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Utilisation of three-dimensional echocardiographic, semi-automated, left ventricular ejection fraction quantification by cardiac nurses: a comparison to cardiac magnetic resonance imaging
Abstract
595 Three-dimensional speckle tracking analysis of left ventricular multi-directional strain in severe aortic stenosis with preserved ejection fraction A. Yamada 1,2,3,∗ , M. Ischenko 1 , D. Walters 1 , C. Hamilton-Craig 1 , D. Platts 1 , V. Speranza 1 , A. Benjamin 1 , M. Harten 1 , D. Burstow 1 , J. Chan 1,2 1 The
Prince Charles Hospital, Heart and Lung Institute, Chermside, QLD, Australia 2 Menzies Health Institute Queensland, Griffith University, QLD, Australia 3 Fujita Health University, Japan Background: Aortic stenosis (AS) is known to cause left ventricular (LV) dysfunction and remodelling. Myocardial strain analysis can detect early myocardial dysfunction before decline in ejection fraction (EF). We aim to analyse the alteration in LV mechanics in patients with severe AS by threedimensional (3D) speckle tracking echocardiography (STE). Methods: Fifteen symptomatic severe AS patients with normal LV systolic function (mean age 86±5 years, EF 61±11%) and 15 normal controls (mean age 68±16 years, EF 65±4%) were examined using 3D STE. Peak systolic 3D global longitudinal (GLS), global circumferential (GCS), global radial (GRS) and global area strain (GAS) were measured by independent blinded observers. LVEF was calculated using 3D echo and 2D modified Simpson’s biplane method. Results: Severe AS patients had significantly reduced GLS (-9.4±3.4 vs. -19.8±1.7%, p<0.0001), GCS (-12.7±4.3 vs. -19.7±2.4%, p<0.0001), GRS (28.3±10.6 vs. 55.5±7.2%, p<0.0001) and GAS (-19.9±6.0 vs. -34.0±2.5%, p<0.0001) compared to controls. Among the 4 types of 3D global strains, GLS had the best correlation with mean aortic valve pressure gradient (r=-0.66, p=0.007), followed by GAS (r=-0.54, p=0.04), GRS (r=0.46, p=0.08) and GCS (r =-0.31, p=0.26). Receiver operator characteristics analysis revealed that GLS -9.6% was the optimal cutoff value to predict mean aortic pressure gradient >50mmHg (AUC 0.74, sensitivity 83%, specificity 67%). Conclusions: 3D global strain was significantly reduced in patients with severe AS in all axes of direction of motion. GLS was the best predictor of early myocardial dysfunction in severe AS with normal LV function. http://dx.doi.org/10.1016/j.hlc.2015.06.598 596 Use of computed tomographic coronary angiography after equivocal stress tests J. Liu, J. Vazirani ∗ , E. Lui, S. Heinze, P. Einsiedel, F. Langenberg, N. Better, S. Joshi The Royal Melbourne Hospital, VIC, Australia Background: Current international guidelines recognise Computed Tomographic Coronary Angiography (CTCA) as appropriate following equivocal stress tests, however this indication is not explicitly stated in the current Medicare
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Benefits Schedule in Australia. CTCA potentially avoids invasive cardiac catheterisation however could be redundant if invasive coronary angiography is still required. We sought to examine CTCA findings in patients with equivocal stress tests. Methods: Records were reviewed of 731 consecutive patients undergoing CTCA at a single institution between 30/09/2009 and 17/12/2014. Patients referred for CTCA following an equivocal cardiac stress test were identified based on radiology request forms. Results: 75 five patients were identified (mean age 59). 39 (52%) patients were of male gender. 44% (33/75) had normal coronary arteries; 36% (27/75) had clearly non-obstructive (<50% stenosis) disease, for which no further investigation was advised; 20% (15/75) had indeterminate or significant stenoses. These findings would have required further clarification or confirmation with invasive coronary angiography. Conclusions: CTCA successfully excluded obstructive coronary artery disease in 80% of patients with equivocal stress tests. Our finding suggest that CTCA can help further stratify patients following and equivocal stress test, and avoid invasive coronary angiography in a vast majority of these patients. http://dx.doi.org/10.1016/j.hlc.2015.06.599 597 Utilisation of three-dimensional echocardiographic, semi-automated, left ventricular ejection fraction quantification by cardiac nurses: a comparison to cardiac magnetic resonance imaging K. Guppy-Coles 1,∗ , S. Prasad 1,3 , S. Hillier 1 , K. Smith 1 , N. Biswas 1 , A. Lo 1 , A. Dahiya 1 , J. Atherton 1,2 1 Royal
Brisbane and Women’s Hospital, Brisbane, Queensland, Australia 2 University of Queensland, Brisbane, Queensland, Australia 3 Mater Adult and Women’s Hospital, Brisbane, Queensland, Australia Background: Three-dimensional Echocardiographic Left Ventricular Ejection Fraction (3D-LVEF) quantification with contour-assisting algorithms is comparable to Cardiac Magnetic Resonance (CMR) LVEF. We have previously shown that nurse quantification of 3D-LVEF on previously acquired images is comparable in accuracy to trained sonographers. The accuracy of nurse-quantified 3D-LVEF to CMR has not been studied. Methods: A total of 25 patients underwent 3D-LVEF assessment (performed by cardiac sonographer; GE Vivid E9) within 24hrs of CMR scan (Siemens 1.5T Avanto). Three nurses (training completed prior) quantified 3D-LVEF values on sonographer-acquired images (GE EchoPAC Auto LVQ). CMR LVEF values were obtained using parasternal stack (Argus). Nurse LVEF values were compared to CMR and sonographer (independently) using correlation (Pearson’s),
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Abstract
.. the R wave to the closing click on the AV Doppler signal. The .. .. observer was blinded to AFI data. .. .. Results. The analysis was 100% feasible in 107 patients. .. .. There was no significant difference in mean AVC time cal.. .. culated by PW Doppler compared to AFI (353ms±41ms .. vs. 358±47ms, p=0.37). There was excellent correlation and .. .. concordance between the 2 different methodologies (r=0.85, .. .. P<0.001). Bland-Altman analysis demonstrated a mean dif.. .. ference of 6±24ms with 95% confidence intervals. .. .. .. LVEF (%) Comparisons Nurse #1 Nurse #3 . Nurse #2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Sonographer comparisons Correlation (R) 0.89 (p<0.005) 0.87 (p<0.005) .. 0.94 (p<0.005) .. . Weighted agreement () 0.63 0.62 .. 0.62 .. .. 3.4 (-8.4, +15.1) Bland-Altman (LOA) 5.4 (-9.2,+20.1) 2.3 (-13.1, +17.8) .. .. CMR comparisons Correlation (R) 0.84 (p<0.005) 0.81 (p<0.005) ... 0.95 (p<0.005) .. Weighted agreement () 0.61 0.68 .. 0.82 .. Bland-Altman (LOA) 2.1 (-13.5, +17.8) -1 (-18.4, +16.4) ... 0 (-9.9, +10) .. .. .. . Conclusion: Sonographer comparisons to CMR are consis- ... . Conclusion. Timing of AVC using AFI is comparable to tent with published literature. Good to excellent correlations ... . conventional pulsed-wave Doppler method of assessment. . and good agreement were found between nurses compared to . . sonographer as well as to CMR. This study indicates nurses, ... AFI automated method is accurate in defining end systole for with focussed echocardiography training, can quantify 3D- ... measurement of peak strain values. . LVEF on previously acquired images with similar accuracy ... .. http://dx.doi.org/10.1016/j.hlc.2015.06.601 to CMR. .. .. .. 599 http://dx.doi.org/10.1016/j.hlc.2015.06.600 ... .. .. Would adding two left atrial piloted images 598 .. to a cardiac magnetic resonance protocol .. .. enable rapid, accurate calculation of left Validation of aortic valve closure timing by .. .. atrial volume (LAV)? Use of 320-slice EchoPAC Automated Function Imaging .. .. cardiac computed tomography (320-CTCA) algorithm: A comparison to conventional .. .. as proof of concept pulsed wave Doppler assessment .. ... N. Nerlekar ∗ , T. Barton, P. Mottram, S. Moir N. Kelly 1,∗ , M. Harten 1 , A. Tucker 1 , D. .. .. Burstow 1 , J. Chan 1,2 MonashHeart, Melbourne, VIC, Australia .. .. 1 The Prince Charles Hospital, Chermside, QLD, .. .. Background: LAV is an important marker of prognoAustralia .. 2 Menzies Health Institute Queensland, Griffith .. sis but is not routinely evaluated by cardiac magnetic .. .. resonance (CMR) as full volume dataset acquisition is University, QLD, Australia .. .. time consuming. Calculation of LAV using the biplane . Background. Automated Function Imaging (AFI) is a soft- ... area-length method (BAL) from routinely acquired 4 and 2ware tool that automates 2D speckle tracking to measure ... chamber views (4CV, 2CV) significantly underestimates true . real-time deformation of the myocardial wall. The determi- ... volume. Aim: We hypothesised this underestimation was due to nation of aortic valve closure (AVC) is important in defining ... .. standard CMR 4CV and 2CV images piloted from mid-mitral end systole for strain measurements. We aim to assess the .. .. valve to LV apex – (LV-piloting) foreshortening the atrium, accuracy of automated AVC algorithm in AFI. .. Methods. Echocardiographic images were retrospectively ... and additional 4CV and 2CV images piloted from mid-mitral analysed in 107 patients. Digital loops were stored over 3 ... valve to the mid posterior wall of the left atrium (LA-piloting) . successive cardiac cycles from the apical long, 2 and 4 cham- ... would enable rapid, accurate calculation of LAV using ber views between 50-80fps. Analysis was performed offline ... BAL. . Methods: We evaluated 3-D datasets from 44 consecusing GE EchoPAC XDclear. The AFI software determined the ... . timing of AVC by an inbuilt fully automated algorithm. AVC .. utive patients undergoing retrospective 320-CTCA. True . was also determined from conventional pulsed-wave (PW) ... 3-D left atrial volume (gold-standard) was calculated at . Doppler signal through the AV. A sweep speed of 100mm/s ... end-systole by a blinded observer excluding pulmonary was utilised with the sample volume placed just proximal to ... veins and left atrial appendage. A second blinded observer . the AV leaflets. AVC timing was measured from the peak of .. manipulated images to create standard ‘CMR’ 4CV and
weighted agreement (Cohen’s Kappa), and Bland-Altman mean differences with limits of agreement (LOA). Results: Demographic averages (+SD) included: height 173cm (+7.8cm), weight 78kg (+17kg), age 54yrs (+17yrs), systolic blood pressure 137mmHg (+8.2mmHg), with 79% being male. Sonographer LVEF compared with CMR found R=0.93 (p<0.005) for correlation, =0.74 for weighted agreement, and 3.3 (-8.1, +14.7) for mean difference (LOA). Nurse LVEF values compared to CMR and Sonographer are listed below.
595 Three-dimensional speckle tracking analysis of left ventricular multi-directional strain in severe aortic stenosis with preserved ejection fraction A. Yamada 1,2,3,∗ , M. Ischenko 1 , D. Walters 1 , C. Hamilton-Craig 1 , D. Platts 1 , V. Speranza 1 , A. Benjamin 1 , M. Harten 1 , D. Burstow 1 , J. Chan 1,2 1 The
Prince Charles Hospital, Heart and Lung Institute, Chermside, QLD, Australia 2 Menzies Health Institute Queensland, Griffith University, QLD, Australia 3 Fujita Health University, Japan Background: Aortic stenosis (AS) is known to cause left ventricular (LV) dysfunction and remodelling. Myocardial strain analysis can detect early myocardial dysfunction before decline in ejection fraction (EF). We aim to analyse the alteration in LV mechanics in patients with severe AS by threedimensional (3D) speckle tracking echocardiography (STE). Methods: Fifteen symptomatic severe AS patients with normal LV systolic function (mean age 86±5 years, EF 61±11%) and 15 normal controls (mean age 68±16 years, EF 65±4%) were examined using 3D STE. Peak systolic 3D global longitudinal (GLS), global circumferential (GCS), global radial (GRS) and global area strain (GAS) were measured by independent blinded observers. LVEF was calculated using 3D echo and 2D modified Simpson’s biplane method. Results: Severe AS patients had significantly reduced GLS (-9.4±3.4 vs. -19.8±1.7%, p<0.0001), GCS (-12.7±4.3 vs. -19.7±2.4%, p<0.0001), GRS (28.3±10.6 vs. 55.5±7.2%, p<0.0001) and GAS (-19.9±6.0 vs. -34.0±2.5%, p<0.0001) compared to controls. Among the 4 types of 3D global strains, GLS had the best correlation with mean aortic valve pressure gradient (r=-0.66, p=0.007), followed by GAS (r=-0.54, p=0.04), GRS (r=0.46, p=0.08) and GCS (r =-0.31, p=0.26). Receiver operator characteristics analysis revealed that GLS -9.6% was the optimal cutoff value to predict mean aortic pressure gradient >50mmHg (AUC 0.74, sensitivity 83%, specificity 67%). Conclusions: 3D global strain was significantly reduced in patients with severe AS in all axes of direction of motion. GLS was the best predictor of early myocardial dysfunction in severe AS with normal LV function. http://dx.doi.org/10.1016/j.hlc.2015.06.598 596 Use of computed tomographic coronary angiography after equivocal stress tests J. Liu, J. Vazirani ∗ , E. Lui, S. Heinze, P. Einsiedel, F. Langenberg, N. Better, S. Joshi The Royal Melbourne Hospital, VIC, Australia Background: Current international guidelines recognise Computed Tomographic Coronary Angiography (CTCA) as appropriate following equivocal stress tests, however this indication is not explicitly stated in the current Medicare
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Benefits Schedule in Australia. CTCA potentially avoids invasive cardiac catheterisation however could be redundant if invasive coronary angiography is still required. We sought to examine CTCA findings in patients with equivocal stress tests. Methods: Records were reviewed of 731 consecutive patients undergoing CTCA at a single institution between 30/09/2009 and 17/12/2014. Patients referred for CTCA following an equivocal cardiac stress test were identified based on radiology request forms. Results: 75 five patients were identified (mean age 59). 39 (52%) patients were of male gender. 44% (33/75) had normal coronary arteries; 36% (27/75) had clearly non-obstructive (<50% stenosis) disease, for which no further investigation was advised; 20% (15/75) had indeterminate or significant stenoses. These findings would have required further clarification or confirmation with invasive coronary angiography. Conclusions: CTCA successfully excluded obstructive coronary artery disease in 80% of patients with equivocal stress tests. Our finding suggest that CTCA can help further stratify patients following and equivocal stress test, and avoid invasive coronary angiography in a vast majority of these patients. http://dx.doi.org/10.1016/j.hlc.2015.06.599 597 Utilisation of three-dimensional echocardiographic, semi-automated, left ventricular ejection fraction quantification by cardiac nurses: a comparison to cardiac magnetic resonance imaging K. Guppy-Coles 1,∗ , S. Prasad 1,3 , S. Hillier 1 , K. Smith 1 , N. Biswas 1 , A. Lo 1 , A. Dahiya 1 , J. Atherton 1,2 1 Royal
Brisbane and Women’s Hospital, Brisbane, Queensland, Australia 2 University of Queensland, Brisbane, Queensland, Australia 3 Mater Adult and Women’s Hospital, Brisbane, Queensland, Australia Background: Three-dimensional Echocardiographic Left Ventricular Ejection Fraction (3D-LVEF) quantification with contour-assisting algorithms is comparable to Cardiac Magnetic Resonance (CMR) LVEF. We have previously shown that nurse quantification of 3D-LVEF on previously acquired images is comparable in accuracy to trained sonographers. The accuracy of nurse-quantified 3D-LVEF to CMR has not been studied. Methods: A total of 25 patients underwent 3D-LVEF assessment (performed by cardiac sonographer; GE Vivid E9) within 24hrs of CMR scan (Siemens 1.5T Avanto). Three nurses (training completed prior) quantified 3D-LVEF values on sonographer-acquired images (GE EchoPAC Auto LVQ). CMR LVEF values were obtained using parasternal stack (Argus). Nurse LVEF values were compared to CMR and sonographer (independently) using correlation (Pearson’s),
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Abstract
.. the R wave to the closing click on the AV Doppler signal. The .. .. observer was blinded to AFI data. .. .. Results. The analysis was 100% feasible in 107 patients. .. .. There was no significant difference in mean AVC time cal.. .. culated by PW Doppler compared to AFI (353ms±41ms .. vs. 358±47ms, p=0.37). There was excellent correlation and .. .. concordance between the 2 different methodologies (r=0.85, .. .. P<0.001). Bland-Altman analysis demonstrated a mean dif.. .. ference of 6±24ms with 95% confidence intervals. .. .. .. LVEF (%) Comparisons Nurse #1 Nurse #3 . Nurse #2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Sonographer comparisons Correlation (R) 0.89 (p<0.005) 0.87 (p<0.005) .. 0.94 (p<0.005) .. . Weighted agreement () 0.63 0.62 .. 0.62 .. .. 3.4 (-8.4, +15.1) Bland-Altman (LOA) 5.4 (-9.2,+20.1) 2.3 (-13.1, +17.8) .. .. CMR comparisons Correlation (R) 0.84 (p<0.005) 0.81 (p<0.005) ... 0.95 (p<0.005) .. Weighted agreement () 0.61 0.68 .. 0.82 .. Bland-Altman (LOA) 2.1 (-13.5, +17.8) -1 (-18.4, +16.4) ... 0 (-9.9, +10) .. .. .. . Conclusion: Sonographer comparisons to CMR are consis- ... . Conclusion. Timing of AVC using AFI is comparable to tent with published literature. Good to excellent correlations ... . conventional pulsed-wave Doppler method of assessment. . and good agreement were found between nurses compared to . . sonographer as well as to CMR. This study indicates nurses, ... AFI automated method is accurate in defining end systole for with focussed echocardiography training, can quantify 3D- ... measurement of peak strain values. . LVEF on previously acquired images with similar accuracy ... .. http://dx.doi.org/10.1016/j.hlc.2015.06.601 to CMR. .. .. .. 599 http://dx.doi.org/10.1016/j.hlc.2015.06.600 ... .. .. Would adding two left atrial piloted images 598 .. to a cardiac magnetic resonance protocol .. .. enable rapid, accurate calculation of left Validation of aortic valve closure timing by .. .. atrial volume (LAV)? Use of 320-slice EchoPAC Automated Function Imaging .. .. cardiac computed tomography (320-CTCA) algorithm: A comparison to conventional .. .. as proof of concept pulsed wave Doppler assessment .. ... N. Nerlekar ∗ , T. Barton, P. Mottram, S. Moir N. Kelly 1,∗ , M. Harten 1 , A. Tucker 1 , D. .. .. Burstow 1 , J. Chan 1,2 MonashHeart, Melbourne, VIC, Australia .. .. 1 The Prince Charles Hospital, Chermside, QLD, .. .. Background: LAV is an important marker of prognoAustralia .. 2 Menzies Health Institute Queensland, Griffith .. sis but is not routinely evaluated by cardiac magnetic .. .. resonance (CMR) as full volume dataset acquisition is University, QLD, Australia .. .. time consuming. Calculation of LAV using the biplane . Background. Automated Function Imaging (AFI) is a soft- ... area-length method (BAL) from routinely acquired 4 and 2ware tool that automates 2D speckle tracking to measure ... chamber views (4CV, 2CV) significantly underestimates true . real-time deformation of the myocardial wall. The determi- ... volume. Aim: We hypothesised this underestimation was due to nation of aortic valve closure (AVC) is important in defining ... .. standard CMR 4CV and 2CV images piloted from mid-mitral end systole for strain measurements. We aim to assess the .. .. valve to LV apex – (LV-piloting) foreshortening the atrium, accuracy of automated AVC algorithm in AFI. .. Methods. Echocardiographic images were retrospectively ... and additional 4CV and 2CV images piloted from mid-mitral analysed in 107 patients. Digital loops were stored over 3 ... valve to the mid posterior wall of the left atrium (LA-piloting) . successive cardiac cycles from the apical long, 2 and 4 cham- ... would enable rapid, accurate calculation of LAV using ber views between 50-80fps. Analysis was performed offline ... BAL. . Methods: We evaluated 3-D datasets from 44 consecusing GE EchoPAC XDclear. The AFI software determined the ... . timing of AVC by an inbuilt fully automated algorithm. AVC .. utive patients undergoing retrospective 320-CTCA. True . was also determined from conventional pulsed-wave (PW) ... 3-D left atrial volume (gold-standard) was calculated at . Doppler signal through the AV. A sweep speed of 100mm/s ... end-systole by a blinded observer excluding pulmonary was utilised with the sample volume placed just proximal to ... veins and left atrial appendage. A second blinded observer . the AV leaflets. AVC timing was measured from the peak of .. manipulated images to create standard ‘CMR’ 4CV and
weighted agreement (Cohen’s Kappa), and Bland-Altman mean differences with limits of agreement (LOA). Results: Demographic averages (+SD) included: height 173cm (+7.8cm), weight 78kg (+17kg), age 54yrs (+17yrs), systolic blood pressure 137mmHg (+8.2mmHg), with 79% being male. Sonographer LVEF compared with CMR found R=0.93 (p<0.005) for correlation, =0.74 for weighted agreement, and 3.3 (-8.1, +14.7) for mean difference (LOA). Nurse LVEF values compared to CMR and Sonographer are listed below.