Poster Session II 2008

POSTER SESSION 2 Monday, June 9, 2008 Presented 9 am – 4:15 pm Moderated Session 2: Valve Disease Moderated 11:30 am – 12:30 pm

Posters Valvular Heart Disease Posters P2-25 – P2-49

Valvular Heart Disease Posters P2-01 – P2-12

3D Echocardiography Posters P2-50 – P2-64

Moderated Session 3: Valve Disease Moderated 2 pm – 3 pm

Contrast Echocardiography Posters P2-65 – P2-79

Valvular Heart Disease Posters P2-13 – P2-16

Exercise and Pharmacologic Stress Echocardiography Posters P2-80 – P2-91

3D Echocardiography Posters P2-17 – P2-24

Ischemic Heart Disease Posters P2-92 – P2-110

P2-01. Moderated Poster

P2-02. Moderated Poster

Assessment of Contractility and Afterload Mismatch as Determinants of Reduced Ejection Fraction in Severe Aortic Stenosis

Clinical Significance of Pulmonary Hypertension for Prediction of Postoperative Left Ventricular Dysfunction after Mitral Valve Repair in Patients with Mitral Regurgitation

Ricardo A Migliore, Maria E Adaniya, Miguel Barranco, Guillermo Miramont, Florencio Guerrero, Horacio Tamagusuku, Alfredo Sinisi Hospital Eva Perón, San Martín, Pcia de Buenos Aires, Argentina Background: Reduced LV ejection fraction (EF) in aortic stenosis (AS) is related to a decrease in contractility or afterload mismatch. Increase in afterload is due to reduced aortic valve area (AVA), changes in LV geometry and the characteristics of arterial vasculature. Objective: To evaluate contractility and afterload mismatch as determinants of reduced EF in severe AS. Methods: We studied 77 patients, age average 70 ± 10 years, 48 men, with severe AS (AVA < 1 cm2) and 63 normal control subjects with Doppler echocardiography. Contractility was assessed by midwall fractional shortening (mFS) - end-systolic stress (ESS) relation in control subjects, with regression equation: mFS = 28.15 - 0.12 x ESS , standard error of estimation (SEE) of 3.75 % (r=0.40 p< 0.001). For any ESS level, a value of mFS predicted by the regression equation below 2 SEE was considered as decreased contractility in patients with AS. Afterload mismatch was defined as EF < 50 % and contractility within normal range. Patients were divided into three groups: group 1, EF < 50 % and decreased contractility (n = 18), group 2, EF < 50 % and normal contractility (afterload mismatch) (n = 20 ) and group 3, EF ≥ 50 % and normal contractility (n = 39). Presence of heart failure (NYHA III-IV), symptoms (dyspnea, angor), AVA, peak and mean gradient (PG, MG), valve resistance, energy loss index, valvuloarterial impedance (Zva) and effective arterial elastance (Ea) were determined in three groups. Results: Heart failure (NYHA III-IV) (n) Symptomatic (n) Asymptomatic (n) Zva (mmHg/ml/m2) Ea (mmHg/ml)

Group 1 10* 3 5 6.1 ± 2.1* 1.9 ± 0.7*

Group 2 10* 7 3 5 ± 1.4* 1.8 ± 0.7*

Group 3 3 7 29* 4.7 ± 1.2 1.6 ± 0.5

P *<0.01

Background: In the current guidelines, pulmonary hypertension (PHTN) with systolic pressure >50 mm Hg is proposed as the surgical indication for severe mitral regurgitation (MR) even in the asymptomatic patients (Pts) with preserved left ventricular (LV) function. However, this recommendation is never firmly established and thus listed as Evidence Level C. Besides, the significance of Doppler-estimated PHTN of mild degree has never been reported. Methods: We retrospectively investigated pre- and post- (median 4 th postoperative day) operative ECHO of the consecutive 249 Pts who underwent mitral valve (MV) repair for chronic and isolated MR. We excluded 50 Pts from inadequate ECHO and 30, absence of at least minimal tricuspid regurgitation. Finally, our study subjects consisted of 169 Pts, whom we divided into 3 groups using Doppler-derived trans-tricuspid pressure gradient (TPG). Results: Preoperative LV ejection fraction (EF) was not different among Pts with no PHTN, mild (Grade I) PHTN, and moderate/severe (Grade II) PHTN [Table]. In Pts with Grade II PHTN, LV end-diastolic (LVDd) and left atrial (LAD) diameter were larger than in those with no PHTN. However, there was no difference in the echo-variables between Pts with Grade I PHTN and those with no PHTN. After MV repair, there was significant decrease in EF in all groups; however, it was more severely deteriorated as with the degree of PHTN [Fig]. The postoperative LV dysfunction, defined as EF <50%, occurred in 52 Pts (31%). Preoperative PHTN was the independent predictor of postoperative LV dysfunction (OR 4.7, 95%CI 2.0-11.1, p <0.001), as well as LV end-systolic diameter (LVDs) and existence of the symptom. Even when Pts with Grade II PHTN were excluded, PHTN remained as an independent predictor (4.2, 1.5-11.7, p <0.01). Conclusion: Doppler-estimated PHTN was proven to be a predictor of postoperative LV dysfunction after MV repair, even when it is of mild degree. However, further studies are needed to determine whether surgical therapy should be indicated just for mild PHTN. PHTN (-)

*<0.01 *<0.01 *<0.01

There were not differences in AVA, valve resistance, energy loss index among three groups. In multivariate analysis Zva, Ea, PG and MG, were predictors of decreased contractility. Conclusions: Patients with severe AS and reduced EF had similar proportion of decreased contractility, afterload mismatch and heart failure. Increase in vascular component of afterload evaluated by mean of Zva and Ea impacts significantly on contractility.

554

Tetsuhiro Yamano, A. Marc Gillinov, Kunitsuga Takasaki, Yoshiki Matsumura, Manatomo Toyono, James D. Thomas, Takahiro Shiota Cleveland Clinic Foundation, Cleveland, OH

Variable, units

TPG <36 mm Hg n=123

PHTN (+) Grade II: Grade I: 36 ≤TPG <50 50 mm Hg mm Hg ≤TPG n=31 n=15

TPG (IQR), 25 (7) 38 (4) mm Hg Age, yrs 54 ± 12 65 ± 10* Asymptomatic 62 (50) 13 (42) patients, n (%) LVDd, mm 57 ± 6 57 ± 5 LVDs, mm 35 ± 6 34 ± 5 LAD, mm 46 ± 6 48 ± 6 EF, % 68 ± 7 69 ± 6 Postoperative variable EF, % 56 ± 9 53 ± 10 Decrease in EF, % 12 ± 7 16 ± 9† LV dysfunction, 28 (23) 12 (39) n (%) *p <0.005, †p <0.05 vs. PHTN (-); ‡p <0.005, §p <0.05 vs. Grade I PHTN. Abbreviations as in abstract. Preoperative variable

ANOVA

57 (18)

-

68 ± 13*

p <0.001

1 (7)*§

-

61 ± 7† 38 ± 8 54 ± 5*§ 66 ± 9 42 ± 11 *‡ 24 ± 12*§

p <0.05 p = NS p <0.001 p = NS p <0.001 p <0.001

12 (80)*§

-

Journal of the American Society of Echocardiography Volume 21 Number 5

555

P2-03. Moderated Poster

P2-04. Moderated Poster

Clinical Implication of Energy Loss Coefficient in Patients with Severe Aortic Stenosis

Echocardiographic Approach to the Decision-Making Process for Tricuspid Valve Repair

Teruyoshi Kume, Hiroyuki Okura, Takahiro Kawamoto, Nozomi Watanabe, Eiji Toyota, Yoji Neishi, Yoshinori Miyamoto, Koichiro Imai, Ryotaro Yamada, Kiyoshi Yoshida Kawasaki medical school, Kurashiki, Japan

Farideh Roshanali, Mohammad Hossein Mandegar, Mohammad Ali Yousefnia Day General Hospital, Tehran, Iran (Islamic Republic of)

Background: The aortic valve effective orifice area (EOA) can be used to grade aortic stenosis (AS) severity as severe at < 1.0 cm2. In the clinical situation, discrepancies in the severity of AS between EOA obtained by using the Gorlin formula (EOA cath) and EOA obtained by using the continuity equation (EOADop) mainly due to the pressure recovery phenomenon are sometimes observed. Recently, Doppler-derived energy loss coefficient (ELCo), which can take into account pressure recovery phenomenon and reconcile discrepancies between EOA cath and EOADop, is proposed as an equivalent index representing EOA cath. Therefore, the purpose of this study was to evaluate the clinical impact of ELCo in patients with severe AS. Methods: A total of 33 patients (mean age 71 ± 8 years, female 20 and male 13) with severe AS by Doppler examination (EOADop < 1.0 cm2), who were referred to the cardiac catheterization laboratory for evaluation of aortic valve stenosis. The ELCo equation was used as previously reported: ELCo = (EOADop × aortic cross-sectional area)/(aortic cross-sectional area - EOA Dop). Study patients were grouped based on the ELCo value; group A, 26 patients with ELCo < 1.0 cm2, group B, 7 patients with ELCo > 1.0 cm2. Symptoms related to the AS (chest pain, syncope, or dyspnea), hemodynamic, and echocardiographic data were compared between the 2 groups. Results: Patients in the group B had significantly lower incidence of symptoms related to AS compared with the group A ( p=0.002). There was a significant correlation between EOA cath and ELCo (R=0.75, p<0.001). Furthermore, superior concordance was demonstrated between EOAcath and ELCo compared with EOAcath and EOADop (κ=0.32, and κ=0.52, respectively). Conclusion: In 21% patients with “severe” AS, ELCo value indicated moderate rather than severe AS (> 1.0 cm 2). These patients had significantly lower incidence of symptoms compared with patients who had ELCo < 1.0 cm2. ELCo, that could be calculated non-invasively from echocardiogram, might be the useful measure for quantifying AS severity.

Background: Early failure of tricuspid valve repair with common repair procedures (Devega and annuloplasty) is high. This study was designed to reduce the failure rate of tricuspid valve repair by reducing leaflet tethering via pericardial patch augmentation, when preoperative probability for recurrence was high. Methods: Between 2001 and 2007, 218 patients underwent tricuspid valve repair. The patients were randomly divided into 4 groups: in 55 patients Devega (Group 1), in 53 ring annuloplasty (Group 2), in 56 patients Devega and augmentation in high risk patients (Group 3), and in 54 annuloplasty and augmentation in high-risk patients (Group 4) were used. We defined high-risk patients for recurrence as those with tether distance>8mm or tether area>16mm2. We also evaluated one-month’s postoperative tricuspid valve regurgitation. Results: Postoperative tricuspid valve regurgitation was statistically significantly different between the groups (PV = 0.007). 14.5% of the patients in the Devega group, 7.5% in the annuloplasty group, 3.5% in the Devega+pericardial group and 1.8% in the ring+pericardial group had severe postoperative regurgitation. Conclusions: An assessment of preoperative tricuspid valve tethering and use of suitable types of repair are essential to have a good surgical outcome in patients with severe functional tricuspid valve regurgitation.

P2-05. Moderated Poster

P2-06. Moderated Poster

Left Ventricular Remodeling and Systolic Dysfunction Rather than Papillary Muscle Displacement is Associated with Mitral Regurgitation in the Acute Phase of Inferior Wall Myocardial Infarction

Mitral Valve Repair for Mitral Regurgitation in the Elderly: Pre- and Postoperative Echocardiographic Study

Sung Jin Hong, Jong-Won Ha, Chi Young Shim, Eui-Young Choi, Jung-Sun Kim, Young-Guk Ko, Donghoon Choi, Yangsoo Jang, Namsik Chung Yonsei University College of Medicine, Seoul, Republic of Korea Background: Ventricular remodeling with papillary muscle displacement has been known as an important mechanism of mitral regurgitation (MR) in the chronic phase of myocardial infarction (MI), especially in patients with inferior wall MI. However, in the acute phase of MI, the mechanism of MR is unclear. The purpose of this study was to compare geometric changes and left ventricular (LV) function between patients with or without MR after acute inferior MI. Methods: In 83 patients (age 59± 10 years, male 83%) with acute inferior wall MI, we evaluated the severity of MR, mitral deformation (tenting and annulus area), LV global remodeling (LV end-diastolic and end-systolic volume index, sphericity), local remodeling (distances between papillary muscle tips and the contralateral mitral annulus), LV ejection fraction and regional wall motion score index (RWSI) within 10 days after MI. Results: MR was present in 28 (34%) of 83 patients; mild in 14 (17%), and moderate to severe in 14 (17%). There were no significant differences in mitral annular area, sphericity index and distances between papillary muscle tips and the contralateral mitral annulus. However, patients with severe MR had significantly larger LV end-diastolic and end-systolic volume, and tenting area. There was a graded relationship between the severity of MR and LV ejection fraction and RWSI. Conclusion: In the acute phase of inferior wall MI, MR was associated with LV remodeling and systolic dysfunction rather with papillary muscle displacement. The presence of ischemic MR in patients with inferior MI may be a reflector of poor LV function and dilated LV. Mitral Regurgitation

None (n=55)

Mild (n=14)

Age (years) 58.2 ± 11.2 60.5 ± 6.7 Male 47 (86%) 12 (86%) Mitral Deformation Tenting area/BSA 0.58 ± 0.25 0.74 ± 0.32 (cm2/m2) Annular area/BSA 3.61 ± 0.85 4.10 ± 1.00 (cm2/m2) LV global and regional function LV ejection fraction (%) 51.8 ± 8.9 43.9 ± 12.8 Total RWSI 1.63 ± 0.51 2.06 ± 1.00 Inferior RWSI 2.13 ± 0.84 2.41 ± 1.03 Posterior RWSI 1.66 ± 0.87 2.04 ± 1.17 LV global remodeling Sphericity 2.24 ± 0.47 2.18 ± 0.54 LVEDVI (mL/m2) 62.1 ± 20.2 65.0 ± 25.5 LVESVI (mL/m2) 28.8 ± 10.7 32.3 ± 20.2 LV local remodeling Annular to APM/BSA 26.5 ± 5.8 28.2 ± 10.7 (mm/m2) Annular to PPM/BSA 25.4 ± 5.8 24.6 ± 8.4 (mm/m2) APM = anterior papillary muscle, PPM = posterior papillary muscle

Moderate Severe (n=14) 60.6 ± 6.9 10 (71%)

pvalue

0.77 ± 0.36

0.040

3.96 ± 1.20

0.215

35.7 ± 11.5 2.25 ± 0.69 2.86 ± 1.07 2.29 ± 0.87

<0.001 0.002 0.031 0.056

2.34 ± 0.70 81.1 ± 35.0 50.3 ± 28.0

0.740 0.052 0.001

27.1 ± 9.5

0.777

25.4 ± 8.8

0.930

Takeshi Kitai, Kazuaki Tanabe, Kazuto Yamaguchi, Yu Syomura, Toshikazu Yagi, Tomoko Tani, Natsuhiko Ehara, Tomoyuki Oda, Minako Katayama, Makoto Kinoshita, Koichi Tamita, Syuichiro Kaji, Atsushi Yamamuro, Shigefumi Morioka, Yutaka Furukawa, Yukikatsu Okada Kobe Medical Center General Hospital, Kobe, Japan Background: Prevalence of degenerative mitral regurgitation (MR) increases with age. Favorable outcomes of mitral valve (MV) repair have been shown in selected patients. However, surgical outcome of complex MV repair in the elderly remains uncertain. The purpose of this study was to assess clinical outcome and the pre- and postoperative echocardiographic parameters in the aged patients who underwent mitral valve repair. Methods: We studied the consecutive 105 patients aged 70 years and older (mean 74.2 ± 3.5 years) who underwent MV repair for MR due to degenerative MVP between 1995 and 2006. Patients were divided into two groups according to the prolapsed leaflets; AML and Bileaflet prolapse (n=52) which required chordal reconstruction using ePTFE with/without PML resection, and PML prolapse (n=53) which required simple resection and suture technique. Late results including mortality, valve-related events, and left ventricular (LV) function were compared between the two groups. Results: Mean follow-up period was 3.6 ± 2.8 years. Preoperative echocardiographic parameters including LV ejection fraction, LV end-diastolic dimension, LV end-systolic dimension, and left atrial dimension were not significantly different between the two groups. At 5 years after surgery, freedom from cardiac death was 93 ± 3%, and freedom from reoperation was 97 ± 2%. Freedom from valve-related events was not significantly different between the two groups. There were no significant differences in LV function at late follow-up period (Table). Late results including LV function in the patients who underwent complex MV repair were comparable to those of simple MV repair. Conclusion: In patients aged 70 years and older, MV repair provides excellent survival irrespective of portion of prolapsed leaflet. pre- and postoperative echocardiographic paramaeters All AML N 105 52 Age 74.2±3.5 74.4± 3.8 Male(%) 47(45) 27(52) Af(%) 43(41) 22(42) LVEF(pre) 64.9±9.8 64.4±10.2 LVDd(pre) 5.2±0.9 5.3±0.9 LVDs(pre) 3.3±0.9 3.5±0.8 LVEF(post) 55.7±1.8 54.4±10.9 LVDd(post) 4.5±0.8 4.6±0.7 LVDs(post) 3.1±0.8 3.2±0.8

PML 53 74.0± 3.1 20(38) 21(40) 65.4± 9.5 5.2±0.9 3.2±1.0 57.1±10.7 4.4±0.9 3.0±0.9

P value 0.61 0.14 0.78 0.58 0.31 0.16 0.21 0.33 0.17

556

Journal of the American Society of Echocardiography May 2008

P2-07. Moderated Poster

P2-08. Moderated Poster

Relation Between the Jet Type and Mitral Valve Geometry in Functional Mitral Regurgitation: A Real-Time Three-Dimensional Color Doppler Echocardiographic Study

Measures of Left Ventricular Filling Pressure are Stronger Predictors of Exercise Capacity than Aortic Valve Area in Severe Aortic Valve Stenosis

Yoshiki Matsumura 1, Manatomo Toyono 1, Kenichi Sugioka2, Hung Tran 1, Neil L Greenberg 1, Tetsuhiro Yamano 1, Shota Fukuda2, Takeshi Hozumi 2, James D Thomas1, Junichi Yoshikawa 3, Minoru Yoshiyama 2, Takahiro Shiota 1 1 Cleveland Clinic, Cleveland, OH; 2Osaka City University Graduate School of Medicine, Osaka, Japan; 3Osaka Ekisaikai Hospital, Osaka, Japan Background: Recently two types of regurgitant jet pattern, a single central jet and two separate jets, have been demonstrated in functional mitral regurgitation (MR) by a three-dimensional (D) color Doppler echocardiography. However, the relation between the jet type and geometry of mitral valve (MV) apparatus is unknown. Methods: Thirty-four patients with functional MR (grade ≥2+) were examined by a real-time 3D transthoracic or transesophageal echocardiography. The left ventricle (LV), MV, and the proximal isovelocity surface area (PISA) of functional MR were analyzed by the 3D software. For the examination of the MV apparatus, we defined the 3 equi-distant anteroposterior (AP) planes (medial, central, and lateral) perpendicular to the commissure-commissure (CC) plane. We measured the MV tenting area, MV tenting height, the length of anterior and posterior mitral leaflets (AML and PML, respectively) and AP length of the mitral annulus on 3 AP planes, and CC length of the mitral annulus on CC plane as shown in Figure 1. The sphericity of mitral annulus was calculated as (AP length)/(CC length). Results: Three-dimensional color Doppler images demonstrated that 13 patients had two separate PISAs or jets (Group A, Figure 2) while 21 had a single PISA and jet (Group B, Figure 3). There was no difference between the 2 groups in LV volumes, ejection fraction, MV tenting area, and tenting height in each AP plane (all P>0.05). The mitral annular sphericity was significantly lower in Group A than in Group B (0.85±0.06 vs. 0.92±0.04, P<0.001). The AML length on the central plane tended to be longer in Group A than in Group B (2.8±0.3 vs. 2.5±0.3 cm, P=0.067). Conclusion: Separate jets of functional MR observed by color Doppler 3D echocardiography were associated with relatively elongate CC length while a single central jet with longer AP distance. These relations are essential for the development of surgical strategies.

Morten Dalsgaard, Jesper Kjaergaard, Redi Pecini, Kasper Iversen, Lars Køber, Peer Grande, Peter Clemmensen, Christian Hassager Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark Background: Aortic valve area (AVA) is not consistently related to symptoms in patients with significant aortic stenosis (AS). The aim of this study was to determine if estimates of increased left ventricular (LV) filling pressure are more closely related to symptoms (exertional dyspnoea) and exercise capacity in severe AS. Method: 25 patients (6 asymptomatic and 19 symptomatic) with severe AS (AVA <1 cm 2) performed a symptom limited multistage supine bicycle exercise test (increment of 25 W every other minute). Pulmonary capillary wedge pressure (PCWP) measured by a Swan-Ganz catheter and echocardiographic measurements of the ratio of early diastolic mitral inflow velocity to septal early diastolic mitral annular velocity (E/e‘) and left atrial (LA) volume as estimates of LV filling pressures were determined simultaneously just before the exercise test. Results: There were no significant differences in AVA between groups (table). AVA was not related to exercise capacity (r = -0.33; NS). PCWP correlated with LA volume (r = 0.79; p < 0.0001) and E/e‘ (r = 0.68; p = 0.0002). PCWP, LA volume and E/e‘ all correlated significantly (p < 0.01) with exercise capacity (r = -0,51 to -0.70). Furthermore, PCWP, E/e‘ and LA volume were significantly higher in the symptomatic group (table). Conclusion: Measurements of LV filling pressure were related to exercise capacity and symptoms. Echocardiographic measurements like LA volume or E/e‘ adds important information to AVA as a maker for disease severity in severe AS.

Age (years) Body surface area (m2) Left ventricular ejection fraction (%) Left ventricular mass (g) Aortic Valve Area (cm 2) PCWP (mmHg) at rest PCWP (mmHg) at peak exercise E/e‘ ratio Left atrial volume (ml) Exercise capacity (W)

Asymptomatic group 72±9 1.8±0.1 64±5 207±36 0.69±0.07 12±4 35±6 14±3 67±13 113±21

Symptomatic group p-value 69±7 1.9±0.2 60±11 221±62 0.71±0.18 21±7 43±10 21±6 105±31 75±12

NS NS NS NS NS 0.02 NS 0.01 0.02 0.01

P2-09. Moderated Poster

P2-10. Moderated Poster

Echocardiographic Recognition of Epicardial and Intramural Coronary Blood Flow Velocity in Patients with Aortic Stenosis and Preserved Left Ventricular Systolic Function

Prognostic Significance of Myocardial Radial Strain Rate in Asymptomatic Patients with Chronic Severe Aortic Regurgitation

Cesare de Gregorio, Alessio Currò, Gianluca Di Bella, Pietro Pugliatti, Sebastiano Coglitore Dpt of Medicine and Pharmacology, University of Messina, Messina, Italy Background: Doppler echocardiography plays a striking role in the noninvasive recognition of cardiac (dys)function in patients with aortic valve stenosis (AVS). In the last few years, only a few ultrasound studies have investigated the behavior of coronary diastolic velocity (CDV) in aortic patients. An increase in the left anterior descending (LAD) CDV, variably related to AV area, transvalvar gradients, left ventricular (LV) hypertrophy or LV workload was reported in some cases. Impaired coronary flow reserve was also demonstrated, but in the best of our knowledge no data on the behavior of CDV in the small intramyocardial (IM) arteries are available yet. Aims: The purpose of this study was to assess both LAD- and IM-CDV at rest, and to determine whether it is related to LV mass or systolic load, AV area or peak gradient. Methods: Thirty-two consecutive patients (18 M, mean aged 70.9 ± 9.8 ys) with senile pure AVS, no evidence of clinical ischemia and/or epicardial coronary artery disease (CAD), and normal LV systolic function were studied by transthoracic ultrasound. Resting CDV in both artery compartments was sampled at color-Doppler and findings were correlated to LV mass (ASE method), LV systolic workload (systolic blood pressure + peak tranvalvar gradient), AV area (by continuity method), AV peak and mean transvalvar gradients. Results: Five patients had mild (15.6%), 16 moderate (50%) and 11 severe (34.4%) AVS. Peak and mean LAD-CDV was 46±13 cm/s (>60 cm/s in 5/32 patients) and 32±10 (>40 cm/s in 7/32), respectively. Peak and mean IM-CDV was 82±28 cm/s (> 60 cm/s in 23/32) and 57±23 cm/s (>40 cm/s in 22/32), respectively. No relationship was found between LAD-CDV and the studied variables. On the contrary, peak and mean IM-CDV showed a correlation with LV workload (r=0.48, p=0.002 and r=0.44, p=0.008, respectively), AV peak gradient (r=0.43, p=0.009 and r=0.43, p=0.01, respectively) and AV area (r= -0.43, p=0.008 and r= -0.39, p<0.02, respectively). No correlation was found between resting LAD- or IM-CDV and LV mass. Conclusion: These findings indicate that resting LAD-CDV is not correlated with the LV mass, systolic load, AV area and gradients. On the contrary, a high IM-CDV can be related with these indices (with the exception of LV mass). Our data likely support the fact that a functional impairment of the small-size coronary artery compartment is dependent on LV workload, high transvalvar gradients and AV area in a large percent of senile aortic patients with preserved LV systolic function, even in the absence of clinical ischemia.

Tetsuari Onishi, Hiroya Kawai, Maky Furuki, Yuko Fukuda, Mariko Okada, Kazuko Norisada, Kazuhiro Tatsumi, Toshiya Kataoka, Yutaka Okita, Ken-ichi Hirata Kobe University Graduate School of Medicine, Kobe, Japan Background: The purpose of this study was to investigate the prognostic value of myocardial peak systolic SR in the initial evaluation in asymptomatic patients with chronic severe AR. Methods: We studied 50 patients with severe AR and moderately dilated LV who did not present with the operative indication in the initial evaluation. During an average 24 months follow-up period, 15 patients underwent surgical corrections (group S) and remaining 35 did not require them (group M). In the initial echocardiographic examination, we obtained enddiastolic and end-systolic LV dimensions, radius to thickness ratio (R/T) and end-systolic wall stress (WS) from M-mode echocardiograms, and did end-diastolic and end-systolic LV volume indices (EDVI and ESVI), LV ejection fraction (EF) and WS to ESVI ratio (WS/ESVI) using the modified Simpson method, and peak systolic strain rate (Ssr) on the LV posterior wall using tissue Doppler imaging. We used a student t-test for 2 group comparison and logistic analysis to search for predictor from parameters. Results: There was no significant difference in EF, R/T, WS, and WS/ESVI between two groups in the initial evaluation. However, in group S, EDVI and ESVI were significantly larger and Ssr was significantly smaller than those in group M. In logistic analysis, we identified Ssr as the only independent factor for the requirement of surgical corrections in advance. Kaplan-Meier analysis according to the cutoff value (Ssr 2.4/s) determined by analysis of receiver operating characteristics curves demonstrated a significantly lower operation-free survival rate in patients with Ssr < 2.4/s than in those with Ssr > or = 2.4/s (p < 0.001). Conclusions: Myocardial systolic strain rate is an independent predictor for the progression of disease, and may be helpful for the risk assessment in the serial evaluation of asymptomatic patients with chronic AR.

Journal of the American Society of Echocardiography Volume 21 Number 5

557

P2-11. Moderated Poster

P2-12. Moderated Poster

Progression and Predictors of Left Ventricular Dilation Secondary to Significant Organic Mitral Regurgitation: Insights from Tissue Doppler Imaging

C-Reactive Protein Predicts Severity and Progression of Aortic Valve Stenosis

Juan Zhang, Li Ching Lee, Huay Cheem Tan, James WL Yip, Tiong Cheng Yeo, Kian Keong Poh National University Hospital, Singapore, Singapore Background: Chronic significant mitral regurgitation (MR) from flail or prolapsed mitral valve (MV) may result in left ventricular (LV) and atrial (LA) dysfunction and dilation. However, progression of MR and predictors of LV dilation are not well defined. In particular, no study has utilized tissue Doppler (TD) imaging. We assess the natural history and hypothesize that TDI predict LV decompensation. Methods: Consecutive patients (N=148, 54±17yrs) with at least moderate organic MR (≥Grade III), preserved LV ejection fraction (EF≥55%) were included. Paired TD at the mitral annulus (lateral and septal) and conventional echocardiograms were performed at an interval of 650±362 days apart. Patients were categorized into 2 groups: with or without LV dilation (interval increase in end-systolic volume (ESV) of >20%). Correlates with change in ESV were also performed. Results: There were significant increases in body-surface area indexed biplane LV ESV (17±5 to 20±6 ml/m 2, P<0.001); end-diastolic volume (49±12 to 55±13 ml/m2, P<0.001); LA volume (35±14 to 42±17 ml/m2, P<0.001); MR severity; E/E’ and decreases in early diastolic TD velocities (E’) (Table). However LVEF, LAEF, TD systolic (S’), and late diastolic (A’) velocities remained the same. There were 38 patients (25%) with progressive LV dilation. Compared to the group without LV dilation, they had lower baseline S’, A’ velocities and LAEF (Table). Time interval between studies and baseline MR volumes were similar between the 2 groups (Table). Multivariate analysis showed that lateral A’ was the only independent predictor of LV dilation (P<0.001). The area under receiver-operator-characteristic curve was 0.78 (95%CI 0.70-0.86). An optimized cut-off of A’<11.0cm predicted subsequent LV dilation with 90% sensitivity and 54% specificity. Interval increase in LV ESV also correlated negatively and significantly with baseline A‘ and LAEF but not with LA volume. Conclusions: Organic significant MR resulted in progression in severity, LV and LA remodeling with time. Reduced baseline lateral A’, consistent with LA dysfunction, appeared to predict subsequent LV dilation. Monitoring of this easily obtainable parameter is warranted.

Koichiro Imai, Hiroyuki Okura, Teruyoshi Kume, Ryotaro Yamada, Yoshinori Miyamoto, Miwako Tsukiji, Kikuko Obase, Nozomi Wada, Akihiro Hayashida, Nozomi Watanabe, Yoji Neishi, Takahiro Kawamoto, Eiji Toyota, Kiyoshi Yoshida Kawasaki Medical School, Kurashiki, Japan Background: Recently, it has been reported that C-reactive protein (CRP) plays a pivotal role in the pathogenesis of atherosclerosis progression. The aim of this study was to assess whether CRP predict the severity and progression of aortic valve stenosis (AS). Methods: We enrolled 135 patients with asymptomatic AS. Aortic valve area (AVA) was calculated by Doppler echocardiography. CRP was measured using a high sensitivity enzyme immunoassay. Patients were diagnosed as mild (n=18, AVA≥1.5cm 2), moderate (n=57, 1.0≤AVA<1.5cm 2), or severe AS (n=60, AVA<1.0cm 2). Serial (baseline and at 1 year) echocardiographyic examination was performed in 47 patients. They were grouped as either slow progression group (n=22, a decrease in AVA<0.15 cm 2/year) or rapid progression group (n=25, a decrease in AVA≥0.15 cm2/year). Results: There was significant difference in baseline CRP among mild, moderate, and severe AS (0.17±0.43 mg/dl, 0.22±0.28 mg/dl, 0.53±0.66 mg/dl, p=0.001). By multivariate logistic regression analysis, CRP was an independent predictor of severe AS (odds ratio, 4.58; p=0.004 [95% confidence interval 1.62-12.93]). Furthermore, CRP was significantly higher in the rapid progression group than the slow progression group (0.56±0.76 mg/dl vs 0.19±0.25 mg/dl, p=0.004). Conclusion: CRP predicts severity and progression of AS. These findings suggest that inflammation may have a pathogenic role in AS.

Table

80±52 64±5

Baseline parameters in gp without LV dilation (N=110) <0.001 63±40 NS 65±4

Baseline parameters in gp with P LV dilation (N=38) 60±46 NS 64±6 NS

0.09 -0.11

NS NS

42±17

<0.001 35±12

37±19

NS

0.02

NS

42±11 10.6±3.6 13.1±4.3 10.8±3.5 9.0±4.3 8.6±2.2 9.5±2.9 9.8±2.6 11.7±4.3

NS NS 0.023 NS <0.001 NS 0.002 NS <0.001

37±10 9.8±2.7 12.9±4.4 8.5±2.2 7.2±3.5 8.1±1.7 9.3±3.3 8.9±2.4 10.5±3.3

0.002 0.045 NS <0.001 NS 0.036 NS 0.005 NS

-0.20 -0.08 -0.03 -0.35 -0.14 -0.09 -0.09 -0.21 -0.04

0.013 NS NS 0.005 NS NS NS 0.012 NS

Echocardiographic parameters

Baseline Follow-up P (N=148) (N=148)

MR Volume (ml) Biplane LVEF (%) LA volume index (ml/m2) LA EF (%) Lateral S’ (cm/s) Lateral E’ (cm/s) Lateral A’ (cm/s) Lateral E/E’ Septal S’ (cm/s) Septal E’ (cm/s) Septal A’ (cm/s) Septal E/E’

62±42 65±4 35±14 43±12 10.8±3.4 13.8±4.5 11.0±3.5 7.5±3.6 9.0±2.9 10.3±3.1 10.1±2.9 10.4±4.6

44±11 11.3±3.4 14.0±4.6 11.8±3.5 7.7±3.7 9.4±3.1 10.6±3.0 10.6±2.9 10.4±4.1

r (correlation with change P in LV ESV)

P2-13. Moderated Poster

P2-14. Moderated Poster

Left Atrial Volume Predicts Post-Operative Outcome in Severe Aortic Stenosis

Different Determinants of Residual Tricuspid Regurgitation after Tricuspid Annuloplasty: Comparison of Atrial Septal Defect and Mitral Valve Disease

Ruby Satpathy, Xuedong Shen, Mark Holmberg, Claire Hunter, Aryan Mooss, Dennis Esterbrooks Creighton University, Omaha, NE Background: The prognostic importance of left atrial volume (LAV) for post operative outcomes after aortic valve replacement (AVR) for aortic stenosis has not been established. Post-operative atrial fibrillation (POAF) is frequent after AVR and is associated with increased morbidity, mortality, prolonged hospital stay and increased costs. The aim of this study was to identify preoperative predictors of POAF among patients undergoing AVR. Methods: A total of 249 patients (mean age 74±13 years, and 24% females) with severe aortic stenosis (mean valve area 0.7±0.13 cm2, mean gradient 49±11 mmHg) undergoing elective AVR were retrospectively analyzed. Clinical risk factors and postoperative outcomes were obtained by detailed medical record review. Preoperative transthoracic echocardiograms were analyzed for assessment of left atrial volume, ejection fraction, and diastolic dysfunction. LAV was obtained by modified biplanar area-length method (Simpson’s method) and indexed to body surface area. Patients with moderate and severe mitral regurgitation were excluded from analysis. Detection of POAF was based on documentation of AF episodes by continuous telemetry throughout the hospitalization. Episodes of more than 30s were considered clinically relevant AF. Results: POAF was found in 126 patients (51% of the study population) at a median of 1.4 days after AVR. The median total duration of AF was 16 hrs. LAV was significantly greater in the group that developed AF (52±17 ml/m 2 vs 32±11 ml/m 2, p<0.001). Univariable predictors of AF were age, HTN, smoking, CAD, concurrent CABG, no of grafts, LAV > 40 ml/m 2 and diastolic dysfunction. However, age and LAV were the only independent predictors of POAF by multivariable cox model (both p<0.001). Interestingly, preoperative use of beta blocker therapy was not associated with incidence of POAF (p= 0.2). Conclusion: Preoperative LAV is a strong and independent predictor of POAF after AVR for aortic stenosis. Preoperative determination of LAV can identify patients at increased risk of postoperative atrial fibrillation and hence outcomes after AVR for severe aortic stenosis.

Manatomo Toyono, Shota Fukuda, A. Marc Gillinov, Gosta B. Pettersson, Yoshiki Matsumura, Tetsuhiro Yamano, Kunitsugu Takasaki, James D. Thomas, Takahiro Shiota The Cleveland Clinic, Cleveland, OH Background: Functional tricuspid regurgitation (TR) often accompanies atrial septal defect (ASD) as well as mitral valve (MV) disease. We aimed to compare predictors of residual TR after tricuspid valve (TV) annuloplasty in ASD and MV disease. Methods: We analyzed 17 consecutive ASD patients who underwent simultaneous ASD closure and TV annuloplasty (age, 58 ± 15 years), 42 patients with MV disease who underwent simultaneous MV and TV annuloplasty (age, 64 ± 12 years), and 20 healthy controls. No subjects had organic TV disease. Two-dimensional and Doppler transthoracic echocardiography was performed to obtain right ventricular (RV) end-diastolic area, RV spherical index defined as the ratio of RV end-systolic area to RV long-axis dimension, RV fractional area change, minimal TV annulus diameter, TV tethering height, and RV systolic pressure before and 6 ± 2 days after surgery. Severity of TR was assessed by the ratio of maximal TR jet area to right atrial area (%TR). Residual TR was defined as postoperative %TR >20. Results: Before surgery, patients with ASD and MV disease showed greater minimal TV annulus diameter, TV tethering height, RV systolic pressure, and %TR and lower RV fractional area change than controls (all p <0.05). After surgery, %TR was decreased in the 2 groups of patients (ASD, from 44 ± 19 to 11 ± 12; MV disease, from 42 ± 17 to 13 ± 12; both p <0.001). Residual TR was shown in 24% of both patients with ASD and MV disease. Multivariate analysis revealed that preoperative TV tethering height and %TR were associated with postoperative %TR in patients with MV disease (both p <0.05). In contrast, preoperative RV fractional area change, RV spherical index, and RV systolic pressure were associated with postoperative %TR in ASD patients (all p <0.02). In ASD patients, the sensitivity and specificity in predicting residual TR after surgery were 80% and 100% for RV fractional area change of <32%, 75% and 92% for RV spherical index of >3.5, and 60% and 92% for RV systolic pressure of >54 mm Hg, respectively. Conclusion: RV dysfunction, RV geometrical change, and RV pressure overload were predictors of residual TR in ASD patients, whereas extensive TV tethering and preoperative TR severity were predictors of residual TR in patients with MV disease. Risk stratification after TV annuloplasty should take the underlying cardiac structural abnormality into consideration.

558

Journal of the American Society of Echocardiography May 2008

P2-15. Moderated Poster

P2-16. Moderated Poster

A Wave Intensity Index Predicts Ventricular Volume Reduction Ratio after Valve Replacement in Patients with Aortic Regurgitation

Impact of Cardiac Rhythm on Determining Mitral Valve Area in Patients with Moderate or Severe Mitral Stenosis: An Unrecognized Limitation of the Pressure Half Time Method

Kiyomi Niki1, Motoaki Sugawara2, Itaru Takamizawa 3, Tetsuya Sumiyoshi 3, Saichi Hosoda3, Tomoki Shimokawa 4, Hitoshi Kasegawa4, Shuichirou Takanashi 4 1 Biomedical Engineering Department, Musashi Institute of Technology, Tokyo, Japan; 2 Department of Medical Engineering, Himeji Dokkyo University, Himeji, Japan; 3 Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan; 4Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan Background: Wave intensity (WI) is an index which provides information about the behavior of both the heart and the arterial system. WI is defined as the product of time-derivatives of pressure (P) and velocity (U): WI = (dP/dt)(dU/dt). WI has two positive sharp peaks during a cardiac cycle. The height of the first positive peak, which appears early in systole and coincides with rising pressure and acceleration, increases with an increase in cardiac contractility. It is a compression wave generated by the heart and indicates the maximum ventricular power and the maximum ventricular power rise. The time interval between the R wave of the ECG and the first peak of WI (R-F), which is the summation of pre-ejection period and the time interval between the start of ejection and the time of the first peak of WI, was considered to be an index of contractile property of the myocardium and to have the potential for preoperative prediction about ventricular volume reduction ratio after surgery in patients with aortic regurgitation (AR). Our purpose was to evaluate this ability of the R-F. Methods: We noninvasively measured carotid arterial WI in 33 patients with AR before and early after valve replacement (56.9 ± 14.4 years, 28 men, 9±3 days after surgery) using a combined color-Doppler and echo-tracking system. The percent change in the end-diastolic volume before and after surgery (EDV change) and other parameters were measured by conventional echocardiography. Results: After surgery, EDV reduced (from 227±69 to 136±42 ml) and R-F prolonged( from 106±15 to 145±25 ms). EDV change (Y) was correlated with R-F (X) before surgery (Linear regression: Y = -0.36X + 77.0, r = 0.52, P < 0.01), but there were no significant relations between EDV change and other preoperative echocardiographic parameters. Conclusion: R-F before surgery predicts ventricular volume reduction ratio after valve replacement in patients with AR.

Hyung-Kwan Kim1, Yong-Jin Kim 1, Sung-A Chang 1, Jin-Shik Park1, Hyuk-Jae Chang2, Dae-Won Sohn 1, Byung-Hee Oh1, Young-Bae Park 1, Yun-Shik Choi 1 1 Seoul National University Hospital, Seoul, Republic of Korea; 2Seoul National University Bundang Hospital, Sung-nam, Republic of Korea Objectives: This study sought to evaluate the effect of cardiac rhythm on the accuracy of the pressure half time (PHT)-derived calculation of mitral valve area (MVA) in relation to left atrial (LA) compliance. Background: The PHT method has been widely used to estimate MVA in patients with moderate to severe mitral stenosis (MS), in the belief that this simple method provides reliable information on the true MVA. However, its limitation has been repeatedly recognized under different circumstances. Methods: Patients (n=41) with rheumatic moderate or severe MS were consecutively recruited. Eighteen patients with sinus rhythm were allocated to group 1 (GrI) and the remaining patients with chronic atrial fibrillation to group2 (GrII). MVA was obtained by using the PHT method and by planimetry (considered the gold standard during this study). Net atrioventricular compliance (Cn) was calculated with the equation previously validated and was regarded as a representative of LA compliance. Results: There were no differences between the 2 groups in terms of age, gender, left ventricular dimensions or ejection fraction and transmitral pressure gradient. LA volume and Cn were higher in GrII than in GrI (198.5±117.7mL vs. 127.4±26.5mL, p=0.02 for LA volume; 6.6±1.5mL/ mmHg vs. 4.7±1.2mL/mmHg, p<0.001 for Cn). Significant correlations were found between the PHT method and planimetry in MVA estimation (Figure1). Nevertheless, there was a significant discrepancy between MVA values derived from each method. The extent of overestimation of the true MVA by the PHT method was 8.0±19.2% for GrI and -24.9±13.9% for GrII (p=0.002), respectively and was significantly correlated with Cn (r2=0.71, p<0.001) (Figure2). Overestimation was exponentially increased in patients with Cn of <4mL/mmHg, most of whom were in sinus rhythm. Conclusions: Changes in cardiac rhythm with associated alterations in Cn can alter the accuracy of the PHT method for estimating MVA in patients with moderate or severe MS. Given the limitation provided here, 2D planimetry, not the PHT method, should be used as a primary echocardiographic tool for MVA calculation.

P2-17. Moderated Poster

P2-18. Moderated Poster

Quantitative Stress Echocardiography: 3D is Getting There

Quantitative Assessment of the Effects of Different Annuloplasty Rings on Mitral Annulus Dynamic Geometry Using Real-Time 3D Echocardiography

Maria Riccarda Del Bene, Elisa Saletti, Giuseppe Barletta Noninvasive Cardiology - Heart and Vessels Dpt., Florence - Careggi Hospital, Italy Introduction: Although 3-D pharmacologic stress echo(SE) may overcome spatial limitations of 2D SE and improve diagnostic accuracy, real advantages over standard 2D SE are still debated. The potential for going forward visual image interpretation by means of quantitative analysis of wall motion offered by 3D dataset analysis remains marginally explored. Methods: Standard 2D SE was routinely integrated with real-time 3D acquisition (Philips iE33-X4 transducer) at baseline and peak stress during 1 year SE activity in a teaching hospital echo-lab. Exclusion criteria were arrhythmias or predicted peak heart rate >130 bpm. Out of 816 consecutive patients (621 dipyridamole, 195 dobutamine studies), 3D data were available in 541. In 227 SE patients with coronary angiography within 2 weeks of SE or in the preceding 3 months if asymptomatic, sensitivity and specificity for ischemia and stenotic vessel identification were analyzed. 2D analysis was visually performed on quad-screen, qualitative 3D analysis on corresponding 2D planes cropped from the 3D pyramidal dataset, 3D quantitative analysis (3Dq) on regional volume curves (QLab 5.0 software). For quantification, a normal range (mean ± standard deviation-SD) of volume changes was defined for all 17 left ventricular (LV) regions from a dataset of 147 pts with normal regional and global LV function, low pretest disease probability and uneventful 1-year follow up. Ischemic response was defined as peak stress systolic %-volume reduction vs. baseline >1 SD provided it was beyond the limits of normal range. Results: Sensitivity and accuracy as to detection of ischemia (Figure) and correct identification of the ischemic coronary territory (Table) improved significantly with 3Dq-SE on visual 2D- and 3D-SE. The diagnostic yield of 3Dq-SE improved greatly in 1- and 2-vessel disease. Sensitivity and diagnostic accuracy for identification of the stenotic vessel and ischemia detection 1-vessel 1-vessel 2-vessel 2-vessel 3-vessel 3-vessel sensitivity accuracy sensitivity accuracy sensitivity accuracy LAD 2D 50 % 77% 61% 83% 77% 88% LAD 3D 56% 79% 76% 88% 82% 90% LAD 3Dq 84% 87% 88% 88% 97% 92% LCX 2D 37% 84% 46% 81% 72% 87% LCX 3D 50% 86% 71% 88% 80% 89% LCX 3Dq 75% 89% 78% 88% 82% 88% RCA 2D 60% 91% 41% 82% 52% 82% RCA 3D 60% 89% 55% 84% 67% 86% RCA 3Dq 87% 91% 76% 87% 85% 89% Conclusions: Regional 3D quantitative analysis of wall motion is feasible in a majority of patients undergoing SE; it enhances SE sensitivity mainly in identification of the ischemic coronary territory.

Enrico G Caiani1, Federico Veronesi 1, Gloria Tamborini 2, Roberto M Lang3, Massimo Zanobini2, Cristiana Corsi4, Emiliano Votta 1, Claudio Lamberti4, Moreno Naliato2, Francesco Alamanni2, Mauro Pepi2 1 Politecnico di Milano, Milano, Italy; 2Centro Cardiologico Monzino, IRCCS, Milano, Italy; 3University of Chicago, Chicago, IL; 4Università di Bologna, Bologna, Italy Background: Mitral annulus dilation is a feature of chronic mitral regurgitation caused by leaflet prolapse. Patients undergoing mitral valve repair usually have leaflet resection combined with ring annuloplasty. Our goal was to compare the dynamic geometry of the mitral annulus after insertion of different rings using new custom software for mitral annulus frame-by-frame tracking on 3D ultrasound datasets. Methods: Transthoracic real-time 3D echocardiography (RT3DE, Philips) was performed in 15 normals (NL) and 20 pts with mitral regurgitation, before and 3 months after mitral valve repair and implant with Cosgrove (COS, N=10) or Carpentier Physio ring (CAR, N=10). Our software tracked the mitral annulus over time in 3D space and computed end-diastolic (ED) and maximal mitral annulus surface area, mitral annulus surface area change (100*(Max area-ED)/ED), maximal mitral annulus longitudinal displacement (LD), peak-systolic (S’) and early diastolic (E’) mitral annulus velocities. Results: Mitral annulus dynamic analysis was feasible in all patients. Prior to surgery and compared with NL, all pts with mitral regurgitation had larger mitral annulus surface area throughout the cardiac cycle, reduced area change and decreased E’. Post-annuloplasty, all pts showed decreased mitral annulus size with reduced area change. In particular, CAR pts showed less ring pulsatility, due to higher rigidity associated with ring shape. On the contrary, a sub-physiological change in annulus dimensions throughout the cardiac cycle was preserved in the COS pts, due to the not complete annular ring morphology. Conclusion: Dynamic analysis of the mitral annulus applied to RT3DE datasets is feasible in patients undergoing surgical repair with concomitant implanted annular prosthesis. This new technique allowed to evaluate in-vivo the changes induced by the intervention in 3D mitral annulus geometry and dynamics. In particular, the proposed procedure could be utilized to gain new insight about the in-vivo performance of the implanted annular prosthesis, offering to the surgeon a new tool for support in the clinical decision process and in follow up monitoring.

Journal of the American Society of Echocardiography Volume 21 Number 5

559

P2-19. Moderated Poster

P2-20. Moderated Poster

Quantitive Analysis of Left Ventricular Morphological Changes after Mitral Valve Repair

Three-Dimensional Assessment of Geometric and Dynamic Changes in the Mitral Annulus Following Mitral Valve Repair

Francesco Maffessanti1, Gloria Tamborini 2, Manuela Muratori2, Enrico G Caiani1, Mauro Pepi2 1 Politecnico di Milano, Milano, Italy; 2Centro Cardiologico Monzino, IRCCS, Milano, Italy

Qiong Zhao1, Patrick M. McCarthy1, Roberto M. Lang2, Federico Veronesi 2, Carolin Sonne2, Bonnie J. Kane1, Susan Underwood1, Robert O. Bonow1, Vera H. Rigolin 1 1 Northwestern University, Chicago, IL; 2Chicago University, Chicago, IL

Background: Mitral valve (MV) repair has become preferential to replacement in the overwhelming majority of patients with MV prolapse, and recent studies and guidelines have underlined the importance of early surgical intervention to preserve long term left ventricular (LV) function. However, few data have explored the complex relationship between LV function vs shape before and after MV repair, mainly because of the unavailability of reliable methods for true 3D LV morphological analysis. Accordingly, the aims of this study were: (1) to develop a technique for the quantification of LV 3D shape from real-time 3D echocardiographic (RT3DE) derived dynamic LV endocardial surfaces; (2) to investigate the effects of MV repair on LV morphology and function. Methods: 40 patients (mean age, 57.6±14.7 years) with MV prolapse and ejection fraction (EF) >55% measured by biplane Simpson’s rule, scheduled for MV repair, were studied. Transthoracic RT3DE imaging (iE33, Philips) was performed the day before the intervention and 6 months later. Dynamic LV endocardial surfaces were extracted using commercial software (LV Analysis, TomTec) and used to compute end-diastolic (ED) and end-systolic (ES) volumes, EF, and new 3D shape indexes of sphericity (S), conicity (C) and ellipsoidality (E). This was performed after deriving from the LV surface a 1D signal by helical sampling, and comparing it with that obtained from a sphere, a cone or an ellipsoid, respectively, having the same aspect ratio of the LV. Results: Six months after MV repair, patients showed an expected reduction in EF and LV ED volume, due to the decreased overload. This was accompanied by changes in ED LV shape, with a reduction in sphericity and a corresponding increase in conicity, while both ES volume and shape indexes were not affected. The ellipsoidal index remained unchanged, in agreeement with the fact that, independently of LV function and volumes, the LV morphology can be always described by an ellipsoidal shape. Conclusion: MV repair led, in the mid-term outcome, to significant changes in ED LV morphology and EF. Our results confirmed the relationship between LV function and shape, and the potential clinical utility of coupled 3D LV shape-function analysis. This methodology could be useful to follow patients during LV remodelling.

Background: Mitral annulus (MA) plays a critical role in maintaining a low and proper stress distribution over the mitral valve (MV). Normal geometry of the MA is markedly altered in chronic mitral regurgitation (MR). The effect of MV repair on the geometry and dynamic motion of the MA has not been well studied due to limitations of 2D echo as the traditional investigation tool. The aim of this study is to investigate these changes using Real Time 3D Echo. Methods: Transthoracic wide angled full volume 3D acquisitions were obtained in 15 patients undergoing successful mitral valve (MV) repair for severe MR with myxomatous etiology before and 3 months (m) following surgery. The MA area, circumference, height, anterior-posterior (AP) and medial-lateral (ML) distances at mid systole as well as maximal longitudinal displacement of the MA and dynamic changes of the MA area throughout the cardiac cycle were quantified off-line using the full volume data. The variables at 3m postop were compared with pre-op and normal control data. Results: Significant reduction in MA area, circumference and ML distance, but not in height or AP distance occurred after MV repair. The post-op geometric MA variables were similar to those of normal controls (n=50). The maximal dynamic reduction of the MA area was significantly decreased postop by absolute value and percentage change. The maximal longitudinal displacement of the annulus was not significantly altered. Interestingly, both dynamic variables were significantly lower post-op vs. normal controls. Conclusion: In MR of myxomatous etiology, the MA area, circumference and ML distance are significantly increased. Successful MV repair helps restore the normal geometry of the MA. The dynamic motion of the annulus was decreased postop to a level that was lower than normal controls, which may be due to the rigidity of the annuloplasty ring.

LV shape and function parameters. (*:p<.0001 pre- vs 6 months post-surgery, paired t-test) ED ES ED volume volume EF (%) Sphericity (ml) (ml) Index

ES Sphericity Index

ED ES ED Conicity Conicity Ellipsoidal Index Index Index

ES Ellipsoidal Index

136±53

52±23

61±6

.59±.04

.76±.03

.82±.02

.92±.02

.90±.03

Post MV 97±29* surgery

45±18

55±7* .64±.05*

.58±.05

.79±.03*

.82±.03

.92±.02

.91±.03

Pre MV surgery

.68±.06

Results Parameters Normal Pre-op 3m A- area /BSA (cm2/m2) 5.1 ± 0.8 6.3±1.2 # 4.7 ± 0.8 * A- circum/BSA (mm/m2) 6.4 ± 1.1 6.8±0.8 # 5.8 ± 0.7 * ML distance/BSA (mm/m2) 21.4 ± 3.5 23.2±2.9 # 19 ± 2.2 * A - maximal longitudinal displacement (mm) 10.5 ± 0.9 8.4±2.3 # 8.0 ± 1.9 # Maximal change of A-area (cm2) 4.0 ± 0.9 3.9 ± 1.5 1.4± 0.8 *# Maximal Change of A- area (%) 38.8 ± 5.7 21.2±1.5 # 14.7±6.5 *# Data are presented as mean ± SD; * P< 0.05 vs. pre-op, # P < 0.05 vs. normal controls, circum - circumference, A - mitral annulus, BSA- body surface area.

P2-21. Moderated Poster

P2-22. Moderated Poster

Quantitative Assessment of Mitral Valve Apparatus in Patients with Degenerative Mitral Valve Disease Using Real-Time 3D Transesophageal Echocardiography

A Practical Approach to the Use of 3D Echo for the Evaluation of Aortic Stenosis

Kyoko Okamatsu1, Masaaki Takeuchi 1, Lissa Sugeng2, Lynn Weinert 2, Ivan S Salgo3, Yutaka Otsuji 1, Roberto M Lang4 1 University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan; 2University of Chicago Medical Center, Chicago, IL; 3Philips Medical Systems, Andover, MA; 4University of Chicago Medical Centern, Chicago, IL Background: Quantitative assessment of mitral annuls and leaflet geometry is important for the surgical planning of mitral valve repair in patients with degenerative mitral valve disease. The recently developed real-time 3D matrix transesophageal echocardiographic (3D-MTEE) transducers provide high resolution images of the mitral valve apparatus (MVA), which are suitable for volumetric quantification of annular and leaflet geometry. The aim of this study was to study mitral geometry as assessed from 3D-MTEE image in patients with severe degenerative mitral regurgitation (MR) secondary to different etiologies. Methods: 3D-MTEE images of the MVA were acquired in a zoom mode in 38 patients undergoing clinically indicated TEE: 9 patients with fibroelastic deficiency (FED) and 8 patients with Barlow’s disease with at least moderate MR, and 21 patients with morphologically normal mitral valves and no MR who were used as a control group. Measurements were performed using Qlab-MVQ software (Philips). Mitral annular points were initialized in 8 cut planes rotated around the mitral annulus, and mitral leaflets were manually traced in multiple cut planes parallel to the anterior-posterior mitral annular plane. The following parameters were measured and compared between patient groups: 3D mitral annulus area and height, leaflet areas, prolapse height and volume and the non-planar angle between anterior and posterior leaflets. Results: Mitral annulus area, both leaflet areas, prolapse height and volume, as well as the non-planar angle between mitral valve leaflets were all significantly larger in Barlow’s disease compared to FED and control subjects. Although no significant difference of mitral annulus area was noted between FED and controls, prolapse height and volume were larger in FED. Conclusions: This newly developed quantitative software allows identification of significant morphologic differences between Barlow and FED. This information will be useful for proper surgical planning and serial follow-up in patients with degenerative MR.

Hussam Suradi, Scott Byers, Deborah Green-Hess, Irmina Gradus-Pizlo, Stephen Sawada, Harvey Feigenbaum Indiana University, Indianapolis, IN Background: Although Doppler echocardiography provides useful hemodynamic information and a calculated aortic valve area (AVA) for aortic stenosis, there are significant limitations and potential errors. Thus a direct anatomic assessment of aortic stenosis (AS) would be useful. The ability of 3D echo to measure AS AVA has been reported. However the technique requires a separate examination, a huge amount of 3D digital data that can overwhelm a routine study, and time consuming analysis using specialized proprietary software. Purpose: The purpose of this study is to confirm the ability of a 3D echo approach which uses a limited data set, is part of a routine echo exam and measures AS AVA using generic off-line software. Method: Short axis realtime, “thick slice” 3D aortic valve images were part of a routine 2D and Doppler echo study in 39 patients (pts) with aortic stenosis (27 male, mean age 68 range 28-88, average EF 55 range 21-77%). A “thick slice” 3D recording is a 2D display of a 3D acquired pyramidal image. The 3D images were calibrated using the known depth of the display and were analyzed as were the 2D and Doppler recordings on a standard off-line review station. Planimetered 3D AVA and 2D AVA were compared to the AVA calculated by the continuity equation (CE AVA). To test the advantages of this 3D technique, we compared the ability to measure a 3D AVA with a similar effort using 2D echo. Results: The 2D AVA could be obtained in 22 pts (56%) versus 3D AVA in 37 pts (95%) p<0.001. The correlation between 2D AVA and CE AVA was 0.551 p<0.008 and between 3D AVA and CE AVA was 0.718 p<0.001 with all but 8 pts within 0.3 cm2 from each other. Blindly recalculating the CE AVA of the outliers brought the two values closer together (correlation coefficient 0.878). Conclusion: The stenotic aortic valve orifice is irregular and not in a single plane, so it is no surprise that a thick slice pyramidal 3D recording would visualize more of the orifice than would a thin slice planar 2D recording. This study confirms that 3D echo can provide a reasonably accurate AS AVA . The 3D approach used in this study should provide a practical supplement to the current routine echocardiographic evaluation of AS.

Journal of the American Society of Echocardiography May 2008

560

P2-23. Moderated Poster

P2-24. Moderated Poster

Geometric Change of Mitral Valve Apparatus Assessed by Real Time ThreeDimensional Transesophageal Echocardiography

Predictors for Mitral Annular Geometric Abnormalities: A Real-Time ThreeDimensional Transesophageal Echocardiographic Study

Masaaki Takeuchi 1, Lissa Sugeng2, Lynn Weinert 2, Ivan Salgo3, Yutaka Otsuji 1, Roberto M Lang2 1 University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan; 2University of Chicago Medical Center, Chicago, IL; 3Philips Medical Systems, Andover, MA

Yoshiki Matsumura, Manatomo Toyono, Neil L Greenberg, Tetsuhiro Yamano, Kunitsugu Takasaki, James D Thomas, Takahiro Shiota Cleveland Clinic, Cleveland, OH

Background: Mitral annular geometry and motion dynamically changes during cardiac cycle. However, previous studies have assessed the mitral valve apparatus (MVA) geometry at a single point in the cardiac cycle using transthoracic 3D data sets. The aim of this study was to evaluate dynamic changes in MVA geometry throughout the cardiac cycle using the new real-time 3D Matrix transesophageal echocardiography (3D-MTEE). Methods: In 21 patients with morphologically normal MV (mean age: 53±18 years, 7 men), wide-angled acquisition of the MVA using 3D-MTEE were studied after a clinically indicated TEE. From volumetric 3D-MTEE data sets, anterior-posterior mitral annular plane and commissure-commissure annular plane were selected. Subsequently, mitral annular points were determined from 8 cutting planes at every 22.5 degree around the mitral annulus, and mitral leaflet was manually traced in multiple cutting planes parallel to the anterior-posterior mitral annular plane using commercially available mitral valve quantitative software (Qlab, MVQ, Philips). Anterior-posterior mitral valve diameter (APD), commissure-commissure diameter (CCD), mitral annulus area (MAA), non-planar angle (NPA) between anterior and posterior leaflet, tenting height (TH) and volume (TV) were calculated in each frame of the cardiac cycle. In order to adjust for intersubject differences in heart rate and frame rate, the time sequence were normalized to the percentage of systolic duration as well as diastolic duration. Results: While the APD increased during systole, the CCD decreased until early diastole resulting in only small changes in MAA. The NPA increased throughout systole consistent with the downward motion of the MVA. Both TV and TH progressively decreased during systole. Conclusions: High resolution images of 3D-MTEE data sets allowed dynamic volumetric quantification of the MVA. This quantitative information could be useful in surgical planning of the mitral valve.

Background: The mitral annular (MA) geometric abnormalities have been demonstrated in patients with various cardiovascular diseases such as atrial fibrillation (Af), mitral regurgitation (MR) and dilated cardiomyopathy. The recent advances of real-time threedimensional (D) transesophageal echocardiography (3DTEE) can enable us to analyze the MA geometry accurately compared with real-time 3D transthoracic echocardiography. Purpose: To determine the independent predictors for MA geometric abnormalities in patients with Af, significant MR, and left ventricular (LV) dysfunction by using 3DTEE. Methods: Twenty patients (11 female, aged 65±9 years) were examined by 3DTEE and 2D transthoracic echocardiography; 4 patients with lone Af, 5 with dilated cardiomyopathy, 4 with mitral valve prolapse, 2 with organic MR and 5 control subjects. In 20 patients, 12 had Af and 8 had significant MR (grade >2+). Patients with severe MA calcification and prior cardiac surgery were excluded. 2D echocardiographic measurements were performed, including LV enddiastolic and end-systolic volume indices, ejection fraction (EF), and left atrial volume index at end-systole (LAVI) by the Simpson method. MR severity was assessed semi-quantitatively by using the ASE standard. By using the 3D software, we measured MA area index, MA circumference index, commissural length of MA, and MA height as shown in Figure 1. For the index of the saddle-shaped MA geometry, MA shape index was calculated as the (MA height)/ (commissural length). Results: MA area index and MA circumference index were associated with not LV volume indices and EF, but LAVI, MR severity, and the presence of Af (all P<0.05) (Figure 2). MA shape index was associated with not LAVI but LV volume indices, EF, and the presence of Af (all P<0.05) (Figure 3). Moreover, MA shape index tended to be associated with MR severity (P=0.067). Multivariate analysis revealed that LAVI and MR severity were independent predictors for MA area index and MA circumference index (all P<0.05), and LV end-systolic volume index independently predicted for MA shape index (P=0.010). Conclusion: MA dilatation was independently associated with larger LA volume and severer MR, not LV volumes and EF, while the saddleshaped MA geometry was associated with LV end-systolic volume.

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Right Ventricular Remodeling Determining Tricuspid Valve Geometry and the Severity of Functional Tricuspid Regurgitation: A Real-Time 3-Dimensional Echocardiography Study

Early and Mid-Term Echocardiographic Follow-Up of Left Ventricular Function after Isolated Aortic Valve Replacement for Aortic Valve Stenosis

Jong-Min Song, Min-Kyoung Jang, Yun-Jeong Kim, Duk-Hyun Kang, Jae-Kwan Song Asan Medical Center, Seoul, Republic of Korea Background: The remodeling of right ventricle (RV) determining tricuspid valve (TV) geometry and the severity of functional tricuspid regurgitation (TR) has not been clearly demonstrated. Methods: In 40 patients with various degrees of functional TR and in sinus rhythm, RV and TV geometries were analyzed using real-time 3-dimensional echocardiography (Figure), including tenting angles of anterior (Aα), posterior (Pα) and septal (Sα) leaflets, septal-lateral and anteroposterior tricuspid annulus diameters, inlet septal-lateral and antero-posterior RV dimensions in 1 cm apart from annulus planes, mid-RV septal-lateral dimension, and the distance between annulus and apex. A mid-systole frame when the TV tenting is smallest was selected for the analysis. The severity of functional TR was determined by distal jet area and vena contracta width. Results: By multiple stepwise linear regression analyses, Aα (r=0.64, p<0.001) and Sα (r=0.69, p<0.001) were mainly determined by mid-RV septal-lateral dimension, while Pα (r=0.45, p<0.005) was by the distance between annulus and apex. Septal-lateral (r=0.74, p<0.001) and antero-posterior annulus diameters (r=0.71, p<0.001) were mainly determined by inlet septal-lateral and antero-posterior RV dimensions, respectively. TR distal jet area correlated significantly with Aα (r=0.65, p<0.001), Pα (r=0.48, p<0.005), Sα (r=0.64, p<0.001), septallateral (r=0.72, p<0.001) and anteroposterior (r=0.43, p<0.01) tricuspid annulus diameters, inlet septal-lateral (r=0.61, p<0.001) and antero-posterior (r=0.38, p<0.05) RV dimensions, mid-RV septal-lateral dimension (r=0.60, p<0.001), and the distance between annulus and apex (r=0.51, p<0.005). TR vena contracta width showed similar results. TR distal jet area was mainly determined by septal-lateral annulus diameter and Aα by multiple stepwise linear regression analysis. TR vena contracta width was determined by septal-lateral annulus diameter, inlet septal-lateral RV dimension and A α. Conclusions: TV leaflet tenting is determined by mid-RV septal-lateral dilation and annulus-apex elongation. Tricuspid annulus dilation is closely linked with inlet RV dilation. Functional TR severity seems to be determined by septal-lateral annulus and RV dilation rather than antero-posterior dilation.

Yoshiki Matsumura, A. Marc Gillinov, Manatomo Toyono, Tetsuhiro Yamano, Nozomi Wada, James D Thomas, Takahiro Shiota Cleveland Clinic, Cleveland, OH Background: Previous studies have shown that the improvement of left ventricular (LV) systolic function has been observed in patients with aortic valve stenosis (AS) after aortic valve replacement (AVR). However, they included the patients who underwent concomitant coronary artery bypass graft (CABG) at the time of AVR. Thus, their conclusions may have been affected by the CABG. Chronological changes in LV systolic and diastolic function and mitral regurgitation (MR) after isolated AVR remains to be clarified. Methods: This study consisted of 34 patients (aged 66±12 years) with critical to severe AS (aortic valve area <1.0cm2) and pre-operative LV systolic dysfunction (ejection fraction; EF <50%) who had echocardiography early (11±18 days), and mid-term (23±14 months) follow up after isolated AVR. Patients with poor echocardiographic image quality, significant aortic or mitral regurgitation (grade >2+), congenital heart disease and other cardiac surgery such as CABG, myectomy, and other valvular surgery were excluded. Echocardiographic measurements were performed, including LV dimensions, LV volumes and EF by the Simpson method, and mitral inflow pattern. MR severity was assessed by using the ASE standard. Results: The mean LV EF significantly improved after isolated AVR and continued to improve progressively from early to mid-term follow-up (Table); 24 patients (71%) showing an increase of more than 10% in the mid-term postoperative EF in comparison with the preoperative EF. In addition, LV volumes, LV wall thickness, and concomitant MR severity were significantly decreased after AVR (Table). Decrease in MR severity after AVR significantly correlated with increase in LV EF (r=0.59, P<0.001). The peak velocities of E wave and A wave and the E/A ratio were not significantly changed, but the deceleration time of E wave was significantly increased after AVR (Table). Conclusions: LV systolic and diastolic function, LV hypertrophy and MR severity improved progressively after isolated AVR even without CABG. Table Mid-term Post P AVR LV EF (%) 35.3±11.2 40.7±14.1** 51.6±11.7*§ <0.001 LV end-diastolic volume (ml) 158±61 142±56*** 126±67** <0.001 LV end-systolic volume (ml) 106±56 89±55** 66±59*§§§ <0.001 LV septal thickness (cm) 1.24±0.15 1.19±0.13*** 1.08±0.14*§ <0.001 LV posterior wall thickness (cm) 1.21±0.16 1.18±0.13 1.09±0.13*§ <0.001 MR severity 1.2±0.6 0.8±0.6*** 0.8±0.5*** 0.001 Mitral inflow E wave (cm/sec.) 95±23 101±25 89±25 0.06 Mitral inflow A wave (cm/sec.) 77±23 78±25 93±27 0.08 E/A ratio 1.47±0.70 1.35±0.63 1.08±0.44 0.13 Decelation time of E wave (msec.) 167±46 205±60*** 224±64** 0.001 AV mean pressure gradient (mmHg) 40±20 14±6* 15±10* <0.001 * P<0.001, ** P <0.005, *** P <0.05 vs. Pre AVR; § P <0.001, §§§P <0.05 vs. Early Post AVR Pre AVR

Early Post AVR

Journal of the American Society of Echocardiography Volume 21 Number 5

561

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Effectiveness of Carvedilol on Experimental Acute Aortic Regurgitation Rats: An Echocardiographic Study

Detection of Left Ventricular Dysfunction with Tei Index in Normal Ejection Fraction Patients with Mitral Regurgitation before Mitral Valve Surgery

Hitoshi Takeuchi, Fuminobu Ishikura, Masahiro Uchida, Kenta Shirahige, Risa Nishikawa, Kasumi Masuda, Toshihiko Asanuma, Shintaro Beppu Osaka University Graduate School of Medicine, Suita, Osaka, Japan

Kunitsugu Takasaki, Tetsuhiro Yamano, A Marc Gillinov, Yoshiki Matsumura, Manatomo Toyono, James D Thomas, Takahiro Shiota Cleveland Clinic Foundation, Cleveland, OH

Background: The recent studies suggest that carvedilol, β-blocker, has a beneficial effect on chronic heart failure. However, it is not clear that carvedilol has the beneficial effect on a cardiac disease with acute volume overload. Purpose: The purpose of this study is to evaluate the effect of carvedilol on cardiac function in rats with acute AR. Methods: Severe AR was created in 13 adult male SD rats by retrograde puncture of the aortic leaflets under echocardiographic guidance using SONOS5500 (PHIILIPS). The quantitative severity was evaluated by the regurgitation ratio (RR) that was calculated from blood flow volume through aortic and pulmonary valve measured by the pulse Doppler method in which over 35% of RR was considered as severe AR. Seven rats received carvedilol (0.4mg/kg) orally for 2 weeks (carvedilol group) after onset of AR, and 6 rats were left untreated (untreated group). LV short axis cross sectional area at end diastolic (EDA) and at end systolic (ESA) were measured, and LV fractional area change (FAC) was calculated. Those parameters were measured before and 2 weeks after onset of acute AR. Results: Soon after operation of acute AR, EDA, ESA, FAC and RR were not different significantly between carvedilol and untreated groups. In an untreated group, both EDA and ESA significantly increased, and FAC significantly decreased 2 weeks after operation (EDA: 0.28±0.03 to 0.47±0.075 cm2, p<0.05, ESA: 0.048±0.02 to 0.18±0.044 cm2, p<0.05 , FAC: 83.3±5.6 to 62.0±4.2%, p<0.05 ).In a carvedilol group, EDA increased significantly (0.31±0.045 vs.0.48±0.04 cm2, p<0.05 ), however, a increased ESA in a control group is larger than that in a carvedilol group (0.055±0.024 to 0.102±0.024 cm2,p<0.05 ). Accordingly FAC did not change 2 weeks after operation (82.9±5.0 to 78.58±5.7%). Conclusion: In the experimental model of severe acute AR, carvedilol had a protective effect on deterioration of FAC.

Background: Chronic severe mitral regurgitation (MR) causes progressive left ventricular (LV) dysfunction. However, ejection fraction (EF) appears to remain normal in most patients with chronic MR while LV dysfunction expressed as reduced EF is often revealed after mitral valve (MV) surgery. EF, derived from volume analysis, is usually overestimated by unloading the LV blood into the low pressure left atrium in patients with MR. In contrast, Tei index is a parameter derived from cardiac time analysis and is considered to be independent of loading conditions of the LV. Thus, we hypothesized that Tei index, expressing global LV function, has the potential to enable detection of LV dysfunction even in apparently normal EF patients with severe MR. Methods: We retrospectively investigated consecutive 89 patients with apparently normal EF (EF ≥ 50%) and chronic MR who underwent MV repair without CABG (58 men and 31 women, 57 ± 12 years old). Pre- and post-operative LV end-systolic and enddiastolic volume and EF were measured by modified Simpson’s method. LV Tei index was measured by Doppler echo pre-operatively as previously reported. Results: 1) EF was significantly decreased after MV repair (69 ± 7% to 54 ± 11%, p < 0.0001). LV dysfunction (EF < 50%) was revealed after MV repair in 31 patients (35% of all patients). 2) Preoperative Tei index was significantly correlated with post-operative LV EF in all patients (r = - 0.64, p<0.0001, Figure) and in asymptomatic patients (n=35, r= - 0.66, p<0.0001). 3) By setting pre-operative Tei index > 0.50 to predict post-operative EF <50%, this index had sensitivity, specificity, and accuracy of 81, 96, and 90% in all patients and 64%, 96%, and 86% in asymptomatic patients respectively. Conclusion: Pre-operative Tei index > 0.5 allows prediction of post-operative LV dysfunction in MR patients with an apparently normal EF. Thus, earlier surgery is recommended in asymptomatic MR patients with normal EF but Tei index > 0.5.

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Value of Baseline Inferolateral Myocardial Contractile Function Assessed by Tissue Doppler Echocardiography to Predict Reduction of Functional Mitral Regurgitation with Dobutamine in Patients with Dilated Cardiomyopathy

Left Ventricular Function after Mitral Valve Repair for Mitral Regurgitation in Patients Who Were Operated on Late According to Guideline Recommendations

Kazuhiro Tatsumi, Hiroya Kawai, Yuko Fukuda, Mariko Okada, Kazuko Norisada, MAKY Furuki, Toshiya Kataoka, Tetsuari Onishi, Ken-ichi Hirata Kobe University Graduate School of Medicine, Kobe, Japan Background: Dobutamine has the ability to reduce functional mitral regurgitation (FMR) in dilated cardiomyopathy and dobutamine stress echocardiography might be useful to make an optimal selection of surgical treatments such as isolated myocardial revascularization or in combination with valve repair. However determinant to reduce FMR has not been well clarified. The purpose of this study was to investigate the relationship between baseline echocardiographic parameters including regional myocardial function and reduction of FMR with dobutamine. Methods: We studied 33 patients with reduced left ventricular (LV) ejection fraction (33 +/-10%) secondary to ischemic or nonischemic cardiomyopathy and FMR. Standard and tissue Doppler echocardiography were performed at rest and with low-dose dobutamine (10 µg/kg/min), and we obtained LV volume, ejection fraction, tenting area of mitral valve (enclosed between the annular plane and leaflets on the 4-chamber view), mitral annular area, FMR volume fraction and, as indices of regional myocardial function, LV longitudinal peak systolic strain rate (Ssr; absolute value) in the anterior, anteroseptal, inferoseptal, anterolateral, inferolateral and inferior segments at mid-ventricular level. According to the reduction of FMR with dobutamine, patients were divided into a large reduction group (%FMR reduction > or = 30%) and a small reduction group (< 30%), 15 and 18 patients, respectively. Results: Dobutamine increased LV ejection fraction and Ssr in all segments, and decreased LV enddiastolic and end-systolic volume, tenting area, mitral annular area and FMR volume fraction (%FMR reduction = 28+/-19%) in all subjects. Regarding the baseline parameters, inferolateral Ssr in the large reduction group was significantly higher than that in the small reduction group (1.38+/-0.40 vs. 0.96+/-0.40 /s, p < 0.01), however, there was no difference in baseline LV volume, LV function, mitral deformation nor Ssr in any other segments. In receiver operating characteristic curve analysis, baseline inferolateral Ssr > 1.00 (/s) was the best predictor of dobutamine-induced %FMR reduction > or = 30% with a sensitivity of 87% and a specificity of 71%. Conclusions: Baseline inferolateral myocardial contractile function was associated with dobutamine-induced reduction of FMR, suggesting that assessment of regional myocardial function is important for an optimal selection of surgical treatment in patients with FMR.

Kazuto Yamaguchi, Kazuaki Tanabe, Tomoko Tani, Minako Katayama, Toshikazu Yagi, Yutaka Furukawa, Shigefumi Morioka, Yukikatsu Okada Kobe City Medical Center General Hospital, Kobe, Japan Background: The impact of late mitral valve (MV) repair for chronic mitral regurgitation (MR) as defined in guidelines on recovery of left ventricular (LV) function has not been evaluated. The purpose of this study was to evaluate postoperative LV function in the group of patients with chronic MR those operated on late according to the guidelines. Methods: We studied 232 patients (mean 56±14 years) with MR due to degenerative MV prolapse who underwent MV repair. Echocardiohgraphic studies were performed immediately before surgery and late after MV repair (mean 4.9±3.6 years). Results: In 51 patients whose preoperative LV ejection fraction (EF) <60%, 13 patients (25%) remained reduced LVEF (<50%, mean 38±8%) late after MV repair. The 13 patients were significantly older at the time of MV repair (64±6 vs. 57±14 years, p<0.04) and had a larger preoperative LV end-systolic dimension (LVESD) (43±5 vs. 37±6 mm, p<0.0002) compared to patients with a return of normal LVEF (EF≥50%). In 57 patients whose preoperative LVESD>40 mm, 18 patients (32%) remained reduced LVEF (<50%, mean 38±7%) after surgery. The 18 patients were significantly older (62±9 vs. 51±14 years, p<0.003) and had a lower preoperative LVEF (56±9 vs. 62±8 %, p<0.01) compared to patients with preserved LVEF. In 25 patients with both preoperative LVEF<60% and LVESD>40 mm, 12 patients (48%) remained reduced LVEF after surgery, and patients aged 65 years and older had a significantly higher probability (9/12, 75%) of LV dysfunction late after surgery. Conclusion: In patients aged 65 years and older, early repair of MR, before deterioration of LVEF and enlargement of LV end-systolic dimension occur, increases the likelihood of normalization of LV function.

Journal of the American Society of Echocardiography May 2008

562

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Commissural Opening after Percutaneous Mitral Commissurotomy: Impact on Long-Term Outcome

Significant Reverse Remodeling of the Left Ventricle One Year After Percutaneous Mitral Repair with the MitraClip® Device

David Messika-Zeitoun, Julie Blanc, Bernard Iung, Eric Brochet, Alec Vahanian AP-HP, Bichat Hospital, Paris, France

Elyse Foster1, Blase Carabello2, Roberto Siegel3, Geoffrey Rose4, Eric Engeron5, Douglas Segar6, Catalin Loghin7, Tasneem Naqvi 8, Richard Smalling9, Kiran Sagar10, Paul Grayburn11, Don Glower12, Ted Feldman 13 1 University of California, San Francisco, San Francisco, CA; 2Baylor College Medicine, Houston, TX; 3Cedars Sinai Medical Center, Los Angeles, CA; 4Sanger Clinic, Charlotte, NC; 5Terrebonne General Medical Center, Houma, LA; 6The Care Group, Indianapolis, IN; 7Memorial Herrmann Hospital, Houston, TN; 8University of Southern California, Los Angeles, CA; 9Memorial Herrmann Hospital, Houston, TX; 10St. Luke‘s Medical Center, Milwaukee, WI; 11Baylor University Medical Center, Dallas, TX; 12Duke Medical Center, Durham, NC; 13Evanston Northwestern Hospital, Evanston, IL

Background: Commissural opening (CO) is the main mechanism by which the mitral valve area (MVA) increases after percutaneous mitral commissurotomy (PMC) but its impact on long-term outcome has never been evaluated. Methods: 875 patients with mitral stenosis (MS) and good immediate results of PMC (MVA≥1.5 cm² and no regurgitation >2/4) were prospectively evaluated and divided into three groups: Group 1 (N=189; both commissures partially opened or not split), Group 2 (N=459; one commissure completely split) and Group 3 (N=227; both commissures completely split). Results: Immediately after PMC, there were significant differences between Groups as regards to mean gradient (Group 1: 5.1±2.1mmHg, Group 2: 4.5±1.7mmHg, Group 3: 4.0±1.6mmHg, p<0.0001) and MVA (Group 1: 1.8±0.2cm², Group 2: 1.9±0.2cm², Group 3: 2.1±0.3cm²; p<0.0001). Ten-year rate of good functional results (survival without need for mitral surgery or repeat dilatation and NYHA functional class I or II at last follow-up) was significantly higher in Group 3 (76±5%) than in Group 1 and 2 (39±8% and 57±11% respectively; p<0.0001). In multivariate analysis, degree of CO did not emerge statistically but when MVA was excluded from the model, complete bi-commissural opening was an independent predictor of good late functional results (p<0.05). Conclusions: Complete CO is associated with larger MVA, smaller gradients and functional improvement. Degree of CO provides important prognostic information and can be considered as a complementary measure of procedural success in addition to the MVA not always easy to assess.

Background: Mitral regurgitation (MR) causes left ventricular (LV) volume overload and LV remodeling. Reduction in MR should be associated with reverse LV remodeling, halting, and potentially reversing, the decline in function. A clinical trial of percutaneous mitral repair using the MitraClip device (Evalve, Inc. Menlo Park, CA) with systematic echocardiographic follow-up provides an opportunity to examine the effect of MR reduction on LV remodeling without the confounding effects of cardiopulmonary bypass and cardiac surgery. Methods: Transthoracic echocardiography was performed at baseline (BL) and 12 months. The American Society of Echocardiography criteria were used for core laboratory assessment of MR and LV function. Results: Matched data for BL and 12 months are available for 54 patients discharged from the hospital with MR severity < 2+ who continue free of surgery at 12 months. Median age was 71 years, mean LV end systolic dimension (LVID-s) and EF at baseline were 3.5 ± 0.8 cm and 60 ± 9%. Significant improvements from BL to 12 months were observed in MR grade (3.2 ± 0.6 to 1.9 ± 0.7), with a reduction in LVID-s (3.5 ± 0.8 cm to 3.3 ± 0.7 cm) and no decline in EF (60 ± 9 to 59 ± 8%). At 12 mo, 40 pts (74%) with sustained MR improvement ≤ 2+ experienced significant reductions in LV dimensions and volumes (LVID-d, LVID-s, LVEDV, LVESV) compared to no reduction in the 14 patients with recurrent MR >2+ (Table). Both groups maintained their LVEF and had significant improvements in NYHA functional class at 12 months.

MR Grade LVESV LVEDV EF NYHA

All (n=54) BL 3.2 ± 0.6 72 ± 30 175 ± 44 60 ± 10 2.6 ± 0.7

12 mo 1.9 ± 0.7 64 ± 23 151 ± 35 59 ± 8 1.5 ± 0.7

P* < .0001 < .003 < .0001 .28 < .0001

MR < 2 at 12-Months (n=40) BL 12 mo P* 3.2 ± 0.6 1.4 ± 0.5 < .0001 73 ± 30 62 ± 23 < .003 174 ± 44 146 ± 35 < .0001 59 ± 10 58 ± 8 .34 2.5 ± 0.7 1.5 ± 0.7 < .0001

MR > 2 at 12-months (n=14) BL 12 mo P* 3.4 ± 0.6 3.2 ± 0.4 0.19 70 ± 28 69 ± 36 0.58 177 ± 33 167 ± 42 0.22 61 ± 9 60 ± 12 0.64 2.6 ± 0.7 1.6 ± 0.6 .0001

* Baseline vs. 12 months by paired t-test. Conclusions: Percutaneous mitral repair with the MitraClip device was associated with significant LV reverse remodeling at 12 months. Statistically significant reductions in LV enddiastolic and end-systolic volumes and dimensions were observed in patients with sustained MR reduction but not in those with recurrent MR. Clinical improvement (NYHA class) was observed in both groups.

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Does Correction of Aortic Valve Area for Body Surface Area Affect the Diagnosis of Severe Aortic Stenosis?

Progression of Mitral Regurgitation in Patients with Mitral Valve Prolapse and Less than Moderate Regurgitation

Juan C. Brenes, Rebecca T. Hahn, Roy Pizzarello, Marco Di Tullio, Shunichi Homma, Linda D. Gillam Columbia University Medical Center, New York, NY

Daniel Monakier, Mordechai Vaturi, Yaron Shapira, Daniel Weisenberg, Michal Perelmoter, Alexander Sagie Rabin Medical Center, Beilinson hospital, Petah Tikvah, Israel

Background: In pts with aortic stenosis (AS), echocardiography plays a pivotal role in quantitation of severity and impacts the interpretation of symptoms and surgical decision making. Recent ACC/AHA Guidelines for Valvular Heart Disease define severe AS using absolute aortic valve area (AVA) (<1.0cm2) and AVA corrected for body surface area (BSA) (<0.6cm2/m2). Nonetheless, BSA is not routinely recorded in many echocardiography labs. The objective of this study was to evaluate the impact of adjusting calculated AVA for BSA in the classification of the severity of AS and to determine whether failure to adjust for BSA results in the underdiagnosis of severe AS. Methods: Echocardiograms of 53 consecutive pts with a post-test diagnosis of AS and AVA calculated with the continuity equation were reviewed. Height and weight were available in all and BSA was calculated. Results: There were 25 males, 28 females with a mean age of 75± 13 years and a mean BSA of 1.81± 0.25 m 2. 38 (72%) had a BSA over 1.7 m 2 See table. 9/28 pts with moderate AS by uncorrected AVA had severe AS post BSA correction. Additionally,11 pts with mild AS had moderate AS with BSA correction. Conclusion: Failure to correct for BSA resulted in underdiagnosis of severe aortic stenosis in 32% of patients with moderate AS, mainly in pts with BSA > 1.7m2. This may result in misattribution of symptoms and failure to pursue appropriate surgical intervention. All echo labs should routinely record BSA and apply BSA correction in patients with AS.

Background: Mitral valve prolapse (MVP) is a progressive disease. However, few data exists regarding the rate of progression and predictors for developing significant mitral regurgitation (MR). Methods: Retrospective study of patients with < moderate MR who had echocardiographic follow up of > 1 year. Clinical and echocardiographic data of patients without progression of MR was compared to those who developed moderate to severe or severe MR over time. Results: There were 114 patients with MVP. Grade of MR was none in 4, minimal in 3, mild in 66 and mild to moderate in 41. The mean age was 52 years (20-97) and 61 (53%) were male. Bileaflet prolapse was present in 45 (39%), posterior prolapse in 44 (38%) and anterior prolapse in 26 (23%) of patients. Over a mean follow up period of 55 ± 29 months, there were 16 (14%) patients who developed moderate to severe (10) or severe (6) MR. This subgroup of patients was older (62.6 vs. 50.4 years; p < 0.001) and most were men (69% vs. 51%; p = 0.28) as compared to the non progressive group. Flail leaflet occurred in 8 patients (50%) and infective endocarditis in none. Posterior prolapse was originally present in 75% (12 pts) vs. 29% (33 pts) of patients with and without significant progression of MR, respectively (p = 0.002). Prolapse of the second leaflet was reported in follow up echocardiography for 20 patients (18%) without progression vs. only 1 patient (6%) with progression of regurgitation (p = 0.3). Conclusion: Patients with MVP who develop significant mitral regurgitation are more likely to be older, and have posterior leaflet prolapse. Development of prolapse of the second mitral leaflet is not uncommon in those without progression of MR.

Severe AS (AVA) n=14

Moderate AS (AVA) n=28

Severe AS

13 (92%)

9 (32%)

Moderate AS

1 (7%)

19 (68%)

p<0.01

Journal of the American Society of Echocardiography Volume 21 Number 5

563

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Acute Changes in Left Ventricular Torsion Following Transfemoral Aortic Valve Implantation in Patients with Severe Aortic Stenosis

Current Guideline Criteria are Discordant for Defining Severe Aortic Stenosis

Kohei Fujimoto, Rebecca T Hahn, Kotaro Arai, Roy Pizzarello, Shunichi Homma, Linda Gillam Columbia University Medical Center, New York, NY Background: Left ventricular (LV) torsion has been shown to be an important index of ventricular function. As measured by magnetic resonance myocardial tagging, LV torsion is increased in patients with aortic stenosis and normalizes late (>12 month) following aortic valve replacement. Whether there is an acute change has not been reported. Speckle tracking has made it possible to assess LV rotation and torsion by echocardiography. Transfemoral aortic valve implantation (TAVI) is a promising new treatment for patients with severe aortic stenosis who are considered high risk for conventional surgical aortic valve replacement. The effect of TAVI on LV torsion has not been previously reported. Methods: Digital 2D transthoracic echo images were obtained before and within 1 week of TAVI in 15 patients. From the basal and apical short-axis data sets, one cardiac cycle was selected for subsequent analysis using syngo® Velocity Vector Imaging ™ (VVI). The peak average rotation of six radial segments was determined using short-axis images at the apex and the base. LV torsion (degrees) was calculated as the average apical LV rotation minus the average basal rotation. Results: A total of 15 patients (53% female, mean age of 82 ± 9 years) with severe symptomatic aortic stenosis (aortic valve area = 0.5 ± 0.1 cm2) underwent successful TAVI with reduction in peak pressure gradient from 80 ± 22 mmHg to 20 ± 8 mmHg (p<0.001). Mean ejection fraction (EF) in all patients increased from 45 ± 16 % at baseline to 49 ± 14 % after TAVI (p<0.05). In 8 patients with a reduced EF (<50%), mean LV torsion increased after TAVI (6.5 ± 2.5º vs. 8.7 ± 4.2º; p<0.04). In 7 patients with normal EF (> 50%), mean LV torsion decreased after TAVI (17.0 ± 7.7º vs. 14.6 ± 7.2º; p<0.04). Conclusion: In the setting of severe symptomatic aortic stenosis in the elderly, LV torsion is supernormal in patients with normal EF and reduced in patients with low EF. LV torsion normalizes in both groups (decreases in those with baseline impaired LVEF and increases in those with baseline reduced LVEF) following TAVI. This is the first study utilizing echocardiographic speckle tracking to document the acute change in torsion following aortic valve replacement.

Steve L Liao, Ricardo Esquitin, Marc A Miller, Rupa L Iyengar, Lori B Croft, Martin E Goldman, Mario J Garcia The Mount Sinai Medical Center, New York, NY Background: The 2006 AHA/ACC echocardiographic criteria for severe aortic stenosis (AS) consists of an aortic valve area (AVA) < 1 cm^2, a mean gradient (Gm) > 40 mm Hg, or a jet velocity (Vmax) > 4 m/s. This abstract investigates the correlation of AS criteria in patients with normal and abnormal left ventricular function (LVF). Methods: We retrospectively analyzed 288 consecutive patients (age 77 ± 13 years, 151 male) undergoing echocardiographic evaluation for suspected or known AS from January to August 2007. Quantitative analyses were performed from digitally stored two-dimensional and Doppler images. AS severity was evaluated by: aortic Vmax, Gm, and continuity-derived AVA, and correlated in patients with normal (LV EF ≥ 60%, stroke volume ≥ 65 mL) and abnormal function. Results: Using current guidelines, 64 patients were classified as having severe AS by Vmax, 49 by Gm, and 158 by AVA. Linear regression analysis showed that an AVA of 0.74 cm^2 was the optimal cutoff for concordance with Gm classification of severe AS. Using an AVA of ≤ 0.74 cm^2, 86 had severe AS, resulting in a 54% reclassification. Accounting for LVF, optimal cutoffs were 0.87, 0.68, 0.59 cm^2 (n = 117, 98, 73) for normal LVF, abnormal EF or SV, and abnormal LVF respectively (Figure). Conclusions: Our data indicates that current criteria for defining AS severity based on AVA, Vmax and Gm are discordant. Regardless of LVF, a significant number of patients who have severe AS based on AVA < 1 cm^2, have only moderate AS by velocity and gradient criteria.

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P2-38

Transthoracic Double-Envelope Techniques Simply Improve the Reproducibility of Aortic Valve Area Measurements in Patients with Aortic Stenosis

Incremental Value of Assessment of Right Heart Structure and Function for Prediction of Outcome in Patients with Prior Mitral Valve Surgery

Nobuhisa Watanabe 1, Takeshi Maruo 2, Manabu Taniguchi 3, Yasuharau Tanabe 1, Norihisa Toh 3, Norio Koide1, Kengo Fukushima Kusano3, Tohru Ohe 3 1 Okayama University Hospital, Okayama, Japan; 2Kurashiki Central Hospital, Kurashiki, Japan; 3Okayama University Graduate School of Medicine, Okayama, Japan

Milena Jani, Mohsin Alhaddad, Masoor Kamalesh, Irmina Gradus-Pizlo, Jothiharan Mahenthiran, Harvey Feigenbaum, Stephen Sawada Indiana School of Medicine, Indianapolis, IN

Backgrounds: In patients with aortic stenosis, an aortic valve area (AVA) is usually calculated using the continuous equation form left ventricular outflow tract (LVOT) flow by pulsedwave Doppler (PW) and aortic valve orifice (AVO) flow by continuous-wave Doppler (CW) (PW/CW technique). Double-envelope (DE) is obtained during CW measurements, which results from the differences of Doppler signal intensity between LVOT and AVO (Fig). We hypothesized that simple AVA measurements by using inner and outer envelopes simultaneously from DE should be possible (DE technique). Thus, we examined the feasibility and accuracy of the AVA by DE technique. Methods: Fifty-four consecutive patients (74±14 years old) with aortic stenosis were examined by transthoracic echocardiograohy. From the apical 5-chamber view, we measured AVA by PW/CW technique. After that, we measured AVA from inner and outer envelopes by DE technique by CW. Bland-Altman analysis was used to compare the results of two techniques and estimate the reproducibility. Results: DE profiles were obtained in 54 patients of 50 patients (93 %) and mean AVA was 1.21±0.48 cm 2. AVA by DE showed good correlation with that by PW/CW (r=0.94, p<0.001) and the mean bias in the AVA measurements between PW/CW and DE was -0.002 cm 2. At inter-observer analysis, the limits of agreement were -0.10 to 0.25 cm 2 by PW/CW, improving to -0.05 to 0.09 cm2 by DE. Conclusions: AVA obtained by DE technique was feasible and in good agreement with that by PW/CW technique. DE technique improved the reproducibility of AVA measurements well. We suggest that DE technique should be considered to estimate the subtle temporal change of AVA more simply and accurately.

Background: Patients with prior mitral valve surgery are at high risk for cardiac events. Methods: Eighty patients (age 59 + 15 yrs) were evaluated by two-dimensional echo, Doppler and tissue Doppler (TDI) late (mean 7.4 yrs) after mitral valve repair or replacement. The mean ejection fraction (EF) was 50 + 16 % and 31% had NYHA class 3 or 4 heart failure (CHF). Patients were followed for events (hospitalization for CHF, repeat mitral or tricuspid valve surgery, death). Results: During follow-up of 2.3 + 1.5 yrs, 27 patients had 33 events (11 CHF, 9 valve surgery, 13 death). NYHA CHF class was the only clinical predictor of events (p < 0.001). Of the left heart variables, lower EF (p = 0.029), increasing mean mitral gradient (MMVG) p < 0.001, increasing left atrial volume index p = 0.019, and increasing Doppler/TDI septal E/E ratio p = 0.01 were univariate predictors of events. Right heart predictors included increased right atrial size p = 0.01, increased RV size p = 0.04, increasing RV systolic pressure p = 0.003, increasing severity of tricuspid regurgitation p = 0.006, and elevated RV free wall TDI diastolic E velocity p < 0.001. Multivariate analysis showed that LV EF p = 0.010, RR 0.96 (0.93-0.99), RV TDI E velocity p < 0.001, RR 1.25 (1.13-1.40), and MMVG p < 0.001, RR 1.22 (1.12-1.33) were independent predictors of events. Step-wise analysis using all univariate predictors was performed to determine the incremental value of right heart variables. Left heart variables added prognostic information to NYHA class (chi-square from 6.7 to 46.2, p = 0.001). Right heart variables added prognostic value to NYHA Class and left heart variables (chi-square from 46.2 to 58.5, p = 0.008). Conclusions: Right heart assessment adds significant value to clinical and left heart assessment for prediction of outcome late after mitral surgery.

Journal of the American Society of Echocardiography May 2008

564

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P2-40

Reperfusion Therapies Reduce Ischaemic Mitral Regurgitation Following an Inferoposterior ST Elevation Myocardial Infarction

Low Transvalvular Gradients in Patients with Severe Isolated Aortic Stenosis and Normal Left Ventricular Ejection Fraction Predict a Poor Outcome

Li Ching Lee, Kian Keong Poh, Han Wen Tee, Huay Cheem Tan, Boon Lock Chia, Juan Zhang, Hean Yee Ong, Tiong Cheng Yeo National University Hospital, Singapore, Singapore

Eddy Barasch1, Dali Fan2, Ebere Chukwu1, Jing Han1, Michael Passick1, Florentina Petillo1, Aracely Norales 1, Nathaniel Reichek1 1 St. Francis Hospital/SUNY at Stony Brook, Roslyn, NY; 2North Shore University Hospital, Manhasset, NY

Background: The presence of ischaemic mitral regurgitation (IMR) post ST elevation myocardial infarction (STEMI) conveys poorer prognosis. The possible protective influence of reperfusion therapy in restoring mitral valve competence in inferoposterior STEMI has not been well elucidated. We sought to examine the effect of reperfusion therapies on the presence and grade of IMR following an inferoposterior STEMI. Methods: We studied 423 consecutive patients with a first inferoposterior STEMI presenting to our institution, evaluated the presence and severity of IMR on transthoracic echocardiography in patients treated with reperfusion therapy versus medical therapy. Patients with primary valvulopathies including presence of mitral valve prolapse or stenosis were excluded. Results: One hundred eighty eight patients had primary percutaneous coronary intervention (PPCI), 74 patients had thrombolytic therapy, 63 patients had rescue PCI while 55 patients had no reperfusion therapy. The median time interval between STEMI presentation and echocardiography was 16±36 days. There was no difference in the presence of IMR between the PPCI and the thrombolytic group (52.2% vs 60.8%, p=1.00). Patients who did not receive reperfusion therapy (PCI or thrombolysis) had more moderate or severe MR compared to those who had received reperfusion therapy, p=0.001. Left ventricular ejection fraction (LVEF) was significantly lower (47.7±10.3% vs 53.1±11.4%, p<0.001) and infarct size (mean CKMB) was significantly higher (271±168 U/L vs 222±151 U/L, p<0.001) in patients with IMR. Dominance of the coronary artery system, involvement of right coronary or left circumflex vessel, presence of underlying triple vessel disease did not correlate with the presence of IMR. After adjustment for age and LVEF, there was a trend towards poorer survival and recurrent admission for heart failure at 1 year in patients with IMR. (Hazard Ratio [HR] =2.4, 95% CI [0.91-6.2], p=0.08). Conclusions: Both thrombolytic therapy and PPCI were equally effective in reducing IMR following an inferoposterior STEMI.

Background: While many patients (pts) with severe aortic stenosis (AS) and low aortic valve gradients have relative AS in association with low LV ejection fraction (EF), others have normal EF. The pathophysiology and the clinical significance of this observation have been less studied. Methods: Between 2002-2006, 215 pts (mean age 77 ± 10 years, 51 % females) in normal sinus rhythm, had at transthoracic echocardiography severe isolated AS (mean aortic valve area -AVA- index = 0.4 ± 0.1 cm 2/m2) with a mean EF = 64 ± 9% by biplane Simpson method. AVA was calculated by continuity equation, stroke volume by volumetric method, systemic arterial compliance by the ratio: stroke volume/pulse pressure, and systemic vascular resistance by equation: 80 x mean arterial pressure/cardiac output. Mean follow-up 21± 11 months. Multivariate logistic regression models unadjusted and adjusted for arterial hypertension were used to determine the effect of mean gradient (MG) on outcome. Results: There were 47 pts (22%) with a MG < 30 mm Hg (MGlow) and 168 with a MG ≥ 30 mm Hg (MGhigh). No age, gender, race or medical history differences besides hypertension which was more prevalent in MG low group compared with MGhigh pts (91% vs 64%, p=0.0004, respectively) have been identified between the 2 groups. The main echocardiogarphic, hemodynamic and outcome data are given in the table. Variable AVA index (cm 2/m2 BSA) Dimensionless velocity index Peak gradient (mm Hg) Mean gradient (mm Hg) LV diastolic volume index (ml/m 2) LVEF (%) Stroke volume index (ml/beat/m2) Systemic vascular resistance (dyne.cm.sec-5) Systemic arterial compliance (ml/mm Hg) AVR (%) Death (%) - before AVR - after AVR

MG <30 mmHg N = 47 Mean ± SD 0.46 ± 0.09 0.31 ± 0.05 39 ± 8 23 ± 5 47 ± 9 62 ± 9 37 ± 12 2163 ± 754 1.05 ± 0.5 33

MG ≥ 30 mm Hg N = 168 Mean± SD 0.37±0.09 0.23 ± 0.05 81 ± 23 50 ± 15 56 ± 12 65 ± 9 41 ± 11 1879 ± 528 1.2 ± 0.5 58

<0.0001 <0.0001 <0.0001 <0.0001 <0.0001 0.03 0.002 0.05 0.13 0.01*

19 8.5

9.5 3

0.05* 0.10*

p-value

* multivariate logistic regression analysis

Conclusions: 1. Almost 25% of pts with isolated severe AS and normal EF had a MG < 30 mm Hg. 2. A combination of a larger AVA index (albeit in the range of severe AS), smaller LV diastolic volume, lower EF and higher systemic vascular resistance may explain the lower MG in this group. 3. The prognosis of pts with MGlow is worst than those with MGhigh possible due to more advanced LV systolic dysfunction and/or a lower referral rate to surgery. 4. Careful evaluation of this subset of pts with severe AS is warranted. P2-41

P2-42

An Intraoperative Study of Real-Time Three-Dimensional Transesophageal Echocardiography in Mitral Valve Repair

Preoperative Determinants of Left Ventricular Mass Regression after Aortic Valve Replacement Surgery in Severe Aortic Stenosis

Xianhong Shu, Cuizhen Pan, Chunsheng Wang, Haozhu Chen Zhongshan Hospital, Fudan University, Shanghai, China

Ji Hyun Yang, Jin-Oh Choi, Kiik Sung, Pyo Won Park, Sang-Chol Lee, Seung Woo Park Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea

Objective: The aim of this study was to investigate the value of intraoperative real-time threedimensional transesophageal echocardiography (RT3D-TEE) in mitral valve repair. Methods: RT3D-TEE was performed in six patients [ 5 male, mean age (45.7±12.6) years] with mitral valve prolapse and severe mitral regurgitation. Preoperative RT-3DTEE studies were compared with surgical findings. Postoperative RT-3DTEE was performed to evaluate the surgical outcomes. Results: RT3D-TEE was successful in all patients. RT3D-TEE could provide surgical views of the valve and the valvular apparatus, display dynamic morphology of mitral valve and its spatial relation to the surrounding tissue. Prolapse of a single mitral valve segment was present in 4 patients and 2 patients had complex disease involving two or more segments by RT3D-TEE. RT3D-TEE correctly predicted mitral prolapse localization and chordae rupture in all patients compared with surgical findings. The anterolateral to posteromedial diameter of annulus, anterior to posterior diameter of annulus , perimeter of annulus , and area of annulus in projection plane were significantly smaller after operation(44.55±3.98mm vs 36.88±3.32mm, 40.47±4.64mm vs 34.67±1.96mm, 155.57±8.20mm vs 127.28±9.58mm, 1553.02±178.35mm2 vs 995.75±101.33mm2, all p<0.05). The maximal prolapse height, the volume of leaflet prolapse and the length of coaptation in projection plane were significantly reduced after repair(5.83±2.40mm vs 2.65±1.08mm, 0.97±0.78ml vs 0.07±0.04ml, 35.40±7.63mm vs 24.73±1.44mm, all p<0.05). Trace or no mitral regurgitation was found after surgery. Conclusions: Intraoperative RT3D-TEE evaluation of mitral valve is feasible, and found to correlate with surgical findings. It is a unique new modality for precisely evaluating mitral valve prolapse, and is valuable to the surgeon when performing mitral valve repair.

Background: Left ventricular (LV) mass index (LVMI) is associated with mortality and morbidity after aortic valve replacement (AVR) in patients with aortic stenosis (AS). However, there are some patients with normal LVMI in the presence of severe AS and their clinical characteristics related to LV mass regression after AVR are not fully understood. We sought to evaluate the preoperative determinants of LV mass regression after AVR in patients with severe AS. Methods: A total of 113 patients with severe AS were evaluated with echocardiography pre- and postoperatively (9 ± 3 months after AVR). Clinical and echocardiographic parameters were measured and compared among groups according to pre- and postoperative LVMI. Results: Mean preoperative LVMI was 148 ± 40 g/m 2, which decreased to 109 ± 28 g/m2 postoperatively. There were 18 patients with low (≤ 110 g/m 2) pre- and postoperative LVMI (Group I), 42 with high (> 110 g/m 2) preoperative and low postoperative LVMI (Group II), and 55 with high pre- and postoperative LVMI (Group III) (see Table). In multivariate analysis, age (R2 = 0.24, p = 0.001), preoperative relative wall thickness (R 2 = 0.35, p = 0.004) and left atrial dimension (R2 = 0.43, p = 0.016) revealed significant relationship with postoperative LVMI in order. Conclusion: Preoperative systolic and diastolic function of LV, and chronicity of the disease might be the important factors of LV mass regression after AVR in patients with severe AS. Clinical and echocardiographic characteristics Group I Group II N 18 45 Age (yr) 55 ± 13† 61 ± 8‡ Male, N (%) 8 (44.4) 32 (71.1) Preop. LVMI (g/m 2) 89.1 ± 15.9† 142.5 ± 25.2‡ 2 0.74 ± 0.30 0.68 ± 0.17 AVA (cm ) RWT 0.36 ± 0.08† 0.43 ± 0.08 LV EF (%) 65.3 ± 6.3 62.1 ± 10.8‡ LA size (mm) 39.4 ± 8.8 40.6 ± 7.1‡ E‘ velocity (cm/s) 5.3 ± 1.8 5.3 ± 1.2‡

Group III 50 65 ± 10§ 32 (64.0) 173.2 ± 33.9§ 0.62 ± 0.13§ 0.45 ± 0.09§ 55.1 ± 12.7§ 44.6 ± 6.3§ 4.5 ± 1.2

p* 0.001 0.145 <0.001 0.032 <0.001 0.001 0.005 0.028

*by 1-way ANOVA or Chi-square test; †p < 0.05 vs group II; ‡p < 0.05 vs group III; §p < 0.05 vs group I via post-hoc analysis with LSD

Journal of the American Society of Echocardiography Volume 21 Number 5

565

P2-43

P2-44

The Long-Term Echocardiographic Follow-Up of Patients Underwent Chordal Cutting for Ischemic Mitral Regurgitation

Association of Recurrent Ischemic Mitral Regurgitation and Functional Mitral Stenosis by Systolic and Diastolic Tethering after Surgical Annuloplasty

Tomoko Tani, Kazuaki Tanabe, Yoshimori Ann, Kitei Kim, Takafumi Yamane, Takeshi Kitai, Minako Katayama, Makoto Kinoshita, Natsuhiko Ehara, Tomoyuki Oda, Koichi Tamita, Atsushi Kobori, Shuichiro Kaji, Atsushi Yamamuro, Yukikatsu Okada, Yutaka Furukawa, Shigefumi Morioka Kobe City Medical Center General Hospital, Kobe, Japan

Kayoko Kubota1, Yutaka Otsuji 2, Shiro Yoshifuku 1, Tetsuya Ueno 1, Eiji Kuwahara1, Kenichi Nakashiki1, Takeshi Uemura 1, Mihoko Kono1, Naoko Mizukami1, Akira Kisanuki1, Robert A Levine 3, Ryuzo Sakata 1, Chuwa Tei 1 1 Kagoshima University, Kagoshima, Japan; 2University of Occupational and Environmental health Japan school of medicine, Kitakyusyu, Japan; 3Massachusetts general hospital, Boston, MA

The purpose of this study was to investigate the long-term efficacy of chordal cutting for ischemic mitral regurgitation (MR) that was assessed by transthoracic echocardiography. Methods: We studied 7 patients that underwent chordal cutting and ring annuloplasty for ischemic MR. Echocardiographic studies were performed before operation and follow-up status after operation. Left ventricular (LV) diastolic and systolic dimension (LVDd, LVDs), LV wall motion index (LVWMI), tenting area and coaptation height were measured. LV end-diastolic and end-systolic volume (EDV, ESV) and ejection fraction (EF) were measured by the Simpson’s method. Right ventricular systolic pressure (RVp) was estimated by Doppler echocardiography. MR was semiquantitatively measured in color Doppler echocardiography (0: none, 1: mild, 2: moderate, 3: severe). We investigated to the characteristics of mitral leaflet configuration. Results: As shown in Table. The long-term result was excellent. The tethering of posterior mitral leaflet (PML) was significantly augmented in 2 patients who resulted in recurrent MR. Conclusions: The chordal cutting and ring annuloplasty is a useful method. The augmented PML tethering may cause recurrent MR.

Background: Excessive LV remodeling and systolic valve tethering causes recurrent ischemic mitral regurgitation (IMR) following surgical annuloplasty. In diastole, excessive valve tethering may cause functional mitral stenosis (MS) in combination with reduced annular size by the surgery (figure). The purpose of this study is to evaluate the relation between recurrent IMR and diastolic mitral valve area (MVA) in patients with surgical annuloplasty for IMR. Methods: In 31 consecutive patients with surgical annuloplasty for ischemic MR, diastolic MVA was obtained by echocardiography with continuity equation (MVA x Velocity Time Integral of mitral filling flow = LV filling volume = LVEDV - LVESV). MR was quantified by the vena contracta (VC) width in the apical long-axis view. Results:1) LVEDV was positively correlated with VC width (r = 0.42, p < 0.05) and negatively correlated with diastolic MVA (r = -0.39, p < 0.05). 2) VC width was negatively correlated with diastolic MVA (r = - 0.54, p < 0.01). 3) Frequency of significant recurrent IMR (VC width < 3 mm) was significantly higher in patients with functional MS (diastolic MVA < 1.5cm 2) compared to those without it (6/15 vs. 3/16, p<0.05). Conclusion: It was suggested that excessive LV remodeling and valve tethering following surgical annuloplasty for IMR can potentially cause both systolic recurrent MR and diastolic functional MS.

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P2-46

Paradoxically Severe Aortic Stenosis with Low-Flow, Low-Gradient Despite Preserved Contraction: Its Prevalence and Clinical Characteristics

Echocardiographic Follow-Up of Tricuspid Valve Repair with a Triple Leaflet Edge-To-Edge Technique

Mika Maeda, Takahiro Ohara, Satoshi Nakatani, Hideki Kanzaki, Jiyoong Kim, Kazuhiro Hashimura, Masafumi Kitakaze National Cardiovascular Center, Osaka, Japan

Manatomo Toyono, Jose L. Navia, Yoshiki Matsumura, Tetsuhiro Yamano, Kunitsugu Takasaki, James D. Thomas, Takahiro Shiota The Cleveland Clinic, Cleveland, OH

Background: Part of severe aortic stenosis (AS) patients shows paradoxically low aortic valvular pressure gradient despite preserved left ventricular contraction. The prevalence and hemodynamic characteristics of this paradoxical severe AS population are to be determined. Methods: We retrospectively studied clinical and echocardiographic characteristics of 161 consecutive (mean age 70±11) patients with severe AS (aortic valve area (AVA) <1.0 cm 2) with preserved left ventricular contraction (%fractional shortening≥30). We divided these patients into low gradient AS (mean pressure gradient≤30 mmHg, LG-AS) and high gradient AS (mean pressure gradient>30 mmHg, HG-AS), and compared their clinical profiles. Results: Forty-five patients (31%) were LG-AS and 116 patients (69%) were HG-AS. Compared in AVA-matched manner, LG-AS patients had lower aortic valve flow velocity, lower stroke volume, and lower systemic arterial compliance index (defined as stroke volume/pulse pressure/body surface area). Meanwhile, AVA, left ventricular outflow tract diameter, time velocity integral (TVI) ratio (defined as left ventricular outflow tract TVI /aortic valve TVI), left ventricular diastolic diameter (46.7±5.9 vs 47.6±4.5 mm), %fractional shortening, and brain natriuretic peptide were not different between LG-AS and HG-AS. Conclusions: Considerable proportion of patients with severe AS and preserved contraction shows paradoxically low pressure gradient due to low stroke volume and low systemic arterial compliance. We have to measure AVA even in low pressure gradient AS patients with clinical data suggestive of severe AS.

Background: Significant tricuspid regurgitation (TR) may persist after tricuspid valve (TV) annuloplasty, with the consequence that postoperative morbidity and mortality rise considerably. We analyzed the efficacy of triple leaflet edge-to-edge TV repair in patients with TR. Methods: From May 2001 to April 2007, 42 patients (age, 63 ± 13 years; male, 43%) with TR underwent triple leaflet edge-to-edge TV repair. The etiology of TR was non-organic in 32 cases and organic in 10 cases. Edge-to-edge TV repair was performed along with ring annuloplasty in 35 cases, Kay annuloplasty in 3 cases, and without any annuloplasty in 4 cases. Two-dimensional and Doppler transthoracic echocardiography was performed before and after edge-to-edge TV repair (range, 2-35 days; median, 5 days) to evaluate cardiac function and geometry as well as TR severity. TR severity was assessed by the ratio of the maximal TR jet area to right atrial area in the apical 4-chamber view (%TR; color Nyquist limit, 58 ± 7 cm/s). TR severity was graded as mild if %TR was <20%, moderate if %TR was between 20% and 40%, and severe if %TR was >40%. Results: Preoperative %TR was significantly associated with preoperative TV tethering height and a history of atrial fibrillation (both p <0.005). After surgery, %TR was significantly decreased from 43 ± 21 to 9 ± 11 (p <0.001); postoperatively moderate and severe TR were observed in 6 (14%) and 1 case (2%), respectively (Figure 1). Postoperative %TR was significantly associated with preoperative %TR and postoperative right ventricular systolic pressure (RVSP; Figure 2) There was no significant difference in the postoperative %TR between non-organic and organic TV diseases (9 ± 12 vs. 8 ± 9, p = 0.8). There was also no significant difference in the postoperative %TR between ring annuloplasty and the others including Kay and no annuloplasty (8 ± 10 vs. 14 ± 15, p = 0.2). Conclusion: Triple leaflet edge-to-edge TV repair is an effective approach for the management of TR, irrespective of the etiology of TR and the type of simultaneous TV procedures.

Journal of the American Society of Echocardiography May 2008

566

P2-47

P2-48

Use of Doppler Myocardial Imaging for Detection of Sub-Clinical Left Ventricular Dysfunction in Patients with Chronic Severe Mitral Regurgitation

Association of Valvular Calcification with Left Ventricular Geometry and Function in Hypertensive Adults with Left Ventricular Hypertrophy: The LIFE Study

Diego Bellavia, Traci Jurrens, Patricia A Pellikka, Jae K Oh, Maurice Sarano, Theodore P Abraham, Gillian Nesbitt, Fletcher A Miller, Charles Bruce Mayo Clinic, Rochester, MN

Zhibin Li1, Michael H. Olsen2, Kristian Wachtell 2, Eva Gerdts3, Markku S. Nieminen3, Björn Dahlöf4, Richard B. Devereux 1 1 Weill Cornell Medical College, New York, NY; 2Department of Medicine, Glostrup University Hospital, Glostrup, Denmark; 3Haukeland University Hospital, Bergen, Norway; 4Sahlgrenska University Hospital, Ostra, Sweden

Background and Aims: Although presenting normal or super-normal ejection fraction (EF), patients with chronic mitral regurgitation (MR) may have sub-clinical left ventricular (LV) dysfunction, as demonstrated by the quota developing low EF after surgical treatment. Doppler myocardial imaging (DMI) has been demonstrated sensitive to study systolic LV function. The aim of this study was to test if DMI can be useful in depicting LV dysfunction in patient with MR and normal EF. Methods and Results: 31 patients with chronic, moderate (n=6, 19%) to severe (n=25, 81%) degenerative MR, and 34 age and sex comparable controls were enrolled. Standard 2D/Doppler echocardiography was performed, severity of MR was graded by calculation of proximal isovelocity surface area. Longitudinal systolic tissue velocity (sTVI), strain rate (sSR) and strain (sS) was measured for all 18 LV segments. DMI measures were also analyzed as clusters of segments, by level (mean of 6 basal, 6 middle and 6 apical segments), and by wall (mean of basal middle and apical segment for each of the 6 LV walls). Wilcoxon rank sum and Fisher exact test were used to compare the two groups. Receiver-Operator curves (ROC) were computed to identify the most accurate DMI measure to discriminate between patients and controls. LV end-diastolic and end-systolic dimensions, were increased in patients as compared to controls (5.5 ± 0.1 vs 4.7 ± 0.1 cm p < 0.001 and 3.4 ± 0.09 vs 3.0 ± 0.07 cm p 0.02, respectively). EF and sTVI were not different in the two groups. sSR of many and sS of most segments was reduced in patients compared to controls (table 1). By ROC analysis, sS mean of the 6 basal segments was the most accurate to differentiate patients from controls (AUC 0.92, 95% CI 0.85, 0.99). Conclusions: patients with chronic degenerative MR have a significant reduction of LV systolic performance compared to age and gender matched controls, detected by DMI. Moreover, sS mean of the 6 basal segments is the most useful measure to identify sub-clinical LV systolic impairment, with an accuracy of 92%. Table 1 Variables Mean ± SD Age Males, n (%) Ejection Fraction (%) Regurgitant Volume (cc) sSR Basal mean (1/s) sSR Middle mean sSR Apex mean sSR Lateral wall sSR InferoSeptum wall sSR Posterior wall sSR AnteroSeptum wall sSR Inferior wall sSR Anterior wall sSR Global average sS Basal mean (%) sS Middle mean sS Apex mean sS Lateral mean sS Inferoseptum mean sS Posterior mean sS AnteroSeptum mean sS Inferior mean sS Anterior mean sS Global average

Controls (n = 34) 60 ± 11 20 (59) 64 ± 4 67 ± 29 -1.3 ± 0.2 -1.2 ± 0.2 -1.0 ± 0.2 -1.1 ± 0.2 -1.2 ± 0.2 -1.2 ± 0.2 -1.2 ± 0.3 -1.2 ± 0.2 -1.2 ± 0.2 -1.2 ± 0.1 -21.5 ± 2 -17.5 ± 2 -18.6 ± 3 -18.6 ± 3 -21.7 ± 3.6 -19.7 ± 2.7 -21 ± 3.3 -21.7 ± 3.1 -19.4 ± 2.4 -20.3 ± 1.9

MR Patients (n = 31) 66 ± 14 18 (58) 62 ± 10 na -1.0 ± 0.3 -1.1 ± 0.4 -1.0 ± 0.3 -1.0 ± 0.4 -1.1 ± 0.3 -1.1 ± 0.5 -1.0 ± 0.2 -1.0 ± 0.4 -1.0 ± 0.3 -1.0 ± 0.3 -14.9 ± 4 -15.3 ± 4.3 -16.5 ± 3.9 -13.6 ± 4.3 -20.1 ± 4.7 -14.6 ± 5.7 -16.5 ± 4.2 -16.2 ± 4.8 -16.8 ± 3.6 -16.5 ± 3.2

p-value 0.11 0.57 0.97 na < 0.001 0.14 0.16 0.001 0.09 0.08 0.006 0.01 0.02 0.01 <0.001 0.003 0.02 <0.001 0.16 <0.001 <0.001 <0.001 0.005 <0.001

Background: Mitral and aortic valvular calcification (V-Ca) has been reported to predict higher cardiovascular mortality and morbidity. Its association with left ventricular (LV) geometry and function in hypertensive patients with electrocardiographic defined left ventricular hypertrophy (LVH) has not been well documented. Methods: Hypertensive patients with LVH by Cornell voltage-duration product or Sokolow-Lyon voltage criteria on a screening electrocardiogram were randomized to treatment with losartan or atenolol and followed a mean of 4.8 years in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study. A total of 960 participants (mean age: 66±7 years, 42% female, 84% Caucasian) in the LIFE echo substudy underwent clinical and echocardiographic evaluation. Results: The presence of V-Ca in 588 (62%) of participants was associated with older age and female gender (both p<0.05). After adjustment for age and gender, V-Ca was associated with higher systolic and pulse pressure, plasma glucose level and diabetes (all p<0.05) but not with serum cholesterol (p>0.05). In analysis of covariance adjusting for above-mentioned clinical covariates, V-Ca was associated with larger mean dimension of left atrial (4.1 versus 3.8 cm) and LV (5.3 versus 5.2 cm), increased mean LV mass index (126 versus 119 g/m 2) (all p<0.01). Using logistic regression adjusting for above-mentioned significant confounders, V-Ca was associated with electrocardiographic and echocardiographic LVH [(OR=1.63) and (OR=1.47) respectively], mitral regurgitation (OR=2.66) and aortic regurgitation (OR= 2.57) (all p<0.05). However, V-Ca was not associated with significantly worse LV systolic and diastolic functional indexes including ejection fraction, midwall shortening and isovolumic relaxation time (all p>0.05). Conclusions: Among hypertensive patients at high risk because of electrocardiographic defined LVH, mitral and/or aortic valve calcification is prevalent and independently associated with female gender, older age, diabetes, higher blood pressures, larger LA, increased LV dimension and mass index, mitral and aortic regurgitation, ECG and echocardiographic LVH, which may contribute to the adverse events associated with V-Ca.

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P2-50

Estimation of Left Ventricular Filling Pressure at Rest and During Exercise by Doppler Echocardiography in Patients with Severe Aortic Valve Stenosis

Measurement of Left Ventricular Mass by Real-Time Three-Dimensional Echocardiography: Comparison with Cardiac Magnetic Resonance, TwoDimensional and M-Mode Measurements

Morten Dalsgaard, Jesper Kjaergaard, Redi Pecini, Kasper Iversen, Lars Køber, Peer Grande, Peter Clemmensen, Christian Hassager Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark Background: Left ventricular (LV) filling pressure can be estimated by Doppler Echocardiography by the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity (E/e’) at rest in patients with heart failure, whereas the relation of E/e’ and invasive haemodynamic measurements in patients with severe aortic valve stenosis (AS) has not been established. The aim of the present study was to describe the relationship between LV filling pressure estimated by pulmonary capillary wedge pressure (PCWP) and E/e’ at rest and during exercise in patients with severe AS. Method: A total of 28 patients with an aortic valve area ≤1 cm2 performed a multistage supine bicycle exercise test (Increment of 25 W every other minute), which was repeated after two days. Data is presented as mean of these two tests. PCWP and E/e’ were measured at rest and at maximal tolerated workload. Results: Mean age was 70±8 years and 11 (39%) were women. Mean aortic valve area was 0.73±0.17 PCWP increased cm2. significantly from 17±8 mmHg at rest to 39±10 mmHg during maximal exercise (p < 0.0001). Both E and e’ increased with exercise whereas E/e’ ratio remained unchanged (19±6 vs 19±6 (NS)). E/e’ and PCWP were significantly correlated at rest (r = 0.71; p < 0.0001) as well as at peak exercise (r = 0.65; p = 0.0004), with similar slopes of the linear regression lines. The intercept however increased 18 mmHg (p=0.01) at peak exercise (see figure). Conclusion: E/e’ is well correlated to left ventricular filling pressure at rest in patients with severe AS. However, E/e’ cannot be used to detect exercise-induced changes in PCWP in these patients.

Masaaki Takeuchi 1, Victor Mor-Avi 2, Lissa Sugeng2, Lynn Weinert 2, Ivan Salgo3, Olivier Gerald4, Roberto M Lang2 1 University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan; 2University of Chicago Medical Center, Chicago, IL; 3Philips Medical Systems, Andover, MA; 4Philips Medical Systems Research, Paris, France Background: Recent development of 3D surface detection from real-time 3D echocardiographic (RT3DE) datasets have allowed direct quantification of left ventricular (LV) mass. The aim of this study was 1) to evaluate the accuracy of RT3DE LV mass using this new detection algorithm against cardiac magnetic resonance (CMR) imaging, and 2) to compare RT3DE LV mass with conventional M-mode and 2D LV mass, and RT3DE-guided 2D LV mass measurements. Methods: (1) RT3DE and CMR imaging was performed on the same day in 55 subjects, and (2) in additional 150 subjects, RT3DE, 2D and M-mode images were acquired. In both groups of patients, RT3DE endocardial and epicardial surfaces were semi-automatically identified and manually adjusted in multiple cut-planes using prototype software (QLab, 3DQAdv Philips Medical Systems) at end-diastole. LV mass was calculated as (epicardial volume - endocardial volume) times 1.05. In addition, using standard formulae, M-mode, 2D and 3D-guided 2D measurements of LV mass using non-foreshortened apical 4- and 2-chamber views extracted from the RT3DE were obtained. Results: 1) No statistical differences in LV mass determination were noted between RT3DE and CMR. High correlation (r=0.95) was noted between RT3DE and CMR derived LV mass with no significant bias (Bland-Altman analysis: mean difference of 2 g with 95% limits of agreement of ±40 g. 2) M-mode derived LV mass (175 ± 64 g, range: 74-443 g) was significantly larger than RT3DE LV mass (123 ± 39 g, range: 67-263 g, mean difference: -52 g) with moderate correlation (r=0.76). No significant differences in LV mass were noted between 2D (125 ± 42 g, range: 58-267 g) and RT3DE LV mass (mean difference ± SD: -1.2±17.6 g) with good correlation (r=0.91, p<0.001). Comparisons between RT3DE and 3D-guided 2D measurements (119 ± 36 g, range: 60-246 g) yielded the highest correlation (r=0.95, p<0.001) with a small bias and the most narrow limits of agreement (4.6±12.6 g). Intra-observer variability of LV mass measured using M-mode, 2D, RT3DE-guided biplane and the volumetric RT3DE techniques was 16±18%, 13±10%, 13±7 and 11±8%, respectively. Inter-observer variability for the M-mode, 2D, RT3DE-guided biplane and RT3DE techniques was 11±19%, 17±16%, 17±11% and 13±7%,respectively. Conclusions: This 3D surface detection algorithm allows accurate and reproducible measurements of LV mass. RT3DE-guided 2D LV mass measurements can be used as an accurate time-saving alternative in clinical practice. These techniques may become a new standard for the risk stratification of LV mass in various cardiovascular diseases.

Journal of the American Society of Echocardiography Volume 21 Number 5

567

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P2-52

Assessment of Staged Palliation of Hypoplastic Left Heart Syndrome by RealTime Three Dimensional Echocardiography

Segmental Contribution to Left Ventricular Systolic Function at Rest and Stress A Quantitative 3D Echocardiographic Study

Grace Choi1, Xiuzhang Lu1, Shuping Ge2 Baylor College of Medicine, Houston, TX; 2Baylor College of Medicine/Texas Heart Institute, Houston, TX

Swapna Mamidipally, Laura Buzzanca, Barbara Blizzard, Juan Gamboa, John Chen, Kathleen Stergiopoulos, Samira Bahrainy, Shervin Sadrpour, Felicia Russo, Smadar Kort Stony Brook University, SUNY, Stony Brook, NY

Background: Staged palliation of hypoplastic left heart syndrome (HLHS) is associated with significant morbidity and mortality. Current echocardiographic assessment of HLHS is largely qualitative. We hypothesize that quantitative evaluation of the systemic ventricular performance in HLHS by real-time three dimensional echocardiography (RT3DE) can provide insight into the pathophysiology of this disease. Methods: A prospective study was performed by enrolling patients with HLHS, including pre- and post-Norwood palliation, and post-bidirectional Glenn (BDG). Transthoracic RT3DE was performed using a X7-2 matrix array transducer with an IE33 ultrasound system (Philips Medical Systems). Volumetric data were analyzed offline using 4D Echo-View or ResearchArena (TomTec Imaging Systems, Munich, Germany) to determine end-diastolic volume (EDV), ejection fraction (EF), cardiac index, ventricular mass, and mass-to-volume ratio of the systemic ventricle. Results were compared using unpaired, two-tailed Student t-test. Results: A total of 23 patients on which 29 studies were performed: 11 pre-Norwood, 10 post-Norwood, 8 post-BDG. Image acquisition and analysis were feasible in all studies. Compared with pre-Norwood state (ages 0 to 11 days, median 4 days), the post-Norwood state (ages 15 days to 4 months, median 2 months) is associated with a trend of increased EDV (57±12 vs 65±17 ml/m 2, p=0.3), decreased EF (48±12 vs. 41±9%, p=0.1), decreased cardiac index (4.3±1.2 vs. 3.7±0.7 L/min/m 2, p=0.2). There was little change in mass (79±47 vs. 84±31 g/m2, p=0.8) and mass-to-volume ratio (1.4±0.5 vs. 1.3±0.3 g/ml, p=0.6). This is in contrast to post-BDG (ages 3 months to 4 years, median 2 years) with the trend of decreasing EDV (61±15 ml/m 2, p=0.7) and improved function (EF 47±15%, p=0.3). Cardiac index continues to decrease (3.4±1.5 L/min/m 2, p=0.6). Mass and mass-tovolume ratio remain unchanged (80±31 g/m2, p=0.8, and 1.3±.0.4 g/ml, p=0.7). Conclusion: This cohort suggests that RT3DE offers an opportunity to quantify the performance of the systemic ventricle in staged palliation of HLHS. The above trends may reflect continued hemodynamic derangement from the pre-Norwood to post-Norwood state. The reversal of trends of EDV and EF in post-BDG may reflect unloading of the systemic ventricle. However, a large sample size is needed. RT3DE may be particularly useful in longitudinal follow-up in patients with staged palliation of HLHS, and to assess the efficacy of staged palliation, and the continued modification and refinement of surgical approaches.

Background: A normal response to exercise is global augmentation in contractility resulting in increased stroke volume and reduced end systolic volume. The relative contribution of each of the myocardial segments to this process is unknown. Methods: Full volume data acquired using real time 3-dimensional echo at rest and immediately following peak exercise in 12 patients who had no ischemia and no dyssynchrony on 2D stress echo (25% men; mean age 51.6 years range 32-75). The following were calculated at rest and peak stress (TomTec 4D LV analysis): end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV=EDV-ESV), ejection fraction (EF=SV/EDV %), ratio of segmental SV to global SV (relative SV) and segmental SV to global EDV (relative EF). One way ANOVA and t-test used to compare the values. Results: With exercise the heart rate increased from 69±10bpm to 107±10bpm. The resting global EDV, ESV, SV and EF were 78.9±26.1 ml, 23.5±10.4 ml, 55.4±19.9 ml and 70±7.2% respectively. With stress an increase in global EDV (88.1±20.5 p<0.05), SV (73.8±17.6 p<0.005), EF (83.7±5.2 p<0.005) and a decrease in ESV (14.4±5.6 p=0.001) were seen. Segmental analysis (see table) revealed significantly higher SV, relative SV and relative EF for the basal anterior, basal anterolateral and basal inferolateral segments compared with the apical septum and apical inferior segments at both rest and stress (p<0.005). There was a significant increase in SV, relative SV and relative EF from apical to mid to basal segments at both rest and stress(p<0.005). Conclusions: The relative contribution of each of the 16 segments of the left ventricle to global systolic function at rest and at peak stress is not uniform. The basal segments contribute more than the mid and the apical segments to stroke volume and ejection fraction during both rest and exercise. Specifically, the basal anterior, basal anterolateral and basal inferolateral are the segments contributing the most.

P2-53

P2-54

Left Ventricular 3-Dimensional Strain Analysis Using Speckle Tracking Imaging: A Validation Study Against Tagged Magnetic Resonance Imaging

Left Atrial Volume and Function in Patients with Obstructive Sleep Apnea Assessed by Real Time Three Dimensional Echocardiography

Yoshihiro Seo, Tomoko Ishizu, Ryo Kawamura, Hideki Nakajima, Kazutaka Aonuma University of Tsukuba, Ibaraki, Japan

Wercules Oliveira, Dalva Poyares, Orlando Campos, Fatima Cintra, Edgar LiraFilho, Andrea Ponchirolli, Angelo De Paola, Sergio Tufik Federal University of Sao Paulo, Sao Paulo, Brazil

Backgound: Global heart translation is the major limitation in analysis of two-dimentional speckle tracking imaging (STI). Newly developed three-dimensional STI should overcome this limitation and could be the idial method in evaluating the complex myocardial deformation. Then, the aim of this study was to assess left ventricular strain by the 3-dimensional STI, and to validate the strain value compared to tagged magnetic resonance imaging (MRI). Methods: Eight healthy volunteers (all male, mean age 37years, range; from 22 to 46 years) were studied. 3-dimensional echocardiographic examinations were performed using the new developed ultrasound system (Aplio ARTIDA, Toshiba Medical Systems Corporation, Tokyo, Japan). In 3-dimensional echocardiographic examinations, apical 4-chamber and 2-chamber imaging were cropped and aligned to obtain the optimal images. On the cropped apical 4-chamber and 2-chamber images, basal, mid, and apical short axis images, the end- and epicardial border lines were manually traced for STI analysis. The radial and circumferential strain values at the total LV 16 segments including basal 6, mid 6, and apical 4 segments were calculated automatically. Tagged MRI was obtained with a 1.5T scanner. The validation of STI with tagged MRI was assessed for circumferential strain. Results: In all subjects, adequate 3-dimentional B-mode imaging and tagged MRI were obtained. In the total 128 segments, 9 segments (7%) with negative radial strain value, and 2 segments (2%) with positive circumferential strain value were excluded as the inadequate tracking segments. Intra-/inter-observer variability for radial strain was 13% / 11% and for circumferential strain 6 % / 6 %, respectively. Basal, mid, and apical radial strain values were 37, 30, and 22 %, and circumferential strain -25, -26, and -31%, respectively. The close relationship between STI derived and tagged MRI derived mid-ventricular circumferential strain were observed (r=0.85, y= 0.7x -1.7, p=0.008). Conclusion: Based on our initial experience, 3-dimensional STI provided acceptable strain value and reproducibility, and the utility and reliability should be studied in patients with various cardiac diseases in further studies.

Background: Studies have suggested that Obstructive Sleep Apnea (OSA) contributes to deterioration of left ventricular (LV) diastolic function, resulting in atrial stretch and enlargement that could be associated to cardiovascular events. We sought to evaluate geometric and functional changes of left atrium (LA) by mean of three-dimensional real time echocardiography (3DRT echo) in OSA patients and the influence of LV diastolic function on these alterations. Methods: Fifty six mild to severe OSA patients diagnosed through polysomnography and 50 controls matched by gender and age underwent bidimensional and 3DRT echo in order to estimate the maximum LA volume indexed for body surface area (LAVmax /m²), minimum LA volume and LA volume before its contraction. Based on these volumes, the following measurements were calculated: Total LA Stroke Volume, Total LA Emptying Fraction, Active LA Stroke Volume, Active and Passive LA Emptying Fraction. Diastolic function was evaluated by Doppler analysis of maximal velocities of E and A waves, E/A ratio, E deceleration time, tissue Doppler of mitral annulus (E’ and A’ waves), and E/E’ ratio. Individuals with atrial fibrillation, cardiomiopathy, and poor quality of imaging were excluded. The severity of OSA was estimated by apnea-hypopnea index. Results: 3DRT echo showed larger LAVmax/m², volume before atrial contraction, active LA systolic volume, and higher active atrial ejection fraction in OSA patients (24.9±12.3 ml vs 18.6±5.5 ml; 31.5±20.4 ml vs 21.7±6.9 ml; 12.8±9.5 ml vs 7.1±3.5 ml; 39.4±13.0 % vs 32.9±12.1 % respectively, p<0.01 for all). E’ was reduced in patients with OSA (7.0±1.8 cm/s vs 7.8±2.2 cm/s, p=0.03) while A’ and E/E´ were increased in the same group (7.1±1.9 cm/s vs 6.2±2.0 cm/s and 10.6±3.0 vs 9.4±2.9 respectively, p<0.05 for both). A linear increase was observed in 3D LAVmax/m² according to OSA severity (figure). Apnea-hypopnea index and E/E´ were independent predictors of increase 3D LAVmax/m² in multiple regression model. No difference were observed in BMI, diabetes, hypertension and bidimensional echo LA volumes between the groups. Conclusion: We demonstrated by 3DRT echo that OSA induces a functional burden to the LA, resulting in LA remodeling. These changes are related to severity of OSA and the diastolic LV impairment observed in this population.

1

Segment Basal anterior Basal anterior septum Basal inferior septum Basal inferior Basal inferolateral Basal anterolateral Mid anterior Mid anterior septum Mid inferior septum Mid inferior Mid inferolateral Mid anterolateral Apical anterior Apical septum Apical inferior Apical lateral Total basal Total mid Total apical Global

SV (ml) 5.7±2.5 4±1.3 3.8±1.4 3.9±1.8 5.5±3.5 5.8±2.9 3.5±1.3 2.5±0.8 2.2±0.9 2.3±1.3 2.9±1.7 3.1±1.9 2.7±1.2 2.1±1 2±1.5 2.8±1.7 28.7±11.1 16.4±6.2 9.7±4.6 55.4±19.9

Rest Relative SV (%) 10.5±2.9 7.8±2.7 7.4±2.5 7.3±2.9 9.4±3.6 9.9±1.9 6.4±1.6 4.6±1 4.1±1.5 4.1±1.9 4.9±1.2 5.3±1.4 5±2 3.8±1.4 3.7±2.2 5±1.7 52.2±9 29.4±3.1 17.5±5.6 100%

RelativeEF (%) 7.4±2.4 5.5±1.9 0.8±1.7 1.5±1.4 6.7±3.1 7±1.8 4.5±1.2 3.2±0.7 2.8±1 2.8±1.2 3.5±1.1 3.8±1.3 3.5±1.5 2.6±0.9 2.5±1.5 3.5±1.3 36.6±7.9 20.5±2.6 12.2±3.9 70.0±7.2

SV (ml) 7.9±3.4 4.8±1.7 5.0±1.8 5.7±1.9 7.7±3.2 9.1±2.8 3.7±1.3 2.6±1.3 2.7±1.2 2.9±1.3 4.1±1.3 4.8±1.8 2.5±09 2.2±1.4 2.3±1 3.7±1.5 40.8±10.3 20.6±4.8 10.8±3.4 73.8±17.6

Stress Relative SV (%) 10.6±3.1 6.5±2.2 6.8±1.5 7.8±2.2 10.7±4.1 12.3±2 5.1±1.4 3.5±1.5 3.5±1.1 3.8±1.1 5.6±1.7 6.6±2.5 3.4±1 2.9±1.5 3.2±1.1 5.2±2 55.3±4.2 28.1±2.7 14.6±3.2 100%

RelativeEF (%) 8.9±2.6 5.4±1.8 5.7±1.5 6.5±1.9 8.9±3.4 10.3±1.9 4.2±1.1 2.9±1.2 2.9±1 3.2±1 4.7±1.4 5.5±2 2.8±0.8 2.4±1.3 2.6±0.9 4.3±1.6 46.3±5.1 23.5±2.2 12.2±2.8 83.7±5.2

Journal of the American Society of Echocardiography May 2008

568

P2-55

P2-56

Assessment of Myocardial Perfusion during Adenosine Stress Using Real Time Three Dimensional and Two Dimensional Myocardial Contrast Echocardiography: Comparison with Single Photon Emission Computed Tomography

Utility of Fetal Full Volume Three Dimensional Echocardiography

Sahar S Abdelmoneim, Mathieu Bernier, Abhijeet Dohble, Stuart Moir, Sue Ann Ness, Mary E Hagen, Sharon L Mulvagh Mayo Clinic, Rochester, MN Background: Two Dimensional myocardial contrast echocardiography (2D-MCE) is useful for detection of myocardial perfusion defects. However it requires the acquisition of multiple views. Real-time three dimensional echocardiography (RT3DE) enables the rapid display of the entire left ventricle (LV) in one image. We compared RT3D-MCE with 2D-MCE for detection of myocardial perfusion defects during adenosine stress Single Photon Emission Computed Tomography (SPECT) testing. Methods: From Jan-August 2007, 30-consecutive patients with known-or-suspected CAD referred to SPECT were prospectively enrolled and underwent simultaneous 2D-MCE and full volume apical acquisition of RT3D-MCE (Definity infusion®-BMS, USA) during (Adenoscan-Astellas, USA) stress using iE33 equipped with power modulation contrast settings (Philips, USA). Qualitative myocardial-perfusion (graded as 1=normal, 0=abnormal) and wall motion in 17-representative segments in the anterior and posterior circulation were analyzed. Results: Out of 30 patients, 3D analysis was performed in 24 patients [mean-age 73.3+8.3years, mean-BMI 27.7+ 4.9Kg/m2, males (13/24) 54%] Figure. Using SPECT, CAD was diagnosed in 9 patients (37%). The mean WMSI at rest and stress was 1.08 + 0.26, and 1.12+ 0.29, respectively. The 3D evaluation resulted in comparable diagnostic accuracy to that of the 2D: sensitivity and specificity was 89% and 68% by 2D and 88% and 79% by 3D [anterior circulation], and 63% and 90% by 2 D and 68% and 90% by 3D [posterior circulation]. Overall agreement with SPECT was 84.7% by 2D and 86.4% by 3D. Conclusion: Assessment of myocardial perfusion by RT3D-MCE is a feasible technique, comparable to 2D MCE in accuracy, and demonstrating excellent agreement with SPECT perfusion. RT3D-MCE may be advantageous due to more rapid acquisition and interpretation.

Alexia B Santos, Regina Lantin-Hermoso, Nancy Ayres, Shuping Ge Texas Children‘s Hospital, Houston, TX Objective: To evaluate the utility and ease of use of full volume three dimensional echocardiography (3D echo) as a fast and reliable imaging tool to distinguish normal fetal hearts from those with congenital heart defects (CHD) that require a more detailed two dimensional fetal echocardiogram (2D echo). Methods: After obtaining a complete 2D echo, 3D full volume images were acquired prospectively in 18 fetuses. The median gestational age was 28 weeks. Six of eighteen patients had CHD. The full volume acquisitions were analyzed using Multiplanar Reconstruction (Phillips QLab Ultrasound Quantification software), with the intent of generating eight standard 2D views: four chamber, bicaval, right and left ventricular outflow tract, two short axis views, and the aortic and ductal arches. An independent, blinded investigator reviewed the 3D images. Results: In 11/12 fetuses with normal anatomy, it was possible to generate all the predefined views. The impression was concordant with 2D echo in all 11 fetuses. In 1 fetus, it was not possible to generate all of the desired views, secondary to poor image quality and artifact. In 4/6 fetuses with CHD, it was possible to generate all of the predefined views. A diagnosis was correctly made in 6/6 fetuses, despite the inability to obtain all 8 views in 2 of them. The time necessary to obtain the 3D images was 3-5 minutes. The analysis time ranged between 9 to 22 minutes (mean 13.5 minutes), including the 15 fetuses in whom all views were obtained. All of the normal studies were analyzed in 15 minutes or less. The analysis time duration decreased (from 15 to 10 minutes) as the independent investigator acquired more familiarity with the techniques. Conclusions: It is feasible to acquire and analyze full volume 3D images in a relatively short time to assess fetal cardiac anatomy. Full volume 3D echo is a promising imaging modality to distinguish between normal fetal hearts and fetuses with CHD who should undergo more detailed cardiac imaging. The addition of other modalities such as 3D color, and pulse Doppler may provide more complete information in fetuses with CHD.

P2-57

P2-58

Efficacy and Reproducibility of Left Atrial Volumetric Measurements by Three Dimensional Echocardiography Compared with Conventional Echocardiography and Three Dimensional Multislice-CT

New Parameters in Evaluation of Ischemia during 3 Dimensional Dobutamine Stress Echocardiography

Miyuki Kawakubo, Nobusada Funabashi, Kouki Nakamura, Masae Uehara, Hiroyuki Takaoka, Koko Ri, Yumi Shiina, Maiko Takahashi, Rei Yajima, Issei Komuro Chiba University Graduate School of Medicine, Chiba, Japan Background: To compare efficacy and reproducibility of 3D-transthoracic echocar diography (TTE) with conventional TTE and 3D-multislice-CT (MSCT) approaches for evaluating left atrial (LA) maximal and minimal volumes during the card iac-cycle. Methods: LA maximum and minimum volumes, and ejection-fraction (LAEF) were assessed in 14-consecutivepatients (9-male, 54.8±20.6 yrs) with normal-sinus-rhythm using 3D-TTE (IE-33) and MSCT (Light- Speed Ultra 16), with ellipsoidal-formula, Simpson-rule and 3D-analy sis. Semi-automated 3D-segmentation-MSCT-technique was applied during the ca rdiac-cycle (Advantage-windows 4.4). Results: Using 3D-TTE, correlation-coeff icients (r) and mean difference±standard deviation (SD) were 0.996, - 1.1±2.3ml for LA maximum volume, 0.991, 0.0±2.8ml for LA minim um volume, and 0.900, -0.9±5.0% for LAEF. Using ellipsoidal formula TTE, these values were 0.991, 0.7±3.2ml, 0.987, -1.2±3.6ml and 0.918, 3.1±6.0%, respectively. Using Simpson rule TTE, these were 0.983, -0.9±4.8ml, 0.988, -0.2±4.1ml and 0.971, 0.0±3.9%, respectively, and using MSCT, 0.996, 3.4±3.3ml, 0.996, 0.4±3.3ml and 0.962, 1.4±3.6%. There were no significant differences of correlation-coefficients and SDs of mean differences among all TTEs and MSCT. Correlations between 3D-TTE and conventional TTEs were as well as those between 3D-MSCT and conventional-TTEs: for LA maximum volume (3D-TTEversus -ellipsoidal-formula, r=0.931, 3D-TTE-versus-Simpson‘s r=0.904, 3D-MSCT-versusellipsoidal-formula r=0.866, 3D-MSCT-versus-Simpson‘s r=0.817); for LA-minimum-volume (3D-TTE-versus-ellipsoidal-formula, r=0.957, 3D-TTE-versus-Simpson‘s r=0.937, 3D-MSCTversus-ellipsoidal-formula r=0.931, 3D-MSCT-versus-Simpson‘s r=0.898), and for LAEF (3D-TTE-versus-ellipsoidal-formula, r=0.876, 3D-TTE-versus-Simpson‘s r=0.796, 3D-MSCTversus-ellipsoidal-formula r=0.899, 3D MSCT-versus-Simpson‘s r=0.908). Conclusion: Assessment of LA-volumes by 3 D-TTE was as reliable and reproducible as by conventionalTTE and 3D-MSCT.

Masood Ahmad, Meneleo Dimaano, Tianrong xie University of Texas, Galveston, TX Background: The present study explored the usefulness of 3D parameters including Contraction time index (SDI), pre and post contraction segmental time volumes (PreTV and PostTV, ml x %) and contraction front map (CFM) based % pixels with delayed contraction in detection of ischemia during Dobutamine Stress Echocardiography (DSE). Methods: Sixty eight pts, age range 45-89 yrs, angiographic CAD in 45 and no CAD in 23, underwent 2D and 3D DSE. CFM’s (bulls eye plot of LV contraction measured every 25 msec, Tom Tec) were obtained at baseline and at peak stress (peak). SDI (standard deviation of the time to peak contraction in 16 segments), PreTV and PostTV (time volumes of segments contracting before and after peak global systolic volume), % delayed segments (% pixels activated after peak global systolic volume) were measured. Results: Out of 45 pts with CAD, stress induced LV wall motion abnormality was seen in 2D DSE in 34 pts (sensitivity 75%) compared to a >10% increase in 3D SDI in 32 pts, (mean ± SD, SDI, 0.55 ± 0.4 at baseline 0.63 ± 0.03 at peak, sensitivity 71%). In 23 pts without CAD, SDI decreased from 0.53 ± 0.02 at baseline to 0.3 ± 0.02 at peak, 2D DSE was negative in 21 pts and nondiagnostic in 2 pts. In pts with CAD, preTVs and postTVs were 3.2 ± 4.0, 7.5 ± 0.6 at baseline and increased to 5.9 ± 3.1, 9.9 ± 1.9 at peak, compared to pts without CAD, 3.7 ± 9.7, 2.4 ± 3.3 at baseline decreasing to 1.7 ± 4.1, 1.9 ± 7.2 at peak (p < 0.05). Percent delayed segments in pts with CAD were 22.48 ± 13.07 at baseline, and 32.11 ± 17.21 at peak (p < 0.01). In pts without CAD % delayed segments were 20.64 ± 12.6 at baseline and 8.75 ± 18.4 at peak (p < 0.05). In all 45 pts with CAD, one or more 3D parameters were abnormal at peak. Figure shows time volume graphs and CFM in a pt with ischemia. Bar graph displays sensitivity of different parameters in detection of CAD. Conclusion: Pts with CAD demonstrate significant increase in SDI, pre and post contraction time volumes and in % segments with delayed contraction during 3D DSE. These 3D parameters are sensitive in detection of ischemia.

Journal of the American Society of Echocardiography Volume 21 Number 5

569

P2-59

P2-60

Feasibility of Cross Platform 3-Dimentional Left Ventricular Volume Reporting System

Evaluation of 2D Echocardiographic Methods of Assessing Left Ventricular Sphericity: Comparison to 3D Echocardiography

Santosh Likki, Mohammad Abdul-Waheed, Yukitaka Shizukuda University of Cincinnati, Cincinnati, OH

Alpesh A Patel, Afamefuna A Onuora, Daniel S Swerdloff, Rena S Toole, Michael Passick, Aasha S Gopal St. Francis Hospital, Roslyn, NY

Background: The assessment of 3-Dimentional (3D) left ventricular (LV) volumes has become important to guide and prognosticate patients with heart failure given their accuracy to cardiac MRI measurements. Currently two vendors provide commercially available 3D echocardiography platforms based on transthoracic echocardiography. 3D LV volumes can be calculated by TomTec 4D LV analysis (GE Medical platform) or Q Lab (Philips Ultrasound platform). Only full version of TomTec software currently allows the analysis of 3D data from both platforms. To make clinical 3D volume reporting efficient, we setup a cross platform single vendor (TomTec) system to analyze and report 3D LV volumes in a university practice setting and we validated feasibility of this system. Methods: 3D echocardiography data from both platforms were transferred to TomTec Research Arena 2.0 and 3D LV volumes were calculated by TomTec 4D LV analysis according to the manufacturer ’s instructions. The 3D data sets from the Philips platform were also analyzed by Q lab (Philips Ultrasound). Results: 3D LV volumes of 35 consecutive patients who had 3D echocardiography (age from 22 to 74, 53±14, 16 females, 19 from GE and 16 from Philips platform, data are mean±SD) were assessed. In 16 3D data sets acquired by the Philips platform, 3D LV volumes assessed by TomTec showed excellent correlations with those by Q Lab (r=0.992 for LV end-diastolic volume, r=0.997 for LV end-systolic volume, r; correlation coefficient, P<0.0001 for both). When the data were pooled and compared with conventional 2D based LV volumes calculated with the biplane modified Simpson method, 3D LV volumes by the cross platform system significantly correlated with 2D based LV volumes (r=0.911 for LV end-diastolic volume, r=0.948 for LV end-systolic volume, P<0.0001 for both, n=33). In addition, 3D LV ejection fraction (EF) significantly correlated with that by 2D based (r=0.891, P<0.0001). However, in the severe and moderate ranges of LV systolic dysfunction (3D LVEF<45%), 2D based LVEF tended to underestimate EF as compared with 3D LVEF (P=0.070 by paired t-test). Conclusions: Cross platform 3D LV volume reporting by TomTec is feasible and it may provide a simple solution for efficient and standardized 3D LV volume reporting.

Background: Three-dimensional echocardiography (3DE) makes no geometric assumptions and may be used to characterize LV shape. We compared 2DE methods of assessing LV sphericity to 3DE. Methods: 107 pts (mean age=66y, 34F, 54 were post-myocardial infarction with EF<30%) were enrolled. Real-time 3DE volume (V) was calculated using apical rotation. From the 3D reconstruction, the long-axis (LAX) was automatically determined by connecting the apex to the center of the mitral annulus. If the LV were a sphere, its volume (Vs) would be (4/3) (2.13) (LAX/2)3 . LV sphericity was defined as actual V/Vs (approaches 1 with increasing sphericity). Sphericity by 2DE was determined by: 1) same method as 3DE but using the 2D apical biplane method of disks for the volume algorithm and determining the longest LAX by examining apical 2, 3, and 4-chamber views 2) calculating the sphericity ratio (width/ length) in the same apical views. Results: Systolic and diastolic sphericities were compared to corresponding 3DE values by linear regression and Bland Altman analysis. Conclusions: 1) Sphericity ratios from the apical 2, 3 or 4 chamber views correlate modestly with 3DE though with wide limits of agreement during diastole only and not during systole due to difficulty in visualizing the apical endocardial border 2) Sphericity can also be assessed during diastole and systole by calculation of 2D volumes by an apical biplane method of disks and measurement of the longest axis of the LV from apical views. The correlation with 3DE is modest. 2DE versus 3DE Sphericity Method

r

SEE

p

Bias

Lower limits

Upper limits

Systolic 2D biplane sphericity

0.42

0.04

0.0006

-0.2

-0.6

0.2

Systolic 2 chamber sphericity ratio

0.15

0.06

ns

0.35

-0.2

0.9

Systolic 3 chamber sphericity ratio

0.13

0.07

ns

0.32

-0.2

0.9

Systolic 4 chamber sphericity ratio

0.01

5.66

ns

2.09

0

34.5

Diastolic 2D biplane sphericity

0.43

0.06

0.0004

-0.2

-0.5

0.2

Diastolic 2 chamber sphericity ratio

0.40

0.04

0.0005

0.1

-0.2

0.4

Diastolic 3 chamber sphericity ratio

0.44

0.05

0.0001

0.1

-0.2

0.4

Diastolic 4 chamber sphericity ratio

0.40

0.04

0.0019

0.1

-0.2

0.4

P2-61

P2-62

Real-Time 3D and Simultaneous Biplane Transesophageal Echocardiography Using a Fully-Sampled Matrix-Array Transducer: Initial Clinical Experiences

Comparison of Right Ventricular Size and Contractility between Real-Time 3-Dimensional Echocardiography and 2-Dimensional Echocardiography: Analysis in Patients with and without Right Ventricular Overload

Hyun Suk Yang 1, Ramesh C. Bansal2, Robert F. Burke 1, Farouk Mookadam1, Steven J. Lester1, Susan Wilansky 1, Bijoy K. Khandheria1, A Jamil Tajik 1, Krishnaswamy Chandrasekaran1 1 Mayo Clinic, Arizona, Phoenix, AZ; 2Loma Linda University Medical Center, Loma Linda, CA Background: A recently introduced matrix-array 3D transesophageal transducer allows online acquisition and display of real-time (RT) 3D images. Its clinical value beyond conventional multi-plane (MP) 2D transesophageal probes has not yet been fully evaluated. Methods: We reviewed 50 patients (pts) (age 65±13, male 28) who underwent a routine transesophageal echocardiography (TEE) using an x7-2t transducer on an iE33 ultrasound machine. Five (10%) of 50 were performed during the procedure (intraoperative 3, catheter guiding 2), and others indications included pre-cardioversion (5 pts), valve exams (23 pts), cardiac source of embolism (13 pts), ASD device (1 pt), Aortic dissection (1 pt), and 2 pt with artificial heart. We compared MP 2D TEE with RT 3D in all and subgroups of surgically proven pathologies (11 pts), and left atrial appendage (LAA) 3D volume images (9 pts). Results: On-line display of 3D images in 3D Zoom mode (max 90x90 degree) gave immediate clinically useful spatial information without post-processing. This was very helpful in guiding a catheter for atrial septal puncture for mitral annular mapping (1 pt) and peri-prosthetic mitral occluder (1 pt) procedures. Out of 11 pts with surgically confirmed valvular diseases, incremental diagnostic value was found in 9 (tear in aortic valve leaflet (AV) 1 pt, thickening and retraction of the AV 1 pt, vegetations on the AV 2 pts, attachment of a papillary fibroelastoma on the AV 1 pt, prolapsed segments of mitral valve 2 pts, and peri-prosthetic mitral regurgitation 2 pts). A RT 3D volumetric image of LAA revealed additional accessory lobes in all pts (9/9 pts). A higher atherosclerosis grade was given via en-face view of 3D compared with MP 2D TEE (7 pts). Aortic mural thrombus was well differentiated in 1 pt suspected of aortic dissection. Images with agitated-saline bubble studies for the patent foramen ovale showed better view from the left atrial perspective in RT 3D (3 pts). RT biplane imaging with targeted tilting (20 pts) saved both time and effort of imaging the LAA, tricuspid valve, pulmonary valve, pulmonary veins, and great vessels. Conclusions: 1. RT 3D TEE without ECG gating using a matrix array transducer played an important role in providing spatial information during catheter guided procedures. Incremental value was demonstrated in evaluation of LAA, valvular heart disease, and aortic atherosclerosis. 2. The ability to obtain RT simultaneous biplane with this matrix probe was useful in the assessment of LAA, tricuspid valve, pulmonary valve, pulmonary veins, and great vessels beyond MP 2DTEE.

Manatomo Toyono, Yoshiki Matsumura, Tetsuhiro Yamano, Kunitsugu Takasaki, Neil L. Greenberg, James D. Thomas, Takahiro Shiota The Cleveland Clinic, Cleveland, OH Background: Two-dimensional echocardiography (2DE) may not be reliable in determining right ventricular (RV) function when abnormal RV geometry and hemodynamics are present. RV volume and ejection fraction (EF) determined by real-time 3-dimensional echocardiography (RT3DE) have been validated by magnetic resonance imaging. We compared RV size and contractility between RT3DE and 2DE in patients with and without RV volume and pressure overloads. Methods: We analyzed 55 patients who underwent simultaneous 2DE and RT3DE studies (age, 56 ± 18 years). Diagnoses consisted of mitral valve disease in 19, coronary artery disease in 12, aortic valve disease in 10, dilated cardiomyopathy in 6, tricuspid valve disease in 5 and congenital heart disease in 3. RV end-diastolic area (EDA), end-systolic area (ESA), fractional area change (FAC) and systolic pressure (SP) were determined by 2DE. RV enddiastolic volume (EDV), end-systolic volume (ESV) and EF were determined by RT3DE acquiring full-volume RV datasets. RV volumes were derived by manual tracing of endocardial border using software (4D RV-Function, TomTec Corporation) and EF was computed. Dilated RV area was defined as EDA of >30 cm 2, whereas increased RV pressure was defined as SP of >40 mm Hg. Results: Average RV-EDA, ESA, FAC and SP were 22 ± 8 cm 2, 14 ± 6 cm2, 37 ± 11% and 36 ± 13 mm Hg, respectively. Average RV-EDV, ESV and EF were 99 ± 38 ml, 52 ± 22 ml and 47 ± 9%, respectively. Dilated RV area and increased RV pressure were observed in 9 and 12 patients, respectively. In all the patients, RV-EDA, ESA and FAC were correlated with RV-EDV, ESV and EF, respectively (all p <0.001). In patients without RV dilation, RV-EDA, ESA and FAC were correlated with RV-EDV, ESV and EF, respectively (all p <0.04); however, 2DE-derived RV parameters did not show any significant correlations with RT3DE-derived RV parameters in those with RV dilation (Fig). In both patients with and without increased RV pressure, RV-EDA, ESA and FAC were correlated with RV-EDV, ESV and EF, respectively (all p <0.04). Conclusion: RV area and FAC determined by 2DE were correlated with RV volume and EF determined by RT3DE, unless RV dilation was present. Attention has to be paid to assess RV function when only 2DE is applied in patients with dilated RV. RT3DE may play an indispensable role for assessing RV function in such patients.

Journal of the American Society of Echocardiography May 2008

570

P2-63

P2-64

The Impact of Transcatheter Atrial Septal Defect Closure on Left Ventricular Volume and Function - a Prospective Study Using 3D Echocardiogram and Serum Natriuretic Peptides

Three-Dimensional Mitral Annular Tracking Demonstrates Important Structural and Functional Annular Differences Depending on the Etiology of Mitral Regurgitation

Masaki Nii1, Kennichi Kurosaki2, Satoshi Yazaki 2, Masataka Kitano2, Osamu Yamada 2, Shigeyuki Echigo2 1 Shizuoka Children‘s Hospital, Shizuoka, Japan; 2National Cardiovascular Center Japan, Osaka, Japan

Stephen H Little, Sagit Ben Zekry, William A Zoghbi The Methodist DeBakey Heart Center, Houston, TX

Background: Underfilled left ventricule (LV) in a patients with atrial septal defect (ASD) increases its end-diastolic volume and stroke volume after transcathter ASD clsoure, which improve exercise capacity. Although most of the patients who had transcatheter ASD closure show uneventful postprocedual course, some patients are reported to develop acute heart failure with lung congestion. The objectives of this study are : 1) to evaluate the change of LV volume in acute and chronic phase by using three-dimensional echocardiogram (3DE), 2) to elucidate the factors that affect the LV volume change. Methods: Of the 36 patients who had trascatheter ASD closure, 35 patients with successful 3DE LV volume analysis were included in this study (male 13, female 22; age median 19 (6-67). LV and right ventricular (RV) dimension, volume and function were assessed by two-dimensional and 3DE using IE33 (PHILIPS) and serum concentrations of natriuretic peptides were measured before ASD closure, 48 hours after, and 3 months after. Results: 1) A mean LV end-diastolic volume masured 41.2 ml/m2 at baseline, 46.2 ml/m2 (p<0.05) at 48 hours and 53.3 ml/m2 (p<0.001) at 3 months. A mean stroke volume at baseline 14.0 ml/m 2, 15.5 ml/m2 (p<0.05) at 48 hours, 18.3 ml/m2 (p<0.001) at 3 months. Due to decrease of heart rate that develops after ASD closure, cardiac index showed small rise and the difference was significant only between baseline and 3months. 2) Of these patients studied, 12 patients showed maladaptation of LV (no increase of LV end-diastolic volume after ASD closure). In these patients LV inflow E/A (1.77±0.62) was significantly lower and pulmonary venous flow S/D (1.25±0.24) was higher than rest of the patients (E/A 2.76±0.90, S/D 0.97±0.18). RV dimensions or function showed no difference between the groups. Serum ANP levels at 48 hours were significantly higher in LV maladaptation group (28.6±8.8 pg/ml) than the rest of patients (21.8±10.8 pg/ml), but BNP levels were not significantly different. Conclusions: About one third of patints who had ASD closure showed LV maladaptation. Relatively impaired ventricular relaxation and increased ANP levels after ASD closure were observed in LV maladaptation group. The influence of RV size or function on LV volume adaptation was not demonstrated.

Background: Real-time 3D echocardiography and unique software permit mitral annulus (MA) tracking throughout systole to assess MA remodeling and function. Whether mitral annulus structure and function are altered differently, depending on the etiology of mitral regurgitation (MR), is currently not well known. Methods: We evaluated dynamic MA characteristics in patients with significant MR secondary to mitral valve prolapse (MVP-MR) and functional MR (F-MR) and compared them to normal controls. Novel 3D tracking software (based on 3D optical flow combined with block matching) was used to identify 16 circumferential equidistant MA points and to track changes in MA area and apical descent from end-diastole to end-systole (see figure-patient example). Patients with at least moderate MR underwent a complete transthoracic 2D and quantitative Doppler study with 3D full volume MA imaging from the apical 4 chamber view. Results: For each group studied, LV size, function and dynamic MA characteristics are shown in the table. Compared to normals, the F-MR patients demonstrated end-diastolic MA area enlargement with reduced systolic area change and reduced apical decent. In comparison, MVP-MR patients demonstrated the largest enddiastolic MA area with preserved annular area change and only mild reduction of apical decent. This finding suggests that MVP-MR may involve significant MA remodeling without deterioration of MA systolic function. Summary Data Normal (N=15) End Diastolic Volume (ml) 133 ± 21 LV Ejection Fraction (%) 61 ± 5 Maximum MA Descente (mm) 11 ± 2 13 ± 3 Largest MA Area (cm2) MA Area Change (%) 26 ± 8 * p<0.05 vs control; § p<0.05 vs MVP-MR or FMR

MVP-MR (N=15) 148 ± 62*§ 63 ± 19 § 9 ± 3*§ 23 ± 5*§ 22 ± 5 §

Functional-MR (N=13) 229 ± 68*§ 31 ± 9*§ 6 ± 2*§ 16 ± 4*§ 15 ± 5*§

Conclusion: Patients with MR have significant mitral annular enlargement, irrespective of MR etiology. However, in contrast to functional MR, patients with MR secondary to MVP have the largest annular remodeling - almost twice normal - and yet have preserved annular function and dynamicity.

P2-65

P2-66

Development of a Method to Track Stem Cell Engraftment Using ContrastEnhanced Ultrasound and Targeted Microbubbles

Noninvasive and Quantitative Assessment of Neovascularization after Stem Cell Transplantation by Contrast Sonography

Michael A. Kuliszewski 1, Alexandra H. Smith 1, Christine Liao1, Aris Xie 2, Jonathan R. Lindner2, Howard Leong-Poi1 1 St. Michael‘s Hospital, Toronto, ON, Canada; 2Oregon Health and Sciences University, Portland, OR

Kentaro Otani1, Shunsuke Ohnishi1, Hiroaki Obata1, Osamu Ishida1, Soichiro Kitamura2, Noritoshi Nagaya1 1 National Cardiovascular Center Research Institute, Suita, Japan; 2National Cardiovascular Center, Suita, Japan

Methods to track the fate of stem cells after their administration would be useful in assessing the efficacy of cell-based therapies. We hypothesized that contrast-enhanced ultrasound (CEU) using microbubbles targeted to a genetically engineered cell-surface marker on endothelial progenitor cells (EPCs) would allow the targeted imaging of vascular engraftment of progenitor cells. Methods: Bone-marrow derived EPCs were isolated from donor F344 rats, cultured for 7 days, and transfected using electroporation to express the marker protein, H-2Kk, on the cell surface. Microbubbles targeted specifically to H-2Kk protein expressed on EPCs (MBH2Kk) were constructed. Control microbubbles (MB C) were also constructed. Binding of targeted microbubbles to EPCs was assessed in vitro using a parallel plate flow chamber system (n=6), where microbubbles (3×107 per mL) were infused at a shear rate of 1 dyne/cm2, followed by saline flush. Imaging of EPC-targeted microbubbles was assessed in vivo in EPCsupplemented (1×106 cells) matrigel plugs implanted subcutaneously into the ventral surface of 9 rats. Each rat received 2 plugs, supplemented with either H-2Kk-transfected EPCs or control non-transfected EPCs. After 7 days growth, targeted CEU was performed with bolus injections of either MBC or MBH2Kk (5×107 per injection). Results: While there was minimal attachment of control bubbles, there was prominent and diffuse attachment of MB H2Kk to plated BM-derived EPCs in flow chamber experiments. The number of adhered microbubbles was significantly greater (p<0.001) for H-2Kk targeted microbubbles as compared to MB C. For matrigel plugs, CEU perfusion was similar for both plugs, with greater flow in the periphery. Targeted CEU demonstrated marked contrast enhancement at the periphery of the H-2Kktransfected EPC-supplemented matrigel plug for MBH2Kk whereas contrast enhancement was low for control non-targeted microbubbles. Contrast enhancement was also low for both microbubbles (MBH2Kk and MBC) within control non-transfected EPC plugs, consisted with a lack of non-specific binding to angiogenic vessels, and specificity for our transfected EPCs. The signal intensity within the H-2Kk-transfected EPC plug was significantly greater (p<0.005) for MBH2Kk as compared to MBC. Conclusions: Microbubbles targeted to a genetically engineered cell-surface marker on EPCs exhibit specific binding to engineered EPCs in vitro. These targeted microbubbles bind to EPCs in vivo within matrigel plugs, and can be detected by their enhancement on CEU imaging.

Background and Aim: Angiogenic therapy including cell transplantation is one of the attractive therapeutic strategies for ischemic diseases. However, there are few methods for noninvasive and quantitative assessment of neovascularization after cell transplantation. The contrast sonography might be a useful diagnostic tool for the assessment of neovascularization after cell transplantation. The aim of this study was to investigate the feasibility of contrast sonography for noninvasive and quantitative assessment of neovascularization after bone marrow-derived mesenchymal stem cell (MSC) transplantation in a rat model of hindlimb ischemia. Methods: Eighteen male Lewis rats with unilateral hindlimb ischemia were used in this study. 2×10 6 MSC (Treated) or saline (Control) (Total volume: 500µL) was injected into the ischemic hindlimb muscle at 1 day after the surgical procedure. Hindlimb blood flow was assessed by laser Doppler perfusion imaging (LDPI), contrast sonography and microspheres (MS) at 14 days after MSC transplantation. In the contrast sonography, the video intensity versus time plots was acquired by using the SONOS5500 (PHILIPS) during the continuous infusion of Levovist (Schering). The blood volume (A), microbubble velocity (β) and blood flow (Aβ) were calculated. All parameters were calculated as the left to right ratio (LDPI index, A-, β-, Aβ- and MS-ratio, respectively). Capillary density was quantified histologically by alkaline phosphatase staining. Results and Conclusion: The LDPI index and MS-ratio in the MSC-Treated group were significantly higher than those in the Control group (LDPI index: 0.89±0.03 vs. 0.74±0.03, MS-ratio: 0.50±0.08 vs. 0.23±0.06). Furthermore, contrast sonography-derived β-ratio and Aβ-ratio in the MSC-Treated group were also significantly higher than those in the Control group (β-ratio: 0.77±0.08 vs. 0.53±0.06, Aβ-ratio: 1.04±0.09 vs. 0.64±0.10), while the A-ratio was not significantly changed. The β-ratio was correlated well with MS-ratio (Figure A), whereas it was modesty correlated with LDPI index (Figure B). The β-ratio was also correlated with the capillary density in histological analysis (Figure C). In conclusion, contrast sonography-derived β-ratio reflects neovascularization in hindlimb ischemia after cell transplantation.

Journal of the American Society of Echocardiography Volume 21 Number 5

571

P2-67

P2-68

Safety of Contrast Administration for Endocardial Enhancement during Stress Echocardiography: Observations from a Large Cohort and Comparison to NonContrast Stress

Acute Mortality in Hospitalized Patients Undergoing Echocardiography with and without Ultrasound Contrast Agents: Results in 18,467 Consecutive Patients

Kamran Shaikh, Su Min Chang, Kathleen Rosendahl-Garcia, Miguel A Quiñones, Sherif F Nagueh, Karla M Kurrelmeyer, William A Zoghbi Methodist DeBakey Heart Center, Houston, TX Background: Recently the FDA issued a warning on the safety of contrast agents. There is a paucity of data regarding the safety of contrast in conjunction with stress echocardiography. Accordingly, we evaluated adverse events of patients undergoing stress echocardiography with contrast (CE) for endocardial enhancement in a large non-select population and compared findings to the no-contrast cohort (NCE). Methods: A detailed retrospective review of digital records was performed on all 3121 consecutive patients who underwent stress echocardiograms (55.8% dobutamine and 44.2% exercise stress) from 2002 through 2007 at the DeBakey Heart center. Demographics, contrast use, hemodynamics, ECG and wall motion changes, symptoms and arrhythmias during and following stress were evaluated till time of discharge from the laboratory. Results: Contrast was administered in 1879 of 3121 pts (60%), the majority being Definity™ (95%). Contrast utilization was higher in in-patients, dobutamine and bicycle stress (77%, 78%, and 73%, respectively). Compared to the NCE group, patients receiving contrast were older (61±13 vs. 56±15 yrs), had higher BMI (30.2±8.4 vs. 27±5.5) and had more depressed LV ejection fraction <50% (13% vs. 8%); all p<0.001. Although the CE group achieved a lower double product of systolic pressure and heart rate (22,901 ± 5,232 vs. 24,365 ± 5,453; p<0.001, the prevalence of abnormal wall motion in CE during stress was higher (28% vs. 22%; p<0.001). In the contrast group, there was a higher incidence of back pain (0.9% vs. 0.08%, p<0.001) and chest pain (11.5% vs. 8.5%, p=0.009). More shortness of breath was seen in the NCE group (17.2% vs. 12.9%, p<0.001). There was one uncomplicated acute myocardial infarction (1/1879) and 1 anaphylactoid reaction in the contrast group and none in the NCE group (p= 0.8 for both). There was no difference in clinically significant arrhythmias (defined as atrial fibrillation/flutter, accelerated idio-ventricular or junctional rhythm, supra-ventricular tachycardia, sustained or non-sustained VT or VF) between the 2 groups (CE=2.1 % vs. NCE=1.9 %; p = 0.8). There was no sustained ventricular tachycardia, ventricular fibrillation, cardiac arrest or death in either group. Conclusions: In a large cohort of consecutive patients undergoing stress echocardiography, contrast was used more often in patients with a higher cardiac risk profile. The risk of major adverse events however is very small in both, contrast and non-contrast echo cohorts.

Lisa L Kusnetzky, Adnan Khalid, Tina R Coggins, Philip G Jones, Tabitha G Moe, Michael L Main Mid America Heart Institute, Kansas City, MO Background: Ultrasound contrast agents are indicated to enhance endocardial border delineation in patients with technically difficult baseline echocardiographic examinations. The U.S. Food and Drug Administration recently issued new contraindications for contrast use, largely based on 4 deaths occurring during or immediately following Definity® injection. It is unknown whether there is any incremental risk associated with contrast use. Objective: Determine acute (24 hour) mortality in patients undergoing in-patient echocardiography with and without contrast administration. Methods: We performed a retrospective review of 18,467 consecutive hospitalized patients who underwent echocardiography between January 2005 and October 2007 within the Saint Luke’s Health System using the Cardiovascular Consultants echocardiography data base (ProSolv® Cardiovascular, Indianapolis, IN). These patient were separated into 2 groups, those performed without contrast enhancement (n=12,277) and those performed with contrast enhancement using Definity® (Bristol Myers Squibb-Medical Imaging, Billerica, MA) (n=6190). Vital status within 24 hours of the echocardiographic study was available for all patients using a combination of the Social Security Death Index and Saint Luke’s Health System medical record. Results: Of the patients undergoing unenhanced echocardiography, 55 died within 24 hours (0.42%). Of patients receiving Definity® during the echocardiogram, 30 died within 24 hours (0.50%). There was no statistical difference between these 2 groups (p=0.41). Conclusion: Approximately 1 in 200 patients die within 24 hours following in-patient echocardiography. There is no incremental mortality risk associated with Definity® administration.

P2-69

P2-70

Comparison of Wall Motion and Perfusion in Detecting Coronary Artery Disease During Treadmill Exercise and Pharmacological Stress Imaging with Real Time Myocardial Perfusion Echocardiography

Left Bundle Branch Block Causes Reduced Septal Wall Thickness and Function Despite Normal Perfusion: Implications Regarding Using Myocardial Contrast Echocardiography not Radionuclide Perfusion Imaging for the Detection of Coronary Artery Disease

Saritha Dodla, Feng Xie, Edward O‘Leary, Monique Smith, Thomas R Porter University of Nebraska Medical Center, Omaha, NE Background: The continuous infusion of microbubbles has permitted the examination of myocardial blood flow changes during stress imaging using real time myocardial perfusion echocardiography (RT-MPE). Although this has improved the sensitivity of pharmacologic stress echocardiography in detecting coronary artery disease (CAD), it is unclear whether this improved sensitivity would also be possible with treadmill exercise echocardiography (TESE). Methods: Between December 2005 and August 2007, 151 patients (mean age 59+13 years) underwent stress echocardiography for suspected CAD during either dobutamine stress echocardiography (DSE; n=95 patients) or TESE (56 patients). RT-MPE was performed at rest and during peak stress using a continuous infusion of ultrasound contrast (3% Definity; Bristol Myers Squibb) and low mechanical index (MI) real time perfusion (Siemens Acuson Sequoia Contrast Pulse Sequencing or Philips Power Modulation). Intermittent high MI impulses were administered in each of the apical windows to visually analyze myocardial perfusion (MP) and wall motion (WM) in each coronary artery territory (CAT). TESE images were obtained immediately after cessation of exercise. All patients underwent subsequent quantitative coronary angiography. Statistical comparisons were examined using > 50% diameter as the cut-off. Results: Seventy seven of the DSE studies were abnormal (81%; 45 multi vessel pattern; 32 single vessel pattern) while 41 of the TESE studies were abnormal (73%; 22 multi-vessel pattern; 19 single vessel pattern). The sensitivity of MP at peak stress was significantly higher than WM for detecting CAD during DSE (p=0.02), while no difference between MP and WM sensitivity was noted during TESE (Table). WM sensitivity during exercise was also tended to be higher than WM sensitivity during DSE (Table, p=0.07). Rate pressure product (RPP) achieved with exercise was not different than dobutamine (Table). Conclusions: Myocardial perfusion imaging with RT-MPE improves the detection of CAD during pharmacologic stress imaging but not treadmill exercise stress imaging. This difference may be attributed to the greater sensitivity of WM analysis during exercise testing. Comparison of Wall Motion and Myocardial Perfusion During Exercise Versus Dobutamine Stress MP WM MP WM DSE DSE Exercise Exercise Sensitivity Accuracy Specificity RPP

90% 71% 33% 22567

74% 67% 55%

89% 76% 55% 22263

89% 78% 60%

Sajad A Hayat, Girish Dwivedi, Alexander Jacobsen, Tiong K Lim, Christopher Kinsey, Roxy Senior Northwick Park Hospital, Harrow, United Kingdom Background: The accuracy of single photon emission computed tomography (SPECT) for the detection of CAD in patients with left bundle branch block (LBBB) is confounded by the heterogenous effects of LBBB on myocardial structure, function and perfusion resulting in a high incidence of septal perfusion defects in the absence of CAD. We aimed to investigate the cardiac effects of LBBB using myocardial contrast echocardiography (MCE) to ascertain the value of MCE for detection of coronary artery disease (CAD) and to uncover the mechanism which affects the accuracy of SPECT in these patients. Methods: Sixty three symptomatic LBBB patients (Group A), 10 left ventricular ejection fraction (LVEF) matched controls without LBBB and no CAD (Group B) and 10 normal controls (Group C) underwent resting echocardiography. Rest and vasodilator MCE (SonoVue) and quantitative SPECT were undertaken in LBBB patients. Septal and posterior wall (SW and PW) thickness, thickening, quantitative myocardial blood flow (MBF) and MBF reserve (MBFR) were measured by MCE. Results: SW/PW thickness and percentage thickening ratios were respectively lower (p<0.01 and p<0.05) in group A compared to both groups B and C but resting SW/PW MBF and MBFR ratios were similar in all 3 groups. MBFR not MBF was reduced in groups A and B (2.2±0.7 vs. 2.2±0.2, p=0.98) compared to C (3.1±0.5), p50% diameter stenosis). MCE (92%) had similar sensitivity to SPECT (92%), but specificity of MCE (95%) was superior (p<0.0001) to SPECT (47%) for the detection of CAD. The number of segments demonstrating reversible defects in patients with CAD was significantly (p=0.008) greater with MCE (6.8±3.0) compared to SPECT (4.4±3.7). If only reversible defects were considered to represent CAD, then the sensitivity of MCE on a vascular territory basis was 84% but the sensitivity of SPECT dropped to 57% (p=0.03). MBF reserve was significantly higher in patients with coronary artery stenosis less than 50% stenosis compared to patients with greater than 50% stenosis, p<0.0001. Conclusion: Despite asymmetric reduction in SW thickness and function, MBF is preserved and MBFR is homogeneously reduced in LBBB patients. Due to partial volume effect accuracy of SPECT for the detection of CAD was significantly compromised compared to MCE in this patient cohort.

Journal of the American Society of Echocardiography May 2008

572

P2-71

P2-72

Assessment of Protective Effect of Ischemic Preconditioning on Myocardial and Microvascular Damage by Myocardial Contrast Echocardiography and Coronary Flow Doppler Imaging

Usefulness of Contrast in Routine Clinical Echocardiography

Xin Chen, Weidong Ren, Li Tang, Zhiwei Zhang, Yuhong Li, Chunyan Ma 1st Affiliated Hospital of China medical university, Shenyang, China

Shizhen Liu1, Peng Li1, Nitanth R Vangala 2, Geu-Ru Hong1, Wei Zhao 1, Mavgavel Knoll3, Mani A Vannan 1 1 Ohio State University, Columbus, OH; 2University of California, Irvine, CA; 3 University of California, Irvine, Medical Center, Orange, CA

Background: Repeated ischemia and reperfusion may renders heart more resistant to the subsequent prolonged ischemia. The phenomenon was termed myocardial ischemic preconditioning (IP). IP as a result of preinfarction angina (PA) can limit necrosis extent after acute myocardial infarction (AMI). The purpose of the study was to evaluate the relationship between PA, microvascular reflow, and myocardial function using myocardial contrast echocardiography (MCE) and transthoracic coronary flow Doppler imaging (TCFDI). Methods: In 42 patients with a first AMI, microvascular perfusion using MCE with Sonovue and coronary flow reserve (CFR) using TCFDI were assessed quantitatively, and we also investigated myocardial contractile recovery with low-dose dobutamine echocardiography (LDSE) and 3-month follow-up echocardiography. CFR was calculated as the values of adenosine/rest ratio of peak coronary flow velocity and velocity time intergral (VTI) respectively. The percentage extent of contrast defect after MCE within the risk area (RA), CFR, wall motion score index (WMSI) and left ventricular volume were evaluated. Results: Typical angina was present in 25 patients and absent in 26 patients during the 7 days preceding the myocardial infarction. Compared with those patients without PA, patients with PA showed a greater microvascular reflow extent and CFR, respectively (0.26±0.19 vs 0.51±0.23, P<0.05, and Vmax/Vbase:2.91 ± 0.61 vs 1.67 ± 0.81, P<0.0001; VTImax/VTIbase: 3.05±0.58 vs 1.81±0.76, P<0.0001). and, less pronounced left ventricular dilation at follow-up. Regional myocardial function expressed with WMSI in the risk area at LDSE was similar in the first echocardiogram (2.49± 0.21 vs 2.51±0.19, P>0.05) between the two groups. However, WMSI was lower in the patients with PA than that in the patients without PA significantlty at both 7days after AMI (1.71 ± 0.31 vs 2.01 ± 0.23, P<0.0001) and 3months follow-up echocardiography (1.69 ± 0.28 vs 2.19 ± 0.17, P<0.0001). Conclusion: Myocardial and microvascular damage were reduced and left ventricular remodeling was limited due to preconditioning effect after AMI. The protection effect of ischemic preconditioning on ischemic-reperfusion myocardium and coronary flow reserve can be objectively evaluated MCE and TCFDI.

Background: There is very little data on the impact of improved visualization of the LV endocardium by contrast echocardiography (CE) on the quality of echo reports and its potential influence of improved reports on management decisions. We evaluated the efficacy and effect of contrast echocardiography on these measures in consecutive patients not selected for the quality of the acoustic window. Methods: 4,148 patients (between January 2005 - August 2007) who underwent both conventional and contrast (Definity, BMS, MA) echo study ) were enrolled. 0.2~0.4 ml slow bolus contrast was given. Parasternal long axis view (LAX), apical four chamber view (A4C) and apical two chamber view (A2C) were used for LV 16 segmental EBD analysis according to ASE standard. EBD score was scaled from 0 to 4. Evaluable segment defined as greater than 50% endocardial visualization (score 3 and 4), and excellent segment defined as full endocardial visualization (score 4). We also tablulated specific findings and management decision based on the non-contrast and contrast echo reports Results: Most nonevaluable segments enhanced to evaluable, and majority to excellent after CE (Fig. 1). Compared with LAX, apical long axis view had better EBD enhancement in posterior wall (3.67 to 3.22 and 3.71 to 3.27 in mid and basal, p < 0.05). In 3,621 (87%) patients with excellent apical visualization after CE, there were 18% additional apical abnormalities after contrast (not seen before contrast). In 1,037 (25%) patients the confidence of medical decision-making increased from poor to excellent with contrast echo report. Of these, patients with chest pain and CAD got more benefit from the additional diagnosis and management strategy influenced by additional diagnostic CE information (Table 1). Conclusions: The data form this large patient population unselected for acoustic window show that improved visualization of endocardial border has a direct positive impact on the quality and confidence of echo reports which translate to additional management decisions. Percentage of diagnosis added and management strategy influenced by additional diagnosis after CE Total

1037

Results added

Management influenced

743/1037 (72%)

388/743 (52%)

AF

190

121/190 (64%)

52/121 (43%)

Chest pain

121

104/121 (86%)

61/104 (58%)

SOB

328

207/328 (63%)

86/207 (42%)

Stroke

156

104/156 (67%)

52/104 (50%)

CAD

242

207/242 (86%)

137/207 (67%)

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P2-74

Contrast Enhanced Ultrasound Molecular Imaging at High and Low Mechanical Index: In Vitro and In Vivo Comparisons

The Safety of Definity Echocardiography Contrast

Beat A Kaufmann, Chad L. Carr, Todd Belcik, Aris Xie, Ben Cron, Qi Yue, Jonathan R. Lindner Oregon Health & Science University, Portland, OR Background: Molecular imaging with contrast enhanced ultrasound has been performed with conventional ultrasound contrast imaging parameters. It is not known whether the relative signal generation during high versus low mechanical index (MI) imaging is affected by ligation of targeted microbubbles in vivo. The aim of this study was to characterize targeted signal enhancement at low versus high MI. Methods: Imaging was performed with Cadence Pulse Sequence imaging at 7MHz at either low or high MI (0.2 or 0.97). The concentration versus intensity relationship for each MI was assessed in a water bath with microbubble concentrations ranging from 0.5 to 50×103 mL-1. The effect of microbubble ligation to cells on signal enhancement at high or low MI was first determined in vitro with microbubbles targeted to VCAM-1 combined with TNF-α activated or non-activated murine endothelial cells. For these experiments, the percentage of microbubbles attached to cells was quantified with microscopy prior to imaging. For in vivo studies, molecular imaging with P-selectin or control microbubbles was performed in a murine model of acute hindlimb ischemiareperfusion. Adhered microbubbles were imaged first at low MI and subsequently at high MI. Results: There was a linear relationship between microbubble concentration and signal enhancement for low and high MI in vitro over the range of concentrations tested. The signal at high MI was 2.7±0.7 times higher than at low MI with no dependence on concentration. When combined with endothelial cells, the percentage of VCAM-1-targeted or control microbubbles that were attached to cells ranged from 0 to 31%. The ratio of signal enhancement for high versus low MI imaging was not influenced by the percentage of microbubbles adhered to cells, and was similar (2.3±0.6) to that obtained in the absence of cells. In vivo imaging (n=164 observations) demonstrated a linear relationship (r2=0.85, p<0.0001) between signal intensity at high and low MI. The ratio of signal intensity at high versus low MI was 2.4. Conclusions: During high frequency imaging (7 MHz) attachment of targeted microbubbles to cells does not significantly dampen their acoustic signal generation. Signal enhancement is 2-3 times higher when imaging at high versus low MI. However, the relative amount of signal enhancement for different numbers of retained microbubbles is similar for high and low MI imaging.

William Duvall 1, Murali Krishnan2, Micah Mann1, Lori Croft1, Eric Stern1, Martin Goldman1 1 Mount Sinai Medical Center, New York, NY; 2Elmhurst Medical Center, Queens, NY Background: Precision microspheres improve echocardiographic images in technically difficult patients, especially in acutely ill or ICU patients in whom accurate LV assessment may be critical. Due to a recent FDA decision, a black box warning was added to the package labeling of Definity® (perflutren lipid microsphere) prohibiting its use in congestive heart failure, acute coronary syndromes, cardiac arrhythmias, respiratory failure, and pulmonary hypertension due to possible serious cardiopulmonary reactions including death. However, in the four postmarketing deaths attributed to Definity®, the implied direct causation was very tenuous and the true risk of Definity® administration is unknown. The purpose of this study was to determine if Definity® administration was associated with increased short or longterm mortality. Methods: Mount Sinai Echocardiography Lab records were reviewed for all inpatients and outpatients who had a transthoracic echocardiogram with Definity® contrast over a one year period from April 2006 to April 2007. Subjects were matched to controls based on their age, gender, left ventricular function, and location of the study (outpatient, inpatient ICU, inpatient telemetry unit, or inpatient floor). Mortality was assessed at 24 hours, one week, and at the end of follow-up using the Social Security Death Index. Chi-square statistics were used to compare groups. Results: A total of 1388 Definity® patients were identified with a mean age of 64 ± 15 yrs, 73% inpatients (21% in a telemetry unit, 21% in an ICU, and 31% on another inpatient floor), 55% had normal LV function, 16% mild LV dysfunction, 16% moderate LV dysfunction, and 14% severe LV dysfunction. Mean follow-up was 6.1 ± 3.4 months. Sixty-nine (5%) Definity® patients had died at follow-up, 1 died at 24 hours, and 6 at one week. In the 666 matched controls that were identified, 85 (13%) had died at follow-up, 2 died at 24 hours, and 8 at one week. At 24 hours, there was no statistical difference in mortality between Definity® patients and the control group (OR 4.2 [0.38-46.2], p=0.52). There was a trend towards higher mortality at one week in the control group (OR 2.8 [0.97-8.1], p=0.09). Discussion: We found no increased mortality risk with the use of Definity® echocardiographic contrast in a diverse patient population including 586 (42%) patients in monitored units. Our findings suggest Definity® administration, even in compromised patients, is not associated with increased mortality. The current stringent restrictions limit the ability to obtain diagnostic quality echocardiographic images in patients who may benefit the most.

Journal of the American Society of Echocardiography Volume 21 Number 5

573

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P2-76

Outcomes of Patients Receiving DEFINITY in the Calgary Health Region between 2003 and 2007

Incremental Diagnostic Utility of Sonicated Contrast for LV Thrombus Detection is Independent of Non-Contrast Echo Image Quality - A Multimodality Imaging Study

Sara L Partington, Jeff Booker, Sarah G Weeks, Sandeep Aggarwal, Albert J Kryski, Dal Disler, Diane Galbraith, Gregory Schnell University of Calgary, Calgary, AB, Canada Background: Fluorocarbon-based echocardiographic contrast agents (ECA), such as DEFINITY, result in improved accuracy of left ventricular function assessment. Recently, a black-box warning and contraindications to ECA use in some high-risk patient groups has been announced based on four deaths temporally related to ECA administration. This has resulted in restricted use of these agents in patients presenting with an acute coronary syndrome (ACS). Objectives: To determine if there is an association between DEFINITY administration and mortality in high-risk subgroups of patients who underwent contrast echocardiography after hospitalization in the Calgary Health Region (CHR). Methods: All patients who received DEFINITY for clinical indications in the CHR from February 2003 until December 2007 were identified from a computer database. Survival status and presenting diagnosis were determined through cross-referencing with the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Registry; a prospective data collection initiative that has captured detailed clinical information on patients with a cardiac admission, cardiac diagnostic investigations or cardiac surgery in the CHR. All-cause mortality is available from the APPROACH database by semi-annual linkage to the Alberta Bureau of Vital Statistics. Patients who died within 48 hours of DEFINITY administration were considered to have an event potentially related to ECA use. A chart review of the patients who died was performed to determine if there was an association between DEFINITY administration and death. Results: Since March 2003, 1331 contrast echocardiography studies using DEFINITY have been performed in 1260 patients in the CHR. Survival and clinical data was available from APPROACH on 832 patients. Only 16 deaths (1.9%) occurred within 48 hours of ECA administration. There were 424 patients who had an admitting diagnosis of ACS (152 with STEMI, 135 with NSTEMI, 137 with unstable angina). In this potentially high-risk subgroup, there were only 8 deaths (1.9%) within 48 hrs of DEFINITY administration. Chart review revealed that all of these patients were critically ill at the time of death and there was no clear association between ECA administration and death. Conclusions: There was a low risk of death in patients who received DEFINITY in the CHR. There was no increased risk of death in patients with a presenting diagnosis of ACS. Chart review of patient deaths revealed a plausible explanation for mortality unrelated to DEFINITY in all cases.

Kirsten O Healy, Michael Ross, Daniel Krauser, Shant J. Manoushagian, James K Min, Ingrid Hriljac, Jorge Kizer, Mary J Roman, Richard B Devereux, Jonathan W Weinsaft Weill Medical College of Cornell University, New York, NY Background: Accurate identification of LV thrombus (LVT) is important for management of at risk patients. Although echo contrast improves LVT detection, guidelines recommend that contrast be reserved for non-contrast echo (NCE) with suboptimal image quality. The utility of a strategy of routine contrast use in patients at high risk for LVT is unknown. Methods: Contrast echo (CE) and NCE (interval 1.1±2.6 days) were uniformly performed in a broad cohort at high clinical risk for LVT. CE was performed irrespective of NCE diagnostic findings or image quality. CE and NCE were independently read for LVT and compared to a reference of delayed enhancement cardiac MRI, a technique previously validated as highly accurate for LVT detection. CE and NCE were graded for cumulative image quality on a 9 point scale comprising indices for border definition, cavity opacification and multiplanar LV imaging. Results: 129 pts were studied (LVEF 37%, NYHA 2.0±0.8, CAD 98%, MI 82%). 21% had LVT verified by MRI, associated with lower LVEF (28 vs. 39% p<0.01) and higher NYHA class (2.5 vs 1.9 p<0.001). Echo diagnostic performance markedly improved by uniform contrast use, with nearly 2-fold higher sensitivity for LVT with CE (62 vs 33%, p<0.05) and a trend for increased specificity (98 vs 92%, p=0.07) vs NCE. Diagnostic improvement was independent of LVEF, LV size or NCE image quality, with similar grades for NCE that detected LVT and those in which contrast identified LVT not detected by NCE (image quality score 7.0±2.1 vs 6.9±2.1 p=0.9). Similarly, while CE improved all quality parameters vs NCE in the overall cohort, LVT detection did not vary based on echo quality, with similar values for all qualitative parameters in NCEs that missed versus detected thrombus (Table). CE was less likely to detect MRI evidenced LVT when mural in shape (p<0.05), non-apical in location or, if apical, small volume (p<0.05). Conclusions: In patients at high risk for LVT, a strategy of uniform contrast use markedly improved LVT detection. Diagnostic utility of CE was independent of NCE image quality or LV structural parameters, suggesting that contrast use should be guided by pretest clinical risk for LVT rather than NCE image quality or findings. Echo Image Quality in Relation to LV Thrombus Detection Image Quality

Endocardial Border Definition

LV Cavity Delineation

Pts with Pts with Overall Thrombus Thrombus P Population* Detected Missed

Pts with Pts with Overall Thrombus Thrombus P Population* Detected Missed

Pts with Pts with Overall Thrombus Thrombus P Population* Detected Missed

NonContrast 7.51±1.67 Echo

7.00±1.93

6.82±1.67

0.82 2.31±0.77

2.00±0.93

2.06±0.66

0.86 2.33±0.89

2.13±0.83

1.81±1.47

0.59

Contrast 8.22±1.27 Echo

7.63±1.36

7.50±1.51

0.83 2.61±0.59

2.50±0.51

2.30±0.67

0.40 2.83±0.42

2.75±0.44

2.40±0.69

0.18

* p < 0.001 for all comparisons between contrast and non-contrast echo

P2-77

P2-78

Contrast Reactions in 16,328 Patients: Routine Monitoring and Reporting Side Effects to Perflutren

Myocardial Blood Volume Assessed by Contrast Echocardiography Can Predict Functional Improvement by β-blocker in Patients with Idiopathic Dilated Cardiomyopathy: Comparison with Dobutamine Echocardiography and MIBG Scintigraphy

Jeanette A St Vrain, Robert E Karsch, Majesh Makan, Julio E Perez Barnes-Jewish Hosp at Washington University, St Louis, MO Background: The clinical value of transpulmonary contrast agents administered in conjunction with technically difficult echocardiograms is well established. Clinical trials have determined that there are certain risks and contraindications involved as described by package inserts. Prior to the recent implementation of a „Black Box“ warning by the FDA we had developed an internal protocol to prospectively monitor, treat and report such contrast reactions. We perform a high volume of procedures with usage of contrast in 41.3% of resting echocardiograms, 81% usage for stress echo. Methods: We tracked apparent contrast related reactions to a perflutren lipid microspheres based contrast agent from January 2006-October 2007 if a patient appeared to have a contrast reaction, staff reported symptoms which were entered into a custom designed electronic database reporting system to generate statistical procedure volumes. Serious adverse events were also reported as necessary to the Patient Safety Council in addition to hotline notification. Appropriate allergy information was conveyed to patients. Allergic wrist band was placed. Allergy medication card was developed and given to patient. Results: Total of 88 pts 43 females 45 males ranging in age 24-95 yrs mean age 58 yrs where noted to have a variety of symptoms while undergoing transthoracic echo 61 pts, DSE 20 pts, Stress Echo 7 pts. Pts were noted to have experienced: 5 hives; 2 extreme shortness of breath; 2 hypotension; 2 ventricular tachycardia with AICD firing in one of these pts during contrast administration; 1 tingling of hands, feet, hot, flushed; 1 throat, neck, face swelling; 1 rash, pruritus; 1 dizzy, nausea, flushing; 3 hip pain; 1 vision disturbance; 1 occipital headache; 10 chest pain, pressure or burning; 12 severe back pain accompanied by either hip, leg, jaw, chest pain, dyspnea, headache; 46 severe back pain with no other symptoms; 9 pts treated with Benadryl; 2 albuterol; 2 saline infusions. Results Dates Jan 2006-Oct 2007

Total Pts Injected 16,328

Reactions 88

%Total Contrast 0.54%

Conclusion: Our incidence level of 0.54% was well below the adverse events reported in package insert of 8.4%. We feel it is prudent to have a process in place to manage, document and report contrast reactions as they occur. Our goal was to create and sustain a process of healthcare safety while at the same time rendering diagnostic quality echocardiographic studies.

Hiroyuki Iwano1, Satoshi Yamada 1, Masako Okada1, Hiroshi Komatsu1, Kaoru Komuro1, Hisao Onozuka2, Taisei Mikami 2, Hiroyuki Tsutsui 1 1 Hokkaido University Gaduate School of Medicine, Sapporo, Japan; 2Hokkaido University School of Medicine, Sapporo, Japan Background: Myocardial contractile reserve assessed by dobutamine echocardiography (DE) and a heart/mediastinum ratio (H/M) on the delayed iodine-123 metaiodobenzylzuanidine (MIBG) scintigraphy have been shown to predict the improvement in left ventricular (LV) systolic function by β-blocker in patients with idiopathic dilated cardiomyopathy (DCM). Recently myocardial blood volume (MBV) can be estimated using myocardial contrast echocardiography (MCE) with the compensation for the acoustic field inhomogeneity. We thus assessed the hypothesis that MBV could better predict the improvement of LV function by β-blocker therapy than contractile reserve or H/M. Methods: In 12 patients with DCM (NYHA I or II, 59±13 years) before initiation of β-blocker therapy and 13 age-matched control subjects (48±15 years), apical 4- and 2-chamber views of intermittent harmonic power Doppler imaging were obtained at end-systole of every sixth beat during continuous infusion of Levovist. MBV was calculated as 10x/10×100%, where X was myocardial contrast intensity minus contrast intensity of the adjacent intracavity blood pool in dB, and averaged among 12 segments. The patients underwent also low-dose DE (up to 20 µg/kg/min) and MIBG scintigraphy at rest. ∆EFdob was defined as the increase in LV ejection fraction (EF) during DE. LVEF was measured at baseline (EFbase) and at 12 month follow-up period (EFf/u). ∆EFf/u was defined as EFf/u minus EFbase. Results: MBV was significantly lower in patients with DCM than in controls (2.7±0.7 vs 3.6±1.1%, p<0.05). In the patients, EF during low-dose DE was significantly higher than EFbase (51±11 vs 32±9%, p<0.01). H/M was 1.8±0.4. EFf/u (44±10%) was significantly higher than EF base (p=0.01). ∆EFdob and H/M did not correlate with ∆EFf/u, whereas MBV correlated significantly with ∆EFf/u (r=0.71, p<0.01). Sensitivity and specificity values of ∆EFdob, H/M, and MBV for predicting ∆EFf/u>5% were 88% and 50% (∆EFdob), 38% and 75% (H/M), 88% and 75% (MBV), respectively. Conclusions: MBV was decreased in patients with DCM and associated with the functional improvement by β-blocker therapy. MCE could better predict the functional improvement than DE or MIBG scintigraphy.

Journal of the American Society of Echocardiography May 2008

574

P2-79

P2-80

Short-Term Cholesterol-Lowering Therapy Improves Myocardial Microvascular Dysfunction in Patients with Hypercholesterolemia: Evaluation of Myocardial Blood Velocity by Myocardial Contrast Echocardiography

Quantitative Assessment of Strain Rate Derived from Vector Velocity Imaging during Dobutamine Stress Echocardiography to Predict Outcome in Patients with Left Bundle Branch Block

Tomoyuki Watanabe 1, Masumi Iwai-Takano 2, Akiomi Yoshihisa 2, Yukio Maruyama 2 Department of Cardiology and Internal medicine, Health Coop. Watari Hospital, Fukushima, Japan; 2First Department of Internal Medicine, Fukushima Medical University, Fukushima, Japan

Ying Shan, Hector R Villarraga, Cristina Pislaru, Stephen S Cha, Patricia A Pellikka Mayo Clinic, Rochester, MN

1

We investigated whether myocardial microvascular dysfunction is improved by short-term cholesterol-lowering therapy in patients with hypercholesterolemia. Twenty-five patients with hypercholesterolemia (HL group) and 12 healthy volunteers (control group) were enrolled. We evaluated β ratio by MCE (an index of myocardial blood velocity: y=A(1-e(-βt))) and coronary flow velocity reserve (CFVR) by transthoracic echocardiography from rest to hyperemia. In 20 patients, these examinations were repeated 4 and 8 weeks after cholesterol-lowering therapy. We assessed relationship with LDL-cholesterol levels, β ratio, CFVR and the change of those indices by cholesterol-lowering therapy. In the HL group compared to the control group, LDL-cholesterol was increased (166±28 vs 107±21mg/dl, P<0.001), and β ratio and CFVR were decreased (β ratio: 1.3±0.2 vs 1.7±0.3; CFVR: 2.7±0.7 vs 3.3±0.4, P<0.05 respectively) at baseline. The LDL-cholesterol had a significant correlated with the β ratio (r=-0.47, p<0.05) and the CFVR (r=-0.592, p<0.05). After treatment, LDL-cholesterol significantly decreased (4w: 138±28, 8w: 145±30, P<0.0001), and β ratio increased (4w: 1.7±0.4, 8w:1.5±0.3, P<0.001), but CFVR did not change. Percent change of LDL-cholesterol had a significant correlation with % change of β ratio ( r=-0.52, P<0.05) by treatment, but not with % change of CFVR. In conclusion, short-term cholesterol-lowering therapy improved myocardial blood velocity reserve in hypercholesteloremic patients. Hypercholesterolemia may play an important role in microvascular dysfunction if patients have not coronary artery disease.

Background: Stress echocardiography (SE) has an important role in risk stratification in patients with known or suspected coronary artery disease (CAD), but patients with left bundle branch block (LBBB) exhibit abnormal septal motion which may limit the interpretation of stress echocardiography. We sought to determine whether quantitative assessment of strain (ε) and strain rate (SR) derived from vector velocity imaging (VVI) has predictive value for risk stratification in patients with LBBB. Methods: In 84 consecutive patients (age 75±9 years, 39% male) with LBBB undergoing dobutamine stress echocardiography for evaluation of known or suspected CAD, VVI was used off-line to measure longitudinal peak systolic strain (εsys) and peak systolic strain rate (SRsys) in sixteen left ventricular segments both at rest and at peak stress on apical 4-,3-and 2-chamber views. Follow-up was obtained for the combined endpoint of all cause death, nonfatal myocardial infarction (MI), and coronary revascularization. Results: During a median followup of 18.3 months, 12 patients (14.3%) died and 11 patients (13.1%) had nonfatal MI or coronary revascularization. Contribution of clinical risk factors, conventional SE variables, and VVI variables to outcome was assessed with Cox proportional hazards model. After adjustment for age and gender, wall motion score index at rest (HR 2.8 per unit; 95%CI, 1.8-5.9; P=0.0047) was the only independent predictor in a model combining clinical risk factors and conventional stress SE variables. However, when VVI variables were included in the model, average SRsys of 16 LV segments at peak stress (HR 76.7 per unit; 95%CI, 8.5-873.3; P<0.0001) was the only independent variable predictive of outcome. The optimal value to identify increased risk of events was average SRsys at peak stress<-0.5/s (sensitivity 66.7%, specificity 89.9%, P=0.0015, area under curve 0.7923). The annualized event-free survival was 45.9% in patients with average SRsys at peak stress<-0.5/s compared with 89.9% in patients with average SRsys at peak stress≥-0.5/s (P<0.0001) (Figure). Conclusion: Average SR sys at peak stress derived from VVI during SE was an independent predictor for combined all-cause mortality and cardiac events in patients with LBBB.

P2-81

P2-82

2D Speckle Tracking Derived Strain: Can it be Used to Reliably Measure the Inotropic Effect of Intravenous Dobutamine?

Age-Related Changes of Left Ventricular Outflow Tract Doppler Pattern during Exercise in Healthy Subjects: Its Implication to Dynamic Arterial Compliance

Amit Bhan, Stamatis Kapetanakis, Bushra S Rana, Francesco Casella, Mark J Monaghan Kings College Hospital, London, United Kingdom

Chi Young Shim, Jong-Won Ha, Woo-In Yang, Sungha Park, Sun-Ha Moon, HyunJin Lee, Jin-Mi Kim, Eui-Young Choi, Namsik Chung Yonsei cardiovascular center, Seoul, Republic of Korea

Background: Measures of 2-dimensional strain derived from speckle tracking are emerging as useful adjuncts in the assessment of regional left ventricular function both at rest and during stress. We set out to see if such technology could reliably document the inotropic effect of intravenous dobutamine during the four stages of a stress echo. Methods: 27 patients (16 male) referred for dobutamine stress echo, with a low pretest probability of coronary artery disease, and who had normal tests were included. Standard stress images were taken at each stage: Rest, low dose (10 mcg/kg/min), intermediate (30 mcg/kg/min) and peak (40 mcg/ kg/min). In addition 2 beat loops were acquired at each stage for off-line analysis with the speckle tracking software. The standard images were interpreted by an experienced operator and speckle tracking was performed by an independent observer. Mean peak radial strain and standard deviation (SD) was calculated for each coronary territory during each stage. Results: Mean peak strain at rest for the left anterior descending (LAD) was 25% (SD 9). This increased to 32% (10.5) at low dose, 57% (18.4) at intermediate and 74% (17.4) at peak. The results for the circumflex (LCx) were 27% (12.4), 33% (6.3), 49% (14.4), and 73% (18.4) respectively and for the right coronary (RCA) they were 10% (5.5), 24% (8.5), 26% (7.5) and 55% (18.2). ANOVA revealed a statistically significant upward trend in all territories with increasing doses of dobutamine (p<0.0002 for all). Post hoc T testing revealed that the only individual stages to not reach a statistically significant change were LCx from rest to low dose and RCA from low dose to intermediate. Conclusion: This study demonstrates that, in normal left ventricular segments, speckle tracking derived strain shows incremental increases that reflect increasing myocardial contractility, secondary to dobutamine infusion. As such it has the potential to be an objective aid to the interpretation of DSE. However, further work needs to be done in both normal and ischemic segments.

Backgrounds: Age-related arterial stiffening and wave reflection may enhance left ventricular (LV) afterload and result in increased systolic pressure. It will, therefore, result in rapid decrease in pressure gradient across LVOT and ascending aorta. The LV outflow tract (LVOT) acceleration have been considered as an index of LV contractility but the implication of LVOT flow deceleration is unclear. We hypothesized that the characteristics of LVOT deceleration would be different with aging and more prominent during exercise. We sought to determine the LVOT Doppler parameters not only at rest but also during exercise in healthy subjects and analyzed according to age group by decade. Methods: The multistage (25 Watt, 3 minutes increments) supine bicycle exercise echocardiography was performed in 50 healthy volunteers aged 20 to 69 years (29 males, 44 ± 17 years); 20-29 yrs (n=15), 30-39 (n=7), 40-49 (n=5), 50-59 (n=12), 60-69 (n=10). All subjects were normotensive (<140/90 mmHg) and free of chronic diseases as assessed by medical history, physical, laboratory and resting echocardiographic examination. The blood flow velocities through the LVOT were recorded using conventional pulsed Doppler at rest and in each stage of exercise and measured parameters as defined as Figure 1. Results: There were no significant differences in gender, history of smoking, blood pressure and heart rate among the groups. At rest, there were no significant differences in LVOT Doppler parameters. However, in elderly subjects, the ratio of deceleration time (DT) to ejection time and the ratio of DT to AT were progressively prolonged during exercise (Figure 2). Conclusions: There were age-related characteristics in LVOT Doppler deceleration and acceleration and it became more prominent with exercise. These changes might reflect dynamic arterial stiffening during exercise. We could suggest that arterial stiffness could be estimate with the changes of LVOT Doppler pattern during exercise.

Journal of the American Society of Echocardiography Volume 21 Number 5

575

P2-83

P2-84

Assessment of Left Ventricular Diastolic Pressure by Doppler during Dobutamine Stress Echocardiography

Estimation of Left Ventricular Filling Pressure with Exercise: Prospective Evaluation in 3,341 Patients

Yoshie Nakajima, Robert B. McCully, Garvan C. Kane, Steve R. Ommen, Patricia A. Pellikka Mayo Clinic, Rochester, MN

Garvan C Kane, Steve R Ommen, Naser M Ammash, Patricia A Pellikka, Jae K Oh, Robert B McCully Mayo Clinic, Rochester, MN

Background: Under resting conditions, left ventricular diastolic filling pressure (LVDP) can be estimated noninvasively by Doppler techniques. Changes in LVDP during exercise have been shown to correlate with invasive measurements and exercise capacity. Less is known about the significance of changes in Doppler measures of LVDP during dobutamine stress echocardiography (DSE). Methods: To characterize the relationship between these diastolic Doppler variables at rest and with dobutamine stress and the development of ischemic wall motion abnormalities in patients undergoing DSE, we prospectively studied 165 consecutive patients (age 66 ± 10 years, 54 % male, 43 % with known coronary artery disease (CAD), ejection fraction 60 ± 9 %) referred for clinicallyindicated DSE. Pulsed wave Doppler parameters including mitral inflow and medial annulus tissue velocities were obtained at baseline, peak stress and recovery. Patients were classified as having stress-induced ischemia (n = 70) or no ischemia (n = 95) based on the development of new or worsening regional wall motion abnormalities. Results: Table shows feasibility and the mean ± SD of Doppler variables at baseline, 20 mcg/kg/min stage, peak stress, and recovery in patients with and without ischemia. There were no significant differences in baseline mitral inflow Doppler variables between the two groups. At baseline, patients who developed ischemia had significantly lower mitral annulus tissue velocity (e’) and tended to have a higher E/e’ ratio compared with patients who did not develop ischemia. Patients with stress-induced ischemia had significantly lower e’ velocity at peak stress and higher E/e’ ratio. These differences in Doppler findings between the 2 groups persisted into recovery. By multivariate logistic regression analysis, e’ velocity at peak stress, the difference of E/e’ ratio from baseline to recovery, known CAD, and chest pain or dyspnea during DSE (present in 33 patients (20 %)) were independent predictors of ischemia with DSE. Conclusions: Impaired diastolic function, as measured by decreased e’ velocity at peak and increased E/e’ ratio in recovery was observed in patients with ischemia. This information may be of adjunctive value for detecting stress-induced myocardial ischemia.

Introduction: Left ventricular (LV) filling pressure can be estimated reliably with exercise as well as at rest using echo-Doppler. The feasibility of routine assessment in patients referred for exercise echocardiography and the overall prevalence and associated characteristics of an elevation in LV filling pressures are unknown. Methods: Doppler-derived measures of LV filling pressures were routinely measured in 4,450 patients (≥18 years, without significant valvular disease, atrial fibrillation or flutter) undergoing treadmill stress echocardiography for the evaluation of known or suspected coronary artery disease in 2006 (43.4% of whom had chest pain and 28.9% dyspnea). Peak early mitral inflow Doppler velocity (E) and peak early medial septal annular tissue Doppler velocity (e’) both at rest and in early postexercise recovery (immediately following acquisition of 2D images for regional wall motion assessment) could be obtained in 3341 (75.1%). Results: The average age of the cohort was 60±13 years, 55% were male and 17.5% had a history of myocardial infarction or coronary revascularization. Resting E/e’ was 9.4±3.8 with 8.9% having an E/e’ ≥ 15 at rest. The mean post-stress E/e’ was 9.9±4.4 (p<0.0001). Of the 9.8% patients with a post stress E/e’ ≥ 15, LV filling pressures at rest were either borderline (57.8%; rest E/e’ 8-15) or elevated (38.5%; rest E/e’ ≥ 15). Patients with a post-stress E/e’≥15 were older (69±11 yrs versus 59±13, p<0.0001) with a trend towards less men (48.9% versus 55.9%, p=0.02). After adjusting for age and sex, patients with a post-stress E/e’≥15 had decreased exercise capacity, increased incidence of ischemic changes on ECG and regional wall motion abnormalities with stress, compared to those with a post-stress E/e’<15. 7.4% of patients with a post-stress E/e’≥15 had a wall motion score index>2 compared to 1.6% of those with an E/e’<15 (p<0.0001). Nine percent of patients with a post-stress E/e’≥15 had an LV that dilated post stress compared to 3% of those with an E/e’<15 (p<0.0001). Conclusion: Estimation of LV filling pressure can be performed in the majority of patients with exercise. Increased filling pressure with exercise measured by echocardiography is associated with impaired functional capacity and exercise-induced ischemia.

Doppler variables at rest, 20mcg/kg/min, peak stress and recovery F e a s i b i l i t y No ischemia I s c h e m i a Doppler variables P % (n = 95) (n = 70) Baseline variables E velocity, cm/s 100 70 ± 20 70 ± 19 0.90 E-DT, ms 100 254 ± 75 237 ± 65 0.15 E/A ratio 100 1.0 ± 0.4 0.9 ± 0.4 0.57 e’ velocity, cm/s 100 6.6 ± 2.0 5.7 ± 1.9 0.008 E/e’ ratio 100 11.8 ± 5.2 13.5 ± 6.0 0.053 20 mcg/kg/min variables e’ velocity at 20 mcg/kg/min 100 7.8 ± 2.5 6.2 ± 2.1 0.0001 E/e’ ratio at 20 mcg/kg/min 100 11.4 ± 4.4 13.9 ± 6.6 0.008 Peak stress variables Peak stress e’ velocity, cm/s 79 7.3 ± 2.6 5.2 ± 1.6 <.0001 Peak stress E/e’ ratio 72 10.7 ± 4.6 13.1 ± 6.3 0.02 Recovery variables Recovery e’ velocity, cm/s 96 6.9 ± 2.2 5.0 ± 1.9 <.0001 Recovery E/e’ ratio 96 10.8 ± 4.6 14.2 ± 7.0 0.001

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Detection of Diastolic Abnormality by Displacement Imaging in Dobutamine Stress Echocardiography

The Utility of Exercise Doppler Echocardiography for the Diagnosis of Residual Stenosis after Operation for Aortic Coarctation in Children

Toshinari Onishi, Masaaki Uematsu, Nobuaki Tanaka, Shinsuke Nanto, Takakazu Morozumi, Tetsuya Watanabe, Masaki Awata, Osamu Iida, Fusako Sera, Hitoshi Minamiguchi, Hirokuni Akahori, Kuniyasu Ikeoka, Shin Okamoto, Haruyo Yasui, Seiki Nagata Kansai Rosai Hospital, Amagasaki, Japan

Shashi Raj, Belinda Ahlhaus, Seya Cesar, Dana Thompson, Bibhuti B Das Kosair Children‘s Hospital, University of Louisville, Louisville, KY

Background: Although dobutamine stress echocardiography (DSE) is useful for the detection coronary artery disease (CAD), the interpretation requires expertise. We have developed an ultrasound tissue Doppler system that readily portrays regional LV post systolic shortening (PSS): detection of diastolic abnormality by displacement imaging (DADI), and have demonstrated DADI at rest detected CAD with comparable diagnostic power to exercise ECG. In this study, we sought to investigate if DADI can be applied to DSE to further enhance the diagnostic power for detecting CAD. Methods: DADI was programmed to detect the timing of regional displacement peaks on two-dimensional echocardiograms by using a tissue Doppler technique. The time window was set from the end-systole to detect the delay, displayed from green (normal) to red (pathologic PSS). DSE was performed in 28 patients with suspected CAD and presenting with visibly normal LV wall motion (male=18, age ranged 45-83 years). DADI was done at rest (R-DADI) and at peak dobutamine (Do-DADI). CAD was diagnosed by DADI when the LV segments were color coded red in accordance with the coronary anatomy. The optimal cut-off value of the time window from the end systole for discriminating normal from CAD (50 ms to 150 ms) was determined by receiver operating characteristic analysis. CAD was confirmed by coronary angiography as having >75% diameter stenosis. Results: Angiographic CAD was present in 15 patients (54%). R-DADI predicted CAD with sensitivity of 60%, specificity of 62%, and predictive accuracy of 61% at the cut-ff value of 100 ms. DoDADI significantly enhanced the diagnostic power (sensitivity of 100%, specificity of 77%, and accuracy of 89%) at the cut-off value of 70 ms. Conclusion: Dobutamine enhances the diagnostic power of DADI for detecting CAD.

Background: Previous studies have shown that children who had history of successfully repaired coarctation of the aorta with normal blood pressure (BP) and no arm-leg gradient at rest may develop an anomalously high BP response and/or arm-leg gradient with exercise. We have studied a cohort of children who had successful repair for isolated coarctation of the aorta to evaluate their systolic BP response, arm-leg BP gradient and transisthmic mean gradient by continuous wave (CW) Doppler at maximal exercise. Methods: Thirty children who had successful coarctation repair (i.e. with a normal BP and arm-leg gradient ≤ 20 mmHg at rest) 8 to 16 years ago underwent treadmill exercise per Bruce protocol. CW Doppler mean gradient was calculated across the isthmus in the supine position at rest and immediately at the end of exercise. Fourteen children who developed abnormal right arm systolic BP (>98 th percentile for body surface area) during exercise had undergone cardiac catheterization and/ or magnetic resonance imaging (MRI). Results: The age range of children is 8-18 years (mean 14± 3) and age at coarctation repair ranged from 1 month to 2 years. At rest, the mean right arm systolic BP, the arm-leg pressure gradient by cuff and the pressure gradient across isthmus by CW Doppler are 114 ±32 mmHg, 20±8 mmHg, and 15±8 mmHg, respectively. At maximum exercise: the mean right arm systolic BP is 180±38 (range 148-250 mmHg) and 14 out of 30 (47%) have exercise induced hypertension, mean arm-leg pressure gradient by cuff is 38±25 mmHg, and in 12 children (40%) the mean pressure gradient across the isthmus by CW Doppler is over 20 mm Hg (mean 44±8 mmHg). Six of 14 children with exercise induced hypertension have mild residual coarctation by MRI and/or cardic catheterization and only two of them required balloon angioplasty. Peak exercise transisthmic Doppler gradient correlated well with arm-leg pressure gradient by cuff in children with mild residual stenosis after successful aortic coarctation repair (figure, r = 0.64). Conclusion: Our results show that normal resting sytolic BP and Doppler gradient across the isthmus may not always rule out residual coarctation. We propose using exercise Doppler echocardiography to diagnose residual coarctation and to identify the children who need referral for catheterization and/or MRI.

Journal of the American Society of Echocardiography May 2008

576

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Incremental Prognostic Value of Stress Wall Motion Score Index Over Rest Wall Motion Score Index: A Stress Echo Study

Prognostic Significance of Positive Stress Echocardiography in Women with Angiographically Non Significant Coronary Artery Disease

Sripal Bangalore, Gangadhara Kabbli, Olga Kristof-Kuteyeva, Zubair Malik, Bilal Ahmed, Vinay Pai, Waqas Shahid, Debbie Kim, Siu-Sun Yao, Farooq A Chaudhry St Lukes-Roosevelt Hospital Center, New York, NY

Roopa Subbarao, Vinayak Belamker, Jothiharan Mahenthiran, Judy Foltz, Irmina Gradus-Pizlo, Harvey Feigenbaum, Stephen Sawada Indiana University, Indianapolis, IN

Background: Stress echocardiography is an important tool for risk stratification and prognosis of patients with known or suspected coronary artery disease. However, the sensitivity of stress echocardiography decreases with increasing resting wall motion abnormalities. The incremental value of stress wall motion score index (WMSI) over resting wall motion score index as a function of baseline wall motion abnormalities is not known. Methods: We evaluated 3258 consecutive patients (mean age 60 ± 13 years; 48% men) referred for stress echocardiography (59% dobutamine). The left ventricle was assessed on a 16-segment model 5-point scale for wall motion abnormalities at rest (R) and during stress (S). WMSI was calculated as the cumulative score of all segments divided by the number of segments. Patients were divided into 3 groups: RWMSI = 1.0 (No resting wall motion abnormalities); RWMSI 1.1-1.7 (Mild to moderate resting wall motion abnormality) and RWMSI >1.7 (Severe resting wall motion abnormality. Follow-up (2.7 ± 1.1 years) for confirmed nonfatal MI (n = 66) and cardiac death (n = 104) were obtained. Cox proportional hazard model was used to find out the incremental value of SWMSI over RWMSI for each of the RWMSI categories. Results: Among 3258 patients undergoing stress echocardiography, 170 (5.2%) patients experied hard events. This included 71 (3.1%) in patients with normal RWMSI, 23 (4.9%) in those with mild to moderately abnormal RWMSI and 75 (15.4%) in those with severely abnormal RWMSI. Cox proportional hazard model showed that SWMSI added incremental prognostic value over RWMSI over each category of baseline wall motion (Figure). However the % increase in global chi 2 decreased with increasing baseline wall motion abnormalities (From 42760% to 151% to 60% for normal, mild-mod and severely abnormal RWMSI respectively). Conclusions: In patients referred for stress echocardiography, the incremental value of stress wall motions score index decreases with baseline wall motion abnormalities. However, stress WMSI provides incremental prognostic value even in patients with severely abnormal resting wall motion.

Background: Prior studies have shown that female patients (pts) without significant coronary artery disease (CAD) by angiography have a good prognosis. We assessed the outcome of female pts without significant CAD who had ischemia on stress echocardiography (stress echo) to determine if ischemia influences the prognosis of these pts. Methods: The study group was comprised of female pts without significant CAD by angiography (0 to < 50% diameter stenosis) who had ischemia on stress echo. Pts with prior revascularization, reduced ejection fraction (EF), and prior transmural infarction were excluded. Cardiac events were defined as admission for angina, heart failure, revascularization, infarction (MI) or death. Results: There were 107 female pts (mean age 56.3 ± 10.3 years). The mode of stress was treadmill 45 (42%), supine bicycle 35 (32.7%), and dobutamine 27 (25.2%). Fifty eight pts (54.2%) had hypertension and 23 (21.5%) were diabetic. The mean EF was 57 ± 10%. The mean resting wall motion score index (WMSI) was 1.04 ± 0.1 and the peak WMSI was 1.3 ± 0.3. Mean follow up was 37 ± 34 months. There were 27 (25%) pts with 36 events (angina 13, heart failure 3, revascularization 2, MI 6, death 12). The annualized event and mortality rates were 10% and 4.4% respectively. Univariate predictors of events were angina (Hazard Ratio {HR} 2.56 [1.18-5.56] p=0.017), resting left anterior descending (LAD) WMSI (HR 12.84 [1.88-87.51] p=0.009), resting left circumflex WMSI (HR 2.64 [1.12-6.19] p=0.026), peak global left ventricular WMSI (HR 8.65 [2.55-29.28] p=0.001), peak LAD WMSI (HR 5.14 [1.95-13.53] p=0.001) and stress induced wall motion abnormality (WMA) in ≥ 2 segments (HR 4.49 [1.99-10.11] p <.0.001). The presence of mild disease (30 to < 50% diameter stenosis) was not predictive. Multivariate predictors of the events are shown in Table 1. Table 1: Multivariate Predictors of Events Variable Angina Peak LAD WMSI Stress induced WMA in ≥ 2 segments

Hazard Ratio 2.53 (1.03-6.22) 18.41 (1.83-185.8) 3.71 (1.42-9.73)

p-Value 0.044 0.013 0.008

Conclusions: Female pts without significant CAD by angiography remain at higher risk for cardiac events and mortality (4.4%) in presence of stress-induced ischemia. Angina, ischemia in LAD territory and stress induced WMA in ≥ 2 segments are independent predictors of events.

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Can Left Atrial Size Predict the Results of Stress Echocardiography? Observations from 7,077 Patients

One Single Intravenous Adenosine Shot for Coronary Flow Reserve Evaluation during Exercise or Dobutamine Stress Echo, Does it Add Any Useful Information for Coronary Heart Disease Diagnosis?

Farhan J Khawaja, Garvan C Kane, Jae K Oh, Steve R Ommen, Clarence Shub, Patricia A Pellikka, Robert B McCully Mayo Clinic, Rochester, MN Background: Small, retrospective studies have suggested that a normal left atrial volume index (LAVI) is strongly predictive of a normal stress echo. We sought to evaluate the predictive value of LAVI in a large cohort of patients (pts) undergoing stress echo in routine clinical practice. Methods: LAVI was measured prospectively in 7,077 consecutive pts who had stress echos in 2006 using the biplane area-length method; 4,108 pts had exercise stress echos (ExEcho) and 2,969 dobutamine stress echos (DSE). The mean age of the study population was 63±13 years and 54% were men. Results: Left atrial enlargement, defined as LAVI ≥28 ml/m 2, was present in 3,510 pts (50%). There was a correlation between left atrial size and the presence of stress-induced ischemia and the severity of the peak stress wall motion abnormalities (wall motion score index (WMSI)). These associations were seen in ExEcho pts (Fig. A) and DSE pts (Fig. B). Of the 830 pts who had an ischemic response on ExEcho, 390 (47%) had a normal LAVI. Of the 746 pts who had an ischemic response on DSE, 210 (28%) had a normal LAVI. Overall, 600 (17%) pts with a normal LAVI (LAVI <28 ml/m 2) had an ischemic response on stress echo. Even amongst the 1,654 pts who were in the smallest LAVI group (<22 ml/m 2), 246 (15%) had an ischemic response on stress echo. Conclusion: In pts undergoing stress echo, the presence of left atrial enlargement is more likely to be associated with abnormal stress echo findings. Although pts with normal LAVI are more likely to have a normal stress echo result, a substantial proportion (in this study 17%) will have stress-induced ischemia. A normal LAVI should, therefore, not be used as a surrogate marker for predicting a normal stress echo.

Cristian Tiano, Federico Rinaldi, Gustavo Lanosa, Sara Berenzstein, Jorge Lowenstein, Jorge Lerman Hospital de Clinicas, Buenos Aires, Argentina Background: Coronary flow reserve is a very useful indicator of coronary function but it is difficult to perform this during exercise or dobutamine stress echo. One simple and reliable test would expand its clinical use. Objectives: 1)To estimate sensitivity, specificity, positive predictive value, negative predictive value and positive and negative likelihood ratio of the adenosine test in order to detect significant stenosis in the anterior descending coronary artery. 2) To estimate side effects during adenosine test and, 3) To quantify the additional information that this test adds to the usual exercise or dobutamine stress echo test. Methods: Before performing a stress test with dobutamine or exercise, the diastolic velocity of the anterior descending artery was evaluated with pulsed wave Doppler at rest and after induced hyperemia with a single shot of 6 mg. intravenous adenosine; the coronary flow reserve was calculated as the peak diastolic velocity / basal diastolic velocity ratio. A coronary flow reserve ≥ 2 was considered normal. A coronary angiography was performed to all the patients within one week of the study. Results: Thirty-three patients were evaluated (mean age= 71.97± 10.33), 2 were excluded due to an ejection fraction under 30%, 17 were men (54.8%). The sensitivity was 88.8% (CI95%: 71,6-100), specificity 84.6% (CI95%: 61.1-100), positive predictive value 88.8% (CI95%: 71.6-100), negative predictive value 84.6% (CI95%: 61.1-100), positive likelihood ratio 5.78 (CI95%: 1.6-20.8), and negative likelihood ratio 0.13 (CI95%: 0.03-0.5). Side effects were: hyperventilation (90.3%), general malaise (19.3%) and bradycardia of less than 45 beats/min (9.6%), all of them were transient and self limited. In 61.2% of the patients, the adenosine test in the anterior descending artery before exercise or dobutamine added extra information ( 29% were stopped due to ischemia in inferior, lateral or posterior territories and 32.2% did not achieve submaximal heart rate). Conclusions: 1) The adenosine test resulted highly sensitive and specific with high negative and positive predictive values. 2) A high incidence of side effects was observed but always transient and self limited. 3) It adds a high percentage of diagnostic information to the conventional exercise or dobutamine stress echo protocols.

Journal of the American Society of Echocardiography Volume 21 Number 5

577

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Evaluation of Global and Regional Right Ventricular Function during the Stress Echocardiography: Velocity Vector Imaging

Prognostic Value of Stress Echocardiography in Women without Typical Angina

Hyun Suk Yang, Tahlil A. Warsame, Bijoy K. Khandheria, A Jamil Tajik, Krishnaswamy Chandrasekaran Mayo Clinic, Arizona, Phoenix, AZ Background: There is a paucity of information regarding right ventricular (RV) function during stress echocardiography (SE). The aim of this study is to evaluate RV global and regional function using velocity vector imaging (VVI) during SE. Methods: We prospectively enrolled 49 patients undergoing stress echocardiography. Echo images were obtained using a conventional 2D probe with the Acuson C512 ultrasound system. RV ejection fraction (EF) and RV fractional area change (FAC) were used to measure global RV function. Longitudinal velocity, strain, and strain rate (SR) of 6 segments from the RV apical 4-chamber view and the radial velocity, circumferential strain, and SR of 4 segments from the RV short-axis view were used to evaluate regional RV function. Rest and stress images were analyzed for LV and RV response. Results: Of the 49 patients (pts), 34 underwent treadmill and 15 dobutamine stress. 33 of the 49 pts (Group A) demonstrated normal LV response to stress, while the remaining 16 (Group B) demonstrated abnormal response (poor LV EF response 4 pts, hypertensive response 7 pts, stress induced elevated RV systolic pressure 7 pts). Group A showed a stressinduced increase of the global RV EF and RV FAC, and significant increases in the longitudinal velocity and SR in both septal and basal-lateral walls (Table 1). Longitudinal displacement of the basal-lateral wall showed no increase at peak-stress with a smaller stroke volume. In group B, however, there was no statistically significant increase in the global RV EF and RV FAC or longitudinal SR in lateral walls. Comparing the baseline-to-peak changes between the two groups, there was a significant difference only in mid-septal circumferential strain (A: -15.6±6.0 to -17.1±8.6 %; B: -19.2±9.9 to -14.7±9.4 %, p=0.03). Conclusions: 1.VVI during SE allows easy quantitative assessment of global and regional RV function. 2. Velocity and SR were better than strain or displacement to detect a stress induced RV response in patients with a normal LV response to stress. 3. Further studies are needed to demonstrate the clinical value of VVI in evaluating RV function during SE in various diseased states. Table 1.Longitudinal parameters in patients with normal stress response (n=33)

B-Sep M-Sep A-Sep B-Lat M-Lat A-Lat

Velocity (cm/s) Baseline Stress 5.6±1.8 7.2±2.4* 4.2±1.4 5.2±1.9* 2.9±1.1 3.5±1.8* 7.9±1.9 10.4±3.1* 5.8±1.3 6.5±2.9 3.3±1.3 3.7±2.3

Strain (%) Baseline -22.5±7.3 -20.0±5.9 -22.5±8.2 -31.7±9.9 -26.2±12.3 -28.8±9.5

Stress -21.9±7.3 -22.0±9.2 -25.7±8.5 -34.2±13.1 -32.6±10.9* -27.0±11.1

Strain Rate (s -1) Baseline Stress -1.3±0.5 -1.7±0.8* -1.2±0.5 -1.7±0.8* -1.4±0.6 -2.0±0.8* -1.9±0.8 -3.0±1.4* -1.7±1.0 -2.4±1.1* -1.7±0.6 -2.1±1.4

Sripal Bangalore, Siu-Sun Yao, Farooq A Chaudhry, Satish Boddepalli St Lukes-Roosevelt Hospital Center, New York, NY Background: Stress echo is an important imaging modality for diagnosis, risk stratification and prognosis of patients with known or suspected coronary artery disease. Women with suspected CAD present with atypical symptoms, with microvascular disease making risk stratification by bayesian approach difficult. The prognostic value of stress echocardiography in women presenting without typical angina is unknown. Methods: We evaluated 1375 consecutive women (mean age 61 ± 13 years) without typical angina referred for stress echocardiography (60% dobutamine). Abnormal stress echo studies were defined as those with infarction (fixed wall motion abnormality) or stress-induced ischemia. Follow-up (2.6 ± 1.0 years) for confirmed nonfatal MI (n = 33) and cardiac death (n = 35) were obtained. Results: Among 1375 women undergoing stress echocardiography majority of them presented with atypical chest pain (51%) while 627 patients (46%) were asymptomatic and 42 (3%) had nonanginal chest pain. Stress echocardiography effectively risk stratified patients into a normal versus abnormal group (event rate 1.1%/y vs. 4.0%/y; P <0.0001) (Figure). A Cox proportional hazard model showed that stress echocardiographic variables added incremental prognostic value beyond clinical, stress electrocardiographic and rest echocardiographic variables (Global Chi2 increased from 48.3 to 52.4 to 83.3 to 86.14; P = 0.017, P <0.0001 and P = 0.017 respectively) for the prediction of hard clinical end points. Age (P = 0.020), prior myocardial infarction (P = 0.002) and an abnormal stress echocardiography study (HR = 2.16; 95% CI = 1.17-4.0; P = 0.014) were significant predictors of cardiovascular events. Conclusions: Stress echocardiography effectively risk stratifies women without typical angina and provides independent and incremental prognostic value beyond standard clinical risk factors, stress electrocardiographic and rest echocardiographic variables. Stress echocardiographic should be routinely used in risk stratification of women presenting with any type of chest pain.

*P<0.05 versus baseline, B-, basal-; M-, mid-; A-, apical-; Sept, septal wall, Lat, lateral wall

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Quantitative Assessment of Transmural Strain Gradient in Stunned and Hibernating Myocardium Using Newly Developed 2D Speckle Tracking System

Post Systolic Shortening Detected by Velocity Vector Imaging is a New Objective Marker for Wall Motion Abnormality

Koichi Kimura1, Katsu Takenaka 1, Kansei Uno1, Aya Ebihara 1, Hiroshi Iwata1, Katsuhito Fujiu1, Yasuhiko Abe 2, Tetsuya Kawagishi 2, Ryozo Nagai1 1 University of Tokyo Hospital, Tokyo, Japan; 2Toshiba Medical Systems Corp, Tokyo, Japan

Koji Kurosawa, Hiroyuki Watanabe, Masaru Aikawa, Hirotsugu Mihara, Kanki Inoue, Itaru Takamisawa, Atsushi Seki, Tetsuya Tobaru, Nobuo Iguchi, Masatoshi Nagayama, Ryuta Asano, Morimasa Takayama, Jun Umemura, Tetsuya Sumiyoshi Sakakibara Heart Institute, Fuchu, Japan

Background: Currently, wall motion of the left ventricle (LV) is subjectively evaluated by endocardial excursion and wall thickening on 2D echo. More objective and quantitative methods are expected. The aim of the present study was to quantify strain of stunned and hibernating myocardium using newly developed prototype 2D speckle tracking system. Methods: LV short-axis images were obtained in 13 pigs as a control group (Aplio, TOSHIBA). An ameroid constrictor was placed around the left circumflex coronary artery in 9 pigs. Two pigs died after surgery. Four weeks later, coronary angiography shows 99% severe stenosis in all of 7 pigs and LV echo images were assessed as a hibernating group. Six pigs were subjected to balloon occlusion of left circumflex coronary artery and assessed 20 minutes after reperfusion as a stunning group. Using the new prototype tracking system which could track three independent layers of myocardium (Fig.1), we measured circumferential strain of the posterior wall. Results: In control subjects, circumferential strain showed distinct transmural gradient across the LV wall (Table 1). Circumferential strain gradient of stunning myocardium was reduced. The gradient was extremely reduced in hibernating myocardium (Fig. 2). These results indicate that the endocardium is the most sensitive to ischemia. Conclusion: The change of strain gradient can be detected and quantified by new 2D speckle tracking system.

Background: Post systolic shortening (PSS) is generally recognized as a characteristic of wall motion of ischemic heart disease. Recently, Velocity Vector Imaging (VVI) based on tissue tracking technique has been developed to detect velocity and its vector of regional wall motion. Thus, the purpose of this study was to test the hypothesis that PSS detected by VVI can be an objective marker for wall motion abnormality. Methods: We studied consecutive 111 patients with ischemic heart disease. Echocardiography was digitally stored by transthoracic echocardiography (Sequoia, Siemens) in a short-axis view for subsequent off-line VVI analysis. After divided into six segments in each cross-sectional image, the direction of the velocity vector in a still frame was determined at timing around mitral valve opening; normal as outward direction and PSS as not outward direction in each segment. Then, we compared the results of VVI with wall motion abnormality by eye-ball detection. Results: Among 666 segments, wall motion abnormality by eye-ball detection was recognized in 151 segments, while PSS by VVI was detected in 232 segments at MVO and 185 segments around MVO (MVO±55msec). Although agreement rate of PSS at MVO with the wall motion abnormality was 73%, the rate of PSS around MVO with wall motion abnormality increased to 90%. Conclusion: Using VVI, wall motion abnormality in ischemic heart disease can be detected objectively.

Journal of the American Society of Echocardiography May 2008

578

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Nonischemic Cardiomyopathy in the Periinfarct and Remote Regions Following Anterior Infarction in Rats Quantified by 2D Radial Strain Echocardiography

Incremental Value of 2-D Strain Over Wall Motion Score for Detection of Flow Limiting Coronary Artery Disease

Raymond Q. Migrino, Xiaoguang Zhu, Mineshkumar Morker, Tejas Brahmbhatt, Megan Bright, Ming Zhao Medical College of Wisconsin, Milwaukee, WI

Meera R, Vijayaraghavan G, Ramakrishnapillai V, Rachel Daniel, Padmaja NP Kerala Institute of Medical sciences, Trivandrum, India

Background: The contribution of periinfarct and remote myocardium to the development of cardiomyopathy remains poorly defined. The aim is to quantify radial strain in infarcted (I), periinfarct (PI) and remote (R) myocardial regions acutely and chronically following anterior infarction in rats using 2D strain echo (2DSE). Methods: The proximal left anterior coronary artery of male Sprague-Dawley rats were occluded for 20-30 minutes and 2DSE was performed in the acute setting (n=10; baseline and 2 hours post-reperfusion) and in the chronic setting (n=14; baseline, 1, 3 and 6 weeks). Using software, radial strain (RS) was measured in the midventricle in short axis view. The ventricle was divided into 3 regions: I (anteroseptum, anterior and anterolateral), PI- (inferoseptum and inferolateral) and R- (inferior). Infarct size was measured using triphenyl tetrazolium chloride in the acute group. Results: see Figure. Radial strain decreased not only in the infarct but also in the periinfarct and remote regions acutely and chronically. Reduced RS in periinfarct and remote regions occurred despite minimal or absent necrosis (area of necrosis I, PI, R: 48.8±23, 5.1±6.6, 0±0%, p<0.001 vs. I). Conclusions: Following left anterior coronary artery occlusion, radial strain decreased at 60 minutes and up to 6 weeks in the periinfarct and remote regions, similar to the reduction in the infarct region. This demonstrates early and chronic nonischemic cardiomyopathy in periinfarct and remote regions following myocardial infarction that may have important contribution to ventricular remodeling.

Background: To study the feasibility of 2-D peak systolic strain (2D PSS) by speckle tracking for demonstration of Left ventricular regional systolic dysfunction and assess superiority of it over 2-D wall motion score (2D WMS), for regional ischemia and predicting flow limiting coronary artery lesion(FLCL) and demonstrate the benefits of revascularisation. Subjects and methods: Echo Doppler study was done on 120 patients. 2D WMS analysed by ACC criteria. 112 patients had 2D PSS imaging done by speckle tracking. Data from 108 patients who had coronary artery disease were analysed. Coronary arteries were scored as Score 0 for non flow limiting coronary artery lesion (NFLCL) and score 1 for FLCL. 19 patients who had single vessel angioplasty had 2DWMS and 2D PSS imaging done after 4 weeks. Data analysed by Least Square Error regression algorithms to find individual correlation for coronary angiogram with 2DPSS.WMS and 2DPSS were analysed in similar manner. Results: 2-D PSS in LAD territory predicted FLCL correctly in 91patients (84.2%), 2D WMS in 69 patients (63.8%). In LCX territory 2DPSS predicted FLCL in 88 patients (81.48%), 2DWMS in 59 (54.62%)patients. In RCA territory, the predictions by 2D PSS and 2DWMS were 87(80.5%) and 69 (63.8%) respectively. Following angioplasty, 12 patients out of the 19(63.2%) showed improvement in deformation in LAD territory, 15 out of 19(78.9%) in LCX and16 (84.2%) in RCA territories, whereas the improvement in wall motion score in the corresponding territories were 5(26.3%), 8(42.1%), 9 (47.4%), respectively. Conclusions: 1. 2DPSS demonstrated the abnormality of regional LV Systolic function. 2. 2DPSS is superior to 2DWMS in predicting FLCL. 3 2DPSS is demonstrable as objective result, while 2DWMS is a subjective impression. 4. 2DPSS is superior to 2 DWMS in demonstrating the results of revascularization.

P2-97

P2-98

Additive Role of Epicardial Fat to Predict Coronary Disease is Useful in Patients with Low Body Mass Index

Need for Different Criteria to Evaluate the Patency of the Right and Left Internal Mammary Artery Grafts by Transthoracic Doppler Echocardiography

Jung-Won Hwang 1, Sung-Gyun Ahn 2, Un-Jung Choi1, Hong-Seok Lim1, Soo-Jin Kang1, Byoung-Joo Choi1, So-Yeon Choi 1, Myeong-Ho Yoon 1, Gyo-Seung Hwang1, Seung-Jea Tahk 1, Joon-Han Shin1 1 Ajou University Hospital, Suwon, Republic of Korea; 2Handong Global University Good Samaritan Hospital, Pohang, Republic of Korea

Naoko Mizukami1, Yutaka Otsuji 2, Shinichi Minagoe3, Ken-ichi Nakashiki1, Takeshi Uemura1, Eishi Kuwahara1, Kayoko Kubota1, Mihoko kono1, Tomonori Uchimura 1, Akira Kisanuki1, Ryuzo Sakata 1, Chuwa Tei 1 1 Kagoshima University School of Medicine, Kagoshima, Japan; 2University of Occupational and Enviromental Health, Kitakyushu, Japan; 3National Hospital Organization Kyushu Cardiovascular Center, Kagoshima, Japan

Background: We have reported that the epicardial adipose tissue(EAT) measured by echocardiography was an independent additive risk factor for coronary artery disease(CAD) regardless of well-known risk factors. The relationship between EAT and coronary atherosclerosis, however, is still unclear in several studies. The aim of this study was to identify the effect of total body weight on predictive role of EAT for coronary disease. Methods: Five-hundred and five consecutive patients(female 249, 58±11 yr-old), who underwent echocardiography and their first coronary angiography, were enrolled. EAT was measured on the free wall of the right ventricle at end diastole in the parasternal windows. Receiver operation characteristic(ROC) curve analysis for predicting CAD was performed in 2 groups according to body mass index(BMI: groups of ≥ 27 and < 27 kg/m²). Results: Mean EAT was significantly thicker in patients with CAD(4.1 vs 2.1 mm, p<0.025). When the EAT was added to well-known risk factors for CAD, predicted probability increased significantly in ROC curve analysis(AUC from 0.750 to to 0.785, p=0.009). In group with high BMI(n= 137), there was no significant change of AUC from 0.747 to 0.765(difference between areas= 0.019; p= 0.489). In group with low BMI(n= 368), however, the AUC increased significantly from 0.761 to 0.802(difference between areas= 0.041; p= 0.007). Conclusion: The Eat measured by echocardiography have an additive value to predict coronary disease regardless of conventional risk factors. However we have to take the BMI into consideration to predict coronary disease. Table 1. differences in AUC by BMI Change in AUC by adding EAT BMI(kg/m2) (difference between areas) < 27 0.761 -> 0.802 (n= 368) (0.041) > 27 0.747 -> (n= 137) (0.019)

p value 0.007 0.481

Background: Augmented diastolic to systolic flow velocity ratio (D/S) of the proximal left internal mammary artery (IMA) after coronary artery bypass grafting (CABG) by transthoracic Doppler echocardiography (TTDE) enables noninvasive assessment of the graft patency. Augmented D/S can potentially be less pronounced in a distant site from the anastomosis and the proximal right IMA is more distant from the anastomosis compared to the proximal left IMA. We hypothesized that augmented D/S is less pronounced in the right compared to the left proximal IMA after CABG, resulting in the need for different criteria for anastomotic stenosis by the D/S. Methods: In 144 consecutive patients with CABG using the left and/or right IMA to the left coronary artery (75 and 69), proximal IMA flow D/S by TTDE from supraclavicular approach and the anastomotic stenosis by coronary angiography were compared. Results: 1) Doppler echocardiographic D/S of both left and right IMA had significant correlation with the angiographic stenosis (r = 0.56 or 0.67, p<0.001). 2) There was no significant difference in a degree of the slope between the 2 correlations, however, the slope of the relation was significantly shifted downward (p<0.01) in the right compared to the left IMA (Figure). 3) While the D/S < 0.57 predicted graft stenosis (diameter stenosis > 75%) with an accuracy of 91% (68/75) in left IMA grafts, the D/S < 0.28 predicted graft stenosis with an accuracy of 97% (67/69) in right IMA grafts. Conclusions: TTDE enables noninvasive assessment of the patency of both left and right IMA graft to the left coronary artery but with need for different criteria for diagnosing significant stenosis.

Journal of the American Society of Echocardiography Volume 21 Number 5

579

P2-99

P2-100

Serial Changes of Post Systolic Shortening during Acute Coronary Syndrome Described by Velocity Vector Imaging

The Assessment of Mitral Deformation Indices and Left Ventricle Geometry in Patients after Myocardial Infarction with Chronic Ischaemic Mitral Regurgitation - the Comparison of Echocardiography and Cardiovascular Magnetic Resonance

Hirotsugu Mihara, Hiroyuki Watanabe, Masaru Aikawa, Koji Kurosawa, Kanki Inoue, Itaru Takamisawa, Atsushi Seki, Tetsuya Tobaru, Nobuo Iguchi, Masatoshi Nagayama, Ryuta Asano, Morimasa Takayama, Jun Umemura, Tetsuya Sumiyoshi Sakakibara Heart Institute, Tokyo, Japan Background: Postsystolic shortening (PSS) is generally recognized as characteristics of ischemic myocardium. Recently, Velocity Vector Imaging (VVI) has been developed to analyze regional wall motion quantitatively using a tissue tracking technique. Our objectives were to quantify PSS in acute coronary syndrome (ACS) patients, and then to assess serial recovery process of PSS after Percutaneous Coronary Intervention (PCI) using VVI. Method: We enrolled 32 consecutive patients with ACS (21 men and 11 women, mean age 64±13 years) who underwent PCI, including acute myocardial infarction (n=17, max CK 3054±2512 IU/l) and unstable angina (n=15). We recorded transthoracic echocardiography before and after PCI (after 6.6±9.9 days, median 3.5 days). Echocardiographic data were digitally stored and analyzed with VVI offline software. First, we measured the angle of the maximum lesion of PSS (PSS-angle) in a parasternal short axis view. Second, we calculated the ratio of PSS area to the whole color M-mode area using color M-mode mapping. Result: PSS was observed in 30 patients (94 %) before PCI, and remained 21 patients (66 %) after PCI. PSS-angle decreased significantly from 103±54 degrees before PCI to 48±45 degrees after PCI (P<0.0001). PSS area ratio decreased significantly from 2.7±2.1 % before PCI to 1.1±1.3 % after PCI (P=0.0003). Conclusion: The area of PSS was successfully quantified by VVI, and this area was decreased significantly after PCI. VVI is a new powerful technique which allows us to measure the recovery process of ischemic damage quantitatively.

Agata M Lesniak-Sobelga1, Ewa Wicher-Muniak 2, Maria Olszowska1, Magdalena Kostkiewicz1, Piotr Klimeczek3, Robert Banys3, Piotr Pieniazek1, Mieczyslaw Pasowicz3, Wieslawa Tracz 1 1 Institute of Cardiology, The John Paul II Hospital, Krakow, Poland; 2Centre for Diagnosis and Rehabilitation,The John Paul II Hospital, Krakow, Poland; 3Centre for Diagnosis and Rehabilitation, The John Paul II Hospital, Krakow, Poland Background: The pathophysiology of ischaemic mitral regurgitation (MR) is related to local and global left ventricular remodeling and the papillary muscle dysfunction. An understanding of geometric alterations of mitral valve and left ventricle seems to be desirable in planning surgical treatment. The aim of this study was to compare the mitral deformation indices and left ventricle remodeling parameters using the transthoracic echocardiography (TTE) and cardiovascular magnetic resonance (CMR) methods. Material and methods: 44 subjects (32 M, 12 F; mean age: 63 ±12.8 years) with coronary artery disease, ≥ 6 months after myocardial infarction, with functional mitral regurgitation (MR I-IV grade) underwent CMR and TTE within the period no longer than 5 days. TTE was performed with Vivid 7 GE Dimension, CMR - using Magnetom Sonata 1.5 T device. Cine gradient echo imaging was used for analysis. The parameters of left ventricle function were obtained manually using cardiac dedicated software Argus. The following parameters were analysed: the mitral deformation indices as end- systolic and end-diastolic mitral annular area, antero-posterior, antero-inferior, septo-lateral mitral annulus diameter in systole and in diastole, the coaptation height, the tenting area, mitral annulus diameter - anterior mitral leaflet lenght ratio and the left ventricle remodeling parameters: left ventricular end-systolic diameter (LVESD), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic diameter (LVEDD), left ventricular end-diastolic volume (LVEDV), stroke volume (SV), ejection fraction (EF), sphericity index (SI), wall motion score index (WMSI). Results: A strong correlation of the left ventricle remodeling parameters was observed between TTE and CMR methods. The strongest correlation was observed of LVESD (p=0.00001; r=0.91), EDV (p=0.00006; r=0.87), LVEDD (p=0.001; r=0.85), ESV (p=0.0004; r=0.82), WMSI (p=0.0003; r=0.82), sphericity index (p=0.004; r=0.72) and a weaker correlation of EF (p=0.006; r=0.7), SV (p=0.026; r=0.59). Upon analysing mitral deformation parameters there was only detected a correlation between TTE and CMR regarding antero-inferior mitral annulus diameter in diastole (p=0.04; r=0.57), septo-lateral mitral annulus diameter in diastole (p=0.01; r=0.65) and tenting area (p=0.07; r=0.5). Conclusions: There were no significant differences in the assessment of left ventricle remodeling parameters between TTE and CMR. In evaluation of mitral complex deformation parameters CMR is more convenient than TTE because of its high contrast resolution.

P2-101

P2-102

Detection of Postischiemic Regional Left Ventricular Diastolic Dyssynchorony in Patients with Unstable Angina Using Strain Image Derived From 2D Speckle Tracking

External Counterpulsation Therapy Restores the Cardiac Functional and Clinical Capacity of End Stage Ischemic Heart Disease Patients to Matched Controls with Revascularized or no Coronary Artery Disease: A Supine Bicycle Stress Echo Study

Katsuhisa Ishii, Makoto Imai, Tamaki Suyama, Masaki Kawanami Kansai Denryoku Hospital, Osaka, Japan

Steve C Smart1, Vicki L McHugh 2, Michelle A Mathiason 2, Kara J Kallies2, Kelly J Ray1, Nada M Al-Khalifa 3, John P Porcari 3 1 Gunderen Lutheran Health System, La Crosse, WI; 2Gunderen Lutheran Medical Foundation, La Crosse, WI; 3University of Wisconsin La Crosse, La Crosse, WI

Background: Regional left ventricular (LV) diastolic dysfunction may persist without systolic dysfunction after an episode of transient severe myocardial ischemia in UAP. Strain image (SI) derived from 2D speckle tracking technology enables quantification of regional myocardial function without tethering effect and Doppler angle dependency with high temporal resolution. Methods: Consecutive 202 patients (126 men, 58 ±11 years) with suspected UAP who had recent chest pain but no definitive ECG changes, apparent LV systolic dysfunction or other ischemic signs, were studied. Prior to coronary angiography (CAG), SI (Aplio, Toshiba) was acquired in the apical long-axis, two- and four-chamber views. Transversal strain curves were obtained and peak values of strain at the closure of aortic valve (A) and at the one third of diastolic duration (B) were measured. The SI-diastolic index (SI-DI) was determined as (A-B)/A×100% and used to identify regional LV diastolic dyssynchrony (D-D). In the 40 normal subjects the SI-DIs were 80.4±7.1, 85.7±6.9, 85.3±8.3 % in the territories of the left anterior descending branch (LAD), the left circumflex branch (LCX) and the right coronary artery (RCA), respectively. Results: 113 patients were diagnosed as having UAP (Braunwald IB: 58, IIB: 27 and IIIB: 28). A total 606 segments were evaluated. Regional LV diastolic dyssynchrony (SI-DI<40%) had been detected using SI in the perfusion territories of the coronary arteries with culprit lesions in 107 (95%) of UAP, whereas it had been noted in 10 (11%) of chest pain syndrome (sensitivity 95%, specificity 89%). In UAP the SI-DIs were 24.4±14 (n=46), 28.7±17 (n=31), 26.3±12 % (n=36) in the culprit lesions of LAD, LCX and RCA, respectively, and 72±11% (n=493) in the segments corresponding to the nonculprit lesions (P<0.01). Regional LV D-D disappeared one week after successful revascularization in 94 (83%) of UAP. Conclusion: Postischemic regional LV diastolic dyssynchrony was frequently detected using SI in UAP. Analysis of SI allows noninvasive identification of the coronary artery with the culprit lesion by the detection of diastolic dyssynchrony, differentiating UAP from chest pain syndrome.

Background: Despite optimal medical therapy and revascularization procedures, patients with end stage inoperable coronary artery disease (CAD) continue to suffer from life-limiting angina. External counterpulsation therapy (ECP) is noninvasive and improves quality of life in these patients. Supine bicycle stress echocardiography with Doppler (SBSED) accurately assesses regional and global left and right ventricular (LV and RV) function, valvular function, and right heart size and pressures. We aimed to evaluate the magnitude of effects of ECP in end stage CAD patients by using SBSED to compared patients before and after ECP treatment with a matched control group including revascularized patients. Methods: SBSED was done in 2-minute stages including multistage quantitative Doppler for tricuspid regurgitation (TR), mitral regurgitation (MR), RV pressure, RV size/function and LV ejection fraction (EF). Group 1 comprised patients that underwent ECP from 8/1/04 to 12/31/06 and SBSED before and after treatment (n=49). ECP was performed according to standard protocol over 7-10 weeks. Group 2 consisted of 3 controls per case subject with SBSED from 8/1/04 to 12/31/06 (n=147) who were revascularized (n=90) or had no know CAD (n=57). Subjects were matched for gender, age and smoking status. Continuous variables assessed by SBSED were analyzed by paired t-tests. Mantel-Haenszel Chi-Square analysis was used to assess graded variables. Results: Mean age for Groups 1 and 2 were 65.1 ± 11.7 (63.3% male) and 65.4 ± 11.5 (63.3% male). The only clinical differences were higher functional class (p<0.001) and higher angina class (p<0.001) in Group 1. Before ECP, Group 1 also had worse wall motion abnormalities at peak stress (p<0.001), lower EF at peak stress (p<0.001), worse capacity (METS, p=0.031), and worse RV size/function (p<0.01). For Group 1, ECP markedly improved functional class (p<0.001) and angina class (p<0.001) and restored values similar to or better than Group 2. Additionally, ECP improved EF at rest and peak (p=0.009 and p<0.001), wall motion abnormalities at rest and peak (p=0.003, p=0.001), RV size at rest and peak (p=0.011, p=0.014), and TR at peak (p=0.001) in Group 1. ECP restored capacity and all echo parameters to values similar to Group 2 except for modest differences in peak stress EF (p=0.038) and wall motion (p=0.013). Conclusion: EECP has dramatic clinical, left and right heart effects in patients with highly symptomatic end stage CAD. ECP restored the clinical and left and right heart abnormalities to values similar to revascularized patients or those without known CAD.

Journal of the American Society of Echocardiography May 2008

580

P2-103

P2-104

Impaired Subendocardial Wall Thickening at Rest in Patients with Severe Coronary Stenosis but Visually Normal Wall Motion

Assessment of Global and Regional Left Ventricular Twist in Patients with Anterior Wall Myocardial Infarction before and after Revascularization by Speckle Tracking Imaging

Tomoko Ishizu 1, Yoshihiro Seo 1, Junji Shiotsuka2, Hidetaka Nishina2, Kazutaka Aonuma1 1 University of Tsukuba, Tsukuba, ibaraki, Japan; 2Tsukuba Medical Center Hospital, Tsukuba, ibaraki, Japan Background: Subendocardial myocardial layer shows greater contraction than subepicardial layer in normal condition, and is more susceptible for ischemia than subepicardial layer. Purpose: The purpose of this study was to clarify the presence of the alternation in transmural strain gradient at rest in hypoperfused myocardium using a novel developed speckle tracking echocardiography. Methods: Forty-six healthy subjects and 18 patients with flow limiting severe coronary artery stenosis but without visual regional wall motion abnormality were studied. Total, subendocardial (inner-), and subepicalrdial (outer-) myocardial peak radial strains were derived from mid- LV wall radial strain curve using an echocardiographic 2D speckle tracking software (Toshiba Medical, Tokyo, Japan). Results: Peak total radial strain was similar in both groups (coronary stenosis group 27.1 ± 8.8 %, control 31.5 ± 9.8 %, NS). In coronary stenosis group, inner-strain was smaller (19.7 ± 8.9 vs. 38.8 ± 14.9 %, p<0.001) and outer-strain was greater than those in normal controls. (37.0 ± ;19.2 vs. 26.8 ± 11.5 %, p<0.001). And inner/outer strain ratio was significantly less in the coronary stenosis group than that of normal controls (0.44 ± 0.14,vs. 2.34 ± 0.86 p<;0.001). Conclusion: Our results with 2D speckle tracking imaging suggest that augmented subepicardial myocardial wall thickening may compensate impaired subendocardial myocardial wall thickening and may preserve total layer wall thickening in the hypoperfused myocardium at rest.

Wei Han, Ming-xing Xie, Xin-fang Wang, Qing Lv Union Hospital, Tongji Medical University of HUST, Wuhan, China Background: The assessment of left ventricular function after myocardial infarction (MI) is very important for clinical prognosis and therapy, such as revascularization and stem cell therapy. Rotation of the LV apex to the base, or LV torsion, is related to myocardial contractility and structure and has recently been recognized as a sensitive indicator of cardiac performance], but it has been difficult to measure. The recent development of speckle tracking imaging (STI) may provide a powerful means of assessing LV torsion, and has allowed LV rotation to be evaluated noninvasively. This study was conducted to evaluate the global and regional left ventricular twist in patients with anterior wall myocardial infarction (AMI) disease before and after revascularization by STI. Methods: In 48 AMI patients undergoing revascularization and 30 normal subjects as normal control group, the values of LV rotation were obtained at each plane using STI. LV twist was defined as apical rotation relative to the base. The standard deviation of time to peak twist (Tw-SD) and the maximal temporal difference of time to peak twist (Tw-diff) of 6 segments were measured. Results: (1) 20 patients with AMI were followed up for one month and clear endocardial images were obtained; (2) Before revascularization, peak LV twist was significantly reduced in patients with AMI as compared with normal control group (P<0.001), most significantly in the anterior and anteriorseptal regions (P<0.001), while Tw-SD and Tw-diff were significantly increased in AMI group as compared with normal control group (both P<0.001). (3) One month after revascularization in AMI patients, LV reconstruction was reversed, and LV global and segment peak twist had obvious changes, especially in the LAD territory areas (P<0.001). At the same time, Tw-diff was reduced significantly (P<0.001). There were significant correlations between LV global peak twist and LVEF (r=0.78, P<0.05), LVDD (r=-0.63, P<0.05) in all subjects. Conclusion: Systolic twist was decreased and unsynchronized in AMI patients. Revascularization therapy can improve the LV function of the AMI patients. STI has a potential to quantify left ventricular global and segment twist in patients with AMI.

P2-105

P2-106

Most Clinically Important Echo Findings are Unrelated to Source of Embolization in Stroke Patients

Prevention of Atrial Fibrillation after Coronary Artery Bypass Grafting via Atrial Electromechanical Interval and Use of Amiodarone Prophylaxis

Subha Ghosh, Nataraj Desai, Shreedhar Kulkarni, Robert Ostfeld, Ythan Goldberg, Daniel M Spevack Montefiore Medical Center, Bronx, NY

Farideh Roshanali, Mohammad Hossein Mandegar, Mohammad Ali Yousefnia Day General Hospital, Tehran, Iran (Islamic Republic of)

Background: Prior works reporting on the yield of echocardiography in stroke have focused on findings related to source of embolization. We examined the yield of transthoracic (TTE) and transesophageal (TEE) echocardiography for predefined findings with potential for important alteration of clinical management that were unrelated to source of embolization in patients referred following a stroke. Methods: Echocardiographic reports were reviewed for the period 1/1/01 through 7/31/07 for all patients referred for stroke (ICD-9 code 436). Each report was examined for any left ventricular (LV) wall motion abnormality (WMA), severe right ventricular (RV) WMA, any severe valve disease, severe pulmonary hypertension (PHT), severe left ventricular hypertrophy (LVH), atrial septal aneurysm (ASA), shunt, masses, thrombi, or vegetations. Only the first report for each individual was included. Bubble studies and aortic arch imaging were routinely performed on TEE exams only. Results: Clinically important abnormalities unrelated to embolization were seen in 698 (17.3%) of 4,032 initially referred for TTE compared with 169 (21.8%) of 775 initially referred for TEE (p = 0.002). In TTE group there were 550 (13.6%) with any LV-WMA, 51 (1.2%) with severe RV-WMA, 116 (2.9%) with severe valve disease, 103 (2.6%) with severe PHT and 40 (1.0%) with severe LVH. On TEE there were 113 (14.6%) with any LV-WMA, 4 (0.5%) with severe RV-WMA, 25 (3.2%) with severe valve disease, 7 (0.9%) with severe PHT, 46 (5.9%) with severe LVH and 10 (1.3%) with coronary stenosis. Source for embolization was more commonly seen on TEE [atrial septal abnormalities (29.4% vs 1.4%, p < 0.001); masses, thrombi or vegetation (4.9% vs 0.4%, p < 0.001); aortic dissection or aneurysm (1.0% vs 0)]. Compared with the TTE group, TEE patients were younger (56 ± 14 vs 68 ±15 years, p < 0.001) and less often women (56% vs 61%, p 0.01). Conclusions: Clinically important echocardiographic findings unrelated to source of embolization are common on both TTE and TEE in patients referred for stroke. Screening this high-risk population with echocardiography has a high yield for diagnosis of coronary artery disease, severe valvular heart disease, severe cardiac hypertrophy and severe right heart dysfunction.

Background: In our previous study on the validity of the atrial electromechanical interval (AEMi), as measured by transthoracic tissue Doppler echocardiography, in determining patients at risk of atrial fibrillation (AF) in the wake of coronary artery bypass grafting (CABG) (post-CABG AF), we defined a cut-off point for the AEMi and chose 120 milliseconds for categorization, which yielded 100% sensitivity and 94.8% specificity. Accordingly, the present study sought to investigate whether or not a prophylactic perioperative administration of amiodarone could reduce the incidence of AF in this high-risk group undergoing CABG. Methods and Results: In this prospective, double-blinded, placebo-controlled, randomized study, 100 patients with AEMi more than 120ms received either amiodarone (n = 50) or placebo (n = 50). The endpoints were the occurrence of AF after CABG and the hospitalization length of stay after CABG. The incidence of postoperative AF was significantly higher in the placebo group than that of the amiodarone group (92 vs. 14% of patients, P < 0.0001). The prophylactic therapy with amiodarone significantly reduced the intensive care length of stay (1.5 +/- 1.3 vs. 2.6 +/- 1.8 days, P <0.001) and hospitalization length of stay (6.1 +/- 1.4 vs. 9.0 +/- 2.2 days, P <0.001). Conclusion: AEMi could be a valuable method for identifying patients vulnerable to post-CABG AF. The incidence of postoperative AF among patients with high AEMi was significantly reduced by a prophylactic amiodarone treatment, resulting in shorter intensive care unit and hospital stays.

Journal of the American Society of Echocardiography Volume 21 Number 5

581

P2-107

P2-108

Aortic Valve Sclerosis on Transthoracic Echocardiography: Comparison with Multi-Slice Computed Tomography

Risk Stratification and Prognosis of Patients with Prior Coronary Artery Bypass Surgery Referred for Stress Echocardiography

Chafik Assal, Bryan Martin, Ricardo Serrano, Sanjay Sarin, Anwer Qureshi, Jamshid Shirani Geisinger Medical Center, Danville, PA

Sripal Bangalore, Gangadhara Kabbli, Chris Cianci, Sandhya K Balaram, Sunil Kumar, Michelle Koolae, Sandeep Joshi, Satish Boddepalli, Siu-Sun Yao, Farooq A Chaudhry St Lukes-Roosevelt Hospital Center, New York, NY

Background: Aortic valve sclerosis (AVS) is an active atherosclerotic lesion and is associated with increased coronary and cerebrovascular ischemic events as well as cardiovascular mortality. Focal areas of calcification and bone formation are often detected as part of the pathology of advanced AVS. We aimed to investigate the relation of transthoracic echocardiographic (TTE) AVS with aortic valve and coronary artery calcification (AVC and CAC) detected on multi (64)-slice computed tomography (MSCT). Methods and Results: AVS, defined as focal areas of increased echogenicity and thickening of the aortic valve cusps without restriction in motion and with a transaortic velocity less than 2.5 m/s, was present on TTE in 51 (16%) of 325 patients [age 56±12 years, 169 (52%) women, 59% hypertensive, 14% diabetic, 35% smokers, 52% hypercholesterolemic] who underwent both TTE and MSCT. In 34 (67%) and 42 (82%) patients with TTE AVS, MSCT also showed AVC or CAC, respectively. In addition, 39 of 274 (14%) patients without TTE AVS showed AVC by MSCT. The mean CAC score was 258±751 in the 325 patients and correlated directly with the presence and severity (0=absent; 1=mild; 2=moderate to severe) of TTE AVS (Table, p<0.0001 by Jonckheere-Terpstra Test). Compared to those with both AVS on TTE and AVC on MSCT, patients with AVS on TTE but no AVC on MSCT were younger (age 58±10-vs-69±11 years, p=0.0019) but were as likely to have a total cholesterol >200 mg/dL (59%-vs-65%, p=NS). Conclusions: AVS on TTE is frequently associated with AVC on MSCT and correlates directly with CAC score, a marker of coronary artery disease. Age appears to be an important determinant of development of calcification in AVS.

Background: Stress echo is an important imaging modality for diagnosis, risk stratification and prognosis of patients with known or suspected coronary artery disease. Patients post coronary artery bypass graft surgery (CABG) have baseline wall motion abnormalities (predominantly septal). Methods: We evaluated 271 consecutive patients (mean age 65 ± 10 years; 69% men) with prior CABG referred for stress echocardiography (73% dobutamine). Abnormal stress echo studies were defined as those with infarction (fixed wall motion abnormality) or stress-induced ischemia. Follow-up (2.6 ± 1.1 years) for confirmed nonfatal MI (n = 7) and cardiac death (n = 16) were obtained. Results: Among 271 patients undergoing stress echocardiography, 195 patients (72%) had an abnormal stress echocardiography study. Stress echocardiography effectively risk stratified patients into a normal versus abnormal group (event rate 0.5%/y vs. 4.3%/y; RR = 9.54, 95% CI = 1.26-72.1; P = 0.0008) (Figure). A multivariate Cox proportional hazard model showed that extent of reversible ischemia (HR = 1.12; 95% CI = 1.03-1.23; P = 0.011) added incremental prognostic value beyond clinical and stress electrocardiographic variables (Global Chi2 increased from 13.3 to 13.3 to 21.3; P = NS and P = 0.013). Conclusions: In patients with prior CABG referred for stress echocardiography, stress echocardiography effectively risk stratifies patients and provides incremental value beyond that provided by clinical and stress electrocardiographic variables.

Relation of TTE AVS to CAC on MSCT TTE AVS Score

% Total Patients

Median MSCT CAC Score

0

84

2 (0, 97)

1

9

151 (20,421)

2

7

256 (9, 821)

All Patients

100

8 (0, 179)

P2-109

P2-110

New Echocardiographic Approach to the Decision-Making Process for Ischemic Mitral Valve

Post-Exercise Ischemic Memory Detected by Velocity Vector Imaging is an Useful Marker for Angina Pectroris: New Marker of Induced Ischemia

Farideh Roshanali, Mohammad Hossein Mandegar, Mohammad Ali Yousefnia Day General Hospital, Tehran, Iran (Islamic Republic of)

Koji Kurosawa, Hiroyuki Watanabe, Nobuo Iguchi, Masaru Aikawa, Hirotsugu Mihara, Kanki Inoue, Itaru Takamisawa, Atsushi Seki, Tetsuya Tobaru, Masatoshi Nagayama, Ryuta Asano, Morimasa Takayama, Jun Umemura, Tetsuya Sumiyoshi Sakakibara Heart Institute, Fuchu, Japan

Background: Given the controversy over the diagnosis and management of ischemic mitral regurgitation (MR), we sought to develop an algorithm for the decision-making process for ischemic MR and to show its efficacy. Methods: Our algorithm was developed in four stages: In the first stage, echocardiography was done to evaluate effective regurgitant orifice area (ERO). In the second stage, the patients were evaluated for life expectancy. In the third stage, low-dose stress echocardiography was carried out to find whose MR was reversible with revascularization. In the fourth stage, papillary muscle distance (PMD) and coaptation depth (CD) were measured. The patients were, subsequently, followed for 34+11 months. Results: In total, 350 patients were evaluated. On the basis of the algorithm, 94 patients because of their ERO<20, 30 patients due to their life expectancy<5 years, and 49 patients on account of their reversible MR despite ERO>20 underwent only CABG. Of the remaining patients, who had ERO>20 and life expectancy >5 years but did not have reversible MR, 120 patients with PMD<20 and CD<10 underwent annuloplasty and the rest, who had PMD>20 and CD>10, 31 patients underwent mitral valve repair and 26 underwent annuloplasty+alternative at the discretion of the surgeon. There was no difference between the groups in terms of age and sex (PV>0.05). The mortality rates in Groups 1 to 6 were %8/5, %66/7, %8/2, %6/7, %9/7, and %11/5, respectively. While there was a statistically significant difference between Group 2 (%66/7) and the rest of the groups (PV<0.005), there was no such difference between the other groups. Except for Group 2, which was in NYHA class 3.1, the NYHA class in the other groups at follow-up was 1.4+.0.5. Conclusion: Our data showed that this echocardiographic algorithm could be a very useful tool for the decision-making process for ischemic mitral valve.

Background: Post-exercise ischemic memory(PIM) has been reported as a new marker of wall motion abnormality induced by ischemia. Recently, Velocity Vector Imaging (VVI) has been developed to visualize regional wall motion abnormality frame by frame as amount of arrows based on vector detected by tissue tracking technique; this technique has a potential to visualize PIM. Thus, the purpose of this study was to test the hypothesis that PIM detected by VVI could be an objective marker for ischemia compared with exercise 201-Thallium schintigraphy (SPECT). Methods: We studied consecutive 102 patients who planned SPECT for diagnosis of angina pectoris. Echocardiography was digitally stored by transthoracic echocardiography (Acuson Sequoia 512, 4V1c probe, Siemens) in a short-axis view for subsequent off-line VVI analysis before and after 15 minutes of exercise for SPECT. PIM segments were diagnosed as regions with newly induced abnormal arrows after exercise, normal arrows have outward direction and abnormal arrows have inward direction at around the timing of mitral valve opening. Then, we compared VVI results with ischemic region by SPECT. Results: Echocardiography suitable for VVI analysis was recorded in 78 of 83 patients without atrial fibrillation and old myocardial infarction (feasibility 94.0%, male 47, female 31, mean age 66±10 years). SPECT revealed 25 patients had induced ischemia, while VVI revealed 22 patients had PIM. Compared with SPECT, VVI can detect inducible ischemia at a sensitivity of 76% and specificity of 94%. Conclusion: Regional diastolic wall motion abnormality after induced ischemia can be successfully detected by VVI imaging. This is a new and powerful objective technique to detect angina pectoris, noninvasively.