21 vs 0.73±0.21 cm2, p=0.026). In the "LowEF"-Group, only SVI VTI (31±8 vs 35±7 ml/m2, p=0.034) and mean gradient (29±12 vs 34±14 mmHg, p=0.003) were higher in "Dmax+PLR". The proportion of patients with SVI VTI ≥ 35 ml/m2 and an increase of SVI VTI of more than 20% compared to "Rest" was highest in "Dmax+PLR" in both groups. CONCLUSIONS Dobutamine decreases the preload in paradoxical low-flow, low-gradient aortic stenosis. Adding PLR counteracts this effect, resulting in increased SVI and flow (in one method). The combined stress maneuver allowed reclassification of some patients from severe to moderate AS and may therefore be useful in selected cases in this population where the severity is uncertain.
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Tsuda D, Mori S, Izawa Y, Toh H, Suzuki M, Takahashi Y, Toba T, Fujiwara S, Tanaka H, Watanabe Y, Kono AK, Hirata KI. Diversity and determinants of the sigmoid septum and its impact on morphology of the outflow tract as revealed using cardiac computed tomography. Echocardiography 2022; 39:248-259. [PMID: 35038184 DOI: 10.1111/echo.15298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 12/27/2021] [Accepted: 01/01/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The sigmoid septum has been generally evaluated subjectively and qualitatively, without detailed examination of its diversity, impact on the morphology of the left ventricular outflow tract (LVOT), and anatomical background. METHODS We enrolled 100 patients without any background cardiac diseases (67.5 ± 12.8 years old; 43% women) who underwent cardiac computed tomography. Basal septal morphology was evaluated using antero-superior and medial bulging angles (bidirectional angulation of the basal septum relative to the LVOT). The eccentricity index of the LVOT, area narrowing ratio (LVOT/virtual basal ring area), aortic-to-left ventricular axial angle (angulation of the aortic root relative to the left ventricle), and wedged height (non-coronary aortic sinus to inferior epicardium distance) were also quantified. RESULTS The antero-superior bulging, medial bulging, aortic-to-left ventricular axial angles, LVOT eccentricity index, area narrowing ratio, and wedged height were 76° ± 17°, 166° ± 27°, 127° ± 9°, 1.8 ± 0.5, 1.0 ± 0.2, and 41.2 ± 9.1 mm, respectively. Both bulging angles were correlated with each other and contributed to the narrowing and deformation of the LVOT. Angulated aortic root was not correlated with either bidirectional septal bulge or LVOT narrowing. Clockwise rotation of the aortic root rotation was an independent predictor of prominent antero-superior septal bulge. Deeper aortic wedging was a common independent predictor of bidirectional septal bulge. CONCLUSIONS The extent of septal bulge varies in normal hearts. Along with deep aortic wedging, the bidirectional bulge of the basal septum deforms and narrows the LVOT without affecting the virtual basal ring morphology.
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Affiliation(s)
- Daisuke Tsuda
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Yu Izawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Toh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masataka Suzuki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yu Takahashi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takayoshi Toba
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Sei Fujiwara
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshiaki Watanabe
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsushi K Kono
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Qing M, Wang J, Zhao J, Liu Y, Qiu Y, Chen X, Zheng T, Yuan D. Predictive value of elliptical neck parameters and oversizing ratio for type Ia endoleaks after endovascular aneurysm repair. J Vasc Interv Radiol 2021; 33:375-383.e5. [PMID: 34952197 DOI: 10.1016/j.jvir.2021.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/09/2021] [Accepted: 12/13/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To assess the predictive value of elliptical geometric parameters regarding type IA endoleak (T1AEL) after endovascular aneurysm repair (EVAR) and investigate optimal range of oversizing ratio (OSR) in patients with elliptical aneurysmal neck. METHODS In this propensity-score matched case-control study, case patients were those diagnosed with T1AEL, control patients were those who did not have T1AEL after EVAR in the same period from 2012 to 2018. Geometric and oversizing parameters were compared based on both 2D and 3D measurement. Net reclassification improvement (NRI) was used to measure prediction increment of elliptical model (major axis OSR, neck length and severe neck angulation (SNA)) compared to conventional model (OSR 2D, neck length and SNA). RESULTS Nineteen case patients and 111 control patients were included. The median OSR 2D of T1AEL patients were 17% (15%-22%), but the median major axis OSR were only 7% (5%-12%). Among geometric parameters, axis difference had the highest area under the curve (AUC) of 0.74 (95%CI 0.63-0.84) in predicting T1AEL. As for elliptical oversizing parameters, major axis OSR had an AUC of 0.89 (95%CI 0.78-0.97) with a cut-off value of 13%. Elliptical model had higher discriminating ability in T1AEL compared to conventional model (AUC 0.91 vs 0.86, P=0.045), with improved reclassification ability (NRI 27.93%, 95% CI 19.22%-36.64%, P<0.0001). CONCLUSION Elliptical aneurysmal neck, assessed by axis difference, is associated with an increased risk of T1AEL. Calculation of oversizing based on major axis for at least 13% can significantly reduce the risk of T1AEL in patients with elliptical aneurysmal neck.
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Affiliation(s)
- Ming Qing
- Department of Applied Mechanics, Sichuan University, Chengdu 610065, China
| | - Jiarong Wang
- Department of Vascular Surgery, West China Hospital, Sichuan University
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital, Sichuan University
| | - Yang Liu
- Department of Vascular Surgery, West China Hospital, Sichuan University
| | - Yue Qiu
- Department of Applied Mechanics, Sichuan University, Chengdu 610065, China
| | - Xiyang Chen
- Department of Vascular Surgery, West China Hospital, Sichuan University
| | - Tinghui Zheng
- Department of Applied Mechanics, Sichuan University, Chengdu 610065, China.
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, Sichuan University
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Cowie B, Bitcon C, Kluger R. Assessment of the left ventricular outflow tract during cardiac anaesthesia with biplane transoesophageal echocardiography: An observational study. Eur J Anaesthesiol 2021; 38:1253-1261. [PMID: 33720064 DOI: 10.1097/eja.0000000000001499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Assessment of left ventricular outflow tract (LVOT) area is a key component of quantification of aortic stenosis and stroke volume. Current international guidelines recommend measurement of the LVOT diameter with two-dimensional (2D) echocardiography and assume a circle. This may lead to erroneous measures of aortic valve area and adversely affect peri-operative decision making. Multiplane orthogonal (biplane) and three-dimensional (3D) echocardiography imaging may allow more accurate calculation of LVOT, aortic valve area and stroke volume. OBJECTIVE To evaluate the shape and area of the LVOT with conventional 2D diameter, short axis cross-sectional planimetry with biplane imaging and 3D multiplane reconstruction in patients undergoing cardiac surgery with transoesophageal echocardiography (TOE). DESIGN A retrospective observational study. SETTING A single centre university hospital. PATIENTS 119 patients undergoing cardiac surgery with TOE. INTERVENTIONS None. MAIN OUTCOME MEASURES Measurements of the shape and area of the LVOT with standard 2D TOE, short axis biplane imaging and 3D TOE. RESULTS The LVOT shape is elliptical in 70% of patients. The (mean ± SD, [range]) LVOT cross-sectional area with 2D TOE was 4.29 cm2 ± 0.98, [2.46 to 6.70], with biplane was 4.68 cm2 ± 1.03, [2.92 to 7.30] and with 3D was 4.59 cm2 ± 0.99, [2.78 to 7.10]. There was a statistically significant difference (P < 0.001) in the three pairwise comparisons. 2D LVOT area had large bias (7 to 9%) and wider limits of agreement (LOA) with both biplane and 3D LVOT area (-17 to 36%). Biplane and 3D LVOT areas had small bias (1.8%) with relatively narrow LOA (-8 to 11%). CONCLUSIONS 2D diameter measures of the LVOT assuming a circle underestimate LVOT area, underestimate aortic valve area and increase the apparent severity of aortic stenosis. This may lead to inappropriate aortic valve intervention. In a busy operating room environment, we suggest that for the calculation of stroke volume and aortic valve area, LVOT area is measured with biplane imaging. TRIAL REGISTRATION Observational study with no interventions so trial not registered.
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Affiliation(s)
- Brian Cowie
- From the Department of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia (BC, CB, RK)
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Nakabachi M, Iwano H, Murayama M, Nishino H, Yokoyama S, Tsujinaga S, Chiba Y, Ishizaka S, Motoi K, Okada K, Kaga S, Nishida M, Teshima T, Anzai T. Application of the proximal isovelocity surface area method for estimation of the effective orifice area in aortic stenosis. Heart Vessels 2021; 37:638-646. [PMID: 34562142 DOI: 10.1007/s00380-021-01945-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 09/17/2021] [Indexed: 11/27/2022]
Abstract
Although the echocardiographic effective orifice area (EOA) calculated using the continuity equation is widely used for the assessment of severity in aortic stenosis (AS), the existence of high flow velocity at the left ventricular outflow tract (LVOT) potentially causes its overestimation. The proximal isovelocity surface area (PISA) method could be an alternative tool for the estimation of EOA that limits the influence of upstream flow velocity. EOA was calculated using the continuity equation (EOACont) and PISA method (EOAPISA), respectively, in 114 patients with at least moderate AS. The geometric orifice area (GOA) was also measured using the planimetry method in 51 patients who also underwent three-dimensional transesophageal echocardiography. Patients were divided into two groups according to the median LVOT flow velocity. EOAPISA could be obtained in 108 of the 114 patients (95%). Although there was a strong correlation between EOACont and EOAPISA (r = 0.78, P < 0.001), EOACont was statistically significantly larger than EOAPISA (0.86 ± 0.33 vs 0.75 ± 0.29 cm2, P < 0.001). Both EOACont and EOAPISA similarly correlated with GOA (r = 0.70, P < 0.001 and r = 0.77, P < 0.001, respectively). However, a fixed bias, which is hydrodynamically supposed to exist between EOA and GOA, was not observed between EOACont and GOA. In contrast, there was a negative fixed bias between EOAPISA and GOA with smaller EOAPISA than GOA. The difference between EOACont and GOA was significantly greater with a larger EOACont relative to GOA in patients with high LVOT flow velocity than in those without (0.16 ± 0.25 vs - 0.07 ± 0.10 cm2, P < 0.001). In contrast, the difference between EOAPISA and GOA was consistent regardless of the LVOT flow velocity (- 0.07 ± 0.12 vs - 0.07 ± 0.15 cm2, P = 0.936). The PISA method was applied to estimate EOA in patients with AS. EOAPISA could be an alternative parameter for AS severity grading in patients with high LVOT flow velocity in whom EOACont would potentially overestimate the orifice area.
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Affiliation(s)
- Masahiro Nakabachi
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Hiroyuki Iwano
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Michito Murayama
- Diagnostic Center for Sonography, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Hisao Nishino
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Shinobu Yokoyama
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Shingo Tsujinaga
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yasuyuki Chiba
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Ko Motoi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Kazunori Okada
- Faculty of Health Sciences, Hokkaido University, Kita-12, Nishi-5, Kita-ku, Sapporo, 060-0812, Japan
| | - Sanae Kaga
- Faculty of Health Sciences, Hokkaido University, Kita-12, Nishi-5, Kita-ku, Sapporo, 060-0812, Japan
| | - Mutsumi Nishida
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Takanori Teshima
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
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Arain FD, Sohn J. Transesophageal Echocardiographic Assessment of Left Ventricular Outflow Tract Area by 2-Dimensional Diameter, Biplane Planimetry, and 3-Dimensional Planimetry and Its Implications: "Thinking Outside the Circle". A A Pract 2021; 15:e01500. [PMID: 34259649 DOI: 10.1213/xaa.0000000000001500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Faisal D Arain
- From the Department of Anesthesiology and Perioperative Medicine, Division of Cardiac Anesthesia, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Guzzetti E, Annabi MS, Pibarot P, Clavel MA. Multimodality Imaging for Discordant Low-Gradient Aortic Stenosis: Assessing the Valve and the Myocardium. Front Cardiovasc Med 2020; 7:570689. [PMID: 33344514 PMCID: PMC7744378 DOI: 10.3389/fcvm.2020.570689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/12/2020] [Indexed: 01/29/2023] Open
Abstract
Aortic stenosis (AS) is a disease of the valve and the myocardium. A correct assessment of the valve disease severity is key to define the need for aortic valve replacement (AVR), but a better understanding of the myocardial consequences of the increased afterload is paramount to optimize the timing of the intervention. Transthoracic echocardiography remains the cornerstone of AS assessment, as it is universally available, and it allows a comprehensive structural and hemodynamic evaluation of both the aortic valve and the rest of the heart. However, it may not be sufficient as a significant proportion of patients with severe AS presents with discordant grading (i.e., an AVA ≤ 1 cm2 and a mean gradient <40 mmHg) which raises uncertainty about the true severity of AS and the need for AVR. Several imaging modalities (transesophageal or stress echocardiography, computed tomography, cardiovascular magnetic resonance, positron emission tomography) exist that allow a detailed assessment of the stenotic aortic valve and the myocardial remodeling response. This review aims to provide an updated overview of these multimodality imaging techniques and seeks to highlight a practical approach to help clinical decision making in the challenging group of patients with discordant low-gradient AS.
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Affiliation(s)
- Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
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Hunter C, Chen T, Gorgone M, Apruzzese P, Mahmood F, Maslow A. The Left Ventricular Outflow Tract Changes in Size and Shape From Pre- to Post-Cardiopulmonary Bypass: Three-Dimensional Transesophageal Echocardiography. J Cardiothorac Vasc Anesth 2020; 35:786-795. [PMID: 33183933 DOI: 10.1053/j.jvca.2020.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare two-dimensional (2D) and 3D imaging of the left ventricular outflow tract (LVOT) and to evaluate geometric changes pre- to post-cardiopulmonary bypass (CPB). DESIGN Retrospective review of intraoperative transesophageal echocardiographic examinations. SETTING Single academic medical center. PARTICIPANTS The study comprised 69 cardiac surgical patients-27 with aortic valve stenosis (AS) and 42 without AS. INTERVENTIONS Two-dimensional and 3D analysis of the LVOT pre- and post-CPB. MEASUREMENTS AND MAIN RESULTS Pre- and post-CPB 2D assessment of LVOT diameter (2D LVOTd) was compared with 3D analysis of the minor (3D LVOTd-min) and major diameters. LVOT areas (LVOTa) were calculated using LVOTd to yield 2D LVOTa and 3D LVOTa-min. These were compared with LVOTa measured by planimetry (3D LVOTa-plan). An ellipticity ratio (ER) (ER = 3D minor/major axes) was calculated. The 2D LVOTd was larger than the 3D LVOTd-min before (2.12 v 2.02 cm respectively (resp); p < 0.001) and after (1.96 v 1.85 cm resp; p = 0.04) CPB. Compared with pre-CPB, there were significant decreases in the 2D LVOTd (p = 0.003) and the 3D LVOTd-min (p < 0.001) post-CPB. Ellipticity increased after CPB (ER 0.80 v 0.75; p = 0.004), and the 2D LVOTa was larger than the 3D LVOTa-min before CPB (3.60 cm2v 3.28 cm2; p < 0.001) and less so after CPB (3.11 cm2v 2.79 cm2; p = 0.053). Compared with pre-CPB, all LVOTa measurements decreased significantly after CPB (p < 0.001). The 3D LVOTa-plan decreased after CPB by approximately 10% (4.05 cm2v 3.61 cm2; p < 0.001). The 2D LVOTa and 3D LVOTa-min underestimated the 3D LVOTa-plan before and after CPB (p < 0.001) by 11% to 14% and 19% to 23%, respectively. When compared with non-AS patients, patients with AS had a smaller LVOTa pre- and post-CPB (p < 0.05). CONCLUSIONS The LVOT is smaller and more elliptical after CPB. Patients with AS have a smaller LVOT compared with non-AS patients. LVOTa calculated using LVOTd underestimates the 3D LVOTa-plan by as much as 23% depending on patient type and timing of measurement. Accurate assessment of the LVOT requires 3D imaging.
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Affiliation(s)
- Caroline Hunter
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Tzonghuei Chen
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Michelle Gorgone
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | | | - Feroze Mahmood
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI.
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10
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Beneduce A, Capogrosso C, Moroni F, Ancona F, Falasconi G, Pannone L, Stella S, Ingallina G, Melillo F, Ancona MB, Romano Rt V, Palmisano A, Latib A, Colombo A, Montorfano M, Esposito A, Agricola E. Aortic valve area calculation using 3D transesophageal echocardiography: Implications for aortic stenosis severity grading. Echocardiography 2020; 37:2071-2081. [PMID: 33026122 DOI: 10.1111/echo.14883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/10/2020] [Accepted: 09/18/2020] [Indexed: 12/18/2022] Open
Abstract
AIMS Aortic stenosis (AS) grading by 2D-transthoracic echocardiography (2D-TTE) aortic valve area (AVA) calculation is limited by left ventricular outflow tract (LVOT) area underestimation. The combination of Doppler parameters with 3D LVOT area obtained by multidetector computed tomography (MDCT) can improve AS grading, reconciling discordant 2D-TTE findings. This study aimed to systematically evaluate the role of 3D-transesophageal echocardiography (3D-TEE) in AS grading using MDCT as reference standard. METHODS AND RESULTS 288 patients (81 ± 6.3 years, 52.4% female) with symptomatic AS underwent 2D-TTE, 3D-TEE, and MDCT for transcatheter aortic valve implantation. Doppler parameters were combined with 3D LVOT areas measured by manual and semi-automated software 3D-TEE and by MDCT to calculate AVA, reassessing AS severity. Both 3D-TEE modalities demonstrated good correlation with MDCT, with excellent intra-observer and inter-observer variability. Compared to MDCT, 3D-TEE measurements significantly underestimated AVA (PANOVA < .0001), although the difference was clinically acceptable. Compared to 2D-TTE, 3D-TEE manual and semi-automated software reclassified severe AS in 21.9% and 25.2% of cases, respectively (P < .0001), overcame grading parameters discordance in more than 40% of cases in patients with low-gradient AS (P < .0001) and reduced the proportion of low-flow states in nearly 75% of cases when combined to stroke volume index assessment (P < .0001). 3D-TEE imaging modalities showed a reduction in the proportion of patients with low-gradient and pathological AVA as defined by 2D-TTE, and improved AVA and mean pressure gradient agreement with current guidelines cutoff values. CONCLUSION 3D-TEE AVA calculation is a reliable tool for AS grading with excellent reproducibility and good correlation with MDCT measurements.
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Affiliation(s)
- Alessandro Beneduce
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Capogrosso
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Francesco Moroni
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ancona
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Giulio Falasconi
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Luigi Pannone
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Stefano Stella
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Giacomo Ingallina
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Francesco Melillo
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Marco Bruno Ancona
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Romano Rt
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Anna Palmisano
- Cardiovascular Radiology, Radiology Department and Experimental Imaging Center, San Raffaele Scientific Institute, Milan, Italy
| | - Azeem Latib
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy.,Department of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Antonio Colombo
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy
| | - Matteo Montorfano
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Esposito
- Cardiovascular Radiology, Radiology Department and Experimental Imaging Center, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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11
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Pu M. Regarding "Estimation of Stroke Volume and Aortic Valve Area in Patients with Aortic Stenosis: A Comparison of Echocardiography versus Cardiovascular Magnetic Resonance". J Am Soc Echocardiogr 2020; 34:104-106. [PMID: 32919858 DOI: 10.1016/j.echo.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/04/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Min Pu
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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12
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Nguyen QS, Maus T. The C-Sept Space: Another Step Forward in the Superiority of 3-Dimensional Echocardiography-Based Measurements. J Cardiothorac Vasc Anesth 2020; 35:197-198. [PMID: 32962937 DOI: 10.1053/j.jvca.2020.08.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Quoc-Sy Nguyen
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA
| | - Timothy Maus
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA
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13
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Guzzetti E, Capoulade R, Tastet L, Garcia J, Le Ven F, Arsenault M, Bédard E, Larose E, Clavel MA, Pibarot P. Estimation of Stroke Volume and Aortic Valve Area in Patients with Aortic Stenosis: A Comparison of Echocardiography versus Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2020; 33:953-963.e5. [PMID: 32580897 DOI: 10.1016/j.echo.2020.03.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND In aortic stenosis, accurate measurement of left ventricular stroke volume (SV) is essential for the calculation of aortic valve area (AVA) and the assessment of flow status. Current American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines suggest that measurements of left ventricular outflow tract diameter (LVOTd) at different levels (at the annulus vs 5 or 10 mm below) yield similar measures of SV and AVA. The aim of this study was to assess the effect of the location of LVOTd measurement on the accuracy of SV and AVA measured on transthoracic echocardiography (TTE) compared with cardiovascular magnetic resonance (CMR). METHODS One hundred six patients with aortic stenosis underwent both TTE and CMR. SV was estimated on TTE using the continuity equation with LVOTd measurements at four locations: at the annulus and 2, 5, and 10 mm below annulus. SV was also determined on CMR using phase contrast acquired in the aorta (SVCMR-PC), and a hybrid AVACMR-PC was calculated by dividing SVCMR-PC by the transthoracic echocardiographic Doppler aortic velocity-time integral. Comparison between methods was made using Bland-Altman analysis. RESULTS Compared with the referent method of phase-contrast CMR for the estimation of SVCMR-PC and AVACMR-PC (SVCMR-PC 83 ± 16 mL, AVACMR-PC 1.27 ± 0.35 cm2), the best agreement was obtained by measuring LVOTd at the annulus or 2 mm below (P = NS), whereas measuring 5 and 10 mm below the annulus resulted in significant underestimation of SV and AVA by up to 15.9 ± 17.3 mL and 0.24 ± 0.28 cm2, respectively (P < .01 for all). Accuracy for classification of low flow was best at the annulus (86%) and 2 mm below (82%), whereas measuring 5 and 10 mm below the annulus significantly underperformed (69% and 61%, respectively, P < .001). CONCLUSIONS Measuring LVOTd at the annulus or very close to it provides the most accurate measures of SV and AVA, whereas measuring LVOTd 5 or 10 mm below significantly underestimates these parameters and leads to significant overestimation of the severity of aortic stenosis and prevalence of low-flow status.
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Affiliation(s)
- Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Romain Capoulade
- Institut du Thorax, INSERM, CNRS, UNIV Nantes, CHU Nantes, Nantes, France
| | - Lionel Tastet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Julio Garcia
- Department of Cardiac Sciences and Radiology, Stephenson Cardiac Imaging Centre, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute of Alberta, Stephenson Cardiac Imaging Centre, University of Calgary, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | | | - Marie Arsenault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Elisabeth Bédard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Eric Larose
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada.
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14
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Khoche S, Silverton NA, Zimmerman J, Poorsattar S, Kothari P, Haughton R, Maus TM. The Year in Perioperative Echocardiography: Selected Highlights From 2019. J Cardiothorac Vasc Anesth 2020; 34:2036-2046. [PMID: 32482504 DOI: 10.1053/j.jvca.2020.03.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 01/09/2023]
Abstract
This article is the fourth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board, for the opportunity to continue this series. In most cases, these were research articles that were targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles targetted the use of perioperative echocardiography in general.
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Affiliation(s)
- Swapnil Khoche
- Department of Anesthesiology, UCSD Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA
| | - Natalie A Silverton
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Joshua Zimmerman
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Sophia Poorsattar
- Department of Anesthesiology, UCSD Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA
| | - Perin Kothari
- Department of Anesthesiology, UCSD Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA
| | - Robert Haughton
- Department of Anesthesiology, UCSD Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA
| | - Timothy M Maus
- Department of Anesthesiology, UCSD Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA.
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15
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Pu M, Dong Z, Zhou L, Stacey RB, Richardson K, Applegate RJ, Zhao D. Impact of anatomical variations of the left ventricular outflow tract on stroke volume calculation by Doppler echocardiography in aortic stenosis. Echocardiography 2020; 37:815-821. [PMID: 32427382 DOI: 10.1111/echo.14681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Accurate calculation of stroke volume (SV) by Doppler echocardiography is important for the assessment of aortic stenosis (AS), which may be impacted by anatomical variations of left ventricular outflow tract (LVOT). METHODS Patients with AS (n = 64) were studied using computed tomography (CT) and transthoracic echocardiography (TTE). Anatomical variations of LVOT areas were measured at (a) the aortic annulus (Aa ); (b) 5 mm (A5 ); and (c) 10 mm below the annulus (A10 ) by CT. LVOT diameters were also measured by 2D TTE at these three levels for calculation of LVOT areas. Stroke volumes (SV) were calculated using continuity equation. The impacts of anatomical variations of LVOT on SV calculation were evaluated. RESULTS Anatomical LVOT area increased from Aa to A10 (5.0 ± 0.9 cm2 vs 5.8 ± 1.9 cm2 , P < .01). Differences between TTE-calculated LVOT areas and anatomical areas were most significant at A10 due to elongation of mediolateral diameters with variable changes in anteroposterior diameters (5.8 ± 1.9 cm2 vs 3.4 ± 1.1 cm2 , P < .001). Although mean calculated SV by TTE was not significant at different LVOT levels (Aa 69 ± 22 mL, vs A5 66 ± 21 mL, vs A10 66 ± 28 ± 22 mL, P > .05), the most significant variations in individuals were at A10 levels (ΔSV: 8.2 ± 6.4 mL, 12 ± 9%). CONCLUSION Variations of LVOT anatomy in individuals with AS significantly impact the SV calculated by Doppler echocardiography. These features should be taken into account for AS diagnosis and a clinical decision-making for intervention.
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Affiliation(s)
- Min Pu
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Zhifeng Dong
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Li Zhou
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Richard B Stacey
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Karl Richardson
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Robert J Applegate
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - David Zhao
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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16
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Liu S, Churchill J, Hua L, Zeng X, Rhoades V, Namasivayam M, Baliyan V, Ghoshhajra BB, Dong T, Dal-Bianco JP, Passeri JJ, Levine RA, Hung J. Direct Planimetry of Left Ventricular Outflow Tract Area by Simultaneous Biplane Imaging: Challenging the Need for a Circular Assumption of the Left Ventricular Outflow Tract in the Assessment of Aortic Stenosis. J Am Soc Echocardiogr 2020; 33:461-468. [PMID: 32248906 DOI: 10.1016/j.echo.2019.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/20/2019] [Accepted: 12/02/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Evaluation of aortic stenosis (AS) requires calculation of aortic valve area (AVA), which relies on the assumption of a circular-shaped left ventricular outflow tract (LVOT). However, the LVOT is often elliptical, and the circular assumption underestimates the true LVOT area (LVOTA). Biplane imaging using transthoracic echocardiography allows direct planimetry of LVOTA. The aim of this study was to assess the feasibility of obtaining LVOTA using this technique and its impact on the discordance between AVA and gradient criteria in AS grading. METHODS We prospectively studied 134 patients (median age, 80 years; interquartile range, 73-87 years; 39% women) with AS, including 82 (61%) with severe AS and 52 (39%) with mild or moderate AS. LVOTA was traced using direct planimetry (LVOTAbiplane) and compared with LVOTA calculated using the circular assumption (LVOTAcirc). In a subset of patients who underwent cardiac computed tomography, direct planimetry of LVOTA was used as a reference standard. RESULTS LVOTAbiplane was significantly larger than LVOTAcirc (4.20 cm2 [interquartile range, 3.66-4.90 cm2] vs 3.73 cm2 [interquartile range, 3.14-4.15 cm2], P < .001). Among 30 patients who underwent cardiac computed tomography, LVOTAbiplane had better agreement with LVOTA by direct planimetry than LVOTAcirc (mean bias, -0.45 ± 0.63 vs -1.02 ± 0.63 cm2; P < .0001). Of 82 patients with severe AS (AVA ≤ 1 cm2 using LVOTAcirc), 40 (49%) had discordant mean gradient (<40 mm Hg). By using LVOTAbiplane, patients with discordant AVA and mean gradient decreased from 49% to 27% (P = .004), and 29% of patients with severe AS were reclassified with moderate AS, with the highest percentage of reclassification in the group with low-gradient AS with preserved left ventricular ejection fraction. CONCLUSIONS Direct planimetry using biplane imaging avoids the inherent underestimation of LVOTA using the circular assumption. LVOTA obtained by biplane planimetry can lead to better concordance between AVA and mean gradient and classification of AS severity.
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Affiliation(s)
- Shiying Liu
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jessica Churchill
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lanqi Hua
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Xin Zeng
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Valerie Rhoades
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mayooran Namasivayam
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vinit Baliyan
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brian B Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tony Dong
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Jacob P Dal-Bianco
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan J Passeri
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert A Levine
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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17
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Surkova E, Badano LP, Muraru D. Author's Reply. J Am Soc Echocardiogr 2020; 33:518-519. [PMID: 31959527 DOI: 10.1016/j.echo.2019.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Elena Surkova
- University of Padua School of Medicine, Padua, Italy; Royal Brompton Hospital, Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Luigi P Badano
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Denisa Muraru
- University of Padua School of Medicine, Padua, Italy; Istituto Auxologico Italiano, IRCCS, Milan, Italy
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18
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Kebed K, Sun D, Addetia K, Mor-Avi V, Markuzon N, Lang RM. Measurement errors in serial echocardiographic assessments of aortic valve stenosis severity. Int J Cardiovasc Imaging 2019; 36:471-479. [PMID: 31865497 DOI: 10.1007/s10554-019-01745-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 12/03/2019] [Indexed: 12/31/2022]
Abstract
Transthoracic echocardiography (TTE) evaluation of aortic stenosis (AS) is routinely performed using the continuity equation. Inaccurate measurements of the left ventricular (LV) outflow tract (LVOT) diameter are considered the most common source of error in AS grading. We hypothesized that inconsistency in LVOT velocity time integral (VTI) is an under-recognized cause of AS assessment error. We sought to determine which parameters contribute most towards inconsistencies in AS grading by studying the prevalence of different errors in a historic cohort. We identified patients with mild to severe AS with multiple studies from our database from 1994 to 2018 (n = 988 patients, 2859 studies). Errors were defined when: (1) LVOT diameter changed by > 2 mm, (2) LVOT VTI changed by > 15% without change in LV function from the initial TTE, (3) aortic valve (AV) maximum velocity (Vmax), mean pressure gradient (ΔP) or AV VTI decreased by > 15% without change in LV function from prior study. The most common error was the LVOT VTI measurement with 22% prevalence. LVOT diameter, AV VTI, AV Vmax and AV ΔP measurement caused errors in < 7% studies. Patients with normal LV function and more severe AS were more likely to have LVOT VTI errors (P < 0.05). LVOT VTI is a frequent, under-recognized source of error in assessing AS. Greater attention should be directed toward the proper positioning of the pulsed Doppler sample volume, particularly in patients with higher grades of AS and normal systolic function, to ensure accurate and reproducible assessment of AS.
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Affiliation(s)
- Kalie Kebed
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Deyu Sun
- Philips Healthcare, Andover, MA, USA
| | - Karima Addetia
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Victor Mor-Avi
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | | | - Roberto M Lang
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA.
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19
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Lang RM, Addetia K, Narang A, Mor-Avi V. 3-Dimensional Echocardiography: Latest Developments and Future Directions. JACC Cardiovasc Imaging 2019; 11:1854-1878. [PMID: 30522687 DOI: 10.1016/j.jcmg.2018.06.024] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/31/2018] [Accepted: 06/22/2018] [Indexed: 01/03/2023]
Abstract
The ongoing refinements in 3-dimensional (3D) echocardiography technology continue to expand the scope of this imaging modality in clinical cardiology by offering new features that stem from the ability to image the heart in its complete dimensionality. Over the years, countless publications have described these benefits and tested new frontiers where 3D echocardiographic imaging seemed to offer promising ways to improve patients' care. These include improved techniques for chamber quantification and novel ways to visualize cardiac valves, including 3D printing, virtual reality, and holography. The aims of this review article are to focus on the most important developments in the field in the recent years, discuss the current utility of 3D echocardiography, and highlight several interesting future directions.
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Affiliation(s)
- Roberto M Lang
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.
| | - Karima Addetia
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Akhil Narang
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Victor Mor-Avi
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
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20
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Ahmed AA, Matyal R, Mahmood F, Feng R, Berry GB, Gilleland S, Khabbaz KR. Impact of left ventricular outflow tract flow acceleration on aortic valve area calculation in patients with aortic stenosis. Echo Res Pract 2019. [PMID: 31682093 PMCID: PMC6826166 DOI: 10.1530/erp-19-0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Objective Due to its circular shape, the area of the proximal left ventricular tract (PLVOT) adjacent to aortic valve can be derived from a single linear diameter. This is also the location of flow acceleration (FA) during systole, and pulse wave Doppler (PWD) sample volume in the PLVOT can lead to overestimation of velocity (V1) and the aortic valve area (AVA). Therefore, it is recommended to derive V1 from a region of laminar flow in the elliptical shaped distal LVOT (away from the annulus). Besides being inconsistent with the assumptions of continuity equation (CE), spatial difference in the location of flow and area measurement can result in inaccurate AVA calculation. We evaluated the impact of FA in the PLVOT on the accuracy of AVA by continuity equation (CE) in patients with aortic stenosis (AS). Methods CE-based AVA calculations were performed in patients with AS once with PWD-derived velocity time integral (VTI) in the distal LVOT (VTILVOT) and then in the PLVOT to obtain a FA velocity profile (FA-VTILVOT) for each patient. A paired sample t-test (P < 0.05) was conducted to compare the impact of FA-VTILVOT and VTILVOT on the calculation of AVA. Result There were 46 patients in the study. There was a 30.3% increase in the peak FA-VTILVOT as compared to the peak VTILVOT and AVA obtained by FA-VTILVOT was 29.1% higher than obtained by VTILVOT. Conclusion Accuracy of AVA can be significantly impacted by FA in the PLVOT. LVOT area should be measured with 3D imaging in the distal LVOT.
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Affiliation(s)
- Andaleeb A Ahmed
- Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Robina Matyal
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Feroze Mahmood
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ruby Feng
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Graham B Berry
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Scott Gilleland
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Kamal R Khabbaz
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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21
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Low Gradient Aortic Stenosis: Role of Echocardiography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9518-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Contemporary Imaging of Aortic Stenosis. Heart Lung Circ 2019; 28:1310-1319. [PMID: 31266725 DOI: 10.1016/j.hlc.2019.05.177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/29/2019] [Accepted: 05/17/2019] [Indexed: 12/26/2022]
Abstract
Degenerative or fibrocalcific aortic stenosis (AS) is now the most common native valvular heart disease assessed and managed by cardiologists in developed countries. Transthoracic echocardiography remains the quintessential imaging modality for the non-invasive characterisation of AS due to its widespread availability, superior assessment of flow haemodynamics, and a wealth of prognostic data accumulated over decades of clinical utility and research applications. With expanding technologies and increasing availability of treatment options such as transcatheter aortic valve replacements, in addition to conventional surgical approaches, accurate and precise assessment of AS severity is critical to guide decisions for and timing of interventions. Despite clear guideline echocardiographic parameters demarcating severe AS, discrepancies between transvalvular velocities, gradients, and calculated valve areas are commonly encountered in clinical practice. This often results in diagnostically challenging cases with significant implications. Greater emphasis must be placed on the quality of performance of basic two dimensional (2D) and Doppler measurements (attention to detail ensuring accuracy and precision), incorporating ancillary haemodynamic surrogates, understanding study- or patient-specific confounders, and recognising the role and limitations of stress echocardiography in the subgroups of low-flow low-gradient AS. A multiparametric approach, along with the incorporation of multimodality imaging (cardiac computed tomography or magnetic resonance imaging) in certain scenarios, is now mandatory to avoid incorrect misclassification of severe AS. This is essential to ensure appropriate selection of patients who would most benefit from interventions on the aortic valve to relieve the afterload mismatch resulting from truly severe valvular stenosis.
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23
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Lavine SJ, Obeng GB. The relation of left ventricular geometry to left ventricular outflow tract shape and stroke volume index calculations. Echocardiography 2019; 36:905-915. [DOI: 10.1111/echo.14323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 02/22/2019] [Accepted: 03/06/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Steven J. Lavine
- Quillen College of MedicineEast Tennessee State University Johnson City Tennessee
- Washington University of St. Louis St. Louis Missouri
| | - George B. Obeng
- Quillen College of MedicineEast Tennessee State University Johnson City Tennessee
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24
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González-Mansilla A, Martinez-Legazpi P, Prieto A, Gomá E, Haurigot P, Pérez Del Villar C, Cuadrado V, Delgado-Montero A, Prieto R, Mombiela T, Pérez-David E, Rodríguez González E, Benito Y, Yotti R, Pérez-Vallina M, Fernández-Avilés F, Bermejo J. Valve area and the risk of overestimating aortic stenosis. Heart 2019; 105:911-919. [PMID: 30772823 PMCID: PMC6582719 DOI: 10.1136/heartjnl-2018-314482] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/15/2019] [Accepted: 01/21/2019] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To obtain reference values of aortic valve area (AVA) in a large population and to infer the risk of overestimating aortic stenosis (AS) when focusing on flow-corrected indices of severity. METHODS We prospectively measured indices of AS in all consecutive echocardiograms performed in a large referral cardiac imaging laboratory for 1 year. We specifically analysed the distribution of AVA, indexed AVA and velocity ratio (Vratio) in patients with and without AS, the latter defined as the coexistence of valvular outflow obstruction (Vmax ≥2.5 m/s) and morphological findings of valve degeneration. RESULTS 16 156 echocardiograms were analysed, 14 669 of which did not show valvular obstruction (peak jet velocity <2.5 m/s). In the latter group, AVA was 2.6±0.7 cm2 in 8190 studies with normal valves and 2.3±0.7 cm2 in 6479 studies with aortic sclerosis (AScl). There was a relatively wide overlap between values of AVA, indexed AVA and velocity ratio between studies of patients with AScl and AS. Values of AVA ≤1.0 cm2 were found in 0.5% of studies with normal valves and 1.8% of studies with AScl. These proportions were 3.1% and 9.3% for AVA ≤1.5 cm2, respectively. Vratio ≤0.25 were found in 0.1% of patients without obstruction. Risk factors for a small AVA in patients without obstruction were AScl, female sex, small body surface area, low ejection fraction and mitral regurgitation. CONCLUSIONS Normal values of continuity-equation derived AVA are smaller than previously considered. AVA values below cutoffs of moderate or severe AS can be found in patients without the disease. Flow-corrected indices may overestimate AS in patients with low gradients, particularly in the presence of well-identified risk factors.
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Affiliation(s)
- Ana González-Mansilla
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Pablo Martinez-Legazpi
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Andrea Prieto
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Elena Gomá
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Pilar Haurigot
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Candelas Pérez Del Villar
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Victor Cuadrado
- Information and Communications Technology Department, Hospital General Universitario Gregorio Maranon, Madrid, Spain
| | - Antonia Delgado-Montero
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Raquel Prieto
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Teresa Mombiela
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Esther Pérez-David
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Elena Rodríguez González
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Yolanda Benito
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Raquel Yotti
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Manuel Pérez-Vallina
- Information and Communications Technology Department, Hospital General Universitario Gregorio Maranon, Madrid, Spain
| | - Francisco Fernández-Avilés
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
| | - Javier Bermejo
- Department of Cardiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid.,Instituto de Investigación Sanitaria Gregorio Marañón.,CIBERCV
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25
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How Do We Reconcile Echocardiography, Computed Tomography, and Hybrid Imaging in Assessing Discordant Grading of Aortic Stenosis Severity? JACC Cardiovasc Imaging 2019; 12:267-282. [DOI: 10.1016/j.jcmg.2018.11.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 12/18/2022]
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26
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Queirós S, Morais P, Fehske W, Papachristidis A, Voigt JU, Fonseca JC, D'hooge J, Vilaça JL. Assessment of aortic valve tract dynamics using automatic tracking of 3D transesophageal echocardiographic images. Int J Cardiovasc Imaging 2019; 35:881-895. [PMID: 30701439 DOI: 10.1007/s10554-019-01532-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/08/2019] [Indexed: 12/13/2022]
Abstract
The assessment of aortic valve (AV) morphology is paramount for planning transcatheter AV implantation (TAVI). Nowadays, pre-TAVI sizing is routinely performed at one cardiac phase only, usually at mid-systole. Nonetheless, the AV is a dynamic structure that undergoes changes in size and shape throughout the cardiac cycle, which may be relevant for prosthesis selection. Thus, the aim of this study was to present and evaluate a novel software tool enabling the automatic sizing of the AV dynamically in three-dimensional (3D) transesophageal echocardiography (TEE) images. Forty-two patients who underwent preoperative 3D-TEE images were retrospectively analyzed using the software. Dynamic measurements were automatically extracted at four levels, including the aortic annulus. These measures were used to assess the software's ability to accurately and reproducibly quantify the conformational changes of the aortic root and were validated against automated sizing measurements independently extracted at distinct time points. The software extracted physiological dynamic measurements in less than 2 min, that were shown to be accurate (error 2.2 ± 26.3 mm2 and 0.0 ± 2.53 mm for annular area and perimeter, respectively) and highly reproducible (0.85 ± 6.18 and 0.65 ± 7.90 mm2 of intra- and interobserver variability, respectively, in annular area). Using the maximum or minimum measured values rather than mid-systolic ones for device sizing resulted in a potential change of recommended size in 7% and 60% of the cases, respectively. The presented software tool allows a fast, automatic and reproducible dynamic assessment of the AV morphology from 3D-TEE images, with the extracted measures influencing the device selection depending on the cardiac moment used to perform its sizing. This novel tool may thus ease and potentially increase the observer's confidence during prosthesis' size selection at the preoperative TAVI planning.
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Affiliation(s)
- Sandro Queirós
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Campus de Gualtar, 4710-057, Braga, Portugal. .,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal. .,Lab on Cardiovascular Imaging and Dynamics, KU Leuven, Leuven, Belgium. .,Algoritmi Center, School of Engineering, University of Minho, Guimarães, Portugal.
| | - Pedro Morais
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Campus de Gualtar, 4710-057, Braga, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal.,Lab on Cardiovascular Imaging and Dynamics, KU Leuven, Leuven, Belgium.,2Ai-Polytechnic Institute of Cávado and Ave, Barcelos, Portugal
| | - Wolfgang Fehske
- Department of Cardiology, St Vinzenz-Hospital, Cologne, Germany
| | | | - Jens-Uwe Voigt
- Department of Cardiology, University Hospital Leuven, Leuven, Belgium
| | - Jaime C Fonseca
- Algoritmi Center, School of Engineering, University of Minho, Guimarães, Portugal
| | - Jan D'hooge
- Lab on Cardiovascular Imaging and Dynamics, KU Leuven, Leuven, Belgium
| | - João L Vilaça
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Campus de Gualtar, 4710-057, Braga, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal.,2Ai-Polytechnic Institute of Cávado and Ave, Barcelos, Portugal
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27
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Affiliation(s)
- Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
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28
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Badiani S, Waddingham P, Lloyd G, Bhattacharyya S. Stress echocardiography in valvular heart disease. Expert Rev Cardiovasc Ther 2018; 16:795-804. [PMID: 30286667 DOI: 10.1080/14779072.2018.1532791] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The management of patients with heart valve disease can be complex. Patients may have symptoms disproportionate to the severity or the severity may be unclear. In addition, the optimal timing of intervention in patients with severe disease may be controversial. Areas covered: This article examines the role of stress echocardiography for assessment of patients with low-flow, low-gradient aortic stenosis, asymptomatic severe valve disease and patients where symptoms are discordant to the resting severity of valve disease. Expert commentary: Stress echocardiography helps clinicians determine the true severity of valve disease and may identify the cause of symptoms in patients with only mild/moderate disease. The data provided by stress echocardiography will help determine the appropriate management strategy and the correct timing of intervention.
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Affiliation(s)
- Sveeta Badiani
- a Echocardiography Laboratory , Barts Heart Centre, St Bartholomew's Hospital , London , UK.,b Heart Valve Clinic, Barts Heart Centre , St Bartholomew's Hospital , London , UK
| | - Peter Waddingham
- a Echocardiography Laboratory , Barts Heart Centre, St Bartholomew's Hospital , London , UK.,b Heart Valve Clinic, Barts Heart Centre , St Bartholomew's Hospital , London , UK
| | - Guy Lloyd
- a Echocardiography Laboratory , Barts Heart Centre, St Bartholomew's Hospital , London , UK.,b Heart Valve Clinic, Barts Heart Centre , St Bartholomew's Hospital , London , UK.,c William Harvey Research Institute, Queen Mary & Westfield , University of London , London , UK.,d Institute of Cardiovascular Sciences, UCL , London , UK
| | - Sanjeev Bhattacharyya
- a Echocardiography Laboratory , Barts Heart Centre, St Bartholomew's Hospital , London , UK.,b Heart Valve Clinic, Barts Heart Centre , St Bartholomew's Hospital , London , UK.,c William Harvey Research Institute, Queen Mary & Westfield , University of London , London , UK.,d Institute of Cardiovascular Sciences, UCL , London , UK
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29
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Nabeshima Y, Nagata Y, Negishi K, Seo Y, Ishizu T, Sato K, Aonuma K, Koto D, Izumo M, Akashi YJ, Yamashita E, Oshima S, Otsuji Y, Takeuchi M. Direct Comparison of Severity Grading Assessed by Two-Dimensional, Three-Dimensional, and Doppler Echocardiography for Predicting Prognosis in Asymptomatic Aortic Stenosis. J Am Soc Echocardiogr 2018; 31:1080-1090.e3. [DOI: 10.1016/j.echo.2018.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Indexed: 10/28/2022]
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30
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Fernando RJ, Garner C, Slaughter TF. A Review of the 2017 American Society of Echocardiography Guidelines for Evaluation of Aortic Stenosis: Considerations for Perioperative Echocardiography. J Cardiothorac Vasc Anesth 2018; 32:1800-1814. [PMID: 29735221 DOI: 10.1053/j.jvca.2018.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC.
| | - Chandrika Garner
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - Thomas F Slaughter
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
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31
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Workup and Management of Patients With Paradoxical Low-Flow, Low-Gradient Aortic Stenosis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:49. [DOI: 10.1007/s11936-018-0642-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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32
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Lahori A, Frogel J, Augoustides JG, Patel PA, Vernick WJ, Gutsche JT, Feinman JW, Patel S, Munroe R, MacKay EJ, Weiss SJ, Dwarakanath S, Sheu RD. Aortic Valve Prosthesis-Patient Mismatch in a Patient Undergoing Redo Mitral Valve Replacement for Infective Endocarditis. J Cardiothorac Vasc Anesth 2018; 32:2802-2809. [PMID: 29555388 DOI: 10.1053/j.jvca.2018.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Anna Lahori
- Cardiovascular and Thoracic Section, Department of Anesthesiology, Sheba Medical Center, Tel HaShomer, Israel
| | - Jonathan Frogel
- Cardiovascular and Thoracic Section, Department of Anesthesiology, Sheba Medical Center, Tel HaShomer, Israel
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William J Vernick
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jared W Feinman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ray Munroe
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Emily J MacKay
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sanjay Dwarakanath
- Department of Anesthesiology, School of Medicine, University of Kentucky, Lexington, KY
| | - Richard D Sheu
- Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, WA
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Abstract
PURPOSE OF REVIEW Three-dimensional (3D) echocardiography (3DE) and 4-dimensional echocardiography (4DE), also known as real-time (RT) 3DE (RT3DE), are rapidly emerging technologies which have made significant impact in the clinical arena over the years. This review will discuss the recent applications of 3DE in diagnosing and treating different types of cardiovascular disease. RECENT FINDINGS Recent studies using 3DE expanded on prior findings and introduced additional applications to different cardiac conditions. Some studies have used 3D parameters to prognosticate long-term outcomes. Numerous innovative software designs including fully automated algorithms have been introduced to better evaluate valvular heart disease and cardiac function. SUMMARY With further evolution of 3DE technologies, this imaging modality will emerge as a powerful tool and likely become the imaging modality of choice in the diagnosis and management of various cardiac disorders.
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Affiliation(s)
- Susan H. Kwon
- Research Department, 100 Port Washington Blvd, Roslyn, NY 11576 USA
| | - Aasha S. Gopal
- Research Department, 100 Port Washington Blvd, Roslyn, NY 11576 USA
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34
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Hahn RT, Pibarot P. Accurate Measurement of Left Ventricular Outflow Tract Diameter: Comment on the Updated Recommendations for the Echocardiographic Assessment of Aortic Valve Stenosis. J Am Soc Echocardiogr 2017; 30:1038-1041. [DOI: 10.1016/j.echo.2017.06.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Indexed: 11/26/2022]
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35
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Babu S, Sreedhar R, Gadhinglajkar SV, Dash PK, Sukesan S, Pillai V, Panicker VT, Shriram LP, Aggarwal N. Intraoperative Transesophageal and Postoperative Transthoracic Echocardiographic Evaluation of a Mechanical Heart Valve Prosthesis Implanted at Aortic Position. J Cardiothorac Vasc Anesth 2017; 32:782-789. [PMID: 29217244 DOI: 10.1053/j.jvca.2017.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aims of this study were to evaluate the intraoperative transesophageal echocardiographic (iTEE) characteristics and Doppler flow profile of aortic Chitra heart valve prosthesis (CHVP) under stable hemodynamic and loading conditions, and to compare and correlate the iTEE data with the postoperative transthoracic echocardiography (TTE) data obtained at 48 hours (TTE1) and 3 months (TTE2) after the surgery. DESIGN Prospective, observational study. SETTING University-level tertiary referral hospital. PARTICIPANTS Forty patients between 18 years and 65 years of age undergoing elective aortic valve replacement (AVR) using CHVP during the period January 2015 to August 2016. INTERVENTIONS After obtaining permission from institutional ethics committee, 40 patients undergoing elective AVR were studied prospectively. The iTEE examination was performed in the pre-cardiopulmonary bypass (CPB) and post-CPB period in all the study subjects. CHVP was subjected to iTEE two-dimensional (2D) echo, color Doppler, and spectral Doppler evaluation under stable hemodynamic and loading condition in the post-CPB period after the administration of protamine. The CHVP were re-evaluated using TTE in all the patients 48 hours after the surgery (TTE1) and 3 months after the surgery (TTE2). The iTEE and postoperative TTE Doppler values were compared and correlated. MEASUREMENTS AND MAIN RESULTS The CHVP could be imaged adequately and interrogated with Doppler in all the patients. None of the patients had restriction of occluder mobility or unstable seating of the valve. The intraoperative flow dependent (peak velocity [PV] and mean pressure gradient [MPG]) and less flow dependent (Doppler velocity index, acceleration time, acceleration time/ejection time, effective orifice area [EOA] and indexed EOA) Doppler parameters of CHVP were measured as per the American Society of Echocardiography recommendations. The PV and MPG of CHVP measured by iTEE showed no statistical difference (p > 0.05) and were in limits of agreement when compared with TTE1 and TTE2 data. CONCLUSION The iTEE features of CHVP were found compliant with the criteria set by the ASE defining normal functioning of an aortic valve prosthesis. The iTEE Doppler parameters obtained under stable loading conditions strongly predicted the postoperative values of Doppler parameters on TTE examination. The iTEE Doppler values can be used as the reference values for the postoperative follow up studies.
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Affiliation(s)
- Saravana Babu
- Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Rupa Sreedhar
- Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
| | - Shrinivas V Gadhinglajkar
- Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Prasanta Kumar Dash
- Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Subin Sukesan
- Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Vivek Pillai
- Department of Cardiothoracic and Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Varghese T Panicker
- Department of Cardiothoracic and Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Lovhale Pravin Shriram
- Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Neelam Aggarwal
- Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
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