-
-
-
[show abstract]
[hide abstract]
ABSTRACT: Transcatheter aortic valve replacement (TAVR) is an effective treatment option for patients with severe aortic stenosis who are at high surgical risk because of multiple comorbidities. Many of these patients have been treated with pacemakers for concomitant conduction disease. The combination of severe aortic stenosis, cardiomyopathy, and conduction abnormalities results in a state of low cardiac output. Here, we report 2 complex TAVR cases where Doppler echocardiography was used to guide adjustment of device settings, leading to improved cardiac hemodynamic profiles.
Echocardiography 04/2013; · 1.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Echocardiography-guided optimization of atrioventricular (AV) delay (AVD) improves left ventricular (LV) filling, and optimized interventricular delay (VVD) leads to further improvement in cardiac output in patients with biventricular (Biv) pacing. Investigators use LV filling and ejection to optimize AV and VV delay in patients with Biv pacing. Effect of such optimization on right-sided hemodynamics remains unknown. In our experience, few patients experience worsening of right ventricle (RV) hemodynamics when LV parameters are optimized. We present a series of cases where we observed suboptimal RV filling or ejection at optimal AVD and VVD for LV. This RV-LV discordance may contribute to nonresponder rate to cardiac resynchronization therapy (CRT) and should be evaluated in a consecutive series of CRT nonresponder patients to help improve CRT response.
Echocardiography 02/2013; · 1.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In spite of improvements in heart failure management and increasing utilization of cardiac resynchronization therapy (CRT), approximately 30-40% of CRT patients remain nonresponders and 50% or more are echocardiographic nonresponders (defined as less than 15% reduction in left ventricular end systolic volume post-CRT). Optimization guided by echocardiography has been studied as one of the methods to improve the nonresponder rate to CRT. Echo-guided biventricular (Biv) pacemaker optimization has been associated with improvement in acute cardiac hemodynamics and improvement in functional class. In this review, the authors discuss various methods to optimize Biv pacemaker by echocardiography, recent advances in pacemaker optimization and the limitations of echocardiography. The authors also demonstrate complex hemodynamic derangements in heart failure via multiple case examples highlighting the role of comprehensive echo Doppler in elucidating cardiac hemodynamics encountered in CRT nonresponders, as well as tailoring of Biv pacemaker optimization to the underlying physiologic derangement.
Expert Review of Cardiovascular Therapy 07/2012; 10(7):859-74.
-
[show abstract]
[hide abstract]
ABSTRACT: Use of rate adaptive atrioventricular (AV) delay remains controversial in patients with biventricular (Biv) pacing. We hypothesized that a shortened AV delay would provide optimal diastolic filling by allowing separation of early and late diastolic filling at increased heart rate (HR) in these patients.
34 patients (75 ± 11 yrs, 24 M, LVEF 34 ± 12%) with Biv and atrial pacing had optimal AV delay determined at baseline HR by Doppler echocardiography. Atrial pacing rate was then increased in 10 bpm increments to a maximum of 90 bpm. At each atrial pacing HR, optimal AV delay was determined by changing AV delay until best E and A wave separation was seen on mitral inflow pulsed wave (PW) Doppler (defined as increased atrial duration from baseline or prior pacemaker setting with minimal atrial truncation). Left ventricular (LV) systolic ejection time and velocity time integral (VTI) at fixed and optimal AV delay was also tested in 13 patients. Rate adaptive AV delay was then programmed according to the optimal AV delay at the highest HR tested and patients were followed for 1 month to assess change in NYHA class and Quality of Life Score as assessed by Minnesota Living with Heart Failure Questionnaire.
81 AV delays were evaluated at different atrial pacing rates. Optimal AV delay decreased as atrial paced HR increased (201 ms at 60 bpm, 187 ms at 70 bpm, 146 ms at 80 bpm and 123 ms at 90 bpm (ANOVA F-statistic = 15, p = 0.0010). Diastolic filling time (P < 0.001 vs. fixed AV delay), mitral inflow VTI (p < 0.05 vs fixed AV delay) and systolic ejection time (p < 0.02 vs. fixed AV delay) improved by 14%, 5% and 4% respectively at optimal versus fixed AV delay at the same HR. NYHA improved from 2.6 ± 0.7 at baseline to 1.7 ± 0.8 (p < 0.01) 1 month post optimization. Physical component of Quality of Life Score improved from 32 ± 17 at baseline to 25 ± 12 (p < 0.05) at follow up.
Increased heart rate by atrial pacing in patients with Biv pacing causes compromise in diastolic filling time which can be improved by AV delay shortening. Aggressive AV delay shortening was required at heart rates in physiologic range to achieve optimal diastolic filling and was associated with an increase in LV ejection time during optimization. Functional class improved at 1 month post optimization using aggressive AV delay shortening algorithm derived from echo-guidance at the time of Biv pacemaker optimization.
Cardiovascular Ultrasound 01/2012; 10:2. · 1.26 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The advent of real-time (RT) 3D transesophageal echocardiography (TEE) in 2007 has enhanced our understanding of the location and extent of the pathology of the native, as well as prosthetic, mitral valve (MV), particularly for MV prolapse and the anatomy of perivalvular dehiscence with prosthetic MV. MV quantification programs provide precise assessment of many quantitative MV parameters allowing 3D echocardiography to determine and quantify the geometry of mitral apparatus, including mitral annulus and periannular region, leaflet volume and anatomy, tethering distances, and tenting volumes. The detailed, accurate and optimal RT spatial visualization of the MV with 3D TEE gives greater confidence to the echocardiographer, interventionalist and the surgeon alike, facilitating medical and surgical treatment decisions. This article highlights recent advances in RT 3D TEE and transthoracic echocardiography echocardiographic imaging of the MV.
Expert Review of Cardiovascular Therapy 11/2011; 9(11):1431-43.
-
[show abstract]
[hide abstract]
ABSTRACT: Biventricular (Biv) pacemaker echo optimization has been shown to improve cardiac output however is not routinely used due to its complexity. We investigated the role of a simple method involving computerized pre-ejection time (PEP) assessment by radial artery tonometry in guiding Biv pacemaker optimization.
Blinded echo and radial artery tonometry were performed simultaneously in 37 patients, age 69.1 ± 12.8 years, left ventricular (LV) ejection fraction (EF) 33 ± 10%, during Biv pacemaker optimization. Effect of optimization on echo derived velocity time integral (VTI), ejection time (ET), myocardial performance index (MPI), radial artery tonometry derived PEP and echo-radial artery tonometry derived PEP/VTI and PEP/ET indices was evaluated.
Significant improvement post optimization was achieved in LV ET (286.9 ± 37.3 to 299 ± 34.6 ms, p < 0.001), LV VTI (15.9 ± 4.8 cm to 18.4 ± 5.1 cm, p < 0.001) and MPI (0.57 ± 0.2 to 0.45 ± 0.13, p < 0.001) and in PEP (246.7 ± 36.1 ms to 234.7 ± 35.5 ms, p = 0.003), PEP/ET (0.88 ± 0.21 to 0.79 ± 0.17, p < 0.001), and PEP/VTI (17.3 ± 7 to 13.78 ± 4.7, p < 0.001). The correlation between comprehensive echo Doppler and radial artery tonometry-PEP guided optimal atrioventricular delay (AVD) and optimal interventricular delay (VVD) was 0.75 (p < 0.001) and 0.69 (p < 0.001) respectively. In 29 patients with follow up assessment, New York Heart Association (NYHA) class reduced from 2.5 ± 0.8 to 2.0 ± 0.9 (p = 0.004) at 1.8 ± 1.4 months.
An acute shortening of PEP by radial artery tonometry occurs post Biv pacemaker optimization and correlates with improvement in hemodynamics by echo Doppler and may provide a cost-efficient approach to assist with Biv pacemaker echo optimization.
Cardiovascular Ultrasound 07/2011; 9:20. · 1.26 Impact Factor
-
Tasneem Z Naqvi
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 03/2011; 24(3):348; author reply 348-9. · 2.98 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: A 51-year-old female undergoing an outpatient stress echocardiogram to evaluate atypical chest pain developed acute ST elevation in the anterior precordial leads on electrocardiogram following exercise. Echocardiography revealed a severe rise in pulmonary artery systolic pressure (PASP) with marked right ventricular (RV) enlargement and interventricular septum flattening. Subsequently, cardiac catherization confirmed an exercise-induced elevation in PASP and diagnosed pulmonary arterial hypertension without evidence of coronary artery disease. This case suggests that an acute elevation in pulmonary artery pressure with RV dilation may be a potential cause of acute ST elevation during stress testing.
Cardiovascular Ultrasound 01/2011; 9:18. · 1.26 Impact Factor
-
The American journal of medicine 12/2010; 123(12):e3-4. · 4.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Patent foramen ovale (PFO) is diagnosed on echocardiography by saline contrast study with or without color Doppler evidence of shunting. PFO is benign except when it causes embolic events.
In this report, we describe unique additional manifestations related to the diagnosis and presentation of PFO. These include demonstration of PFO during the release phase of "sigh" on the ventilator in the operating room, use of a separate venipuncture to allow preparation of blood-saline-air mixture after multiple failed saline bubble injections, resting and stress hypoxemia related to left to right shunting across a PFO in the absence of pulmonary hypertension, presentation of quadriperesis secondary to an embolic event from a PFO and development of a thrombus on the left atrial aspect of PFO in a patient with atrial fibrillation, and on the right atrial aspect of PFO in a patient who had undergone repair of a flail mitral valve. Finally, in one patient with end-stage renal disease, aortic valve endocarditis and periaortic abscess, PFO acted as a vent valve relieving right atrial pressure following development of aortoatrial fistula.
PFO diagnosis can be elusive if appropriate techniques are not used during saline contrast administration. PFO can present as hypoxemia in the absence of pulmonary hypertension, can be a rare cause of quadriperesis, and can be associated with thrombus formation on either side of interatrial septum. Finally, PFO presence can be lifesaving in those with sudden increase in right atrial pressure such as with aortoatrial fistula.
Echocardiography 09/2010; 27(8):897-907. · 1.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Background: Patent foramen ovale (PFO) is diagnosed on echocardiography by saline contrast study with or without color Doppler evidence of shunting. PFO is benign except when it causes embolic events. Methods and Results: In this report, we describe unique additional manifestations related to the diagnosis and presentation of PFO. These include demonstration of PFO during the release phase of “sigh” on the ventilator in the operating room, use of a separate venipuncture to allow preparation of blood-saline-air mixture after multiple failed saline bubble injections, resting and stress hypoxemia related to left to right shunting across a PFO in the absence of pulmonary hypertension, presentation of quadriperesis secondary to an embolic event from a PFO and development of a thrombus on the left atrial aspect of PFO in a patient with atrial fibrillation, and on the right atrial aspect of PFO in a patient who had undergone repair of a flail mitral valve. Finally, in one patient with end-stage renal disease, aortic valve endocarditis and periaortic abscess, PFO acted as a vent valve relieving right atrial pressure following development of aortoatrial fistula. Conclusion: PFO diagnosis can be elusive if appropriate techniques are not used during saline contrast administration. PFO can present as hypoxemia in the absence of pulmonary hypertension, can be a rare cause of quadriperesis, and can be associated with thrombus formation on either side of interatrial septum. Finally, PFO presence can be lifesaving in those with sudden increase in right atrial pressure such as with aortoatrial fistula. (Echocardiography 2010;27:897-907)
Echocardiography 08/2010; 27(8):897 - 907. · 1.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Doppler echocardiography of mitral inflow or aortic outflow or both has been validated and advocated to guide biventricular (Biv) pacemaker optimization. A comprehensive and tailored Doppler echocardiographic evaluation may be required in patients with heart failure to assist with Biv pacemaker optimization. The third heart sound (S(3)), an acoustic cardiographic parameter, has been demonstrated to be a highly specific finding for hemodynamic evaluation in patients with heart failure. The aims of this study were to evaluate the use of comprehensive Doppler echocardiography as a guide during Biv pacemaker optimization in patients after cardiac resynchronization therapy and to evaluate the feasibility of S(3) intensity to be a cost-efficient parameter for Biv pacemaker optimization compared with Doppler echocardiography.
Comprehensive Doppler echocardiographic evaluations were performed during Biv pacemaker optimization in 44 patients referred for pacemaker optimization (mean age, 71 + or - 12 years; mean left ventricular ejection fraction, 34 + or - 11%). Blinded assessment of S(3) intensity was performed simultaneously using acoustic cardiography. The correlation and improvement in cardiac hemodynamics were analyzed between the methods.
Echocardiographically guided optimization resulted in significant improvements in the left ventricular outflow velocity-time integral (15.92 + or - 4.77 to 18.51 + or - 5.19 cm, P < .001), ejection time (278 + or - 40 to 293 + or - 40 ms, P < .001), myocardial performance index (0.57 + or - 0.19 to 0.44 + or - 0.14, P < .002), and peak pulmonary artery systolic pressure (42 + or - 13 to 36 + or - 11 mm Hg, P < .04) and decreased S(3) intensity from 4.81 + or - 1.84 at baseline to 3.96 + or - 1.22 after optimization (P < .02) for the overall study group and from 6.63 + or - 1.37 to 4.85 + or - 1.13 (P < .001) in the 18 patients with baseline S(3) intensity > 5.0. The correlation between echocardiographic and acoustic cardiographic S(3) intensity for optimal atrioventricular delay was 0.86 (P < .001) and for optimal interventricular delay was 0.64 (P < .001). Optimal atrioventricular delay was identical by echocardiographic and acoustic cardiographic S(3) intensity in 56%, and optimal interventricular delay was identical in 75% of patients. Pacemakers were permanently programmed on the basis of echocardiographic evaluation. In 35 patients available for follow up, the mean New York Heart Association class reduced from 2.55 + or - 0.81 to 1.77 + or - 0.90 (P < .001) and the mean quality-of-life score as assessed by Minnesota Living With Heart Failure Questionnaire improved from 45 + or - 28 to 32 + or - 28 (P = .08) at 2.5 + or - 2.1 months.
Comprehensive echocardiographically guided Biv pacemaker optimization produces significant improvement in Doppler echocardiographic hemodynamics, a reduction in S(3) intensity, and an improvement in functional class in patients after cardiac resynchronization therapy.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 08/2010; 23(8):857-66. · 2.98 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The cardiovascular (CV) risk assigned by the Framingham risk score (FRS) misses many subjects destined for CV events. Coronary artery calcification (CAC) as measured by computed tomography and carotid intima-media thickness (CIMT) and plaque assessment using B-mode ultrasound can identify subclinical atherosclerosis. The comparative relation of CAC and CIMT and carotid plaque after integration into the FRS is not established. The aim of this study was to develop a CV screening approach incorporating FRS, CAC, and CIMT.
The prevalence of subclinical atherosclerosis, defined as CAC score > 0, CIMT > or = 75th percentile, or plaque > or = 1.5 mm, was determined in the groups with low, intermediate, and high FRS among 136 asymptomatic subjects. The CIMT and CAC values were used to determine "vascular age" and "coronary calcium" age, respectively, with established nomograms.
In the 103 low-risk (FRS < 10%) subjects, 41%, 50%, 59%, and 66% had CAC scores > 0, CIMT > or = 75th percentile, plaque > or = 1.5 mm, and CIMT > or = 75th percentile or plaque > or = 1.5 mm, respectively. In the 33 subjects with intermediate (n = 14) or high (n = 19) FRS, 70%, 81%, 87%, and 87% had CAC scores > 0, CIMT > or = 75th percentile, plaque > or = 1.5 mm, and CIMT > or = 75th percentile or plaque > or = 1.5 mm, respectively. Fifty-two percent of subjects with coronary calcium scores of zero had carotid plaque. Adjusted for FRS, body mass index was an independent predictor of abnormal CIMT in the low-FRS group, but not of abnormal CAC. Mean vascular CIMT age was significantly higher than coronary calcium age (61.6 + or - 11.4 vs 58.3 + or - 11.1 years, P = .001), and both were significantly higher than chronologic age (56.9 + or - 10.1 years) (P < .0001 and P < .04, respectively). CIMT upgraded or downgraded FRS by >5% in more cases than CAC (42% vs 17%).
In asymptomatic patients without CV disease, CIMT and plaque assessment are more likely to revise FRS than CAC. Body mass index predicts increased CIMT in low-FRS subjects. These findings may have broad implications for screening in low-FRS subjects.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 08/2010; 23(8):809-15. · 2.98 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: AIMS: Conflicting data exists on the benefit of cardiac resynchronization treatment (CRT) in patients with narrow QRS (Narrow-QRS) cardiomyopathy (CMP). We determined the effect of CRT in patients with CMP and mechanical asynchrony based on a comprehensive assessment by multiple echocardiographic criteria. METHODS AND RESULTS: Ninety patients, 65 +/- 16 years, 32 with Narrow-QRS <120 ms and 58 with wide QRS >or=120 ms (Wide-QRS) CMP who met criteria for significant mechanical asynchrony by 15 criteria before CRT were studied. Responders were patients in whom end-systolic volume (ESV) reduced by >or=15% post-CRT. There was no difference in the response to CRT in the Narrow-QRS (ESV 132 +/- 60 to 120 +/- 60 mL, P = 0.02) or Wide-QRS (123 +/- 54 to 102 +/- 50 mL, P < 0.01) groups at 1 +/- 2 month follow-up. A difference of >or=40% in time to peak contraction in a cardiac cycle on tissue velocity imaging between the earliest and the most delayed segment had the best area under curve for response to CRT, 0.71 (0.55-0.85), P = 0.02. Using logistic regression model, delay in mid-posterolateral segment of >or=20% in a cardiac cycle compared with remaining 10 segments was the only predictor of response to CRT in the overall study population. Conclusion In patients with CMP and mechanical asynchrony by multiple criteria, response to CRT in Narrow-QRS group is similar to those with Wide-QRS. Greater than or equal to 40% delay in systolic contraction between 12 left ventricular (LV) segments or >or=20% delay of posterolateral segment to other LV segments predicted CRT response.
Europace 05/2010; 12(8):1127-35. · 1.98 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The authors describe the case of a 79-year-old man with prior mitral valve repair and a maze procedure who developed recurrent atrial fibrillation, in whom transesophageal echocardiography revealed an accessory lobe of the left atrial appendage in sinus rhythm when the remaining body of the left atrial appendage was in atrial fibrillation or flutter. Electrophysiology confirmed dissociated rhythm within the left atrium. This case emphasizes the need for careful Doppler interrogation of the left atrial appendage and its lobes to look for dissociated atrial rhythm.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 04/2010; 23(10):1113.e1-4. · 2.98 Impact Factor
-
JACC. Cardiovascular imaging 03/2010; 3(3):325-7. · 14.29 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The left atrial appendage (LAA) is a common source of cardiac thrombus formation and systemic embolism. It is a 'blind' cul-de-sac and multilobed anatomic structure with variable anatomy. Therefore, it requires detailed evaluation in multiple imaging planes to evaluate for thrombus formation. Transesophageal echocardiography is the most common imaging modality used to rule out LAA thrombus. Doppler imaging enhances understanding of LAA function. 3D imaging of the LAA with live 3D transesophageal echocardiography, computed tomography and MRI may be further utilized for thrombus detection, as well as for sizing, and the development of new transcatheter occluder devices for LAA to prevent thrombus formation is needed.
Expert Review of Cardiovascular Therapy 01/2010; 8(1):65-75.
-
Tasneem Z Naqvi
[show abstract]
[hide abstract]
ABSTRACT: Echocardiography has played a critical role in valve reconstructive surgery and more recently in developments in percutaneous techniques for mitral valve repair and aortic valve implantation. A combination of transthoracic echocardiography and transesophageal echocardiography (TEE) provide diagnostic and screening data pre-procedure, intraprocedural guidance, and assessment of valve function and left ventricular reverse remodeling post-percutaneous valve procedures. The role of intracardiac echocardiography and live 3-dimensional TEE in percutaneous valve interventions is evolving. This review summarizes the role of echocardiography during percutaneous device-based valve procedures.
JACC. Cardiovascular imaging 10/2009; 2(10):1226-37. · 14.29 Impact Factor
