[Show abstract][Hide abstract] ABSTRACT: Background-Risk prediction is a critical step in patient selection for aortic valve replacement (AVR), yet existing risk scores incorporate very few echocardiographic parameters. We sought to evaluate the incremental predictive value of a complete echocardiogram to identify high-risk surgical candidates before AVR. Methods and Results-A cohort of patients with severe aortic stenosis undergoing surgical AVR with or without coronary bypass was assembled at 2 tertiary centers. Preoperative echocardiograms were reviewed by independent observers to quantify chamber size/function and valve function. Patient databases were queried to extract clinical data. The cohort consisted of 432 patients with a mean age of 73.5 years and 38.7% females. Multivariable logistic regression revealed 3 echocardiographic predictors of in-hospital mortality or major morbidity: E/e' ratio reflective of elevated left ventricular (LV) filling pressure; myocardial performance index reflective of right ventricular (RV) dysfunction; and small LV end-diastolic cavity size. Addition of these echocardiographic parameters to the STS risk score led to an integrated discrimination improvement of 4.1% (P<0.0001). After a median follow-up of 2 years, Cox regression revealed 5 echocardiographic predictors of all-cause mortality: small LV end-diastolic cavity size; LV mass index; mitral regurgitation grade; right atrial area index; and mean aortic gradient <40 mm Hg. Conclusions-Echocardiographic measures of LV diastolic dysfunction and RV performance add incremental value to the STS risk score and should be integrated in prediction when evaluating the risk of AVR. In addition, findings of small hypertrophied LV cavities and/or low mean aortic gradients confer a higher risk of 2-year mortality.
Full-text · Article · Oct 2015 · Journal of the American Heart Association
[Show abstract][Hide abstract] ABSTRACT: The ability to properly evaluate the right ventricular size and function can have important consequences for clinical management and prognosis. Echocardiography is and will remain the leading method of right ventricle (RV) assessment due to its ease of use and wealth of diagnostic information provided. Understanding the various strengths and limitations of the diverse echocardiographic methods of RV assessment can allow a systematic approach to resolve situations where one's quantitative parameters are not necessarily concordant. Quantification of RV volume can be done by two-dimensional (2D) and three-dimensional (3D) echocardiography. Measurements of RV systolic function include fractional area change (FAC), right-sided index of myocardial performance (RIMP), RV ejection fraction (RVEF), tricuspid annular plane excursion by M-Mode (TAPSE), tricuspid annular systolic longitudinal velocity by tissue Doppler (S'), and regional strain and strain rate. RVEF can also be assessed volumetrically by 3D echocardiography. This article will review the current methods used in contemporary echocardiography laboratories, with an emphasis on a guideline-based approach as well as emerging techniques.
No preview · Article · Apr 2015 · Current Cardiology Reports
[Show abstract][Hide abstract] ABSTRACT: Purpose: Three-dimensional echocardiography (3DE) has superior accuracy and reproducibility for quantification of right ventricular (RV) size and function. However, the lack of consolidated normative data has been a factor in limiting its widespread clinical use.
Methods: We performed a comprehensive review of the literature to identify all published studies that measured RV parameters by 3DE in healthy control groups. The parameters of interest were ejection fraction (RVEF), end-diastolic volume (RVEDV), end-systolic volume (RVESV); both non-indexed and indexed to body surface area. Age- and sex-specific normative data were extracted when available. Using a novel statistical approach, we performed a random-effects meta-analysis of these normative data to generate pooled mean values, upper reference values (mean + 2SD), lower reference values (mean – 2D), and 95% confidence intervals.
Results: We identified 29 studies encompassing a total of 1610 healthy individuals. Semi-automated border detection algorithms were used in most studies. The results of the normative data meta-analysis are shown in the table. Using these results, the following 3DE cutoffs are recommended to define abnormality: RVEF <45.6%, RVEDV >124.0 mL, RVEDVi >84.3 mL/m2, RVESV >61.0 mL, and RVESVi >38.5 mL/m2. Few studies reported age-specific (N=2) and sex-specific (N=4) data. Each decade of advancing age was associated with a gradual mild decline in volumes and preserved RVEF. Female sex was associated with mildly higher RVEF and moderately lower indexed and non-indexed volumes compared to males.
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Full-text · Article · Aug 2013 · European Heart Journal
[Show abstract][Hide abstract] ABSTRACT: Post-operative atrial fibrillation (AF) is a serious yet common complication after coronary artery bypass grafting surgery (CABG). Risk factors for post-operative AF have been identified, including echocardiographic parameters, and these are relied upon to implement preventative strategies that reduce the incidence of AF. There has yet to be a study examining the impact of echocardiographic right heart parameters for the prediction of post-operative AF. Thus, a panel of right heart parameters was measured in a cohort of patients undergoing isolated CABG, excluding those who did not have echocardiographic assessment within 30 days before surgery and those with any prior history of AF. The primary outcome was post-operative AF defined as any episode of AF requiring treatment during the index hospitalization. Post-operative AF occurred in 197 of 768 patients (25.6%); these were older and more likely to have hypertension and chronic kidney disease. After adjustment for clinical and echocardiographic variables, left atrial volume index ≥34 mL/m2 (OR 1.98, 95% CI 1.36 to 2.87), abnormal right ventricular myocardial performance index (RV-MPI) (OR 1.50 95% CI 1.01 to 2.24), and advancing age (OR 1.05, 95% CI 1.03 to 1.07) were found to be independent predictors of post-operative AF. In conclusion, RV-MPI is a novel predictor of post-operative AF in patients undergoing isolated CABG and appears to be additive to established risk factors such as age and left atrial volume.
No preview · Article · Jan 2013 · The American journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: Background:
Although echocardiography is commonly performed before coronary artery bypass surgery, there has yet to be a study examining the incremental prognostic value of a complete echocardiogram.
Methods and results:
Patients undergoing isolated coronary artery bypass surgery at 2 hospitals were divided into derivation and validation cohorts. A panel of quantitative echocardiographic parameters was measured. Clinical variables were extracted from the Society of Thoracic Surgeons database. The primary outcome was in-hospital mortality or major morbidity, and the secondary outcome was long-term all-cause mortality. The derivation cohort consisted of 667 patients with a mean age of 67.2±11.1 years and 22.8% females. The following echocardiographic parameters were found to be optimal predictors of mortality or major morbidity: severe diastolic dysfunction, as evidenced by restrictive filling (odds ratio, 2.96; 95% confidence interval, 1.59-5.49), right ventricular dysfunction, as evidenced by fractional area change <35% (odds ratio, 3.03; 95% confidence interval, 1.28-7.20), or myocardial performance index >0.40 (odds ratio, 1.89; 95% confidence interval, 1.13-3.15). These results were confirmed in the validation cohort of 187 patients. When added to the Society of Thoracic Surgeons risk score, the echocardiographic parameters resulted in a net improvement in model discrimination and reclassification with a change in c-statistic from 0.68 to 0.73 and an integrated discrimination improvement of 5.9% (95% confidence interval, 2.8%-8.9%). In the Cox proportional hazards model, right ventricular dysfunction and pulmonary hypertension were independently predictive of mortality over 3.2 years of follow-up.
Preoperative echocardiography, in particular right ventricular dysfunction and restrictive left ventricular filling, provides incremental prognostic value in identifying patients at higher risk of mortality or major morbidity after coronary artery bypass surgery.
[Show abstract][Hide abstract] ABSTRACT: Background:
Recent registries describe a significant prevalence of pulmonary arterial hypertension (PAH) in the elderly, but little is known of their characteristics. We aimed to examine the features and prognostic factors of long-term survival in elderly (≥65 years) PAH patients.
Clinical, echocardiographic, angiographic, hemodynamic, treatments, and survival data were reviewed in consecutive patients over the course of 20 years. Elderly PAH patients (n = 47) were compared to younger PAH patients (n = 107).
At presentation, elderly patients were more likely to have hypertension, diabetes, dyslipidemia, coronary disease, and PAH associated with scleroderma (42.6 vs. 24.3 %; p = 0.02) than younger patients. Prior to PAH therapy, elderly patients had better right ventricular myocardial performance index (RV-MPI; 0.48 ± 0.20 vs. 0.62 ± 0.23, p = 0.006) and lower mean pulmonary arterial pressure (PAP; 45.0 ± 11.1 vs. 49.2 ± 11.8 mmHg, p = 0.04). Elderly patients were treated less often with epoprostenol (8.5 vs. 29 %, p = 0.006) or trepostinil (8.5 vs. 23.4 %, p = 0.04). The 1, 3, and 5 year survival rates of elderly patients were estimated to be 76.4, 50.5, and 37.6 %, respectively. In comparison, younger patients had survival estimates of 92.2, 74.2 and 64.0 % (p = 0.002). Baseline right atrial pressure, mean PAP, cardiac index, and RV-MPI were associated with survival in elderly patients; however in these patients, survival was not affected by any PAH subgroup or age (per year) by itself.
The diagnosis of PAH in elderly patients is associated with poorer survival which is in part explained by a greater vulnerability to the hemodynamic disturbances of PAH.
No preview · Article · Oct 2012 · Beiträge zur Klinik der Tuberkulose
[Show abstract][Hide abstract] ABSTRACT: Background:
The incidence of pericardial effusion (PEF) during long-term follow-up among patients with pulmonary arterial hypertension (PAH) is unknown. We aimed to determine the incidence and prognostic significance of developing a new PEF among PAH patients.
Records of consecutive patients diagnosed with PAH between January 1990 and May 2010 were reviewed. Patients had systematically undergone right heart catheterization, transthoracic echocardiography, and coronary angiography during their initial assessment as well as routine echocardiograms during follow-up. Effusions were graded as small (echo-free space in diastole <10 mm), moderate (10-20 mm), or large (≥ 20 mm).
The entire cohort consisted of 154 patients. The prevalence of identified PEF during initial assessment was 28.6%. The incidence of PEF among patients with no effusions who had additional echocardiographic studies during follow-up (n = 102) was 44.1%. Patients who developed PEF during follow-up had no differences with respect to baseline characteristics, associated aetiologies, hemodynamic parameters, and extent of coronary disease. Among these 102 patients, survival estimates were 94.9%, 75.0%, and 62.4% at 1, 3, and 5 years, respectively. Development of a PEF that was at least moderate-sized at its first appearance was a predictor of mortality in univariate (hazard ratio, 6.85; 95% confidence interval, 2.60-18.10) as well as multivariate analysis (hazard ratio, 3.95; 95% confidence interval, 1.26-12.40).
PEF develops frequently in PAH patients. In patients with no PEF at baseline, the appearance of a new moderate-size or larger PEF is associated with increased mortality, whereas no significantly increased mortality was observed when a small PEF develops.
No preview · Article · Jun 2012 · The Canadian journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: In the last decade, the role of the right ventricle (RV) has been increasingly recognized in a variety of conditions, contributing
to the pathophysiology of disease and the prediction of outcomes. Recent echocardiography guidelines focused on the RV have
been published by the American Society of Echocardiography to encourage a standardized approach in assessing RV size and function.
In this article, we review the recently published echocardiography guidelines for assessing RV size and function, and their
importance in clinical practice. We discuss advantages and disadvantages of currently available imaging techniques for evaluating
the RV morphology, size, and systolic function. Basic methods such as TAPSE, tissue Doppler, RIMP, and fractional area change
are discussed, as are more emerging techniques such as strain and strain rate. Additional insights are provided into upcoming
uses of echocardiography in the areas or RV dyssynchrony and three-dimensional echocardiography.
KeywordsEchocardiography–Right ventricle–Echocardiography - 3 dimensional–Strain imaging–Strain rate imaging–Resynchronization–Right heart
No preview · Article · Oct 2011 · Current Cardiovascular Imaging Reports
[Show abstract][Hide abstract] ABSTRACT: Guidelines for the provision of echocardiography in Canada were jointly developed and published by the Canadian Cardiovascular Society and the Canadian Society of Echocardiography in 2005. Since their publication, recognition of the importance of echocardiography to patient care has increased, along with the use of focused, point-of-care echocardiography by physicians of diverse clinical backgrounds and variable training. New guidelines for physician training and maintenance of competence in adult echocardiography were required to ensure that physicians providing either focused, point-of-care echocardiography or comprehensive echocardiography are appropriately trained and proficient in their use of echocardiography. In addition, revision of the guidelines was required to address technological advances and the desire to standardize echocardiography training across the country to facilitate the national recognition of a physician's expertise in echocardiography. This paper summarizes the new Guidelines for Physician Training and Maintenance of Competency in Adult Echocardiography, which are considerably more comprehensive than earlier guidelines and address many important issues not previously covered. These guidelines provide a blueprint for physician training despite different clinical backgrounds and help standardize physician training and training programs across the country. Adherence to the guidelines will ensure that physicians providing echocardiography have acquired sufficient expertise required for their specific practice. The document will also provide a framework for other national societies to standardize their training programs in echocardiography and will provide a benchmark by which competency in adult echocardiography may be measured.
No preview · Article · Jul 2011 · The Canadian journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: The occurrence and impact of coronary artery disease (CAD) among patients with pulmonary arterial hypertension (PAH) are unknown. We aimed to determine the prevalence, clinical correlates, and effect of CAD in patients with PAH. We reviewed the medical records of consecutive patients diagnosed with PAH at a university-based referral center for pulmonary vascular disease from January 1990 to May 2010. The patients systematically underwent right heart catheterization and coronary angiography as a part of their evaluation. The patients with PAH with CAD (defined as ≥50% stenosis in ≥1 major epicardial coronary artery) were compared to patients without CAD. Among the 162 patients with PAH, the prevalence of CAD was 28.4%. The presence of CAD was associated with older age (66.6 ± 11.5 vs 49.2 ± 14.0 years, p <0.001), systemic hypertension, and dyslipidemia. The patients with PAH and CAD had a lower mean pulmonary arterial pressure (44.6 ± 11.1 vs 49.2 ± 14.0 mm Hg; p = 0.02) than patients without CAD. During a median follow-up of 36 months, 73 patients died. The presence of CAD was a predictor of all-cause mortality on univariate analysis (hazard ratio 1.97, 95% confidence interval 1.21 to 3.20) but not on multivariate analysis, which identified older age (hazard ratio 1.03, 95% confidence interval 1.01 to 1.05) and right atrial pressure (hazard ratio 1.08, 95% confidence interval 1.03 to 1.14) as the only independent predictors. In conclusion, our study has demonstrated that CAD is common among patients with PAH. CAD prevalence increases with age, dyslipidemia, and hypertension, but we did not detect an independent prognostic effect of CAD on mortality.
No preview · Article · May 2011 · The American journal of cardiology