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Preoperative evaluation of the mitral valve but also of tricuspid valve and right ventricular (RV) function is mandatory in primary mitral regurgitation (MR) secondary to mitral valve prolapse (MVP). Tricuspid annulus (TA) diameter plays a pivotal role in the surgical decision to perform preventive combined tricuspid valve annuloplasty. Cardiac magnetic resonance (CMR) is the gold standard for the assessment of RV size and function. Based on 70 consecutive patients (17 women; mean age 64 ± 12) with severe MR secondary to MVP referred for CMR, we sought to assess RV geometry and function and TA dimensions and to study the interaction between TA dilatation and right-sided cardiac chambers. Frequency of RV dilatation, RV systolic dysfunction, and TA dilatation (TA diameter ≥ 40 or 21 mm/m²) were 11%, 51%, and 49%, respectively. Left ventricular (LV) end-diastolic volume index was the only independent predictor of RV dilatation. Presence of symptoms, larger LV end-diastolic volume index, and LV ejection fraction60% were independently associated with RV dysfunction. Absolute TA diameter was 36 ± 6 mm and TA diameter index was 20 ± 3 mm/m². Reproducibility TA diameter measurement was excellent (coefficient of variation ≤10%). TR velocity220 cm/s (odds ratio = 20.17; [3.57 to 113.90]; p = 0.001 and right atrial volume index ≥ 38 ml/m² (odds ratio = 13.44; [3.57 to 50.54]; p = 0.0001) were independent predictors of TA diameter ≥40 or 21 mm/m². CMR provides accurate right-sided cardiac chambers assessment and may help surgical planning of concomitant tricuspid valve annuloplasty before mitral valve repair in severe MR secondary to MVP. In conclusion, TA dilatation, RV enlargement, and dysfunction are related to pulmonary pressure and left-sided cardiac chambers enlargement, reflecting the long-standing consequences of severe MR.

PURPOSE To evaluate the accuracy and reproducibility of a new fully automated fast three-dimensional (3D) transthoracic echocardiography (TTE) software for the simultaneous assessment of left atrial (LA) volumes and LA ejection fraction (EF), left ventricular (LV) volumes, LV mass, and LVEF, and to compare the results obtained with a cardiac magnetic resonance (CMR) reference. METHODS We included retrospectively 56 patients (46 men; mean age 63 ± 13 years) in sinus rhythm who had had comprehensive 3D TTE and CMR examinations within 24 hours. RESULTS Despite a slight underestimation of LV and LA volumes, LVEF and LAEF were similar using CMR or 3DTTE (58% ± 16% vs 58% ± 12%; P = .65 and 45% ± 14% vs 46% ± 15%; P = .38, respectively) in the total population. Despite significant correlation between TTE and CMR measurements (r = 0.78; P

Aims Survival in pulmonary arterial hypertension (PAH) and Eisenmenger syndrome (ES) relates to right ventricular (RV) function. Little is known about differences of ventricular function between ES patients and those suffering from other PAH aetiologies. In this study, we compared global ventricular function assessed by speckle-tracking in adult patients with ES, other PAH aetiologies, or healthy controls; and assessed the relationship between ventricular function and survival. Methods and results We performed a prospective cohort study recruiting 83 adult PAH patients (43 ES and 40 other PAH aetiologies patients) and 37 controls between March 2011 and June 2015. Patients with complex congenital heart disease were excluded. Fifty-three patients (63.9%) were in NYHA functional class ≥III at baseline and 60 (72.3%) were on advanced therapies. Mean RV peak longitudinal strain was −16.3 ± 7% in ES, lower compared with healthy controls ( P

Background Two-dimensional transesophageal echocardiography (2DTEE) is currently validated for left atrial appendage (LAA) thrombus assessment but has some limitations. Aims To evaluate the performance and interest of systematic real time three-dimensional transesophageal echocardiography (3DTEE) for LAA thrombus assessment, when performed after 2DTEE. Methods and results Consecutive patients undergoing TEE were prospectively included. LAA was first evaluated using 2DTEE, and patients were classified as "2D-NT" if no thrombus was found, "2D-T" in case of clear thrombus, or "2D-EQ" if equivocal. Then, 3DTEE of the LAA was performed and patients were similarly classified as "3D-NT," "3D-T," or "3D-EQ." Additional LAA CT scan was only performed if LAA thrombus was not clearly ruled out or confirmed by TEE. Additional value of 3DTEE after 2DTEE LAA evaluation was then assessed. We included 104 patients undergoing TEE. Agreement between 2DTEE and 3DTEE was very good for thrombus diagnosis (k = 0.936), but moderate for vacant LAA (k = 0.562) due to more frequent 2D-EQ than 3D-EQ (11.5% vs 2.9%; P = .016). 3DTEE allowed to refine the LAA status in 11 of 12 (91.7%) 2D-EQ patients: 10 3D-NT, 1 3D-T, and 1 3D-EQ. Coupling 3DTEE to 2DTEE permitted a definite LAA diagnosis in 103 of 104 (99%) vs 92 of 104 (88.5%) patients when 2DTEE was used alone (P = .002). Nine (8.7%) LAA thrombi were diagnosed, and 3 CT scan were performed. Conclusion 3DTEE of the LAA is more effective for thrombus assessment than 2DTEE. 3DTEE should be particularly considered in case of equivocal 2DTEE, as it allows to reach a definite LAA diagnosis in almost all of the patients.

A 28-year-old woman with a history of long-standing dysphagia (since the age of 10 years) was admitted to the emergency room with respiratory distress and marked stridor in the context of upper res...

BACKGROUND Quantitative assessment of primary mitral regurgitation (MR) using left ventricular (LV) volumes obtained with three-dimensional transthoracic echocardiography (3D TTE) recently showed encouraging results. Nevertheless, 3D TTE is not incorporated into everyday practice, as current LV chamber quantification software products are time consuming. AIMS To investigate the accuracy and reproducibility of new automated fast 3D TTE software (HeartModelA.I.; Philips Healthcare, Andover, MA, USA) for the quantification of LV volumes and MR severity in patients with isolated degenerative primary MR; and to compare regurgitant volume (RV) obtained with 3D TTE with a cardiac magnetic resonance (CMR) reference. METHODS Fifty-three patients (37 men; mean age 64±12 years) with at least mild primary isolated MR, and having comprehensive 3D TTE and CMR studies within 24h, were eligible for inclusion. MR RV was calculated using the proximal isovelocity surface area (PISA) method and the volumetric method (total LV stroke volume minus aortic stroke volume) with either CMR or 3D TTE. RESULTS Inter- and intraobserver reproducibility of 3D TTE was excellent (coefficient of variation≤10%) for LV volumes. MR RV was similar using CMR and 3D TTE (57±23mL vs 56±28mL; P=0.22), but was significantly higher using the PISA method (69±30mL; P

International audience; Background: Survival in pulmonary hypertension (PH) relates to right ventricular (RV) function. However, the RV unique anatomy and structure limit 2D analysis and its regional 3D function has not been studied yet. The aim of this study was to assess the implications of global and regional 3D RV deformation on clinical condition and survival in adults with PH and healthy controls.Methods and Results: We collected a prospective longitudinal cohort of 104 consecutive PH patients and 34 healthy controls between September 2014 and December 2015. Acquired 3D transthoracic RV echocardiographic sequences were analysed by semi- automatic software (TomTec 4D RV-Function 2.0). Output meshes were post-processed to extract regional motion and deformation. Global and regional statistics provided deformation patterns for each subgroup of subjects.RV lateral and inferior regions showed the highest deformation. In PH patients, RV global and regional motion and deformation (both circumferential, longitudinal and area strain) were affected in all segments (p-18% was the most powerful RV function parameter, identifying patients with a 48%-increased risk of death (AUC 0.83 [0.74-0.90], p

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Takotsubo cardiomyopathy (TTC) has recently been identified [1,2].TTC prevalence is up to 7% of all suspected acute coronary syndromes(ACS) in women, and 1% when both sexes are considered [3,4]. Re-hospitalizations are frequent and TTC mortality rate is higher than inthe general population [5]. Early phases of TTC mimic ACS anddistinguishing one from the other could betricky [6]. Cardiac biomarkersusewouldthereforebeinteresting.However,onlyfewbiologicaldataareavailable [7,8].WeaimedtoanalyzeB-typenatriureticpeptide(BNP)andtroponin I (TnI) in TTC patients.We conducted a multicentric prospective study between May 2009and October 2012. We recruited consecutive patients hospitalized forTTC and anterior ACS (age and gender matched) in 3 centers. ACS wasdiagnosed and treated in accordance with the European Society ofCardiology and American College of Cardiology Foundation/AmericanHeart Association criteria [9–11]. TTC was diagnosed using the MayoClinic criteria [6,12]. We conducted this study in compliance with theethical principles of the Declaration of Helsinki. Approval by the localethicscommittee wasobtained. Each patientgavehis written informedconsent.BNPlevelsweremeasuredonadmission.TnIdosagewasrealizedonadmission, then every 6 h for 24 h. Three patterns of TnI kinetic wereidentified: 1) peak (when TnI reaches a maximum before decreasing),2) decreasing (when TnI decreases continuously after the first assay)and 3) plateau (in the absence of clear peak). BNP/TnI ratio was calcu-lated using the TnI peak value. TnI measurements were performedwith the Beckman Access method, with a lowest detection limit of0.01ng/mlandapositivitythresholdof0.06ng/ml.BNPmeasurementswereperformedusinganimmunoassayBeckmanTriagemethod,withapositivity threshold of 100 pg/L. Glomerular filtration rate was evaluated(Modification of Diet in Renal Disease formula). Patients with severerenal failure were excluded ( b30 ml/mn).Ahighriskofbleedingwasde finedwithatleastoneofthefollowingcriteria: symptomatic bleeding, organic lesions likely to bleed,hemostatic abnormalities (platelet count b100,000/mm3, aPTT ratioN2,prothrombin time b40%),or thepresence of severe anemia (hemo-globin b8 g/dl) due to bleeding or unexplained.In this study, 62 TTC and 90 ACS patients (47 anterior ST-segmentelevation myocardial infarctions (STEMI) and 43 anterior non-ST-segment elevation myocardial infarctions (NSTEMI)) were recruitedover a 41-month period. The main features of our population are

Summary Background Three-dimensional (3D) transthoracic echocardiography (TTE) is superior to two-dimensional Simpson's method for assessment of left ventricular (LV) volumes and LV ejection fraction (LVEF). Nevertheless, 3D TTE is not incorporated into everyday practice, as current LV chamber quantification software products are time-consuming. Aims To evaluate the feasibility, accuracy and reproducibility of new fully automated fast 3D TTE software (HeartModel A.I. ; Philips Healthcare, Andover, MA, USA) for quantification of LV volumes and LVEF in routine practice; to compare the 3D LV volumes and LVEF obtained with a cardiac magnetic resonance (CMR) reference; and to optimize automated default border settings with CMR as reference. Methods Sixty-three consecutive patients, who had comprehensive 3D TTE and CMR examinations within 24 hours, were eligible for inclusion. Nine patients (14%) were excluded because of insufficient echogenicity in the 3D TTE. Thus, 54 patients (40 men; mean age 63 ± 13 years) were prospectively included into the study. Results The inter- and intraobserver reproducibilities of 3D TTE were excellent (coefficient of variation P r = 0.93; P = 0.0001). Enlarging default border detection settings leads to frequent volume overestimation in the general population, but improved agreement with CMR in patients with LVEF ≤ 50%. Correlations between 3D TTE and CMR for ESV and LVEF were excellent ( r = 0.93 and r = 0.91, respectively; P Conclusion 3D TTE using new-generation fully automated software is a feasible, fast, reproducible and accurate imaging modality for LV volumetric quantification in routine practice. Optimization of border detection settings may increase agreement with CMR for EDV assessment in dilated ventricles.

An 89-year-old female was referred to the authors' institution for repeating pulmonary edema. Recent transthoracic echocardiography (TTE) showed only a mild mitral regurgitation (MR), but a transient severe reversible functional MR was observed during an episode of respiratory distress. TTE demonstrated the functional nature of the regurgitation with a transient tenting of the mitral leaflets, resulting in a total absence of coaptation.

Purpose To evaluate proton beam therapy (PBT) as a means to preserve the eye and spare some vision while not deteriorating survival in patients with large choroidal melanomas. Design This is a retrospective, consecutive cohort study of patients with T3-4 choroidal melanomas according to the 7th edition of the American Joint Cancer Classification treated with PBT over a 24-year period. Results A total of 492 patients were included. Mean (range) tumor thickness and diameter were 8.77 (2–15) mm and 14.91 (7–24.1) mm, respectively. Mean macular and optic disc distance were 4.56 (0–19.9) mm and 4.59 (0–22.1) mm, respectively. Mean follow-up was 61.9 months. Rates of neovascular glaucoma (NVG) and enucleation (mainly for local recurrence or NVG) were 27.0% and 19.5%, respectively. Enucleation rates decreased over time. The 5-year local control was 94%. Mean baseline visual acuity was 20/63, and visual acuity ≥20/200 was preserved in 20% of patients. At 5 years, 25% of T3 patients presented with metastasis; overall and specific survival rates were 65% and 75%, respectively. Conclusion Local control after PBT remained good with increasingly manageable complications and fewer secondary enucleations over time for these large melanomas. As PBT does not seem to deteriorate survival in these patients having a high risk of metastasis, PBT may be considered as a safe and efficient alternative to enucleation in patients with large choroidal melanoma, and may help to spare some vision.

Pheochromocytoma is usually diagnosed in patients with resistant high blood pressure or the classical triad of symptoms including palpitations, sweats and headache. To our knowledge, we describe here the first case of concomitant bifocal complications of pheochromocytoma with a concomitant ischaemic colitis and Takotsubo-like cardiomyopathy. A 65-year-old man with a history of thyroid surgery 20 years ago, dyslipidaemia and smoking was admitted for syncope. Troponine Ic level rose to 3.72 ng/ mL and transthoracic echocardiography revealed severe left ventricular (LV) systolic dysfunction with large akinesia involving midventricular segments. Coronary angiogram was normal and cardiac magnetic resonance (CMR) confirmed the decreased LV ejection fraction (20%) with no evidence of late-gadolinium enhancement (Figure 1), compatible with a median form of Takotsubo. Surprisingly, on the second day of hospitalisation, he presented diarrhoea, abdominal pain and fever (40 8C). An abdominal CT scan suspected sigmoid colitis and revealed a voluminous left adrenal mass. Rectosigmoidoscopy confirmed sigmoid bleeding colitis and all bacteriologic samples remained sterile. Evolution was marked with resolution of digestive symptoms in four days with fasting and symptomatic treatment and recovery of LV systolic function in five days. Given this adrenal mass, pheochromocytoma screening was undertaken and plasmatic catecholamine and chromogranine A showed abnormally high levels. Once adequate aand b-adrenergic receptor blockages were obtained, the patient underwent resection of this left adrenal mass (30 day). Anatomical pathology (histology and immunology) confirmed the suspected diagnosis of pheochromocytoma.

BackgroundSurvival is improved in pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD) patients and is related to right ventricular (RV) function. In this study we aimed to investigate the prognostic role of RV mechanics in Eisenmenger Syndrome (ES) compared with other causes of PAH using speckle-tracking imaging.Methods and resultsWe performed a prospective cohort study. We recruited 80 consecutive adult PAH patients: 39 patients with ES and noncomplex CHD (mean age 41,5±15,6 years) and 41 patients with group 1 PAH (mean age 58,9±17,8). Clinical assessment, BNP and echocardiography were realised at the time of inclusion and then clinical outcomes were collected during the regular follow-up. Normal strain values were obtained from 37 control volunteers. On inclusion, 53 patients (66.3%) were in functional class III or higher. Mean BNP was lower in ES (p

Background: The benefit of volume expansion (VE) in submassive pulmonary embolism (PE) with right ventricular dysfunction (RVD) is unclear. We sought to compare the effects of a diuretic treatment versus fluid expansion in patients hospitalized for PE with RVD. Methods: We prospectively included 46

Background Non-O blood group patients are at higher risk of first episode of venous thromboembolism (VTE). However, only little is known about the risk of recurrence according to the blood group. In this study, we aimed to determine the impact of ABO blood group on VTE recurrence. Methods We prospectively recruited 106 consecutive patients with a first documented episode of pulmonary embolism (PE). Patients were followed at least 12 months after anticoagulation discontinuation. The main endpoint was recurrence of symptomatic VTE. Results Data from 100 patients were analyzed. Median follow-up was 28 months [24–34.8]. PE was unprovoked in 48 patients. Mean anticoagulation duration was 5.3 ± 2.2 months. The rate of VTE recurrence was 12.7 per 100 patient-years (30 recurrences). B blood group patients had a 2.7-fold increased risk of VTE recurrence (95%CI 1.1-6.2, p = 0.03). On multivariate analysis, B blood group was the strongest independent predictor of VTE recurrence (Hazard Ratio (HR) 2.6, 95%CI 1.1-6.1, p = 0.04). In contrast, A and AB blood groups were not associated with VTE recurrence. VTE recurrences were less frequent in O blood group compared to non-O patients (HR 0.5, 95%CI 0.2-1.1, p = 0.09). O blood group women had a 5-fold decreased risk of VTE recurrence (HR 0.2, 95%CI 0.1-0.8, p = 0.01). Conclusions Non-O blood groups, beyond being involved in the occurrence of a first VTE event, also contribute to VTE recurrence. B blood group is strongly associated with VTE recurrence, thus high-risk B blood group patients could benefit from long-term anticoagulation therapy after a first VTE event.

Introduction Speckle tracking imaging is a recent technique that can be achieved using either vendor dependent or vendor-independent software. Right ventricular (RV) strain is increasingly used as a prognostic tool in both left and right ventricular diseases. Only little is known regarding the variability of vendor-dependent and - independent speckle-tracking imaging software in the assessment of RV free wall longitudinal strain (RLS). The aim of our study was to compare a vendor-dependent (Qlab 9.0, Philips Medical System, Andover, MA, USA) and - independent (Cardiac Performance Analysis, Tomtec Imaging Systems, Germany) software for RLS analysis. Methods and results We prospectively enrolled 90 consecutive patients with pulmonary hypertension (mean age 55,8±19years) and 26 control patients (mean age 33,9±13years) who underwent a comprehensive echocardiogram including a RV focused 4-chamber view optimised for speckle-tracking analysis. DICOM data sets were stored and analysed by 2 different cardiologists using Qlab and TomTec, blindly to the context and each other. In the whole population, mean RLS was -17,3%±9 and -8,6% ±7,2 respectively using Qlab and Tomtec. Qlab and Tomtec intra-observer coefficients of variation (CV) were -13,19% and -9,56% and interobserver CVs were -22% and -15% respectively. The concordance correlation coefficient was 0,55, indicating poor agreement between the two methods. In the control population, Qlab CV was - 3,63%, whereas CV was -17,8% in RV disease patients. Conclusion Despite an acceptable level of variability for both techniques, Tomtec appears less variable. Variability of Qlab is excellent in control patients but is highly influenced by RV morphology. The agreement between the two software products is low and should lead in clinical practice to the follow-up of patients with the same software and advocates for the development of dedicated RV speckle-tracking software products.

BackgroundCardiac sarcoidosis (CS) is associated with high morbidity and sudden death. Currently, cardiac magnetic resonance (CMR) is the most sensitive method for the diagnosis of CS, however as CMR is being positive relatively late, new imaging methods to improve the early diagnosis of CS are lacking.The aimof this study was to assess the role of left ventricular (LV) strain estimated by 2D speckle tracking imaging in patients with newly diagnosed sarcoidosis without cardiac involvement according to the current guidelines.Methods and resultsWe performed a prospective cohort study including 10 patients with newly diagnosed sarcoidosis and normal cardiac function as assessed by classic echocardiography and CMR and 10 healthy age- and gender- matched controls. All patients underwent a comprehensive LV strain echocardiographic study. Speckle tracking analysis was performed by 2 experienced cardiologists blinded to each other and to clinical data. Mean age of patients was 53±14 years old (5 women). All patients presented mediastinal lymphadenopathy, 1 had renal involvement and 4 had pulmonary manifestations. Compared with controls, LV longitudinal strain was reduced: long axis longitudinal (-16.1±2.8% vs -21.7±2.2%, p

Background In submassive pulmonary embolism (PE), when a right ventricular (RV) dysfunction (RVD) is present, the benefit of fluid expansion (FE) is questionable. The Franck-Starling law suggests that the reduction of the RV overload may enhances the RV systolic function. Purpose The aim of our study was to compare the effects of a diuretic treatment (DT) versus FE in patients hospitalized for normotensive PE with RVD. Methods We performed a prospective study. Consecutive patients hospitalized for normotensive PE were treated with diuretic (40mg IV furosemide at admission) or FE (500cc of sodium chloride infusion during four hours at admission). The primary endpoint was the timing for normalization of BNP and troponin Ic values. The secondary endpoints were variations of clinical and RV echographic parameters. Results Forty five patients were included. Timing for Troponin and BNP normalization was 60,7±28 hours in the DT versus 93,2±42 hours in the FE group (figure 1, p=0.02). Normalization of RV dilatation took 91,7±14,2 hours in the DT group versus 108,4±17,5 hours in the FE group (p=0.01). Normalization of the RVD took 81,2±18 hours in the DT group versus 94,9±13,1 hours in the FE group (p=0.03). Conclusion In the early management of normotensive PE with RVD, DT may be superior to FE in order to improve the time to normalization of biological and echocardiographic markers. Download : Download high-res image (49KB) Download : Download full-size image Abstract 0358 – Figure 1