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Background: Although measures of longitudinal displacement of the tricuspid annulus measured by M‐mode as tricuspid annular systolic plane excursion (TAPSE) and systolic velocity by tissue Doppler imaging (TA TDI s) are routinely used for assessment of right ventricular (RV) systolic function; these measures describe different phenomena and should not be used interchangeably. Methods: Previously published data was used to determine the individual relationship between TAPSE and TA TDI s with increasing pulmonary artery systolic pressures (PASP). Results: In this retrospective analysis, 488 patients were divided into 2 groups based on TAPSE (Group 1: <1.8 cm and Group 2: ≥1.8 cm). A robust correlation (R =.79) between TAPSE and TA TDI s noted for the entire population. However, a statistically lower correlation (R =.43) was seen between Group 1 and Group 2 (R =.65; p <.0047). With increasing pulmonary pressures, only PASP (p <.0001) and TA TDI s (p <.0001) discriminated between low and normal TAPSE/PASP values. Suggesting that a TA TDI s/PASP ratio would be most useful than TAPSE/PASP with a specificity of 80%. Conclusions: Significant differences exist between TAPSE and TA TDI s, particularly at low TAPSE values with increased PASP, were uncoupling occurs. Our data seems to suggest that TA TDI s/PASP would be most useful than TAPSE/PASP ratio. Future studies should address, if abnormalities in the material properties along the RV free wall account for these differences seen between TAPSE and TA TDI s. [ABSTRACT FROM AUTHOR]

Background: Objective right ventricular (RV) systolic function assessment is attained using a series of well‐described and validated echo‐Doppler measurements. However, how left ventricular (LV) systolic function influences these RV functional measurements has not been previously studied. Consequently, we conducted a retrospective proof‐of‐concept analysis to answer this important question. Methods: A total of 100 echocardiographic studies were included and patients were divided into two groups according to their LV ejection fraction (LVEF). The following RV variables were acquired including, tricuspid annular systolic plane excursion (TAPSE), velocity of the systolic motion (TA TDI s'), RV outflow tract velocity time integral (VTI), pulmonary vascular resistance (PVR), and the TAPSE to pulmonary artery systolic pressure (PASP) ratio. Results: Not only TAPSE, TA DI s', RVOT VTI, PVR, and TAPSE/PASP were all significantly different between patients with normal versus abnormal LVEF; but most importantly, RVOT VTI (p <.0001) was the best discriminatory variable in assessing normal versus abnormal LVEF followed by TAPSE (p =.0001). Using receiver operating characteristic curve analysis, an RVOT VTI value > 11 identified patients with a normal LVEF with a sensitivity of 90% and specificity of 76%. Conclusion: Based on our results, reduced LVEF affects the RV, likely mediated by mechanisms of interventricular dependence. Therefore, RV analysis cannot be performed in isolation as it not only reflects intrinsic RV systolic function but also, is dependent on LV systolic function. In cases of reduced LVEF, additional measures of RV assessment should be used to provide better objective assessments. [ABSTRACT FROM AUTHOR]

Background: Tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio has been validated as a valuable noninvasive measure of right ventricular (RV) elastance and systolic function. However, the more reliable TA systolic (s') velocity measure of RV systolic function compared to TAPSE has not been previously studied. Methods: We conducted a pilot study using several variables of RV function in 50 patients with the main aim to determine which numerical expression between TA TDI s'/PASP and TAPSE/PASP ratio was most useful. Results: In a stepwise multiple regression analysis, TA TDI s'/PASP ratio (p <.0002); LVOT VTI/RVOT VTI ratio (p <.0002); RVOT VTI (p <.0047); TAPSE/PASP ratio (p <.0259) and TA TDI e' (p <.0292) were best in discriminating normal versus abnormal RV systolic function. Using receiver operator curve analysis, cut‐off values for both TA TDI s'/PASP (>3.9 mm/c/mmHg) had 82.1% sensitivity and 77.3% specificity while the TAPSE/PASP (>.61 mm/mmHg) had 89.3% sensitivity and 68.2% specificity in identifying normal RV function in our studied population. Conclusion: Our results indicate that TA TDI s'/PASP is a better mathematical expression when examining the relationship between RV contractility and RV resistance relationship. Furthermore, we also found that inclusion of RVOT VTI, RV diastolic properties, and left ventricular systolic function are important determinants of RV systolic function assessments and should be routinely included. Additional prospective studies are now needed to confirm these results using hemodynamic data. [ABSTRACT FROM AUTHOR]

Background: Normal right ventricular (RV) function has been traditionally assessed from the apical window. However, in several patients the subcostal window is the only available acoustic. Methods: Given the intricate functional and mechanical inter‐dependence between longitudinal tricuspid annular (TA) displacement and RV free wall contractility (RVFW), we studied the utility of RVFW inward motion using both M‐mode and velocity with tissue Doppler imaging (TDI) from the subcostal transthoracic view. Results: If a TAPSE value ≥ 2 cm is used to identify normal RV function, an RVFW M‐mode value >.8 cm, TA TDI s' velocity >.06 cm/s and TA TDI e' velocity value >.05 cm/s identify normal RV systolic function. Furthermore, ROC curve analysis for the RVFW M‐mode showed an area under the curve (AUC) of.753 (95% CI:.604–.868) with a cut‐off value >.8, sensitivity 75% and specificity 73%; for TA TDI s' AUC at.822 (95% CI:.681–.919) with a cut‐off value >.06, sensitivity 75% and specificity 77% and for TA TDI e' the AUC was.771 (95% CI:.624–.882) with a cut‐off value >.05, sensitivity 90% and specificity 46%. Reproducibility of repeat RVFW M‐mode, TDI s' and e' measurements was good with strong inter‐rater agreement (Kappa >.8). Conclusions: The subcostal window appears useful for assessing RV systolic function. Additional studies are now required to prospectively use these measures in the routine evaluation of RV systolic function particularly in patients with suboptimal apical windows. [ABSTRACT FROM AUTHOR]

Background: Speckle‐tracking echocardiography (STE) has provided a reliable means to enhance characterization and quantification of global right ventricular (RV) systolic function. The use of Automated Functional Imaging (AFI) software has been previously used to quantify RV longitudinal peak global strain (PGS) values during two‐dimensional (2D) transthoracic echocardiographic examinations. However, there is a paucity of data regarding relative strain contribution of each individual regional segments when compared with global strain assessment. Consequently, our goal was to use AFI STE to examine the strain contribution of each regional segment when assessing RV function. Methods: A retrospective analysis was performed on 107 patients that met our study criteria to correlate 2D TTE measures of RV systolic function to both RV AFI STE longitudinal peak global strain (PGS) and each individual regional RV free wall (RVFw) and inter‐ventricular septum (IS) strain values. Results: We found that TTE variables of RV systolic function only correlated with PGS (RVFAC; P <.0001, TAPSE; P <.0001, and TA TDI S'; P <.0001) but none of the six individual regional AFI strain values. When PGS was not included in the multivariate analysis, only the mid RVFw and mid IS strain regions correlated with measures of RV systolic function. Conclusions: Regional differences do exist with regards to strain generation along the RVFw and IS. These differences could be physiologically and anatomically explained based on our current understanding of RV muscle fiber arrangement. Further research is now needed to better characterize RV function in different clinical entities. [ABSTRACT FROM AUTHOR]

Introduction: There is scarce information about right ventricle (RV) function in patients with secondary pulmonary hypertension (PH) undergoing transcatheter aortic valve implantation (TAVI). We aim to identify possible RV abnormalities in patients referred for TAVI with severe aortic stenosis (sAS) and secondary PH. Methods: Objective measures of RV function, as well as noninvasive estimates of pulmonary artery systolic pressures (PASP) were obtained from 30 sAS patients undergoing percutaneous valve intervention. Results: Sixteen (53%) evaluated patients had some degree of PH. As expected, left ventricular mass index (281 ± 75 g/m2) and left atrial volume index (89 ± 23 mL/m2) values were significantly elevated. Even though RV end-systolic (8 ± 4 cm2) and end-diastolic (17 ± 4 cm2) areas were normal as well as RV fractional area change values (57 ± 16%); both longitudinal measures of RV systolic function such as tricuspid annular plane systolic excursion (1.9 ± 0.5 cm) and systolic velocity (10 ± 2 cm/ s) were clearly reduced with just mild elevations in PASP (54 ± 7 mmHg). Conclusions: Subclinical RV dysfunction is present in patients with sAS and secondary PH undergoing TAVI. Whether longitudinal measures of RV systolic function could predict clinical outcomes in these patients needs to be further explored. [ABSTRACT FROM AUTHOR]

A case of a patient presenting with an acute myocardial infarction is presented. A transthoracic echocardiographic examination revealed an abnormal color flow signal that traversed the myocardial wall from a large inferior aneurysm and initially considered to be a ventricular septal defect. However, further echocardiographic manipulation utilizing modified views along with sequential injections of both agitated saline and Definity® proved very useful to identify a pseudoaneurysm. There was no further need for any other diagnostic test, and the patient was treated surgically, undergoing successful repair of the pseudoaneurysm as well as coronary artery bypass grafting of the left coronary artery. [ABSTRACT FROM AUTHOR]

Background. While the mitral annular plane systolic excursion (MAPSE) has been suggested as a surrogate measurement of left ventricular ejection fraction, less is known about the relative value of mitral annular ascent (MAa). Methods. Our database was queried for complete transthoracic echocardiograms performed for any clinical indication. Baseline echocardiographic measurements were compared to determine any correlation between MAa and traditional Echo-Doppler echocardiographic measures to characterize left ventricular diastolic dysfunction (LVDD). Results. Patients with normal LV diastolic function were younger (41±13 years) than patients with LVDD (stage 1: 61±13 years; stage 2: 57±14 years; and stage 3: 66±17 years; p=0.156). LV ejection fraction decreased in patients with stage 2 LVDD (63±17%) and was further reduced in patients with stage 3 LVDD (28±21; p=0.003). Discussion. While a vigorous MAa excursion was seen in patients with stage 1 LVDD, MAa significantly decreased in stage 2 and stage 3 LVDD patients. Our results highlight the importance of atrioventricular coupling, as MAa motion seems to reflect changes in left atrial pressure. Additional studies are now required to better examine atrioventricular interactions and electromechanical coupling that might improve our assessment of LV diastolic function. [ABSTRACT FROM AUTHOR]

Acute coronary syndromes (ACSs) present most frequently with chest pain, but angina equivalents such as dyspnea, diaphoresis, and fatigue are not uncommon. Atypical presentations are especially seen in women, the elderly, and diabetics. Cardiac evaluation using a transthoracic echocardiogram is almost always done before or immediately after someone undergoes left heart catheterization for ACS. It provides information valuable information regarding wall motion, left ventricular systolic function, diastolic function, right ventricular involvement, pulmonary pressures, incidental valvular disease, pericardial fluid, or any other unsuspected abnormality. We describe a novel case where an atypical presentation of ACS was suspected based on the lack of intravenous contrast administered, to enhance endocardial border resolution. The use of contrast during echocardiography has been used during stress protocols to assess microcirculation during perfusion assessment studies. However, we described a reduced uptake during the acquisition of resting myocardial echocardiogram images and it was very useful to direct therapy. [ABSTRACT FROM AUTHOR]

Background Even though systolic eccentricity index has been traditionally categorized based on right ventricular ( RV) pressure overload, which hemodynamic component is particularly responsible for modulating leftward ventricular septal bowing ( LVSB) in chronic pulmonary arterial hypertension ( PAH) is less well-known. Methods Therefore, currently used echocardiographic variables, as suggested by the American Society of Echocardiography, for evaluation of RV performance were evaluated in 60 patients to determine which of these commonly used parameters best determine an abnormal LVSB in chronic PAH patients. Results In a stepwise multiple regression analysis of the echocardiographic variables used in this study, elevated pulmonary artery systolic pressures was the best discriminatory variable to identify an abnormal LVSB at any level along the interventricular septum in chronic PAH patients followed by smaller left ventricular end-diastolic volumes and larger RV end-systolic areas. Conclusion Progressive RV failure in chronic PAH not only is associated with a decline in longitudinal base to apical motion of the annulus; but also with reduced inward displacement of the RV free wall. Additional reduction in RV systolic function also occurs as a result of progressive displacement of the interventricular septum toward the left ventricle. Therefore, as measures of LVSB along the interventricular septum not only are easily obtained and related to RV systolic performance in chronic PAH patients, routine use of these parameters might be helpful in monitoring decline of RV function as well as progression of end-stage PAH. [ABSTRACT FROM AUTHOR]

Objectives: Right ventricular (RV) dilatation and systolic dysfunction are known remodeling changes occurring in chronic pulmonary hypertension and are likely the result of increases in pulmonary vascular resistance (PVR). It remains unclear whether PVR affects primarily the main RV chamber (mRVc) or the RV outflow tract (RVOT). Methods: Standard echocardiography data were collected from a heterogeneous population of 85 consecutive patients (mean age of 54 ± 12 years and mean pulmonary artery systolic pressure of 56 ± 28 mm Hg) to determine how PVR affected size and function of both RV chambers. Results: Regarding size, PVR correlated more with mRVc end systolic area (r = 0.77; P < 0.0001) than either mRVc end diastolic area (r = 0.58;P < 0.0001) or RVOT systolic length (r = 0.54; P < 0.0001), although it did not correlate with RVOT end diastolic length. In terms of fractional area change, a stronger negative correlation was seen between PVR and mRVc (r = -0.77; P < 0.0001) than with PVR and RVOT (r = -0.69; P < 0.0001). Systolic velocity of the tricuspid annulus was the best parameter in identifying elevated PVR. Conclusions: Based on the echocardiography results, increasing PVR values appear to result in differential RV remodeling with significant mRVc dilation and systolic dysfunction when compared with RVOT. It is important to determine whether the different RV remodeling processes occur in all patients with chronic pulmonary hypertension, regardless of etiology; alter therapeutic response; or determine clinical outcomes. [ABSTRACT FROM AUTHOR]

Background Increased left ventricular ( LV) mass is a well-known independent predictor of cardiovascular morbidity and mortality. Even though these patients have an increased risk of LV diastolic dysfunction; recent data have suggested the presence of subtle LV systolic abnormalities. This study sought to demonstrate if a novel speckle tracking automated functional imaging ( AFI) tool would be useful in identifying differences in strain generation between patients with normal and increased LV wall mass. Methods Standard measures of LV systolic and diastolic function were collected from 90 patients divided into Group I with LV mass index <100 g/m2 and Group II with LV mass index values ≥100 g/m2. AFI was also obtained to measure peak global LV myocardial strain. Results As expected, patients with an increased LV mass index had significant LV diastolic abnormalities. However, in addition these patients in Group II not only had significantly lower peak systolic strain values but also significantly lower mitral annular plane systolic excursion ( MAPSE) and MA tissue Doppler imaging systolic velocity values than patients in Group I despite having comparable estimates of LV ejection fraction, based on the Simpson's method. Conclusion Based on these results, AFI provides prompt point of care information regarding LV function and mechanics and identifies differences in longitudinal strain generation between patients with normal and increased LV wall mass. Additional studies are now required to prospectively determine if AFI measures of LV function might be useful to identify patients with an increased LV mass that will develop symptomatic systolic or diastolic heart failure. [ABSTRACT FROM AUTHOR]

Background A growing body of evidence seems to suggest that reduction in right ventricular (RV) systolic function is not only associated with both development of symptoms associated with pulmonary arterial hypertension (PAH) but also increased morbidity and adverse clinical outcomes. Recent data suggest that supine bicycle stress echocardiography ( sBEE) is feasible and provides realistic resistance and compliance estimations. Methods The study design was a retrospective analysis of sBEE obtained for clinical indications of dyspnea on exertion or unexplained exercise intolerance. A total of 30 sBEE studies were included. The first 10 sBEE studies served as a calibration cohort not only to establish objective measures of RV performance but also to determine feasibility and reproducibility. The following 20 sBEE served as a validation cohort. Results Our results demonstrate that tricuspid annular plane systolic excursion and tricuspid annular systolic velocity, even when measured by an untrained reader, are reliable and accurate measures of the RV response to exercise during a sBEE protocol. Furthermore, measurements of RV myocardial performance (Tei index) or peak RV strain during exercise not only are time consuming but also simply unreliable and should not be utilized to evaluate RV function during sBEE. Conclusion The results of our pilot study suggest that sBEE might be promising for detecting RV abnormalities during exercise. A larger prospective study is now needed to determine if TAPSE and tricuspid annular systolic velocity recorded during sBEE might be useful in assessing patients presenting with dyspnea during exercise or suspected of having PAH. [ABSTRACT FROM AUTHOR]

Background The severity of pulmonary vascular resistance (PVR) is known to be a critical determinant of right ventricular (RV) systolic function; this relationship remains poorly characterized. We therefore, designed a study to examine the relationship that exists between echocardiographically measured PVR and maximal tricuspid annular plane systolic excursion (TAPSE) to gain some insight regarding RV ejection efficiency (RVEe) in patients with chronic pulmonary hypertension ( cPH). Methods Standard echocardiographic measures of RV size and systolic performance were recorded from 95 patients (age 54 ± 15 years and pulmonary artery systolic pressures [ PASP] that range from 20 to 125 mmHg). For this study, RVEe was defined as TAPSE/Echocardiographic PVR. Results A strong negative correlation (R2 = −0.51, P < 0.001) was seen between TAPSE and PASP; however, a power curve trend line fit the relationship between RVEe and PASP (R2 = 0.77; P < 0.01). In a multiple regression analysis, abnormal pulmonary pressures were better identified when RVEe (P < 0.0001) was used. Conclusions Based on these results, it appears that measurement of RVEe might be extremely useful for the assessment of RV mechanics and plasticity. The power curve relationship clearly demonstrates that minimal changes in PASP (up to 50 mmHg) result in dramatic reductions in RVEe. A steady decline in RVEe, though at a lower rate, continues to occur with increasing PASP. Additional studies are required using RVEe into a functional RV imaging algorithm and determine if RVEe correlates with development of symptoms, response to therapy and overall clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Maximal systolic tricuspid annulus (TA) descent by M-mode (MM) is a well described and accepted standard reference of right ventricular (RV) systolic function; however, the contribution of each individual TA contour during the cardiac cycle has not been well characterized. Therefore, the aim of this study was to define each peak and nadir component of the constantly moving annulus. Material and Methods: Standard echocardiographic data was collected from 35 patients over a wide range of both normal and abnormal RV systolic function. Time to onset and total duration of each recognizable component of the TA tissue Doppler imaging (TDI) signal was measured and correlated to each individual change in contour of the TA, obtained by MM, during the cardiac cycle. Results: In this heterogeneous patient population, careful measurement of each recognizable component of the TA TDI signal corresponded to conformational changes in the TA contour. Furthermore, these TA TDI intervals were imprinted into the TA MM tracing and precisely identified specific systolic as well as diastolic events, regardless of RV systolic function or pulmonary hypertension severity. Conclusions: Careful observation of the constant dynamic motion of the TA, aided by high temporal resolution MM, allows better understanding of each individual component of annular motion. It appears that each peak and nadir component not only is useful in characterizing RV systole and diastole, but also would be invaluable to assess the functional relationship that exists between the right atria and ventricle; particularly, when annular motion directly reflects the contribution of both cardiac chambers. [ABSTRACT FROM AUTHOR]

Background: Understanding of right ventricular ( RV) function has significantly improved in recent years; however, objective assessment remains problematic. This study sought to demonstrate that a novel speckle tracking method can be used to assess RV global systolic function when compared with traditional echocardiographic measures. Methods: A total of 125 patients (mean age 50 ± 16 years) with a wide range not only of systolic function for both ventricles but also pulmonary pressures and acoustic windows based on patient's body surface areas were studied. Standard parameters of left and RV systolic function were collected and echocardiographic images from four-chamber apical planes were analyzed by conventional manual tracing using a novel General Electric ( GE) automated functional imaging ( AFI) to measure myocardial strain. Results: Global longitudinal RV strain measurements obtained with manual tracing showed good correlation with traditional parameters of main RV chamber as well as right ventricular outflow tract ( RVOT) systolic performance. In a stepwise multiple regression analysis, tricuspid annular systolic motion was the best independent variable that correlated with global AFI RV peak systolic strain followed by RV outflow tract systolic excursion. Receiver operating characteristic analysis showed a global RV AFI peak systolic strain value <−17% to be abnormal (sensitivity 73%, specificity 91%). Discussion: This new automated AFI method provides simultaneous quantitation of global and regional RV function that is angle independent and correlates with standard measures of RV performance without the need for additional derivative measurements, complex calculations, or tedious offline analysis. [ABSTRACT FROM AUTHOR]

Background Even though chronic pulmonary hypertension ( cPH) and acute pulmonary embolism ( aPE) increase pulmonary vascular resistance and result in right ventricular ( RV) dilatation and systolic dysfunction; both conditions operate through drastically different mechanisms. Unfortunately, simple echocardiographic examination might be insufficient to distinguish both entities. This study attempted to determine which objective measures would be useful in differentiating aPE from cPH. Methods Standard measures of main RV as well as RV outflow tract ( RVOT) size and systolic performance calculations were retrospectively measured from 15 patients with confirmed aPE by chest computed tomography and compared with similar data collected from the same number of age-matched patients with moderate ( mcPH), severe ( scPH), and patients without PH. Results Although a positive McConnell sign was seen in 60% of aPE patients and in 17% of the cPH patients, all aPE had a profound reduction in RVOT systolic excursion when compared with cPH patients. Furthermore, maximal tricuspid annular plane systolic excursion, velocity time integral of the RVOT ejection signal, end-systolic or end-diastolic RV to left ventricle ( LV) dimension ratio were not useful to distinguish aPE from any of the 2 forms of cPH. Conclusion This study demonstrated that measurement of RVOT systolic excursion not only is feasible but also extremely useful in identifying aPE and it is particularly helpful in differentiating it from patients with either mcPH or scPH. This variable might be useful to estimate the global impairment in RV contractility and acute hemodynamic derangement seen in aPE. [ABSTRACT FROM AUTHOR]

We describe the case of a 37-year-old female with severe pulmonary hypertension on intravenous Remodulin and Tracleer who experienced presyncope following a six-minute walk. A transthoracic echocardiogram, in addition to showing the usual findings of chronic pulmonary hypertension, also demonstrated a noticeable increase in both mitral annular systolic and early diastolic (E') velocities while performing the Valsalva maneuver. Most importantly, a significant increase in the propagation velocity to an almost perpendicular tilt was noted with Valsalva, resembling the propagation velocity profile that has only been previously described in cases of constrictive pericarditis. The clinical relevance of this finding and the pathophysiologic implications are reviewed and discussed. [ABSTRACT FROM AUTHOR]

Background: Color M-mode (CMM) has been useful in characterizing left ventricular (LV) relaxation as well as providing information regarding right ventricular (RV) filling dynamics and pressure gradients. The spatiotemporal resolution of CMM offers a unique opportunity to study the effect of chronic pulmonary hypertension (cPH) on biventricular diastolic function. Methods: Propagation velocities of LV and RV diastolic flows were obtained from 20 individuals with normal pulmonary artery systolic pressures, designated Group I (mean age 50 ± 12 years and 32 ± 6 mmHg) and from 30 patients with cPH, designated Group II (mean age 55 ± 14 years and 81 ± 25 mmHg). Results: Group II patients not only had a significant difference between RV and LV onset of early (13 ± 55 vs. −223 ± 333 msec; P < 0.003) and late (−494 ± 467 vs. −125 ± 258 msec; P < 0.001) diastolic flows; but also had lower propagation velocities of the main RV (40 ± 10 vs. 28 ± 10 cm/sec; P < 0.0001) and LV (52 ± 11 vs. 37 ± 15 cm/sec; P < 0.0003) diastolic flows than Group I individuals. Conclusions: It appears that cPH disrupts not only RV and LV diastolic signal distribution but also their temporal occurrence as well as reducing the propagation velocities of the main diastolic signals in both ventricles. These results seem to imply that cPH causes significant interventricular diastolic dyssynchrony and further studies are now needed to correlate these findings with regard to symptoms and patient clinical outcomes. (Echocardiography 2012;29:653-660) [ABSTRACT FROM AUTHOR]

Background: Tissue Doppler imaging (TDI) of mitral (MA) and tricuspid annulus (TA) events characterizes systolic and diastolic properties of each respective ventricle. However, the effect of chronic pulmonary hypertension (cPH) on these TDI annular events has not been well described. Methods: Measurements of right ventricular (RV) performance with TDI of the lateral mitral and tricuspid annuli, to measure isovolumic contraction (IVC) and systolic (S) signals were recorded from 50 individuals without PH and from 50 patients with cPH. To avoid confounding variables, all patients had normal left ventricular ejection fraction and were in normal sinus rhythm at the time of the examination. Results: As expected, markers of RV systolic performance were markedly reduced while LV systolic function remained largely unaffected in cPH patients when compared to patients without PH. TDI interrogation of the MA revealed lengthening of the time interval between IVC and systolic signal (70 ± 17 msec) when compared to individuals without PH (43 ± 8 msec; P < 0.0001). In contrast, cPH markedly shortened the time interval between IVC and the TA systolic signal (34 ± 12 msec) when compared to individuals without PH (65 ± 17 msec; P < 0.0001). Conclusions: cPH lengthens time interval between the IVC and the MA systolic signal while shortening this same interval when the TA is interrogated with TDI; reflecting the potential influence that cPH exerts in biventricular performance. Whether measuring these intervals be routinely used in the follow-up of cPH patients will require further study. (Echocardiography 2010;27:969-976) [ABSTRACT FROM AUTHOR]

Background: The McConnell sign has been regarded as a highly specific echo finding in acute pulmonary embolism (aPE). However, a completely satisfying explanation to account for this observation in aPE remains elusive. We used longitudinal velocity vector imaging (VVI) using a dedicated software program (Research Arena, Siemens, California) to assess regional right ventricular global and apical (RVa) mechanics between aPE and chronic pulmonary hypertension (cPH) patients. Methods: Standard echo parameters of RV performance as well as base to apex RV strain and dyssynchrony were quantified using VVI in a total of 30 patients. The population studied was divided into three groups: Group I included 10 healthy volunteers (50 ± 16 years), Group II consisted of 10 patients (47 ± 13 years) with known cPH, and Group III comprised 10 patients (58 ± 18 years; P = 0.323) with documented aPE. Results: Progressively lower indices of RV performance as well as RV basal and apical strain were recorded in Groups II and III, respectively. Most importantly, no difference in RVa segmental strain values was seen between Groups II and III. Conclusions: Based on this pilot data, aPE patients demonstrate a significant reduction in overall RV strain with a similar reduction in RV apical deformation. Therefore, regional RVa function is not truly spared in aPE and the probable visual illusion of preserved contractility might simply reflect tethering of the RVa to a hyperdynamic left ventricle in the presence of an acutely dilated RV. (Echocardiography 2010;27:614-620) [ABSTRACT FROM AUTHOR]

Background: Systolic eccentricity index (sEI) has been traditionally measured at the papillary muscle (PM) level. However, this measurement does not take into account the remodeling that occurs in the right ventricle (RV) during chronic pulmonary hypertension (cPH). Methods: Standard echocardiographic data were collected on 50 patients (age 58 ± 14 years) with known cPH (74 ± 22 mmHg; range 45–120 mmHg) who had adequate short-axis views at the mitral valve (MV), PM, and apical (AP) levels to measure sEI. All had a normal left ventricular ejection fraction (72 ± 10%). Results: In a multivariate analysis, the traditional PM level sEI correlated the best with cPH when pulmonary artery systolic pressures (PASP) ranged between 45 and 60 mmHg (r =−0.569, P < 0.001) while AP level sEI was better when all patients were included in the analysis (r =−0.843, P < 0.0001). Not only was AP level sEI the only echo variable helpful in identifying a dilated end diastolic RV area (r =−0.730, P < 0.0001) but also patients with worse RV systolic performance (r = 0.686, P < 0.0001). MV level sEI was not better than PM level sEI. Conclusions: AP level sEI appears to be superior to traditional PM level sEI measurement as it correlates better with worsening PH severity, RV cavity dilation and RV systolic dysfunction. Further studies are now required to prospectively study how these septal abnormalities in cPH may affect RV as well as LV systolic and diastolic function. (Echocardiography 2010;27:534-538) [ABSTRACT FROM AUTHOR]

Background: Left ventricular diastolic dysfunction (LVDD) is known to occur in severe chronic pulmonary hypertension (PH); however, the mechanism(s) remains unclear. Methods: Tissue Doppler imaging (TDI) was used to track early (E) diastolic signals of basal and mid portions of the interventricular septum (IS) and LV free wall (LVFw) in 20 patients (60 ± 8 years) with documented LVDD without PH and in 30 patients (60 ± 11 years) with known chronic PH. All subjects were in normal sinus rhythm and had normal LV ejection fraction. Results: PH patients had lower early (E) wave velocities in basal IS (–4.2 ± 1.9 vs. –5.9 ± 1.2 cm/sec; P < 0.001), distal IS (–2.6 ± 2.6 vs. –4.2 ± 1.1 cm/sec; P < 0.01), and basal LVFw (–5.2 ± 1.7 vs. –6.5 ± 1.2 cm/sec; P < 0.01) than patients with LVDD and no PH. Finally, worsening PH distorts the entire IS diastolic tracing resulting in asynchronous diastolic signals. Conclusions: The presence of PH not only decreases IS early (E) wave diastolic velocity generation but also distorts the entire pattern of IS diastolic relaxation when compared to patients with typical LVDD and no PH. Further studies are now needed to assess the full effect of PH on LV diastole and how this influences clinical outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Even though pulmonary hypertension (PH) results in right ventricular (RV) dilatation and contractile dysfunction; the exact mechanism(s) remain to be identified. RV fractional area change (RVFAC), right atrial (RA) areas, tricuspid annular plane systolic excursion (TAPSE), and systolic (sEI) eccentricity index were measured in 19 PH patients and 11 individuals without PH. Furthermore, time to maximal peak (tmp) TV annular ascent and descent intervals were obtained and corrected for heart rate. Finally, P wave and QRS interval durations as well as heart rates were also measured. As expected, PH results in lower RVFAC and TAPSE, smaller sEI and larger RA areas. More interestingly, longer P wave and QRS durations without significant difference in heart rate are noted in PH patients. Similarly, it took longer to reach maximal TV annular ascent as well as annular descent in PH patients than in those patients without PH. PH significantly prolongs both electrical as well as mechanical events related to annular motion, implying that PH contributes to increased atrial as well ventricular activation times. The nature of this functional coupling between RA and RV necessitates further study. [Copyright &y& Elsevier]

Background: Tissue Doppler imaging (TDI) has been quite useful in determining the mechanical properties of right ventricular (RV) function in patients with pulmonary hypertension (PH). However, to what extent these mechanical properties are expected to identify RV dysfunction in PH patients is less clear. Methods: Our echocardiography database was queried for patients with PH of different etiologies (111 patients, age 55 ± 14 years, mean pulmonary artery pressure 63 ± 24 mmHg) who had undergone TDI analysis and compared to similarly collected data from a group of healthy individuals (35 patients, mean age 45 ± 15 years, mean pulmonary artery pressure 27 ± 5 mmHg). Results: ROC analysis demonstrated that a mechanical delay between the RVFw and IS > 25 ms detects PH while a delay > 37 ms detects abnormal RV performance. Peak RV strain < −20% identifies PH greater than 40 mmHg and a reduced RV systolic function. However, on a stepwise multiple regression analysis model RV dyssynchrony was the most significant predictor of PH (r = 0.515; P = 0.0003) over peak longitudinal RV strain (r = 0.553; P = 0.02) and RVFAC (r =−0.603; P = 0.01). Peak longitudinal strain was the most significant predictor (r =−0.722; P < 0.0001) of an abnormal RVFAC over PH (r =−0.603; P = 0.004) and RV dyssynchrony (r =−0.471; P = 0.01). Conclusion: A normal range of RV mechanical variables in PH patients are provided that can be applied in the assessment of RV performance. [ABSTRACT FROM AUTHOR]

Background: Although right ventricular (RV) dyssynchrony has been identified in patients with severe pulmonary hypertension due to significant RV enlargement and compromise in systolic function, a more clinically relevant question pertains to RV mechanical properties in patients with mild elevation in pulmonary artery systolic pressures (PASP). Methods: Several echocardiographic parameters and peak longitudinal strain were measured in 40 patients and divided into two groups of 20 patients based on their PASP. Results: Group I included 20 individuals (mean age 48 ± 16 years with a mean PASP of 27 ± 5 mmHg) and Group II included 20 patients (mean age 63 ± 14 years with a mean PASP of 49 ± 7 mmHg.) All time intervals were adjusted for heart rate. RV fractional area change and tricuspid annular plane systolic excursion for Group I (62 ± 12% and 2.74 ± 0.56 cm) and Group II (49 ± 14%; P < 0.02 and 2.09 ± 0.40; P < 0.002) were both normal. However, Group II had lower peak longitudinal RV free wall (RVF) strain (−27.3 ± 7.1 % vs. −31.9 ± 8.7%, P < 0.04), longer time to peak RVF strain (448 ± 57 ms vs. 411 ± 43 ms; P < 0.03) and evidence of significant RV dyssynchrony (−83 ± 55 ms vs. 1 ± 17 ms, P < 0.00001) in contrast to Group I. Conclusion: In conclusion, mild elevations in PASP affect the mechanical properties of the RV and result in RV dyssynchrony despite absence of gross abnormalities in RV size or function. [ABSTRACT FROM AUTHOR]

Background: Annular motion (AM) has been shown to occur during all dynamic phases of the cardiac cycle; but little is known regarding comparisons between mitral and tricuspid AM. We elected to use M-mode to examine the extent and timing of mitral and tricuspid AM events. Methods: A complete echocardiogram was obtained in 50 patients [mean age 53 ± 16 years, mean left ventricular ejection fraction (LVEF) 57 ± 19%, and mean right ventricular fractional area change (RVFAC) of 49 ± 20%]. Timing of all AM intervals was corrected for heart rate. Results: A strong linear correlation was noted for both LVEF and maximal mitral annular systolic excursion and for RVFAC and maximal tricuspid annular systolic excursion (r = 0.91, P < 0.0001). The amplitude of both maximal mitral annular descent (1.54 ± 0.45 cm) and ascent (0.64 ± 0.23 cm) was significantly smaller than for the tricuspid annulus (2.26 ± 0.73 and 0.98 ± 0.37 cm; P < 0.0001, respectively). Furthermore, while it takes longer for the mitral than for the tricuspid annulus (403 ± 52 ms vs 308 ± 50 ms; P < 0.0001, respectively) to descend to its lowest point; the duration to reach maximal ascent is shorter for the mitral than for tricuspid annulus (90 ± 22 ms vs 115 ± 19 ms; p < 0.0001, respectively). Conclusion: Significant differences exist in both amplitude and timing of AM events between the mitral and tricuspid annuli, likely reflecting intrinsic anatomical and electromechanical differences between both sides of the heart that require further investigation. [ABSTRACT FROM AUTHOR]

Maximal tricuspid annular plane systolic excursion (TAPSE) correlates well with right ventricular (RV) function; however, little is known regarding the impact of left ventricular (LV) systolic function on TAPSE. Consequently, TAPSE was examined in 206 patients (105 men; mean age 56 ± 17 years), and the data were analyzed with respect to RV (RV fractional area change 45 ± 19%) and LV (56 ± 17%) systolic function. The mean TAPSE for the population studied was 1.97 ± 0.72 cm. Although a strong linear correlation was noted between RV fractional area change and TAPSE (r = 0.73, p <0.0001), relative differences with regard to TAPSE were also found. First, the greatest TAPSE was noted only when RV and LV systolic function were normal (2.46 ± 0.50 cm). Second, patients with reduced RV systolic function had the smallest TAPSE (1.28 ± 0.48 cm, p <0.0001). Third, patients with normal RV function but reduced LV systolic function had TAPSE (1.91 ± 0.54 cm, p <0.0001) that was intermediate between that of patients with normal RV and LV systolic function and those with abnormal RV systolic function. Fourth, patients with reduced biventricular function had the smallest TAPSE (1.16 ± 0.41 cm, p <0.0001). In conclusion, TAPSE is not only determined by RV systolic function but also appears to depend on LV systolic function. TAPSE <2.0 cm is associated with some degree of either RV or LV dysfunction, whereas a value >2.0 cm suggests normal biventricular systolic function. [Copyright &y& Elsevier]

The presence of right ventricular (RV) dysfunction is an adverse prognostic indicator but current echocardiographic methods have some limitations. RV apical angles in systole and diastole were correlated with known parameters of RV function in patients without pulmonary hypertension (Group 1) and in patients with pulmonary hypertension (Group 2). RV apical angles were significantly smaller in both systole (22 ± 7°) and diastole (33 ± 6°) in Group 1 patients when compared to Group 2 (54 ± 18°, p < 0.0001 and 59 ± 17°, p < 0.0001, respectively). RV apical angles, both in systole and diastole, were strongly correlated with RV end-systolic area (R = 0.89, p < 0.0001) and end-diastolic area (R = 0.81, p < 0.0001), respectively. Similarly, the apical systolic and diastolic angle correlated well with decreased tricuspid annular plane systolic excursion (TAPSE, R =−0.76 and R =−0.73, p < 0.001) as well as with decreased RV fractional area change (R =−0.81 and R =−0.77, p < 0.001). Therefore, we conclude that this new measurement of RV apical angle is simple and useful to quantify RV apical structural and functional abnormalities that are well correlated with global RV impairment in patients with chronic pulmonary hypertension. [ABSTRACT FROM AUTHOR]

Several well-established echocardiographic parameters used in the assessment of right ventricular (RV) performance, as well as tissue Doppler imaging (TDI) to investigate RV free wall mechanical events, were prospectively obtained from a heterogenous group of 20 patients with varying degrees of pulmonary hypertension (mean age 51 ± 13 years; World Health Organization class average 2.8, mean pulmonary systolic pressure 78 ± 24 mm Hg) and compared with similar data retrospectively obtained from 20 healthy volunteers (mean age 45 ± 15 years). Patients with varying degrees of pulmonary hypertension had worse RV performance parameters than healthy volunteers (RV fractional area change 37 ± 13% vs 52 ± 5%, p &#60; 0.0001; RV myocardial performance index 0.76 ± 0.31 vs 0.29 ± 0.11, p &#60; 0.0001; and eccentricity index 1.41 ± 0.57 vs 0.98 ± 0.06, p &#60; 0.005). Similarly, in these patients with abnormal RV performance, TDI showed statistically significant smaller peak longitudinal RV free wall strain (−21.5 ± 9.0% vs −28.0 ± 4.1%, p &#60; 0.01) and significantly delayed time to peak strain (459 ± 76 vs 388 ± 29 ms, p &#60; 0.0005) values than in healthy volunteers; a very strong correlation between RV mechanical delay and RV fractional area change (r = −0.89) was noted. [Copyright &y& Elsevier]

Background: Histological studies in animal models have showed that extensive atrial fibrosis or fatty deposition as a result of loss of atrial cardiomyocytes increases the propensity to develop atrial fibrillation (AF). Although several reports have suggested that AF in humans may be a consequence of these mechanisms, no study has correlated the presence of AF with interatrial septal thickness (IAST). Methods: Accordingly, we conducted a prospective analysis in 150 consecutive patients referred for transesophageal echocardiography (TEE) for numerous medical reasons. A total of 105 patients (mean age 62± 14 years) who met inclusion and exclusion criteria were included for analysis. Pertinent demographics, echocardiographic chamber dimensions, left ventricular ejection fraction (LVEF), color flow, and spectral Doppler analysis, as well as IAST measured in both systole (S) and diastole (D) were obtained. Results: When patients with a documented history of AF were compared to patients without documented AF, no statistical difference was noted in terms of patients’ height, weight, IVS thickness, or LVEF. Patients with AF had a significantly larger left and right atrial dimensions (P<0.001), lower left atrial appendage emptying velocities (P<0.002), and pulmonary vein systolic Doppler signal (P<0.01). The IAST in systole in patients with AF was 0.75± 0.27 cm versus 0.60± 0.16 cm in patients without AF (P<0.006) while the IAST in diastole was 0.61± 0.22 cm versus 0.49± 0.12 cm, respectively (P<0.009). However, no statistical difference was noted between IAST in either systole (P<0.8) or diastole (P<0.8) among patients with AF based on the duration of this arrhythmia. Conclusions: The results of this prospective TEE study show a statistically significant increase in IAST with the presence of AF independent of patient's age, height, weight, and the degree of IVS thickness. In addition, since no significant valvular abnormalities or compromise in left ventricular systolic function were present, the increase in IAST in patients with AF then suggest possible changes in the material properties of the atrial wall, easily identified by TEE on the interatrial septum, either as a cause or as a result of AF. Since no correlation was found between the degree of IAST and the duration of AF, the presence of IAST not only might identify patients with a higher propensity to have or develop this atrial arrhythmia; but also be a surrogate marker of changes within the components of the atrial wall in AF.(ECHOCARDIOGRAPHY, Volume 22, May 2005) [ABSTRACT FROM AUTHOR]

We report the case of a female patient emergently transferred to our institution with the presumptive diagnosis of myocardial infarction in heart failure given the constellation of symptoms and abnormal laboratory cardiac markers on presentation. However, on closer examination, prior to instituting an invasive cardiac work-up, pulmonary embolism was instead strongly considered to explain a common etiology. Therefore, an echocardiogram was promptly obtained, which revealed the presence of McConnell's sign. This noninvasive imaging modality proved to be critical in the prompt recognition and management of this patient. We reviewed the literature regarding the use of echocardiography and the clinical significance of abnormal cardiac markers in patients presenting pulmonary embolism.(ECHOCARDIOGRAPHY, Volume 22, March 2005) [ABSTRACT FROM AUTHOR]

Background: Coronary cameral fistulas are an uncommon entity, the etiology of which may be congenital or traumatic. They involve abnormal termination of a coronary artery, usually the right coronary, into a cardiac chamber, usually the right ventricle. Case Presentation: We describe a case of female patient with severe aortic stenosis and interventricular septal hypertrophy that underwent bioprosthetic aortic valve replacement with concomitant septal myectomy. On subsequent follow-up an abnormal flow traversing the septum into the left ventricle was identified and Doppler interrogation demonstrated a continuous flow, with a predominantly diastolic component, consistent with coronary arterial flow. Conclusion: The literature on coronary cameral fistulas is reviewed and the etiology of the diagnostic findings discussed. In our patient, a coronary artery to left ventricle fistula was the most likely explanation secondary to trauma to the septal perforator artery during myectomy. Since the patient was asymptomatic at the time of diagnosis no intervention was recommended and has done well on follow-up. [ABSTRACT FROM AUTHOR]

Background: An unusual sequence of post operative events heralded by hemodynamic deterioration followed by dyspnea and rapidly progressive dilatation of superficial neck and facial veins, resembling a superior vena cava syndrome, two days post surgical resection of filamentous aortic valve masses, closure of a patent foramen ovale, and performance of a modified Maze procedure for atrial fibrillation in a patient that presented with transient neurologic findings is presented. Case Presentation: Although both clinical findings and hemodynamic derangements completely resolved following tricuspid valve repair aimed to correct the new onset severe tricuspid regurgitation noted post operatively; a clear mechanism was not readily obvious and diagnostic testing data somewhat conflictive. We present a careful retrospective examination of all clinical data and review possible clinical entities that could have been implicated in this particular case and recognize that transesophageal echocardiographic findings were most useful in identifying the best course of action. Conclusion: After reviewing all clinical data and despite the inconclusive nature of test results; the retrospective examination of transesophageal echocardiographic findings proved to be most useful in identifying the best course of action. We postulate that in our case, resolution of the suspected pulmonary embolism with anticoagulation and reestablishment of a normal right ventricular geometry with tricuspid valve repair worked in unison in restoring normal hemodynamics and resolving both dyspnea and venous dilatation. [ABSTRACT FROM AUTHOR]

Background: Abnormalities in right ventricular function are known to occur in patients with pulmonary arterial hypertension. Objective: Test the hypothesis that chronic elevation in pulmonary artery systolic pressure delays mechanical activation of the right ventricle, termed dyssynchrony, and is associated with both symptoms and right ventricular dysfunction. Methods: Fifty-two patients (mean age 46 ± 15 years, 24 patients with chronic pulmonary hypertension) were prospectively evaluated using several echocardiographic parameters to assess right ventricular size and function. In addition, tissue Doppler imaging was also obtained to assess longitudinal strain of the right ventricular wall, interventricular septum, and lateral wall of the left ventricle and examined with regards to right ventricular size and function as well as clinical variables. Results: In this study, patients with chronic pulmonary hypertension had statistically different right ventricular fractional area change (35 ± 13 percent), right ventricular end-systolic area (21 ± 10 cm2), right ventricular Myocardial Performance Index (0.72 ± 0.34), and Eccentricity Index (1.34 ± 0.37) than individuals without pulmonary hypertension (51 ± 5 percent, 9 ± 2 cm2, 0.27 ± 0.09, and 0.97 ± 0.06, p < 0.005, respectively). Furthermore, peak longitudinal right ventricular wall strain in chronic pulmonary hypertension was also different -20.8 ± 9.0 percent versus -28.0 ± 4.1 percent, p < 0.01). Right ventricular dyssynchrony correlated very well with right ventricular end-systolic area (r = 0.79, p ± 0.001) and Eccentricity Index (r = 0.83, p < 0.001). Furthermore, right ventricular dyssynchrony correlates with pulmonary hypertension severity index (p < 0.0001), World Health Organization class (p < 0.0001), and number of hospitalizations (p < 0.0001). Conclusion: Lower peak longitudinal right ventricular wall strain and significantly delayed time-to-peak strain values, consistent with right ventricular dyssynchrony, were found in a small heterogeneous group of patients with chronic pulmonary hypertension when compared to individuals without pulmonary hypertension. Furthermore, right ventricular dyssynchrony was associated with disease severity and compromised functional class. [ABSTRACT FROM AUTHOR]

Cardiovascular manifestations in patients infected with human immunodeficiency virus (HIV) have been altered by the introduction of highly active antiretroviral therapy regimens that allow more effective prophylactic treatment and an increased time of survival. Because of this, noninfectious cardiac conditions associated with HIV disease are being recognized with increasing frequency in these patients. Cardiac involvement in HIV-infected patients varies from clinically silent to overtly symptomatic disease. By some estimates a direct cardiac cause of mortality is between 1% and 6% of all cases. Pericardial effusion, pericarditis, myocarditis, cardiomyopathy, endocarditis, and pulmonary hypertension are well-recognized cardiac illnesses associated with HIV infection. Echocardiography has been crucial in evaluating HIV-infected patients to assess the extent of cardiac involvement. This case report illustrates atypical echocardiographic manifestations of endocarditis and paravalvular abscess in an immunocom-promised patient.(ECHOCARDIOGRAPHY, Volume 21, November 2004) [ABSTRACT FROM AUTHOR]

A case of a large left atrial appendage thrombus in the presence of severe mitral regurgitation is presented. The use of transesophageal echocardiography in this setting was not only useful but also crucial despite the low anticipated diagnostic yield given the expected altered left atrial flow dynamics from the turbulent regurgitant lesion. However, additional confounding factors could have acted as potential mechanisms to enhance thrombosis in this setting and consequently are discussed.(ECHOCARDIOGRAPHY, Volume 21, October 2004) [ABSTRACT FROM AUTHOR]

A case of a 70-year-old female with a history of hypertension, atrial fibrillation, pacer implantation for symptomatic bradycardia, and a prior cerebrovascular accident, and had developed persistent methicillin-sensitive Staphylococcus aureus bacteremia is reported here. As part of her evaluation, a transesophageal echocardiogram was performed, and even though no vegetations were seen on either pacer wires or cardiac valves, a massive homogeneous thickening of the superior portion of the interatrial septum extending to the posterior and roof portions of the right atrial wall as well as to the superior vena cava causing proximal compression of this vessel was noted. Computed tomographic examination of the chest helped to determine that this mass density was not a tumor but in fact intrapericardial fat. Imaging findings and existing literature on this topic are reviewed. [ABSTRACT FROM AUTHOR]

Abstract: Systolic eccentricity index (sEI) has been shown to correlate with pulmonary hypertension (PH). However, its relative value with regards to other echocardiographic indices of right ventricular (RV) size and function in PH has not been studied. Consequently, several echocardiographic variables were collected from 103 patients (mean age 54±15 years, 46 males) with a mean PASP 62±37 mm Hg (range 24 to 130 mm Hg). Of the studied variables sEI was the only multivariate predictor of PH (p <0.0001, 95% CI −0.924 to −0.671). This was further confirmed in a subgroup of patients who underwent invasive cardiac hemodynamic assessment showing a similar correlation between invasive hemodynamics and sEI. Based on these results, sEI appears to be an easily obtained variable that should be routinely included in the identification of RV dysfunction in PH patients. [Copyright &y& Elsevier]

Introduction: Early left ventricular (LV) filling has been described as an asymmetric toroidal vortex ring of blood entering the LV upon opening of the mitral valve. This phenomenon is in part responsible for cyclical changes in LV volumes during the cardiac cycle and also contributes to the apical and basal longitudinal displacements of the mitral annulus (MA). Although MA early diastolic (e') velocities have been used to assess early LV filling characteristics, accurate distinction between normal aging and pathological diastolic dysfunction (DD) might be challenging at times. Methods: In this pilot study, echocardiographic data from 60 consecutive patients were reviewed. The studied population was allocated into three groups based on the new American Society of Echocardiography guidelines for diastolic dysfunction classification. To better define LVDD, we based our interpretation of MA tissue Doppler imaging (TDI) signals on the well-described displacement pump mechanism of the MA plane functioning as a piston unit. Results: Patients with normal diastolic function were younger (50 ± 14 years) than those with DD (group II: 69 ± 8 and group III: 63 ± 17 years) (p < 0.001) with a slight female predominance (57%). As expected, volumetric variables as well as mitral inflow and MA TDI measures were significantly different among the three studied groups (p < 0.001) with the exception of the left atrial volume index. Interestingly, careful interrogation of the MA TDI signal revealed a distinctive appearance of a recoil signal right after the MA e' velocity only occurring in patients with normal LV diastolic function. Conclusions: Identification of an early characteristic recoil signal occurring on the MA TDI right after the e' velocity seems to be useful in the characterization of LVDD. Additional prospective studies are now needed to validate its utility as an additional criterion to be used in LVDD. [ABSTRACT FROM AUTHOR]

Background Even though the tricuspid annulus (TA) is anatomically and functionally related to right atrioventricular dependence and tricuspid annular plane systolic excursion (TAPSE) is a well-known measure of right ventricular (RV) systolic function, there is paucity of data regarding the potential impact that right atrial (RA) size and function have on TAPSE. Hence, we sought to determine whether RA volumetric and longitudinal measures affect TAPSE in patients with chronic pulmonary hypertension (cPH). Methods In this retrospective study, echocardiographic data from 110 patients were reviewed and the studied population was divided into Group I consisting of 50 patients (50±11 years) without PH and Group II that included 60 patients (55±14 years) with cPH. Results Even though RA areas, RA fractional area change, and maximal long-axis length measurements were abnormal in cPH patients, TA tissue Doppler imaging systolic velocity and RV fractional area change were the only useful variables in identifying patients with abnormal TAPSE ( P<.0001 and P=.018, respectively). Additionally, TAPSE was independent of all RA measures, left ventricular ejection fraction, and age ( P>.05). Conclusions Based on these results, TAPSE does not appear to be influenced by either RA size or function. Additional studies using strain echocardiography to interrogate RA mechanics might now be very useful to advance our understanding of TA motion in cPH patients given recent data showing that RA function accounts for a significantly greater proportion of total right heart function in patients with cPH than in normal subjects. [ABSTRACT FROM AUTHOR]

The article presents information on a continuing medical education activity related to the article "Chronic Pulmonary Hypertension Causes Significant Interventricular Spatiotemporal Dyssynchrony When Onset of Diastolic Flow Signals are Assessed by Color M-Mode," which medical professionals can participate in to receive continuing education credits.

Abstract: We appreciate the interest shown by Dr. Song regarding our recent paper demonstrating the utility of tissue strain imaging to identify right ventricular (RV) dysfunction in pulmonary hypertension (PH). Dr. Song raises several questions that deserve comment. Both RV strain and systolic eccentricity index have been shown to correlate with RV function in patients with PH. We believe that both methods are complimentary to each other in their assessment of RV dysfunction. RV diastolic function was not measured in our study and therefore we cannot comment on its correlation with hemodynamic variables. Future research is warranted to ascertain the role of RV diastolic dysfunction in the progression of RV failure in patients with PH. [ABSTRACT FROM AUTHOR]

Article Title: Right Ventricular Apical Contractility in Acute Pulmonary Embolism: The McConnell Sign Revised (Echocardiography 2010;27:613) [ABSTRACT FROM AUTHOR]

Abstract: This case report presents a rare clinical finding of an isolated quadricuspid aortic valve in an otherwise healthy 24-year-old female who was referred for cardiac evaluation due to newly identified murmur. A transthoracic echocardiogram suggested an unusual case of a bicuspid aortic valve with two raphes with normal opening and mild aortic regurgitation. This case exemplified that caution should be taken when encountering circumstances like the one presented, as the aortic valve anatomy might be mistaken based on a new proposed classification for bicuspid aortic valves recently published. Further evaluation identified the presence of a quadricuspid aortic valve using computer tomography of the chest. Care should be taken in evaluating aortic valves as in this case. The literature regarding quadricuspid aortic valves is reviewed. [Copyright &y& Elsevier]

Abstract: A 44-year-old female presents with disabling dyspnea and is unable to perform a regular treadmill stress test; instead a dobutamine stress echocardiogram is performed and although negative for ischemia reveals a vigorous paradoxical motion of the interventricular septum with dilatation of the inferior vena cava without respiratory variation and an increased diastolic flow signal in the hepatic veins after expiration with the infusion of dobutamine. The diagnosis of constrictive physiology is confirmed with cardiac magnetic resonance imaging (MRI) and right heart hemodynamics and the patient underwent pericardiectomy without complications with resolution of symptoms. [Copyright &y& Elsevier]

Background: A growing body of evidence suggests that the presence of a right bundle branch block (RBBB) is a negative prognostic indicator in patients with and without preexisting heart disease. Even though electromechanical activation of the right ventricle (RV) in patients with RBBB and pulmonary hypertension (PH) has been investigated; a direct comparison of the presence of RBBB, on the duration of RV mechanical systole using echocardiography has not been studied. Materials and Methods: In this retrospective study, we analyzed the echocardiograms of 40 patients by measuring the magnitude and timing of tricuspid annulus plane systolic excursion (TAPSE) and tricuspid annulus systolic velocity (TA S'). Patients were selected to form four groups of ten patients based on the presence or absence of RBBB and PH to determine if RBBB has any effect on the time-to-peak of TAPSE or TA S', which for our purposes serves as a measure of duration of RV mechanical systole. Results: Our results demonstrate that RBBB leads to a measurable prolongation of TAPSE and TA S' in patients without PH. Time-to-peak of TAPSE or TA S' was not significantly prolonged in patients with PH. Conclusions: The results of this pilot study show that RV mechanical systole is prolonged in patients with RBBB, and the addition of PH attenuates this change. Additional prospective studies are now required to elucidate further the electrical and mechanical dyssynchrony that occurs as a result of RBBB, and how these new echocardiographic measurements can be applied clinically to risk stratify patients with RBBB and PH. [ABSTRACT FROM AUTHOR]

Obstructive sleep apnea (OSA) is one of the most common and serious sleep-related breathing disorders with a high prevalence among patients with cardiovascular (CV) diseases. Despite its widespread presence, OSA remains severely undiagnosed and untreated. CV mortality and morbidity are significantly increased in the presence of OSA as it is associated with an increased risk of resistant hypertension, heart failure, arrhythmias, and coronary artery disease. Evaluation and treatment of OSA should focus on recognizing patients at risk of developing OSA. The use of screening questionnaires should be routine, but a formal polysomnography sleep study is fundamental in establishing and classifying OSA. Recognition of OSA patients will allow for the institution of appropriate therapy that should alleviate OSA-related symptoms with the intent of decreasing adverse CV risk. In this review, we focus on the impact OSA has on CV disease and evaluate contemporary OSA treatments. Our goal is to heighten awareness among CV practitioners. [ABSTRACT FROM AUTHOR]