Publications by authors named "Roberto M Lang"

450 Publications

Three-Dimensional Echocardiographic Left Atrial Appendage Volumetric Analysis.

J Am Soc Echocardiogr 2021 Mar 25. Epub 2021 Mar 25.

MedStar Health and Vascular Institute, MedStar Washington Hospital Center, Washington, DC. Electronic address:

Background: Left atrial appendage (LAA) echocardiographic assessment is difficult because of its complex shape and relatively small size. Three-dimensional echocardiographic (3DE) imaging can overcome the limitations of two-dimensional (2D) imaging. Pulsed wave (PW) Doppler is the only currently standard LAA functional parameter. The aim of this study was to test a new approach for 3DE volumetric analysis to obtain LAA ejection fraction (EF), its size and shape.

Methods: Transesophageal 2D and 3D LAA images were prospectively obtained in 159 consecutive patients. LAA volumes were measured from 3DE images using available software. PW Doppler was considered the reference value for LAA function, and used for comparison with LAA EF. Comparison to cardiac computed tomography (CT) was performed in a subgroup of 32 patients. Comparisons included linear regression and Bland-Altman analyses. Repeated measurements were performed to assess measurement variability.

Results: Nine patients were excluded because of suboptimal image quality (94%feasibility). 3D LAA calculated EF was in good agreement with LAA PW measurements. 3D morphologic evaluation showed that 43% of the patients had "chicken wing", 33% "cactus", 19% "windsock" and 5% Cauliflower shape. At the time of data acquisition, patients with atrial fibrillation had non-significantly larger LAA end-systolic and diastolic volumes (ESV, EDV), leading to a lower calculated EF. 3DE LAA ESVs were in good agreement with cardiac CT (r = 0.75), with small biases: -2.5±3.9ml. Reproducibility was better for larger LAA volumes.

Conclusions: A novel 3DE approach can determine geometry, size, and function of the LAA. A new parameter, LAA EF, provides functional quantitation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.echo.2021.03.008DOI Listing
March 2021

Impact of Wideband Late Gadolinium Enhancement Cardiac Magnetic Resonance Imaging on Device-Related Artifacts in Different Implantable Cardioverter-Defibrillator Types.

J Magn Reson Imaging 2021 Mar 19. Epub 2021 Mar 19.

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

Background: Late gadolinium enhancement (LGE) imaging in patients with implantable cardioverter-defibrillators (ICD) is limited by device-related artifacts (DRA). The use of wideband (WB) LGE protocols improves LGE images, but their efficacy with different ICD types is not well known.

Purpose: To assess the effects of WB LGE imaging on DRA in different non-MR conditional ICD subtypes.

Study Type: Retrospective.

Population: A total of 113 patients undergoing cardiac magnetic resonance imaging with three ICD subtypes: transvenous (TV-ICD, N = 48), cardiac-resynchronization therapy device (CRT-D, N = 48), and subcutaneous (S-ICD, N = 17).

Field Strength/sequence: 5 T scanner, standard LGE, and WB LGE imaging with a phase-sensitive inversion recovery segmented gradient echo sequence.

Assessment: DRA burden was defined as the number of artifact-positive short-axis LGE slices as percentage of the total number of short-axis slices covering the left ventricle from based to apex, and was determined for WB and standard LGE studies for each patient. Additionally, artifact area on each slice was quantified.

Statistical Tests: Shapiro-Wilks, Kruskal-Wallis analysis of variance, Dunn tests with Bonferroni correction, and Mann-Whitney U-test.

Results: In patients with TV-ICD, DRA burden was significantly reduced and nearly eliminated with WB LGE compared to standard LGE imaging (median [interquartile range]: 0 [0-7]% vs. 18 [0-50]%, P < 0.05), but WB imaging had less of an impact on DRA in the CRT-D (8 [0-23]% vs. 16 [0-45]%, p = 0.12) and S-ICD (60 [15-71]% vs. 67 [50-92]%, P = 0.09) patients. Residual DRA was significantly greater (P < 0.05) for S-ICD compared to other device types with WB LGE imaging, despite the generators of all three ICD types having similar proximity to the heart. The area of S-ICD associated DRA was smaller with WB LGE (P < 0.001) than with standard LGE imaging and the artifacts had different characteristics (dark signal void instead of a bright hyperenhancement artifact).

Data Conclusion: Although WB LGE imaging reduced the burden of DRA caused by S-ICD, the residual artifact was greater than that observed with TV-ICD and CRT-D devices. Further developments are needed to better resolve S-ICD artifacts.

Level Of Evidence: 1 TECHNICAL EFFICACY: STAGE: 5.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jmri.27608DOI Listing
March 2021

Utility of a Deep-Learning Algorithm to Guide Novices to Acquire Echocardiograms for Limited Diagnostic Use.

JAMA Cardiol 2021 Feb 18. Epub 2021 Feb 18.

Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois.

Importance: Artificial intelligence (AI) has been applied to analysis of medical imaging in recent years, but AI to guide the acquisition of ultrasonography images is a novel area of investigation. A novel deep-learning (DL) algorithm, trained on more than 5 million examples of the outcome of ultrasonographic probe movement on image quality, can provide real-time prescriptive guidance for novice operators to obtain limited diagnostic transthoracic echocardiographic images.

Objective: To test whether novice users could obtain 10-view transthoracic echocardiographic studies of diagnostic quality using this DL-based software.

Design, Setting, And Participants: This prospective, multicenter diagnostic study was conducted in 2 academic hospitals. A cohort of 8 nurses who had not previously conducted echocardiograms was recruited and trained with AI. Each nurse scanned 30 patients aged at least 18 years who were scheduled to undergo a clinically indicated echocardiogram at Northwestern Memorial Hospital or Minneapolis Heart Institute between March and May 2019. These scans were compared with those of sonographers using the same echocardiographic hardware but without AI guidance.

Interventions: Each patient underwent paired limited echocardiograms: one from a nurse without prior echocardiography experience using the DL algorithm and the other from a sonographer without the DL algorithm. Five level 3-trained echocardiographers independently and blindly evaluated each acquisition.

Main Outcomes And Measures: Four primary end points were sequentially assessed: qualitative judgement about left ventricular size and function, right ventricular size, and the presence of a pericardial effusion. Secondary end points included 6 other clinical parameters and comparison of scans by nurses vs sonographers.

Results: A total of 240 patients (mean [SD] age, 61 [16] years old; 139 men [57.9%]; 79 [32.9%] with body mass indexes >30) completed the study. Eight nurses each scanned 30 patients using the DL algorithm, producing studies judged to be of diagnostic quality for left ventricular size, function, and pericardial effusion in 237 of 240 cases (98.8%) and right ventricular size in 222 of 240 cases (92.5%). For the secondary end points, nurse and sonographer scans were not significantly different for most parameters.

Conclusions And Relevance: This DL algorithm allows novices without experience in ultrasonography to obtain diagnostic transthoracic echocardiographic studies for evaluation of left ventricular size and function, right ventricular size, and presence of a nontrivial pericardial effusion, expanding the reach of echocardiography to clinical settings in which immediate interrogation of anatomy and cardiac function is needed and settings with limited resources.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamacardio.2021.0185DOI Listing
February 2021

Anatomic Description of Tricuspid Apparatus Interference From Implantable Intracardiac Devices.

JACC Cardiovasc Imaging 2021 Feb 2. Epub 2021 Feb 2.

Section of Cardiology, Department of Medicine, Cardiac Imaging Center, the University of Chicago Medicine, Chicago, Illinois, USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcmg.2020.12.016DOI Listing
February 2021

Right atrial volume is a major determinant of tricuspid annulus area in functional tricuspid regurgitation: a three-dimensional echocardiographic study.

Eur Heart J Cardiovasc Imaging 2020 Dec 2. Epub 2020 Dec 2.

Department of Medicine, Section of Cardiology, University of Chicago, 5801 S Ellis Ave, Chicago 60637, IL, USA.

Aims: The aim of this study is to explore the relationships of tricuspid annulus area (TAA) with right atrial maximal volume (RAVmax) and right ventricular end-diastolic volume (RVEDV) in healthy subjects and patients with functional tricuspid regurgitation (FTR) of different aetiologies and severities.

Methods And Results: We enrolled 280 patients (median age 66 years, 59% women) with FTR due to left heart disease (LHD), pulmonary hypertension (PH), corrected tetralogy of Fallot (TOF), chronic atrial fibrillation (AF), and 210 healthy volunteers (45 years, 53% women). We measured TAA at mid-systole and end-diastole, tenting volume of tricuspid leaflets, RAVmax, and RVEDV by 3D echocardiography. Irrespective of TA measurement timing, TAA correlated more closely with RAVmax than with RVEDV in both controls and FTR patients. On multivariable analysis, RAVmax was the most important determinant of TAA, accounting for 41% (normals) and 56% (FTR) of TAA variance. In FTR patients, age, RVEDV, and left ventricular ejection fraction were also independently correlated with TAA. RAVmax (AUC = 0.81) and TAA (AUC = 0.78) had a greater ability than RVEDV (AUC = 0.72) to predict severe FTR (P < 0.05). Among FTR patients, those with AF had the largest RAVmax and smallest RVEDV. RAVmax and TA were significantly dilated in all FTR groups, except in TOF. PH and TOF had largest RVEDV, yet tenting volume was increased only in PH and LHD.

Conclusion: RA volume is a major determinant of TAA, and RA enlargement is an important mechanism of TA dilation in FTR irrespective of cardiac rhythm and RV loading conditions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ehjci/jeaa286DOI Listing
December 2020

Visualization of Number of Tricuspid Valve Leaflets Using Three-Dimensional Transthoracic Echocardiography.

J Am Soc Echocardiogr 2021 Apr 28;34(4):449-450. Epub 2020 Dec 28.

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

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.echo.2020.12.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026547PMC
April 2021

A New Strategy for Left Ventricular Assist Device Outflow Graft Interrogation Using Ultrasound Contrast.

J Am Soc Echocardiogr 2021 Apr 11;34(4):445-447. Epub 2020 Dec 11.

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

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.echo.2020.12.001DOI Listing
April 2021

Prevalence of newly diagnosed sarcoidosis in patients with ventricular arrhythmias: a cardiac magnetic resonance and 18F-FDG cardiac PET study.

Int J Cardiovasc Imaging 2021 Apr 22;37(4):1361-1369. Epub 2020 Nov 22.

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

Cardiac sarcoidosis (CS) is known to be associated with ventricular tachycardia (VT); however, most investigations to date have focused on patients with known extra-cardiac sarcoidosis. The presence of CS is typically evaluated using 18F-fluorodeoxyglucose (18F-FDG) uptake on cardiac positron emission tomography (PET) or late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR). In this study, we sought to determine the prevalence of primary CS and the relationship between myocardial 18F-FDG uptake and LGE in patients with VT without known sarcoidosis. We retrospectively identified 67 patients without known sarcoidosis or active ischemic heart disease (i.e. significant ischemic disease that had not been previously revascularized) referred for both CMR and PET for evaluation of VT. Standard cine- and LGE- CMR and cardiac PET protocols were used. Myocardial LGE was defined as signal intensity > 5 SDs above the mean signal intensity of normal myocardium. Cardiac PET images were considered positive if there was focal myocardial 18F-FDG uptake having greater activity than the left ventricular blood pool. 45 patients (67%) had LGE, while only 4 (6%) had myocardial FDG uptake. Nine percent of patients with LGE had FDG-uptake while none without LGE did, and 10% of the cohort had indeterminate FDG uptake presumably from poor dietary preparation. Of those with both FDG uptake and LGE, 3/4 ultimately received a clinical diagnosis of CS. 4.5% of patients without previously known sarcoidosis or active ischemic heart disease presenting with VT have newly diagnosed CS. Detection of CS can be increased using a CMR first approach followed by cardiac PET for patients with non-ischemic LGE.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10554-020-02090-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8035303PMC
April 2021

Normal Values of Right Atrial Size and Function According to Age, Sex, and Ethnicity: Results of the World Alliance Societies of Echocardiography Study.

J Am Soc Echocardiogr 2021 Mar 17;34(3):286-300. Epub 2020 Nov 17.

University of Chicago, Chicago, Illinois. Electronic address:

Background: The World Alliance Societies of Echocardiography study is a multicenter, international, prospective, cross-sectional study whose aims were to evaluate healthy adult individuals to establish age- and sex-normative values of echocardiographic parameters and to determine whether differences exist among people from different countries and of different ethnicities. The present report focuses on two-dimensional (2D) and three-dimensional (3D) right atrial (RA) size and function.

Methods: Transthoracic 2D and 3D echocardiographic images were obtained in 2,008 healthy adult individuals evenly distributed among subgroups according to sex (1,033 men, 975 women) and age 18 to 40 years (n = 854), 41 to 65 years (n = 653), and >65 years (n = 501). For ethnicity, 34.9% were white, 41.6% Asian, and 9.7% black. Images were analyzed in a core laboratory according to current American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. RA measurements included 2D dimensions, 2D and 3D RA volumes (RAVs) indexed to body surface area (BSA), emptying fraction (EmF), and global longitudinal strain, including total/reservoir, passive/conduit, and active/contractile phases. Differences among age and sex categories and among countries were also examined.

Results: RAVs were larger in men (even after BSA indexing), while 3D total EmF and global longitudinal strain magnitudes were higher in women. For both sexes, there were no significant age-related differences in 2D RAV measurements, but 3D RAV values differed minimally with age, remaining significant after BSA indexing. RA total EmF and reservoir strain and passive EmF and conduit strain magnitude were lower in older groups for both sexes. Interestingly, whereas RA active EmF increased with age, contractile strain magnitude decreased. Considerable geographic variations were identified: Asians of both sexes had significantly lower BSA than non-Asians, and their 2D and 3D end-systolic RAVs were significantly smaller even after BSA indexing. Of note, 2D end-systolic RAVs in this group were considerably lower than normal values provided in the current guidelines.

Conclusions: There is significant sex, age, and geographic variability in normal RA size and function parameters. Current guideline-recommended normal ranges for RA size and function parameters should be adjusted geographically on the basis of the results of this study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.echo.2020.11.004DOI Listing
March 2021

Validation of non-contrast multiple overlapping thin-slab 4D-flow cardiac magnetic resonance imaging.

Magn Reson Imaging 2020 12 6;74:223-231. Epub 2020 Oct 6.

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

Background: Cardiac magnetic resonance (CMR) flow quantification is typically performed using 2D phase-contrast (PC) imaging of a plane perpendicular to flow. 3D-PC imaging (4D-flow) allows offline quantification anywhere in a thick slab, but is often limited by suboptimal signal, potentially alleviated by contrast enhancement. We developed a non-contrast 4D-flow sequence, which acquires multiple overlapping thin slabs (MOTS) to minimize signal loss, and hypothesized that it could improve image quality, diagnostic accuracy, and aortic flow measurements compared to non-contrast single-slab approach.

Methods: We prospectively studied 20 patients referred for transesophageal echocardiography (TEE), who underwent CMR (GE, 3 T). 2D-PC images of the aortic valve and three 4D-flow datasets covering the heart were acquired, including single-slab, pre- and post-contrast, and non-contrast MOTS. Each 4D-flow dataset was interpreted blindly for ≥moderate valve disease and compared to TEE. Flow visualization through each valve was scored (0 to 4), and aortic-valve flow measured on each 4D-flow dataset and compared to 2D-PC reference.

Results: Diagnostic quality visualization was achieved with the pre- and post-contrast 4D-flow acquisitions in 25% and 100% valves, respectively (scores 0.9 ± 1.1 and 3.8 ± 0.5), and in 58% with the non-contrast MOTS (1.6 ± 1.1). Accuracy of detection of valve disease was 75%, 92% and 82%, respectively. Aortic flow measurements were possible in 53%, 95% and in 89% patients, respectively. The correlation between pre-contrast single-slab measurements and 2D-PC reference was weak (r = 0.21), but improved with both contrast enhancement (r = 0.71) and with MOTS (r = 0.67).

Conclusions: Although non-contrast MOTS 4D-flow improves valve function visualization and diagnostic accuracy, a significant proportion of valves cannot be accurately assessed. However, aortic flow measurements using non-contrast MOTS is feasible and reaches similar accuracy to that of contrast-enhanced 4D-flow.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.mri.2020.10.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931662PMC
December 2020

Virtual Reality Analysis of Three-Dimensional Echocardiographic and Cardiac Computed Tomographic Data Sets.

J Am Soc Echocardiogr 2020 11 25;33(11):1306-1315. Epub 2020 Sep 25.

TOMTEC Imaging Systems GmbH, Unterschleissheim, Germany.

Background: Three-dimensional echocardiographic (3DE) imaging and cardiac computed tomographic (CCT) imaging are important cardiac imaging tools. Despite the three-dimensional nature of these image acquisitions and reconstructions, they are visualized on two-dimensional monitors with shading and coloring to create the illusion of three dimensions. Virtual reality (VR) is a novel tool that allows true three-dimensional visualization and manipulation. The aims of this study were to test the feasibility of converting 3DE and CCT data into three-dimensional VR models, compare the variability of measurements performed in VR and conventional software, assess the diagnostic quality of VR models, and understand the value of VR over conventional viewing.

Methods: Custom software with clinically relevant postprocessing tools (interactively adjustable visualization parameters, multiplanar reconstructions, cropping planes, and nonplanar measurements) was developed to convert 3DE and CCT data into VR models. Anatomic measurements of 15 3DE and 15 CCT data sets of the mitral valve were compared using conventional software and in the VR environment. Additionally, the diagnostic quality of the VR models created from 3DE and CCT data sets was assessed.

Results: The 3DE and CCT data sets were successfully converted into VR models in <3 min. The measurement variabilities were reduced by 40% (20.1% vs 12.2%) for 3DE imaging and 34% (15.3% vs 10.1%) for CCT imaging by using VR. The mean time needed for measurements was reduced by 31% (from 61 to 42 sec) for 3DE imaging and 39% (from 37 to 23 sec) for CCT imaging. Most users reported facile manipulation of VR models, diagnostic quality visualization of the anatomy, and high confidence in the measurements.

Conclusions: This study demonstrates the feasibility of converting 3DE and CCT data into diagnostic-quality VR models. Compared with conventional imaging, VR analysis is associated with faster navigation and accurate measurements with lower variability.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.echo.2020.06.018DOI Listing
November 2020

Improved Delineation of Cardiac Pathology Using a Novel Three-Dimensional Echocardiographic Tissue Transparency Tool.

J Am Soc Echocardiogr 2020 11 21;33(11):1316-1323. Epub 2020 Sep 21.

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

Background: Accurate visualization of cardiac valves and lesions by three-dimensional (3D) echocardiography is integral for optimal guidance of structural procedures and appropriate selection of closure devices. A new 3D rendering tool known as transillumination (TI), which integrates a virtual light source into the data set, was recently reported to effectively enhance depth perception and orifice definition. We hypothesized that adding the ability to adjust transparency to this tool would result in improved visualization and delineation of anatomy and pathology and improved localization of regurgitant jets compared with TI without transparency and standard 3D rendering.

Methods: We prospectively studied 30 patients with a spectrum of structural heart disease who underwent 3D transesophageal imaging (EPIQ system, Philips) with standard acquisition and TI with and without the transparency feature. Six experienced cardiologists and sonographers were shown randomized images of all three display types in a blinded fashion. Each image was scored independently by all experts using a Likert scale from 1 to 5, while assessing each of the following aspects: (1) ability to recognize anatomy, (2) ability to identify pathology, including regurgitant jet origin, (3) depth perception, and (4) quality of border delineation.

Results: TI images with transparency were successfully obtained in all cases. All experts perceived an incremental value of the transparency mode, compared with TI without transparency and standard 3D rendering, in terms of ability to recognize anatomy (respective scores: 4.5 ± 1.1 vs 4.1 ± 1.1 vs 3.6 ± 1.1, P < .05), ability to identify pathology (4.1 ± 1.1 vs 3.9 ± 1.2 vs 3.3 ± 1, P < .05), depth perception (4.6 ± 0.7 vs 4.1 ± 0.8 vs 3.2 ± 1.0, P < .05), and border delineation (4.6 ± 0.8 vs 4.1 ± 1.0 vs 3.1 ± 1.1, P < .05).

Conclusions: The addition of the transparency mode to TI rendering significantly improves the diagnostic and clinical utility of 3D echocardiography and has the potential to markedly enhance echocardiographic guidance of cardiac structural interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.echo.2020.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920620PMC
November 2020

Pathoanatomy of Mitral Regurgitation.

Struct Heart 2020 12;4(4):254-263. Epub 2020 Jun 12.

Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/24748706.2020.1765055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461701PMC
June 2020

Guided by the Light-Transillumination of a Paravalvular Leak.

JAMA Cardiol 2020 08 19;5(8):e203260. Epub 2020 Aug 19.

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

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamacardio.2020.3260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7921814PMC
August 2020

Same-Day Cancellations of Transesophageal Echocardiography: Targeted Remediation to Improve Operational Efficiency.

J Am Soc Echocardiogr 2020 11 11;33(11):1409-1410. Epub 2020 Aug 11.

Non-Invasive Imaging Laboratories, Section of Cardiology, Department of Medicine, University of Chicago Medicine, Chicago, Illinois.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.echo.2020.06.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920618PMC
November 2020

Left Ventricular Diastolic Function in Healthy Adult Individuals: Results of the World Alliance Societies of Echocardiography Normal Values Study.

J Am Soc Echocardiogr 2020 10 31;33(10):1223-1233. Epub 2020 Jul 31.

MedStar Health Research Institute, Washington, D.C.. Electronic address:

Background: The World Alliance Societies of Echocardiography (WASE) study was conducted to describe echocardiographic normal values in adults and to compare races and nationalities using a uniform acquisition and measurement protocol. This report focuses on left ventricular (LV) diastolic function.

Methods: WASE is an international, cross-sectional study. Participants were enrolled with equal distribution according to age and gender. Echocardiograms were analyzed in a core laboratory based on the latest American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Left ventricular diastolic function was assessed by E, E/A, e' velocities, E/e', left atrial volume index (LAVI), and tricuspid regurgitation velocity. Determination of LV diastolic function was made using the algorithm proposed by the guidelines.

Results: A total of 2,008 subjects from 15 countries were enrolled. The majority were of white or Asian race (42.8%, 41.8%, respectively). E and E/e' were higher in female patients, while LAVI was similar in both genders. Consistent increase in E/e' and decrease in E/A, E, and e' were found as age increased. The upper limit of normal for LAVI was higher in WASE compared with the guidelines. The lower limits of normal for e' were smaller in elder groups than those in the guidelines, while the upper limits of normal for E/e' were below the guideline values. These findings suggest that the cutoff value for LAVI should be shifted upward and age-specific cutoff values for e' should be considered. In WASE, <93.6% of patients were classified as normal LV diastolic function using the guidelines' algorithm, and the proportion increased to 97.4% when applying the revised cutoff values for LAVI obtained in our study.

Conclusions: Guideline-recommended normal values for e' velocities and LAVI should be reconsidered. The algorithm for the determination of LV diastolic function proposed by the guidelines is useful, but adjustments to LAVI could further improve it.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.echo.2020.06.008DOI Listing
October 2020

Myocardial strain analysis of the right ventricle: comparison of different cardiovascular magnetic resonance and echocardiographic techniques.

J Cardiovasc Magn Reson 2020 07 23;22(1):51. Epub 2020 Jul 23.

Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Avenue, MC9067, Chicago, IL, 60637, USA.

Background: Right ventricular (RV) strain is a useful predictor of prognosis in various cardiovascular diseases, including those traditionally believed to impact only the left ventricle. We aimed to determine inter-modality and inter-technique agreement in RV longitudinal strain (LS) measurements between currently available cardiovascular magnetic resonance (CMR) and echocardiographic techniques, as well as their reproducibility and the impact of layer-specific strain measurements.

Methods: RV-LS was determined in 62 patients using 2D speckle tracking echocardiography (STE, Epsilon) and two CMR techniques: feature tracking (FT) and strain-encoding (SENC), and in 17 healthy subjects using FT and SENC only. Measurements included global and free-wall LS (GLS, FWLS). Inter-technique agreement was assessed using linear regression and Bland-Altman analysis. Reproducibility was quantified using intraclass correlation (ICC) and coefficients of variation (CoV).

Results: We found similar moderate agreement between both CMR techniques and STE in patients: r = 0.57-0.63 for SENC; r = 0.50-0.62 for FT. The correlation between SENC and STE was better for GLS (r = 0.63) than for FWLS (r = 0.57). Conversely, the correlation between FT and STE was higher for FWLS (r = 0.60-0.62) than GLS (r = 0.50-0.54). FT-midmyocardial strain correlated better with SENC and STE than FT-subendocardial strain. The agreement between SENC and FT was fair (r = 0.36-0.41, bias: - 6.4 to - 10.4%) in the entire study group. All techniques except FT showed excellent reproducibility (ICC: 0.62-0.96, CoV: 0.04-0.30).

Conclusions: We found only moderate inter-modality agreement with STE in RV-LS for both FT and SENC and poor agreement when comparing between the CMR techniques. Different modalities and techniques should not be used interchangeably to determine and monitor RV strain.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12968-020-00647-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376701PMC
July 2020

Short-Term Ventricular Structural Changes Following Left Ventricular Assist Device Implantation.

ASAIO J 2021 02;67(2):169-176

From the Department of Medicine, New York Presbyterian Hospital-Columbia University Medical Center, New York.

Reverse remodeling of the left ventricle has been reported following left ventricular assist device (LVAD) implantation. However, left ventricular (LV) and right ventricular (RV) volumetric and shape changes have not been described. Consecutive candidates for LVAD were prospectively enrolled. Comprehensive 2- and 3-dimensional echocardiographic (2DE, 3DE) images were acquired before and 1 to 2 months following LVAD implantation. 3D endocardial surfaces were analyzed to derive shape indices, including LV sphericity and conicity and RV septal and free-wall curvatures. Sixty patients were enrolled with a mean age 56 ± 13 years, 77% male, and 83% destination therapy. 3DE showed that LV end-diastolic volume (EDV) improved from 461 ± 182 to 287 ± 144 ml (p < 0.001) and RV EDV showed no change (p = 0.08). RV longitudinal strain (LS) worsened from -9.1 ± 3.1 to -5.9 ± 2.6% (p < 0.01). LV sphericity and conicity improved (p < 0.001 for both), whereas the curvature of the interventricular septum and RV free wall did not change (p = 0.79 and 0.26, respectively). At 1 month following LVAD implantation, LV volumes decrease dramatically, and there is a favorable LV shape improvement, indicating reverse remodeling. RV shape did not change, whereas RV LS worsened, indicating an absence of RV reverse remodeling.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAT.0000000000001214DOI Listing
February 2021

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.echo.2020.05.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955649PMC
September 2020

Advanced imaging of right ventricular anatomy and function.

Heart 2020 Oct 3;106(19):1469-1476. Epub 2020 Jul 3.

Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milano, Italy.

Right ventricular (RV) size and function are important predictors of cardiovascular morbidity and mortality in patients with various conditions. However, non-invasive assessment of the RV is a challenging task due to its complex anatomy and location in the chest. Although conventional echocardiography is widely used, its limitations in RV assessment are well recognised. New techniques such as three-dimensional and speckle tracking echocardiography have overcome the limitations of conventional echocardiography allowing a comprehensive, quantitative assessment of RV geometry and function without geometric assumptions. Cardiac magnetic resonance (CMR) and CT provide accurate assessment of RV geometry and function, too. In addition, tissue characterisation imaging for myocardial scar and fat using CMR and CT provides important information regarding the RV that has clinical applications for diagnosis and prognosis in a broad range of cardiac conditions. Limitations also exist for these two advanced modalities including availability and patient suitability for CMR and need for contrast and radiation exposure for CT. Hybrid imaging, which is able to integrate anatomical information (usually obtained by CT or CMR) with physiological and molecular data (usually obtained with positron emission tomography), can provide optimal in vivo evaluation of Rv functional impairment. This review summarises the clinically useful applications of advanced echocardiography techniques, CMR and CT for comprehensive assessment of RV size, function and mechanics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/heartjnl-2019-315178DOI Listing
October 2020

The Quest to Better Quantitate Tricuspid Regurgitation.

JACC Cardiovasc Imaging 2020 07 17;13(7):1472-1474. Epub 2020 Jun 17.

Department of Medicine, Section of Cardiology, Heart and Vascular Center, University of Chicago Medicine, Chicago, Illinois.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcmg.2020.03.001DOI Listing
July 2020

Asymmetric Calcification in Rheumatic Mitral Stenosis and Implications for Balloon Valvuloplasty.

JACC Case Rep 2019 Dec 18;1(4):493-494. Epub 2019 Dec 18.

Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL.

A 50 year-old male with severe rheumatic mitral stenosis was deemed too high risk for surgery and referred for percutaneous balloon valvuloplasty. The valvuloplasty was successful in reducing the trans-mitral gradient and improving the patient's symptoms, however was complicated by a tear in the posteromedial commissure and moderate mitral regurgitation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jaccas.2019.10.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7277047PMC
December 2019

Utilization and Appropriateness of Transthoracic Echocardiography in Response to the COVID-19 Pandemic.

J Am Soc Echocardiogr 2020 Jun 10;33(6):690-691. Epub 2020 Apr 10.

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

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.echo.2020.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146676PMC
June 2020

Stabbed Through The Heart: An Unusual VSD Presentation.

JACC Case Rep 2020 Apr 15;2(4):559-564. Epub 2020 Apr 15.

Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL.

Traumatic ventricular septal defects due to penetrating cardiac injury are uncommon. Transthoracic echocardiography is an essential tool in diagnosis. Options for closure include either surgical or percutaneous repair. We present a case of a trauma-related ventricular septal defect in a young patient that was successfully repaired by using a percutaneous approach. (Level of difficulty: Intermediate.).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jaccas.2019.12.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7255421PMC
April 2020

Progression of aortic stenosis and echocardiographic criteria for its severity.

Eur Heart J Cardiovasc Imaging 2020 07;21(7):737-743

Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Ave., MC 9067, DCAM 5509, Chicago, IL 60637, USA.

Aims: Guidelines-recommended criteria for identifying severe aortic stenosis (AS) are based on small, homogenous cohorts of patients, leading to potentially inconsistent or missed diagnosis. We used a large cohort of patients with varying degrees of AS to (i) characterize its progression; (ii) evaluate the influence of demographic and echocardiographic variables; and (iii) derive haemodynamically consistent cut-off values.

Methods And Results: We identified 916 patients with mild to severe AS who had undergone >1 echocardiographic study (N = 2547). For each study, aortic valve area (AVA), peak transaortic velocity (Vmax), and mean pressure gradient (ΔP) were extracted. Annual rates of AVA change were determined by a linear mixed-effects model. To determine the prevalence of inconsistent diagnosis of severe AS, AVA was plotted against ΔP and Vmax, with quadrants defined using guidelines-recommended cut-offs. The rate of AVA change was -0.070 ± 0.003 cm2/year and was more rapid in men than women and in Whites than African Americans. AVA = 1 cm2 corresponded to ΔP = 32 mmHg and Vmax = 3.7 m/s, causing discrepancies in defining severe AS in 480 (19%) and 458 (18%) studies, respectively. Conversely, ΔP = 40 mmHg corresponded to AVA = 0.89 cm2 and Vmax = 4.0 m/s corresponded to AVA = 0.92 cm2, confirming the inconsistency of the guidelines. Notably, discrepancy rate was higher in 206 patients with low flow (SVi < 35 mL/m2): 40% vs. 16% in the remaining patients.

Conclusion: Our findings demonstrated gender- and race-related differences in AS progression and underscored the need to refine the multiparametric criteria for diagnosis of severe AS to minimize internal inconsistencies, which are high with the current cut-offs and amplified in patients with low stroke volumes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ehjci/jeaa075DOI Listing
July 2020

Echocardiographic reference ranges for normal left ventricular layer-specific strain: results from the EACVI NORRE study.

Eur Heart J Cardiovasc Imaging 2020 08;21(8):896-905

Department of Cardiology, GIGA Cardiovascular Sciences, University of Liège Hospital, Heart Valve Clinic, CHU Sart Tilman, CHU Sart Tilman, 4000 Liège, Belgium.

Aims: To obtain the normal range for 2D echocardiographic (2DE) measurements of left ventricular (LV) layer-specific strain from a large group of healthy volunteers of both genders over a wide range of ages.

Methods And Results: A total of 287 (109 men, mean age: 46 ± 14 years) healthy subjects were enrolled at 22 collaborating institutions of the EACVI Normal Reference Ranges for Echocardiography (NORRE) study. Layer-specific strain was analysed from the apical two-, three-, and four-chamber views using 2DE software. The lowest values of layer-specific strain calculated as ±1.96 standard deviations from the mean were -15.0% in men and -15.6% in women for epicardial strain, -16.8% and -17.7% for mid-myocardial strain, and -18.7% and -19.9% for endocardial strain, respectively. Basal-epicardial and mid-myocardial strain decreased with age in women (epicardial; P = 0.008, mid-myocardial; P = 0.003) and correlated with age (epicardial; r = -0.20, P = 0.007, mid-myocardial; r = -0.21, P = 0.006, endocardial; r = -0.23, P = 0.002), whereas apical-epicardial, mid-myocardial strain increased with the age in women (epicardial; P = 0.006, mid-myocardial; P = 0.03) and correlated with age (epicardial; r = 0.16, P = 0.04). End/Epi ratio at the apex was higher than at the middle and basal levels of LV in men (apex; 1.6 ± 0.2, middle; 1.2 ± 0.1, base 1.1 ± 0.1) and women (apex; 1.6 ± 0.1, middle; 1.1 ± 0.1, base 1.2 ± 0.1).

Conclusion: The NORRE study provides useful 2DE reference ranges for novel indices of layer-specific strain.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ehjci/jeaa050DOI Listing
August 2020

Prevalence of mitral annular disjunction in patients with mitral valve prolapse and severe regurgitation.

Int J Cardiovasc Imaging 2020 Jul 27;36(7):1363-1370. Epub 2020 Mar 27.

Biological Sciences Division, University of Chicago Medicine, Chicago, IL, USA.

Mitral annular disjunction (MAD) is routinely diagnosed by cardiac imaging, mostly by echocardiography, and shown to be a risk factor for ventricular arrhythmias. While MAD is associated with mitral valve (MV) prolapse (MVP), it is unknown which patients with MAD are at higher risk and which additional imaging features may help identify them. The value of cardiac computed tomography (CCT) for the diagnosis of MAD is unknown. Accordingly, we aimed to: (1) develop a standardized CCT approach to identify MAD in patients with MVP and severe mitral regurgitation (MR); (2) determine its prevalence and identify features that are associated with MAD in this population. We retrospectively studied 90 patients (age 63 ± 12 years) with MVP and severe MR, who had pre-operative CCT (256-slice scanner) of sufficient quality for analysis. The presence and degree of MAD was assessed by rotating the view plane around the MV center to visualize disjunction along the annulus. Additionally, detailed measurements of MV apparatus and left heart chambers were performed. Univariate logistic regression analysis was performed to determine which parameters were associated with MAD. MAD was identified in 18 patients (20%), and it was typically located adjacent to a prolapsed or flail mitral leaflet scallop. Of these patients, 75% had maximum MAD distance > 4.8 mm and 90% > 3.8 mm. Female gender was most strongly associated with MAD (p = 0.04). Additionally, smaller end-diastolic mitral annulus area (p = 0.045) and longer posterior leaflet (p = 0.03) were associated with greater MAD. No association was seen between MAD and left ventricular size and function, left atrial size, and papillary muscle geometry. CCT can be used to readily detect MAD, by taking advantage of the 3D nature of this modality. A significant portion of MVP patients referred for mitral valve repair have MAD. The presence of MAD is associated with female gender, smaller annulus size and greater posterior leaflet length.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10554-020-01818-4DOI Listing
July 2020