when does 3d echo make a difference?...2017/01/03 · cardiomyopathy and congestive heart failure...
TRANSCRIPT
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When Does 3D Echo Make a Difference?
Anthony DeMariaUniversity of California, San Diego
No Disclosures
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Why do 3D imaging ?
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•Matrix Array Transducer
Real-time, Touch-button 3DE
• Fully sampled
• Supercomputing
• Instantaneous volume rendering
• Intelligent Navigator
• Matrix Array Transducer
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3D &2D vs CMR
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3D Makes a Difference• LV volumes and EF
– Choosing pharmacologic therapy– Using resynchronization– Implanting defibrillators– Cardio-oncology
• RV structure and function• Mitral Valve Disease
– Prolapse– Stenosis
• Tricuspid Valve Disease
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Published Trials in Which EF wasPart of the Entry Criteria (Partial List)
• SOLVD Treatment Trial• SOLVD Prevention Trial• SAVE• US Cravedilol Trials• MERIT-HF• CIBIS 1 & 2• COPERNICUS
• CAPRICORN• RALES• ELITE 1 & 2• Val-HEFT• PRAISE 1 & 2• OVERTURE• CHARM• PARADIGM
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Guidelines for Cardiac Resynchronization
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PresenterPresentation Notesthere is a growing number of cancer survivors in US, in 2012 there were over 13 millions, and it is estimated that by 2022 the number will exceed 17 millions.
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Patnaik, 2011
LEADING CAUSES OF DEATH AFTER BREAST CANCER DIAGNOSIS
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CARDIOVASCULAR COMPLICATIONS OF CANCER THERAPY
Oeffinger, NEJM 2006
PresenterPresentation NotesThis NEJM paper retrospectively compared incidence of various health conditions in cancer survivors and their cancer-free siblings as a control.
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Yeh, 2009
CHEMOTHERAPY ASSOCIATED WITH MYOCARDIAL DYSFUNCTION
PresenterPresentation NotesCardiomyopathy and congestive heart failure are the most common complications of chemotherapy, and this is the list of agents which can cause this. This data is from MDACC, and 3 pluses means that over 5000 doses were dispensed in a year at MD Anderson. Incidence varies between the reports, and this depends on cumulative doses of anthracyclines, concomitant XRT, population studied, and various underlying risk factors
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CLINICAL PROGRAMECHOCARDIOGRAPHY
STRAIN IMAGING
JASE 2014
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Plana, JASE 2014
• Anthracycline-based regimen: echo at baseline, upon completion of therapy and 6 months after
• HER-2 inhibitors (Herceptin/trastuzumab): echo at baseline, and every 3 months during therapy, and once after completion of therapy
PresenterPresentation NotesEcho is the mainstay for EF surveilance of cardiotoxicity during chemotherapy
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MINIMAL DETECTABLE CHANGE BETWEEN SERIAL EXAMS FOR EF MEASUREMENT WITH
SIMPSON’S BIPLANE METHOD IS 12%
Thavendiranathan, 2013
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0
5
10
15
20
25
Biplane Biplane+Co Triplane Triplane+Co 3D 3D+Co
Thavendiranathan, 2013
MINIMAL DETECTABLE CHANGE FOR EF MEASUREMENT
%
N=56
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Thavendiranathan, 2013
TEMPORAL VARIABILITY OF EFN=56
1 year follow-up
PresenterPresentation NotesTemporal variability is defined as standard error of measurement and 95% CI for each technique for entire 1 year follow-up period. Noncontrast 3D had the lowest temporal variability and CI for EF measurement.
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Thavendiranathan, 2013
TEMPORAL VARIABILITY IN EDV AND ESVN=56
PresenterPresentation NotesTemporal variability is defined as standard error of measurement and 95% CI for each technique for entire 1-year follow-up period. Non-contrast 3D had the lowest temporal variability and CI for EDV and ESV measurements.
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Thavendiranathan, 2013
INTEROBSERVER AND INTRAOBSERVERVARIABILITY FOR EF MEASUREMENT
0
1
2
3
4
5
6
7
8
Biplane Biplane+Co Triplane Triplane+Co 3D 3D+Co
IntraobserverInterobserverInterobservertest-retest
%
N=56
PresenterPresentation NotesTemporal variability is defined as standard error of measurement and 95% CI for each technique for entire follow-up period. Noncontrast 3D had the lowest temporal variability and CI for EDV and ESV measurements.
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CLINICAL PROGRAM
ASE RECOMMENDATION FOR ECHO SURVEILLANCE OF
ANTHRACYCLINE CARDIOTOXICITY
Plana, JASE 2014
PresenterPresentation NotesCurrent ASE guidelines call for 3D echo use for EF surveillance with chemotherapy when possible
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3D in Mitral Valve Disease
http://files.abstractsonline.com/CTRL/59/C/42D/CDE/EDE/49F/2BE/77E/A4C/700/A52/B0/g391_1.gifhttp://files.abstractsonline.com/CTRL/59/C/42D/CDE/EDE/49F/2BE/77E/A4C/700/A52/B0/g391_1.gif
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Regurgitation
Round holeIn a flat object
Perfect PISAhemisphere
CircularVena Contrata
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PISA, Vena ContractaPitfalls
Assumptions“Regurgitant orifice circular”“Flow convergence perfect hemisphere”“Vena contracta circular”“1 frame in 1 view reflects whole Regurg”“There is only one regurgitant orifice”
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3D Imaging to studyCardiac Remodeling
What isCardiac Remodeling ?
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Remodeling
RemakingAdjustmentAdaptationAlterationConversionRefittingTransformationReformationReshapingDistortionEnlargement
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Ventricular Remodeling
… more thanchamber enlargement …
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Ventricular Remodeling
Physiologic Pathologic
AthletesNormal Growth
IschemiaOther diseases
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InjuryInflammation
Increased Load
Molecular PathwaysMetabolic Pathways
Mechanical Pathways
AdaptiveRemodeling
AdverseRemodeling
Cardiac Remodeling
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LV Remodeling
Normal Physiologic
Pathologic
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Ventricular Remodeling
•Structural Remodeling
Size, Mass, Shape
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Ventricular Remodeling
• Structural Remodeling
Size, Mass, Shape
• Mechanical Remodeling
Systole, Diastole
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Ventricular Remodeling
• Structural Remodeling
Size, Mass, Shape
• Mechanical Remodeling
Systole, Diastole
• Electrical Remodeling
Arrhythmias
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Ventricular Remodeling
Why worry aboutVentricular Remodeling ?
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Ventricular DilatationMyocardial Stretch
ChronicAcute
Mechano-electrical coupling
Stretch-activated channels(esp non-selective channels, Na and Ca entering the cells)
Depolarization, Change in action potential duration
Gene expression activation
growth factorsAngiotensin IIEndothelin-1
Cell proliferationHypertrophyFibrosis
Arrhythmia
Ravens. Progress in Biophysics and Molecular Biology 2003; 82:255-266
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Dilatation of LV and ArrhythmiaAfter Myocardial Infarction
Dilation of the infarcted/non-infarcted zonesIncreased dispersion in the refractorinessEarly afterdepolarizations
(caused by an increased in wall stress;contraction-excitation feedback)
LVESV: continued enlargement in 1 yearassociated with high frequency of arrhythmias
(CATS: captril and thrombolysis study)
J Cardiac Failure 1994; 1:3-11.
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Multitude ofstudies and trials…
Systolic Function
Diagnosis Prognosis Therapy
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0.0
0.6
0.7
0.8
0.9
0 1 2 3 4
1.0
MADIT II
Probability of survival
Year
Defibrillator
Conventional
No. at riskDefibrillator 742 503 (0.91) 274 (0.84) 110 (0.78) 9Conventional 490 329 (0.90) 170 (0.78) 65 (0.69) 3
P=0.016
CP1053888-2
Coronary Disease
EF < 30%
ICD
EF > 30%
VT
EPS
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LV MassChiang et al. Circulation 41:31, 1970Koyanagi et al. Circulation 65:1192, 1982Casale et al. Ann Int Med 105:173, 1986Marcus et al. Circulation 75:119, 1987Cooper et al. 65:441, 1990Levy et al. NEJM 322:1561, 1990Verdecchia et al. Circulation 97:48, 1998Devereux et al. AJC 86:1090, 2000Aurigemma et al. JACC 37:1042, 2001Gardin et al. AJC 87:1051, 2001
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LV Mass
Chiang et al. Circulation 41:31, 1970Koyanagi et al. Circulation 65:1192, 1982Casale et al. Ann Int Med 105:173, 1986Marcus et al. Circulation 75:119, 1987Cooper et al. 65:441, 1990Levy et al. NEJM 322:1561, 1990Verdecchia et al. Circulation 97:48, 1998Devereux et al. AJC 86:1090, 2000Aurigemma et al. JACC 37:1042, 2001Gardin et al. AJC 87:1051, 2001
Independent Predictor of MorbidityIndependent Predictor of Mortality
Marker of Sudden DeathBoth in Preserved and Decreased EF
Independent of Diastolic DysfunctionNeurohormonal Activation
Deranged Myocyte Perfusion
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LV Shape
Diagnostic ImplicationsPrognostic Connotations
Therapeutic Value
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• Determinant of heart failureand related complications
Ventricular Remodeling
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HeartFailure
Remodeling
Ventricular Remodeling
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Ventricular Remodeling
HeartFailure
Remodeling
Need to reverse the process
• Impacts Survival
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Ventricular Remodeling
What methods to studyVentricular Remodeling?
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Ventricular Remodeling
• Echocardiography
• Radionuclide Anhiography
• Magnetic Resonance
• Computed Tomography
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Echocardiography
Increasd LVEDV and LVESVConcentric or Eccentric HypertrophyIncreased Volume/Mass RatioAltered GeometryReduced Ejection FractionIncreased global/regional wall stressImpaired diastolic functionVentricular dyssynchronyRV remodelingAtrial remodelingValvular Disorder
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Echocardiography
• M-mode: Dimension, %FS
• 2D Echo: Volumes, EF,
Shape, Mass
• Doppler: Hemodynamics
Flow disorders
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… more thandimension/area increase …
Ventricular Remodeling
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M-mode, 2DELimitations
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50%
40%
35%
Ejection FractionImpact Numbers
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Problems in the 2D EchoQuantification of Volumes and EF :
• Can’t see the borders
• Foreshortened views
• Off-axis views
• Translational motion
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Life is not always easy …
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118 ml 142 ml
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• Foreshortened views
• Off-axis views
• Translational motion
Problems in the 2D EchoQuantification of Volumes and EF :
3D Echo improves the accuracy
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3D Echo Quantification
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R=0.95 p
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3D quantitation ofLV Geometry
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3D Echo Quantitationof Ischemic Mass
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Circulation 2003;107:2207-2212
The left atrial function and volume: prognostic markers in different cardiac diseases (arrhythmias, valvular and congenital disease)
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Monoplane volume (M-mode, Teicholz formula)
(EDD³x 7)/(2.4 +EDD)
Monoplane volume (area/length, Dodge correction)
((area planimetry² x 8)/(3 x π x long axis)) x 0.951)-3
Biplane volume(area/length, Dodge correction)
(area planimetry 1 x area planimetry 2 x 8)/(3 x π x smallest long axis)
M-mode and 2D methods to measure LA size
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LA Volumes
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RV Dysfunction and Outcome
0%
10%
20%
30%
40%
50%
60%
No RV Dysf RV Dysfunction
DeathCVDHFDeath or HFRecurrent MI
SAVE Investigators
J Am Coll Cardiol 2002 May 1;39(9):1450-5
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Studies examining RV Functionand Outcomes in Heart Failure
DiagnosisClinical expression
PrognosisTherapeutic decision makingImplications for assist devices
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LVAD, RVAD or Both ?
Patients waitingFor Transplant
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77% (95%CI 58-95%)80% (95%CI 62-97%)NPV
57% (95%CI 35-79%)80% (95%CI 62-97%)PPV
70% (95%CI 50-90%)80% (95%CI 62-97%)Accuracy
77% (95%CI 58-95%)92% (95%CI 80-100%)Specificity
57% (95%CI 35-79%)57% (95%CI 35-79%)Sensitivity
TDI < 10TDI < 9
Tricuspid Annulur Velocity in the Identification of Systolic RV dysfunction (RV EF < 40%)
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Quantitation of RV volumes, EF
http://files.abstractsonline.com/CTRL/8D/1/FDC/39F/BA9/42C/D8E/E23/273/689/7FE/63/g830_1.jpghttp://files.abstractsonline.com/CTRL/8D/1/FDC/39F/BA9/42C/D8E/E23/273/689/7FE/63/g830_1.jpg
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75,00 100,00 125,00 150,00
50,00
75,00
100,00
125,00
150,00
A
A
A
A
A
AA
A
A
A
A
AA
A
A
A
A
A A
A
AA
EDV (ml) Live 3D Echo
ESV
(ml)
TEE
40,00 60,00 80,00 100,00
40,00
60,00
80,00
100,00
120,00
G
G
G
GG
G
G
G
G
G
G
G
G
G
G
GG
G
G
G G
ESV (ml) Live 3D Echo
EDV
(ml)
TEE
30,00 40,00 50,00
20,00
30,00
40,00
50,00
B
BB
B
B
B
B
B
B
B
B
BB
B
B
B
B
B
B
BB
EF (%) Live 3D Echo
EF (%
) TEE
80,00 100,00 120,00 140,00-60,00
-40,00
-20,00
0,00
20,00
40,00
60,00
A
A
A
A AA
A
A
AA
A
A
A
A
A
A
A
A
AA
A
A
Mean EDV (ml)
Diff
EDV
(ml)
(3D
Echo
-TEE
)
40,00 60,00 80,00 100,00-20,00
-10,00
0,00
10,00
20,00
G
G
G
G
G
G
G
G
G
GG
G
G
G
G
G
GG G
G
G
Mean ESV (ml)
Diff
ESV
(ml)
(3D
Echo
-TEE
)
30,00 40,00 50,00-20,00
-10,00
0,00
10,00
20,00
B
B
B
B
BB
B
B
B
B
B
B
B
B
B
BB
BB
BB
Mean EF (%)
Diff
EF (%
) (3D
Ech
o-TE
E)
Linear regression with 95% Mean Prediction Interval
Bland-Altman Plots
RV Volumes by Live 3D Echo
-
75,00 100,00 125,00 150,00
50,00
75,00
100,00
125,00
150,00
A
A
A
A
A
AA
A
A
A
A
AA
A
A
A
A
A A
A
AA
EDV (ml) Live 3D Echo
ESV
(ml)
TEE
40,00 60,00 80,00 100,00
40,00
60,00
80,00
100,00
120,00
G
G
G
GG
G
G
G
G
G
G
G
G
G
G
GG
G
G
G G
ESV (ml) Live 3D Echo
EDV
(ml)
TEE
30,00 40,00 50,00
20,00
30,00
40,00
50,00
B
BB
B
B
B
B
B
B
B
B
BB
B
B
B
B
B
B
BB
EF (%) Live 3D Echo
EF (%
) TEE
80,00 100,00 120,00 140,00-60,00
-40,00
-20,00
0,00
20,00
40,00
60,00
A
A
A
A AA
A
A
AA
A
A
A
A
A
A
A
A
AA
A
A
Mean EDV (ml)
Diff
EDV
(ml)
(3D
Echo
-TEE
)
40,00 60,00 80,00 100,00-20,00
-10,00
0,00
10,00
20,00
G
G
G
G
G
G
G
G
G
GG
G
G
G
G
G
GG G
G
G
Mean ESV (ml)
Diff
ESV
(ml)
(3D
Echo
-TEE
)
30,00 40,00 50,00-20,00
-10,00
0,00
10,00
20,00
B
B
B
B
BB
B
B
B
B
B
B
B
B
B
BB
BB
BB
Mean EF (%)
Diff
EF (%
) (3D
Ech
o-TE
E)
Linear regression with 95% Mean Prediction Interval
Bland-Altman Plots
RV Volumes by Live 3D Echo
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Heart Failure
Pharmacologic Rx
Mechanical Interventions
Transplantation
Novel Therapy
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• QRS does not
predict response
• QRS does not represent
true dyssynchrony
CRT - Issues
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Before CRT After CRT
Assessment of Dyssynchronyby 3D Echo
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Geometric ProceduresFor Heart Failure
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Surgical Ventricular Restoration
ConstraintDevices
SupportDevice
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PISA technique
Regurgitant volumeRegurgitant fraction
Regurgitant Orifice Area
http://files.abstractsonline.com/CTRL/59/C/42D/CDE/EDE/49F/2BE/77E/A4C/700/A52/B0/g391_1.gifhttp://files.abstractsonline.com/CTRL/59/C/42D/CDE/EDE/49F/2BE/77E/A4C/700/A52/B0/g391_1.gif
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PISA, Vena ContractaAssumptions
“Regurgitant orifice circular”“Flow convergence perfect hemisphere”“Vena contracta circular”“1 frame in 1 view reflects whole AR”“There is only one regurgitant orifice
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Regurgitation
Round holeIn a flat object
Perfect PISAhemisphere
CircularVena Contrata
Reallife
http://files.abstractsonline.com/CTRL/59/C/42D/CDE/EDE/49F/2BE/77E/A4C/700/A52/B0/g391_1.gifhttp://files.abstractsonline.com/CTRL/59/C/42D/CDE/EDE/49F/2BE/77E/A4C/700/A52/B0/g391_1.gif
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MV TV
Ao
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Regurgitant Orifices
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• Pts with post-MI MR more likely toexperience combined end point of
CV mortalitysevere HF, orrecurrent MI
• Independent predictor of CV mortality(relative risk, 2.00; 95% CI, 1.28 to 3.04)
SOLVD trial 1997
47% vs. 29%P < .001
Mitral Regurgitation
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Geometric Distortion Contributing to MR
Regional LV dilation/dysfunction Global LV dilation/dysfunction
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Surgical Annuloplasty for Functional MR in CHF
First 48 patients*
Operative Mortality = 2.1%
LOS = 9 ± 4 d (5-37)
Expanded series - 92 patients*
30 d Operative Mortality = 5.4%
Sicker pts, Less experienced Surgeon
Operative Mortality = ?
*Bolling S et al
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Hung et al
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LV
LA
Catheter device
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3D Imaging in Heart Failure
3D Echo vs. CMR
Widely available
Easy to use in any setting
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3D Imaging in Heart Failure
• Better appraisal of functional morphology
• More accurate study of remodeling
• Aid to innovative therapeutic procedures
• Good investigative tool to study the heart
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Thank you !
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