Analysis of left ventricular regional dyssynchrony: comparison between real time 3D echocardiography and tissue Doppler imaging

3D Echocardiography for Rheumatic Heart Disease Analysis: Ready for Prime Time

Rheumatic heart disease (RHD) remains to be a very important health issue worldwide, mainly in underdeveloped countries. It continues to be a leading cause of morbidity and mortality throughout developing countries. RHD is a delayed non-suppurative immunologically mediated inflammatory response to the throat infection caused by a hemolytic streptococcus from the A group (Streptococcus pyogenes). RHD keeps position 1 as the most common cardiovascular disease in young people aged <25 years considering all the continents. The disease can lead to valvular cardiac lesions as well as to carditis. Rheumatic fever valvular injuries lead most commonly to the fusion and thickening of the edges of the cusps and to the fusion, thickening, and shortening of the chordae and ultimately to calcification of the valves. Valvular commissures can also be deeply compromised, leading to severe stenosis. Atrial and ventricular remodeling is also common following rheumatic infection. Mixed valvular lesions are more common than isolated valvular disorders. Echocardiography is the most relevant imaging technique not only to provide diagnostic information but also to enable prognostic data. Further, it presents a very important role for the correction of complications after surgical repair of rheumatic heart valvulopathies. Three-dimensional (3D) echocardiography provides additional anatomical and morphofunctional information of utmost importance for patients presenting rheumatic valvopathies. Accordingly, three-dimensional echocardiography is ready for routine use in patients with RHD presenting with valvular abnormalities.

Real-time three-dimensional echocardiographic evaluation of left ventricular systolic synchronicity in patients with chronic heart failure: comparison with tissue Doppler imaging

BACKGROUND

To investigate the clinical value of real-time three-dimensional echocardiography (RT-3DE) for assessing of left ventricular systolic synchronicity.

METHODS

Thirty healthy volunteers and 62 patients with congestive heart failure (CHF) were enrolled. The SD of time to peak systolic motion (TDI-Ts12-SD) was measured with tissue Doppler imaging in 12 myocardial segments. The SD and maximal difference of the time to minimal systolic volume (Tmsv) between 16, 12, or 6 myocardial segments, expressed as a percentage of cardiac cycle duration, were measured with RT-3DE and labeled Tmsv16-SD%, Tmsv12-SD%, Tmsv6-SD%, Tmsv16-D%, Tmsv12-D%, and Tmsv6-D%, respectively. The Spearman coefficient and Kappa value were calculated, and Bland-Altman analysis was performed to investigate the correlation and agreement between the two methods. Tmsv values were compared with ejection fraction (EF).

RESULTS

There was a moderately positive (p< 0.01) correlation between TDI-Ts12-SD and Tmsv16-SD%, Tmsv12-SD%, Tmsv16-D%, and Tmsv12-D% (r = 0.65, 0.64, and 0.65, respectively, with Kappa values of 0.66, 0.65, 0.72, and 0.74, respectively, p< 0.01). Tmsv16-SD%, Tmsv12-SD%, and Tmsv12-D% were significantly different between CHF patients with EF ≤ 35% and those with EF > 35%.

CONCLUSIONS

RT-3DE can be used in patients with CHF to quantify left ventricular mechanical dyssynchrony. Tmsv12-SD% and Tmsv12-D% were the best indices of left ventricular systolic synchronicity in relation to the severity of CHF as evaluated from EF.

New equation for prediction of reverse remodeling after cardiac resynchronization therapy

OBJECTIVES

To integrate data from two-dimensional echocardiography (2D ECHO), three-dimensional echocardiography (3D ECHO), and tissue Doppler imaging (TDI) for prediction of left ventricular (LV) reverse remodeling (LVRR) after cardiac resynchronization therapy (CRT). It was also compared the evaluation of cardiac dyssynchrony by TDI and 3D ECHO.

METHODS

Twenty-four consecutive patients with heart failure, sinus rhythm, QRS ≥ 120 msec, functional class III or IV and LV ejection fraction (LVEF) ≤ 0.35 underwent CRT. 2D ECHO, 3D ECHO with systolic dyssynchrony index (SDI) analysis, and TDI were performed before, 3 and 6 months after CRT. Cardiac dyssynchrony analyses by TDI and SDI were compared with the Pearson's correlation test. Before CRT, a univariate analysis of baseline characteristics was performed for the construction of a logistic regression model to identify the best predictors of LVRR.

RESULTS

After 3 months of CRT, there was a moderate correlation between TDI and SDI (r = 0.52). At other time points, there was no strong correlation. Nine of twenty-four (38%) patients presented with LVRR 6 months after CRT. After logistic regression analysis, SDI (SDI > 11%) was the only independent factor in the prediction of LVRR 6 months of CRT (sensitivity = 0.89 and specificity = 0.73). After construction of receiver operator characteristic (ROC) curves, an equation was established to predict LVRR: LVRR =-0.4LVDD (mm) + 0.5LVEF (%) + 1.1SDI (%), with responders presenting values >0 (sensitivity = 0.67 and specificity = 0.87).

CONCLUSIONS

In this study, there was no strong correlation between TDI and SDI. An equation is proposed for the prediction of LVRR after CRT. Although larger trials are needed to validate these findings, this equation may be useful to candidates for CRT.

Personalized echocardiography: clinical applications of advanced echocardiography and future directions

Future cardiology practice will be increasingly individualized, and thus to maintain its central role, echocardiography must keep pushing to expand the boundaries of real-time data acquisition from tissue and fluid motion, and yet still provide efficient and timely data analysis that leads to succinct, clear clinical recommendations tailored to each person in our care. In this article, recent efforts to expand echocardiography techniques into an era of increasingly personalized cardiology, including advances in color-coded tissue Doppler, 3D echocardiography and complex exercise stress echocardiography are described. The common metric for success in each of these efforts is the development of robust and institutionally supportable echocardiography protocols for specific cardiology disease populations that currently may be underdiagnosed and/or undertreated. The common result in each case should be the creation of new guidelines that can supplement the current standard protocols advocated by professional echocardiography organizations.

Comparison of effectiveness of right ventricular septal pacing versus right ventricular apical pacing

Chronic right ventricular apical pacing (RVAP) has been associated with negative hemodynamic and clinical effects. The aim of the present study was to compare RVAP with right ventricular septal pacing (RVSP) in terms of echocardiographic features and clinical outcomes. A total of 93 patients without structural heart disease and with an indication for a permanent pacemaker were randomly assigned to receive a screw-in lead either in the RV apex (n = 46) or in the RV mid-septum (n = 47). The patients were divided into 3 subgroups according to the percentage of ventricular pacing: control group (n = 21, percentage of ventricular pacing < or =10%), RVAP group (n = 28), or RVSP group (n = 32; both latter groups had a percentage of ventricular pacing >10%). The RVAP group had more intraventricular dyssynchrony and a trend toward a worse left ventricular ejection fraction compared to the RVSP and control groups at 12 months of follow-up (maximal delay to peak systolic velocity between any of the 6 left ventricular basal segments was 57.8 +/- 38.2, 35.5 +/- 20.6, and 36.5 +/- 17.8 ms for RVAP, RVSP, and control group, respectively; p = 0.006; mean left ventricular ejection fraction 62.9 +/- 7.9%, 66.5 +/- 7.2%, and 66.6 +/- 7.2%, respectively, p = 0.14). Up to 48.1% of the RVAP patients showed significant intraventricular dyssynchrony compared to 19.4% of the RVSP patients and 23.8% of the controls (p = 0.04). However, no overt clinical benefits from RVSP were found. In conclusion, RVAP was associated with increased dyssynchrony compared to the RVSP and control patients. RVSP could represent an alternative pacing site in selected patients to reduce the harmful effects of traditional RVAP.

New method for evaluation of left ventricular dyssynchrony and success of cardiac resynchronization therapy: real-time 3-dimensional echocardiography

A klinikai tapasztalat azt mutatja, hogy a jelenleg elérhető kritériumok alapján kiválasztott szívelégtelen betegek közel egyharmada a kardiális reszinkronizációs terápia (CRT) ellenére nonreszpondernek bizonyul, vagyis az optimális kezelés ellenére klinikai állapotukban javulás nem észlelhető. Ez a tény vezetett ahhoz a kutatási irányhoz, hogy találjunk olyan, noninvazív képalkotó diagnosztika (például echokardiográfia) során mérhető és/vagy számítható értéket, amely alkalmas a diszszinkrónia megítélésére és jobban segíti kiválasztani a CRT-re alkalmas betegeket. Ennek az áttekintő közleménynek a célja a legújabb noninvazív echokardiográfiás módszer, a real-time háromdimenziós echokardiográfia lehetséges szerepének bemutatása lenne az elérhető irodalom alapján.