Three-dimensional visual guidance improves the accuracy of calculating right ventricular volume with two-dimensional echocardiography

Comparison of Right Ventricular Function Between Three-Dimensional Transesophageal Echocardiography and Pulmonary Artery Catheter

OBJECTIVE

This study aimed to compare measurements of right ventricular function using three-dimensional transesophageal echocardiography (3D TEE), and pulmonary artery catheters (PACs) in patients undergoing cardiac surgery. The authors examined the practicality of using the 3D TEE.

DESIGN

Prospective observational.

SETTING

Cardiac operating room at a single university hospital.

PARTICIPANTS

All adult patients undergoing elective cardiac surgery at a single tertiary care university hospital over two years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), stroke volume (SV), and right ventricular ejection fraction (RVEF) were measured with both 3D TEE and PACs. Assessments were performed using correlation coefficients, paired t tests, and Bland-Altman plots. Thirty-one patients participated in this study. Each measurement showed good agreement. RVEDV and RVESV were slightly lower on 3D TEE than on PAC (205.9 mL v 220.2 mL, p = 0.0018; 143.0 mL v 155.5 mL, p = 0.0143, respectively), whereas no significant differences were observed for SV and RVEF (31.0% v 31.1%, p = 0.0569; 61.6 mL v 66.9 mL, p = 0.92, respectively). Linear regression analysis showed high correlation between 3D TEE and PAC for RVEDV (r = 0.87) and RVESV (r = 0.81), and moderate correlation for SV (r = 0.67) and RVEF (r = 0.67). In the Bland-Altman plot, most patients were within the 95% limits of the agreement throughout all measurements.

CONCLUSION

A high correlation was found between measurements made with a PAC and with 3D TEE in the assessment of right ventricular function. Three-dimensional TEE would be a potential alternative to PAC for assessment of right ventricular function during intraoperative periods.

Echocardiography in functional midgut neuroendocrine tumors: When and how often

The management of patients with midgut neuroendocrine tumors (MNET) is rapidly evolving. Current preoperative detection rates of primary tumor sites are higher than ever and progression-free survival in patients with already advanced disease is expanding due to the implementation of novel efficacious treatment strategies. This survival benefit may potentially translate into a need for a multidisciplinary approach to an even more heterogenous variety of clinical conditions, among these, carcinoid syndrome (CS) and carcinoid heart disease (CHD). The latter often triggers substantial morbidity and mortality, hence a systematic screening, an accurate diagnosis, as well as effective interventions are critically important. The rarity of the disease has result in a relative lack of statistically powerful evidence, which in turn may have rendered significant variability between practices. In this regard, despite recent guidelines, the optimal follow-up of patients with CHD remain debatable to some authors, perhaps due to the preponderance of certain schools throughout the manuscript. Herein, we present a concise and practical guidance document on clinical screening and echocardiographic surveillance of patients with CHD based on a comprehensive review of the literature, and complemented by our experience at the Center for Carcinoid and Neuroendocrine Tumors at The Mount Sinai Hospital.

Validity of the surface electrocardiogram criteria for right ventricular hypertrophy: the MESA-RV Study (Multi-Ethnic Study of Atherosclerosis-Right Ventricle)

OBJECTIVES

The study aimed to assess the diagnostic properties of electrocardiographic (ECG) criteria for right ventricular hypertrophy (RVH) measured by cardiac magnetic resonance imaging (cMRI) in adults without clinical cardiovascular disease.

BACKGROUND

Current ECG criteria for RVH were based on cadaveric dissection in small studies.

METHODS

MESA (Multi-Ethnic Study of Atherosclerosis) performed cMRIs with complete right ventricle (RV) interpretation on 4,062 participants without clinical cardiovascular disease. Endocardial margins of the RV were manually contoured on diastolic and systolic images. The ECG screening criteria for RVH from the 2009 American Heart Association Recommendations for Standardization and Interpretation of the ECG were examined in participants with and without left ventricular (LV) hypertrophy or reduced ejection fraction. RVH was defined using sex-specific normative equations based on age, height, and weight.

RESULTS

The study sample with normal LV morphology and function (n = 3,719) was age 61.3 ± 10.0 years, 53.5% female, 39.6% Caucasian, 25.5% African American, 21.9% Hispanic, and 13.0% Asian. The mean body mass index was 27.9 ± 5.0 kg/m(2). A total of 6% had RVH, which was generally mild. Traditional ECG criteria were specific (many >95%) but had low sensitivity for RVH by cMRI. The positive predictive values were not sufficiently high as to be clinically useful (maximum 12%). The results did not differ based on age, sex, race, or smoking status, or with the inclusion of participants with abnormal LV mass or function. Classification and regression tree analysis revealed that no combination of ECG variables was better than the criteria used singly.

CONCLUSIONS

The recommended ECG screening criteria for RVH are not sufficiently sensitive or specific for screening for mild RVH in adults without clinical cardiovascular disease.

Current concepts in diagnosis and perioperative management of carcinoid heart disease

Carcinoid tumors are neuroendocrine tumors with a very unpredictable clinical behavior. In the setting of hepatic metastases, the tumor's release of bioactive substances into the systemic circulation results in carcinoid syndrome: a constellation of symptoms among which cutaneous flushing, gastrointestinal hypermotility, and cardiac involvement are the most prominent. Cardiac manifestations, also known as carcinoid heart disease, are secondary to a severe fibrotic reaction which frequently involves the right-sided valves and may extend towards the subvalvular apparatus leading to valve thickening and retraction. Left-sided involvement is rare and mostly observed in the presence of an interatrial shunt, endobronchial tumor localization, and high tumor activity. Echocardiographic techniques often reveal noncoaptation of the valves, which are fixed in a semiopen position. In patients with advanced lesions and severe valvular dysfunction, surgery is currently the only definitive treatment to potentially improve quality of life and provide survival benefit. Although cardiac surgery has been traditionally reserved for those patients with symptomatic right ventricular failure, a significant trend towards improved surgical outcomes has triggered a more liberal referral for valve replacement. Carcinoid heart disease poses two distinct challenges for the anesthesiologist: carcinoid crisis and low cardiac output syndrome secondary to right ventricular failure. Carcinoid crisis, characterized by flushing, hypotension, and bronchospasm, may be precipitated by catecholamines and histamine releasing drugs used routinely in patients undergoing valve surgery. Although a broader utilization of octreotide have significantly simplified the anesthetic and perioperative management of these patients, a very balanced anesthetic technique is required to identify and manage low cardiac output syndrome.

Three-Dimensional Echocardiographic Evaluation of the Heart Chambers: Size, Function, and Mass

The major advantage of three-dimensional (3D) ultrasound imaging of the heart is the improvement in the accuracy of the echocardiographic evaluation of cardiac chamber volumes, which is achieved by eliminating the need for geometric modeling and the errors caused by foreshortened 2D views. In this article, we review the literature that has provided the scientific basis for the clinical use of 3D ultrasound imaging of the heart in the assessment of cardiac chamber size, function, and mass, and discuss its potential future applications.

Normal Values of Right Ventricular Size and Function by Real-time 3-Dimensional Echocardiography: Comparison with Cardiac Magnetic Resonance Imaging

BACKGROUND

Assessment of right ventricular function by 2-dimensional echocardiography (2DECHO) is difficult because of its complex shape. Real-time 3-dimensional echocardiography (RT3DECHO) may be superior.

METHODS

End-diastolic volume, end-systolic volume, stroke volume, and ejection fraction obtained by 2DECHO, RT3DECHO short-axis disk summation (DS), and RT3DECHO apical rotation were compared with cardiac magnetic resonance imaging in 71 healthy individuals.

RESULTS

RT3DECHO DS showed less volume underestimation compared with 2DECHO and RT3DECHO apical rotation. Test-retest variability for RT3DECHO DS end-diastolic volume, end-systolic volume, stroke volume, and ejection fraction were 3.3%, 8.7%, 10%, and 10.3%, respectively. Normal reference ranges of indexed volumes (mean +/- 2SD) for right ventricular end-diastolic volume, end-systolic volume, stroke volume, and ejection fraction were 38.6 to 92.2 mL/m(2), 7.8 to 50.6 mL/m(2), 22.5 to 42.9 mL/m(2), and 38.0% to 65.3%, respectively, for women and 47.0 to 100 mL/m(2), 23.0 to 52.6 mL/m(2), 14.2 to 48.4 mL/m(2), and 29.9% to 58.4%, respectively, for men.

CONCLUSIONS

RT3DECHO DS is superior to RT3DECHO apical rotation and 2DECHO for right ventricular quantification, and performs acceptably when compared with cardiac magnetic resonance imaging in healthy individuals.

Three-Dimensional Echocardiography

Over the past 3 decades, echocardiography has become a major diagnostic tool in the arsenal of clinical cardiology for real-time imaging of cardiac dynamics. More and more, cardiologists' decisions are based on images created from ultrasound wave reflections. From the time ultrasound imaging technology provided the first insight into the human heart, our diagnostic capabilities have increased exponentially as a result of our growing knowledge and developing technology. One of the most significant developments of the last decades was the introduction of 3-dimensional (3D) imaging and its evolution from slow and labor-intense off-line reconstruction to real-time volumetric imaging. While continuing its meteoric rise instigated by constant technological refinements and continuing increase in computing power, this tool is guaranteed to be integrated in routine clinical practice. The major proven advantage of this technique is the improvement in the accuracy of the echocardiographic evaluation of cardiac chamber volumes, which is achieved by eliminating the need for geometric modeling and the errors caused by foreshortened views. Another benefit of 3D imaging is the realistic and unique comprehensive views of cardiac valves and congenital abnormalities. In addition, 3D imaging is extremely useful in the intraoperative and postoperative settings because it allows immediate feedback on the effectiveness of surgical interventions. In this article, we review the published reports that have provided the scientific basis for the clinical use of 3D ultrasound imaging of the heart and discuss its potential future applications.

Live 3D Echocardiography: A Replacement for Traditional 2D Echocardiography?

OBJECTIVE

We describe the development of real-time 3D imaging and review the previously used versions of 3D echocardiography so that the reader will appreciate why current developments truly do represent a quantum leap in the technology.

CONCLUSION

Three-dimensional echocardiography has now been shown to have several advantages over 2D echocardiography, particularly for volume measurements, visualization of septal defects, and whole-valve evaluation. Given these data, it is clear that 3D echocardiography is here to stay and soon will become part of routine echocardiographic examinations.

Role of Biplane Echocardiography in a Large-volume Clinical Practice: Revamping Strategies for Echocardiography in a Limited Time

OBJECTIVES

We determined the feasibility, learning curve, time efficacy, and the quality of imaging during biplane echocardiography performed in clinical practice with a view to reduce a sonographer's time for image acquisition.

BACKGROUND

Multidimensional echocardiographic imaging has improved the assessment of cardiac geometry and function in clinical settings. However, concerns regarding ease of performance and effects on overall clinical work flow remain inadequately addressed.

METHODS

The study included 100 consecutive unselected patients referred to our echocardiography laboratory. They were randomized to conventional or biplane echocardiography performed by a sonographer without previous knowledge of biplane imaging. Image acquisition time and variables influencing the learning curve and overall image quality were analyzed.

RESULTS

Mean time required for biplane and mono-plane imaging was not different in the first 24 cases. In the remaining cases, mean image acquisition time was reduced significantly in 58 cases (76.3%): biplane, 5.6 minutes (SD 1.3); and monoplane, 6.6 minutes (SD 1.6) ( P = .0003). For both techniques, scanning time was not affected by referral pattern, body habitus, or underlying cardiac lesion. Overall, biplane scanning resulted in reduction in echocardiographic imaging time of 9.1%, maintaining an acceptable image quality in 87% of patients. In the last 20 cases, new software design and superior instrumentation technique improved the mean time gain to 15%.

CONCLUSION

In a high-volume echocardiography laboratory, biplane imaging effectively reduces sonographer time for imaging and improves throughput by increasing the number of comprehensive ultrasound studies that can be performed in a limited time.

Effect on right ventricular volume of percutaneous Amplatzer closure of atrial septal defect in adults

In adult patients with atrial septal defects (ASDs), right ventricular (RV) cavity size may return to normal after operative closure. This study demonstrated improved RV volumes and right atrial areas in 20 adult patients after successful transcatheter closure of large ASDs. RV volumes decreased by 22%, 30%, and 41% at 1 day, 1 month, and 6 months, respectively, after the procedure. Right atrial areas decreased by 5%, 23%, and 26%, respectively, over the same time.

Measurement of right ventricular volume from biplane contrast ventriculograms: Validation by cast and three-dimensional echo

We compared six models for measuring right ventricular (RV) volume from biplane ventriculograms in the 30 degrees right anterior oblique and 60 degrees left anterior oblique projections in adult and dilated RVs. We used 27 casts of normal RVs plus 37 three-dimensional (3D) echocardiographic RV reconstructions that we rotated to the oblique projections for contour extraction. Biplane volumes were computed using published formulas. RV volumes ranged from 18.9 to 322.4 ml. Both sets of volumes correlated similarly to true volume and were combined. Simpson's method with 50 slices yielded the lowest absolute error (19.5 +/- 28.9 ml); Simpson's with 20 slices yielded the lowest bias (1.3 +/- 35.7 ml). The prism and area-length models performed within this range. The Simpson's method provides the most accurate measurement of RV volume from biplane contrast ventriculograms recorded in oblique projections. Volume validation can be performed using 3D echo data.