Publications by authors named "Lynn Weinert"

100 Publications

Refining Severe Tricuspid Regurgitation Definition by Echocardiography with a New Outcomes-Based "Massive" Grade.

J Am Soc Echocardiogr 2020 09 7;33(9):1087-1094. Epub 2020 Jul 7.

Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois. Electronic address:

Background: Current echocardiographic guidelines recommend that tricuspid regurgitation (TR) severity be graded in three categories, following assessment of specific parameters. Findings from recent trials have shown that the severity of TR frequently far exceeds the current definition of severe. We postulated that a grading approach that emphasizes outcomes could be useful to identify patients with severe TR at increased risk of mortality.

Methods: We identified 284 patients with echocardiograms demonstrating severe functional TR, defined as vena contracta (VC) ≥ 0.7 cm. Demographics and mortality data were obtained from the medical records. Patients were divided into study (n = 122 patients with three-dimensional images) and validation (n = 162) cohorts. The VC was measured in both the right ventricular (RV) inflow and apical four-chamber views and averaged. For the study cohort, tricuspid annular, RV end-diastolic (basal, mid, long axis) dimensions, tricuspid leaflet tenting height and area, RV free-wall longitudinal strain, and RV volumes were measured from two- and three-dimensional data sets. A K-partition algorithm was used in the study cohort to derive a mortality-related cutoff VC value, above which TR was termed "massive." The ability of this VC cutoff to identify patients at greater mortality risk was then tested in the validation cohort using Kaplan-Meier survival analysis.

Results: In the study cohort, VC > 0.92 cm (massive TR) was optimally associated with worse survival. Tricuspid annular and RV size were larger in the massive group (P < .05), while there were no significant differences in demographics between the TR groups. Importantly, in the independent validation cohort, the above VC cutoff also correlated with increased mortality in the massive group (log-rank P < .05).

Conclusions: Among patients traditionally defined as having severe TR, a subset exists with massive TR, resulting in greater adverse RV remodeling and increased mortality. These patients may derive the greatest benefit from emerging percutaneous therapies.
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http://dx.doi.org/10.1016/j.echo.2020.05.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955649PMC
September 2020

Echocardiographic evaluation of the effects of sacubitril-valsartan on vascular properties in heart failure patients.

Int J Cardiovasc Imaging 2020 Feb 3;36(2):271-278. Epub 2019 Oct 3.

Section of Cardiology, Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Ave., MC 9067, Chicago, IL, 60637, USA.

Increased vascular stiffness is known to be an independent predictor of mortality in patients with heart failure with reduced ejection fraction (HFrEF). The effects of sacubitril-valsartan on vascular structure and function have not been systematically studied in this patient population. We hypothesized that aortic distensibility (AD) and fractional area change (AFAC), as assessed by 2D transthoracic echocardiography (TTE), would improve over time in HFrEF patients on sacubitril-valsartan therapy, due to the vasodilatory properties of the medication. We prospectively studied 30 patients with HFrEF (25 < EF < 40%) on optimal guideline-directed medical therapy who were subsequently started on sacubitril-valsartan. Patients underwent serial 2D TTE imaging at baseline, 3 and 6 months following therapy initiation. Ascending aortic diameters were measured 3 cm above the aortic valve in the parasternal long-axis view and used to calculate AD and AFAC, two markers of vascular compliance. For reference, we also measured AD and AFAC in 30 healthy, age and gender-matched controls at a single time point. Normal controls had significantly higher values of AD and AFAC than HFrEF patients at baseline (AD: 4.0 ± 1.1 vs. 2.2 ± 0.9 cmdyne10, p < 0.0001 and AFAC: 18.8 ± 3.7% vs. 10.3 ± 4.3%, p < 0.0001). In HFrEF patients on sacubitril-valsartan, both indices of aortic compliance progressively improved towards normal from baseline to 6 months: AD from 2.2 ± 0.9 to 3.6 ± 1.5 cmdyne10 (p < 0.0001) and AFAC from 10.3 ± 4.3 to 13.7 ± 4.1% (p < 0.0001). In conclusion, AD and AFAC are decreased in patients with HFrEF and gradually improve with sacubitril-valsartan treatment. The echocardiographic markers used in this study may become a useful tool to assess the effectiveness of sacubitril-valsartan therapy in HFrEF patients.
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http://dx.doi.org/10.1007/s10554-019-01708-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7135917PMC
February 2020

Three-dimensional echocardiography investigation of the mechanisms of tricuspid annular dilatation.

Int J Cardiovasc Imaging 2020 Jan 20;36(1):33-43. Epub 2019 Aug 20.

Section of Cardiology, Cardiac Imaging Center, University of Chicago Medical Center, 5758 S. Maryland Ave., MC 9067, Chicago, IL, 60637, USA.

Tricuspid annular (TA) size, assessed by 2D transthoracic echocardiography (TTE), has a well-established prognostic value in patients undergoing mitral valve surgery, with TA dilatation triggering simultaneous tricuspid annuloplasty. While TA dilatation is common in patients with dilated atria secondary to atrial fibrillation, little is known about the mechanisms of TA dilatation in patients with sinus rhythm (SR). This study aimed to identify echocardiographic parameters most closely related to the TA size as a potential tool for identification of patients prone to developing TA enlargement. 120 patients with SR underwent clinically indicated TTE, including 30 patients with normal hearts and 90 patients diagnosed with at least one right heart abnormality, defined as: right ventricular (RV) or right atrial (RA) dilatation, ≥ moderate tricuspid regurgitation (TR) and elevated systolic pulmonary artery pressure (sPAP). RA and RV end-diastolic and end-systolic volumes (EDV, ESV) and function were measured using commercial 3D software (TomTec). 3D RV long and short axes were used as surrogate indices of RV shape. Degrees of TR and sPAP were estimated by 2D TTE. 3D TA sizing was performed at end-diastole using 3D custom software. Linear regression analysis was used to identify variables best correlated with TA size, followed by multivariate analysis to identify independent associations. The highest correlations were found between TA area and: RA ESV (r = 0.73; p < 0.01), RV EDV (r = 0.58; p < 0.01), RV end-diastolic long and short axes (r = 0.53, 0.42; both p < 0.01), TR degree (r = 0.40; p < 0.01) and sPAP (r = 0.32; p < 0.01). Multivariate analysis revealed that RA ESV was the only parameter independently associated with TA area (p < 0.05, r = 0.85). In conclusion, RA volume plays an important role in TA dilatation even in patients with normal SR. Understanding of annular remodeling mechanisms could aid in identifying patients at higher risk for TA dilatation, especially those scheduled for mitral valve surgery.
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http://dx.doi.org/10.1007/s10554-019-01686-7DOI Listing
January 2020

Machine Learning-Based Three-Dimensional Echocardiographic Quantification of Right Ventricular Size and Function: Validation Against Cardiac Magnetic Resonance.

J Am Soc Echocardiogr 2019 08 4;32(8):969-977. Epub 2019 Jun 4.

University of Chicago Medical Center, Chicago, Illinois. Electronic address:

Background: Three-dimensional echocardiography (3DE) allows accurate and reproducible measurements of right ventricular (RV) size and function. However, widespread implementation of 3DE in routine clinical practice is limited because the existing software packages are relatively time-consuming and skill demanding. The aim of this study was to test the accuracy and reproducibility of new machine learning- (ML-) based, fully automated software for three-dimensional quantification of RV size and function.

Methods: Fifty-six unselected patients with a wide range of RV size and function and image quality, referred for clinically indicated cardiac magnetic resonance (CMR) imaging, underwent a transthoracic 3DE exam on the same day. End-systolic and end-diastolic RV volumes (ESV, EDV) and ejection fraction (EF) were measured using the ML-based algorithm and compared with CMR reference values using Bland-Altman and linear regression analyses.

Results: RV function quantification by echocardiography was feasible in all patients. The automatic approach was accurate in 32% patients with analysis time of 15 ± 1 seconds and 100% reproducible. Endocardial contour editing was necessary after the automated postprocessing in the remaining 68% patients, prolonging analysis time to 114 ± 71 seconds. With these minimal adjustments, RV volumes and EF measurements were accurate in comparison with CMR reference (biases: EDV, -25.6 ± 21.1 mL; ESV, -7.4 ± 16 mL; EF, -3.3% ± 5.2%) and showed excellent reproducibility reflected by coefficients of variation <7% and intraclass correlations ≥0.95 for all measurements.

Conclusions: The new ML-based 3DE algorithm provided accurate and completely reproducible RV volume and EF measurements in one-third of unselected patients without any boundary editing. In the remaining patients, quick minimal editing resulted in reasonably accurate measurements with excellent reproducibility. This approach provides a promising solution for fast three-dimensional quantification of RV size and function.
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http://dx.doi.org/10.1016/j.echo.2019.04.001DOI Listing
August 2019

3D echocardiographic global longitudinal strain can identify patients with mildly-to-moderately reduced ejection fraction at higher cardiovascular risk.

Int J Cardiovasc Imaging 2019 Sep 1;35(9):1573-1579. Epub 2019 Apr 1.

Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA.

Severely reduced left ventricular (LV) ejection fraction (EF) derived from 2D echocardiographic (2DE) images is associated with increased mortality and used to guide therapeutic choices. Global longitudinal strain (GLS) is more sensitive than LVEF to detect abnormal LV function, and accordingly may help identify patients with mildly-to-moderately reduced LVEF who are at a similarly high cardiovascular (CV) risk. We hypothesized that 3D echocardiographic (3DE) measurements of EF and GLS, which are more reliable and reproducible, may have even better predictive value than the 2DE indices, and compared their ability to identify such patients. We retrospectively studied 104 inpatients with 2DE-derived LVEF of 30-50% who underwent transthoracic echocardiography during 2006-2010 period, had good quality images, and were followed-up through 2016. Both 2DE and 3DE images were analyzed to measure LVEF and GLS. Kaplan-Meier survival curves were generated for two subgroups defined by the median of each parameter as the cutoff. Of the 104 patients, 32 died of CV related causes. Cox regression revealed that 3D GLS was the only variable associated with CV mortality. Kaplan-Meier curves showed that 2D LVEF, 2D GLS and 3D EF were unable to differentiate patients at higher CV mortality risk, but 3D GLS was the only parameter to do so. Because 3D GLS is able to identify patients with mildly-to-moderately reduced LVEF who are at higher CV mortality risk, its incorporation into clinical decisions may improve survival of those who would benefit from therapeutic interventions not indicated according to the current guidelines.
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http://dx.doi.org/10.1007/s10554-019-01589-7DOI Listing
September 2019

Echocardiographic Assessment of the Tricuspid Annulus: The Effects of the Third Dimension and Measurement Methodology.

J Am Soc Echocardiogr 2019 02 17;32(2):238-247. Epub 2018 Nov 17.

Cardiac Imaging Center, University of Chicago Medical Center, Chicago, Illinois.

Background: Evaluation of the tricuspid annulus is crucial for the decision making at the time of left heart surgery. Current recommendations for tricuspid valve repair are based on two-dimensional (2D) transthoracic echocardiography (TTE), despite the known underestimation compared with three-dimensional (3D) echocardiography. However, little is known about the differences in 3D tricuspid annular (TA) sizing using TTE versus transesophageal echocardiography (TEE). The aims of this study were to (1) compare 2D and 3D TA measurements performed with both TTE and TEE and (2) compare two 3D methods for TA measurements: multiplanar reconstruction (MPR) and dedicated software (DS) designed to take into account TA nonplanarity.

Methods: Seventy patients underwent 2D and 3D TTE and TEE. Two-dimensional images were used to measure TA diameter from apical four-chamber, right ventricular-focused (TTE), and midesophageal four-chamber (TEE) views. Three-dimensional full-volume data sets were analyzed using both MPR and DS, to obtain major and minor axes, perimeter, and area. Intertechnique agreement was assessed using Bland-Altman analysis.

Results: Measurements on 2D TTE and TEE, which were view dependent, underestimated TA major dimensions in all views compared with 3D values, irrespective of the 3D method. MPR and DS measurements were significantly different, with DS resulting in larger values for all parameters, irrespective of approach. No differences were found between 3D TTE and 3D TEE for both MPR and DS.

Conclusions: Our findings highlight the need for methodology that respects the 3D geometry of the tricuspid annulus, including its nonplanarity, which cannot be accurately assessed from 2D images and is not equally taken into account by different 3D measurement methodologies. Accordingly, a 3D cutoff value for TA enlargement needs to be established and is likely to be larger than the guideline-recommended 2D-based 40-mm cutoff. Importantly, noninvasive 3D TTE can be used instead of 3D TEE because TA measurements are not different.
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http://dx.doi.org/10.1016/j.echo.2018.09.008DOI Listing
February 2019

Load Dependency of Left Atrial Strain in Normal Subjects.

J Am Soc Echocardiogr 2018 11 8;31(11):1221-1228. Epub 2018 Sep 8.

University of Chicago Medical Center, Chicago, Illinois. Electronic address:

Background: Left atrial (LA) longitudinal strain is a novel parameter used for the evaluation of LA function, with demonstrated prognostic value in several cardiac diseases. However, the extent of load dependency of LA strain is not well known. The aim of this study was to evaluate the impact of acute changes in preload on LA strain, side by side with LA volume, in normal subjects.

Methods: Twenty-five healthy volunteers (13 men; mean age, 31 ± 2 years) were prospectively enrolled, who underwent two-dimensional and three-dimensional echocardiographic imaging during acute stepwise reductions in preload using a tilt maneuver: baseline at 0°, followed by 40° and 80°. Left ventricular and LA size and function parameters were measured using standard methodology, and LA strain-time curves were obtained using speckle-tracking software (TomTec), resulting in reservoir, conduit, and contractile strain components. All parameters were compared among the three loading conditions using one-way analysis of variance for repeated measurements.

Results: Although there were no significant changes in blood pressure, heart rate increased significantly with tilt. As expected, LA volumes, left ventricular volumes, and left ventricular ejection fraction, as well as E wave, A wave, and e' significantly decreased with progressive inclination. In parallel, LA reservoir, conduit, and contractile strain values decreased with reduction in preload (reservoir: 42.9 ± 3.9% to 27.5 ± 3.8%, P < .001; conduit: 29.3 ± 2.7% to 20.2 ± 5.0%, P < .001; contractile: 13.6 ± 2.9% to 7.3 ± 3.5%, P < .001). Paired post hoc analysis showed that all LA strain values were significantly different among all three tilt phases. Of note, percentage change in LA reservoir strain was significantly smaller than that in LA maximum volume.

Conclusions: In normal subjects, LA strain is preload dependent but to a lesser degree than LA volume. This difference underscores the relative advantage of LA strain over maximum volume, when LA assessment is used as part of the diagnostic paradigm.
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http://dx.doi.org/10.1016/j.echo.2018.07.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7147871PMC
November 2018

Diagnosis of Isolated Cleft Mitral Valve Using Three-Dimensional Echocardiography.

J Am Soc Echocardiogr 2018 11 7;31(11):1161-1167. Epub 2018 Aug 7.

Department of Medicine, University of Chicago Medical Center, Chicago, Illinois. Electronic address:

Background: The prevalence of isolated cleft mitral valve (MV; no concomitant congenital heart disease or degenerative MV disease) with significant mitral regurgitation (MR) diagnosed using two-dimensional echocardiography (2DE) has been reported to be very low. Three-dimensional echocardiography (3DE) has enabled a more comprehensive visualization of the MV and detailed understanding of the mechanisms of MR and can potentially reveal isolated cleft MV that is not recognized with 2DE. The aim of this study was to determine, using 3DE, the prevalence, location, and associated MV annular and left ventricular characteristics of isolated cleft MV, in the absence of associated congenital heart disease, in patients with significant MR.

Methods: A total of 1,092 patients with unexplained moderate or greater MR on two-dimensional transthoracic echocardiography who were referred for three-dimensional transesophageal echocardiography between 2005 and 2017 (n = 626) were retrospectively studied. Left ventricular dimensions and function were determined, and quantitative MR assessment and three-dimensional analysis of the MV annulus was performed.

Results: Twenty-one patients (prevalence 3.3%) were diagnosed with isolated cleft MV using three-dimensional transesophageal echocardiography but not 2DE. The majority of these patients (n = 16) were noted to have anterior cleft MVs, with most located in the mid-A1 (n = 10) or mid-A3 (n = 5) scallops. Posterior clefts were less common (n = 5) and occurred at the site of the natural scallop indentations (three between P1 and P2 and two between P2 and P3). Among patients with either anterior or posterior MV cleft, there were no differences in left ventricular ejection fraction or three-dimensional MV geometry (annular distance, height, circumference, and area). There was a trend toward worse MR severity in patients with anterior cleft MV.

Conclusions: In patients with otherwise unexplained significant MR referred for transesophageal echocardiography, 3DE uncovered a considerably higher prevalence of isolated cleft MV than previously reported by 2DE, with the majority located in the anterior MV. Although the annular geometry was similar between patients with anterior and posterior cleft MVs, a trend toward more severe MR in anterior clefts may reflect underlying abnormalities in the embryologic development of the anterior MV leaflet. Evaluation of MV pathology is improved by 3DE, which should be used routinely in the setting significant MR.
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http://dx.doi.org/10.1016/j.echo.2018.06.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6252053PMC
November 2018

Residual native left ventricular function optimization using quantitative 3D echocardiographic assessment of rotational mechanics in patients with left ventricular assist devices.

Echocardiography 2018 10 25;35(10):1606-1615. Epub 2018 Jul 25.

Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.

Preservation of native left ventricular (LV) function in patients supported with LV assist device (LVAD) may be beneficial to attain optimal hemodynamics and enhance potential recovery. Currently, LVAD speed optimization is based on hemodynamic parameters, without considering residual native LV function. We hypothesized that alternatively, LV rotational mechanics can be quantified by 3D echocardiography (3DE), and may help preserve native LV function while optimizing LVAD speed. The goal of this study was to test the feasibility of quantifying the effects of LVAD implantation on LV rotational mechanics and to determine whether conventional speed optimization maximally preserves native LV function. We studied 55 patients with LVADs, who underwent 3DE imaging and quantitative analysis of LV twist. Thirty patients were studied before and after LVAD implantation. The remaining 25 patients were studied during hemodynamic ramp studies. The pump speed at which LV twist was maximal was compared with the hemodynamics-based optimal speed. LV twist decreased following LVAD implantation from 4.2 ± 2.7 to 2.3 ± 1.9° (P < 0.01), reflecting the constricting effects on native function. With lower pump speeds, no significant changes were noted in LV twist, which peaked at a higher speed. In 11/25 (44%) patients, the conventional hemodynamic/2DE methodology and 3DE assessment of maximal residual function did not indicate the same optimal conditions, suggesting that a higher pump speed would have better preserved native function. In conclusion, quantitative 3DE analysis of LV rotational mechanics provides information, which together with hemodynamics may help select optimal pump speed, while maximally preserving native LV function.
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http://dx.doi.org/10.1111/echo.14101DOI Listing
October 2018

Activin A and Late Postpartum Cardiac Dysfunction Among Women With Hypertensive Disorders of Pregnancy.

Hypertension 2018 07 29;72(1):188-193. Epub 2018 May 29.

Department of Obstetrics and Gynecology, Section of Maternal Fetal Medicine (H.R., A.M., R.N., S.C., S.R.).

Women with hypertensive disorders of pregnancy have an increased risk of subsequent heart failure and cardiovascular disease when compared with women with normotensive pregnancies. Although the mechanisms underlying these findings are unclear, elevated levels of the biomarker activin A are associated with myocardial dysfunction and may have predictive value. We hypothesized that elevated levels of antepartum activin A levels would correlate with postpartum cardiac dysfunction in women with hypertensive disorders of pregnancy. We prospectively studied 85 women to determine whether increased antepartum activin A levels were associated with cardiac dysfunction at 1 year postpartum as measured by global longitudinal strain. Thirty-two patients were diagnosed with preeclampsia, 28 were diagnosed with gestational or chronic hypertension, and the remainder were nonhypertensive controls. Activin A levels were measured with ELISA both in the third antepartum trimester and at 1 year postpartum. Comprehensive echocardiograms including measurement of global longitudinal strain were also performed at enrollment and at 1 year postpartum. Antepartum activin A levels correlated with worsening antepartum global longitudinal strain (=0.70; =0.0001). Across the entire cohort, elevated antepartum activin A levels were associated with the development of abnormal global longitudinal strain at 1 year (C statistic 0.74; =0.004). This association remained significant after multivariable adjustment for clinically relevant confounders (C statistic 0.93; =0.01). Postpartum activin A levels also correlated with increasing left ventricular mass index (=0.02), increasing mean arterial pressures (=0.02), and decreasing E' values (=0.01). Activin A may be a useful tool for identifying and monitoring patients at risk for postpartum development of cardiovascular disease.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.118.10888DOI Listing
July 2018

Feasibility of Left Ventricular Global Longitudinal Strain Measurements from Contrast-Enhanced Echocardiographic Images.

J Am Soc Echocardiogr 2018 03 23;31(3):297-303. Epub 2017 Nov 23.

Department of Medicine, University of Chicago Medical Center, Chicago, Illinois. Electronic address:

Background: Although left ventricular global longitudinal strain (GLS) is an index of systolic function recommended by the guidelines, poor image quality may hamper strain measurements. While contrast agents are commonly used to improve endocardial visualization, no commercial speckle-tracking software is able to measure strain in contrast-enhanced images. This study aimed to test the accuracy of speckle-tracking software when applied to contrast-enhanced images in patients with suboptimal image quality.

Methods: We studied patients with a wide range of GLS values who underwent transthoracic echocardiography. Protocol 1 included 44 patients whose images justified use of contrast but still allowed noncontrast speckle-tracking echocardiography (STE), which was judged as accurate and used as a reference. Protocol 2 included 20 patients with poor image quality that precluded noncontrast STE; cardiac magnetic resonance- (CMR-) derived strain was used as the reference instead. Half the manufacturer recommended dose of a commercial contrast agent (Definity/Optison/Lumason) was used to provide partial contrast enhancement. Higher than normal mechanical indices (0.6-0.7) and lowest frequency range for maximal penetration settings were used for imaging. GLS was measured (Epsilon) with and without contrast-enhanced images and by CMR-derived feature tracking (TomTec). Comparisons included linear regression and Bland-Altman analyses.

Results: The contrast STE analysis failed in 4/64 patients (6%). Manual corrections were needed to optimize tracking with contrast in all patients. GLS measurements were in good agreement between contrast and noncontrast images (r = 0.85; mean GLS in the contrast images, -12.9% ± 4.7%; bias, 0.34% ± 2.4%). Good agreement was also noted between contrast STE- and CMR-derived strain (r = 0.83; mean, GLS -13.5% ± 4.0%; bias, 0.72% ± 2.5%).

Conclusions: We found that GLS measurements from contrast-enhanced images are feasible and accurate in most patients, even in those with poor image quality that precludes strain measurements without contrast enhancement.
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http://dx.doi.org/10.1016/j.echo.2017.10.005DOI Listing
March 2018

2D and 3D Echocardiography-Derived Indices of Left Ventricular Function and Shape: Relationship With Mortality.

JACC Cardiovasc Imaging 2018 11 15;11(11):1569-1579. Epub 2017 Nov 15.

Department of Medicine, University of Chicago Medical Center, Chicago, Illinois. Electronic address:

Objectives: This study hypothesized that left ventricular (LV) ejection fraction (EF) and global longitudinal strain (GLS) derived from 3-dimensional echocardiographic (3DE) images would better predict mortality than those obtained by 2-dimensional echocardiographic (2DE) measurements, and that 3DE-based LV shape analysis may have added prognostic value.

Background: Previous studies have shown that both LVEF and GLS derived from 2DE images predict mortality. Recently, 3DE measurements of these parameters were found to be more accurate and reproducible because of independence of imaging plane and geometric assumptions. Also, 3DE analysis offers an opportunity to accurately quantify LV shape.

Methods: We retrospectively studied 416 inpatients (60 ± 18 years of age) referred for transthoracic echocardiography between 2006 and 2010, who had good-quality 2DE and 3DE images were available. Mortality data through 2016 were collected. Both 2DE and 3DE images were analyzed to measure LVEF and GLS. Additionally, 3DE-derived LV endocardial surface information was analyzed to obtain global shape indices (sphericity and conicity) and regional curvature (anterior, septal, inferior, lateral walls). Cardiovascular (CV) mortality risks related to these indices were determined using Cox regression.

Results: Of the 416 patients, 208 (50%) died, including 114 (27%) CV-related deaths over a mean follow-up period of 5 ± 3 years. Cox regression revealed that age and body surface area, all 4 LV function indices (2D EF, 3D EF, 2D GLS, 3D GLS), and regional shape indices (septal and inferior wall curvatures) were independently associated with increased risk of CV mortality. GLS was the strongest prognosticator of CV mortality, superior to EF for both 2DE and 3DE analyses, and 2D EF was the weakest among the 4 functional indices. A 1% decrease in GLS magnitude was associated with an 11.3% increase in CV mortality risk.

Conclusions: GLS predicts mortality better than EF by both 3DE and 2DE analysis, whereas 3D EF is a better predictor than 2D EF. Also, LV shape indices provide additional risk assessment.
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http://dx.doi.org/10.1016/j.jcmg.2017.08.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5945352PMC
November 2018

Quantification of Right Ventricular Size and Function from Contrast-Enhanced Three-Dimensional Echocardiographic Images.

J Am Soc Echocardiogr 2017 Dec 17;30(12):1193-1202. Epub 2017 Oct 17.

Department of Medicine, University of Chicago Medical Center, Chicago, Illinois. Electronic address:

Background: Three-dimensional (3D) echocardiography directly assesses right ventricular (RV) volumes without geometric assumptions, despite the complex shape of the right ventricle, and accordingly is more accurate and reproducible than the two-dimensional methodology, which is able to measure only surrogate parameters of RV function. Volumetric analysis has been hampered by frequent inability to clearly visualize RV endocardium, especially the RV free wall, in 3D echocardiographic images. The aim of this study was to test the hypothesis that RV contrast enhancement during 3D echocardiographic imaging would improve the accuracy of RV volume and function analysis.

Methods: Thirty patients with a wide range of RV size and function and image quality underwent transthoracic 3D echocardiography with and without contrast enhancement and cardiovascular magnetic resonance imaging on the same day. RV end-diastolic and end-systolic volumes and ejection fraction were measured from contrast-enhanced and nonenhanced 3D echocardiographic images and compared with cardiovascular magnetic resonance reference values using linear regression and Bland-Altman analyses. Blinded repeated measurements were performed to assess measurement variability.

Results: RV contrast enhancement was feasible in all patients. RV volumes obtained both with and without contrast enhancement correlated highly with cardiovascular magnetic resonance (end-diastolic volume, r = 0.90 and r = 0.92; end-systolic volume, r = 0.92 and r = 0.94, respectively), but the correlation for ejection fraction was better with contrast (r = 0.87 vs r = 0.70). Biases were smaller with contrast for all three parameters (end-diastolic volume, -16 ± 23 vs -36 ± 25 mL; end-systolic volume, -10 ± 16 vs -23 ± 18 mL; ejection fraction, -0.7 ± 5.5% vs -2.7 ± 8.1% of the mean measured values), reflecting improved accuracy. Also, measurement reproducibility was improved by contrast enhancement.

Conclusions: Contrast enhancement improves the visualization of RV endocardial borders, resulting in more accurate and reproducible 3D echocardiographic measurements of RV size and function. This approach may be particularly useful in patients with suboptimal image quality.
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http://dx.doi.org/10.1016/j.echo.2017.08.003DOI Listing
December 2017

Three-Dimensional Echocardiographic Automated Quantification of Left Heart Chamber Volumes Using an Adaptive Analytics Algorithm: Feasibility and Impact of Image Quality in Nonselected Patients.

J Am Soc Echocardiogr 2017 Sep 6;30(9):879-885. Epub 2017 Jul 6.

Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.

Background: Although 3D echocardiography (3DE) allows accurate and reproducible quantification of cardiac chambers, it has not been integrated into clinical practice because it relies on manual input, which interferes with workflow. A recently developed automated adaptive analytics algorithm for simultaneous quantification of left ventricular and atrial (LV, LA) volumes was found to be accurate and reproducible in patients with good images. We sought to prospectively test its feasibility and accuracy in consecutive patients in relationship with image quality and reader experience.

Methods: Three hundred consecutive patients underwent 3DE. Image quality was graded as poor, adequate, or good. Images were analyzed by an expert echocardiographer to obtain LV volumes and ejection fraction (EF) and LA volume using the automated analysis (HeartModel, Philips, Andover, MA) with and without editing the endocardial boundaries and using conventional manual tracing (QLAB, Philips, Andover, MA) blinded to the automated measurements as a reference. In a subgroup of 100 patients, automated analysis was repeated by two readers without 3DE experience.

Results: Automated analysis failed in 31/300 patients (10%). Patients with poor image quality (n = 72, 24%) showed suboptimal agreement with the reference technique, especially for LVEF. Importantly, patients with adequate (n = 89, 30%) and good (n = 108, 36%) images showed small biases and excellent correlations without border corrections, which were further improved with editing. In contrast, border corrections by inexperienced readers did not improve the agreement with reference values.

Conclusions: Automated 3DE analysis allows accurate quantification of left-heart size and function in 66% of consecutive patients, while in the remaining patients, its performance is limited/unreliable due to image quality. Border corrections require 3DE experience to improve the accuracy of the automated measurements. In patients with sufficient image quality, this automated approach has the potential to overcome the workflow limitations of the 3D analysis in clinical practice.
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http://dx.doi.org/10.1016/j.echo.2017.05.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741442PMC
September 2017

Three-dimensional echocardiographic quantification of the left-heart chambers using an automated adaptive analytics algorithm: multicentre validation study.

Eur Heart J Cardiovasc Imaging 2018 01;19(1):47-58

University of Chicago, Medical Center, Chicago, Illinois, USA.

Aims: Although recommended by current guidelines, adoption of three-dimensional echocardiographic (3DE) chamber quantification in clinical practice has lagged because of time-consuming analysis. We recently validated an automated algorithm that measures left atrial (LA) and left ventricular (LV) volumes and ejection fraction (EF). This study aimed to determine the accuracy and reproducibility of these measurements in a multicentre setting.

Methods And Results: 180 patients underwent 3DE imaging (Philips) at six sites. Images were analysed using automated HeartModel (HM) software with endocardial border correction when necessary and by manual tracing. Measurements were performed by each site and by the Core Laboratory (CL) as the reference. Inter-technique comparisons included HM measurements by the sites against manual tracing by CL, and showed strong correlations (r-values: LVEDV: 0.97, LVESV: 0.97, LVEF: 0.88, LAV: 0.96), with the automated technique slightly underestimating LV volumes (biases: LVEDV: -14 ± 20 ml, LVESV: -6 ± 20 ml), LVEF (-2 ± 7%) and LAV (-9 ± 10 ml). Intra-technique comparisons included HM measurements by the sites against CL, with and without corrections. Corrections were unnecessary or minimal in most patients, and improved the measurements only modestly. Comparisons without corrections showed perfect agreement for all parameters. With corrections, correlations were better (r-values: LVEDV: 0.99, LVESV: 0.99, LVEF: 0.94, LAV: 0.99) and biases (LVEDV: -8 ± 12 ml, LVESV: -6 ± 12 ml, LVEF: 1 ± 5%, LAV: -10 ± 6 ml) smaller than in inter-technique comparison. All automated measurements with corrections were more reproducible than manual measurements.

Conclusion: Automated 3DE analysis of left-heart chambers is an accurate alternative to conventional manual methodology, which yields almost the same values across laboratories and is more reproducible. This technique may contribute towards full integration of 3DE quantification into clinical routine.
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http://dx.doi.org/10.1093/ehjci/jew328DOI Listing
January 2018

Transthoracic 3D Echocardiographic Left Heart Chamber Quantification Using an Automated Adaptive Analytics Algorithm.

JACC Cardiovasc Imaging 2016 07 15;9(7):769-782. Epub 2016 Jun 15.

University of Chicago Medical Center, Chicago, Illinois. Electronic address:

Objectives: The goal of this study was to test the feasibility and accuracy of an automated algorithm that simultaneously quantifies 3-dimensional (3D) transthoracic echocardiography (TTE)-derived left atrial (LA) and left ventricular (LV) volumes and left ventricular ejection fraction (LVEF). Conventional manual 3D TTE tracings and cardiac magnetic resonance (CMR) images were used as a reference for comparison.

Background: Cardiac chamber quantification from 3D TTE is superior to 2D TTE measurements. However, integration of 3D quantification into clinical practice has been limited by time-consuming workflow and the need for 3D expertise. A novel automated software was developed that provides LV and LA volumetric quantification from 3D TTE datasets that reflect real-life manual 3-dimensional echocardiography measurements and values comparable to CMR.

Methods: A total of 159 patients were studied in 2 separate protocols. In protocol 1, 94 patients underwent 3D TTE imaging (EPIQ, iE33, X5-1, Philips Healthcare, Andover, Massachusetts) covering the left atrium and left ventricle. LA and LV volumes and LVEF were obtained using the automated software (HeartModel, Philips Healthcare) with and without contour correction, and compared with the averaged manual 3D volumetric measurements from 3 readers. In protocol 2, automated measurements from 65 patients were compared with a CMR reference. The Pearson correlation coefficient, Bland-Altman analysis, and paired Student t tests were used to assess inter-technique agreement.

Results: Correlations between the automated and manual 3D TTE measurements were strong (r = 0.87 to 0.96). LVEF was underestimated and automated LV end-diastolic, LV end-systolic, and LA volumes were overestimated compared with manual measurements. Agreement between the automated analysis and CMR was also strong (r = 0.84 to 0.95). Test-retest variability was low.

Conclusions: Automated simultaneous quantification of LA and LV volumes and LVEF is feasible and requires minimal 3D software analysis training. The automated measurements are not only comparable to manual measurements but also to CMR. This technique is highly reproducible and timesaving, and it therefore promises to facilitate the integration of 3D TTE-based left-heart chamber quantification into clinical practice.
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http://dx.doi.org/10.1016/j.jcmg.2015.12.020DOI Listing
July 2016

Segmentation of the left ventricular endocardium from magnetic resonance images by using different statistical shape models.

J Electrocardiol 2016 May-Jun;49(3):383-91. Epub 2016 Mar 9.

Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Italy.

We evaluate in this paper different strategies for the construction of a statistical shape model (SSM) of the left ventricle (LV) to be used for segmentation in cardiac magnetic resonance (CMR) images. From a large database of LV surfaces obtained throughout the cardiac cycle from 3D echocardiographic (3DE) LV images, different LV shape models were built by varying the considered phase in the cardiac cycle and the registration procedure employed for surface alignment. Principal component analysis was computed to describe the statistical variability of the SSMs, which were then deformed by applying an active shape model (ASM) approach to segment the LV endocardium in CMR images of 45 patients. Segmentation performance was evaluated by comparing LV volumes derived by ASM segmentation with different SSMs and those obtained by manual tracing, considered as a reference. A high correlation (r(2)>0.92) was found in all cases, with better results when using the SSM models comprising more than one frame of the cardiac cycle.
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http://dx.doi.org/10.1016/j.jelectrocard.2016.03.017DOI Listing
November 2017

Elongation of chordae tendineae as an adaptive process to reduce mitral regurgitation in functional mitral regurgitation.

Eur Heart J Cardiovasc Imaging 2016 May 28;17(5):500-9. Epub 2015 Dec 28.

Noninvasive Cardiac Imaging Laboratory, Section of Cardiology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA

Aims: In functional mitral regurgitation (FMR), increased leaflet area has been described as a remodelling compensatory mechanism. We hypothesized that chordae tendineae elongation would also occur as part of this remodelling. In this study, the lengths of primary chords and measurements of mitral leaflets and annulus were compared with varying degrees of mitral regurgitation (MR).

Methods And Results: We studied 58 patients who underwent three-dimensional (3D) transoesophageal echocardiography, including 38 with FMR and 20 with normal mitral valves (NL). The FMR group was divided into two subgroups according to two-dimensional vena contracta width (VCW). Three-dimensional datasets from transgastric or mid-oesophageal approach were used to measure primary chordal length, coaptation length, inter-papillary muscle distances, and quantitative 3D measurements of the annulus and leaflets. Leaflet surface area was increased and coaptation length was decreased in FMR compared with NL. While no difference in other 3D measurement of annulus/leaflets was noted between the FMR subgroups, averaged chordal length was shorter in patients with more severe FMR. Chords of the anterior leaflet in FMR with larger VCW were shorter compared with both NL and FMR with smaller VCW. In contrast, the chords of the posterior leaflet were longer in FMR with smaller VCW compared with the other two groups.

Conclusion: Our results suggest the posterior leaflet chords possibly remodel by elongating and contribute to reduced MR and that in a subgroup of FMR patients, the primary chords may remodel by shortening, resulting in augmented MR. This information could be useful in choosing strategy for FMR correction.
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http://dx.doi.org/10.1093/ehjci/jev314DOI Listing
May 2016

Leaflet-chordal relations in patients with primary and secondary mitral regurgitation.

J Am Soc Echocardiogr 2015 Nov 15;28(11):1302-8. Epub 2015 Sep 15.

Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois. Electronic address:

Background: The strategy for mitral valve (MV) repair has recently focused on the restoration of the submitral apparatus. However, the relationship between geometric changes of the submitral apparatus and the mitral leaflets has not been systematically investigated. The aim of this study was to determine the relationships among chordal length (CL) and LV size and leaflet surface area (LSA) in normal subjects, patients with primary (degenerative) mitral regurgitation (PMR), and patients with functional (secondary) mitral regurgitation (FMR).

Methods: A total of 72 patients who underwent three-dimensional transesophageal echocardiography, including: 27 with PMR with isolated P2 flail leaflet, 25 with FMR with greater than mild mitral regurgitation, and 20 with normal mitral valves. LSA was quantified at midsystole from full-volume midesophageal views. CL was calculated by averaging the lengths of eight primary chords from transgastric full-volume data sets using multiplanar reconstruction.

Results: Both CL and LSA in the PMR group were significantly longer compared with the FMR and normal control groups. No difference in CL was noted between patients with FMR and normal subjects. In all three groups, CL and LSA did not correlate with LV systolic or diastolic dimensions. Although CL did not correlate with LSA in the FMR group, a moderate correlation (R = 0.62) was observed in the PMR group.

Conclusions: In patients with FMR with greater than mild mitral regurgitation, the chords retain normal length, despite LSA and LV enlargement. In patients with PMR with flail P2 scallops, CL elongation of primary chords is associated with larger LSA but not with LV dimensions. This information may have implications for clinical strategies for mitral valve repair surgery, including the submitral approach and percutaneous procedures.
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http://dx.doi.org/10.1016/j.echo.2015.08.009DOI Listing
November 2015

Three-dimensional echocardiography-based analysis of right ventricular shape in pulmonary arterial hypertension.

Eur Heart J Cardiovasc Imaging 2016 May 9;17(5):564-75. Epub 2015 Jul 9.

Department of Medicine, Section of Cardiology, University of Chicago, 5841 South Maryland Avenue, MC5084, Chicago, IL 60637, USA

Aims: Right ventricular (RV) remodelling involves changes in size, function, and shape. Although three-dimensional echocardiography (3DE) allows imaging of RV morphology, regional RV shape analysis has not been evaluated using 3DE. We developed a technique to quantify RV shape and tested its ability to differentiate normal from pressure overloaded right ventricles. Methods Transthoracic 3DE RV images were acquired in 54 subjects, including 39 patients with pulmonary artery hypertension (PAH) and 15 normal controls (NL). 3D RV surfaces were reconstructed (TomTec) at end-diastole and end-systole (ED, ES) and processed using custom software to calculate mean curvature of the inflow and outflow tracts (RVIT, RVOT), apex, and body (both divided into free wall and septum).

Methods And Results: Septal segments (apical and body) in NLs were characterized by concavity (curvature < 0) in ED and slight convexity (curvature > 0) in ES. In PAH, however, the septum remained convex, bulging into the left ventricle throughout the cardiac cycle. In keeping with the 'bellows-like' action of RV contraction in the NL group, the body free wall transitioned from a convex surface at ED to a more flattened surface at ES, while the apex free wall progressed from a less convex surface at ED to a more convex surface at ES. In contrast, in PAH, both RV free-wall segments (apical and body) remained equally convex throughout the cardiac cycle.

Conclusions: Curvature analysis using 3D echocardiography allows quantitative evaluation of RV remodelling, which could be used to track differential changes in regional RV shape, as a way to assess disease progression or regression.
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http://dx.doi.org/10.1093/ehjci/jev171DOI Listing
May 2016

Reconstruction of the descending thoracic aorta by multiview compounding of 3-D transesophageal echocardiographic aortic data sets for improved examination and quantification of atheroma burden.

Ultrasound Med Biol 2015 May 13;41(5):1263-76. Epub 2015 Feb 13.

Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy. Electronic address:

A robust and efficient approach to reconstruction of the descending thoracic aorta from contiguous 3-D transesophageal echocardiographic (TEE) images is proposed. An ad hoc image acquisition protocol was designed to acquire ordered and partially overlapped 3-D TEE data sets, followed by dedicated image processing to align and fuse all acquired data sets. Alignment strategy implemented pairwise rigid registration guided by a priori knowledge, and it was validated using artificially misaligned images. Image fusion was finally performed to enable visualization and analysis of extended field-of-view of the acquired aorta. The application of different fusion techniques was also investigated. The method was applied to a population of 17 consecutive patients. Qualitative and quantitative results supported the feasibility and accuracy of the proposed approach. In a clinical scenario, its application could allow the quantitative assessment of aortic plaque burden in the descending thoracic aorta from 3-D TEE images.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2014.12.669DOI Listing
May 2015

Impact of implantable transvenous device lead location on severity of tricuspid regurgitation.

J Am Soc Echocardiogr 2014 Nov 14;27(11):1164-75. Epub 2014 Aug 14.

Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois. Electronic address:

Background: Implantable device leads can cause tricuspid regurgitation (TR) when they interfere with leaflet motion. The aim of this study was to determine whether lead-leaflet interference is associated with TR severity, independent of other causative factors of functional TR.

Methods: A total of 100 patients who underwent transthoracic two-dimensional and three-dimensional (3D) echocardiography of the tricuspid valve before and after lead placement were studied. Lead position was classified on 3D echocardiography as leaflet-interfering or noninterfering. TR severity was estimated by vena contracta (VC) width. Logistic regression analysis was used to identify factors associated with postdevice TR, including predevice VC width, right ventricular end-diastolic and end-systolic areas, fractional area change, right atrial size, tricuspid annular diameter, TR gradient, device lead age, and presence or absence of lead interference. Odds ratios were used to describe the association with moderate (VC width ≥ 0.5 cm) or severe (VC width ≥ 0.7 cm) TR, separately, using bivariate and stepwise multivariate logistic regression analysis.

Results: Forty-five of 100 patients showed device lead tricuspid valve leaflet interference. The septal leaflet was the most commonly affected (23 patients). On bivariate analysis, preimplantation VC width, right atrial size, tricuspid annular diameter, and lead-leaflet interference were significantly associated with postdevice TR. On multivariate analysis, preimplantation VC width and the presence of an interfering lead were independently associated with postdevice TR. Furthermore, the presence of an interfering lead was the only factor associated with TR worsening, increasing the likelihood of developing moderate or severe TR by 15- and 11-fold, respectively.

Conclusion: Lead-leaflet interference as seen on 3D echocardiography is associated with TR after device lead placement, suggesting that 3D echocardiography should be used to assess for lead interference in patients with significant TR.
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http://dx.doi.org/10.1016/j.echo.2014.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455541PMC
November 2014

Right ventricular strain in pulmonary arterial hypertension: a 2D echocardiography and cardiac magnetic resonance study.

Echocardiography 2015 Feb 28;32(2):257-63. Epub 2014 Jun 28.

University of Chicago Medicine, Chicago, Illinois; Northwestern Memorial Hospital, Chicago, Illinois.

Background: Right ventricular (RV) strain is a potentially useful prognostic marker in patients with pulmonary arterial hypertension (PAH). However, published reports regarding the accuracy of two-dimensional echocardiography (2DE)-derived RV strain against an independent reference in this patient population are limited. The aims of this study were: (1) to study the relationship between 2DE RV longitudinal strain and cardiovascular magnetic resonance (CMR)-derived RV ejection fraction (RVEF) in patients with PAH; (2) to compare 2DE-derived and CMR-derived RV longitudinal strain in these patients; and (3) to determine the reproducibility of these measurements.

Methods: Thirty patients with PAH underwent 2DE and CMR imaging within a 2-hour time period. 2DE RV longitudinal strain was measured from a focused RV apical four-chamber view using speckle tracking software. CMR RV longitudinal strain was measured from short-axis slices acquired using fast-strain-encoded sequence. Global peak systolic RV longitudinal strain was calculated for both 2DE and CMR.

Results: RV longitudinal strain using 2DE software correlated well with CMR-derived RVEF (R = 0.69, P = 0.0006). There was moderate agreement when comparing 2DE to CMR RV longitudinal strain (R = 0.74, P = 0.0002; bias -1%, limits of agreement -9 to 7%). Inter-observer variability and intra-observer variability for RV longitudinal strain were lower for 2DE than CMR.

Conclusions: RV longitudinal strain by 2DE provides a good alternative for CMR-derived RVEF in patients with PAH. The moderate agreement in strain measurements between 2DE and CMR suggests that further software improvements are needed before these measurements can be used interchangeably in clinical practice.
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http://dx.doi.org/10.1111/echo.12662DOI Listing
February 2015

3D echocardiographic location of implantable device leads and mechanism of associated tricuspid regurgitation.

JACC Cardiovasc Imaging 2014 Apr 13;7(4):337-47. Epub 2014 Mar 13.

Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois. Electronic address:

Objectives: This study sought to: 1) determine the feasibility of using 3-dimensional transthoracic echocardiography (3D TTE) in patients with implantable cardiac resynchronization devices, pacemakers, and defibrillators to visualize the device leads in the right heart and their position relative to the tricuspid valve leaflets; 2) determine the prevalence of different lead positions; and 3) study the relationship between lead location and tricuspid regurgitation (TR) severity.

Background: Pacemaker, defibrillator, and cardiac resynchronization device implantation is currently guided by fluoroscopy, not allowing targeted lead positioning relative to the tricuspid valve leaflets. These leads have been reported to cause TR of variable degrees, but echocardiography is not routinely used to elucidate the mechanisms of lead interference with tricuspid valve leaflets in individual patients.

Methods: 3D TTE full-volume images of the right ventricle and/or zoomed images of the tricuspid valve were obtained in 121 patients with implanted devices. Images were viewed offline to determine the position of the device-lead relative to the tricuspid valve leaflets. Severity of TR was estimated on the basis of vena contracta measurements.

Results: 3D TTE clearly depicted lead position in 90% of patients. The right ventricular lead was impinging on either the posterior (20%) or septal (23%) leaflet or was not interfering with leaflet motion (53%) when positioned near the posteroseptal commissure or in the central portion of the tricuspid valve orifice. In the remaining patients, leads were impinging on the anterior leaflet (4%) or positioned in either the anteroposterior or anteroseptal commissure (3%). Leads interfering with normal leaflet mobility were associated with more TR than nonimpinging leads (vena contracta: median 0.62 cm [1st and 3rd quartiles: 0.51, 0.84 cm] vs. 0.27 cm [1st and 3rd quartiles: 0.00, 0.48 cm]; p < 0.001).

Conclusions: 3D TTE showed a clear association between device lead position and TR. To minimize TR induced by device-leads, 3D TTE guidance should be considered for placement in a commissural position.
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http://dx.doi.org/10.1016/j.jcmg.2013.11.007DOI Listing
April 2014

A new definition for an old entity: improved definition of mitral valve prolapse using three-dimensional echocardiography and color-coded parametric models.

J Am Soc Echocardiogr 2014 Jan 2;27(1):8-16. Epub 2013 Oct 2.

University of Chicago, Chicago, Illinois. Electronic address:

Background: Differentiating between mitral valve (MV) prolapse (MVP) and MV billowing (MVB) on two-dimensional echocardiography is challenging. The aim of this study was to test the hypothesis that color-coded models of maximal leaflet displacement from the annular plane into the atrium derived from three-dimensional transesophageal echocardiography would allow discrimination between these lesions.

Methods: Three-dimensional transesophageal echocardiographic imaging of the MV was performed in 50 patients with (n = 38) and without (n = 12) degenerative MV disease. Definitive diagnosis of MVP versus MVB was made using inspection of dynamic three-dimensional renderings and multiple two-dimensional cut planes extracted from three-dimensional data sets. This was used as a reference standard to test an alternative approach, wherein the color-coded parametric models were inspected for integrity of the coaptation line and location of the maximally displaced portion of the leaflet. Diagnostic interpretations of these models by two independent readers were compared with the reference standard.

Results: In all cases of MVP, the color-coded models depicted loss of integrity of the coaptation line and maximal leaflet displacement extending to the coaptation line. MVB was depicted by preserved leaflet apposition with maximal displacement away from the coaptation line. Interpretation of the 50 color-coded models by novice readers took 5 to 10 min and resulted in good agreement with the reference technique (κ = 0.81 and κ = 0.73 for the two readers).

Conclusions: Three-dimensional color-coded models provide a static display of MV leaflet displacement, allowing differentiation between MVP and MVB, without the need to inspect multiple planes and while taking into account the saddle shape of the mitral annulus.
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http://dx.doi.org/10.1016/j.echo.2013.08.025DOI Listing
January 2014

Interinstitutional measurements of left ventricular volumes, speckle-tracking strain, and dyssynchrony using three-dimensional echocardiography.

J Am Soc Echocardiogr 2013 Nov 18;26(11):1253-7. Epub 2013 Sep 18.

Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.

Background: Three-dimensional echocardiographic (3DE) analysis provides better measurements of left ventricular (LV) volumes, ejection fraction, myocardial deformation, and dyssynchrony. Many studies have shown that this technique has high intrainstitutional reproducibility. However, interinstitutional reproducibility is low, limiting its adoption. The aim of this study was to determine if standardization of training could reduce the interinstitutional variability in 3DE data analysis.

Methods: In total, 50 full-volume, transthoracic 3DE data sets of the left ventricle were analyzed by two readers. Measurements obtained included LV volumes, ejection fraction, global longitudinal strain, and two dyssynchrony indices. The cases represented a wide spectrum of ejection fraction. After initial analysis of 21 studies, readers formally met to standardize their analytic approach on six additional cases. Five months after the intervention, 23 new cases were analyzed. Paired t tests were performed to identify systematic institutional differences in measurements. Interinstitutional variability was quantified using intraclass correlation coefficients and variability.

Results: Before the intervention, there was a systematic bias in LV volumes, which was eliminated after intervention. Intraclass correlation coefficients showed that the intervention improved agreement in measurements of LV volumes, strain, and dyssynchrony between the two centers and decreased variability.

Conclusions: A simple intervention to standardize analysis can reduce interinstitutional variability of measurements obtained from 3DE analysis. This intervention is needed before the use of 3DE measurement in multicenter trials and to increase the reproducibility of such measurements in routine clinical practice.
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http://dx.doi.org/10.1016/j.echo.2013.07.023DOI Listing
November 2013

Three-dimensional modeling of the right ventricle from two-dimensional transthoracic echocardiographic images: utility of knowledge-based reconstruction in pulmonary arterial hypertension.

J Am Soc Echocardiogr 2013 Aug 13;26(8):860-7. Epub 2013 Jun 13.

Section of Cardiology, Department of Medicine, University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA.

Background: Right ventricular (RV) volume and functional assessments are essential in the management of pulmonary arterial hypertension but are often difficult to perform. Three-dimensional (3D) echocardiography is limited by acoustic dropout of the RV free wall in dilated ventricles. The aim of this study was to test the hypothesis that knowledge-based reconstruction, a novel method for 3D modeling of RV endocardium from two-dimensional echocardiographic images, could provide accurate measurements of RV volumes and systolic function.

Methods: Twenty-seven patients with pulmonary arterial hypertension were prospectively recruited for same-day echocardiography and cardiovascular magnetic resonance (CMR), which was used as a reference standard. Two-dimensional transthoracic echocardiographic images were acquired with 3D spatial localization equipment to allow 3D reconstruction. Image analysis was performed with dedicated software to obtain end-diastolic volume (EDV) and end-systolic volume (ESV) and RV ejection fraction (EF). The method of disks was used to determine RV volumes on CMR.

Results: Echocardiographic RV volumes correlated well with CMR (EDV, R = 0.87; ESV, R = 0.88; EF, R = 0.75). For interobserver analyses, coefficients of variability were 7.8 ± 7.0% for EDV, 10.2 ± 8.0% for ESV, and 15.4 ± 13.8% for EF. For intraobserver analyses, coefficients of variability were 7.1 ± 5.1% for EDV, 8.3 ± 7.0% for ESV, and 10.9 ± 9.2% for EF. On Bland-Altman analyses, volumes obtained on transthoracic echocardiography (TTE) were slightly larger than those obtained by CMR (ΔEDVTTE-CMR, 5.8 ± 33.7 mL; ΔESVTTE-CMR, 3.5 ± 27.8 mL), whereas EFs tended to be slightly higher by CMR (ΔEFCMR-TTE, 0.5 ± 6.5%).

Conclusions: Knowledge-based reconstruction provides accurate and reproducible measurements of RV volumes in patients with pulmonary arterial hypertension. Larger studies are needed to confirm these results and to determine the practicality of this approach in daily practice and as an end point in clinical trials.
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http://dx.doi.org/10.1016/j.echo.2013.05.007DOI Listing
August 2013

Mitral valve dynamics in severe aortic stenosis before and after aortic valve replacement.

J Am Soc Echocardiogr 2013 Jun 17;26(6):606-14. Epub 2013 Apr 17.

University of Chicago Medical Center, Chicago, Illinois, USA.

Background: The aortic and mitral valves are anatomically linked through a fibrous continuity. The investigators hypothesized that severe aortic stenosis (AS) would alter this fibrous continuity, affecting both the mitral valve and left ventricular function, and that mitral valve function would be altered after aortic valve replacement (AVR). The aim of this study was to evaluate the impact of AS and its treatment with surgical AVR on the mitral valve.

Methods: Three-dimensional transesophageal echocardiography (using a Philips iE33 system) was performed on 49 patients: 20 controls with normal valves and left ventricular function, 20 with AS and normal left ventricular function studied before and after AVR, and nine with systolic heart failure and normal valves. Custom software tracked the aortic and mitral valves in three-dimensional space, allowing automated measurements of aortic and mitral annular (MA) morphology throughout the cardiac cycle.

Results: Patients with AS before AVR had reduced MA velocities. After AVR, aortic and MA areas were significantly smaller throughout the cardiac cycle compared with controls and pre-AVR values. MA displacement was reduced after AVR and in patients with systolic heart failure compared with those with AS and controls.

Conclusions: Dynamic MA function is changed with AS and after AVR through alterations in the aortic-mitral fibrous continuity. The prosthetic valve ring results in reduced aortic and MA areas, which could affect blood flow in and out of the left ventricle. These changes suggest that the design of future prosthetic aortic valves should be more flexible to preserve the function of the aortic-mitral fibrous continuity.
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http://dx.doi.org/10.1016/j.echo.2013.03.004DOI Listing
June 2013

Localizing mitral valve perforations with 3D transesophageal echocardiography.

JACC Cardiovasc Imaging 2013 Mar;6(3):407-10

Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois 60637, USA.

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http://dx.doi.org/10.1016/j.jcmg.2012.11.012DOI Listing
March 2013

Real-time 3D echocardiographic quantification of left atrial volume: multicenter study for validation with CMR.

JACC Cardiovasc Imaging 2012 Aug;5(8):769-77

University of Chicago Medical Center, Chicago, IL, USA.

Objectives: We studied in a multicenter setting the accuracy and reproducibility of 3-dimensional echocardiography (3DE)-derived measurements of left atrial volume (LAV) using new, dedicated volumetric software, side by side with 2-dimensional echocardiography (2DE), using cardiac magnetic resonance (CMR) imaging as a reference.

Background: Increased LAV is associated with adverse cardiovascular outcomes. Although LAV measurements are routinely performed using 2DE, this methodology is limited because it is view dependent and relies on geometric assumptions regarding left atrial shape. Real-time 3DE is free of these limitations and accordingly is an attractive alternative for the evaluation of LAV. However, few studies have validated 3DE-derived LAV measurements against an accepted independent reference standard, such as CMR imaging.

Methods: We studied 92 patients with a wide range of LAV who underwent CMR (1.5-T) and echocardiographic imaging on the same day. Images were analyzed to obtain maximal and minimal LAV: CMR images using standard commercial tools, 2DE images using a biplane area-length technique, and 3DE images using Tomtec LA Function software. Intertechnique comparisons included linear regression and Bland-Altman analyses. Reproducibility of all 3 techniques was assessed by calculating the percentage of absolute differences in blinded repeated measurements. Kappa statistics were used to compare 2DE and 3DE classification of normal/enlarged against the CMR reference.

Results: 3DE-derived LAV values showed higher correlation with CMR than 2DE measurements (r = 0.93 vs. r = 0.74 for maximal LAV; r = 0.88 vs. r = 0.82 for minimal LAV). Although 2DE underestimated maximal LAV by 31 ± 25 ml and minimal LAV by 16 ± 32 ml, 3DE resulted in a minimal bias of -1 ± 14 ml for maximal LAV and 0 ± 21 ml for minimal LAV. Interobserver and intraobserver variability of 2DE and 3DE measurements of maximal LAV were similar (7% to 12%) and approximately 2 times higher than CMR (4% to 5%). 3DE classified enlarged atria more accurately than 2DE (kappa: 0.88 vs. 0.71).

Conclusions: Compared with CMR reference, 3DE-derived LAV measurements are more accurate than 2DE-based analysis, resulting in fewer patients with undetected atrial enlargement.
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http://dx.doi.org/10.1016/j.jcmg.2012.05.011DOI Listing
August 2012