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European Journal of Echocardiography
Eur J Echocardiogr
http://www.oxfordjournals.org/	Pubmed

European Heart Journal - Cardiovascular Imaging - current issue
European Heart Journal - Cardiovascular Imaging - RSS feed of current issue

• Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging
  

  Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Echocardiography has become the primary non-invasive imaging method for the evaluation of valvular regurgitation. The echocardiographic assessment of valvular regurgitation should integrate the quantification of the regurgitation, assessment of the valve anatomy and function, as well as the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation thus largely integrates the results of echocardiography. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing regurgitation.

• The year 2012 in the European Heart Journal - Cardiovascular Imaging. Part II
  

  The part II of the best of the European Heart Journal - Cardiovascular Imaging in 2012 specifically focuses on studies of valvular heart diseases, heart failure, cardiomyopathies, and congenital heart diseases.

• Device closure of interatrial communications: peri-interventional echocardiographic assessment
  

  The interventional closure of interatrial communications requires peri-interventional echocardiographic assessment and guidance to make those treatments as safe as possible. Transoesophageal echocardiography (TEE) including real-time three-dimensional (RT-3D) imaging, later complemented and in part replaced by intracardiac echocardiography (ICE), has become established as the standard approach to prepare for and to guide the interventional treatment of interatrial communications. Accurate imaging of the anatomic features of the particular communication is critical for case selection, planning, and intraprocedural guidance. Especially in the atrial septal defect (ASD) closure, which tends to be more challenging than the patent foramen ovale (PFO) closure, a certain risk of severe complications remains and may result from suboptimal device performance. Other complications may be related to discontinuous use of echocardiographic monitoring. Image fusion and RT-3D ICE are currently under clinical testing and might be suitable to facilitate spatial orientation. Nowadays, two-dimensional ICE is the method of choice for guiding percutaneous device closure, especially of ASDs and ‘complex’ PFOs. Uninterrupted TEE under deep sedation is an alternative. In contrast, the closure of ‘simple’ PFOs will often require nothing but final confirmation of the result, and therefore, short echocardiographic viewing is sufficient in many cases.

• Imaging cardiac fat
  

  Ectopic fat deposition has been associated with lipotoxicity and derangement in local and systemic metabolism, insulin resistance, cardiac dysfunction, atherosclerosis, local, and systemic inflammation. The mechanisms and potentially detrimental effects of such an accumulation should be fully investigated in order to establish preventive strategies. The aim of this review is to provide an overview of current knowledge regarding imaging techniques to measure cardiac fat deposition and its potential clinical relevance, if any.

• Circumferential ascending aortic strain and aortic stenosis
  Background

  Two-dimensional speckle tracking (2D-ST) echocardiography for the measurement of circumferential ascending thoracic aortic strain (CAAS) in the context of aortic stenosis (AS) is not elucidated.

  Purpose

  This study assesses the thoracic ascending aortic deformation using 2D-ST echocardiography in AS patients.

  Population and methods

  Forty-five consecutive patients with an aortic valvular area (AVA) ≤0.85 cm²/m² were included. Regarding aortic deformation, the global peak CAAS was the parameter used, and an average of six segments of arterial wall deformation was calculated. The corrected CAAS was calculated as the global CAAS/pulse pressure (PP). Aortic stiffness (β₂) index was assessed according to ln(P_s/P_d)/CAAS. The sample was stratified according to the stroke volume index (SVI) as: Group A (low flow, SVI ≤35 mL/m²; n = 19) and Group B (normal flow, SVI >35 mL/m²; n = 26).

  Results

  The mean age was 76.8 ± 10.3 years, 53.3% were male, the mean indexed AVA was 0.43 ± 0.15 cm²/m², and the mean CAAS was 6.3 ± 3.0%. The CAAS was predicted by SVI (β = 0.31, P < 0.01) and by valvulo-arterial impedance (Z_va). The corrected CAAS was correlated with the M-mode guided aortic stiffness index (β1) (r = –0.39, P < 0.01), and was predicted by SVI, Z_va, and systemic arterial compliance (β = 0.15, P < 0.01). The β₂ index was significantly higher for the low-flow patients (16.1 ± 4.8 vs. 9.8 ± 5.3, P < 0.01), and was predicted by SVI (β –0.58, P < 0.01) and PP (β = 0.17, P < 0.01). Global CAAS was more accurate to predict low flow than Z_va, systolic function and systemic vascular resistance.

  Conclusion

  In patients with moderate-to-severe aortic stenosis, SVI and LV afterload-related variables were the most important determinants of 2S-ST global CAAS.

• Incremental diagnostic accuracy of hybrid SPECT/CT coronary angiography in a population with an intermediate to high pre-test likelihood of coronary artery disease
  Aims

  Hybrid myocardial perfusion imaging with single photon emission computed tomography (SPECT) and CT coronary angiography (CCTA) has the potential to play a major role in patients with non-conclusive SPECT or CCTA results. We evaluated the performance of hybrid SPECT/CCTA vs. standalone SPECT and CCTA for the diagnosis of significant coronary artery disease (CAD) in patients with an intermediate to high pre-test likelihood of CAD.

  Methods and results

  In total, 98 patients (mean age 62.5 ± 10.1 years, 68.4% male) with stable anginal complaints and a median pre-test likelihood of 87% (range 22–95%) were prospectively included in this study. Hybrid SPECT/CCTA was performed prior to conventional coronary angiography (CA) including fractional flow reserve (FFR) measurements. Hybrid analysis was performed by combined interpretation of SPECT and CCTA images. The sensitivity, specificity, positive (PPV), and negative (NPV) predictive values were calculated for standalone SPECT, CCTA, and hybrid SPECT/CCTA on per patient level, using an FFR <0.80 as a reference for significant CAD. Significant CAD was demonstrated in 56 patients (57.9%). Non-conclusive SPECT or CCTA results were found in 32 (32.7%) patients. SPECT had a sensitivity of 93%, specificity 79%, PPV 85%, and NPV 89%. CCTA had a sensitivity of 98%, specificity 62%, PPV 77%, and NPV 96%. Hybrid analysis of SPECT and CCTA improved the overall performance: sensitivity, specificity, PPV, and NPV for the presence of significant CAD to 96, 95, 96, and 95%, respectively.

  Conclusions

  In > 40% of the patients with a high pre-test likelihood no significant CAD was demonstrated, emphasizing the value of accurate pre-treatment cardiovascular imaging. Hybrid SPECT/CCTA was able to accurately diagnose and exclude significant CAD surpassing standalone myocardial SPECT and CCTA, vs. a reference standard of FFR measurements.

• Concentric hypertrophic remodelling and subendocardial dysfunction in mitochondrial DNA point mutation carriers
  Aims

  Hypertrophic remodelling and systolic dysfunction are common in patients with mitochondrial disease and independent predictors of morbidity and early mortality. Screening strategies for cardiac disease are unclear. We investigated whether myocardial abnormalities could be identified in mitochondrial DNA mutation carriers without clinical cardiac involvement.

  Methods and results

  Cardiac magnetic resonance imaging was performed in 22 adult patients with mitochondrial disease due to the m.3243A>G mutation, but no known cardiac involvement, and 22 age- and gender-matched control subjects: (i) Phosphorus-31- magnetic resonance spectroscopy, (ii) cine imaging (iii), cardiac tagging and (iv) late gadolinium enhancement (LGE) imaging. Disease burden was determined using the Newcastle Mitochondrial Disease Adult Scale (NMDAS) and urinary mutation load. Compared with control subjects, patients had an increased left ventricular mass index (LVMI), LV mass to end-diastolic volume (M/V) ratio, wall thicknesses (all P < 0.01), torsion and torsion to endocardial strain ratio (both P < 0.05). Longitudinal shortening was decreased in patients (P < 0.0001) and correlated with an increased LVMI (r = –0.52, P < 0.03), but there were no differences in the diastolic function. Among patients there was no correlation of LVMI or the M/V ratio with diabetic or hypertensive status, but the mutation load and NMDAS correlated with the LVMI (r = 0.71 and r = 0.79, respectively, both P < 0.001). The phosphocreatine/adenosine triphosphate ratio was decreased in patients (P < 0.001) but did not correlate with other parameters. No patients displayed focal LGE.

  Conclusion

  Concentric remodelling and subendocardial dysfunction occur in patients carrying m.3243A>G mutation without clinical cardiac disease. Patients with higher mutation loads and disease burden may be at increased risk of cardiac involvement.

• Ascending aortic thrombi in the absence of valvular pathology: a rare cause of ST-segment elevation myocardial infarction
  
• Haemodynamic response during low-dose dobutamine infusion in patients with chronic systolic heart failure: comparison of echocardiographic and invasive measurements
  Aims

  To investigate whether left ventricular (LV) systolic shortening velocity (s'), diastolic lengthening velocity (e'), and non-invasively estimated LV filling pressure (E/e') during low-dose dobutamine echocardiography (LDDE) reflect invasive measures of cardiac output and pulmonary capillary wedge pressure (PCWP) in stable patients with chronic systolic heart failure.

  Methods and results

  Fourteen patients with heart failure (aged 65 ± 8 years, LVEF 36 ± 8%) underwent simultaneous tissue Doppler echocardiography and invasive measurements of cardiac output and PCWP by right heart catheterization at rest and during dobutamine infusion at rates of 10 and 20 µg/kg/min. Cardiac output increased from rest to peak dobutamine (4.9 ± 1.2 to 6.6 ± 2.0 L/min, P < 0.001) and correlated with the peak systolic tissue velocity (s') at rest (R = 0.61, P = 0.02) and during dobutamine stimulation (R = 0.79, P < 0.001). Increases in early diastolic mitral inflow (E, 74.9 ± 29.0–90.8 ± 29.5 cm/s) and LV lengthening (e', 6.5 ± 2.4–8.2 ± 2.8 cm/s) velocities were observed during LDDE leaving the E/e' ratio unchanged. Although a mean PCWP was also unchanged from rest to peak dobutamine (16.6 ± 8.3–14.2 ± 9.2, P = 0.25), E/e' and PCWP only correlated at rest (R = 0.64, P = 0.014).

  Conclusion

  The LV systolic shortening velocity is closely associated with cardiac output during LDDE in CHF patients. Dobutamine stimulation increases early diastolic mitral inflow and lengthening velocities, but the E/e' ratio does not reflect the PCWP during LDDE, which warrants some caution in converting changes in E/e' into changes in LV filling pressure. The sample size is, however, small and the observation need to be confirmed in a larger population.

• Alterations of left ventricular myocardial strain in obese children
  Aims

  Obesity may have implications in the myocardial structural change, which may contribute to mechanical consequences. Using 2D speckle echocardiography, we looked for myocardial changes and investigated their relation to obesity, inflammation, insulin resistance and physical capacity in children with isolated obesity.

  Methods and results

  Standard echocardiography and 2D strain were prospectively performed in obese children and compared them with age- and sex-matched controls. Z-score body mass index (BMI Z-score), ultra-sensitive C reactive protein, indices of insulin resistance (HOMA-IR) and metabolic stress test were assessed in obese children. Thirty-two consecutive obese patients [age: 12.8 (8–17) years; 15 males; BMI Z-score: 5.8 [2.05–8.6)] were compared with 32 controls. Longitudinal strain and circumferential strain were significantly lower in the obese group (respectively –18.0 ± 2.4% vs. –20.6 ± 2.5%; P = 0.0001 and –18.2 ± 3.5% vs. –20.1 ± 2.3%; P = 0.013), while radial strain did not differ. Longitudinal strain was correlated with HOMA-IR (Pearson's rho = –0.39) and with the exercise capacity (Pearson's rho = 0.62). In the multivariate analysis, after adjusting for age, the mean arterial pressure and left ventricular (LV) mass, the BMI Z-score remained independently related to the longitudinal and circumferential strain.

  Conclusion

  Childhood obesity may be associated with an early alteration of the longitudinal and circumferential LV strain. These findings have potentially significant clinical implications for the outcomes and follow-up of obese children meriting further studies.

• Mediastinal lung herniation in an adult patient with Scimitar syndrome
  
• Coronary flow reserve as a link between diastolic and systolic function and exercise capacity in heart failure
  Aims

  In heart failure, a reduced exercise capacity is the prevailing symptom and an important prognostic marker of future outcome. The purpose of the study was to assess the relation of coronary flow reserve (CFR) to diastolic and systolic function in heart failure and to determine which are the limiting factors for exercise capacity.

  Methods and results

  Forty-seven patients with left ventricular ejection fraction (LVEF) <35 [median LVEF 31 (inter-quartile range 26–34)] underwent cardiorespiratory exercise test with measurement of VO₂ peak, a dual X-ray absorptiometry scan for body composition, and a full echocardiography with measurement of LVEF using the biplane Simpson model, mitral inflow velocities, and pulsed wave tissue Doppler. Peak coronary flow velocity (CFV) was measured in the LAD, using pulsed-wave Doppler. CFR was calculated as the ratio between peak CFV at rest and during 2 min of adenosine stress.

  Fat-free-mass-adjusted VO₂ peak correlated significantly with CFR (r = 0.48, P = 0.002), E/e' (r = –0.35, P = 0.02), and s' (r = 0.45, P = 0.001) but not with LVEF (r = 0.23, P = 0.11). CFR correlated significantly with E/e' (r = –0.46, P = 0.003) and s' (r = 0.36, P = 0.02), but not with LVEF (r = 0.18, P = 0.26). When adjusting for CFR in a multivariable linear model, s' but not E/e' remained independently associated with VO₂ peak.

  Conclusion

  In this group of heart failure patients, VO₂ peak was correlated with CFR, E/e', and s' but not with traditional measures of systolic function. CFR remained associated with VO₂ peak independently of diastolic and systolic function and is likely to be a limiting factor in functional capacity of heart failure patients.

• Left atrial volumetry from routine diagnostic work up prior to pulmonary vein ablation is a good predictor of freedom from atrial fibrillation
  Aims

  This study aimed to identify whether left atrial (LA) volume assessed by multidetector computed tomography (MDCT) is related to the long-term success of pulmonary vein ablation (PVA). MDCT is used to guide PVA for the treatment of atrial fibrillation (AF). MDCT permits accurate sizing of LA dimensions.

  Methods and results

  We analysed data from 368 ablation procedures of 279 consecutive patients referred for PVA due to drug-refractory symptomatic AF (age 62 ± 10; 58% men; 71% paroxysmal AF). Prior to the procedure, all patients underwent ECG-gated 64-MDCT scan for assessment of LA and PV anatomy, LA thrombus evaluation, LA volume estimation, and electroanatomical mapping integration. Within a mean follow-up of 356 ± 128 days, 64% of the patients maintained sinus rhythm after the initial ablation, and 84% when including repeat PVA. LA diameter (P = 0.004), LA volume (P = 0.002), and type of AF (P = 0.001) were independent predictors of AF recurrence in univariate analysis. There was a relatively low correlation between the echocardiographic LA diameter and LA volume from MDCT (P = 0.01, r = 0.5). In multivariate analysis, paroxysmal AF (P < 0.006) and LA volume below the median value of 106 mL (P = 0.042) were significantly associated with the success of PVA, whereas LA diameter was not (P = 0.245). Analysing receiver-operator characteristics, the area under the curve for LA volume was 0.73 (P = 0.001) compared with 0.60 (P = 0.09) for LA diameter from echocardiography.

  Conclusion

  LA volume assessed by MDCT is a better predictor of AF recurrence after PVA than echocardiograpic LA diameter and can be derived from the pre-procedural imaging data set.

• Cardiac magnetic resonance-derived anatomy, scar, and dyssynchrony fused with fluoroscopy to guide LV lead placement in cardiac resynchronization therapy: a comparison with acute haemodynamic measures and echocardiographic reverse remodelling
  Aims

  Left ventricular (LV) lead positioning for cardiac resynchronization therapy (CRT) is largely empirical and operator-dependent. Our aim was to determine whether cardiac magnetic resonance (CMR)-guided CRT may improve the acute and the chronic response.

  Methods and results

  CMR-derived anatomical models and dyssynchrony maps were created for 20 patients. The CMR targets (three latest activated segments with <50% scar) were overlaid on to live fluoroscopy. Acute haemodynamic response (AHR) to LV pacing was assessed using an intra-ventricular pressure wire. Chronic CRT response (end-systolic volume reduction ≥15%) was assessed 6 months post-implantation. All patients underwent successful CMR-guided LV lead placement. A CMR target segment was paced in 75% of patients. The mean change in LVdP/dt_max for the CMR target was +14.2 ± 12.5 vs. +18.7 ± 11.9% for the best AHR in any segment and +12.0 ± 13.8% for the segment based on coronary sinus (CS) venography. Using CMR guidance, the acute responder rate was 60 vs. 50% on the basis of venography. At 6 months 60% of patients were echocardiographic responders. Of the echocardiographic responders, 92% were successfully paced in a CMR target segment compared with only 50% of non-responders (P = 0.04).

  Conclusion

  CMR guidance compared well when validated against the AHR. Lead placement was possible in the CMR target region in most patients with an AHR comparable with the best achieved in any CS branch. The chronic response was significantly better in patients paced in a CMR target segment. These results suggest that CMR guidance may represent a clinically useful tool for CRT.

• Comparison of three-dimensional echocardiographic software packages for assessment of left ventricular mechanical dyssynchrony and prediction of response to cardiac resynchronization therapy
  Aims

  We directly compared TomTec and QLAB software packages for the three-dimensional echocardiographic (3DE) assessment of left ventricular (LV) dyssynchrony including their ability to predict response to cardiac resynchronization therapy (CRT) in patients with ischaemic and non-ischaemic cardiomyopathy.

  Methods and results

  A total of 140 heart failure patients with the LVEF ≤35% and 60 healthy volunteers underwent 3DE. A subgroup of 60 patients underwent CRT and were evaluated before and 6–12 months after implantation. The systolic dyssynchrony index (SDI) was derived from the dispersion of time to minimum regional volume for all 16 LV segments and measured with both software packages and compared using Pearson's correlation and Bland–Altman analysis. Measurements of SDI were significantly higher using TomTec compared with QLAB in both patients (10.9 ± 3.8 vs. 9.7 ± 3.9, P < 0.001) and healthy volunteers (4.1 ± 0.8 vs. 2.4 ± 1, P < 0.001), with large biases and wide limits of agreement. A moderate correlation (r = 0.65, P < 0.001) was observed between both software packages in patients while their inter-observer and intra-observer reliability were good. Of the 60 patients undergoing CRT, reverse remodelling as a measure of response was observed in 41 patients (68%). The optimal SDI cut-off value to predict response to CRT was higher for TomTec than for QLAB (8.8 vs.7.3%, P < 0.001) and demonstrated better sensitivity and specificity (93 and 61%, respectively) compared with QLAB (88 and 33%, respectively). Response prediction in patients with non-ischaemic cardiomyopathy was excellent with a sensitivity and specificity of 95 and 100% for TomTec and 70 and 83% for QLAB using similar cut-off values of 9.1 and 9.2%, respectively.

  Conclusion

  Different 3DE software packages for the assessment of mechanical dyssynchrony should not be used interchangeably until better software standardization is achieved. Dyssynchrony assessment with 3DE for the prediction of response to CRT seems particularly useful in patients with non-ischaemic cardiomyopathy.

• Calcified pulmonary emboli as a late complication of the arterial switch operation
  
• The unbearable futility of deriving the left atrial size from a single-linear dimension
  
• Contribution of guidance by optical coherence tomography (OCT) in rescue management of spontaneous coronary artery dissection
  
• Provisional side branch stenting: presentation of an automated method allowing online 3D OCT guidance
  
• A dancing stone in the pericardial cavity
  
• Superior vena cava syndrome as a rare complication to lipomatous atrial septal hypertrophy (LASH)
  
• Indolent cardiac angioma mimicking hypertrophic obstructive cardiomyopathy and causing right ventricular outflow tract obstruction
  
• Cardiac rhabomyoma in a young adult presenting with junctional tachycardia
  
• Giant unruptured left ventricular pseudoaneurysm as a rare cause of heart failure after an unnoticed coronary ischaemic event
  

 

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