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In 14 patients requiring aggressive therapy for circulatory failure resulting from massive pulmonary embolism, hemodynamic and two-dimensional echocardiography data were obtained at bedside (acute phase) and again after circulatory improvement (intermediate phase) and during recovery. The acute stage was characterized by a low cardiac output state despite inotropic support (cardiac index 1.9 ± 0.6 liters/min per m2) associated with increased right atrial pressure (12.4 ± 4.2 mm Hg), increased right ventricular end-systolic and end-diastolic area (12.4 ± 3.4 and 15.4 ±4.1 cm2/m2, respectively) and reduced right ventricular fractional area contraction (20.1 ± 8.6%). Two-dimensional echocardiography also revealed interventricular septal flattening at both end-systole and end-diastole and markedly decreased left ventricular end-diastolic dimensions. Left ventricular fractional area contraction remained normal. Hemodynamic improvement occurred during the intermediate phase as shown by restoration of cardiac index (3.3 ± 0.6 liters/min per nr), decrease in right atrial pressure (8.3 ± 4.8 mm Hg), reduction in right ven- tricular end-systolic area (9.0 ± 3.6 cm2/m2at the intermediate stage and 6.1 ± 1.8 cm2/m2at recovery) and end-diastolic area (10.5 ± 3.6 cm2/m2at the intermediate stage and 8.9 ± 2.9 cm2/m2at recovery) and improvement in right ventricular fractional area contraction (31.5 ± 16.4%). The interventricular septum progressively returned to a more normal configuration at both endsystole and end-diastole, and left ventricular diastolic dimension steadily increased. It is concluded that circulatory failure secondary to massive pulmonary embolism was mediated through a profound decrease in left ventricular preload, resulting from both pulmonary outflow obstruction and reduced left ventricular diastolic compliance. Acute dilation of the right ventricle with the concomitant restraining action of the pericardium accounted for the leftward shift of the interventricular septum and reduced left ventricular compliance. Left ventricular systolic function was unaltered.

To elucidate the mechanism of paradoxic pulse in severe bronchial asthma, we performed hemodynamic studies and measured esophageal pressure in nine patients who had status asthmaticus and clinical paradoxic pulse. Two-dimensional echocardiography allowed simultaneous assessment of cyclic changes in right- and left-heart size throughout the respiratory cycle. Esophageal pressure varied from a markedly negative level during inspiration (-24.4 +/- 6.5 cm H2O) to a positive level during expiration (7.6 +/- 6.0 cm H2O). Competition between right- and left-heart chambers for pericardial space during inspiration was suggested by the reduced left ventricular cross-sectional area at end-systole (-24%, p less than 0.01) and end-diastole (-32%, p less than 0.01), the leftward septal shift, and the increased right ventricular internal diameter at end-systole (42%, p less than 0.01) and end-diastole (40%, p less than 0.001). Competition for filling, however, could not entirely account for the paradoxic pulse, for systemic and pulmonary pulse pressures were almost (within one cardiac cycle) in phase: both were minimal at inspiration and maximal at expiration. The increase in impedance to right ventricular ejection is another major factor reducing left ventricular preload at inspiration. This reduction in preload was shown to be the predominant mechanism for the decrease in left ventricular stroke output at inspiration.

Two dimensional echocardiographic analysis of global and regional left ventricular function was applied in seven closed chest dogs to study the effects of nitroprusslde In ischemic heart failure. Simultaneous hemodynamic and two dimensional echocardiographic measurements were obtained sequentially: (1) in the control period, (2) after proximal occlusion of the left anterior descending coronary artery, (3) after volume loading, which increased left ventricular end-diastollc pressure to 30.3 ± 9.1 mm Hg (mean ± siandard deviation), (4) during nltroprusside infusion at 33.8 ± 29.4 jug/min and (5) after discontinuation of infusion of nitroprusside. A Simpson reconstruction using five echocardiographic short axis cross sections was used for assessment of left ventricular volumes. Regional function in short axis cross sections at different levels of the left ventricle was expressed as sectional systolic fractional area of change. Furthermore, each short axis section was subdivided into eight 45 ° segments and segmental fractional area change was automatically calculated by computer. Nitroprusside reduced global end-diastolic and end-systolic volumes (p

A 50-yr-old woman exhibiting streptococcal neck cellulitis developed severe septic shock with low cardiac output, which was reversed by infusion of dopamine plus dobutamine. Two-dimensional echocardiography performed at the bedside demonstrated severe myocardial failure. The patient's condition remained dependent on inotropic drug support for 2 days and ultimately improved. Two-dimensional echocardiography repeated on the fourth day corroborated the disappearance of transient myocardial failure.

Les modifications cycliques du pouls arteriel paraissent resulter directement de l'augmentation transitoire du volume d'ejection ventriculaire gauche pendant l'inflation pulmonaire, alors qu'au meme moment le volume d'ejection ventriculaire droit chute. Des variations en sens inverse sont observees lors de l'expiration

The aim of this study was to evaluate the role of echocardiography in the diagnosis of sinus of Valsalva aneurysms projecting toward the right heart cavities. Three patients who had a ruptured aneurysm of a sinus of Valsalva diagnosed by echocardiography and confirmed by catheterization underwent cardiac surgery. In two patients, the aneurysm originated from the right coronary sinus and had perforated into either the inflow or outflow tract of the right ventricle. In the third patient, the aneurysm, which originated from the noncoronary sinus, ruptured into the right atrium. A fourth patient was also investigated and had an unruptured aneurysm of the right coronary sinus projecting into the right ventricular outflow tract. M-mode, two-dimensional and contrast echocardio-graphic studies were performed before cardiac catheterization in all patients and after surgery in three pa- tients. M-mode echocardiography was Useful only when the aneurysm had an anterior projection, whether or not the aneurysm was ruptured. Conversely, two-dimensional echocardiography was always able to identify the aneurysmal sac which appeared as an abnormal circular thin-walled structure protruding into the right heart cavities. By using multiple views, it was possible to investigate the whole abnormal structure and locate the sinus from which the aneurysm originated. The use of the echo contrast technique allowed more precise definition of the aneurysmal sac and diagnosis of a left to right shunt by demonstrating a negative contrast image in the right cavities. On the other hand, no negative contrast image was recorded in the patient with an unruptured aneurysm or in the two instances of a successful surgically reconstructed aorta.

Cross-sectional echocardiography was utilized for quantification of volume in 19 formalin-fixed left ventricles in the presence or absence of ventricular symmetry, defined by the ratio of septal-lateral to anterior-posterior diameter. In 10 symmetric ventricles this ratio was 1.23 ± 0.06 (mean ± SEM), whereas in nine asymmetric ventricles the ratio was 1.80 ± 0.07. Area, diameter, and length measurements were obtained from short- and long-axis cross-sectional images of the left ventricle and volume was calculated by five mathematical models previously described. To evaluate the reliability of each model, echocardiographic left ventricular volume was compared by linear regression and percent error analyses to directly measured fluid volume. In symmetric ventricles, excellent correlations (r = 0.996 to 0.967) and reasonable mean percent errors (6% to 31%) were observed for all models. In asymmetric ventricles, models utilizing short-axis area or two short-axis diameters retained high correlation coefficients (r = 0.985 to 0.956) and similar mean percent errors, but standard formulas previously used with M-mode echo and angiography showed lower correlations (r = 0.886 to 0.873) and higher mean percent errors (52% to 54%). Thus, in the presence of ventricular asymmetry, analysis of short-axis areas or diameters with cross-sectional echocardiography is well suited for quantification of left ventricular volumes.

The aim of the study was to assess the duration of the haemodynamic effects of a new sustained-release oral formulation of isosorbide dinitrate (ISDN). Twenty patients (17 men and 3 women; mean age 60 years) with acute myocardial infarction (10 anterior, 10 inferior) complicated by moderate left ventricular failure took part in a randomized controlled trial. Ten patients were randomly assigned to the placebo group and 10 to the ISDN group, who received 40 mg sustained release isosorbide dinitrate. Haemodynamic variables were measured before treatment, after 0.5 and 1 h and then every 2 hours up to the 8th hour after treatment. There was no significant change in any haemodynamic parameter in the placebo group, during the study period. In the ISDN group there was a significant fall in pulmonary artery diastolic pressure at 4 and 8 h, from 19.0 +/- 1.0 mm Hg to 16.5 +/- 1.2 mm Hg and 15.5 +/- 0.8 mmHg, respectively. The mean pulmonary capillary wedge pressure fell progressively from 17.9 +/- 1.0 to 12.5 +/- 1.2 mmHg at 2 h (p less than 0.001 in comparison with the placebo group. The fall remained significant up to 8 h. There was no statistically significant change in heart rate, cardiac index, systemic blood pressure or systemic and pulmonary vascular resistances. On the whole the cardiac index remained unchanged. There were numerous individual variations of cardiac index in relation to the initial mean pulmonary capillary wedge pressure and the magnitude of its fall following administration of ISDN. The change in cardiac index was inversely correlated with the control cardiac index (r = -0.69, p less than 0.02).

Left ventricular stroke volumes derived by two-dimensional echocardiography (2D echo) were compared with thermodilution and cineangiography measurements in closed-chest dogs before andone hour after proximal LAD occlusion. Stroke volume was calculated from end-diastolic and end-systolic volumes reconstructed by two models: 1) Simpson's rule employing left ventricular length and five short-axis cross-sectional areas; 2) a simplified volume formula (V = 5/6 area . length), utilizing a single short-axis area at either the mitral valve or midpapillary muscle level. The comprehensive Simpson reconstruction yielded a good correlation of 2D echo stroke volume against thermodilution (r = 0.89) over a range of normal (N = 14) and ischemic (N = 8) states. The simplified formula provided a satisfactory correlation (r = .90, N = 22) when using the midpapillary cross-section, which encompassed the induced ischemic dys-synergy. In contrast, when using the mitral valve level cross-section above the site of ventricular asymmetry, there was no significant statistical correlation. Comparison of cineangiography with 2D echo volume reconstruction based on the simplified formula with the midpapillary muscle level section yielded good correlations for stroke volume (r = 0.87) and ejection fraction (r = 0.97). Intraobserver and interobserver variability of duplicate echo stroke volume measurements was 8% and 10%, respectively. We conclude that 2D echocardiography in dogs permits quantitation of left ventricular stroke volume in normal and ischemic states.

The incidence of left ventricular thrombosis after acute transmural myocardial infarction has been evaluated with two-dimensional echocardiography. To assess the preventive action of early anticoagulation with full-dose heparin, 90 patients, admitted within 5.2 +/- 4.6 hours after the onset of symptoms of their first episode of acute myocardial infarction (46 anterior and 44 inferior), were prospectively studied. Patients were randomly assigned either to therapeutic anticoagulation with heparin or to no anticoagulant therapy. Serial two-dimensional echocardiograms were recorded on the day of admission, the next day, days 4 to 7 and days 20 to 50 to detect left ventricular thrombus and to assess global left ventricular performance. On the first echocardiogram (10.3 +/- 8.0 hours after the onset of symptoms) no thrombus was visualized. In 44 patients with inferior myocardial infarction (23 receiving heparin and 21 not receiving heparin) no further left ventricular thrombus developed. In 46 patients with anterior myocardial infarction, 21 additional thrombi developed (45.6%) within 4.3 +/- 3.0 days after the acute event. Thrombus developed in 8 (38%) of 21 patients receiving heparin, compared with 13 (52%) of 25 patients not receiving heparin. This difference in ventricular thrombosis was not statistically significant (chi-square with the Yates correction = 0.76; NS). No difference was found between the subgroups in terms of clinical variables, infarct size, hemodynamic impairment, intensity of the inflammatory process and quantitative two-dimensional echocardiographic and cineangiographic left ventricular function. It is concluded that early anticoagulation with heparin reduced by 27% the incidence of left ventricular thrombus formation in anterior acute transmural myocardial infarction, and this relative risk reduction was not statistically significant when compared with findings in the untreated group.

Measurements of right ventricular ejection fraction and volumes were obtained at bedside by the thermodilution method performed with a fast-response balloon-tipped thermistor in a group of 18 patients undergoing respiratory therapy for the adult respiratory distress syndrome (ARDS). These measurements were compared with right ventricular dimensions simultaneously obtained with two-dimensional echocardiography. A significant correlation was found between right ventricular ejection fraction by thermodilution and two-dimensional echocardiographic fractional area contraction (r = 0.74; p

A quantitative two dimensional echocardiographic study was conducted in 10 normal subjects performing bicycle exercise in a supine position. Standardized two dimensional echocardiographic short axis and apical views of the left ventricle were analyzed to derive left ventricular sectional areas and length. Over a range of exercise heart rates from 108 to 152 beats/min, satisfactory two dimensional echocardiographic views and measurements were obtained for quantitative assessment of sectional and global left ventricular function. Variability of left ventricular short axis area measurements ranged from 2.9 to 8.3 percent. Left ventricular volume reconstruction employed a simplified formula (volume = 5/6 area X length) with a single papillary muscle level short axis area and left ventricular length. Changes in left ventricular function from rest to exercise quantitated by two dimensional echocardiography indicated a significant reduction in end-systolic volume (from 28.1 +/- 5.6 to 20.8 +/- 4.3 cc/m2, p less than 0.001) and increased left ventricular ejection fraction (from 63.4 +/- 6.3 to 72.1 +/- 5.7 percent, p less than 0.001). The change in end-diastolic volume was not significant. It is concluded that standardized two dimensional echocardiographic study during supine bicycle exercise in normal subjects provides good reproducibility of measurement of sectional and global left ventricular function. Quantitative two dimensional echocardiographic exercise study of global as well as segmental left ventricular performance in patients may be feasible using standardized procedure and analysis.

Two dimensional echocardiography was applied experimentally in the closed chest dog to quantitate left ventricular function during and immediately after single premature ventricular contractions induced through threshold stimulation at the apex. Coupling intervals were varied over a range from 35 to 85 percent of the R-R interval during normal sinus rhythm (920 to 980 ms). The quality of tomographic echocardiographic images during premature as well as postextrasystolic beats was found to be satisfactory for quantitating short axis section areas at end-diastole and end-systole. A systolic fractional area change was computed from two dimensional echocardiographic measurements to characterize mid ventricular cardiac function, which correlated significantly with peak left ventricular pressure and maximal first derivative of left ventricular pressure (dP/dt). Marked shortening of coupling intervals reduced fractional shortening during premature systole and enhanced the degree of potentiation during the postextrasystolic beat. By contrast, premature beats with relatively long coupling intervals caused less reduction in contraction and only minor postextrasystolic potentiation. Systolic shortening of left ventricular length as well as transverse diameters were studied in a two dimensional echocardiographic long axis cross section. During long coupling intervals contraction was normal except for distinct regional systolic outward “bulging” in the apical region. In contrast, short coupling intervals were associated with a more significant generalized derangement of ventricular wall motion during systole. It is concluded that the two dimensional echocardiographic method can be used to portray and quantitate global as well as regional left ventricular function during disturbances of cardiac rhythm.

Eighty patients with continued or repeated episodes of chest pain at rest and transitory ischemic electrocardiographic (ECG) changes were classified as having unstable angina pectoris. Following 10 days of intensive medical therapy, including beta blockade, all underwent coronary arteriography. Medical treatment completely relieved the chest pain in 43 patients (Group I, 54 percent). In 37 patients (Group II, 46 percent) angina recurred within a week of admission (12 patients) or later (25 patients). Seventeen patients were not operated upon (nine were inoperable, four refused operation, and in four operation was not recommended). Sixty-three underwent saphenous vein bypass grafting either following a month of medical therapy (Group I) or within 24 to 48 hours of recurrent angina (Group II). The over-all operative mortality rate was 1.6 percent (I patient) and the incidence of peroperative infarction was 11 percent. Of the 62 operative survivors, 71 percent were asymptomatic (mean follow-up period 22 months). The incidence of late operative myocardial infarction was 5 percent. Of 44 operative survivors tested by treadmill ECG, 66 percent had a negative response. Thirteen patients underwent postoperative angiographic evaluation (mean, 19.5 months). The over-all patency rate was 84 percent, and in 92 percent of patients at least one graft was patent. Thus, after stabilization by medical treatment, bypass operation could be performed with a low operative mortality rate and the long-term results compare favorably with those achieved in patients with chronic stable angina.

Right ventricular size and contractility were evaluated using two-dimensional echocardiography during the first days of respiratory support in 23 patients requiring mechanical ventilation for acute respiratory failure. Nine patients had normal echocardiographic right ventricular function, and nine other patients had a slightly enlarged right ventricle with normal systolic function. The remaining five patients had a severely enlarged right ventricle with abnormal contractile pattern. In these five patients, two-dimensional echocardiography also showed a reduction in left ventricular size suggesting detrimental ventricular interdependence. All 23 patients had normal left ventricular systolic function by two-dimensional echocardiography.

Cross-sectional echocardiography was used to quantify volume in 21 canine left ventricles that were fixed in formalin and immersed in mineral oil. Area, length and diameter measurements were obtained from short- and long-axis cross-sectional images of the left ventricle and volume was calculated by seven mathematic models. Calculated volume was then compared, by linear regression and percent error analyses, with fluid volume of the left ventricle, obtained by filling the chamber with a known amount of fluid. Volumes ranged from 13-146 ml. Mathematic models using short-axis area and long-axis length gave higher correlation coefficients (r = 0.982 and r = 0.969) and lower mean errors (10-20%) than standard formulas previously used for M-mode echo and angiography. Thus, short-axis area analysis with cross-sectional echocardiography is well-suited for quantifying left ventricular volumes in dogs.

In a series of 24 consecutive patients referred to the echocardiography laboratory because of suspected patent foramen ovale, contrast two-dimensional and M-mode echocardiographic studies were performed during normal breathing and during two provocative tests: the Valsalva maneuver and cough. A right to left shunt was visualized in 8 patients during normal breathing, in 11 patients during the Valsalva maneuver and in 17 patients during the cough test. Cardiac catheterization performed in all 24 patients and postmortem examination available in 3 patients confirmed the patency of the foramen ovale in only 15 patients. In these 15 patients, echo contrast appeared in the left heart cavities in early systole and almost simultaneously with complete right heart opacification. In contrast, for the two false positive results during the cough test, ultrasound contrast appeared at any time of the cardiac cycle when the right heart cavities had been partially cleared of contrast material. Right and left atrial pressures were simultaneously measured in four patients, and the normal interatrial pressure gradient was reversed during the Valsalva maneuver and the cough test. Echocardiography during both provocative tests showed that the interatrial septum flattened or became convex toward the left atrium. The cough test appears to be more reliable and easier to perform in critically ill patients than the Valsalva maneuver for the detection of right to left shunting through a patent foramen ovale.

The extent of left ventricular (LV) dyssynergy was assessed noninvasively in 19 dogs with two-dimensional echocardiographic short-axis sections during myocardial ischemia and infarction. After coronary occlusion, two-dimensional echocardiography uniformly indicated an increase in LV end-diastolic volume and a decrease in LV ejection fraction. Two-dimensional echocardiographic measurements of dyssynergy were evaluated and compared in three subgroups against (1) the extent of LV dyssynergy determined by force-gauge mapping during 10 coronary occlusions of 30-60 minutes' duration in eight open-chest dogs, (2) infarct size delineated by nitroblue tetrazolium (NBT) staining of left ventricular slabs after 48 hours of left anterior descending coronary artery (LAD) occlusion in five closed-chest dogs, and (3) NBT infarct size after 3-hour LAD occlusion followed by 45 hours of reperfusion in six closed-chest dogs. Linear regression analysis of results from these three comparisons gave good correlations (r = 0.89) for groups 1 and 2; in group 2, the extent of dyssynergy by two-dimensional echocardiography was consistently greater than infarct size by NBT. In group 3, the correlation was poor (r = 0.39). These results suggest that an adequate estimate for the extent of LV dyssynergy or infarct size may be obtained with two-dimensional echocardiography during myocardial ischemia or infarction, but not in the presence of coronary reflow, which causes an acute discrepancy between myocardial viability and function.

A computerized system was developed for real time acquisition, enhanced processing, analysis, and display of cross-sectional images of the left ventricle derived by two-dimensional echocardiography (2DE). The new methodology couples a standard medical imaging computer system to the video output of any current 2DE unit, uses a 128 x 128 or 64 x 64 matrix window and stores the real time 30 frames/sec digitized images on a magnetic disk. Computerized beat-to-beat and frame-by-frame processing employs space-time smoothing the automatic detection of endocardial interfaces by standard threshold and second derivative techniques. Multiple views are displayed in real time with 256 levels of gray and color. The methodology was used to analyze and graphically display frame-by-frame changes throughout the cardiac cycle. In addition, regional wall motion and thickness were analyzed in 12 sectors of individual cross-sections using a standardized angular subdivision originating at the center of area and indexed by an external reference point. An algorithm was developed to correct cross-sectional interference definition from the commonly used trailing-to-leading edge to the more valid leading-to-leading outline technique. Computerized analysis of spatial and temporal variations of cardiac contraction were demonstrated in several clinical and experimental applications, including bicycle exercise testing, investigation of acute myocardial infarction, and assessment of interventions. Initial evaluation indicates that the new real time computerized digital acquisition and data analysis represents a major advances toward quantitation of left ventricular function using 2DE.

Background and aim: This study is a part of the Euro-CCAD (CalcificCoronary Artery Disease) project, investigating the geographic prevalence of a coronary artery calcium (CAC) score of >400 in p ...

Euro-ccad : Differing conventional atherosclerosis risk factors for coronary calcification depending on degree of luminal stenosis

Background In dysfunctional segment, contractility in delayed segments does not fully contribute to end-systolic function. This reserve of contraction (strain delay index) related to mechanical dyssynchrony is supposed to be greater in viable and ischemic segments than in infarct segments. Methods Percutaneous coronary occlusion (circumflex) was performed in 13 anesthetized pigs to investigate changes in strain delay index during acute ischemia (after 3’ of occlusion) and after induced myocardial necrosis (>2 hours of occlusion). The strain delay index, which was defined as the difference between peak and end-systolic strain was computed from circumferential and radial strain curves obtained by speckle tracking analysis performed on short axis view. Results In related coronary occluded segments, delayed myocardial contraction and impaired regional peak strain was observed during early ischemia for circumferential and radial strain. However, despite prolonged coronary occlusion, delayed contraction and peak circumferential and radial strain remained unchanged. In contrast, regional strain delay index showed a biphasic pattern with an increased during early ischemia and a significant decrease after a prolonged coronary occlusion. Conclusions Delayed myocardial contraction and reduce peak strain by speckle tracking can be similarly observed during early and prolonged coronary occlusion. In contrast, regional strain delay index used to quantify contractile reserve appears to more sensitive to identify myocardial viability. Download : Download full-size image

BackgroundThe rational and the benefit of load expansion is controversial in acute pulmonary embolism (PE). Diuretic may reduce RV preload and improve hemodynamic status. The present study reported the safety of furosemide in normotensive acute PE with oligo-anuria.Methods and ResultsWe prospectively included 68 consecutive normotensive patients (systolic blood pressure ≥90mmHg) admitted for acute PE with oligoanuria and RV dilation. RV dilation was defined by a right and left ventricular diameter ratio >0.6. Overall, 29 patients were treated by a repeated bolus of furosemide (83±84mg, range 40 to 160mg), while 39 patients received isotonic saline solution (1.6±0.8 L, range, 0.5 to 4,0L). Patients treated by furosemide and fluid expansion had similar severity of hypoxemia but the furosemide group had lower admission blood pressure (119±21mmHg vs. 132±18mmHg, P=0.007) and greater shock index defined as heart rate and blood pressure ratio (0.81±0.23 vs. 0.69±0.18, P=0.02). Despite these differences, only the furosemide group had decrease shock index (0.81±0.23 vs. 0.62±0.17, P

Aims To evaluate the prognostic impact of QRS width in patients with low-flow/low-gradient aortic stenosis (LF/LGAS). Methods and results Among 88 consecutive patients referred to our institution for LF/LGAS from September 1994 to March 2007, baseline demographic, clinical, echocardiographic and electrocardiographic data were collected. This population was divided in two groups according to baseline QRS duration (cutoff: QRS≥ 130ms). Follow-up data, including electrocardiographic evolution and overall mortality were analyzed. The mean follow-up duration was 3.1 (2.2-6.2) years. In the whole group, 67 patients underwent surgical aortic valve replacement. Forty-nine patients (56%) had a QRS duration≥ 130ms. Among operated patients, there was no significant change in QRS duration between baseline and latest follow-up (126±26 vs. 131±25ms; p=0.82). In addition, wider QRS was a strong independent predictor of overall mortality [HR=2.20; CI, 1.15–4.24; p=0.027]. Conclusion Significant intra-ventricular conduction disturbances are common in patients with LF/LGAS and do not recover after aortic valve replacement. QRS duration is strongly associated with mortality in this selected population.

BackgroundMitral valve planimetry obtained from a transverse parasternal view may be particularly challenging, even with the use of a 3-Dimensional (3D) biplane imaging. This issue may be resolved by trans-thoracic echocardiography using real-time full volume 3D datasets that allow mitral valve planimetry from the apical view.MethodsThis study included 26 patients (69% women, aged 67±20 years, 45% degenerative etiology) referred for mitral valvular stenosis assessment. Mitral valve area computed from real-time 3D datasets (apical views) was compared to the results of 2D planimetry (parasternal transverse view), proximal isovelocity surface area (PISA), the continuity equation and patient’s clinical status. For functional status asssessment, the following events were considered: previous heart failure, history of systemic embolic event or systolic pulmonary hypertension defined by systolic pulmonary artery pressure >50mmHg at rest or >60mmHg during exercise.ResultsMitral valve area assessed from real time 3D planimetry was feasible in all patients (100%), while the feasibility from other methods ranged from 76% to 92%. Mitral valve area obtained from 3D planimetry correlated well with 2D planimetry (r=0.9, P

Background The management of patients with asymptomatic severe aortic stenosis remains controversial. We sought to develop a continuous risk score for predicting the mid-term development of symptoms or adverse events in this setting. Methods and Results We prospectively followed 107 patients with asymptomatic aortic stenosis (aged 72 years [63-77]; 35 women; aortic-jet velocity, 4.1 m/s [3.5-4.4]) at a single center in France. Predefined endpoints for assessing outcome were the occurrence within 24 months of death or aortic valve replacement necessitated by symptoms or by a positive exercise test. Variables independently associated with outcome were used to build a score that was validated in an independent cohort of 107 patients from Belgium. Independent predictors of outcome were female gender, peak aortic jet velocity and B-Type Natriuretic Peptide (BNP) at baseline. Accordingly, the score could be calculated as: Score = [Peak velocity (m/s) x 2] + [natural logarithm of BNP x 1.5] + 1.5 (if female gender). Event-free survival after 20 months was 80% for patients within the first Score quartile, as compared to only 7% for the fourth quartile (Figure). Areas under the ROC curve for the score were 0.90 and 0.89 in the development and validation cohorts respectively. Conclusions If further validation is achieved, this score may be useful to predict outcome in individual patients with asymptomatic aortic stenosis in order to select those who might benefit from early surgery. Download : Download full-size image

BackgroundTo assess the prognostic value of right ventricular (RV) function by 2D global strain, RV fractional area change (RVFAC) and tricuspid annular plane systolic excursion (TAPSE) in patients referred to cardiac surgery.MethodsThe study included 344 patients (67±13 years, LVEF= 52%±12%) referred for left side cardiac surgery (121 isolated CABG, 146 aortic valve surgery, EuroSCORE 10.5%±13). RV function before cardiac surgery assessed by RV-2D global strain by speckle tracking (6-segments model), RVFAC and TAPSE was compared to postoperative outcome defined by one-month mortality.ResultsRV-2D global strain was feasible in 73% of patients (n=250), while RVFAC and TAPSE were computed in all. RV-2D global strain averaged - 18±5% and moderately correlated with RVFAC (r=-0.49, P-20% and >-18%, respectively] than by TAPSE-18%), postoperative mortality was strongly reduced (7.5% vs. 24%, P=0.02) when cardiac pulmonary bypass duration was

ObjectiveTo compare single and multi beat 3D echocardiography for the assessment of left ventricular (LV) volumes and function.MethodsLV end-diastolic (LVEDV), end-systolic (LVESV) volumes and ejection fraction (LVEF) computed from one and multi-beat (2, 3 and 4) 3D echocardiography (GE-E9, 4DLVQ) were compared to cine-MRI measurements in 50 consecutive patients.ResultsAmong patients with analyzable 3D echocardiography (n=35; LVEDV=155±54mL, LVESV=84±49mL, LVEF=49±14%), single and multi-beat modality provided a fair correlation with MRI for LVED (r2 ranged from 0.8 to 0.85) with no difference for the 95%CI agreement (2SD ranged from 42-50ml). However, agreement for LVES volume was broader for one beat [2SD=41ml] than for multi-beat [2SD=31ml for 2, 35ml for 3 and 4 beat]. Consequently, the best accuracy for LVEF measurement was obtained using two beat modality (r2=0.85; p

ObjectiveTo evaluate the impact of echocardiography 2D image quality on longitudinal global strain for assessing left ventricular (LV) systolic function.MethodsThe study was conducted in 54 patients, 29 with a poor acoustic window (mean=5 non analyzable segments/patient) and 25 with a good 2D image quality. LV ejection fraction (LVEF) by Simpson biplane and longitudinal global strain by speckle tracking were compared to LVEF by MRI.ResultsGlobal strain was closely correlated to LVEF by MRI both in patients with (r=0.79, p

Background and aimOutcomes of AMI patients have substantially improved over the past 2 decades. Whether similar trends are observed in elderly (≥75 years of age) and younger patients has not been extensively studied.MethodsWe analysed one-year mortality of elderly vs younger patients in 4 nationwide French survey carried out 5 years apart from 1995 to 2010. Consecutive STEMI and NSTEMI patients (≤48 hours from onset) were recruited over one-month periods. Among 10610 patients included in the 4 surveys, 3389 (32%) were aged 75+.ResultsFrom 1995 to 2010, the proportion of 75+remained stable in NSTEMI (1995: 36%, 2010: 38%), but decreased in STEMI patients (1995: 30%, 2010: 25.5%, P=0.006). Use of PCI≤72 hours of admission increased from 6.0% to 54.9% in tin the past 15 years he 75+, and from 19% to 77% in the younger pts, use of new anticoagulants increased from 0 to 62% and 0 to 79%, respectively, and use of recommended secondary prevention medications from 2% to 43% and from 9% to 69% respectively. All clinical outcomes improved both in the 75+and

Background Paravalvular aortic regurgitation (AR) occurs in up to 86% of patients undergoing Transcatheter Aortic Valve Implantation (TAVI). Its prevalence remains unchanged after one year follow-up but its determinants are unclear. We sought to evaluate the impact of annulus measurement by transthoracic echocardiography (TTE) and by CT scan on the occurrence of AR. Methods The study included 43 symptomatic patients (83 ± 8 years, 72% in NYHA ≥ III) with severe aortic stenosis [0.76 ± 0.19 cm 2 , mean gradient 42 ± 14 mmHg] who underwent TAVI using CoreValve® LLC Percutaneous Aortic Valve Implantation System, Medtronic, Minneapolis USA. Left ventricular outflow tract (LVOT) area was computed from LVOT diameter (21 ± 2 mm) by TTE using a spherical model and from CT using an ellipsoidal model according to the larger (25 ± 3 mm) and the smaller outflow tract diameters (22 ± 3 mm). These data were compared to the prosthesis area and the occurrence of AR after TAVI. Results In patients with AR greater or equal to 2/4 (32%), LVOT area measured by CT was significantly greater as compared to patients with no or mild AR (478 ± 65 mm 2 vs. 411 ± 85 mm 2 , p = 0.009). Furthermore, the difference between actual prosthesis area and LVOT area measured by CT scan was significantly smaller (113 ± 55 vs. 171 ± 67, p = 0.009) in patients with significant AR (≥2/4) after TAVI. In contrast, LVOT area from TTE did not correlate with AR severity. Conclusion CT scan is more accurate than TTE for calculating LVOT area for prosthesis sizing before TAVI in order to avoid post-implantation AR.

BackgroundLeft Ventricular Ejection Fraction (LVEF) is commonly used to identify patients at high risk of sudden cardiac death and ventricular arrhythmia. However LVEF by Simpson biplane method may be challenging in heart failure patients with severe LV deformation and abnormal wall motion. The aim of the study was to assess the additional value of global longitudinal strain by 2D speckle tracking in predicting the occurrence of ventricular arrhythmia.MethodsThe study included 45 heart failure patients (86% men, 64±22 years, 60% ischemic) with left ventricular dysfunction (median=28%, range 13 to 47%) referred for Implantable Cardiac Defibrillator (ICD). LVEF and longitudinal global strain by speckle tracking before ICD implantation was compared to major cardiac outcome (MACE defined by cardiovascular death and ventricular arrhythmia).ResultsGlobal strain averaged −7±3% (median=7%, range −3 to −13%) and correlated with LVEF (r=−0.71, p – 7% (100% vs. 41%, p=0.06).ConclusionGlobal longitudinal strain by 2D speckle tracking may improve the identification of patients at risk of ventricular arrhythmia and death in heart failure population with severe left ventricular dysfunction.

International audience; Importance: Low cardiac output syndrome after cardiac surgery is associated with high morbidity and mortality in patients with impaired left ventricular function.Objective: To assess the ability of preoperative levosimendan to prevent postoperative low cardiac output syndrome.Design, setting, and participants: Randomized, double-blind, placebo-controlled trial conducted in 13 French cardiac surgical centers. Patients with a left ventricular ejection fraction less than or equal to 40% and scheduled for isolated or combined coronary artery bypass grafting with cardiopulmonary bypass were enrolled from June 2013 until May 2015 and followed during 6 months (last follow-up, November 30, 2015).Interventions: Patients were assigned to a 24-hour infusion of levosimendan 0.1 µg/kg/min (n = 167) or placebo (n = 168) initiated after anesthetic induction.Main outcomes and measures: Composite end point reflecting low cardiac output syndrome with need for a catecholamine infusion 48 hours after study drug initiation, need for a left ventricular mechanical assist device or failure to wean from it at 96 hours after study drug initiation when the device was inserted preoperatively, or need for renal replacement therapy at any time postoperatively. It was hypothesized that levosimendan would reduce the incidence of this composite end point by 15% in comparison with placebo.Results: Among 336 randomized patients (mean age, 68 years; 16% women), 333 completed the trial. The primary end point occurred in 87 patients (52%) in the levosimendan group and 101 patients (61%) in the placebo group (absolute risk difference taking into account center effect, -7% [95% CI, -17% to 3%]; P = .15). Predefined subgroup analyses found no interaction with ejection fraction less than 30%, type of surgery, and preoperative use of β-blockers, intra-aortic balloon pump, or catecholamines. The prevalence of hypotension (57% vs 48%), atrial fibrillation (50% vs 40%), and other adverse events did not significantly differ between levosimendan and placebo.Conclusions and relevance: Among patients with low ejection fraction who were undergoing coronary artery bypass grafting with cardiopulmonary bypass, levosimendan compared with placebo did not result in a significant difference in the composite end point of prolonged catecholamine infusion, use of left ventricular mechanical assist device, or renal replacement therapy. These findings do not support the use of levosimendan for this indication.Trial registration: EudraCT Number: 2012-000232-25; clinicaltrials.gov Identifier: NCT02184819.