[Show abstract][Hide abstract] ABSTRACT: Dyspnea on exertion and peripheral edema occur routinely during normal gestational stage, making early diagnosis of congestive heart failure (CHF) during pregnancy difficult. Abnormal left ventricular (LV) diastolic function may be associated with dyspnea on exertion and peripheral edema, and brain natriuretic peptide (BNP) correlates with volume overload in nonpregnant populations. We tested the hypothesis that abnormal echocardiographic diastolic parameters and elevated BNP correlate in symptomatic pregnant patients.
Sixty-six gravidas presented to an Obstetric Cardiology Clinic were analyzed. Data including symptoms of CHF, BNP, and maternal and gestational ages were recorded. Echocardiograms were reviewed to measure the diastolic parameters E, A, e', and a' wave velocities and left atrial volume index (LAVI). Logistic regression was performed to characterize the relationship between diastolic parameters and BNP.
Among the 66 pregnant patients included in the analysis, only 6 were found to have significant LV systolic dysfunction. LAVI, E, and E/e' ratio correlated positively with BNP in this symptomatic population (p = 0.008, 0.007, and 0.002, respectively).
Abnormal diastolic parameters that represent increased LV filling pressures correlated with higher BNP levels in pregnant patients with symptoms of CHF. This suggests that symptoms may be due to diastolic dysfunction, and BNP levels may identify elevated LV filling pressures in symptomatic pregnant patients.
Hypertension in Pregnancy 06/2012; 31(3):367-74. · 0.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The mitral annulus (MA) has a complex dynamic geometry that is difficult to visualize in two dimensions; hence, novel real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) provides insights into its dynamic nature. The study aim was to investigate changes in MA geometry in normal subjects and to explore differences in patients with myxomatous mitral valve disease (MMVD), using 3D quantitation with RT-3D-TEE.
Thirty-five participants (18 with MMVD, 17 normal subjects as controls) were enrolled into the study. The following geometric measurements were obtained at end-systole (ES) and end-diastole (ED): surface area, circumference, perimeter, height, commissure-to-commissure (C-C) diameter, anterior-to-posterior (A-P) diameter, and the ratio of A-P diameter to C-C diameter (circularization). To detect the effect of the severity of mitral regurgitation (MR) on MA dynamics, patients with MMVD were allocated to two subgroups with mild (n = 7) or moderate/severe (n = 11) MR.
Control subjects demonstrated a saddle-shaped, elliptical MA configuration with slightly larger ES parameters. The MA shape was changed during the cardiac cycle, being more circular at ES and flatter at ED (p < 0.05). In MMVD patients, the MA retained a saddle shape but became dilated and circular with larger ED parameters compared to controls (p < 0.05). The degree of MA geometric changes was more prominent in moderate/severe MR patients (p < 0.001), while mild MR patients displayed MA geometry and dynamics similar to those of controls.
The MA geometry is altered in MMVD patients, with the extent of changes being determined by the severity of the MR. RT-3D-TEE provides high-quality images that permit a precise quantitative analysis of the 3D geometry of the MA.
The Journal of heart valve disease 05/2012; 21(3):299-310. · 1.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Broken heart syndrome or stress-induced non-ischemic cardiomyopathy (SICM) has rarely been reported in the setting of myasthenic crisis. We describe a case of reversible SICM that occurred simultaneously with myasthenic crisis in a 77-year-old man without prior cardiac history, and we discuss the previous findings that support an association of other cardiac disorders with myasthenia gravis.
[Show abstract][Hide abstract] ABSTRACT: Information is limited regarding the functional correlates of intramural scar burden in myopathic hearts. We aimed to explore the use of speckle tracking echocardiography selectively at three intramural locations, to investigate the variance in cardiac strains and their relationship to contrast-enhanced magnetic resonance imaging-derived scar distribution and global left ventricular systolic function.
Fifty-nine patients with evidence of myocardial fibrosis on contrast-enhanced magnetic resonance imaging and 18 healthy subjects underwent speckle tracking echocardiography for measuring subendocardial, midmyocardial, and subepicardial strains in longitudinal, circumferential, and radial directions. Patients were divided into three categories of scar distribution: Group A, endocardial and midmyocardial; Group B, midmyocardial and epicardial; and Group C, transmural. When these patients were compared with 18 healthy control subjects, longitudinal left ventricular deformation was attenuated equally for all three groups, whereas circumferential strain was relatively well preserved. On multivariate analysis, circumferential strain and scar burden were independent determinants of left ventricular ejection fraction (R(2) = 0.57; P = 0.003 for strain burden and P = 0.01 for scar burden).
Longitudinal strains are attenuated independent of myocardial scar location. This alteration in left ventricular deformation is associated with circumferential mechanics becoming a key determinant of global left ventricular pump function in myopathic hearts.
European heart journal cardiovascular Imaging. 10/2011; 13(2):152-8.
[Show abstract][Hide abstract] ABSTRACT: Distinguishing the pathologic hypertrophy of hypertrophic cardiomyopathy (HC) from the physiologic hypertrophy of professional football players (PFP) can be challenging when septal wall thickness falls within a "gray zone" between 12 and 16 mm. It was hypothesized that 2-dimensional and speckle-tracking strain (ε) echocardiography could differentiate the hearts of PFPs from those of patients with HC with similar wall thicknesses. Sixty-six subjects, including 28 professional American football players and 21 patients with HC, with septal wall thicknesses of 12 to 16 mm, along with 17 normal controls, were studied using 2-dimensional echocardiography. Echocardiographic parameters, including modified relative wall thickness (RWT; septal wall thickness + posterior wall thickness/left ventricular end-diastolic diameter) and early diastolic annular tissue velocity (e'), were measured. Two-dimensional ε was analyzed by speckle tracking to measure endocardial and epicardial longitudinal ε and circumferential ε and radial cardiac ε. Septal wall thickness was higher in patients with HC than in PFPs (14.7 ± 1.1 vs 12.9 ± 0.9 mm, respectively, p <0.001), while posterior wall thickness showed no difference. RWT was larger in patients with HC than in PFPs (0.68 ± 0.10 vs 0.48 ± 0.06, p <0.001). Longitudinal endocardial ε and radial cardiac ε were significantly higher in PFPs than in patients with HC, while circumferential endocardial ε was no different. RWT was the parameter that most accurately differentiated PFPs from patients with HC. An RWT cut point of 0.6 differentiated PFPs from patients with HC, with an area under the curve of 0.97. In conclusion, a 2-dimensional echocardiographic measure of RWT (septal wall + posterior wall thickness/left ventricular end-diastolic dimension) accurately differentiated PFPs' hearts from those of patients with HC when septal wall thickness was in the gray zone of 12 to 16 mm. Two-dimensional strain analysis identifies variations in myocardial deformation between PFPs and patients with HC with gray-zone hypertrophy.
The American journal of cardiology 08/2011; 108(9):1322-6. · 3.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In patients with hypertrophic obstructive cardiomyopathy and dynamic left ventricular outflow tract obstructions, an additional fixed obstruction may uncommonly coexist. In these situations, flow through the aortic valve is usually delayed but typically still throughout the entire ejection period. We describe a case of marked reduction in aortic flow during mid and late systole, diagnosed by Doppler echocardiography, caused by combined hypertrophic obstructive cardiomyopathy and severe calcific bicuspid aortic stenosis.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 04/2011; 24(4):471.e1-4. · 2.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We assessed the hypothesis that global and regional left atrial (LA) function is altered in patients with chronic primary mitral regurgitation (MR) secondary to myxomatous mitral valve disease (MMVD).
Velocity vector imaging of the LA was acquired from apical four- and two-chamber views in 41 normal and 43 subjects with chronic MR due to MMVD. All had normal left ventricular systolic function. The LA subendocardium was traced to obtain atrial volumes, ejection fraction, velocities, and strain (ε)/strain rate (SR) measurements. To explore the effects of MR severity on LA function, subjects were divided into two groups: mild vs. moderate/severe MR. Reservoir (expansion and diastolic emptying indices), booster pump (active emptying index) functions, and LA ejection fraction were markedly impaired in subjects with MR (P < 0.001). Mean LA ε was reduced in moderate/severe MR compared with control subjects (P < 0.01). A consistent pattern of differences in atrial regional function was noted with the anterior wall having a lower peak systolic ε/SR, which is more evident in the moderate/severe MR group (P < 0.01) when compared with controls and mild MR groups.
LA filling during ventricular systole (reservoir function), LA contraction (booster pump function), and ejection fraction were significantly impaired in patients with chronic MR. Regional differences in LA contractility at the anterior wall were noted presumably due to the eccentricity of the systolic anteriorly directed MR jet hitting the anterior wall and altering local wall mechanics.
[Show abstract][Hide abstract] ABSTRACT: Progressive left ventricular (LV) dilatation and irreversible myocardial damage are important causes of morbidity and mortality in patients with chronic primary mitral regurgitation (MR) due to myxomatous mitral valve disease. We assessed the hypothesis that early subclinical LV dysfunction secondary to chronic primary MR could be signalled by abnormal LV rotation mechanics, utilizing velocity vector imaging (VVI).
Forty-three with chronic primary MR and 41 normal subjects were evaluated. All had normal LV systolic function. Peak endocardial and epicardial rotations in systole were measured in apical and basal short-axis images. LV twist was defined as the net difference between apical and basal angles of rotation while LV torsion was calculated as LV twist divided by LV diastolic longitudinal length. To explore the effects of MR severity on LV rotation, patients were divided into three groups: mild, moderate, and severe MR. The peak twist and torsion of the LV endocardium displayed significant differences across the study groups (P = 0.005 and 0.015, respectively). Subjects with moderate MR revealed the highest LV rotation profile (2.26 ± 0.66°/cm and 17.83 ± 5.2° for torsion and twist, respectively), implicating hyperdynamic LV function. However, severe MR group showed the lowest LV rotation profile (1.39 ± 0.8°/cm and 11.43 ± 6.09° for torsion and twist, respectively), suggesting incipient LV dysfunction. There were no significant differences in epicardial LV rotations.
Evaluation of global LV function by VVI is a novel reproducible index for detecting subnormal latent LV dysfunction in chronic MR patients, which may aid in the optimal timing of surgery.
[Show abstract][Hide abstract] ABSTRACT: Abstract
Purpose: Distinguishing pathological hypertrophy from physiological hypertrophy in athlete's (AT) heart can be a challenge when septal wall thickness is between 12-15mm. We assessed the hypothesis that left atrial and ventricular dimensions and diastolic function can differentiate these groups when septal wall thickness falls within this indeterminate range.
Methods: Fifty-three subjects comprised of 28 professional football players (AT) and 8 age-matched hypertrophic cardiomyopathy (HC) patients with septal wall thickness between 12-15mm, along with 17 age-matched normal controls were studied by two-dimensional echocardiography. Septal and posterior wall thickness along with relative wall thickness (septal plus posterior wall divided by left ventricular diastolic dimension), left ventricular (LV) mass index (LVMI), LV systolic and diastolic dimensions, early diastolic annular tissue velocity (E′) and left atrial volume index (LAVI) were determined.
Results: Average septal wall thickness was similar in AT and HCM (12.9±0.9 vs. 13.6±0.9 mm respectively, p = 0.07), as was posterior wall thickness. LV end-diastolic and end-systolic diameter and volumes (indexed for BSA) were higher in the AT group than the HC and normal group (p < 0.001 for each). E′ and LAVI were no different between AT and HC (p = 0.9 and 0.6 respectively). By univariate analysis, RWT and LV diameter and volumes were each predictors of an AT versus HC patient. A RWT value <0.53 could differentiate an AT from HC patient with 82% specificity and 88% sensitivity (AUC 0.92, P = 0.0001)
Conclusions: Left ventricular cavity dimensions and volumes are increased in the athlete's heart with increased wall thickness compared to hypertrophic cardiomyopathy patients with mild hypertrophy. Left atrial volume index and E′ do not aid in differentiating these groups. Relative wall thickness can differentiate an athlete's heart from a hypertrophic cardiomyopathy patient with high sensitivity when these patients fall within the "gray zone" of septal wall thickness between 12 and 15 mm.
[Show abstract][Hide abstract] ABSTRACT: This report describes a series of symptomatic patients with obstructive hypertrophic cardiomyopathy with significant postprandial hemodynamic changes. This finding was identified by history, clinical examination, and echocardiography in 6 consecutive symptomatic patients referred for the evaluation of ventricular septal reduction therapy. Counseling these patients with dietary changes to include small frequent meals and to increase noncaffeinated fluid intake resulted in reductions in symptoms. In conclusion, severe symptoms in obstructive hypertrophic cardiomyopathy unresponsive to pharmacologic treatment frequently result in referral for definitive septal reduction therapy through surgery or, less frequently, alcohol septal ablation therapy. However, recognition of postprandial exacerbation in symptomatic patients may allow for nonpharmacologic dietary interventions that may obviate the need for more invasive therapies and their associated complications.
The American journal of cardiology 11/2010; 106(9):1313-6. · 3.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Accurate triage of emergency department (ED) patients presenting with chest pain is a primary goal of the ED physician. In addition to standard clinical history and examination, a hand-held echocardiogram (HHE) may aid the emergency physician in making correct decisions. We tested the hypothesis that an HHE performed and interpreted by a cardiology fellow could help risk-stratify patients presenting to the ED with chest pain.
ED physicians evaluated 36 patients presenting with cardiovascular symptoms. Patients were then dispositioned to either an intensive care bed, a monitored bed, an unmonitored bed, or home. Following disposition, an HHE was performed and interpreted by a cardiology fellow to evaluate for cardiac function and pathology. The outcomes evaluated (1) a change in the level of care and (2) additional testing ordered as a result of the HHE.
The HHE showed wall motion abnormalities in 31% (11 out of 36) of the studies, but the level of care did not change after HHE for any patients who presented with chest pain to the ED. No additional laboratory or imaging tests were ordered for any patients based on the results of the HHE. Eighty-six percent (31 out of 36) of the studies were of adequate quality for interpretation, and 32 out of 36 (89%) interpretations correlated with an attending overread.
Despite the high prevalence of abnormal wall motion in this population, hand-held echocardiography performed in this ED setting did not aid in the risk stratification process of chest pain patients.
[Show abstract][Hide abstract] ABSTRACT: We present a case of wide-complex tachycardia occurring during coronary angiography in a patient with a dual chamber pacemaker. This rhythm recurred only during coronary injection of contrast and appeared to be ventricular tachycardia. However, subsequent examination revealed the development of fusion beats followed by fully paced ventricular beats during coronary injection, which only mimicked a potentially dangerous arrhythmia.
Cardiovascular revascularization medicine: including molecular interventions 01/2009; 10(1):60-1.