Limitations of Apical Sparing Pattern in Cardiac Amyloidosis: A Multicenter Echocardiographic Study

BACKGROUND

Although impaired left ventricular (LV) global longitudinal strain (GLS) with apical sparing is a feature of cardiac amyloidosis (CA), its diagnostic accuracy has varied across studies. We aimed to determine the ability of apical sparing ratio (ASR) and most common echocardiographic parameters to differentiate patients with confirmed CA from those with clinical and/or echocardiographic suspicion of CA, but with this diagnosis ruled out.

METHODS

We identified 544 patients with confirmed CA and 200 controls as defined above (CTRL Patients). Measurements from transthoracic echocardiograms (TTE) were performed using artificial intelligence software (Us2.AI, Singapore) and audited by an experienced echocardiographer. Receiver-operating characteristic curve analysis was used to evaluate the diagnostic performance and optimal cutoffs for the differentiation of CA patients from CTRL Patients. Additionally, a group of 174 healthy subjects (Healthy CTRL) was included to provide insight on how Patients and Healthy controls differed echocardiographically.

RESULTS

LV GLS was more impaired (-13.9 ± 4.6% vs -15.9 ± 2.7%, p < 0.0005) and ASR was higher (2.4 ± 1.2 vs 1.7 ± 0.9, p < 0.0005) in the CA group vs. CTRL Patients. Relative wall thickness and ASR were the most accurate parameters for differentiating CA from CTRL Patients (AUC: 0.77 and 0.74, respectively). However, even with the optimal cutoff of 1.67, ASR was only 72% sensitive and 66% specific for CA, indicating presence of apical sparing in 32% of CTRL Patients and even in 6% Healthy CTRLs.

CONCLUSIONS

Apical sparing did not prove to be a CA-specific biomarker for accurate identification of CA, when compared to clinically similar controls with no CA.

Insights of tricuspid regurgitation mechanisms in patients with right ventricular apical pacing by three-dimensional echocardiography

OBJECTIVE

Device lead-induced tricuspid regurgitation (LITR) mechanisms are well-defined by 3D transthoracic echocardiography (3D-TTE). There is a lack of data on the Latin-American population. The objective of this study was to describe the prevalence of several mechanisms and insights in patients with permanent right ventricular (RV) implanted devices by 3D-TTE examination.

METHODS

We performed a cross-sectional analysis of 101 patients with permanent cardiac devices such as pacemakers or defibrillators. 3D-TTE was obtained on all patients in RV-focused apical views to perform a complete tricuspid valve (TV) evaluation: leaflets, subvalvular apparatus, precise lead location, and functional assessment to evaluate possible mechanisms of tricuspid regurgitation (TR).

RESULTS

In a total of 101 patients, the leads did not interfere with TV function in 53 p. (59%), while LITR was observed in 38 (41%) patients. Adherent, impinging, entangled, and mixed lead-induced mechanisms were observed. Time in years since device implantation was significantly higher in patients with LITR.

CONCLUSIONS

LITR was present in a high proportion of our population. LITR is the result of damage to the TV as well as its subvalvular apparatus due to the fibrotic and inflammatory response over time when leads are situated in unfavorable locations.

Normative values of the aortic valve area and Doppler measurements using two-dimensional transthoracic echocardiography: results from the Multicentre World Alliance of Societies of Echocardiography Study

AIMS

Aortic valve area (AVA) used for echocardiographic assessment of aortic stenosis (AS) has been traditionally interpreted independently of sex, age and race. As differences in normal values might impact clinical decision-making, we aimed to establish sex-, age- and race-specific normative values for AVA and Doppler parameters using data from the World Alliance Societies of Echocardiography (WASE) Study.

METHODS AND RESULTS

Two-dimensional transthoracic echocardiographic studies were obtained from 1903 healthy adult subjects (48% women). Measurements of the left ventricular outflow tract (LVOT) diameter and Doppler parameters, including AV and LVOT velocity time integrals (VTIs), AV mean pressure gradient, peak velocity, were obtained according to ASE/EACVI guidelines. AVA was calculated using the continuity equation. Compared with men, women had smaller LVOT diameters and AVA values, and higher AV peak velocities and mean gradients (all P < 0.05). LVOT and AV VTI were significantly higher in women (P < 0.05), and both parameters increased with age in both sexes. AVA differences persisted after indexing to body surface area. According to the current diagnostic criteria, 13.5% of women would have been considered to have mild AS and 1.4% moderate AS. LVOT diameter and AVA were lower in older subjects, both men and women, and were lower in Asians, compared with whites and blacks.

CONCLUSION

WASE data provide clinically relevant information about significant differences in normal AVA and Doppler parameters according to sex, age, and race. The implementation of this information into clinical practice should involve development of specific normative values for each ethnic group using standardized methodology.

Age-, Sex-, and Race-Based Normal Values for Left Ventricular Circumferential Strain from the World Alliance Societies of Echocardiography Study

BACKGROUND

Left ventricular (LV) circumferential strain has received less attention than longitudinal deformation, which has recently become part of routine clinical practice. Among other reasons, this is because of the lack of established normal values. Accordingly, the aim of this study was to establish normative values for LV circumferential strain and determine sex-, age-, and race-related differences in a large cohort of healthy adults.

METHODS

Complete two-dimensional transthoracic echocardiograms were obtained in 1,572 healthy subjects (51% men), enrolled in the World Alliance Societies of Echocardiography Normal Values Study. Subjects were divided into three age groups (<35, 35-55, and >55 years) and stratified by sex and by race. Vendor-independent semiautomated speckle-tracking software was used to determine LV regional circumferential strain and global circumferential strain (GCS) values. Limits of normal for each measurement were defined as 95% of the corresponding sex and age group falling between the 2.5th and 97.5th percentiles. Intergroup differences were analyzed using unpaired t tests.

RESULTS

Circumferential strain showed a gradient, with lower magnitude at the mitral valve level, increasing progressively toward the apex. Compared with men, women had statistically higher magnitudes of regional and global strain. Older age was associated with a stepwise increase in GCS despite an unaffected ejection fraction, a decrease in LV volume, and relatively stable global longitudinal strain in men, with a small gradual decrease in women. Asian subjects demonstrated significantly higher GCS magnitudes than whites of both sexes and blacks among women only. In contrast, no significant differences in GCS were found between white and black subjects of either sex. Importantly, despite statistical significance of these differences across sex, age, and race, circumferential strain values were similar in all groups, with variations of the order of magnitude of 1% to 2%. Notably, no differences in GCS were found among brands of imaging equipment.

CONCLUSION

This study established normal values of LV regional circumferential strain and GCS and identified sex-, age-, and race-related differences when present.

Socioeconomic variations determine the clinical presentation, aetiology, and outcome of infective endocarditis: a prospective cohort study from the ESC-EORP EURO-ENDO (European Infective Endocarditis) registry

AIMS

Infective endocarditis (IE) is a life-threatening disease associated with high mortality and morbidity worldwide. We sought to determine how socioeconomic factors might influence its epidemiology, clinical presentation, investigation and management, and outcome, in a large international multicentre registry.

METHODS AND RESULTS

The EurObservational Programme (EORP) of the European Society of Cardiology EURO-ENDO (European Infective Endocarditis) registry comprises a prospective cohort of 3113 adult patients admitted for IE in 156 hospitals in 40 countries between January 2016 and March 2018. Patients were separated in three groups, according to World Bank economic stratification [group 1: high income (75.6%); group 2: upper-middle income (15.4%); group 3: lower-middle income (9.1%)]. Group 3 patients were younger [median age (interquartile range, IQR): group 1, 66 (53-75) years; group 2, 57 (41-68) years; group 3, 33 (26-43) years; P < 0.001] with a higher frequency of smokers, intravenous drug use, and human immunodeficiency virus infection (all P < 0.001) and presented later [median (IQR) days since symptom onset: group 1, 12 (3-35); group 2, 19 (6-54); group 3, 31 (12-62); P < 0.001] with a higher likelihood of developing congestive heart failure (13.6%, 11.1%, and 22.6%, respectively; P < 0.001) and persistent fever (9.8%, 14.2%, and 27.9%, respectively; P < 0.001). Among 2157 (69.3%) patients with theoretical indication for cardiac surgery, surgery was performed less frequently in group 3 patients (75.5%, 76.8%, and 51.3%, respectively; P < 0.001), who also demonstrated the highest mortality (15.0%, 23.0%, and 23.7%, respectively; P < 0.001).

CONCLUSION

Socioeconomic factors influence the clinical profile of patients presenting with IE across the world. Despite younger age, patients from the poorest countries presented with more frequent complications and higher mortality associated with delayed diagnosis and lower use of surgery.

Design and rationale of the inferior vena CAVA and Lung UltraSound-guided therapy in Acute Heart Failure (CAVAL US-AHF Study): a randomised controlled trial

Background

Between 25% and 30% of patients hospitalised for acute heart failure (AHF) are readmitted within 90 days after discharge, mostly due to persistent congestion on discharge. However, as the optimal evaluation of decongestion is not clearly defined, it is necessary to implement new tools to identify subclinical congestion to guide treatment.

Objective

To evaluate if inferior vena cava (IVC) and lung ultrasound (CAVAL US)-guided therapy for AHF patients reduces subclinical congestion at discharge.

Methods

CAVAL US-AHF is a single-centre, single-blind randomised controlled trial designed to evaluate if an IVC and lung ultrasound-guided healthcare strategy is superior to standard care to reduce subclinical congestion at discharge. Fifty-eight patients with AHF will be randomised using a block randomisation programme that will assign to either lung and IVC ultrasound-guided decongestion therapy (‘intervention group’) or clinical-guided decongestion therapy (‘control group’), using a quantitative protocol and will be classified in three groups according to the level of congestion observed: none or mild, moderate or severe. The treating physicians will know the result of the test and the subsequent adjustment of treatment in response to those findings guided by a customised therapeutic algorithm. The primary endpoint is the presence of more than five B-lines and/or an increase in the diameter of the IVC, with and without collapsibility. The secondary endpoints are the composite of readmission for HF, unplanned visit for worsening HF or death at 90 days, variation of pro-B-type natriuretic peptide at discharge, length of hospital stay and diuretic dose at 90 days. Analyses will be conducted as between-group by intention to treat.

Ethics and dissemination

Ethical approval was obtained from the Institutional Review Board and registered in the PRIISA.BA platform of the Ministry of Health of the City of Buenos Aires.

Trial registration number

NCT04549701.

3D-Echocardiography in the assessment of lead-induced tricuspid regurgitation

Background

Lead-induced tricuspid regurgitation (LITR) is caused by several mechanisms that can be assessed by 3D-Echocardiography (3DE). Its prevalence was not studied to date in the Latin-American series.

Purpose

To determine prevalence and mechanisms of LITR in a series of patients with permanent cardiac devices by 3DE.

Methods

We perform a cross-sectional analysis of 101 patients with permanent cardiac devices as pacemakers or defibrillators. Transthoracic 3DE was obtained on all patients in RV-focused apical views to perform a complete tricuspid valve leaflets, subvalvular apparatus, lead placement and functional assessment to evaluate possible mechanisms of tricuspid regurgitation.

Results

Of a total of 101 patients, lead visualization was possible in 88%. In 59% lead was in commissural position and did not interfere with tricuspid leaflet mobility. Nevertheless, in 41% LITR was observed by several mechanisms. Leaflet impingement was the most prevalent cause in 30,7% causing valve leaflet interference and organic damage. Catheter adherence and/or entrapment to the leaflet or the tricuspid subvalvular apparatus was present in 10.3%. Two patients seem to have leaflet perforation by the catheter as the main mechanism; however, a further assessment was not possible. Patients with LITR had higher time since catheter implantation, lower left ventricular ejection fraction, more severity of tricuspid regurgitation, and right ventricular dilatation.

Conclusions

3DE enables to the identification of 41% of patients with LITR and leaflet impingement was the most prevalent mechanism. LITR patients had more time since cardiac device implantation. Some unfavorable catheter locations on the tricuspid valve can have some influence on the development of LITR over time.

Funding Acknowledgement

Type of funding sources: None.

Three-Dimensional Transthoracic Static and Dynamic Normative Values of the Mitral Valve Apparatus: Results from the Multicenter World Alliance Societies of Echocardiography Study

BACKGROUND

Recent advances in mitral valve (MV) percutaneous interventions have escalated the need for a more quantitative and comprehensive assessment of the MV, which can be best achieved using three-dimensional echocardiography. Understanding normal valve size, structure, and function is essential for differentiation of healthy from disease states. The aims of this study were to establish normative values for MV apparatus size and morphology and to determine how they vary across age, sex, and race groups using data from the World Alliance Societies of Echocardiography Normal Values Study.

METHODS

Three-dimensional volumetric data sets obtained on transthoracic echocardiography in 748 normal subjects (51% men) were analyzed using commercial MV analysis software (TomTec Imaging Systems) to determine annular and leaflet dimensions and areas. The subjects were divided into groups by sex (378 men and 370 women) and age (18 to 40 years [n = 266], 41 to 65 years [n = 249], and >65 years [n = 233]) to identify sex- and age-related differences. In addition, differences among black, white, and Asian populations were studied. Inter- and intraobserver variability was assessed in a subset of 30 subjects and expressed as mean absolute difference between pairs of repeated measurements.

RESULTS

Compared with women, men had larger annular size measurements, larger tenting size parameters, and larger leaflet length and area. Compared with the black and white populations, the Asian population showed significantly smaller mitral annular size. Although many of the age, sex, and race differences in MV parameters were statistically significant, they were comparable with or smaller than the corresponding measurement variability. Indexing to body surface area and height did not eliminate these differences consistently, suggesting that parameters may need to be indexed according to their dimensionality.

CONCLUSIONS

This analysis of the World Alliance Societies of Echocardiography data provides normative values of mitral apparatus size and morphology. Although sex- and age-related differences were noted, they need to be interpreted with caution in view of the associated measurement variability.

Socio-economic variations in the clinical presentation, etiology and outcome of infective endocarditis in the ESC-EORP EURO-ENDO (European Infective Endocarditis) registry: a prospective cohort study

Background

Infective endocarditis (IE) is a life threatening disease associated with high mortality and morbidity worldwide. We sought to determine how socio-economic factors may influence variations in epidemiology, clinical presentation, investigation and management (and their consequence upon clinical outcomes) in a large international multi-centre registry.

Methods

The ESC-EORPEURO-ENDO registry comprises a prospective cohort of 3116 adult patients admitted to 156 hospitals in 40 countries with IE between January 2016 and March 2018. We analysed the complete dataset to assess potentially important determinants of variation according to World Bank economic stratification (high income (Group 1) [73.8%]; upper-middle income (Group 2) [17.1%]; lower-middle income (Group 3)[9.1%]).

Results

Patients in Group 3 were younger (median age [IQR]: Group 1 - 66 [54–75] years; Group 2 - 57 [40–68] years; Group 3 - 33 [26–43] years; p&lt;0.001) with a higher prevalence of smoking, intravenous drug use and human immunodeficiency virus (HIV) infection (all p&lt;0.001). Group 3 patients with IE presented later (median [IQR) days since symptom onset: Group 1 - 12 [3–35]; Group 2 - 20 [6–51]; Group 3 - 31 [12–62]; p&lt;0.001) and were more likely to develop congestive heart failure (13.6%; 11.3%; and 22.6%, respectively; p&lt;0.001), septic shock (8.3%; 11.1%; 13.4%; p=0.007), and persistent fever for greater than 7 days (9.6%; 14.4%; 27.9%; p&lt;0.001) following hospital admission. Surgery was performed less frequently in Group 3 (75.4%, 76.8% and 51.3% in Groups 1, 2 and 3, respectively; p&lt;0.001) and mortality was highest in the poorest countries (14.6%; 23.6% and 23.7%, respectively; p&lt;0.001).

Conclusion

Socio-economic factors influence the clinical profile of patients presenting with IE across the world. Despite being younger, patients from the poorest countries presented with more frequent complications and higher mortality associated with delayed diagnosis and less frequent use of surgery.

Funding Acknowledgement

Type of funding sources: None.

Hemodynamically significant prosthesis-patient mismatch can be predicted and is associated with early prosthetic valve dysfunction in aortic bioprosthesis

OBJECTIVES

To evaluate the accuracy of predicted prosthesis-patient mismatch (PPM) regarding actual PPM measured postoperatively. To assess the association between PPM and prosthetic valve dysfunction.

METHODS

Retrospective cohort study including adult patients after aortic valve replacement surgery with a biological prosthesis. Predicted PPM status was determined using mean reference effective orifice area indexed to total body surface (iEOA), without considering reference standard deviations. Postoperative PPM status was determined by measuring iEOA within the first 60 postoperative days. Prosthetic valve dysfunction was defined as thrombosis, pannus, valve degeneration, and/or disruption.

RESULTS

205 patients were enrolled between January 2003 and June 2017: predicted PPM was absent in 52 patients (25.4%), moderate in 137 patients (66.8%), and severe in 16 patients (7.8%). After surgery, the actual postoperative iEOA was measured: 53 (25.9%) did not have PPM, 73 had moderate PPM (35.6%), and 79 had severe PPM (38.5%). Predicted PPM identified the presence of hemodynamically significant actual postoperative PPM (OR = 2.56; 95%CI 1.30-5.05; P = .006), though not its degree of severity. Prosthetic valve dysfunction was more frequent among patients with hemodynamically significant PPM (53.9% vs. 11.3%; P < .001), compared to those without PPM. The association between PPM and prosthetic valve dysfunction was maintained after adjusting for gender, age, and ever-smoking (OR = 9.03; P < .001). The incidence of thrombosis or pannus was also nonsignificantly higher in patients with moderate or severe PPM.

CONCLUSIONS

Predicted PPM identifies the presence, possibly not the severity, of actual postoperative PPM. Moderate or severe PPM is associated with prosthetic valve dysfunction. Actual postoperative prosthesis-patient mismatch measured within 60 postoperative days showed a distinctive hemodynamic profile and presented a stronger association with prosthetic valve dysfunction than predicted prosthesis-patient mismatch. A. Echocardiographic follow-up in patients according to the actual postoperative PPM measured within 60 postoperative days. B. Prediction of prosthetic valve dysfunction based on preoperative predicted PPM or on actual postoperative PPM within 60 postoperative days. PPM: prosthesis-patient mismatch. OR: Odds ratio.

[Positron emission tomography in infective endocarditis associated with intracardiac devices and prosthetic valves]

Infective endocarditis (IE) is a serious and potentially lethal condition. The diagnostic capacity of the modified Duke criteria is high for native valves, but it declines in the case of EI of prosthetic valves or EI associated with devices. Echocardiography and microbiological findings are essential for diagnosis but may be insufficient in this group of patients. Our objective was to evaluate the usefulness of positron emission tomography and fusion with computed tomography (PET / CT) in patients with suspected IE, carriers of prosthetic valves or intracardiac devices; 32 patients were studied, who underwent PET / CT with 18F-Fluorine deoxyglucose (18F-FDG). Those with intense focal and/or heterogeneous uptake with a Standard Uptake Value SUV) cut-off point greater than or equal to 3.7 were considered suggestive of infection. The initial diagnoses according to the modified Duke criteria were compared with the final diagnosis established by the Institutional Endocarditis Unit. The addition of PET / CT to these criteria, provided a conclusive diagnosis in 22 of the 32 initial cases reclassifying 11 cases in definitive EI; another 5 cases were negative for that diagnosis. EI continues to be a serious clinical problem. In those cases where the Duke criteria are not sufficient to establish the diagnosis and clinical suspicion persists, PET / CT can be a useful complementary tool to increase the diagnostic sensitivity.

Differences in the extent of fibrosis in obstructive and nonobstructive hypertrophic cardiomyopathy

AIMS

Left ventricular outflow tract (LVOT) obstruction is a key feature of hypertrophic cardiomyopathy (HCM) that identifies patients at increased risk of adverse outcomes. Previous studies have hypothesized that LVOT obstruction enhances myocardial fibrosis and increases left ventricular (LV) filling pressures, producing greater clinical deterioration. However, this hypothesis has not been demonstrated in a clinical cohort comparing obstructive and nonobstructive patients.

METHODS

Patients with HCM in whom Doppler echocardiography was performed within 30 days of cardiac MRI were enrolled, using the E/e' ratio to assess LV diastolic function and late gadolinium enhancement to evaluate the extent of fibrosis. Data were assorted according to LVOT obstruction status at rest.

RESULTS

The current study enrolled 67 patients who were mostly middle-aged (56.8 ± 13.2 years old) men (75%) with preserved ejection fraction. Obstructive HCM presented a significant association with a high fibrosis extent [odds ratio (OR) 3.33; P = 0.034] which was maintained after adjusting for sex and age (OR 4.37; P = 0.016) but not for maximum LV wall thickness (OR 2.13; P = 0.225). Obstructive HCM was also associated with a clinically significant E/e' ratio more than 14 (OR 7.8; P = 0.001) which decreased slightly after adjusting for age, sex and maximum LV thickness (OR 6.54; P = 0.014). There was a significant association between an E/e' ratio more than 14 and the extent of fibrosis (OR 1.29; P < 0.001) which was maintained after adjusting for age, sex and maximum LV wall thickness (OR 1.36; P = 0.001).

CONCLUSION

LVOT obstruction may play a role in the extent of fibrosis in HCM, possibly conditioning greater diastolic dysfunction.

[Infective endocarditis in Argentina: what have we learned in the last 25 years ?]

The epidemiology of infectious endocarditis (IE) has undergone changes due to a series of factors such as aging, comorbidities and medical procedures. The aim of this study was to evaluate the main clinical, epidemiological and etiological changes of the IE in the last 25 years in Argentina. A comparative analysis of three observational prospective registries was performed in which cases of definite and possible IE were consecutively included according to the Duke criteria: two multicentre studies (EIRA-1 [1992-1994] and EIRA-2 [2001-2002]) and one study in a reference cardiology center (CRC [2007-2017]). In the 1065 episodes of EI evaluated, there were no differences regarding sex, and the patients were older in each period (p < 0.001). Intracardiac device-associated IE was more frequent in the last decade: pacemaker (5.4 vs. 23% p < 0.0001) and prosthetic valve IE (8.5% vs. 19.2% vs. 47.5% p < 0.0001). On the other hand, IE associated with intravenous drugs (P < 0.0001) and congenital heart diseases (p = 0.001) was significantly less frequent. The etiology changed substantially: Streptococcus viridans group decreased (30.8% vs. 26.8% vs. 15.9%, p < 0.001) and IE by Staphylococcus spp. predominated over other microorganisms, with a statistically significant increase in IE due to coagulase-negative Staphylococcus. Surgical treatment was more frequently implemented in the last decade and was accompanied by a trend towards lower mortality in the CRC (23.5%, 24.3% vs. 17.2% p = 0.058).

[Infective endocarditis due to non-HACEK gram-negative bacilli in a Level III cardiovascular center in Argentina (1998-2016)]

Non-HACEK Gram-negative bacilli are a rare cause of infective endocarditis. Epidemiological, diagnostic and prognostic aspects of this entity are little known, and there is limited experience. The aim of this study was to analyze the clinical, microbiological and in-hospital outcomes of non-HACEK Gram negative bacilli endocarditis and to compare them with those due to other microorganisms.

E/e' ratio and left atrial area are predictors of atrial fibrillation in patients with hypertrophic cardiomyopathy

INTRODUCTION

Atrial fibrillation (AF) occurs in about 20%-25% of patients with hypertrophic cardiomyopathy and is associated with increased risk of cardioembolism and heart failure impacting on patients' morbidity and mortality. The aim of this study was to identify echocardiographic predictors of AF in a cohort of patients with hypertrophic cardiomyopathy (HCM).

METHODS

Patients were recruited from 2 centers: Buenos Aires Cardiovascular Institute and the Hospital Vall d'Hebron of Barcelona which were analyzed together. Retrospective study using electronic charts.

RESULTS

A total of 321 patients with HCM and no documented history of AF were included. Median follow-up was 3 years. Mean age was 54 ± 16 years. Obstructive HCM was present in 41% of the patients, and 94.2% had preserved systolic function. Thirty-eight patients developed AF during the follow-up period (11.8%). Univariate analysis showed that age, maximum myocardial thickness, atrial area, an E/e' ratio ≥ 17, and systolic pulmonary pressure estimated by echocardiography were associated with new-onset AF. Multivariate analysis showed that E/e' ≥ 17 ratio {HR 3.27 ([1.10-9.27] P = .033)} and atrial area {HR 1.06 ([1.01-1.13] P = .037)} remained predictors of AF.

CONCLUSIONS

An E/e' ratio ≥ 17, as an expression of left ventricular filling pressures with impact on the left atrium, and left atrial area ≥28 cm² are strong predictors of AF in patients with HCM.

Estimation of Prevalence of the Left Ventricular Noncompaction Among Adults

The prevalence of left ventricular noncompacted myocardium (LVNC) is not clearly defined yet. The goal of this study was to prospectively assess the prevalence of LVNC in a population of patients assessed for cardiovascular disease and to analyze the coincidence between observers using the echocardiographic criteria for diagnosis of LVNC. We included patients prospectively during a 1-year period. To analyze the concordance between different observers, we performed a blind analysis of 50 patients between 7 operators to calculate Kappa index for each criteria. The analysis of concordance for final diagnosis of LVNC was free-marginal kappa: 0.94. A total of 10,857 patients underwent echocardiography; 2,931 (27%) were normal. LVNC was found in 26 patients (prevalence = 0.24%), 16 patients were women, mean age of 52.6 years. Patients were divided into 2 groups; group A: ejection fraction (EF) <50% (n = 20) and group B: normal systolic function (n = 6). Among abnormal studies, 294 (2.7%) were dilated cardiomyopathies (DCs) Patients with LVNC and EF <50% comprised 6.8% of DC (20 of 294) and 24% (20 of 75) of patients with idiopathic DC (p <0.0001). Group A patients were older and with less presence of women (both p <0.05). In conclusion, the prevalence of LVNC in a population assessed for cardiovascular diseases is low. In contrast, it is very high in the subgroup of patients with idiopathic DC. The group of patients with LVNC and normal LVEF is younger and with a higher presence of women than those with LVNC and depressed LVEF. Coincidence between operators is very good for the identification of echocardiographic criteria.

Utility of Real Time 3D Echocardiography for the Assessment of Left Ventricular Mass in Patients with Hypertrophic Cardiomyopathy: Comparison with Cardiac Magnetic Resonance

INTRODUCTION AND OBJECTIVES

Patients with hypertrophic cardiomyopathy (HCM) have irregular ventricular shapes with small and sometimes obliterated cavities at end-systole that affect the quantification of left ventricular mass (LVM) by conventional methods, such as M-mode or two-dimensional echocardiography. The goal of this study was to validate the use of real time three-dimensional echocardiography (RT3DE) to quantify LVM using cardiac magnetic resonance imaging (CMR) as a reference, in a large population of patients with different types of HCM.

METHODS

Forty-eight consecutive patients with HCM had a complete transthoracic examination and CMR performed within 7 days. LVM was calculated by M-mode and RT3DE and compared to CMR that served as gold standard.

RESULTS

Left ventricular mass calculated by RT3DE was 195 ± 41 g and 187 ± 49 g by CMR. The correlation between the two methods was moderate, with a Lin index of 0.63 and good linear correlation (r = 0.63, P < 0.0001). The correlation was high when RT3DE was of high or adequate image quality. The correlation between LVM by M-mode and CMR was poor.

CONCLUSION

Three-dimensional echocardiography is an accurate method for the quantification of LVM in patients with different subtypes of HCM that is in better agreement with CMR reference values than M-mode measurements.

Influence of dynamic obstruction and hypertrophy location on diastolic function in hypertrophic cardiomyopathy

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is a disease with marked genetic and phenotypic heterogeneity. It is well known that obstructive septal forms of this disease entail worse clinical outcome compared with nonobstructive septal and apical forms. The objective of this study was to analyze the differences in left ventricular diastolic function in different subgroups of HCMs and to assess the influence of the location of myocardial hypertrophy and the presence of dynamic obstruction on impairment of diastolic function and its correlation with the clinical status.

METHODS

We studied 86 patients with HCM; 27 with the obstructive asymmetric septal type (OAS), 37 with the nonobstructive asymmetric septal type (NOAS) and 22 with apical hypertrophic cardiomyopathy (ApHCM). Patients underwent conventional and tissue Doppler echocardiography and were assessed applying the latest recommendations regarding diastolic dysfunction. Cardiac magnetic resonance was used to study the various morphologic subtypes and quantify left ventricular mass (LVM).

RESULTS

The early diastolic annular velocity (e') was significantly lower in OAS with a median of 5 cm/s compared with NOAS with 7 cm/s and ApHCM with 7.5 cm/s (P = 0.0002), and the E/e' ratio was 8.5 in ApHCM, 10 in NOAS and 14 in OAS (P = 0.0001); no significant differences were found in LVM or maximal wall thickness.

CONCLUSION

In HCM, the location of left ventricular hypertrophy and the presence of dynamic obstruction affect the degree of diastolic dysfunction; impairment is greater in patients with the OAS type, and markedly less in patients with apical involvement.

Traumatic rupture of the tricuspid valve and multi-modality imaging

INTRODUCTION

Motor vehicle accident (MVA) account for most cases of traumatic rupture of the tricuspid valve. Valve rupture during an MVA is generated by an abrupt deceleration coupled with an increase in right-side cardiac pressures (Valsalva maneuver and thorax compression).

CASE

A 39-year-old asymptomatic man was referred for an echocardiogram due to the presence of a systolic murmur. He had no prior significant medical history, except for a remote MVA 3 years ago. Real-time 3D echocardiography (RT3DE) showed a tear in the body of the anterior leaflet and not at the cord, as was suggested by two-dimensional transthoracic echocardiography (2D-TTE). Based on these findings, the mechanism was considered anterior leaflet rupture of the tricuspid valve, secondary to chest blunt trauma. The anterior leaflet was repaired using two polytetrafluoroethylene sutures, and tricuspid annuloplasty with an Edwards ring was performed.

CONCLUSIONS

Multimodality imaging helps to determine timing of surgery in asymptomatic traumatic tricuspid rupture. The combination of echocardiography and magnetic resonance imaging provide information of volumetric data and contractility of the right ventricle (RV) during follow-up. RT3DE gives information relevant to the morphological and functional characterization of the valve, allowing the planning of appropriate surgical procedure.

Lateral left ventricular wall rupture following acute myocardial infarction: pathophysiological interpretation by multimodality imaging approach

Lateral left ventricular wall rupture (LVWR) is a rare complication following acute myocardial infarction (AMI) less than 1%. After cardiogenic shock, LVWR constitutes the most common cause of in-hospital death in AMI patients. Around 40% of all LVWR occurred during the first 24 hours and 85% within the first week. In the present case, 76 hours following the intervention, LVWR was observed likely due to a small infarction at the lateral left ventricular wall possibly due to the marginal lesion. Our patient refused surgery and was followed clinically. Eighteen months later, real time three-dimensional echocardiography showed a pseudoaneurysm.

Reverse atrial electrical remodeling: a systematic review

Atrial remodeling is a term introduced in 1995 to describe alterations in atrial structure or function. Atrial electrical remodeling is characterized by a reduction of refractory period and action potential duration, dispersion in refractoriness, and a reduction in conduction velocity of impulse propagation. Numerous animal and human studies have demonstrated that atrial electrical remodeling impairs normal atrial conduction and provides an environment for ectopic and re-entrant activity, thus creating a substrate for the initiation or maintenance of atrial fibrillation. Interestingly, atrial electrical remodeling has been shown to be reversible. In this systematic review, we examine the occurrence of reverse atrial electrical remodeling in various clinical settings.

[Echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction: role of mitral regurgitation]

INTRODUCTION AND OBJECTIVES

Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction.

METHODS

We included 150 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290 m): Group 1, <290 m and Group 2, ≥290 m.

RESULTS

Mitral regurgitation was detected in 112 patients (75%), which was significant in 40 (27%). Group 1 showed more significant mitral regurgitation (35 vs 18%), increased left atrium area (27±1 vs 24±1cm(2)), mitral E amplitude (88±5 vs 72±3cm/s) and systolic pulmonary pressure (37±1 vs 32±1mmHg, all P<.05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02-11.66, P<.05). By multiple linear regression, the only independent predictor of walked distance was left atrium area (r=0.25, beta coefficient: -6.52±2, P<.01).

CONCLUSIONS

In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation.

Morphologic pattern of late gadolinium enhancement in Takotsubo cardiomyopathy detected by early cardiovascular magnetic resonance

BACKGROUND

Takotsubo cardiomyopathy (TTC) presents clinically as an acute coronary syndrome. It is characterized by transient left ventricular wall dyskinesis-akinesis, without significant epicardial coronary lesions. Late gadolinium enhancement (LGE) sequences on cardiac magnetic resonance (CMR) allow to clarify the pathophysiology in patients with chest pain, elevated troponin, and normal epicardial coronary arteries; in patients with TTC, previous studies have shown absence of LGE.

HYPOTHESIS

Early CMR in Takotsubo patients could show a morphological pattern of LGE improving clinical diagnosis.

METHODS

Between January 2005 and January 2007, 8 consecutive patients with TTC criteria underwent CMR within the first 3 days of admission. Cine, T2-weighted, and LGE images were acquired. Patient follow-up included clinical exam and imaging techniques: echocardiogram on days 3, 7, 30, and 60, and CMR at 3 months.

RESULTS

Six patients had experienced a previous stressful situation. No significant lesions were found on coronary angiography, and wall motion improvement was noted at 15 (7-30) days. Median EFs at admission and recovery were 46.5% and 65%, respectively. Dyskinesis was midapical in 6 cases, apical in 1 case, and mid-ventricular in 1 case. Late gadolinium enhancement showed mild hyperenhancement in areas of abnormal wall motion, whereas normal segments had no contrast enhancement. On follow-up CMR, wall motion was normal without late enhancement.

CONCLUSIONS

Early CMR in TTC demonstrates a special morphological pattern of late gadolinium uptake that might correspond to localized inflammation and edema in the affected area, suggesting diffuse microcirculation damage rather than epicardial vessel involvement.

Prognostic stratification of patients with left-sided endocarditis determined at admission

BACKGROUND

The prognosis of patients with left-sided endocarditis remains poor despite the progress of surgical techniques. Identification of high-risk patients within the first days after admission to the hospital would permit a more aggressive therapeutic approach.

METHODS

We designed a prospective multicenter study to find out the clinical, microbiologic, and echocardiographic characteristics available within 72 hours of admission that might define the profile of high-risk patients. Of 444 episodes, 317 left-sided endocarditis cases were included and 76 variables were assessed. Events were surgery in the active phase of the disease and in-hospital death. A stepwise logistic regression analysis was undertaken to determine variables predictive of events.

RESULTS

Multivariate analysis of the clinical variables found to have statistical significance in the univariate analysis identified the following as predictive: patient referred from another hospital (odds ratio [OR]: 1.8; confidence interval [CI], 1.1-2.9), atrioventricular block (OR: 2.5; CI, 1.1-5.9), acute onset (OR: 1.7; CI, 1.1-2.9), and heart failure at admission (OR: 2.3; CI, 1.4-3.8). When the echocardiographic and microbiological variables statistically significant in the univariate analysis were introduced, the presence of heart failure at admission (OR: 2.9; CI, 1.8-4.8), periannular complications (OR: 1.8; CI, 1.1-3.1), and Staphylococcus aureus infection (OR: 2.0; CI, 1.1-3.8) retained prognostic power. Risk could be accurately stratified when combining the 3 variables with predictive power: 0 variables present: 25% of risk; 1 variable present: 38% to 49% of risk; 2 variables present: 56% to 66% of risk; and 3 variables present: 79% of risk.

CONCLUSIONS

The risk of patients with left-sided endocarditis can be accurately stratified with the assessment of variables easily available within 72 hours of admission to the hospital.

Diagnostic role of new Doppler index in assessment of renal artery stenosis

Background

Renal artery stenosis (RAS) is one of the main causes of secondary systemic arterial hypertension. Several non-invasive diagnostic methods for RAS have been used in hypertensive patients, such as color Doppler ultrasound (US). The aim of this study was to assess the sensitivity and specificity of a new renal Doppler US direct-method parameter: the renal-renal ratio (RRR), and compare with the sensitivity and specificity of direct-method conventional parameters: renal peak systolic velocity (RPSV) and renal aortic ratio (RAR), for the diagnosis of severe RAS.

Methods

Our study group included 34 patients with severe arterial hypertension (21 males and 13 females), mean age 54 (± 8.92) years old consecutively evaluated by renal color Doppler ultrasound (US) for significant RAS diagnosis. All of them underwent digital subtraction arteriography (DSA). RAS was significant if a diameter reduction > 50% was found. The parameters measured were: RPSV, RAR and RRR. The RRR was defined as the ratio between RPSV at the proximal or mid segment of the renal artery and RPSV measured at the distal segment of the renal artery. The sensitivity and specificity cutoff for the new RRR was calculated and compared with the sensitivity and specificity of RPSV and RAR.

Results

The accuracy of the direct method parameters for significant RAS were: RPSV >200 cm/s with 97% sensitivity, 72% specificity, 81% positive predictive value and 95% negative predictive value; RAR >3 with 77% sensitivity, 90% specificity, 90% positive predictive value and 76% negative predictive value. The optimal sensitivity and specificity cutoff for the new RRR was >2.7 with 97% sensitivity (p < 0.004) and 96% specificity (p < 0.02), with 97% positive predictive value and 97% negative predictive value.

Conclusion

The new RRR has improved specificity compared with the direct method conventional parameters (RPSV >200cm/s and RAR >3). Both RRR and RPSV show better sensitivity than RAR for the RAS diagnosis.

Risk of embolization after institution of antibiotic therapy for infective endocarditis

OBJECTIVES

This study was designed to assess the risk of systemic embolization in patients with left-sided infective endocarditis, once adequate antibiotic treatment had been initiated, on the basis of prospective clinical follow-up.

BACKGROUND

As one of the complications of infective endocarditis, embolization has a great impact on prognosis. Prediction of an individual patient's risk of embolization is very difficult.

METHODS

We studied 217 episodes of left-sided endocarditis that were experienced among a cohort of 211 prospectively recruited patients. According to the Duke criteria, 91% of the episodes were definite infective endocarditis. Seventy-two episodes involved infections located on prosthetic valves. All patients were studied by transthoracic and transesophageal echocardiography. Clinical, echocardiographic and microbiologic data were entered in a data base. The mean follow-up interval was 151 days.

RESULTS

Twenty-eight episodes (12.9%; group I) of endocarditis had embolic events after the initiation of antibiotic therapy. The remaining 189 episodes did not embolize (group II). Most emboli (52%) affected the central nervous system, and 65% of the embolic events occurred during the first two weeks after initiation of antibiotic therapy. Previous embolism was associated with new embolism (relative risk [RR] 1.73, 95% confidence interval [CI] 1.02 to 2.93; p = 0.05). There was an increase in the risk of embolization with increasing vegetation size (RR 3.77, 95% CI 0.97 to 12.57; p = 0.07). Vegetation size had no impact on the risk of embolization in streptococcal endocarditis or aortic infection. By contrast, large (> or = 10 mm) vegetations had a higher incidence of embolism when the microorganism was staphylococcus (p = 0.04) and the mitral valve was infected (p = 0.03). The increase in vegetation size at follow-up showed a higher risk for embolization (RR 2.64, 95% CI 0.98 to 7.16; p = 0.02).

CONCLUSIONS

Embolism before antimicrobial therapy is a risk factor for new emboli. The risk of embolization seems to increase with increasing vegetation size, and this is particularly significant in mitral endocarditis and staphylococcal endocarditis. An increase in vegetation size, despite antimicrobial treatment, may predict later embolism.

Periannular extension of infective endocarditis

OBJECTIVES

This prospective study was designed to assess the current clinical course, risk factors, microbiologic profile and echocardiographic findings of patients with left-sided endocarditis and perivalvular complications.

BACKGROUND

Periannular complications worsen the prognosis of patients with endocarditis. The relation between these complications and the clinical and microbiologic data has not been clearly defined.

METHODS

In this clinical cohort study, 211 patients with left-sided endocarditis, according to the Duke criteria, were prospectively recruited. All patients underwent conventional and transesophageal echocardiography. The mean follow-up interval was 151 days.

RESULTS

Perivalvular complications were detected in 78 patients (37%). The incidence of periannular extension of infection in native and prosthetic valves was 29% and 55%, respectively. The presence of prosthesis (relative risk [RR] 1.88, 95% confidence interval [CI] 1.35 to 2.64) and previous endocarditis (RR 1.78, 95% CI 1.16 to 2.7) were the only pre-existing heart conditions associated with perivalvular complications. Aortic infection (RR 1.8, 95% CI 1.23 to 2.66) and the development of atrioventricular (AV) block (RR 2.55, 95% CI 1.91 to 3.41) were related with the existence of these complications. Coagulase-negative staphylococci were very common in patients with perivalvular complications (RR 1.77, 95% CI 1.21 to 2.59), and small vegetations were more frequent in these patients (RR l.45, 95% CI 0.95 to 2.22). An operation was more frequently performed in patients with perivalvular complications, but mortality was similar in patients with and without these complications.

CONCLUSIONS

Aortic infection, prosthetic endocarditis, new AV block and coagulase-negative staphylococci were independent risk factors of periannular complications. The period between symptom onset and diagnosis, the incidence of pericardial effusion and persistent signs of infection were similar between patients with and without perivalvular complications. Patients with perivalvular complications did not demonstrate a difference in the presence or size of vegetations or the frequency of embolism. An operation was more frequently performed in these patients, but mortality was similar in both groups.

Clinical course, microbiologic profile, and diagnosis of periannular complications in prosthetic valve endocarditis

Whether periannular extension of prosthetic valve endocarditis (abscesses, pseudoaneurysms, fistulas) is related to the etiologic agent, the clinical course and the prognosis is still unknown. Likewise, transesophageal echocardiographic accuracy in detecting periannular complications in prosthetic recipients remains unsettled. We retrospectively analyzed data from 87 patients with anatomically proven prosthetic valve endocarditis who underwent a transesophageal echocardiographic examination. Periannular complications (30 abscesses, 18 pseudoaneurysms, 8 fistulas; 8 with >1) were found in 46 patients; results were compared with the remaining 41 without complications. Transesophageal echocardiography correctly identified 27 abscesses (90%) and all pseudoaneurysms and fistulas. One diagnosis of pseudoaneurysm by echocardiography was not found at surgery. No statistical differences were found regarding age, sex, type of prosthesis (mechanical vs biologic), and etiologic agent. Periannular complications were more frequent in aortic location (70% vs 20% in mitral position; p <0.001) and in early (within 6 months after surgery) endocarditis (63% vs 38% in late endocarditis; p = 0.04). The same percentage of patients from both groups underwent surgery (98% with and 90% without complications). At discharge, 62% and 67% of patients were alive, respectively. Thus, periannular complications in prosthetic valve endocarditis are more frequent in aortic location and within 6 months after surgery. Neither the type of prosthesis nor the etiologic agent are related to the presence of periannular complications. Short-term prognosis in patients who underwent surgery is not affected by the presence of periannular complications.