Cardiovascular Ultrasound最新文献

Purpose: Chronic mitral regurgitation promotes left atrial (LA) remodeling. However, the significance of LA dysfunction in the setting of ventricular functional mitral regurgitation (FMR) has not been fully investigated. Our aim was to assess the prognostic impact of peak atrial longitudinal strain (PALS), a surrogate of LA function, in patients with FMR and reduced left ventricular ejection fraction (LVEF).

Methods: Patients with at least mild ventricular FMR and LVEF < 50% under optimized medical therapy who underwent transthoracic echocardiography at a single center were retrospectively identified in the laboratory database. PALS was assessed by 2D speckle tracking in the apical 4-chamber view and the study population was divided in two groups according to the best cut-off value of PALS, using receiver operating characteristics (ROC) curve analysis. The primary endpoint-point was all-cause mortality.

Results: A total of 307 patients (median age 70 years, 77% male) were included. Median LVEF was 35% (IQR: 27 - 40%) and median effective regurgitant orifice area (EROA) was 15mm² (IQR: 9 - 22mm²). According to current European guidelines, 32 patients had severe FMR (10%). During a median follow-up of 3.5 years (IQR 1.4 - 6.6), 148 patients died. The unadjusted mortality incidence per 100 persons-years increased with progressively lower values of PALS. On multivariable analysis, PALS remained independently associated with all-cause mortality (adjusted hazard ratio 1.052 per % decrease; 95% CI: 1.010 - 1.095; P = 0.016), even after adjustment for several (n = 14) clinical and echocardiographic confounders.

Conclusion: PALS is independently associated with all-cause mortality in patients with reduced LVEF and ventricular FMR.

Aims: The pathophysiological effects of chronic right ventricular pacing and the role of right ventricular lead position are not well understood. Therefore, we investigated the association between left ventricular contractile dyssynchrony and pacing-induced cardiomyopathy (PICM) in patients with chronic right ventricular pacing. Furthermore, we assessed the association between right ventricular lead location and left ventricular contractile dyssynchrony.

Methods: This was a retrospective study using data from 153 pacemaker patients with normal (≥ 50%) pre-implant left ventricular ejection fraction (LVEF). Baseline and follow-up echocardiograms were analyzed, and PICM was defined as LVEF < 50% with ≥ 10% decrease in LVEF after pacemaker implantation. Relative index of contractile asymmetry (rICA), a novel strain rate-based method, was calculated to quantify left ventricular contractile dyssynchrony between opposing walls in the three apical views. Right ventricular lead position was categorized into anterior septum, posterior septum, free wall, and apex based on contrast-enhanced cardiac computed tomography.

Results: Forty-seven (31%) developed PICM. Overall contractile dyssynchrony, measured by mean rICA, was higher in the PICM group compared with the non-PICM group (1.19 ± 0.21 vs. 1.03 ± 0.19, p < 0.001). Left ventricular anterior-inferior dyssynchrony, assessed in the apical two-chamber view, was independently associated with PICM (p < 0.001). Thirty-seven (24%) leads were implanted anterior septal, 11 (7.2%) posterior septal, 74 (48.4%) apical, and 31 (20.3%) free wall. Left ventricular anterior-inferior dyssynchrony was significantly different between the four pacing lead locations (p < 0.01) with the highest rICA observed in the posterior septal group (1.30 ± 0.37).

Conclusions: PICM is significantly associated increased contractile dyssynchrony assessed by rICA. This study suggests that especially left ventricular dyssynchrony in the anterior-inferior direction is associated with PICM, and pacing the right ventricular posterior septum resulted in the highest degree of anterior-inferior dyssynchrony. Quantification of left ventricular dyssynchrony by rICA provides important insights to the potential pathophysiology of PICM and the impact of right ventricular lead position.

Background: Left ventricular global longitudinal strain (GLS) obtained from two-dimensional speckle-tracking echocardiography (2D-STE) can reflect cancer therapy-related cardiac dysfunction in breast cancer (BC) patients, however, the accuracy and reproducibility of 2D-STE are restricted due to poor image quality.

Methods: Between January 2019 and October 2021, 160 consecutive BC patients aged ≥ 18 years were recruited. The 160 BC patients (mean age: 48.41 ± 9.93 years, 100% women) underwent both 2D-STE and Contrast-enhanced echocardiography (CEcho), 125 of whom were included in the measurement of GLS. The intraclass correlation coefficient (ICC) was used to determine the intra- and inter-observer reproducibility of 2D-STE and CEcho-STE. Correlation (r) was calculated using Pearson correlation. Statistical significance was set at P < 0.05.

Results: Among 160 BC patients, more segments were recognized by CEcho-STE than by 2D-STE (2,771, 99.53% vs. 2,440, 84.72%). The left ventricular ejection fraction (LVEF) obtained by 2D was lower than CEcho (61.75 ± 6.59% vs. 64.14 ± 5.97%, P < 0.0001). The GLS obtained by 2D-STE was lower than CEcho-STE (-21.74 ± 2.77% vs. -26.79 ± 4.30%, P = 0.001). The ICC of the intraobserver and interobserver agreements in the CEcho-STE group was lower than that in the 2D-STE group. GLS measurements were in good agreement between the 2D-STE and CEcho-STE groups (r = 0.773).

Conclusions: CEcho can overcome some imaging limitations and recognize more segments than 2D, which may provide an LVEF and GLS closer to the true value. Based on AutoStrain, CEcho-STE may serve as a complementary method for those with poor image quality.

Background: Anatomical characteristics of the left atrium and the pulmonary veins (PVs) may be relevant to the success rate of cryoballoon (CB)-ablation for atrial fibrillation (AF). Cardiac computed tomography (CCT) is considered as the gold standard for preablation imaging. Recently, three-dimensional transesophageal echocardiography (3DTOE) has been proposed for preprocedural assessment of cardiac structures relevant to CB-ablation. The accuracy of 3DTOE has not been validated by other imaging modalities.

Objective: We prospectively evaluated the feasibility and the accuracy of 3DTOE imaging for the assessment of left atrial and PV structures prior to pulmonary vein isolation (PVI). In addition, CCT was used to validate the measurements obtained with 3DTOE.

Methods: PV anatomy of 67 patients (59.7% men, mean age 58.5 ± 10.5 years) was assessed using both 3DTOE and CCT scan prior to PVI with the Arctic Front CB. The following parameters were measured bilaterally: PV ostium area (OA), the major and minor axis diameters of the ostium (a > b) and the width of the carina between the superior and the inferior PVs. In addition, the width of the left lateral ridge (LLR) between the left atrial appendage and the left superior PV. Evaluation of inter-technique agreement was based on linear regression with Pearson correlation coefficient (PCC) and Bland-Altman analysis of biases and limits of agreement.

Results: Moderate positive correlation (PCC 0.5-0.7) was demonstrated between the two imaging methods for the right superior PV's OA and both axis diameters, the width of the LLR and left superior PV (LSPV) minor axis diameter (b) with limits of agreement ˂50% and no significant biases. Low positive or negligible correlation (PCC < 0.5) was found for both inferior PV parameters.

Conclusions: Detailed assessment of the right superior PV parameters, LLR and LSPV b is feasible with 3DTOE prior to AF ablation. This 3DTOE measurements demonstrated a clinically acceptable inter-technique agreement with those obtained with CCT.

Background: Aorto-ventricular tunnel (AVT) is an abnormal communication channel between the ascending aorta and the ventricle. It commonly has two orifices, i.e., one aortic opening and one ventricular opening. In this study, we present a unique case of AVT with three orifices: one aortic opening, one LV opening, and one RV opening.

Case presentation: A 64-year-old male presented with chest discomfort and dyspnea on exertion lasting the past six months. Physical examination revealed a grade 4/6 continuous biphasic murmur along the left sternal edge and a grade 3/6 systolic murmur at the apex. Transthoracic echocardiography (TTE) demonstrated: (1) an AVT with three orifices, i.e., one aortic opening, one LV opening, and one RV opening. The LV and RV openings were located in the left and right ventricular outflow tracts, respectively. (2) The aortic valve (AV) was calcified with a small aneurysm at the non-coronary cusp. (3)The mitral valve (MV) chordal rupture of the P2 and P3 segments was observed in the posterior leaflet with severe eccentric regurgitation. Subsequent coronary computed tomography angiography (CTA) further confirmed the diagnosis of AVT with three openings, and clarified the coronary arteries normally arose from the aortic sinuses. The patient was then referred for surgical treatment, consisting of closure of three AVT orifices, AV replacement, and MV replacement. Six months following surgery, the patient was asymptomatic. TTE demonstrated normal mechanic AV and MV function, and there was no residual shunt among the ascending aorta, LV and RV.

Conclusions: It is the first case to report an AVT with three orifices. This paper described the entire process from diagnosis to treatment of this unique case, thus providing some novel insights into AVT.

Background: Intracardiac echocardiography (ICE) provides accurate left atrial (LA) anatomical information in the procedure of atrial fibrillation (AF) ablation but lacks LA functional assessment. LA reservoir strain (LASr) is an excellent marker of LA reservoir function. This study aimed to assess the agreement between LASr derived from ICE and transthoracic echocardiography (TTE) in AF patients and analyze the reproducibility of LASr assessed by ICE combined with speckle tracking imaging.

Methods: This study prospectively enrolled 110 patients with a clinical diagnosis of AF who were ready for AF ablation, including 71 patients with paroxysmal AF and 39 with persistent AF. TTE and ICE examinations were performed on each individual before AF ablation. LASr measurements derived from ICE and TTE images were using dedicated LA-tracking software. Pearson correlation coefficients (r) and Bland-Altman plots were used to evaluate the agreement of LASr between the two modalities. Intraclass correlation coefficients (ICCs) were used to assess intra- and inter-observer reproducibility.

Results: The agreement between LASr obtained from ICE and TTE, especially between LASr_LPV (LASr derived from LA left pulmonary vein view of ICE) and LASr_TTE (LASr derived from TTE) were good in both paroxysmal and persistent AF patients [r = 0.890 (P < 0.001) for overall population; r = 0.815 (P < 0.001) and Bias ± LOA: -0.3 ± 9.9% for paroxysmal AF; r = 0.775 (P < 0.001) and Bias ± LOA: -2.6 ± 3.9% for persistent AF, respectively]. But the values of LASr derived from ICE were slightly lower than those of TTE, especially in patients with persistent AF. The ICCs for LASr derived from ICE were excellent (all ICCs > 0.90).

Conclusions: In patients with AF, LASr derived from ICE demonstrated excellent reproducibility and showed good agreement with LASr obtained from TTE. Obtaining LASr from ICE images may be a supplementary method to evaluate LA reservoir function in AF patients and expands the potential of ICE in the field of cardiac function assessment.

Background: Infective endocarditis (IE) is a serious condition that requires prompt diagnosis and treatment. Transthoracic echocardiography (TTE) is usually the initial imaging modality, however transoesophageal echocardiography (TOE) is sometimes necessary because of its higher sensitivity for IE. Yet, TOE may imply an increased risk of complications. This project aims to evaluate whether TTE can be used to a greater extent in the diagnostics of IE to avoid unnecessary TOE examinations without jeopardizing diagnostic accuracy.

Methods: Data from all TOE examinations performed on patients hospitalized with clinical suspicion of IE between 2019-05-01 and 2020-04-30 at a university hospital in Stockholm, Sweden, were obtained and analysed. Variables included for analysis were age, sex, blood culture results, aetiology, results from TOE, number of TOEs during the inclusion period, results from positron emission tomography/computed tomography (PET/CT), new regurgitation, cardiac murmur, previous IE, prosthetic valve, predisposing factors, i.e. cardiac comorbidities, injection drug use, fever, vascular phenomena, and immunological phenomena. To assess associations between predisposing factors or aetiology of IE and TOE findings, chi square tests and logistic regression models were used. For continuous variables, linear regression was used for comparisons of means and quantile regression was used for comparisons of medians. P < 0.05 was considered significant.

Results: In total 195 TOE examinations (Table 1) from 160 patients were included, of which 61 (31%) were positive for IE. In total, 36 examinations had negative TTE prior to TOE of which 32 (86%) also had negative TOE. Of the 5 (14%) negative TTE prior to TOE that had positive TOE, all had cardiovascular implantable electronic device (CIED) and/or prosthetic valves.

Conclusions: The existing recommendations for TOE in patients with clinical suspicion of IE are probably broad enough not to miss patients with IE, but there might be an unnecessarily large number of patients being referred for TOE with negative results. Negative TTE examination with good image quality and no CIED or prosthetic valves, may be sufficient without jeopardizing the IE diagnosis.

Background: Left ventricular (LV) myocardial work index (WI) and work efficiency (WE) have become the latest indicators for assessing LV function. Reference ranges for normal LV segmental WI and WE have not been established.

Methods: Four hundred eleven healthy Asian subjects (47% men, median age: 35 years) were enrolled prospectively. WI and WE were analysed using the LV pressure-strain loop (LVPSL) with specific software.

Results: WI and WE differed significantly between segments as well as between walls and levels of the left ventricle. The anteroseptal basal segment had the lowest WI and WE (1440 mmHg ± 324 and 92% [88-96], respectively) among the eighteen segments. Significant WI and WE differences were found between sexes and age groups. No correlation was observed between age groups and the average WI of any wall or level in men, while the average WI of several different walls and levels in women showed significant differences between age groups. The average WI of most walls and levels increased with age in women. No correlation was found between age groups and the average WE of any wall or level in either men or women.

Conclusions: This study establishes the normal reference values of WI and WE of eighteen segments for clinical work and clinical experiments. There were significant differences in WI and WE between segments, levels, and walls of the normal left ventricle. Sex should be considered when analysing WI and WE. Age should be considered when analysing WI in women.

Background: Point-of-care ultrasound (POCUS) is a useful diagnostic tool for non-invasive assessment of critically ill patients. Mortality of elderly patients with COVID-19 pneumonia is high and there is still scarcity of definitive predictors. Aim of our study was to assess the prediction value of combined lung and heart POCUS data on mortality of elderly critically ill patients with severe COVID-19 pneumonia.

Methods: This was a retrospective observational study. Data of patients older than 70 years, with severe COVID-19 pneumonia admitted to mixed 25-bed, level 3, intensive care unit (ICU) was analyzed retrospectively. POCUS was performed at admission; our parameters of interest were pulmonary artery systolic pressure (PASP) and presence of diffuse B-line pattern (B-pattern) on lung ultrasound.

Results: Between October 2020 and March 2021, 117 patients aged 70 years or more (average age 77 ± 5 years) were included. Average length of ICU stay was 10.7 ± 8.9 days. High-flow oxygenation, non-invasive ventilation and invasive mechanical ventilation were at some point used to support 36/117 (31%), 39/117 (33%) and 75/117 (64%) patients respectively. ICU mortality was 50.9%. ICU stay was shorter in survivors (8.8 ± 8.3 vs 12.6 ± 9.3 days, p = 0.02). PASP was lower in ICU survivors (32.5 ± 9.8 vs. 40.4 ± 14.3 mmHg, p = 0.024). B-pattern was more often detected in non-survivors (35/59 (59%) vs. 19/58 (33%), p = 0.005). PASP and B-pattern at admission, and also mechanical ventilation and development of VAP, were univariate predictors of mortality. PASP at admission was an independent predictor of ICU (OR 1.061, 95%CI 1.003-1.124, p = 0.039) and hospital (OR 1.073, 95%CI 1.003-1.146, p = 0.039) mortality.

Conclusions: Pulmonary artery systolic pressure at admission is an independent predictor of ICU and hospital mortality of elderly patients with severe COVID-19 pneumonia.

Background: Venous thromboembolism represents the third most frequent acute cardiovascular syndrome worldwide. Its clinical manifestations are deep vein thrombosis and/or pulmonary embolism. Despite a considerable mortality, diagnosis is often missed.  CASE PRESENTATION: We report the management of a female patient with high-risk pulmonary thromboembolism treated initially with thromboaspiration, complicated by embolus jailing in a patent foramen ovale. In this situation, left cardiac chambers and systemic circulation were jeopardized by this floating embolus.

Conclusions: High-risk pulmonary embolism requires reperfusion strategy but sometimes mechanical thromboaspiration may be not fully successful; transesophageal echocardiography led to a prompt diagnosis of this unexpected finding; in this very particular case, open surgery represented a bail-out procedure to avoid cerebral and systemic embolism.