Andaleeb A Ahmed, Robina Matyal, Feroze Mahmood, Ruby Feng, Graham B Berry, Scott Gilleland, Kamal R Khabbaz
Objective: Due to its circular shape, the area of the proximal left ventricular tract (PLVOT) adjacent to aortic valve can be derived from a single linear diameter. This is also the location of flow acceleration (FA) during systole, and pulse wave Doppler (PWD) sample volume in the PLVOT can lead to overestimation of velocity (V1) and the aortic valve area (AVA). Therefore, it is recommended to derive V1 from a region of laminar flow in the elliptical shaped distal LVOT (away from the annulus). Besides being inconsistent with the assumptions of continuity equation (CE), spatial difference in the location of flow and area measurement can result in inaccurate AVA calculation. We evaluated the impact of FA in the PLVOT on the accuracy of AVA by continuity equation (CE) in patients with aortic stenosis (AS).
Methods: CE-based AVA calculations were performed in patients with AS once with PWD-derived velocity time integral (VTI) in the distal LVOT (VTILVOT) and then in the PLVOT to obtain a FA velocity profile (FA-VTILVOT) for each patient. A paired sample t-test (P < 0.05) was conducted to compare the impact of FA-VTILVOT and VTILVOT on the calculation of AVA.
Result: There were 46 patients in the study. There was a 30.3% increase in the peak FA-VTILVOT as compared to the peak VTILVOT and AVA obtained by FA-VTILVOT was 29.1% higher than obtained by VTILVOT.
Conclusion: Accuracy of AVA can be significantly impacted by FA in the PLVOT. LVOT area should be measured with 3D imaging in the distal LVOT.
目的：由于左心室近端通道（PLVOT）呈圆形，其邻近主动脉瓣的面积可通过单一线性直径得出。这也是收缩期血流加速（FA）的位置，PLVOT 中的脉搏波多普勒（PWD）样本量会导致速度（V1）和主动脉瓣面积（AVA）被高估。因此，建议从椭圆形 LVOT 远端（远离瓣环）的层流区域推导 V1。除了与连续性方程（CE）的假设不一致外，血流位置和面积测量的空间差异也会导致 AVA 计算不准确。我们评估了 PLVOT 中的 FA 对主动脉瓣狭窄（AS）患者用连续性方程（CE）计算 AVA 的准确性的影响：方法：我们对 AS 患者进行了基于 CE 的 AVA 计算，计算时先在 LVOT 远端（VTILVOT）使用 PWD 导出的速度时间积分（VTI），然后在 PLVOT 获取 FA 速度曲线（FA-VTILVOT）。对 AVA 的计算结果进行配对样本 t 检验（P LVOT 和 VTILVOT）：共有 46 名患者参与了研究。与 VTILVOT 峰值相比，FA-VTILVOT 峰值增加了 30.3%，FA-VTILVOT 获得的 AVA 比 VTILVOT 高 29.1%：结论：PLVOT 中的 FA 会严重影响 AVA 的准确性。结论：PLVOT 的 FA 会严重影响 AVA 的准确性。
{"title":"Impact of left ventricular outflow tract flow acceleration on aortic valve area calculation in patients with aortic stenosis","authors":"Andaleeb A Ahmed, Robina Matyal, Feroze Mahmood, Ruby Feng, Graham B Berry, Scott Gilleland, Kamal R Khabbaz","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>Due to its circular shape, the area of the proximal left ventricular tract (PLVOT) adjacent to aortic valve can be derived from a single linear diameter. This is also the location of flow acceleration (FA) during systole, and pulse wave Doppler (PWD) sample volume in the PLVOT can lead to overestimation of velocity (V<sub>1</sub>) and the aortic valve area (AVA). Therefore, it is recommended to derive V<sub>1</sub> from a region of laminar flow in the elliptical shaped distal LVOT (away from the annulus). Besides being inconsistent with the assumptions of continuity equation (CE), spatial difference in the location of flow and area measurement can result in inaccurate AVA calculation. We evaluated the impact of FA in the PLVOT on the accuracy of AVA by continuity equation (CE) in patients with aortic stenosis (AS).</p><p><strong>Methods: </strong>CE-based AVA calculations were performed in patients with AS once with PWD-derived velocity time integral (VTI) in the distal LVOT (VTI<sub>LVOT</sub>) and then in the PLVOT to obtain a FA velocity profile (FA-VTI<sub>LVOT</sub>) for each patient. A paired sample t-test (P < 0.05) was conducted to compare the impact of FA-VTI<sub>LVOT</sub> and VTI<sub>LVOT</sub> on the calculation of AVA.</p><p><strong>Result: </strong>There were 46 patients in the study. There was a 30.3% increase in the peak FA-VTI<sub>LVOT</sub> as compared to the peak VTI<sub>LVOT</sub> and AVA obtained by FA-VTI<sub>LVOT</sub> was 29.1% higher than obtained by VTI<sub>LVOT</sub>.</p><p><strong>Conclusion: </strong>Accuracy of AVA can be significantly impacted by FA in the PLVOT. LVOT area should be measured with 3D imaging in the distal LVOT.</p>","PeriodicalId":45749,"journal":{"name":"Echo Research and Practice","volume":"6 4","pages":"97-103"},"PeriodicalIF":3.2,"publicationDate":"2019-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6826166/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141731497","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Echocardiographic assessment of patients with transposition of the great arteries and congenitally corrected transposition requires awareness of the morphology and commonly associated lesions. The pre-operative echocardiography should include a full segmental and sequential analysis. Post-operative assessment is not possible without awareness of the type of surgical procedure performed and consists of assessing surgical connections and residual lesions.
{"title":"EDUCATIONAL SERIES IN CONGENITAL HEART DISEASE: Echocardiographic assessment of transposition of the great arteries and congenitally corrected transposition of the great arteries","authors":"Meryl S. Cohen, L. Mertens","doi":"10.1530/ERP-19-0047","DOIUrl":"https://doi.org/10.1530/ERP-19-0047","url":null,"abstract":"Echocardiographic assessment of patients with transposition of the great arteries and congenitally corrected transposition requires awareness of the morphology and commonly associated lesions. The pre-operative echocardiography should include a full segmental and sequential analysis. Post-operative assessment is not possible without awareness of the type of surgical procedure performed and consists of assessing surgical connections and residual lesions.","PeriodicalId":45749,"journal":{"name":"Echo Research and Practice","volume":"6 1","pages":"R107 - R119"},"PeriodicalIF":6.3,"publicationDate":"2019-10-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49288880","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
E. Donal, E. Galli, A. Anselmi, A. Bidaut, G. Leurent
In this review, we discuss the central role of the imager in the heart team in the successful application of current guidelines for heart valve diseases to daily practice, and for improving patient care through new approaches, new techniques and new strategies for dealing with increasingly complex cases. This is an opportunity to emphasize the importance of having good imagers and the value of continuous learning in a modern heart team. It is essential to employ technological improvements and to appropriately adapt guidelines to the patients we see day to day.
{"title":"EDUCATIONAL SERIES ON THE SPECIALIST VALVE CLINIC: The central role of the cardiac imager in heart valve disease","authors":"E. Donal, E. Galli, A. Anselmi, A. Bidaut, G. Leurent","doi":"10.1530/ERP-19-0046","DOIUrl":"https://doi.org/10.1530/ERP-19-0046","url":null,"abstract":"In this review, we discuss the central role of the imager in the heart team in the successful application of current guidelines for heart valve diseases to daily practice, and for improving patient care through new approaches, new techniques and new strategies for dealing with increasingly complex cases. This is an opportunity to emphasize the importance of having good imagers and the value of continuous learning in a modern heart team. It is essential to employ technological improvements and to appropriately adapt guidelines to the patients we see day to day.","PeriodicalId":45749,"journal":{"name":"Echo Research and Practice","volume":"6 1","pages":"T15 - T21"},"PeriodicalIF":6.3,"publicationDate":"2019-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46641022","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A. Ahmed, R. Matyal, Feroze Mahmood, R. Feng, Graham B Berry, Scott Gilleland, K. Khabbaz
Objective Due to its circular shape, the area of the proximal left ventricular tract (PLVOT) adjacent to aortic valve can be derived from a single linear diameter. This is also the location of flow acceleration (FA) during systole, and pulse wave Doppler (PWD) sample volume in the PLVOT can lead to overestimation of velocity (V1) and the aortic valve area (AVA). Therefore, it is recommended to derive V1 from a region of laminar flow in the elliptical shaped distal LVOT (away from the annulus). Besides being inconsistent with the assumptions of continuity equation (CE), spatial difference in the location of flow and area measurement can result in inaccurate AVA calculation. We evaluated the impact of FA in the PLVOT on the accuracy of AVA by continuity equation (CE) in patients with aortic stenosis (AS). Methods CE-based AVA calculations were performed in patients with AS once with PWD-derived velocity time integral (VTI) in the distal LVOT (VTILVOT) and then in the PLVOT to obtain a FA velocity profile (FA-VTILVOT) for each patient. A paired sample t-test (P < 0.05) was conducted to compare the impact of FA-VTILVOT and VTILVOT on the calculation of AVA. Result There were 46 patients in the study. There was a 30.3% increase in the peak FA-VTILVOT as compared to the peak VTILVOT and AVA obtained by FA-VTILVOT was 29.1% higher than obtained by VTILVOT. Conclusion Accuracy of AVA can be significantly impacted by FA in the PLVOT. LVOT area should be measured with 3D imaging in the distal LVOT.
{"title":"Impact of left ventricular outflow tract flow acceleration on aortic valve area calculation in patients with aortic stenosis","authors":"A. Ahmed, R. Matyal, Feroze Mahmood, R. Feng, Graham B Berry, Scott Gilleland, K. Khabbaz","doi":"10.1530/ERP-19-0017","DOIUrl":"https://doi.org/10.1530/ERP-19-0017","url":null,"abstract":"Objective Due to its circular shape, the area of the proximal left ventricular tract (PLVOT) adjacent to aortic valve can be derived from a single linear diameter. This is also the location of flow acceleration (FA) during systole, and pulse wave Doppler (PWD) sample volume in the PLVOT can lead to overestimation of velocity (V1) and the aortic valve area (AVA). Therefore, it is recommended to derive V1 from a region of laminar flow in the elliptical shaped distal LVOT (away from the annulus). Besides being inconsistent with the assumptions of continuity equation (CE), spatial difference in the location of flow and area measurement can result in inaccurate AVA calculation. We evaluated the impact of FA in the PLVOT on the accuracy of AVA by continuity equation (CE) in patients with aortic stenosis (AS). Methods CE-based AVA calculations were performed in patients with AS once with PWD-derived velocity time integral (VTI) in the distal LVOT (VTILVOT) and then in the PLVOT to obtain a FA velocity profile (FA-VTILVOT) for each patient. A paired sample t-test (P < 0.05) was conducted to compare the impact of FA-VTILVOT and VTILVOT on the calculation of AVA. Result There were 46 patients in the study. There was a 30.3% increase in the peak FA-VTILVOT as compared to the peak VTILVOT and AVA obtained by FA-VTILVOT was 29.1% higher than obtained by VTILVOT. Conclusion Accuracy of AVA can be significantly impacted by FA in the PLVOT. LVOT area should be measured with 3D imaging in the distal LVOT.","PeriodicalId":45749,"journal":{"name":"Echo Research and Practice","volume":"6 1","pages":"97 - 103"},"PeriodicalIF":6.3,"publicationDate":"2019-10-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44182018","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Despite 3D echocardiography (3DE) acquiring significantly greater data than standard 2D echocardiography (2DE), it is underutilized in assessing cardiac anatomy and physiology. A key advantage is the ability of a single 3DE acquisition to be post-processed to generate volume rendered 3D models and an unlimited number of multiplanar reconstruction (MPR) images. We describe the case of a highly anxious patient with life-threatening complex aortic valve endocarditis and aortic root abscess, refusing transesophageal echocardiography (TOE) under general anaesthesia with tachycardia, breathlessness and acute kidney injury precluding accurate or safe gated (computed tomography) CT, who was comprehensively assessed with a rapid 3DE-TOE under sedation. This led to timely surgery and an excellent outcome for the patient.
{"title":"3D echocardiography allows rapid and accurate surgical planning in complex aortic root abscess cases.","authors":"Viren Ahluwalia, Faizel Osman, Jitendra Parmar, Jamal Nasir Khan","doi":"10.1530/ERP-19-0043","DOIUrl":"10.1530/ERP-19-0043","url":null,"abstract":"<p><p>Despite 3D echocardiography (3DE) acquiring significantly greater data than standard 2D echocardiography (2DE), it is underutilized in assessing cardiac anatomy and physiology. A key advantage is the ability of a single 3DE acquisition to be post-processed to generate volume rendered 3D models and an unlimited number of multiplanar reconstruction (MPR) images. We describe the case of a highly anxious patient with life-threatening complex aortic valve endocarditis and aortic root abscess, refusing transesophageal echocardiography (TOE) under general anaesthesia with tachycardia, breathlessness and acute kidney injury precluding accurate or safe gated (computed tomography) CT, who was comprehensively assessed with a rapid 3DE-TOE under sedation. This led to timely surgery and an excellent outcome for the patient.</p>","PeriodicalId":45749,"journal":{"name":"Echo Research and Practice","volume":"6 1","pages":""},"PeriodicalIF":6.3,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6893311/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48138197","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Cardiovascular MRI and CT are useful imaging modalities complimentary to echocardiography. This review article describes the common indications and consideration for the use of MRI and CT in the management of congenital heart disease.
{"title":"EDUCATIONAL SERIES IN CONGENITAL HEART DISEASE: Cardiovascular MRI and CT in congenital heart disease.","authors":"Kuberan Pushparajah, Phuoc Duong, Sujeev Mathur, Sonya Babu-Narayan","doi":"10.1530/ERP-19-0048","DOIUrl":"10.1530/ERP-19-0048","url":null,"abstract":"<p><p>Cardiovascular MRI and CT are useful imaging modalities complimentary to echocardiography. This review article describes the common indications and consideration for the use of MRI and CT in the management of congenital heart disease.</p>","PeriodicalId":45749,"journal":{"name":"Echo Research and Practice","volume":"6 1","pages":""},"PeriodicalIF":6.3,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6893312/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43111798","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Valvular heart disease (VHD) is responsible for a major societal and economic burden. Incidence and prevalence of VHD are high and increase as the population ages, creating the next epidemic. In Western countries, the etiology is mostly degenerative or functional disease and strikes an elderly population with multiple comorbidities. Epidemiological studies have shown that VHD is commonly underdiagnosed, leading to patients presenting late in their disease course, to an excess risk of mortality and morbidity and to a missed opportunity for intervention. Once diagnosed, VHD is often undertreated with patients unduly denied intervention, the only available curative treatment. This gap between current recommendations and clinical practice and the marked under-treatment is at least partially related to poor knowledge of current National and International Societies Guidelines. Development of a valvular heart team involving multidisciplinary valve specialists including clinicians, imaging specialists, interventional cardiologists and surgeons is expected to fill these gaps and to offer an integrated care addressing all issues of patient management from evaluation, risk-assessment, decision-making and performance of state-of-the-art surgical and transcatheter interventions. The valvular heart team will select the right treatment for the right patient, improving cost-effectiveness and ultimately patients’ outcomes.
{"title":"EDUCATIONAL SERIES ON THE SPECIALIST VALVE CLINIC: Challenges in the diagnosis and management of valve disease: the case for the specialist valve clinic","authors":"D. Messika‐Zeitoun, I. Burwash, T. Mesana","doi":"10.1530/ERP-19-0041","DOIUrl":"https://doi.org/10.1530/ERP-19-0041","url":null,"abstract":"Valvular heart disease (VHD) is responsible for a major societal and economic burden. Incidence and prevalence of VHD are high and increase as the population ages, creating the next epidemic. In Western countries, the etiology is mostly degenerative or functional disease and strikes an elderly population with multiple comorbidities. Epidemiological studies have shown that VHD is commonly underdiagnosed, leading to patients presenting late in their disease course, to an excess risk of mortality and morbidity and to a missed opportunity for intervention. Once diagnosed, VHD is often undertreated with patients unduly denied intervention, the only available curative treatment. This gap between current recommendations and clinical practice and the marked under-treatment is at least partially related to poor knowledge of current National and International Societies Guidelines. Development of a valvular heart team involving multidisciplinary valve specialists including clinicians, imaging specialists, interventional cardiologists and surgeons is expected to fill these gaps and to offer an integrated care addressing all issues of patient management from evaluation, risk-assessment, decision-making and performance of state-of-the-art surgical and transcatheter interventions. The valvular heart team will select the right treatment for the right patient, improving cost-effectiveness and ultimately patients’ outcomes.","PeriodicalId":45749,"journal":{"name":"Echo Research and Practice","volume":"6 1","pages":"T1 - T6"},"PeriodicalIF":6.3,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47104934","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
N. McDicken, A. Thomson, A. White, I. Toor, G. Gray, C. Moran, R. Watson, T. Anderson
A technology based on velocity ratio indices is described for application in the myocardium. Angle-independent Doppler indices, such as the pulsatility index, which employ velocity ratios, can be measured even if the ultrasound beam vector at the moving target and the motion vector are not in a known plane. The unknown plane situation is often encountered when an ultrasound beam interrogates sites in the myocardium. The velocities employed in an index calculation must be close to the same or opposite directions. The Doppler velocity ratio indices are independent of angle in 3D space as are ratio indices based on 1D strain and 1D speckle tracking. Angle-independent results with spectral Doppler methods are discussed. Possible future imaging techniques based on velocity ratios are presented. By using indices that involve ratios, several other sources of error cancel in addition to that of angular dependence for example errors due to less than optimum gain settings and beam distortion. This makes the indices reliable as research or clinical tools. Ratio techniques can be readily implemented with current commercial blood flow pulsed wave duplex Doppler equipment or with pulsed wave tissue Doppler equipment. In 70 patients where the quality of the real-time B-mode looked suitable for the Doppler velocity ratio technique, there was only one case where clear spectra could not be obtained for both the LV wall and the septum. A reproducibility study of spectra from the septum of the heart shows a 12% difference in velocity ratios in the repeat measurements.
{"title":"3D angle-independent Doppler and speckle tracking for the myocardium and blood flow","authors":"N. McDicken, A. Thomson, A. White, I. Toor, G. Gray, C. Moran, R. Watson, T. Anderson","doi":"10.1530/ERP-19-0040","DOIUrl":"https://doi.org/10.1530/ERP-19-0040","url":null,"abstract":"A technology based on velocity ratio indices is described for application in the myocardium. Angle-independent Doppler indices, such as the pulsatility index, which employ velocity ratios, can be measured even if the ultrasound beam vector at the moving target and the motion vector are not in a known plane. The unknown plane situation is often encountered when an ultrasound beam interrogates sites in the myocardium. The velocities employed in an index calculation must be close to the same or opposite directions. The Doppler velocity ratio indices are independent of angle in 3D space as are ratio indices based on 1D strain and 1D speckle tracking. Angle-independent results with spectral Doppler methods are discussed. Possible future imaging techniques based on velocity ratios are presented. By using indices that involve ratios, several other sources of error cancel in addition to that of angular dependence for example errors due to less than optimum gain settings and beam distortion. This makes the indices reliable as research or clinical tools. Ratio techniques can be readily implemented with current commercial blood flow pulsed wave duplex Doppler equipment or with pulsed wave tissue Doppler equipment. In 70 patients where the quality of the real-time B-mode looked suitable for the Doppler velocity ratio technique, there was only one case where clear spectra could not be obtained for both the LV wall and the septum. A reproducibility study of spectra from the septum of the heart shows a 12% difference in velocity ratios in the repeat measurements.","PeriodicalId":45749,"journal":{"name":"Echo Research and Practice","volume":"6 1","pages":"105 - 114"},"PeriodicalIF":6.3,"publicationDate":"2019-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41976436","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jet van Zalen, Sveeta Badiani, Lesley M Hart, Andrew J Marshall, Louisa Beale, Gary Brickley, Sanjeev Bhattacharyya, Nikhil R Patel, Guy W Lloyd
Background: Mortality dramatically rises with the onset of symptoms in patients with severe aortic stenosis (AS). Surgery is indicated when symptoms become apparent or when there is ventricular decompensation. Cardiopulmonary exercise testing (CPET) in combination with exercise echocardiography can unmask symptoms and provides valuable information regarding contractile reserve. The aim of the present study was to determine the prevalence of reduced exercise tolerance and the parameters predicting adverse cardiovascular events.
Methods: Thirty-two patients with asymptomatic severe AS were included in this study. Patients were followed up as part of an enhanced surveillance clinic.
Results: Age was 69 ± 15.7 years, 75% of patients were male. Patients had a raised NT-ProBNP of 301 pg/mL. VO2peak was 19.5 ± 6.2 mL/kg/min. Forty-one percent of patients had a reduced %VO2peak and this predicted unplanned cardiac hospitalisation (P = 0.005). Exercise systolic longitudinal velocity (S') and age were the strongest independent predictors for VO2peak (R 2 = 0.76; P < 0.0001). Exercise S' was the strongest independent predictor for NT-ProBNP (R 2 = 0.48; P = 0.001).
Conclusion: A large proportion of patients had a lower than predicted VO2peak. The major determinant of exercise and NT-ProBNP is the ability of the left ventricle (LV) to augment S' on exercise rather than the severity of aortic valve obstruction or resting structural remodelling of the LV. Reduced exercise tolerance and more adverse remodelling, rather than valve obstruction predicted unplanned hospitalisation. This study demonstrates that for those patients, in whom a watchful waiting is an agreed strategy, a detailed assessment should be undertaken including CPET, exercise echocardiography and biomarkers to ensure those with exercise limitation and risk of decompensation are detected early and treated appropriately.
{"title":"The importance of contractile reserve in predicting exercise tolerance in asymptomatic patients with severe aortic stenosis.","authors":"Jet van Zalen, Sveeta Badiani, Lesley M Hart, Andrew J Marshall, Louisa Beale, Gary Brickley, Sanjeev Bhattacharyya, Nikhil R Patel, Guy W Lloyd","doi":"10.1530/ERP-19-0005","DOIUrl":"10.1530/ERP-19-0005","url":null,"abstract":"<p><strong>Background: </strong>Mortality dramatically rises with the onset of symptoms in patients with severe aortic stenosis (AS). Surgery is indicated when symptoms become apparent or when there is ventricular decompensation. Cardiopulmonary exercise testing (CPET) in combination with exercise echocardiography can unmask symptoms and provides valuable information regarding contractile reserve. The aim of the present study was to determine the prevalence of reduced exercise tolerance and the parameters predicting adverse cardiovascular events.</p><p><strong>Methods: </strong>Thirty-two patients with asymptomatic severe AS were included in this study. Patients were followed up as part of an enhanced surveillance clinic.</p><p><strong>Results: </strong>Age was 69 ± 15.7 years, 75% of patients were male. Patients had a raised NT-ProBNP of 301 pg/mL. VO2peak was 19.5 ± 6.2 mL/kg/min. Forty-one percent of patients had a reduced %VO2peak and this predicted unplanned cardiac hospitalisation (P = 0.005). Exercise systolic longitudinal velocity (S') and age were the strongest independent predictors for VO2peak (R 2 = 0.76; P < 0.0001). Exercise S' was the strongest independent predictor for NT-ProBNP (R 2 = 0.48; P = 0.001).</p><p><strong>Conclusion: </strong>A large proportion of patients had a lower than predicted VO2peak. The major determinant of exercise and NT-ProBNP is the ability of the left ventricle (LV) to augment S' on exercise rather than the severity of aortic valve obstruction or resting structural remodelling of the LV. Reduced exercise tolerance and more adverse remodelling, rather than valve obstruction predicted unplanned hospitalisation. This study demonstrates that for those patients, in whom a watchful waiting is an agreed strategy, a detailed assessment should be undertaken including CPET, exercise echocardiography and biomarkers to ensure those with exercise limitation and risk of decompensation are detected early and treated appropriately.</p>","PeriodicalId":45749,"journal":{"name":"Echo Research and Practice","volume":"6 3","pages":"43-52"},"PeriodicalIF":3.2,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/40/26/ERP-19-0005.PMC6589858.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"37249924","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Hinton, George Hunter, M. Dissanayake, R. Hatrick
Summary Pseudo-aneurysms are a rare, potentially life-threatening complication of a myocardial infarction. We present the case of a 45-year-old male who was brought to the emergency department in extremis and had a previous history of a late presentation inferior ST-elevation myocardial infarction treated percutaneously. Clinical examination revealed evidence of cardiogenic shock, pulmonary edema and a pulsatile epigastric mass. Chest X-ray demonstrated marked cardiomegaly and pulmonary edema. Urgent echocardiography confirmed the presence of a huge basal inferior wall pseudo-aneurysm with bi-directional flow. This was also associated with severe mitral regurgitation, due to posterior mitral annular involvement. The patient was transferred to the local cardiothoracic surgical unit where he underwent emergency repair of the pseudo-aneurysm and mitral valve replacement. Despite the surgery being complex he made a full recovery.
{"title":"Acute respiratory distress secondary to a huge chronic left ventricular pseudo-aneurysm","authors":"J. Hinton, George Hunter, M. Dissanayake, R. Hatrick","doi":"10.1530/ERP-19-0018","DOIUrl":"https://doi.org/10.1530/ERP-19-0018","url":null,"abstract":"Summary Pseudo-aneurysms are a rare, potentially life-threatening complication of a myocardial infarction. We present the case of a 45-year-old male who was brought to the emergency department in extremis and had a previous history of a late presentation inferior ST-elevation myocardial infarction treated percutaneously. Clinical examination revealed evidence of cardiogenic shock, pulmonary edema and a pulsatile epigastric mass. Chest X-ray demonstrated marked cardiomegaly and pulmonary edema. Urgent echocardiography confirmed the presence of a huge basal inferior wall pseudo-aneurysm with bi-directional flow. This was also associated with severe mitral regurgitation, due to posterior mitral annular involvement. The patient was transferred to the local cardiothoracic surgical unit where he underwent emergency repair of the pseudo-aneurysm and mitral valve replacement. Despite the surgery being complex he made a full recovery.","PeriodicalId":45749,"journal":{"name":"Echo Research and Practice","volume":"6 1","pages":"K19 - K22"},"PeriodicalIF":6.3,"publicationDate":"2019-08-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47755164","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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