Regional left ventricular (LV) myocardial functional changes in early diabetic cardiomyopathy have not been well documented. LV multidirectional strain and strain rate analyses by 2-dimensional ...speckle tracking were used to detect subtle myocardial dysfunction in 47 asymptomatic, male patients (age 57 ± 6 years) with type 2 diabetes mellitus. The results were compared to those from 53 male controls matched by age, body mass index, and body surface area. No differences were found in the LV end-diastolic volume index (40.7 ± 8.9 vs 44.1 ± 7.8 ml/m2 , p = NS), end-systolic volume index (16.0 ± 4.8 vs 17.8 ± 4.3 ml/m2 , p = NS), ejection fraction (61.0 ± 5.5% vs 59.8 ± 5.3%, p = NS). The transmitral E/A (0.95 ± 0.21 vs 1.12 ± 0.32, p = 0.007) and pulmonary S/D (1.45 ± 0.28 vs 1.25 ± 0.27, p = 0.001) ratios were more impaired in the patients with diabetes mellitus. Importantly, the diabetic patients had impaired longitudinal, but preserved circumferential and radial systolic and diastolic, function. Diabetes mellitus was an independent predictor for longitudinal strain, systolic strain rate and early diastolic strain rate on multiple linear regression analysis (all p <0.001). In conclusion, the LV longitudinal systolic and diastolic function were impaired, but the circumferential and radial functions were preserved in patients with uncomplicated type 2 diabetes mellitus.
3D transesophageal echocardiography (TEE) may provide more accurate aortic annular and left ventricular outflow tract (LVOT) dimensions and geometries compared with 2D TEE. We assessed agreements ...between 2D and 3D TEE measurements with multislice computed tomography (MSCT) and changes in annular/LVOT areas and geometries after transcatheter aortic valve implantations (TAVI).
Two-dimensional circular (pixr(2)), 3D circular, and 3D planimetered annular and LVOT areas by TEE were compared with "gold standard" MSCT planimetered areas before TAVI. Mean MSCT planimetered annular area was 4.65+/-0.82 cm(2) before TAVI. Annular areas were underestimated by 2D TEE circular (3.89+/-0.74 cm(2), P<0.001), 3D TEE circular (4.06+/-0.79 cm(2), P<0.001), and 3D TEE planimetered annular areas (4.22+/-0.77 cm(2), P<0.001). Mean MSCT planimetered LVOT area was 4.61+/-1.20 cm(2) before TAVI. LVOT areas were underestimated by 2D TEE circular (3.41+/-0.89 cm(2), P<0.001), 3D TEE circular (3.89+/-0.94 cm(2), P<0.001), and 3D TEE planimetered LVOT areas (4.31+/-1.15 cm(2), P<0.001). Three-dimensional TEE planimetered annular and LVOT areas had the best agreement with respective MSCT planimetered areas. After TAVI, MSCT planimetered (4.65+/-0.82 versus 4.20+/-0.46 cm(2), P<0.001) and 3D TEE planimetered (4.22+/-0.77 versus 3.62+/-0.43 cm(2), P<0.001) annular areas decreased, whereas MSCT planimetered (4.61+/-1.20 versus 4.84+/-1.17 cm(2), P=0.002) and 3D TEE planimetered (4.31+/-1.15 versus 4.55+/-1.21 cm(2), P<0.001) LVOT areas increased. Aortic annulus and LVOT became less elliptical after TAVI.
Before TAVI, 2D and 3D TEE aortic annular/LVOT circular geometric assumption underestimated the respective MSCT planimetered areas. After TAVI, 3D TEE and MSCT planimetered annular areas decreased as it assumes the internal dimensions of the prosthetic valve. However, planimetered LVOT areas increased due to a more circular geometry.
Fabry cardiomyopathy is characterized by progressive left ventricular hypertrophy (LVH) associated with diastolic dysfunction and is the most common cause of death in Fabry disease (FD). However, LVH ...is not present in all subjects, particularly early in disease progression and in female patients. Direct assessment of myocardial deformation by strain and strain rate (SR) analysis may be sensitive to detect subclinical Fabry cardiomyopathy independent of the presence of LVH.
Systolic (longitudinal, circumferential, and radial systolic strain and SR) and diastolic (SR during isovolumic relaxation SR(IVR) and early diastole and strain at peak transmitral E wave) function was assessed in 16 patients with FD using two-dimensional speckle-tracking echocardiography. In addition, mean S' and E' mitral annular velocities by Doppler tissue imaging were measured. Diastolic filling indices, including E/SR(IVR) and E/E' ratios, were calculated. The patients were compared with 24 healthy age-matched and gender-matched controls.
All 16 patients with FD had normal left ventricular ejection fractions, and nine patients had LVH. Compared with controls, patients with FD had reduced longitudinal systolic strain (P < .001) and systolic SR (P = .007), while there were no differences in circumferential systolic strain and S'. Diastolic function assessment showed reduced longitudinal early diastolic SR (P = .001), SR(IVR) (P < .001), and E/SR(IVR) (P < .001), while radial and circumferential diastolic function was not affected. Of the conventional diastolic function indices, reductions were seen in E (P = .006), E' (P = .021), and E/E' ratio (P < .001). After correcting for LVH, only SR(IVR) (P < .001) and E/SR(IVR) (P = .025) remained significantly different between patients with FD and controls, with sensitivity of 94% and specificity of 92% for SR(IVR) of 0.235 sec(-1) (area under the receiver operating characteristic curve, 0.953).
Strain and SR analysis is useful in identifying patients with FD with reduced myocardial function, with longitudinal systolic strain and diastolic isovolumic SR being superior to the other echocardiographic measurements of myocardial contraction and relaxation and independent of LVH.
Anderson-Fabry disease (AFD) is a lysosomal storage disease caused by the inappropriate accumulation of globotriaosylceramide in tissues due to a deficiency in the enzyme α-galactosidase A (α-Gal A). ...Anderson-Fabry cardiomyopathy is characterized by structural, valvular, vascular and conduction abnormalities, and is now the most common cause of mortality in patients with AFD. Large-scale metabolic and genetic screening studies have revealed AFD to be prevalent in populations of diverse ethnic origins, and the variant form of AFD represents an unrecognized health burden. Anderson-Fabry disease is an X-linked disorder, and genetic testing is critical for the diagnosis of AFD in women. Echocardiography with strain imaging and cardiac magnetic resonance imaging using late enhancement and T1 mapping are important imaging tools. The current therapy for AFD is enzyme replacement therapy (ERT), which can reverse or prevent AFD progression, while gene therapy and the use of molecular chaperones represent promising novel therapies for AFD. Anderson-Fabry cardiomyopathy is an important and potentially reversible cause of heart failure that involves LVH, increased susceptibility to arrhythmias and valvular regurgitation. Genetic testing and cardiac MRI are important diagnostic tools, and AFD cardiomyopathy is treatable if ERT is introduced early.
Background Advances in the minimally invasive mitral valve repair techniques increase the demands on accurate and reliable morphologic assessment of the mitral valve using three-dimensional imaging ...modalities. The present study compared mitral valve geometry measurements obtained by three-dimensional transesophageal echocardiography (TEE) to those obtained with multidetector row computed tomography (MDCT) used as a standard reference. Methods Clinical preoperative MDCT and intraoperative three-dimensional TEE were performed in 43 patients (mean age 81.0 ± 7.7 years) considered for transcatheter valve implantation procedure. Various measurements of mitral valve geometry were obtained from three-dimensional TEE datasets using mitral valve quantification software, and compared with those obtained from MDCT images using multiplanar reformation planes. Results Moderate and severe mitral regurgitation was present in 48.9% of patients. There was good agreement in mitral valve geometry measurements between three-dimensional TEE and MDCT without significant overestimation or underestimation and tight 95% limits of agreement. For linear dimensions, angles and areas, the 95% limits of agreement were less than 1 cm, less than 15 degrees, and less than 2 cm2 , respectively. In addition, the intraclass correlation coefficients were more than 0.8 for all parameters. Finally, the measurements were highly reproducible, with low intraobserver and interobserver variability (nonsignificant overestimation or underestimation and narrow 95% limits of agreement). Conclusions The present study demonstrates the accuracy and clinical feasibility of the assessment of the mitral valve geometry with three-dimensional TEE that is comparable to the MDCT measurements. Three-dimensional TEE and MDCT provide accurate and complementary information in the evaluation of patients with mitral valve disease. Its potential incremental clinical value in the field of transcatheter mitral repair procedures needs further assessment in the future studies.
Transcatheter Valve-in-Valve: A Cautionary Tale Luc, Jessica G.Y; Shanks, Miriam, MD, PhD; Tyrrell, Benjamin D., MD ...
The Annals of thoracic surgery,
09/2016, Letnik:
102, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Transcatheter aortic valve replacement (TAVR) by valve-in-valve (VIV) implantation is an alternative treatment for high-risk patients with a degenerating aortic bioprosthesis. We present a case of ...transapical TAVR VIV with a 29-mm Edwards SAPIEN XT (ESV) (Edwards Lifesciences, Irvine, CA) into a 29-mm Medtronic Freestyle stentless bioprosthesis (Medtronic Inc, Minneapolis, MN) in which unanticipated dilatation of the Freestyle bioprosthesis resulted in intraprocedural embolization of the TAVR valve, necessitating urgent conversion to a conventional surgical aortic valve replacement (AVR). Our experience suggests that TAVR VIV with the 29-mm ESV in the setting of a degenerated 29-mm Freestyle stentless bioprosthesis must be undertaken with caution.
Background Accurate aortic root measurements and evaluation of spatial relationships with coronary ostia are crucial in preoperative transcatheter aortic valve implantation assessments. ...Standardization of measurements may increase intraobserver and interobserver reproducibility to promote procedural success rate and reduce the frequency of procedurally related complications. This study evaluated the accuracy and reproducibility of a novel automated multidetector row computed tomography (MDCT) imaging postprocessing software, 3mensio Valves (version 4.1.sp1, Medical Imaging BV, Bilthoven, The Netherlands), in the assessment of patients with severe aortic stenosis candidates for transcatheter aortic valve implantation. Methods Ninety patients with aortic valve disease were evaluated with 64-row and 320-row MDCT. Aortic valve annular size, aortic root dimensions, and height of the coronary ostia relative to the aortic valve annular plane were measured with the 3mensio Valves software. The measurements were compared with those obtained manually by the Vitrea2 software (Vital Images, Minneapolis, MN). Results Assessment of aortic valve annulus and aortic root dimensions were feasible in all the patients using the automated 3mensio Valves software. There were excellent agreements with minimal bias between automated and manual MDCT measurements as demonstrated by Bland-Altman analysis and intraclass correlation coefficients ranging from 0.97 to 0.99. The automated 3mensio Valves software had better interobserver reproducibility and required less image postprocessing time than manual assessment. Conclusions Novel automated MDCT postprocessing imaging software (3mensio Valves) permits reliable, reproducible, and automated assessments of the aortic root dimensions and spatial relations with the surrounding structures. This has important clinical implications for preoperative assessments of patients undergoing transcatheter aortic valve implantation.
The authors discuss an incremental value of assessing left ventricular (LV) twist mechanics in patients with heart failure (HF) and its potential usefulness in characterizing response to cardiac ...resynchronization therapy (CRT) and reversal of LV remodeling at 6 months follow-up. They also underscore a critical relationship between LV lead position and changes in LV twist after CRT, and suggest that the reversal of LV remodeling in HF patients following CRT primarily results from restoration of the global sequence of LV twist mechanics.
Abstract Background Cardiac troponin is elevated in several clinical settings apart from thrombotic acute coronary syndrome (ACS) and is associated with increased adverse events. It is not clear ...whether troponin elevation in type II myocardial infarction (MI) is associated with increased cardiovascular events. Our objectives were to identify the cause of mortality in type II MI and to attempt to establish the threshold range of cardiac troponin-I (cTnI) elevation as well as clinical factors associated with adverse outcomes in type II MI. Methods This retrospective cohort study included 245 patients presenting with a noncardiac primary diagnosis associated with cTnI elevation at a single centre from January 2003 to December 2011. Primary outcome was a composite of cardiovascular and noncardiovascular mortality. Secondary outcomes included subsequent stroke, ACS, and heart failure (HF). Results At 1 year, ACS occurred in 13 patients (5.3%), stroke was seen in 10 (4.1%) patients, and HF occurred in 19 (7.8%) patients. Overall 1-year mortality included 102 events (41.6%), with 10 cardiovascular deaths (9.8%), 65 noncardiovascular deaths (63.7%), and 27 (26.5%) deaths from unknown causes. In multivariable analysis, factors independently associated with increased overall 1-year mortality included cTnI elevation ≥ 4.63 μg/L (odds ratio OR, 3.37; 95% confidence interval CI, 1.55-7.34; P = 0.002), age ≥ 70 years (OR, 2.44; 95% CI, 1.40-4.29; P = 0.002), and estimated glomerular filtration rate < 30 mL/min/1.73m2 (OR, 2.40; 95% CI 1.31-4.40; P = 0.005). Conclusions Unlike the published literature, our study includes a variety of both operative and nonoperative clinical settings associated with troponin elevation. We illustrate that although overall mortality is high after type II MI, the majority of mortality is caused by noncardiovascular events.
Objectives This study sought to examine the changes in diastolic dyssynchrony with cardiac resynchronization therapy (CRT). Background Little is known about the effect of CRT on diastolic ...dyssynchrony. Methods Consecutive heart failure patients (n = 266, age 65.7 ± 10.0 years) underwent color-coded tissue Doppler imaging at baseline, 48 h, and 6 months after CRT. Systolic and diastolic dyssynchrony were defined as maximal time delay in peak systolic and early diastolic velocities, respectively, in 4 basal LV segments. CRT responders were defined as those with ≥15% decrease in LV end-systolic volume at 6 months. Results Baseline LVEF was 25.2 ± 8.1%; 63.5% patients were CRT responders. Baseline incidence of systolic and diastolic dyssynchrony, and a combination of both was 46.2%, 51.9%, and 28.6%, respectively. Compared to nonresponders, responders had longer baseline systolic (79.2 ± 43.4 ms vs. 45.4 ± 30.4 ms; p < 0.001) and diastolic (78.5 ± 52.0 ms vs. 50.1 ± 38.2 ms; p < 0.001) delays. In follow-up, systolic delays (45.4 ± 31.6 ms at 48 h; 38.9 ± 26.2 ms at 6 months; p < 0.001) and diastolic delays (49.4 ± 36.3 ms at 48 h; 37.7 ± 26.0 ms at 6 months; p < 0.001) improved only in responders. Conclusions At baseline: 1) diastolic dyssynchrony was more common than systolic dyssynchrony in HF patients; 2) nonresponders had less baseline diastolic dyssynchrony compared to responders. After CRT: 1) diastolic dyssynchrony improved only in responders. Further insight into the pathophysiology of diastolic dyssynchrony and its changes with CRT may provide incremental information on patient-specific treatments.
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