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1. Prognostic Significance of Echocardiographic Measures of Cardiac Remodeling

   Publication date: Available online 14 October 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Beatrice von Jeinsen, Meghan I. Short, Martin G. Larson, Vanessa Xanthakis, David D. McManus, Emelia J. Benjamin, Gary F. Mitchell, Jayashri Aragam, Susan Cheng, Ramachandran S. Vasan

   Background

   In recent decades, novel echocardiographic measures have constantly emerged. It is still unclear which echocardiographic measures have the most significant prognostic value in the general population. Accordingly, the aim of this study was to compare the prognostic value of a large panel of echocardiographic measures to identify the most promising measures.

   Methods

   A total of 1,497 Framingham study participants (mean age, 65 years; 55.4% women) who underwent echocardiographic measurements of left ventricular ejection fraction, left ventricular mass index, global longitudinal strain, global circumferential strain, mitral annular plane systolic excursion, mitral E/e′ ratio, maximum and minimum left atrial (LA) volume index, LA emptying fraction, and left ventricular longitudinal synchrony were evaluated. These measures were related to the incidence of two composite outcomes: cardiovascular disease (CVD) or death and atrial fibrillation (AF) or congestive heart failure (CHF).

   Results

   On follow-up (mean, 8.3 years), there were 241 CVD events or deaths and 139 AF or CHF events. In multivariate-adjusted Cox models, higher LA emptying fraction was associated with a lower risk (hazard ratios per SD, 0.80 and 0.70 for CVD or death and AF or CHF, respectively; P ≤ .001 for both) while higher minimum LA volume index (hazard ratios per SD, 1.32 and 1.70 for CVD or death and AF or CHF, respectively; P ≤ .001 for both) and maximum LA volume index (hazard ratios per SD, 1.26 and 1.54 for CVD or death and AF or CHF, respectively; P ≤ .002 for both) were associated with a higher risk for both composite outcomes.

   Conclusions

   In this community-based sample, LA volumes and function were the best echocardiographic predictors of clinical outcomes. Therefore, these values should be considered for inclusion in standard echocardiographic assessments for the purpose of risk stratification.

2. Lack of Increased Cardiovascular Risk due to Functional Tricuspid Regurgitation in Patients with Left-Sided Heart Disease

   Publication date: Available online 14 October 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Diab Mutlak, Emad Khoury, Jonathan Lessick, Izhak Kehat, Yoram Agmon, Doron Aronson

   Background

   Significant tricuspid regurgitation (TR) is associated with higher risk for adverse cardiovascular outcomes. Left-sided heart disease (LHD) is a potentially important confounder of this association because it is strongly linked to both TR and clinical outcome.

   Methods

   We studied 5,886 patients who were followed for a period of 10 years after the index echocardiographic examination. The relationship between TR severity and the end point of admission for heart failure or cardiovascular mortality was analyzed using competing risk analysis, Cox model, and propensity score matching.

   Results

   Higher TR grade was associated with markers of LHD including left ventricular systolic dysfunction, valvular heart disease ≥ moderate, left atrial enlargement, and pulmonary hypertension (all P < .001). There was a significant interaction between TR and the presence of LHD with regard to the end point of heart failure in the competing risks model (P = .01) and the combined end point of heart failure and cardiovascular mortality (P = .02). In both models, moderate/severe TR was associated with higher risk for heart failure (hazard ratio [HR] = 3.10; 95% CI, 1.41-6.84; P = .005) and the combined end point of heart failure or cardiovascular mortality (HR = 2.75; 95% CI, 1.33-5.63, P = .006) only in patients without LHD. Propensity score matching yielded 350 patient pairs, of which 88% had LHD. The HR for heart failure or cardiovascular mortality at 10 years was 0.78 (95% CI, 0.56-1.08; P = .14) in the moderate/severe TR group as compared with the trivial/mild TR.

   Conclusions

   Moderate or severe functional TR portends an increased risk for heart failure and cardiovascular mortality only when isolated, without concomitant LHD.

3. The Average Pixel Intensity Method and Outcome of Mitral Regurgitation in Mitral Valve Prolapse

   Publication date: Available online 13 October 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Victor Kamoen, Milad El Haddad, Tine De Backer, Marc De Buyzere, Frank Timmermans

   Background

   Mitral regurgitation (MR) is a frequent consequence of mitral valve prolapse (MVP). However, the echocardiographic grading of MR is challenging, and the recommended grading parameters have several limitations. The authors developed a novel echocardiographic parameter to grade MR, the average pixel intensity (API) method, on the basis of pixel intensity analysis of the continuous-wave Doppler signal.

   Methods

   Transthoracic echocardiography was performed prospectively in consecutive patients with MVP (N = 149). MR was quantitatively assessed using the API method, vena contracta width, effective regurgitant orifice area, and regurgitant volume. The primary clinical events were cardiovascular mortality, mitral valve surgery, percutaneous mitral intervention, and heart failure hospitalization.

   Results

   The API method was feasible in 90% of all patients with MVP, which was significantly higher than vena contracta width, effective regurgitant orifice area, and regurgitant volume. During a median follow-up period of 17 months, 44 patients (32%) had major adverse cardiac events, and the majority of events occurred in the holosystolic MVP subgroup. The degree of MR severity by the API method was highly significant for the prediction of events. An API cutoff of 111 arbitrary units was defined as “severe” MR due to MVP, with overall superior sensitivity and specificity compared with cutoffs for established MR grading parameters. In patients who did not have major adverse cardiac events during the follow-up period (n = 92), no significant changes in measures of MR severity were found on follow-up echocardiography.

   Conclusions

   The API method is predictive of clinical events and outcomes in MR due to MVP. Therefore, the API method may be considered for grading the severity of MR due to MVP in clinical practice.

4. The Prevalence of the Double-Barrel View with Prominent Eustachian Valve in Patients with Atrial Septal Defect

   Publication date: Available online 13 October 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Esra Kaya, Sakiko Miyazaki, Tomohiro Kaneko, Ryoko Morimoto, Masaki Maruyama, Kuniaki Hirose, Hiroyuki Daida

5. Practical Impact of New Diastolic Recommendations on Noninvasive Estimation of Left Ventricular Diastolic Function and Filling Pressures

   Publication date: Available online 13 October 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Regina Sorrentino, Roberta Esposito, Ciro Santoro, Andrea Vaccaro, Sara Cocozza, Maria Scalamogna, Maria Lembo, Federica Luciano, Alessandro Santoro, Bruno Trimarco, Maurizio Galderisi

   Background

   In 2016, an update of the 2009 recommendations for the evaluation of left ventricular (LV) diastolic function (DF) was released by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. The aims of this study were to assess the concordance between the 2016 and 2009 recommendations and to test the impact of the consideration of “myocardial disease” recommended in the 2016 update on the evaluation of diastolic dysfunction (DD) and LV filling pressures in patients with normal and reduced LV ejection fractions referred to a general echocardiography laboratory.

   Methods

   A total of 1,508 outpatients referred to an echocardiography laboratory during a predefined 5-month period were prospectively enrolled. All patients underwent targeted clinical history and Doppler echocardiographic examination. DD and LV filling pressures were assessed according to 2009 and 2016 recommendations. Concordance was calculated using the κ coefficient and overall proportion of agreement.

   Results

   Overall proportion of agreement between the two recommendations was 64.7% (κ = 0.43). Comparing the 2009 and 2016 recommendations, 47.5% and 36.1% patients, respectively, had DD (P < .0001), and 22.7% and 12.6% had elevated LV filling pressures (P < .0001). This difference remained significant in the setting of patients with normal LV ejection fractions (21.6% vs 10.7%, P < .0001). In the application of the 2016 recommendations, whether or not the presence of “myocardial disease” was considered, the prevalence of indeterminate diastolic function was, respectively, 7.3% versus 13.7%, while patients in whom the DD grade could not be determined were 8.1% versus 14.4% (P < .0001 for all).

   Conclusions

   Considering the presence of myocardial disease when applying the 2016 recommendations resulted in a lower prevalence of inconclusive diagnosis.

   Graphical abstract

   

6. Alteration in Left Ventricular Contractile Function Develops in Puppies With Duchenne Muscular Dystrophy

   Publication date: Available online 11 October 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Bijan Ghaleh, Inès Barthélemy, Lucien Sambin, Alain Bizé, Luc Hittinger, Stéphane Blot, Jin Bo Su

   Background

   Dystrophin-deficient cardiomyopathy is becoming the dominant cause of death in patients with Duchenne muscular dystrophy (DMD), but its developmental process remains elusive. This study aimed to assess the development of left ventricular (LV) dysfunction that mimics DMD pathologies in golden retriever muscular dystrophy (GRMD) dogs.

   Methods

   Transthoracic echocardiography was sequentially performed in GRMD dogs (n = 23) and age-matched healthy littermates (n = 7) from 2 to 24 months old. Conventional, tissue Doppler imaging, and speckle-tracking echocardiography parameters were analyzed.

   Results

   At 2 months of age, GRMD dogs showed a pathologic decrease in the subendocardial-subepicardial gradient of radial systolic myocardial velocity along with altered LV twist and longitudinal strain, all being aggravated with age (analysis of variance, P < .001). Receiver operator characteristic curve analysis showed good ability to discriminate normal from GRMD dogs. LV ejection fraction was significantly decreased in GRMD dogs starting from 9 months and reached a pathologic level (<50%) at 24 months.

   Conclusions

   The development of cardiomyopathy in GRMD dogs was characterized by subendocardial dysfunction, altered LV twist, and reduced longitudinal strain at a very young age to overall LV dysfunction in adults with transmural dysfunction, reduced LV ejection fraction and diastolic abnormalities, and even heart failure. This indicates the necessity to evaluate LV transmural myocardial velocity gradient, twist, and longitudinal strain in the early childhood of DMD patients.

7. Spatial Orientation in the Three-Dimensional Assessment of Tricuspid Annulus

   Publication date: Available online 11 October 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Yue Zhong, Wenjuan Bai, Li Rao

8. Normal Ranges of Left Ventricular Strain by Three-Dimensional Speckle-Tracking Echocardiography in Adults: A Systematic Review and Meta-Analysis

   Publication date: Available online 11 October 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Vien T. Truong, Hoang T. Phan, Khanh N.P. Pham, Hoang N.H. Duong, Tam N.M. Ngo, Cassady Palmer, Tuy T.H. Nguyen, Bao H. Truong, Minh A. Vo, Justin T. Tretter, Sherif F. Nagueh, Eugene S. Chung, Wojciech Mazur

   Background

   Establishing normal values and associated variations of three-dimensional speckle-tracking echocardiography– (3DSTE-) derived left ventricular (LV) strain is necessary for accurate interpretation and comparison of measurements. We aimed to perform a meta-analysis of normal ranges of LV global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS) measurements derived by 3DSTE and to identify confounding factors that may contribute to variance in reported measures.

   Methods

   The authors searched four databases, PubMed, Scopus, Embase, and Cochrane Library, through January 2019 using the key terms “left ventricular/left ventricle/left ventricles”, “strain/deformation/speckle tracking”, and “three dimensional/three-dimensional/three-dimension/three dimension/3D”. Studies were included if the articles reported LV strain using 3DSTE in healthy normal subjects, either in the control group or comprising the entire study cohort. The weighted mean was estimated by using the random effects model with a 95% CI. Heterogeneity across studies was assessed using the I² test. Effects of demographic (age), clinical, and vendor variables were assessed in a metaregression. The National Institutes of Health tools were used to assess the quality of included articles. Publication bias was examined by Begg's funnel plot and Egger's regression test.

   Results

   The search yielded 895 articles. After abstract and full-text screening we included 33 data sets with 2,346 patients for meta-analysis. The reported normal mean values of GLS among the studies varied from −15.80% to −23.40% (mean, −19.05%; 95% CI, −18.18% to −19.93%; I² = 99.0%), GCS varied from −15.50% to −39.50% (mean, −22.42%; 95% CI, −20.96% to −23.89%, I² = 99.7%), GRS varied from 19.81% to 86.61% (mean, 47.48%; 95% CI, 41.50%-53.46%; I² = 99.8%), and GAS varied from –27.40% to –50.80% (mean, –35.03%; 95% CI, –33.19% to –36.87%; I² = 99.3%). Software for strain analysis was consistently associated with variations in normal strain values (GLS: P = .016; GCS: P < .001; GRS: P < .001; GAS: P < .001).

   Conclusions

   Variations in the normal ranges across studies were significantly associated with the software used for strain analysis, emphasizing that this factor must be considered in the interpretation of strain data.

9. Safety of Transesophageal Echocardiography for Cardiac Surgery in Patients with Histories of Bariatric Surgery

   Publication date: Available online 10 October 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Marta Kelava, Marijan Koprivanac, Andrej Alfirevic, Mariya Geube, Jennifer Hargrave

10. Combined Femoral and Carotid Plaque Burden Identifies Obstructive Coronary Artery Disease in Women

    Publication date: Available online 10 October 2019

    Source: Journal of the American Society of Echocardiography

    Author(s): Kayla N. Colledanchise, Laura E. Mantella, Milena Bullen, Marie-France Hétu, Joseph G. Abunassar, Amer M. Johri

    Background

    It remains difficult to assess cardiovascular risk in symptomatic women. The development of femoral plaque precedes adverse cardiovascular events. However, associations of femoral plaque burden with coronary artery disease (CAD) severity and extent are unknown. The aim of this study was to determine sex-specific plaque quantification markers by vascular ultrasound for identifying significant, obstructive CAD.

    Methods

    In this cross-sectional study, 500 participants (34% women) underwent carotid and femoral ultrasound following coronary angiography. Maximal plaque height and total plaque area were quantified. Logistic regression was used to determine associations of plaque burden with significant, obstructive CAD (≥50% stenosis), when adjusted for age and cardiac risk factors. CAD prediction was evaluated using receiver operating characteristic areas under the curve (AUCs).

    Results

    Two hundred thirty-one men (70%) and 78 women (46%) had significant CAD. A combined assessment of femoral bifurcation and carotid maximal plaque height was the most accurate identifier of CAD in men (AUC = 0.773, cutoff ≥ 2.7 mm, 87% sensitivity, 53% specificity) but a poorer indicator of CAD in women (AUC = 0.659, P < .01). In contrast, the strongest identification of CAD in women was achieved by a combined analysis of common femoral and carotid total plaque area (AUC = 0.764, cutoff ≥ 42.0 mm², 86% sensitivity, 53% specificity). At this value, more than half of women with false-positive stress test results were correctly identified as having no significant CAD.

    Conclusion

    Combined femoral and carotid plaque burden assessments effectively ruled out significant disease in both sexes. Vascular ultrasound may have particular value for cardiovascular risk stratification in women, in whom traditional screening tools are less effective.