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Cantinotti M, Di Salvo G, Voges I, Raimondi F, Greil G, Ortiz Garrido A, Bharucha T, Grotenhuis HB, Köstenberger M, Bonnello B, Miller O, McMahon CJ. Standardization in paediatric echocardiographic reporting and critical interpretation of measurements, functional parameters, and prediction scores: a clinical consensus statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology and the Association for European Paediatric and Congenital Cardiology. Eur Heart J Cardiovasc Imaging 2024; 25:1029-1050. [PMID: 38833586 DOI: 10.1093/ehjci/jeae147] [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: 05/22/2024] [Accepted: 05/23/2024] [Indexed: 06/06/2024] Open
Abstract
This document has been developed to provide a guide for basic and advanced reporting in paediatric echocardiography. Furthermore, it aims to help clinicians in the interpretation of echocardiographic measurements and functional data for estimating the severity of disease in different paediatric age groups. The following topics will be reviewed and discussed in the present document: (i) the general principle in constructing a paediatric echocardiographic report, (ii) the basic elements to be included, and (iii) the potential and limitation of currently employed tools used for disease severity quantification during paediatric reporting. A guide for the interpretation of Z-scores will be provided. Use and interpretation of parameters employed for quantification of ventricular systolic function will be discussed. Difficulties in the adoption of adult parameters for the study of diastolic function and valve defects at different ages and pressure and loading conditions will be outlined, with pitfalls for the assessment listed. A guide for careful use of prediction scores for complex congenital heart disease will be provided. Examples of basic and advanced (disease-specific) formats for reporting in paediatric echocardiography will be provided. This document should serve as a comprehensive guide to (i) structure a comprehensive paediatric echocardiographic report; (ii) identify the basic morphological details, measures, and functional parameters to be included during echocardiographic reporting; and (iii) correctly interpret measurements and functional data for estimating disease severity.
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Affiliation(s)
- Massimiliano Cantinotti
- Department of Pediatric Cardiology and Congenital Heart Disease, National Research Council-Tuscany Region G. Monasterio Foundation (FTGM), Massa, Pisa 54100, Italy
| | - Giovanni Di Salvo
- Paediatric Cardiology and Congenital Heart Disease, Woman and Children's Health Department, University of Padua; Experimental Cardiology, Paediatric Research Institute (IRP), Padua, Italy
| | - Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | - Gerald Greil
- Division Pediatric Cardiology, UT Southwestern, Dallas, TX, USA
| | | | - Tara Bharucha
- Department of Paediatric Cardiology, University Hospital Southampton, Southampton, UK
| | - Heynric B Grotenhuis
- Department Pediatric Cardiology, Wilhelmina Children's Hospital/UMCU, Utrecht, The Netherlands
| | - Martin Köstenberger
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of Gratz, Gratz, Austria
| | | | - Owen Miller
- Department Pediatric Cardiology, Evelina London Children's Hospital, London, UK
| | - Colin J McMahon
- Department Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, Dublin, Ireland
- Maastricht School of Health Professions Education, Maastricht, The Netherlands
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Ghorbannia A, Spearman AD, Sawalhi S, Woods RK, Maadooliat M, LaDisa JF. A Novel Diastolic Doppler Index Less Affected by Aortic Arch Anomalies Co-existing with Coarctation. Pediatr Cardiol 2024:10.1007/s00246-024-03569-8. [PMID: 38995425 DOI: 10.1007/s00246-024-03569-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/24/2024] [Indexed: 07/13/2024]
Abstract
Severity assessment for coarctation of the aorta (CoA) is challenging due to concomitant morphological anomalies (complex CoA) and inaccurate Doppler-based indices. Promising diagnostic performance has been reported for the continuous flow pressure gradient (CFPG), but it has not been studied in complex CoA. Our objective was to characterize the effect of complex CoA and associated hemodynamics on CFPG in a clinical cohort. Retrospective analysis identified discrete juxtaductal (n = 25) and complex CoA (n = 43; transverse arch and/or isthmus hypoplasia) patients with arm-leg systolic blood pressure gradients (BPG) within 24 h of echocardiography for comparison to BPG by conventional Doppler indices (simplified Bernoulli equation and modified forms correcting for proximal kinetic energy and/or recovered pressure). Results were interpreted using the current CoA guideline (BPG ≥ 20 mmHg) to compare diagnostic performance indicators including receiver operating characteristic curves, sensitivity, specificity, and diagnostic accuracy, among others. Echocardiography Z-scored aortic diameters were applied with computational simulations from a preclinical CoA model to understand aspects of the CFPG driving performance differences. Diagnostic performance was substantially reduced from discrete to complex CoA for conventional Doppler indices calculated from patient data, and by hypoplasia and/or long segment stenosis in simulations. In contrast, diagnostic indicators for the CFPG only modestly dropped for complex vs discrete CoA. Simulations revealed differences in performance due to inclusion of the Doppler velocity index and diastolic pressure half-time in the CFPG calculation. CFPG is less affected by aortic arch anomalies co-existing with CoA when compared to conventional Doppler indices.
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Affiliation(s)
- Arash Ghorbannia
- Department of Biomedical Engineering, Marquette University and the Medical College of Wisconsin, Milwaukee, WI, USA.
- Department of Pediatrics - Division of Cardiology, Herma Heart Institute, Children's Wisconsin and the Medical College of Wisconsin, 8701 W Watertown Plank Rd., Milwaukee, WI, 53226, USA.
| | - Andrew D Spearman
- Department of Pediatrics - Division of Cardiology, Herma Heart Institute, Children's Wisconsin and the Medical College of Wisconsin, 8701 W Watertown Plank Rd., Milwaukee, WI, 53226, USA
| | - Shahd Sawalhi
- Department of Biomedical Engineering, Marquette University and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ronald K Woods
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, USA
| | - Mehdi Maadooliat
- Department of Mathematical and Statistical Sciences, Marquette University, Milwaukee, WI, USA
| | - John F LaDisa
- Department of Biomedical Engineering, Marquette University and the Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics - Division of Cardiology, Herma Heart Institute, Children's Wisconsin and the Medical College of Wisconsin, 8701 W Watertown Plank Rd., Milwaukee, WI, 53226, USA
- Departments of Physiology, and Medicine - Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Ghorbannia A, Spearman AD, Sawalhi S, Woods RK, Maadooliat M, LaDisa JF. Consistency of the continuous flow pressure gradient despite aortic arch anomalies co-existing with coarctation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.30.23297763. [PMID: 37961134 PMCID: PMC10635219 DOI: 10.1101/2023.10.30.23297763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Aims Severity assessment for coarctation of the aorta (CoA) is challenging due to concomitant morphological anomalies (complex CoA) and inaccurate Doppler-based indices. Promising diagnostic performance has been reported for the continuous flow pressure gradient (CFPG), but it has not been studied in complex CoA. Our objective was to characterize the effect of complex CoA and associated hemodynamics on CFPG in a clinical cohort. Methods and Results Retrospective analysis identified discrete juxtaductal (n=25) and complex CoA (n=43; transverse arch and/or isthmus hypoplasia) patients with arm-leg systolic blood pressure gradients (BPG) within 24 hours of echocardiography for comparison to BPG by conventional Doppler indices (simplified Bernoulli equation and modified forms correcting for proximal kinetic energy and/or recovered pressure). Results were interpreted using the current CoA guideline (BPG ≥20 mmHg) to compare diagnostic performance indicators including receiver operating characteristic curves, sensitivity, specificity, and diagnostic accuracy, among others. Echocardiography Z-scored aortic diameters were applied with computational stimulations from a preclinical CoA model to understand aspects of the CFPG driving performance differences.Diagnostic performance was substantially reduced from discrete to complex CoA for conventional Doppler indices calculated from patient data, and by hypoplasia and/or long segment stenosis in simulations. In contrast, diagnostic indicators for the CFPG only modestly dropped for complex vs discrete CoA. Simulations revealed differences in performance due to inclusion of the Doppler velocity index and diastolic pressure half-time in the CFPG calculation. Conclusion CFPG is less affected by aortic arch anomalies co-existing with CoA when compared to conventional Doppler indices.
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Affiliation(s)
- Arash Ghorbannia
- Department of Biomedical Engineering, Marquette University and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pediatrics - Division of Cardiology, Herma Heart Institute, Children’s Wisconsin and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Andrew D. Spearman
- Department of Pediatrics - Division of Cardiology, Herma Heart Institute, Children’s Wisconsin and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Shahd Sawalhi
- Department of Biomedical Engineering, Marquette University and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ronald K. Woods
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children’s Wisconsin, Milwaukee, Wisconsin, USA
| | - Mehdi Maadooliat
- Department of Mathematical and Statistical Sciences, Marquette University, Milwaukee, Wisconsin, USA
| | - John F. LaDisa
- Department of Biomedical Engineering, Marquette University and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pediatrics - Division of Cardiology, Herma Heart Institute, Children’s Wisconsin and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Departments of Physiology, and Medicine - Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Marquetand C, Aboud A, Hasfurther M, Göttmann J, Bahlmann E, Busch-Tilge C, Tilge P, Ivannikova M, Ensminger S, Stierle U, Reil GH, Reil JC. New insights into the hemodynamics of pulmonary homograft patients under stress echocardiography: The contribution of pressure recovery. Echocardiography 2023; 40:1058-1067. [PMID: 37638407 DOI: 10.1111/echo.15675] [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: 03/30/2023] [Revised: 07/13/2023] [Accepted: 08/10/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND The importance of pulmonary artery pressure recovery (PR) in patients with Ross procedures in whom a homograft substitutes the resected pulmonary valve, is unknown. The aim of the study was to evaluate the occurrence and extent of PR in the pulmonary artery in 65 asymptomatic patients with pulmonary homograft after Ross surgery during rest and exercise. METHODS Stress echocardiography was performed in 65 pulmonary homograft patients and 31 controls with native pulmonary valves up to 75 W. Right ventricular systolic pressure (RVSP), transvalvular flow, mean pressure gradient (Pmean ), valve resistance, and RV stroke work were determined in the exercise (max. 75 W) and recovery phases in increments of 25 W each. RESULTS Pulmonary homografts demonstrated significantly elevated Pmean compared to controls at all stages. When considering pressure recovery (absolute and relative PR at rest 3.8 ± 1.8 mm Hg, 42.6 ± 7.2%, respectively) and transvalvular energy loss (EL; at rest 4.5 ± 4.3 mm Hg) the homograft hemodynamics reached the level of controls. In a subgroup of patients with tricuspid regurgitation, resting RVSP was the same in homograft patients and controls (21.3 ± 6.1 vs. 20.4 ± 6.3, p = .62), despite significant different Pmax values. CONCLUSIONS Ross patients with pulmonary homograft showed systematically increased hemodynamic parameters compared to normal pulmonary valves. These differences were abolished when PR was considered for homograft patients. The equality of RVSP values at rest in both groups shows non-invasive evidence for PR in the pulmonary system after homograft implantation. Therefore, PR appears to be an important measure in calculating the actual hemodynamics in pulmonary homografts.
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Affiliation(s)
- Christoph Marquetand
- Klinik für Innere Medizin II, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Anas Aboud
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Maria Hasfurther
- Klinik für Innere Medizin II, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jan Göttmann
- Department of Analysis and Modeling of Complex Data, Johannes Gutenberg University, Mainz, Germany
| | - Edda Bahlmann
- Department of Cardiology, Asklepios Kliniken St. Georg, Hamburg, Germany
| | - Claudia Busch-Tilge
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Patric Tilge
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Maria Ivannikova
- Klinik für allgemeine und interventionelle Kardiologie, HDZ-NRW, Bad Oeynhausen, Germany
| | - Stephan Ensminger
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ulrich Stierle
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Gert-Hinrich Reil
- Universitätsklinik für Innere Medizin I, Kardiologie, Klinikum Oldenburg, Oldenburg, Germany
| | - Jan-Christian Reil
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
- Klinik für allgemeine und interventionelle Kardiologie, HDZ-NRW, Bad Oeynhausen, Germany
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Reil JC, Marquetand C, Busch-Tilge C, Ivannikova M, Rudolph V, Aboud A, Ensminger S, Schäfers HJ, Stierle U, Reil GH. Functional interaction of aortic valve and ascending aorta in patients after valve-sparing procedures. Sci Rep 2023; 13:15340. [PMID: 37714924 PMCID: PMC10504237 DOI: 10.1038/s41598-023-42068-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023] Open
Abstract
Pressure recovery (PR) is essential part of the post stenotic fluid mechanics and depends on the ratio of EOA/AA, the effective aortic valve orifice area (EOA) and aortic cross-sectional area (AA). In patients with advanced ascending aortic aneurysm and mildly diseased aortic valves, the effect of AA on pressure recovery and corresponding functional aortic valve opening area (ELCO) was evaluated before and after valve-sparing surgery (Dacron graft implantation). 66 Patients with ascending aortic aneurysm (mean aortic diameter 57 +/- 10 mm) and aortic valve-sparing surgery (32 reimplantation technique (David), 34 remodeling technique (Yacoub)) were routinely investigated by Doppler echocardiography. Dacron graft with a diameter between 26 and 34 mm were implanted. EOA was significantly declined after surgery (3.4 +/- 0.8 vs. 2.6 +/- 0.9cm2; p < 0.001). Insertion of Dacron prosthesis resulted in a significant reduction of AA (26.7 +/- 10.2 vs. 6.8 +/- 1.1cm2; p < 0.001) with increased ratio of EOA/AA (0.14 +/- 0.05 vs. 0.40 +/- 0.1; p < 0.001) and pressure recovery index (PRI; 0.24 +/- 0.08 vs. 0.44 +/- 0.06; p < 0.0001). Despite reduction of EOA, ELCO (= EOA corrected for PR) increased from 4.0 +/- 1.1 to 5.0 +/- 3.1cm2 (p < 0.01) with reduction in transvalvular LV stroke work (1005 +/- 814 to 351 +/- 407 mmHg × ml, p < 0.001) after surgery. These effects were significantly better in patients with Yacoub technique than with the David operation. The hemodynamic findings demonstrate a valve-vessel interaction almost entirely caused by a marked reduction in the ascending AA with significant PR gain. The greater hemodynamic benefit of the Yacoub technique due to higher EOA values compared to the David technique was evident and may be of clinical relevance.
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Affiliation(s)
- Jan-Christian Reil
- Klinik für Allgemeine und Interventionelle Kardiolgie, Herz-und Diabetes-Zentrum Nordrhein-Westphalen, Georgstrasse 11, 32545, Bad Oeynhausen, Germany.
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany.
| | - Christoph Marquetand
- Medizinische Klinik II, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
| | - Claudia Busch-Tilge
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
| | - Maria Ivannikova
- Klinik für Allgemeine und Interventionelle Kardiolgie, Herz-und Diabetes-Zentrum Nordrhein-Westphalen, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Volker Rudolph
- Klinik für Allgemeine und Interventionelle Kardiolgie, Herz-und Diabetes-Zentrum Nordrhein-Westphalen, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Anas Aboud
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
| | - Stephan Ensminger
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
| | - Hans-Joachim Schäfers
- Klinik für Herz-und Thoraxchirurgie, Universitätsklinkum des Saarlandes, Kirrberger Strasse, 66421, Homburg, Saar, Germany
| | - Ulrich Stierle
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
| | - Gert-Hinrich Reil
- Universitätsklinik für Innere Medizin - Kardiologie, Klinikum Oldenburg, Rahel Strauss Strasse 10, Oldenburg, Germany
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Rao PS. Balloon Dilatation in the Management of Congenital Obstructive Lesions of the Heart: Review of Author's Experiences and Observations-Part I. J Cardiovasc Dev Dis 2023; 10:227. [PMID: 37367392 DOI: 10.3390/jcdd10060227] [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: 03/12/2023] [Revised: 04/22/2023] [Accepted: 05/17/2023] [Indexed: 06/28/2023] Open
Abstract
Balloon dilatation techniques became available to treat congenital obstructive lesions of the heart in the early/mid-1980s. The purpose of this review is to present the author's experiences and observations on the techniques and outcomes of balloon dilatation of pulmonary stenosis (PS), aortic stenosis (AS) and aortic coarctation (AC), both native and postsurgical re-coarctations. Balloon dilatation resulted in a reduction of peak pressure gradient across the obstructive lesion at the time of the procedure as well as at short-term and long-term follow-ups. Complications such as recurrence of stenosis, valvar insufficiency (for PS and AS cases) and aneurysm formation (for AC cases) have been reported, but infrequently. It was recommended that strategies be developed to prevent the reported complications.
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Affiliation(s)
- P Syamasundar Rao
- Children's Heart Institute, University of Texas-Houston McGovern Medical School, Children's Memorial Hermann Hospital, Houston, TX 77030, USA
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Ghorbannia A, Ellepola CD, Woods RK, Ibrahim ESH, Maadooliat M, Ramirez HM, LaDisa JF. Clinical, Experimental, and Computational Validation of a New Doppler-Based Index for Coarctation Severity Assessment. J Am Soc Echocardiogr 2022; 35:1311-1321. [PMID: 36122791 PMCID: PMC9729418 DOI: 10.1016/j.echo.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 08/15/2022] [Accepted: 09/11/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Long-term morbidity including hypertension often persists in coarctation patients despite current guidelines. Coarctation severity can be invasively assessed via peak-to-peak catheter pressure gradient (PPCG), which is estimated noninvasively via simplified Bernoulli equation and conventionally reported as peak instantaneous Doppler gradient (PIDG). However, underlying simplifications of the equation limit diagnostic accuracy. We studied the diagnostic performance of a new Doppler-based diastolic index called the continuous flow pressure gradient (CFPG) versus conventional indices in assessing coarctation severity. METHODS In a rabbit model mimicking human aortic coarctation, temporal blood pressure waveforms revealed the diastolic instantaneous pressure gradients and spectral Doppler features impacted by coarctation severity. We therefore hypothesized that CFPG provides superior correlation with coarctation gradients measured invasively. PIDG and CFPG were quantified using color flow echocardiography in humans and rabbits with discrete coarctations. Results were compared with PPCG in rabbits (n = 34) and arm-leg systolic gradients (n = 25) in humans via 1-way analysis of variance, Pearson's correlation, linear regression, and Bland-Altman analysis. RESULTS A threshold of CFPG ≥ 4.6 mm Hg was identified via the Youden index as representative of PPCG ≥ 20 mm Hg (the current guideline value for coarctation intervention) in rabbits, while a CFPG ≥1.0 mm Hg represented an arm-leg systolic gradient ≥20 mm Hg in humans. Accuracy measures revealed superior correlation of CFPG (R2 > 0.80) and mild receiver operating characteristic improvement (area under the receiver operating characteristic curve, 0.94-0.95) compared with PIDG (R2 < 0.63; area under the receiver operating characteristic curve, 0.89-0.95). Inter-/intraobserver variability tested by intraclass correlation coefficient revealed measurement reliability with differences ≤8.2% and 10.7%, respectively. Computational simulations of anesthetized versus conscious hemodynamics showed parameters were minimally impacted by isoflurane inherent in the data used to derive CFPG. These results confirm the potential diagnostic accuracy of CFPG in echocardiography-based coarctation severity assessment. We are optimistic that CFPG will be useful for translation of results from preclinical studies that revisit current guidelines to limit morbidity in humans with aortic coarctation.
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Affiliation(s)
- Arash Ghorbannia
- Department of Biomedical Engineering, Medical College of Wisconsin, and Marquette University, Milwaukee, Wisconsin; Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Chalani D Ellepola
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ronald K Woods
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - El-Sayed H Ibrahim
- Department of Biomedical Engineering, Medical College of Wisconsin, and Marquette University, Milwaukee, Wisconsin; Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mehdi Maadooliat
- Department of Mathematics and Statistical Sciences, Marquette University, Milwaukee, Wisconsin
| | - Hilda Martinez Ramirez
- Department of Biomedical Engineering, Medical College of Wisconsin, and Marquette University, Milwaukee, Wisconsin
| | - John F LaDisa
- Department of Biomedical Engineering, Medical College of Wisconsin, and Marquette University, Milwaukee, Wisconsin; Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Medicine, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Reil J, Marquetand C, Busch‐Tilge C, Rohde J, Bahlmann E, Aboud A, Eitel I, Ensminger S, Charitos EI, Reil G, Stierle U. Impact of pressure recovery on the assessment of pulmonary homograft function using Doppler ultrasound. Physiol Rep 2022; 10:e15432. [PMID: 36511522 PMCID: PMC9746035 DOI: 10.14814/phy2.15432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 06/17/2023] Open
Abstract
Relevant pressure recovery (PR) has been shown to increase functional stenotic aortic valve orifice area and reduce left ventricular load. However, little is known about the relevance of PR in the pulmonary artery. The study examined the impact of PR using 2D-echocardiography in the pulmonary artery distal to the degenerated homograft in patients after Ross surgery. Ninety-two patients with pulmonary homograft were investigated by Doppler echocardiography (mean time interval after surgery 31 ± 26 months). PR was measured as a function of pulmonary artery diameter determined by computed tomography angiography. Homograft orifice area, valve resistance, and transvalvular stroke work were calculated with and without considering PR. PR decreased as the pulmonary artery diameter increased (r = -0.69, p < 0.001). Mean PR was 41.5 ± 7.1% of the Doppler-derived pressure gradient (Pmax ), which resulted in a markedly increased homograft orifice area (energy loss coefficient index [ELCOI] vs. effective orifice area index [EOAI], 1.3 ± 0.4 cm2 /m2 vs. 0.9 ± 0.4 cm2 /m2 , p < 0.001). PR significantly reduced homograft resistance and transvalvular stroke work (822 ± 433 vs. 349 ± 220 mmHg × ml, p < 0.0001). When PR was considered, the correlations of the parameters used were significantly better, and 11 of 18 patients (61%) in the group with severe homograft stenosis (EOAI <0.6 cm2 /m2 ) could be reclassified as moderate stenosis. Our results showed that the Doppler measurements overestimated the degree of homograft stenosis and thus the right ventricular load, when PR was neglected in the pulmonary artery. Therefore, Doppler measurements that ignore PR can misclassify homograft stenosis and may lead to premature surgery.
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Affiliation(s)
- Jan‐Christian Reil
- Medizinische Klinik II, Kardiologie, Angiologie und Internistische IntensivmedizinUniversitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig‐HolsteinLübeckGermany
- Klinik für HerzchirurgieUniversitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig‐HolsteinLübeckGermany
| | - Christoph Marquetand
- Medizinische Klinik II, Kardiologie, Angiologie und Internistische IntensivmedizinUniversitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig‐HolsteinLübeckGermany
| | - Claudia Busch‐Tilge
- Klinik für HerzchirurgieUniversitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig‐HolsteinLübeckGermany
| | - Jule Rohde
- Medizinische Klinik II, Kardiologie, Angiologie und Internistische IntensivmedizinUniversitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig‐HolsteinLübeckGermany
| | - Edda Bahlmann
- Department of CardiologyAsklepios Kliniken St. GeorgHamburgGermany
| | - Anas Aboud
- Klinik für HerzchirurgieUniversitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig‐HolsteinLübeckGermany
| | - Ingo Eitel
- Medizinische Klinik II, Kardiologie, Angiologie und Internistische IntensivmedizinUniversitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig‐HolsteinLübeckGermany
| | - Stephan Ensminger
- Klinik für HerzchirurgieUniversitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig‐HolsteinLübeckGermany
| | | | - Gert‐Hinrich Reil
- Universitätsklinik für Innere Medizin – Kardiologie, Klinikum OldenburgOldenburgGermany
| | - Ulrich Stierle
- Klinik für HerzchirurgieUniversitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig‐HolsteinLübeckGermany
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Baseline intracardiac echocardiography predicts haemodynamic changes and Doppler velocity patterns during follow-up after percutaneous pulmonary valve implantation. Cardiol Young 2022; 32:444-450. [PMID: 34140059 DOI: 10.1017/s1047951121002365] [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] [Indexed: 11/06/2022]
Abstract
BACKGROUND Intracardiac echocardiography Doppler-derived gradients have previously been shown to correlate with post-procedure echocardiographic evaluations when compared with invasive gradients measured during percutaneous pulmonary valve implantation, suggesting that intracardiac echocardiography could offer an accurate and predictable starting point to estimate valve function after percutaneous pulmonary valve implantation. METHODS We performed a retrospective chart review of 51 patients who underwent percutaneous pulmonary valve implantation between September 2018 and December 2019 in whom intracardiac echocardiography was performed immediately after valve implantation. We evaluated the correlation between intracardiac echocardiography gradients and post-procedural Doppler-derived gradients. Among the parameters assessed, those which demonstrated the strongest correlation were used to create a predictive model of expected echo-derived gradients after percutaneous pulmonary valve implantation. The equation was validated on the same sample data along with a subsequent cohort of 25 consecutive patients collected between January 2020 and July 2020. RESULTS All the assessed correlation models between intracardiac echocardiography evaluation and post-procedure transthoracic echocardiographic assessments were statistically significant, presenting moderate to strong correlations. The strongest relationship was found between intracardiac echocardiography mean gradients and post-procedural transthoracic echocardiographic mean gradients. Therefore, an equation was created based on the intracardiac echocardiography-derived mean gradient, to allow prediction of the post-procedural and follow-up transthoracic echocardiographic-derived mean gradients within a range of ±5 mmHg from the observed value in more than 80% of cases. CONCLUSIONS There is a strong correlation between intracardiac echocardiography and post-procedure transthoracic echocardiographic. This allowed us to derive a predictive equation that defines the expected transthoracic echocardiographic Doppler-derived gradient following the procedure and at out-patient follow-up after percutaneous pulmonary valve implantation.
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10
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Rao PS. Biomarkers and pulmonary stenosis. Echocardiography 2021; 39:5-6. [PMID: 34913198 DOI: 10.1111/echo.15218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/13/2021] [Accepted: 09/27/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- P Syamasundar Rao
- Department of Pediatrics, Division of Pediatric Cardiology, The University of Texas-Houston McGovern Medical School/Children's Memorial Hermann Hospital, Houston, Texas, USA
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11
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Ventricular outflow tract obstruction: An in-silico model to relate the obstruction to hemodynamic quantities in cardiac paediatric patients. PLoS One 2021; 16:e0258225. [PMID: 34653194 PMCID: PMC8519477 DOI: 10.1371/journal.pone.0258225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/21/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Right (R) or left (L) ventricular outflow tract (VOT) obstruction can be either a dynamic phenomenon or a congenital anatomic lesion, which requires a prompt and optimal timing of treatment to avoid a pathological ventricular remodelling. OBJECTIVE To develop a simple and reliable numerical tool able to relate the R/L obstruction size with the pressure gradient and the cardiac output. To provide indication of the obstruction severity and be of help in the clinical management of patients and designing the surgical treatment for obstruction mitigation. METHODS Blood flow across the obstruction is described according to the classical theory of one-dimensional flow, with the obstruction uniquely characterized by its size. Hemodynamics of complete circulation is simulated according to the lumped parameter approach. The case of a 2 years-old baby is reproduced, with the occlusion placed in either the R/ or the L/VOT. Conditions from wide open to almost complete obstruction are reproduced. RESULTS Both R/LVOT obstruction in the in-silico model resulted in an increased pressure gradient and a decreased cardiac output, proportional to the severity of the VOT obstruction and dependent on the R/L location of the obstruction itself, as it is clinically observed. CONCLUSION The in-silico model of ventricular obstruction which simulates pressure gradient and/or cardiac output agrees with clinical data, and is a first step towards the creation of a tool that can support the clinical management of patients from diagnosis to surgical treatments.
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Marquetand C, Reil JC. Response by Marquetand and Reil to Letter Regarding Article, "Invasive and Echocardiographic Characteristics of a Patient With Severe Pulmonary Valve Regurgitation Pretending Severe Pulmonary Stenosis". Circ Heart Fail 2021; 14:e008618. [PMID: 33951938 DOI: 10.1161/circheartfailure.121.008618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christoph Marquetand
- Department of Cardiology, Angiology and Intensive Care, Medicine Medical Clinic II, University Heart Center Lübeck, Germany
| | - Jan-Christian Reil
- Department of Cardiology, Angiology and Intensive Care, Medicine Medical Clinic II, University Heart Center Lübeck, Germany
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Swanson L, Owen B, Keshmiri A, Deyranlou A, Aldersley T, Lawrenson J, Human P, De Decker R, Fourie B, Comitis G, Engel ME, Keavney B, Zühlke L, Ngoepe M, Revell A. A Patient-Specific CFD Pipeline Using Doppler Echocardiography for Application in Coarctation of the Aorta in a Limited Resource Clinical Context. Front Bioeng Biotechnol 2020; 8:409. [PMID: 32582648 PMCID: PMC7283385 DOI: 10.3389/fbioe.2020.00409] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/14/2020] [Indexed: 12/14/2022] Open
Abstract
Congenital heart disease (CHD) is the most common birth defect globally and coarctation of the aorta (CoA) is one of the commoner CHD conditions, affecting around 1/1800 live births. CoA is considered a CHD of critical severity. Unfortunately, the prognosis for a child born in a low and lower-middle income country (LLMICs) with CoA is far worse than in a high-income country. Reduced diagnostic and interventional capacities of specialists in these regions lead to delayed diagnosis and treatment, which in turn lead to more cases presenting at an advanced stage. Computational fluid dynamics (CFD) is an important tool in this context since it can provide additional diagnostic data in the form of hemodynamic parameters. It also provides an in silico framework, both to test potential procedures and to assess the risk of further complications arising post-repair. Although this concept is already in practice in high income countries, the clinical infrastructure in LLMICs can be sparse, and access to advanced imaging modalities such as phase contrast magnetic resonance imaging (PC-MRI) is limited, if not impossible. In this study, a pipeline was developed in conjunction with clinicians at the Red Cross War Memorial Children’s Hospital, Cape Town and was applied to perform a patient-specific CFD study of CoA. The pipeline uses data acquired from CT angiography and Doppler transthoracic echocardiography (both much more clinically available than MRI in LLMICs), while segmentation is conducted via SimVascular and simulation is realized using OpenFOAM. The reduction in cost through use of open-source software and the use of broadly available imaging modalities makes the methodology clinically feasible and repeatable within resource-constrained environments. The project identifies the key role of Doppler echocardiography, despite its disadvantages, as an intrinsic component of the pipeline if it is to be used routinely in LLMICs.
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Affiliation(s)
- Liam Swanson
- Department of Mechanical Engineering, University of Cape Town, Cape Town, South Africa
| | - Benjamin Owen
- Department of Mechanical, Aerospace and Civil Engineering (MACE), The University of Manchester, Manchester, United Kingdom
| | - Amir Keshmiri
- Department of Mechanical, Aerospace and Civil Engineering (MACE), The University of Manchester, Manchester, United Kingdom
| | - Amin Deyranlou
- Department of Mechanical, Aerospace and Civil Engineering (MACE), The University of Manchester, Manchester, United Kingdom
| | - Thomas Aldersley
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - John Lawrenson
- Department of Paediatrics and Child Health, Tygerberg Hospital, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Paul Human
- Christiaan Barnard Division of Cardiothoracic Surgery, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Rik De Decker
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Barend Fourie
- Department of Paediatrics and Child Health, Tygerberg Hospital, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - George Comitis
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Mark E Engel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Bernard Keavney
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom.,Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Liesl Zühlke
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Malebogo Ngoepe
- Department of Mechanical Engineering, University of Cape Town, Cape Town, South Africa
| | - Alistair Revell
- Department of Mechanical, Aerospace and Civil Engineering (MACE), The University of Manchester, Manchester, United Kingdom
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Rao PS. The Author's Contributions to Echocardiography Literature (Part II-1991-2020). CHILDREN (BASEL, SWITZERLAND) 2020; 7:E34. [PMID: 32294978 PMCID: PMC7230637 DOI: 10.3390/children7040034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/19/2020] [Accepted: 03/21/2020] [Indexed: 11/25/2022]
Abstract
The author's contribution up to 1990 was reviewed in part I and the echo contributions from 1991 to 2020 will be reviewed in part II. These include defining the relationship between the quantity of shunt across the atrial septal defect (ASD) and the diameter of ASD by echo and angio on the one side and the stretched diameter of the ASD on the other; echocardiographic assessment of balloon-stretched diameter of secundum ASDs; development of echocardiographic predictors of accomplishment of percutaneous closure of ASDs with the buttoned device, highlighting limitations of echocardiography in comprehensive assessment of mixed type of total anomalous pulmonary venous connection; description of follow-up echocardiographic results of transcatheter closure of ASD with buttoned device; review of ultrasound studies; depiction of collaborative echocardiographic and Doppler studies; echocardiographic appraisal of the outcome of balloon pulmonary valvuloplasty; editorials; ventricular septal aneurysm causing pulmonary outflow tract obstruction in the morphologic left ventricle in corrected transposition of the great arteries; dependability of echocardiographic assessment of angiographic minimal diameter of the ductus; occurrence of supravalvular pulmonary artery stenosis after a Nuss procedure; echocardiographic assessment of neonates who were suspected of having heart disease; role of echocardiographic studies in the appraisal of patent ductus arteriosus in the premature babies; and the role of pressure recovery in explaining differences between simultaneously measured Doppler and cardiac catheterization pressure gradients across outflow tract stenotic lesions.
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Affiliation(s)
- P Syamasundar Rao
- University of Texas-Houston McGovern Medical School, Children's Memorial Hermann Hospital, 6410 Fannin Street, UTPB Suite # 425, Houston, TX 77030, USA
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