Jan 6, 2011 - Surveillance and monitoring of vital signs at baseline and throughout ...... 16- Spodick DH: Macrophysiology, microphysiology, and anatomy of.
Tanta University. Faculty of Medicine. Cardiovascular Department.
COMPARATIVE ASSESSMENT OF LEFT ATRIAL APPENDAGE BY TRANSESOPHAGEAL AND COMBINED TWO AND THREE DIMENSIONAL TRANSTHORACIC ECHOCARDIOGRAPHY.
THESIS Submitted To Faculty Of Medicine, Tanta University In Partial Fulfillment Of Requirements Of The Master Degree In Cardiovascular Medicine.
BY: Mohammed Ahmed El Gohary El Barbary. M.B.B.Ch. Cardiovascular Medicine Department, Tanta University.
SUPERVISORS: Prof. Dr: Ahmed Mohammed Zaghloul Darwish. Professor of cardiology. Faculty of medicine. Tanta University.
Prof. Dr: Seham Fahmy Badr.
Prof. Dr: Samiah Mahmoud Sharaf El-Din.
Professor of cardiology. Faculty of medicine. Tanta University.
Professor of cardiology. Faculty of medicine. Tanta University. 2011
( َوقُلْ َرب ِزدْ نِي عِ ْل ًما ) صد َ ه يم َ َق َّللا ُ ا ْل َعظِ ِ سورة :طة-االية 114 :
DEDICATION I dedicate this thesis to my loved parents, sisters and wife for their love and encouragement. My parents' integrity, humility, love, and compassion. I am eternally grateful for their constant encouragement and for setting the right example in my life. My father; who taught me that the best kind of knowledge to have is that is learned for its own sake. I dream of being like him for my son. My mother, who taught me that even the largest task can be accomplished if it is done one step at a time. My sisters, for their constant love, support and inspiration. And i dedicate this thesis to my hope, my present and future life: My wife; for her unconditional love and enthusiastic spirit and for standing beside me. Thank you for being a pillar of support in my life. Without you all this would have been an impossible task.
Mohammed El Barbary. 1-6-2011.
ج
ACKNOLEGGEMENT
First and forever, thanks for ALLAH helping me to complete this work. I would like to express my deepest gratitude and appreciation to Prof. Dr. Ahmed Mohammed Zaghloul Darwish, Professor of Cardiology, Faculty of Medicine, Tanta University, for his constructive keen supervision, fruitful criticism, indispensable advice and continuous support to complete this work. I owe him special feelings of gratitude and thanks.
My
sincere
gratitude
and
cardinal
appreciation
to
Prof. Dr. Seham Fahmy Badr, Professor of Cardiology, Faculty of Medicine, Tanta University. I owe her much more than I can express for her patience, invaluable guidance, sincere help and encouragement.
Very special thanks and appreciation to Prof. Dr Samiah Mahmoud Sharaf El-Din, Professor of Cardiology, Faculty of Medicine, Tanta
University, the person behind all efforts and good things in this work and the source for moral and scientific support.
I
heartily offer my regards and blessings and I am to thankful to
Prof. Suzan Bayoumy EL-Hefnawy, Assistant professor of Cardiology, Faculty of Medicine, Tanta University and to Dr. Sameh Samir Mohammed, Lecturer of Cardiology, Faculty of Medicine, Tanta University whose encouragement, guidance and support from the initial to the final level enabled me to develop and create this subject.
Finally
I would like to thank all members of cardiology
department for their unforgettable kindness and help. And we should not forget our patients who were really patient, kind and share by themselves in this work.
CONTENTS
PAGE NUMBER
SUBJECT
PREFACE:
Title. Dedication.
iii
Acknowledgements.
iv
Contents.
v
List of figures
viii
List of tables.
xv
Abbreviations & symbols.
xvi
INTRODUCTION.
1
AIM OF THE WORK.
3
REVIEW OF LITERATURE: I.
Left Atrial Appendage (LAA): Structure, Function, and Role In Thromboembolism. Anatomy of Left Atrial Appendage.
4
Ultrastructure and Anatomical Relations.
10
v
Function of the LAA.
11
Role of LAA in Thromboembolism.
12
II.
Multi-Modality Imaging To Assess LA/LAA Size Anatomy And Function. Causes and Mechanisms of LA Dilatation.
18
Importance of Assessment of LA/LAA Size and Anatomy.
20
Echocardiography.
20
Multi Slice CT.
26
MRI.
27
III.
LAA Two - Dimensional Transeosophageal Echocardiographic Exploration:
Transesophageal echocardiography (TEE).
30
Complications of TEE.
37
IV.
Three Dimensional Echocardiography Principles And Promises :
Introduction and History of development.
39
Data acquisition.
40
Data post-processing and representation:
42
Potential applications of 3D-echocardiography
43
Role Of 3D-TTE In Detection Of LAA Thrombus.
48
Three dimensional echocardiography examinations.
53
Limitations of 3D Echocardiography.
59
3D Echocardiography Future Direction.
60
vi
61
PATIENTS AND METHODS. RESULTS. Clinical data.
68
ECG data.
71
Echocardiographic data.
74
Comparison between 3D-TTE and 2D-TTE.
79
Comparison of 3D-TTE and 2D-TEE.
81
Comparison between 2D-TTE and 2D-TEE.
83
Cases.
84
Master table.
91
DISCUSSION.
95
SUMMERY AND CONCLUSION
102
REFERANCES.
107
ARABIC SUMMERY
vii
LIST OF FIGURES.
FIGURE
COMMENT
PAGE
Figure 1
Synthetic resin cast of the LA. The LAA contains pectinate muscles, while the body of the LA is a smooth-walled structure.
4
Figure 2
Picture of a gross specimen of the heart with
5
the pericardium. Figure 3
A coronal section of the heart showing: trabeculated appendages in contrast to the
5
smooth walled atrial bodies.
Figure 4
Pathologic specimens of the LAA:
7
Figure 5
The transverse sinus and its relation to LAA.
8
Figure 6
TEE of the transverse sinus with echo density
9
noted within the space.
Figure 7
TEE in the vertical plane demonstrates a fluid filled transverse sinus in which the LAA appears in as a circular object (arrow).
viii
9
Figure 8
LAA
flow
determined
during by
atrial
pulsed
fibrillation, Doppler
as
14
during
transoesophageal echocardiography
Figure 9
Measurement of LA volumes with transthoracic
21
echocardiography using the modified biplane Simpson’s rule.
Figure 10
Real-time three-dimensional echocardiogram
23
for the assessment of LA volumes.
Figure 11
Intracardiac echocardiography (ICE) during a
25
catheter ablation procedure for AF.
Figure 12
Volume
rendered
three
dimensional
26
reconstruction of a 64 slice MSCT scan.
Figure 13
Assessment of LA volumes with MRI.
27
Figure 14
Color coded tissue Doppler imaging in the apical four chamber views for the assessment of regional LA function.
29
Figure 15
TEE in the horizontal plane (00) demonstrates a normal LAA with prominently noted pectinate muscles (arrows).
31
ix
Figure 16
TEE of LA and LAA showing SEC.
32
Figure 17
Example of 2-D imaging assessment of LAA by contrast agent injection, color tissue Doppler imaging (DTI), and a combination of these two methods.
34
Figure 18
Example of 2-D transthoracic assessment of the
36
LAA and with the pulsed Doppler assessment of flows.
Figure 19
Figure 20
Figure 21
Figure 22
Three-dimensional reconstruction of the mitral valve (left) as seen from the left atrium. An anatomical specimen for comparison is shown on the right.
44
Patient with a partial flail leaflet as seen during mitral valve repair. 3D-Echo is able to demonstrate the location and morphology on the defect (arrow).
44
Three-dimensional reconstruction of a patient with mitral stenosis, morphologic features such as doming of the anterior leaflet and commissural fusion can be noticed. In addition, quantification of mitral valve area can be performed. Dissection of the descending aorta. The true
x
45
lumen is separated from the false lumen by an
45
intima flap.
Figure 23
Three-dimensional analysis of left ventricular function allows computation of global and regional ejection fraction (bottom) and the three-dimensional display of the ventricle (top panel).
Figure 24
3DTTE image of LAA. Arrowheads point to
46
48
individual lobes as visualized by cropping a 3D data set of LAA.
Figure 25
Figure 26
Figure 27
ATwo - dimensional transthoracic echocardiogram. Arrowhead points to a thrombus within the LAA. B, C, D. Threedimensional transthoracic echocardiogram. The thrombus (arrowhead) was cropped from the top and rotated to view it en face in short axis.
51
A, 2D TEE: Arrowhead points to an echo dense mass. B, C, and D. 3D TTE: Within the LAA there is two echoes densities noted. Sequential cropping shows both to be parts of pectinate muscles, which traverse the LAA within the LAA consistent with a thrombus.
52
Standard
54
transducer
positions
for
echocardiography exam used to acquire a full-
xi
volume dataset of the heart.
Figure 28
Figure 29
The long axis of the heart is at an angle to the body axis. The planes of the heart are in reference to the heart itself and not the body axis.
55
The heart may be described using two
56
descriptive terms, the plane and the viewing perspective.
Figure 30
Sagittal (long axis or longitudinal) sectionviewed from left side or right side.
57
Figure 31
Oblique coronal (frontal) section viewed from
58
above and below.
Figure 32
Transverse (short axis) section viewed from
58
base or apex. Figure 33
GE Vivid 7® Pro Color Ultrasound System.
62
Figure 34
Clinical characters of study population.
70
Figure 35
Sex distribution in the study.
70
Figure 36
Rhythm distribution in the study.
72
xii
Figure37
Comparison between 2D-TTE, 2D-TEE and 3DTTE in LAA visualization for thrombus.
78
Figure38
2D-TTE, apical four chambers (4CH) view
84
showing: tight M.S and dilated LA with swirling echo shadows inside it.
Figure39
2D-TTE parasternal long axis (PSLAX) view,
84
showing: M.S dilated LA with swirling echo shadows in the left atrium. Figure40
2D-TTE showing: LA and LAA thrombus.
85
Figure41
3D-TTE PSLAX view showing: LA and LAA
85
thrombus. Figure42
2D-TTE apical 4 CH view with RHD, severe
86
M.S and moderate MR. Figure43
2D-TEE: left atrium is dilated with thrombus
86
inside. Figure44
2D-TEE: dilated LA and LAA with a thrombus
87
inside. Figure45
3D-TTE PSLAX showing: dilated LA and LAA
xiii
87
with a thrombus inside.
Figure46
2D-TEE for a case of cerebral stroke. No intra
88
atrial masses. Figure47
3D-TTE PSALX view; for a case of cerebral
88
stroke. No intra atrial masses or thrombi.
Figure48
2D-TTE apical 4CH view showing Small LV cavity. Marked LV hypertrophy i.e. Septum & post wall= 2.4 cm hugely dilated RA about 10 cm in diameter with a smoky echo shadow in side.
Figure49
2D-TTE parasternal short axis view showing:
89
89
hugely dilated RA about 10 cm in diameter with a smoky echo shadow inside. Figure50
2D-TEE Showing hugely dilated RA with a
90
thrombus in side. Figure51
3D-TTE apical 4 CH view; showing hugely
90
dilated RA with a thrombus inside. Figure52
Suggested algorithm for LAA evaluation for thrombus starting with 2D- TTE.
xiv
106
LIST OF TABLES.
TABLE
COMMENT
PAGE
Table 1
Methods for left atrial volume quantification with twodimensional echocardiography.
22
Table 2
Qualitative Definition Of The SEC.
33
Table 3
Clinical Characters of Study Population
69
Table 4
ECG findings in the study population.
72
Table 5
Rhythm distribution of the Patients
73
Table 6
Two Dimensional Transthoracic Echocardiography Data.
74
Table 7
TEE examination findings.
76
Table 8
Transosophageal Echocardiography Data
76
Table 9
Comparison between 2D-TTE, 3D-TTE and 2D-TEE For LAA visualization
80
Table 10
X2 and P value comparing 3D-TTE and 2D-TTE.
80
Table 11
X2 and P value comparing 3D-TTE and 2D-TEE.
82
X2 and P value comparing 2D-TTE and 2D-TEE.
83
Table 12
xv
ABBREVIATIONS.
LA
LAA
2D
Left Atrium.
Left Atrial Appendage.
Two Dimensional.
2D-TTE
Two Dimensional Transthoracic Echocardiography.
2D-TEE
Two Dimensional Transesophageal Echocardiography.
TEE
3D-TTE
Transesophageal Echocardiography.
Three Dimensional Transthoracic Echocardiography.
L3D
Live Three Dimensional.
ANP
Atrial Natriuretic Peptide.
SEC
Spontaneous Echo Contrast.
ICE
Intracardiac Echocardiography.
xvi
MSCT
Multi Slice Computed Tomography.
MRI
Magnetic Resonance Imaging.
TDI
Tissue Doppler Imaging.
SVT
Supraventricular Tachycardia.
HZ
Hertz.
DCM
Dilated Cardiomyopathy.
RCM
Restrictive Cardiomyopathy.
IHD
Ischaemic Heart Disease.
HHD
Hypertensive Heart Disease.
4CH
Four Chamber.
2CH
Two Chamber.
PSALX
Para Sternal Long Axis.
MS
Mitral Stenosis.
INR
International Normalized Ratio.
CXR
Chest X Rays.
ECG
Electrocardiogram.
CBC
Complete Blood Picture.
xvii
LFTs
Liver Function Tests.
KFTs
Kidney Function Tests.
LV
Left Ventricle.
RV
Right Ventricle.
X2
CHI-SQUARED Test.
NYHA
New York Heart Association.
PPV
Positive Predictive Value.
NPV
Negative Predictive Value.
xviii
INTRODUCTION
INTRODUCTION. Left atrial appendage (LAA) is an important site of thrombus formation and a common source of systemic emboli. Two-dimensional echocardiography (2D) is an excellent technique in diagnosis of intracardiac masses e.g. LA thrombus, but it is limited in visualizing (LAA) and its contents because of the complex three dimensional anatomy of the LAA with its multilobed muscular extensions1. It has long been believed that the (LAA) is not well visualized on two dimensional transthoracic echocardiography (2D-TTE). However, two dimensional transosophageal echocardiography (2D-TEE) has been shown to obtain superior images of the (LAA) because of its close proximity to the esophagus, hence 2D-TEE is the accepted gold standard for the assessment of the (LAA). Early studies showed that transosophageal echocardiography (TEE) is vastly superior to 2D-TTE in visualizing (LAA), with a sensitivity of nearly 100% and a specificity of 99%.2-4 However; TEE is semi invasive, uncomfortable to the patient and not without risk5. Also both 2D-TEE and 2D-TTE are only slice techniques, visualizing only one plane at any given time so prevent comprehensive examination of the (LAA) and make it difficult to differentiate a clot from pectinate muscles in some patients6-8. This limitation may be overcome by obtaining a three dimensional TTE image of the (LAA). Once (LAA) can be visualized from transthoracic images, it is possible to obtain a live/real time 3D image of the (LAA). After 1
INTRODUCTION
a good quality image is acquired, it can be sectioned in any plane with any desired angulation, thereby increasing the confidence in accurately identifying the presence or absence of a thrombus and differentiating it from pectinate muscles especially if they are prominent or hypertrophied with a non-invasive manner.
2
AIM OF THE WORK.
AIM OF THE WORK.
The aim of this study is to compare the utility of combined 2D-TTE and 3D-TTE versus 2D-TEE in evaluation of the left atrial appendage (LAA) for thrombus.
3
REVIEW OF LITERATURE
LEFT ATRIAL APPENDAGE (LAA): STRUCTURE, FUNCTION, AND ROLE IN THROMBOEMBOLISM.
Review of literature.
LEFT ATRIAL APPENDAGE: STRUCTURE, FUNCTION AND ROLE IN THROMBOEMBOLISM Anatomy of the left atrial appendage (LAA): The LAA is a remnant of the original embryonic left atrium formed during the third week of gestation. The left atrial appendage LAA is a long, hook-like true diverticulum of the left atrium (LA).While parallel running pectinate muscles are contained within the tubular LA (figure 1), the body of the LA is a smooth-walled structure.9-11 The LAA lies within the pericardium, next to the superior lateral aspect of the main pulmonary artery, and superior to the left ventricular free wall and it’s often multilobed (figure 2, 3). 11
Figure.1 Synthetic resin cast of the LA. The LAA contains pectinate muscles, while the body of the LA is a smooth-walled structure. Pulmonary venous component = pulmonary veins; vestibule = vestibule of the mitral orifice. After Anderson et al.9
4
Review of literature.
Figure 2.Picture of a gross specimen of the heart with the pericardium. The position of the appendage between the left ventricle and pulmonary artery and in close relation to the pericardium can be appreciated. After Al-Saady, NM .9
Figure.3 A coronal section of the heart showing: trabeculated appendages in contrast to the smooth walled atrial bodies. After Al-Saady, NM .9
5
Review of literature.
An autopsy study of 220 cases with resin casts of the LAA found a range of volumes from 0.7 to19.2 ml, minimum diameter from 5 to 27 mm, maximum diameter from 10 to 40 mm, and a variation in length from 16 to 51 mm. In 70% of the cases, the long axis was significantly “bent “or spiral shaped12. A subgroup of patients who was in atrial fibrillation prior to death; was noted to have larger LAA volume, larger orifice, and fewer “lobes.21
LAA structure varies significantly. Another autopsy study (n = 500) with 25 males and 25 females for each decade of life (age 1–100 years) was performed in patients without history of heart disease 8 (Figure 4). Over 97% had pectinate muscles of >1mm in size. Those with pectinate muscles of 15% of strokes originate from the heart, and from the LAA in particular.86, 87
TEE provides an access to this small structure, enabling cardioversion in patients with atrial fibrillation (AF) without 4 weeks of prior anticoagulation4. The encouraging results of radiofrequency ablation therapy increase the need for good left atrial (LA) and LAA assessment by TEE or intracardiac echocardiography.88,
89
In addition; Doppler echocardiographic studies
provide us with a better understanding of the determinants of LAA function.
When investigating the LAA by Transoesophageal Two-Dimensional Echocardiography , it is important to keep in mind that he LAA is a threedimensional (3D) multilobed structure. Therefore; a multiplane probe revolving around the cavity (0 to180°) will improve the assessment of its frequently complex structure. Meticulous LAA cavity evaluations should be sufficient to exclude an abnormal intraluminal echo-density signal. 90 Nevertheless, exclusion of clot might be difficult, and even experts postpone electrical cardioversion because of inability to exclude clot formation. Clots may remain hidden because of the three-dimensional
30
Review of literature. complexity of the LAA, and a false-positive diagnosis of thrombus may stem from false interpretation of a prominent pectinate muscle. Therefore; evaluation should include imaging in multiple planes, including orthogonal views, in order to image the entire 3D complex structure. Pectinate muscles should not be confused with thrombus91 (figure 15).
Figure.15 .TEE in the horizontal plane (00) demonstrates a normal LAA with prominently noted pectinate muscles (arrows).* is the transverse sinus. After Kerut, EK et al.20 Two-dimensional (2-D) images of the appendage can help to diagnose a thrombus and spontaneous echo contrast (SEC). When blood flow velocities are reduced in cardiac chambers and especially in the LAA, “smoke-like” echoes in the cavity may be seen91 (figure 16, table 2).
31
Review of literature.
Figure. 16 (A): Example of a polylobed LAA with severe SEC and the corresponding pulsed Doppler of LAA flows . (B): Second example of polylobed LAA. (C): Example of an LAA ligated by the surgeon at the time of plasty of the mitral valve; the ligature is incomplete and there is still flow between the LAA and the LA cavity.After Erwan, D et al.91
32
Review of literature. TABLE 2—QUALITATIVE DEFINITION OF THE SEC: 92
Score 0
Attributes Absence of echogenicity. Mild :
1
Minimal echogenicity. Only transiently detectable with optimal gain settings during the cardiac cycle
Mild to moderate : Transient SEC without increased gain settings and more
2
dense pattern than 1 Moderate : Dense swirling pattern throughout the cardiac cycle.
3
Severe : 4
Intense echo density.
very slow swirling patterns in the LA appendage, usually with similar density in the main cavity
From Fatkin et al 92. Although it remains an “eye-ball” judgment, dependent on echo gain control, backscatter signal information has been tested in an attempt to quantify SEC.93,
94
Results have been published regarding the atrium and
LAA. 93, 94
33
Review of literature. However, this signal is not characterized on all echo platforms, and its evaluation requires complex and time-consuming post processing. With respect to imaging LAA, few studies95-99 by magnetic resonance imaging MRI and spiral CT scan have been reported on detection of LAA thrombus and SEC. Although TEE is considered the “gold standard “for excluding LAA thrombi, in some patients dense SEC and artifacts may hamper the identification or exclusion of thrombi.32 Injection of contrast agent may also enhance detection of the complex borders of the LAA100-101(figure 17)
Figure.17 Example of 2-D imaging assessment of LAA by contrast agent injection, color tissue Doppler imaging (DTI), and a combination of these two methods. After Erwan, D et al.91
34
Review of literature. A preliminary study97 indicates that color tissue Doppler imaging (TDI) with a contrast agent may improve understanding of LAA structure and function as well as quantify the SEC and subsequent thrombogenic risk
Three-dimensional echocardiographic imaging should improve the delineation of LAA complexity and thus compensate for current limitations in the measurement of LAA ejection fraction by 2D planimetry.102
During TEE, SEC and thrombi may also be found in the right atrial appendage. In the study by Bashir et al, 103 SEC and thrombi were found with 14% and 1% prevalence, respectively. The feasibility and the accuracy of transthoracic Doppler of LAA recording have also been reported. However; data are scant, although it seems possible to measure LAA emptying flow approximately; SEC or thrombi may not be detected (figure 18). Furthermore, this type of transthoracic examination misses other sources of cardio embolic event (aorta, valves, inter atrial septum).104 The early report from the study by Sallach et al105 assessing the interest of TTE for assessment of cardiac embolic risk, showed that the pulsed TDI findings on the LAA were well correlated with LAA SEC, sludge, or thrombus as assessed by TEE.
35
Review of literature.
Figure.18 Example of 2-D transthoracic assessment of the LAA and with the pulsed Doppler assessment of flows. After Erwan, D et al.91
36
Review of literature. COMPLICATION OF TRANSOSOPHAGEAL ECHOCARDIOGRAPHY.
1. Gastrointestinal Complications: I. Injuries of Gastrointestinal Tract: Dental trauma, sub-mucosal hematoma106, 107 and jaw subluxation108, 109
may occur during probe insertion. Esophageal perforations mostly occur
in the abdominal followed by intrathoracic and cervical portions. They are caused by anatomic variations, poor cooperation and inadequate skill. Perforation if goes unnoticed; ultimately results in mediastinitis and sepsis. II. Gastroesophageal Lesions and Anatomic Variations; Neoplasm, diverticulum, cervical spine
106,110
, achalasia, Barrett’s
esophagus, esophagitis, scleroderma and tumors are risk factors. Esophageal intubations most often fail at the level of cricopharynx. Esophageal varices due to portal hypertension can cause bleeding.111 III. Unsuccessful Esophageal Intubation: Due to incooperation, inexperience and anatomic abnormalities. IV. Bleeding of Esophageal Tract: Risk factors are ulcerative process, failure to use H2 antagonist in the perioperative
period112,
reoperation113,
emergency
surgery,
and
anticoagulants.114, 115 V. Injury to Other Solid Organs & Oral Injuries: Splenic laceration can occur due to deep insertion of the probe into the stomach for transgastric imaging.116 Dysphagia can occur due to local
37
Review of literature. compression from probe insertion which affects pharyngoesophageal tissue and laryngeal nerve especially in female and pediatric patients.117 2. Respiratory Complications: Incidence of oxygen desaturation and aspiration increases with obesity 118
and during emergency procedures.119 In awake patients; bronchospasm,
laryngospasm, posterior pharyngeal wall hematoma, supraglottic hematoma may occur along with pulmonary edema.120-125 3. Cardiovascular Complications: Intubation can induce vagal and sympathetic reflexes such as hypertension
or
hypotension
or
even
myocardial
infarction.126-128
Arrhythmias are manifested as non-sustained ventricular tachycardia, SVT, AF and third degree heart block.129 Large intrathoracic pressure and hemodynamic changes resulting from retching may cause pulmonary embolization from right atrial mass130,131 mitral vegetation and left intracardiac thrombus132 resulting in stroke, aortic dissection and cardiac tamponade.133 4. Infections: Such as endocarditis by staph aureus and staph epidermidis.134, 135 5. Medication Related Complications: Sedation: Benzodiazepines and propofol may cause respiratory depression, hypotension and allergy. Local
Anaesthetic
Medication:
Congenital
absence
of
methemoglobin reductase enzyme and topical local anaesthetics like lidocaine and benzocaine can lead to methemoglobinemia. 136,137
38
THREE-DIMENSIONAL ECHOCARDIOGRAPHIC TECHNOLOGY
Review of literature. THREE DIMENSIONAL ECHOCARDIOGRAPHY PRINCIPLES AND PROMISES Introduction: The interpretation of echocardiographic images requires a complex mental integration of multiple image planes for a true understanding of anatomic and pathologic structures. The representation of images in a three dimensional format more closely resembles reality and could therefore enhance image interpretation. In addition, 3-dimensional imaging allows direct calculation of volumes and is, thus, more accurate than current models relying on geometric assumptions.138 First attempts to incorporate multiple views to form a three dimensional image were made in the seventies. But, because of technical limitations (e.g. lack of processing power, relatively poor image quality, difficulties in image plane alignment) this technique was limited to an experimental setting. The advent of transesophageal echocardiography together with newer imaging probes and enhanced image processing capabilities have now led to a remarkable progress in the field of three dimensional imaging.138 Numerous applications of three-dimensional echocardiography (3Decho) have been proposed. For example, improvements in image interpretation with 3D-echo could be of value in the decision making and planning of cardiac surgery, and in the diagnosis of complex cardiac lesions 139
. In addition, 3-dimensional imaging allows quantitative parameters such
39
Review of literature. as valve areas, the size of defects (atrial septal defect, ventricular septal defect) or volumes to be obtained.140, 141 With new developments that allow system integration of 3D scanning, rapid or even near real time 3D-reconstruction and measurements, 3D-echo is now on the verge of becoming an integral part of an echo examination 138. Data acquisition: Three-dimensional echocardiography requires the collection of a volumetric data set where each image (cut plane) is defined with respect to its exact position in space142. Most systems currently rely on sequential collection of image planes. With this technique it is necessary to use ECG and respiratory triggering or breath hold acquisition to account for motion artifacts caused by respiration and to permit alignment of the images in the time domain. Newer developments use a transthoracic probe technology with volumetric scanning capabilities, which allows simultaneous acquisition of an entire 3D-data set. As a result, data acquisition is less time consuming and less susceptible to artifacts.143 3D-reconstructions have also been applied to the color Doppler information allowing a three dimensional representation of jets superimposed on the 3D gray scale image. Image acquisition can be performed from both a transthoracic and a transoesophageal approach (TEE).143 Transthoracic 3D-Echo: Three-dimensional transthoracic imaging can be performed with mechanical steering devices, which are attached to standard transducers. These devices steer the transducer motion causing incremental changes in the 40
Review of literature. scan plane either by rotating, shifting or fanning the probe. In addition, various locating systems (i.e. acoustic or electromagnetic) have been used effectively. The advantage of this technique is that freely definable image planes can be chosen allowing for more flexibility. Others have proposed a rapid (6 seconds) acquisition technique that collects apical tomograms (within 6 sec) using an internally rotating transthoracic transducer .144 Volumetric real-time echocardiography is a recently developed technique based on the design of an ultrasound transducer with a matrix array that instantaneously acquires the image contained in a pyramidal volume. Volumetric real-time echocardiography is a novel imaging concept, which holds promise as a ―break-through‖ technology for 3D-echo. Employing a matrix array echo probe this technique allows instant (real-time) acquisition of a complete 3 dimensional data set without complex post-processing. Several studies have already demonstrated the validity of real-time volumetric echocardiography for the calculation of cardiac volumes.143 Transoesophageal 3D-Echo: First attempts to acquire a 3-dimensional data set from the oesophagus were made with a specially designed probe (echo-CT, lobster tail probe, Tom Tec). This probe was capable of acquiring parallel data sets by passing a transducer along the oesophagus. Newer technologies, however, use multiplane TEE probes that acquire sequential images at different transducer rotation points (0–180o). 3D echocardiography can, thus, be performed as an adjunct to a routine TEE simply by mounting the steering device onto the TEE probe. 145
41
Review of literature. data post-processing and representation: Post-processing of the data for sequentially acquired images is performed off-line using dedicated software. Varying amounts of user interaction are required to define the region of interest, view, cut-plane, rendering algorithm, filter, magnification and thresholds. The systems provide a variety of 3D-tools for advanced image processing.138 Multiplanar, 3D reconstructions (volume rendering) as well as wire frame (surface rendering) display formats can be chosen and measurements (distance, area, angle, volume) can be performed. Recent advances in computing capabilities such as parallel processing have greatly reduced the time necessary for data manipulation. Three-dimensional reconstruction can now be achieved within seconds and viewed from different angels in a dynamic format. It is even possible to ―electronically‖ dissect the heart to visualize otherwise concealed structures.138 Volumetric scanning allows instantaneous (real-time) display of multiple views (multiplanar) using a split screen. In addition, prototype systems have demonstrated the feasibility of near real-time 3Dreconstruction, which permits almost simultaneous display of 3D-images during the examination. 138
42
Review of literature. POTENTIAL APPLICATIONS OF 3D-ECHOCARDIOGRAPHY: The potential applications of 3D-echo can be categorized into 3 major areas: 138 (1) Interpretation of morphology and pathology. (2) Quantification of volumes and function. (3) 3D echocardiography as a teaching tool.
1-Interpretation of Morphology and Pathology The clinical potential of 3D-echocardiography has been thoroughly explored. Our own experience and that of others have clearly demonstrated that the anatomy (Figure 19) and pathology of the heart and the great vessels can often be displayed in a more comprehensive format.
146,147
Even fairly
small structures such as coronary arteries, a paravalvular leak or small masses and vegetations can be visualized. 145, 148
Findings also show that this technique can be applied in numerous settings. For example, in valvular heart disease (Figure 20), to determine the size of infectious vegetations, to determine the mitral valve area in mitral stenosis (Figure 21), for complex congenital malformations, or aortic dissection (Figure 22). Furthermore, it has also been shown that jets can be reconstructed from color Doppler information to assist in the quantification of valvular lesions.149
43
Review of literature.
Figure 19. Three-dimensional reconstruction of the mitral valve (left) as seen from the left atrium. An anatomical specimen for comparison is shown on the right. After Binder T. 138
Figure 20. Patient with a partial flail leaflet as seen during mitral valve repair. 3D-Echo is able to demonstrate the location and morphology on the defect (arrow). After Binder T. 138 44
Review of literature.
Figure 21. Three-dimensional reconstruction of a patient with mitral stenosis, morphologic features such as doming of the anterior leaflet and commissural fusion can be noticed. In addition, quantification of mitral valve area can be performed. After Binder T. 138
Figure 22. Dissection of the descending aorta. The true lumen is separated from the false lumen by an intima flap. After Binder T. 138 45
Review of literature. 2- Quantification of ventricular volumes and function:
3D-echo has been applied to derive quantitative measurements of volume, mass and dimensions of the left and right ventricles and also other cardiac lesions, such as atrial and ventricular septal defects150. While quantification of ventricular volumes with two-dimensional imaging requires geometric assumptions, measurement obtained with 3Decho represents true volumes. Several studies have shown 3D-echo to be superior to 2D-echocardiography for both left and right ventricular volumes. The process requires acquisition of a 3-dimensional data set and manual endocardial contour tracing. Several calculations including volumes (throughout the cardiac cycle), global and regional ejection fractions can be computed (Figure 23).151
Figure 23. Three-dimensional analysis of left ventricular function allows computation of global and regional ejection fraction (bottom) and the threedimensional display of the ventricle (top panel). After Binder T. 138 46
Review of literature. The endocardial surface of the ventricular cavity can be displayed from multiple angles in a dynamic mode. Since the process of manual endocardial border tracing is still time-consuming, semi-automated contour detection algorithms are now being developed. In addition, there is experimental evidence that contrast opacification of the left ventricle could further enhance the applicability of 3D-volume computation.152 The advent of real time volumetric scanning will certainly enhance the applicability of 3Dvolume computation.153
3- 3D-Echocardiography as Teaching and Research Tool: Spatial representation of cardiac structures greatly enhances the understanding of cardiac function and pathology. Thus, three dimensional images could assist in the teaching of echocardiography where a significant amount of spatial understanding is required. An example of such an application is a system which couples 3D-echo with a virtual reality heart model. The system allows standardized echocardiographic views to be selected on the virtual heart and displayed from the 3D-dataset to provide a correlation between anatomy of the heart and echocardiographic image planes.154
47
Review of literature. ROLE OF THREE DIMENSIONAL TRANSTHORASIC ECHOCARDIOGRAPHY IN DETECTION OF LEFT ATRIAL THROMBI. The left atrium (LA) is the most important location for the formation of thrombi in many cardiovascular conditions. Most of these clots occur in the left atrial appendage LAA, which is a small finger-like out-pouching of the left atrium. The shape and location of LAA allow for stasis of blood in atrial fibrillation, mitral stenosis, and other conditions with low cardiac output, particularly states with poor LV function, or enlargement of the left atrium.5 The LAA, a multilobulated structure (figure 24), has been described by Veinot et al in their autopsy study. The LAA may have anywhere between 1 and 4 lobes in 80% of the general population, with about 54% having 2 lobe.8 It is internally lined by pectinate muscles which are arranged in a parallel fashion, giving it a web-like appearance. Most pectinate muscles are greater than1 mm in size8.
Figure.24 3DTTE image of LAA. Arrowheads point to individual lobes as visualized by cropping a 3D data set of LAA. After Karakus, G et al.138 48
Review of literature. Traditionally, it has been difficult to visualize by two-dimensional transthoracic echocardiography (2DTTE), and in most cases two-dimensional transoesophageal echocardiography (2DTEE) has been considered to evaluate its morphology and for any abnormality such as the presence of a thrombus. It has long been believed that the LAA is not well visualized on 2DTTE. However; 2DTEE has been shown to obtain superior images of the LAA because of its close proximity to the esophagus permitting use of a higher frequency transducer. 11
The LAA is usually a multilobed structure. Thus, the LAA should be scanned meticulously in multiple echocardiographic planes, most precisely by multiplane TEE, and the number of lobes determined. A detailed examination of all lobes is necessary for exclusion of LAA thrombi. Owing to this complex structural feature of the LAA, the diagnosis of LAA thrombi by TEE is prone to misdiagnosis,
over diagnosis(false interpretation of prominent pectinate muscles) 8,155
Under diagnosis (occult thrombi in multilobed appendages).156
Although the visualization of this structure is much clearer in 2D-TEE with a sensitivity of 100% and a specificity of 99%, TEE is semi invasive, uncomfortable to the patient and not without risks. More recently, it has been increasingly possible to visualize the LAA by 2D-TTE due to improved technology such as improved harmonics, as well as increasing awareness, diligence and experience. The LAA can be visualized not only in parasternal short-axis views (aortic-pulmonic and mitral-pulmonic planes) but also from the apical approach.5 49
Review of literature. The LAA is larger in patients with atrial fibrillation, mitral stenosis, and in patients with a LAA thrombus making it easier to visualize on 2DTTE.5 But both 2DTEE and 2DTTE are only slice techniques, visualizing only one plane at any given time, preventing comprehensive examination of the LAA and making it difficult to differentiate a clot from pectinate muscles in some patients. 6, 7, 8. This limitation may be overcome by obtaining a 3D transthoracic image of the LAA (figure 25, 26). Once the LAA can be visualized from transthoracic images, it is possible to obtain a live/real time 3D image of the LAA. After a good quality image is acquired, it can be sectioned in any plane with any desired angulation, thereby increasing the confidence in accurately identifying the presence or absence of a thrombus and differentiating it from pectinate muscles especially if they are prominent or hypertrophied.157
50
Review of literature.
Figure.25 A-Two-dimensional transthoracic echocardiogram. Arrowhead points to a thrombus within the LAA. B, C, D. Three-dimensional transthoracic echocardiogram. The thrombus (arrowhead) was cropped from the top and rotated to view it en face in short axis. There was no evidence of lysis within the thrombus. AV = aortic valve, LA = left atrium, LAA = left atrial appendage, MPA = main pulmonary artery, RVO = right ventricular outflow tract. After Karakus, G et al.157
51
Review of literature.
Figure.26 A, 2D TEE. Arrowhead points to an echo dense mass within the LAA consistent with a thrombus. B, C, and D. 3D TTE: Within the LAA there is two echoes densities noted. Sequential cropping shows both to be parts of pectinate muscles, which traverse the LAA. The upper echo density (upper arrowhead) is larger because it represents a short-axis cut through two pectinate muscles virtually in contact with each other. This most likely represents the “thrombus” seen on the transesophageal echocardiogram. The second echo density (bottom arrowhead) is smaller because only one pectinate muscle is involved.After Karakus, G et al.157 52
Review of literature. THREE-DIMENSIONAL ECHOCARDIOGRAPHY EXAMINATION158-165 2D echocardiography orientation of the heart: Digital imaging modalities such as X-ray, MR, and CT display and describe the heart in relation to the standard anatomical position. Traditional 2D echocardiography has described and displayed the image of the heart in relation to the left ventricle. The long axis is described as the plane that sections the heart from the apex to base through the mitral valve. This orientation method allows the cardiac chambers to be described in a long and short-axis approach without foreshortening or elongation of structures.158-165 In
2D
echocardiography,
the
parasternal short-axis
plane
demonstrates the short axis of the heart. The apical two-chamber view demonstrates the
vertical
long
axis.
The
apical
four chamber view
demonstrates the horizontal long axis. 158-165 3D imaging planes and orientation of the heart: The standard anatomical position is the starting point for 3D echocardiography orientation. Anatomic orientation assumes the body is standing upright, facing the observer. The feet are flat on the floor. The arms are hanging at the sides of the body. The palms face forward and the thumbs are pointed away from the body. 158-165 All images are displayed as if the observer is facing the patient. The standard acquisition windows for echocardiography will remain the same: left parasternal, right parasternal, apical, subcostal, suprasternal, and right supraclavicular. 158-165 53
Review of literature. Most 3D echo images are displayed in two different acquisition formats. The Live 3D Echo format displays a volumetric sector. Full volume datasets are used to image a larger portion of the cardiac structures. A fullvolume dataset is comprised of multiple sectors that are obtained during consecutive heartbeats without moving the transducer. 158-165 The sectors are integrated to provide a pyramid-shaped dataset of 90◦ by 90◦. The guidelines put forth here pertain to the real-time volumetric sector and the full volume dataset. In pediatric echocardiography, the realtime volumetric sector can often visualize the entire heart 158-165 (figure 27).
Figure27. Standard transducer positions for echocardiography exam used to acquire a full-volume dataset of the heart After Nanda, CN et al.158 54
Review of literature. Image orientation As in the study of anatomy, echocardiography images may be dissected or sectioned in planes. For the purposes of this discussion, the planes described are relative to the heart itself and not to the heart’s orientation to the body. In dissection, the most frequently used planes are the sagittal, coronal, and transverse planes. These planes lie at right angles to each other (figure 28). 158-165
Figure.28 the long axis of the heart is at an angle to the body axis. The planes of the heart are in reference to the heart itself and not the body axis. After Nanda, CN et al.158 55
Review of literature. 1. A sagittal plane (long axis or longitudinal) is a vertical plane that divides an organ into right and left portions. 2. A coronal plane (frontal) is also a vertical plane that divides an organ into anterior and posterior portions. A four chamber view represents an oblique coronal plane of the heart. 3. A transverse plane (short axis) runs parallel to the ground, and divides the organ into superior and inferior portions. These planes can be used to reveal the structures of the heart in both anatomic specimens and echocardiography images. The use of anatomical planes to describe real-time 3D echocardiography images results in six possible views for the valves, atria, and ventricles. Each structure of the heart can be assessed from these anatomic perspectives or views 158-165 (figure 29).
Figure.29 The heart may be described using two descriptive terms, the plane and the viewing perspective. After Nanda, CN et al.15 56
Review of literature. Recommended 3D echocardiography basic sections: The concept of using sections to identify structures in the heart is based on viewing perspectives. For example, the heart is sectioned and the sections are displayed like opening a book and viewing the pages. To use this viewing method, the heart is displayed with the apex down. Some users may prefer to view the heart with the apex up to correspond to 2D images. Learning curve with the proposed method may be faster if the heart is viewed with the apex down 158-165 (figure 30-32). 1. Sagittal section—viewed from left-hand side or right-hand side. 2. Coronal section—viewed from above and below. 3. Transverse section—viewed from base or apex. 4. Oblique plane—sections performed as necessary to visualize structures outside of the basic imaging views, but may be related to nearest basic sections, for example, an oblique sagittal plane.
Figure.30 Sagittal (long axis or longitudinal) section-viewed from left side or right side. After Nanda, CN et al.158 57
Review of literature.
Figure.31 Oblique coronal (frontal) section—viewed from above and below. After Nanda, CN et al.158
Figure.32 Transverse (short axis) section—viewed from base or apex. After Nanda, CN et al.158 58
Review of literature. LIMITATIONS OF 3D ECHOCARDIOGRAPHY Despite the potential of 3D-echo to visualize cardiac structures and perform volume computations, this technique have not gained wide spread acceptance to date. 138 This might be related to several factors138: (1) 3D can only visualize what is also seen on the two dimensional image, thus, an experienced echocardiographer will obtain similar information from a conventional examination without the need for costly instrumentation and long post-processing times. (2) Operator experience with the reconstruction and interpretation of 3Dimages is necessary. (3) 3D-image quality greatly depends on the quality of the two-dimensional image and the ability to obtain a motion and artifact free 3D-data set. (4) Three-dimensional imaging only creates a ―virtual sense of depth‖ on a flat (2-dimensional) screen. (5) And finally, manual endocardial contour tracing is still required to obtain 3D-volumes. Some of these limitations will certainly be overcome with newer techniques and growing experience with 3D-echo.
59
Review of literature. FUTURE DIRECTIONS. Ongoing developments in 3D echocardiography include technological innovations and expanding clinical applications. Automated surface extraction and quantification, single-heartbeat full-volume acquisition, transesophageal RT3D imaging, the ability to navigate within the 3D volume, and stereoscopic visualization of 3D images are some of the technological advances that can be expected. 166
Over the next several years; these will further enhance the quality and clinical applications of 3D echocardiography. In addition, standardized and focused 3D protocols will be developed and refined to optimize clinical application of this technique. Tagging and/or tracking the LV surface in real time may provide new approaches to quantifying myocardial mechanics, such as regional shape and strain. This approach has great potential and will complement and likely compare favorably with the quantitative ability of cardiac MRI. The superior temporal resolution of echocardiography should offer unique advantages for this purpose. 166
In the future, combining the greater temporal resolution of 3D echocardiography with the excellent spatial resolution of MRI (or computed tomography) may yield an imaging data set with unsurpassed anatomic and physiological information, an approach called ―fusion image. 166
60
PATIENTS AND METHODS.
Patients & Methods
PATIENT AND METHODS
Study Population: One hundred patients, age range from 20 to 54 years, of both sex referred to our departement for transthoracic and transesophageal echocardiography were included in the study.
Place of the study: Cardiology Department, Tanta University Hospital. Tanta City. The study was approved by the ethics committee of faculity of medecine,Tanta University.
Duration of the study: From February 2010 to February 2011.
Inclusions criteria: Patients having risk factors to LA thrombus:
Atrial Fibrillation (Valvular - Ischemic AF)
RHD ; M.S
Patients with Embolic manifestations i.e. cerebral stroke.
Exclusion criteria (for TEE):
Dysphagia.
Esophageal stricture.
Esophageal Varices.
Blood diseases.
Unconscious patients. 61
Patients & Methods The Machine:GE Vivid 7® Pro Color Ultrasound System;
GE 3V Probe / Vector Array: 3V Cardiac Vector Array Probe (1.5 - 3.6 MHz). For 2D/3D/4D Cardiac applications.
GE 6T TEE Probe: 6T Multiplane Transesophageal Transducer (2.9 - 6.7 MHz). Adult Transesophageal Probe.
GE M4S Probe / Matrix Sector Array: M4S Matrix Sector Array Probe (2 - 5 MHz). Adult Cardiac applications.
Figure 33. GE Vivid 7® Pro Color Ultrasound System.
62
Patients & Methods Procedures:
An informed consent was taken from all prticipitants.
All patients were subjected to : a) Full history taking. b) Full clinical examination. c) Chest X rays (CXR), Electrocardiogram (ECG). d) Routine laboratory investigation e.g.
Prothrombin time, activity and INR.
Complete blood count (CBC).
Liver function tests (LFT).
Kidney function tests (KFT).
2D-TTE, 2D-TEE and 3D-TTE were done on the same day or the next day within 24 hours from the initial test.
44 patients were excluded from TEE examination because of either refusal or contraindication and only2 D-TTE and 3D-TTE were performed.
Transthoracic Echocardiography:
Transthoracic studies were done by a standard technique using GE Vivid 7 with M4S probe. LA diameter was taken in the parasternal long axis view in M-mode at end systole.
Measurements were taken in three beats in patients with normal sinus rhythm and in ten beats in atrial fibrillation and the mean values were taken for analysis.
63
Patients & Methods
To maximize the transthoracic visualization of LA thrombus, the LA was examined in standard parasternal long axis, apical, subcostal and parasternal short axis views with angulation of transducer to enhance the imaging of LA appendage.
Three Dimensional Transthoracic Echocardiography:
L3D images were obtained using a GE vivid 7 with 3V Probe / Vector Array: 3V Cardiac Vector Array Probe (1.5 - 3.6 MHz).
The instrument acquires four ECG-gated (60◦ × 60◦) full volume pyramidal images during a breath hold.
Images were acquired from parasternal and apical windows and displayed in parasternal long-axis, short-axis, apical four- and fivechamber views.
LAA was sectioned; focus was placed on the presence or absence of a clot and differentiating it from pectinate muscles.
The image was rotated 180◦ to display the LAA in an orientation similar to the display from mid-esophageal TEE acquisition.
L3D and 2D images were analyzed by two independent reviewers for LAA visualization and further stratified based on image quality.
For the purposes of LAA visualization, L3D and 2D image quality was classified as suboptimal (LAA walls were not clearly identifiable) or diagnostic quality (all the walls and cavity of LAA seen clearly).
64
Patients & Methods Transesophageal Echocardiography.
TEE was performed after TTE.
GE vivid 7 with 6T TEE Probe (6T Multiplane Transesophageal Transducer (2.9 - 6.7 MHz)) was used.
All patients were given local pharyngeal anaesthesia (1% lidocaine spray) and intravenous diazepam 3mg.
During the study: heart rate, blood pressure, ECG and pulse oximetry were monitored.
TEE probe was introduced with the patient lying supine in left lateral position.
The LA was scanned in short axis view and bicaval view. With a counterclockwise rotation of the probe at the level of aortic valve, the LA appendage was visualized.
LA thrombus was diagnosed by the presence of well-defined echogenic intracavity mass with an echo texture different from that of underlying endocardium and not due to pectinate muscle.
LA spontaneous echo contrast was diagnosed by the presence of dynamic smoke like echoes in the LA cavity and LA appendage with swirling motion distinct from white noise artifact after adjusting the gain setting properly.
After completion of TEE, patients were observed in the ward for 2 hours prior to discharge.
TEE images were independently evaluated by two different echo cardiographers, each of whom was blinded to the other’s findings.
65
Patients & Methods Measures to prevent TEE Complications.
Careful medical history : allergy - bleeding disorder - dysphagia - esophageal varices - GIT bleeding - esophageal and neck surgeries -
use
of
antacid,
salicylates, anticoagulants and antiplatelet agents.
Physical Examination. a.
Oral and dental hygiene and loose teeth.
b. Assessment of neck mobility, stability and arthritic changes. c. Assessment of airway.
Endocarditis prophylaxis for high risk patients.
Fasting for 6 hours before the procedure.
Surveillance and monitoring of vital signs at baseline and throughout the procedure.
Supplementation and venous access are established.
Suction device and resuscitation equipments are kept ready.
Dentures were removed and bite guard were placed.
TEE probe is lubricated and kept in unlocked control-wheel position.
Awake patient is asked to swallow.
Insertion of probe only up to 40-50 cm from incisors is advocated.
Patients were monitored until fully awake and eating and drinking is allowed once the effect of local anesthetic is dissipated.
66
Patients & Methods STATISTICAL ANALYSIS.
CHI-SQUARED TEST (X2):
Used to check if the difference between the expected results (by 2DTTE) and the observed (by 3D-TTE and 2D-TTE) results is significant.
Calculated using the following equation: X2 = ∑ (0-E) 2 / E Where:
0 is the observed results.
E is expected results.
∑ = (sigma) is sum of.
67
RESULTS
Results
RESULTS OF THE STUDY.
CLINICAL DATA (Table 3, Figure 34, 35):
The present study included 100 adult patients: 60 males (60%), 40 females (40%); age range 20–54 years; mean age 30 years ± 7.75.
They were refereed to our department for echocardiographic examination for: Evaluation of mitral valve pathology before BMV and mitral valve replacement in 85 patients (85%) who had rheumatic mitral stenosis. Assessment of LA and LAA in : -
7 patients (7%) with dilated cardiomyopathy (DCM).
-
5 patients (5%) with ischaemic heart disease (IHD).
-
2 patients (2%) with hypertensive heart disease (HHD).
Evaluation of intracardiac mass in one patient (1%) with restrictive cardiomyopathy (RCM).
Fifty five patients (55%) were in AF; while the remaining 45 patients (45%) were in sinus rhythm.
Seventy eight patients (78%) were in NYHA class III followed by 17 patients (17%) in NYHA class II and 5 patients (5%) in NYHA class IV.
68
Results Table 3. Clinical Characters of Study Population
CHARACTER
Number
Percentag e
MALE
60
60%
FEMALE
40
40%
SINUS
45
45%
AF
55
55%
RDH (M.S)
85
85%
DCM
7
7%
RCM.
1
1%
HTN.
2
2%
IHD.
5
5%
II
17
17%
CLINICAL
NYHA CLASS III
78
78%
CONDITION:
NYHA CLASS IV
5
5%
SEX
RHYTHM
UNDERLYING DISEASE
NYHA CLASS
69
Results
85%
2%
5%
DCM
IHD
HHD
MS
RCM
7%
1%
Figure 34.Clinical characters and underlying diseases of study population.
40
males 60
Figure 35. Sex distribution in the study. 70
female
Results ECG DATA (table 4 , 5 – figure 36):
Fifty five patients (55%) of the total populations of the present study were in atrial fibrillation. They included : 45 patients having mitral valve disease. 5 patients with DCM. 3 cases with ischaemic heart disease. A case with hypertensive heart disease. A case with restrictive cardiomyopathy.
The remaining 45 patients (45%) were in sinus rhythm. They included : 40 cases with mitral valve disease. 2 cases with ischaemic heart disease. A case with hypertensive heart disease. 2 cases with dilated cardiomyopathy.
Three cases (3%) had the ECG criteria of LVH.
By 3D –TTE LA thrombus was found in 48 patients: 28 patients with AF. 20 patients with sinus rhythm.
71
Results Table 4.ECG findings in the study population.
ECG Findings
Number Of Patients
Percentage%
Sinus rhythm
45
45%
AF
55
55%
LVH
3
3%
27 30
AF with LA thrombus AF with no LA thrombus Sinus rhythm with LA thrombus sinus rhythm with no LA thrombus
18 25
Figure 36.Rhythm distribution in the study.
72
Results Table 5. Rhythm distribution of the Patients.
SINUS RHYTHM
AF
CHARACTER.
TOTAL
NO.
%
NO
%
NO.
%
55
100%
45
100%
100
100%
45
82%
40
89%
85
85%
-DCM.
5
9%
2
4.4%
7
7%
-Coronary Artery Disease.
3
5.4%
2
4.4%
5
5%
-Hypertensive Heart Disease.
1
1.8%
1
2.2%
2
2%
-Restrictive Cardiomyopathy.
1
1.8%
0
0%
1
1%
LAA thrombus by 3D-TTE.
30
54.5%
18
40%
48
48%
No LAA thrombus by 3D-TTE.
25
45.5%
27
60%
52
52%
Number of patients.
Underlying cardiac diseases: -Valvular
Heart Disease.
73
Results ECHOCARDIOGRAPHIC DATA. Two Dimensional Echocardiographic Examinations (Table 6, Figure 37):
2D-TTE was done for 100 patients (100%) of different diseases.
For the purposes of LAA visualization, the image quality was classified as sub-optimal (LAA walls were not clearly identifiable) or diagnostic (all walls and cavity of LAA seen clearly).
LAA was seen in 70 patients with good quality in 40 patients (58%) and sub-optimal quality in 30 patients (42%).
By 2D-TTE; 32 patients (32% of total population of the study) had thrombus in their LA and LAA. Of them: 11 patients (35%) had mitral stenosis with a small MVA 5cm. 3 patients (7%) had impaired left ventricular i.e. EF < 40%. 6 patients (17%) and dilated LV i.e. LVED > 6cm. Table 6. Two Dimensional Transthoracic Echocardiography Data
Parameter
Number Of Patients
With LAA Thrombus
With No LAA Thrombus
NO
%
NO
%
MVA 5 cm.
32
30
93%
2
7%
EF < 40%.
49
3
7%
46
93%
LVED > 6cm.
35
6
17%
29
83%
LAA visualization.
70
32
45%
38
55%
S
74
Results Transosophageal Echocardiographic Examination (Table 7&8 ,Figure 37):
2D-TEE was done only for 56 patients (37 male and 19 female) of the total 100 patients.
They had TEE for: Evaluation before balloon mitral valvuplasty and mitral valve replacement in 48 patients. Assessment of LA/LAA in 3 patients having IHD and AF. Evaluation of intracardiac mass in one patient with restrictive cardiomyopathy (RCM). Exclusion of cardiac source of cerebral stroke in 4 patients (4%).
LAA was seen in the all 56 patients (100%) with good quality in 55 patients (98.2 %) and sub- optimal quality in one case (1.8%).
Thrombus was seen in 42 cases (75%) while the other 14 patients (25%) had no thrombi.
The other 44 patients were excluded from TEE examination because either TEE was refused or contra indicated (dysphagia, stricture, varices, and unconscious patients). Those 44 patients had only 2DTTE and 3DTTE examination.
75
Results
TABLE 7.TEE examination findings. 56
LAA THROMBUS
42
NO LAA THROMBUS
14
LAA THROMBUS BY 3D-TTE
6
NO LAA THROMBUS BY EDTTE
38
TEE DONE
44
TEE NOT DONE
TABLE 8. Transosophageal Echocardiography Data CHARACTER
Number
%
Patients examined.
56
100%
Mean age (years).
27±7.7
Gender: Male
37
66%
Female
19
34%
-Evaluation before BMV and mitral valve replacement.
48
85%
-Assessment of LA/LAA in patients having IHD and AF.
3
5.3%
1
1.7%
4
8%
< 4.0 cm
12
21%
>4.0 cm
44
79%
56
100%
- Good LAA quality.
55
98.2%
- Sub- optimal LAA quality.
1
1.8%
42
75%
14
25%
Indications for TEE:
-Evaluation of intracardiac mass.
-Exclusion of cardiac source of cerebral stroke. LA diameter:
LAA Visualization:
- With LAA thrombus. - Without LAA thrombus.
76
Results Three Dimensional Transthoracic Echocardiography (Figure 37)
On 3D-TTE, an attempt was made to visualize the LA and LAA using parasternal short-axis views and apical views.
Focus was placed on the presence or absence of a clot.
The LAA was seen in 100% of patients: 92% with good quality and 8% with sub-optimal quality.
Thrombus was seen in 48 patients (48%) of while the remaining 52 patients (52%) had none.
One patient was noted to have a large echo density on within the right atrium, consistent with a thrombus.
In the 44 patients in whom 2D-TEE was not performed; combined 2D-TTE and 3D-TTE examination showed LA/LAA thrombus in 6 patients while the remaining 38 patients showed none.
77
Results
78
Results Comparison between 3D-TTE and 2D-TTE in LAA visualization (table 9 - figure 37):
3D-TTE and 2D images were analyzed by two independent reviewers for LAA visualization and further stratified based on image quality. The inter observer agreement between the two reviewers was 100%.
By 3D-TTE: LAA could be visualized in 100 patients (100%) with good quality in 92 of them (92%) and sub-optimal quality in 8 patients (8%).While; by 2D-TTE LAA was visualized in 70 patients (70%) with good quality in 40 of them(58%) and sub-optimal quality in 30 patients(48%).
Thrombus was seen in 32 cases by 2D-TTE while in 48 cases by 3D-TTE.
By CHI-SQUARED test there was significant statistical difference between the expected (3D-TTE) and the observed (2D-TEE) results. X2 = 32.62 and P value = 0.618 i.e. 3D-TTE is better in LAA visualization.
79
Results Table 9. Comparison between 2D-TTE, 3D-TTE and TEE For LAA visualization.
PARAMETER
2D -TTE
3D -TTE
2D-TEE
NO. 100
% 100%
NO. 100
% 100%
NO. 56
% 100%
LAA visualized.
70
70%
100
100%
56
100%
Sub-optimal LAA Quality.
30
42%
8
8%
1
1.8%
Good LAA Quality.
40
58%
92
92%
55
98.2%
LAA thrombus seen.
32
46%
48
48%
42
75%
LAA with no thrombus
38
54%
52
52%
14
25%
Total number of patients.
Table 10. X2 and P value comparing 3D-TTE and 2D-TTE. Observed(0) 2D-TTE
Expected(E) 3D-TTE
(O-E)
(O-E)2
(O-E)2/E
LAA Visualization
70
100
-30
900
9
Sub-optimal Quality
30
8
22
484
60.5
Good Quality
40
92
-52
2704
29.39
Thrombus seen
32
48
-16
256
5.3
Thrombus not seen
38
52
-14
196
3.7
Parameter
Result
X2 = ∑ (O-E) 2/E =32.62 and P value =0.618
Conclusion:
There is significant statistical difference between the expected (3D-TTE) and the observed (2D-TEE) results.
80
Results Comparison of 3D-TTE and 2D-TEE in LAA visualization (table 9, 11-figure 37):
In the 56 patients who underwent 2D-TEE, 3D-TTE and 2D-TTE examinations, TEE images were independently evaluated by two different echocardiographers, each of whom was blinded to the other’s findings.
In the 56 patients who underwent TEE examination; LAA was seen in all of them with good quality in 55 patients (98.2%) and suboptimal quality in in one case (1.8%).42 patients (75%) had thrombus in their LAA; while 14 patients had no thrombus.
By 3D-TTE examination LAA was visualized in 100 patients (100%) with good diagnostic image quality in 92 of them (92%) and sub- optimal in 8 patients. thrombus was present in 48 cases (48%).
All patients with LAA thrombus had enlarged LA (>4.0 cm in parasternal long-axis by 2D) and enlarged LAA by TEE.
An echo dense mass consistent with thrombus was noted by 2D-TEE in 42 patients and this thrombus was also noted by 3D-TTE.
Concordance between detection of thrombus by 3D-TTE and TEE was high.
The 44 patients in whom 2D-TEE was not performed; combined 2DTTE and 3D-TTE examination showed LA/LAA thrombus in 6 patients while the remaining 38 patients showed none.
One patient was noted to have a large echo density on 3D-TTE and 2D-TEE within the right atrium, consistent with a thrombus.
CHI-SQURED test showed that there is no significant statistical difference between expected (2D-TEE) and observed (3D-TTE)
81
Results results: X2 = 21.10 and P value =0.001 i.e. accuracy is similar between 2D-TEE and 3D-TTE in LAA visualization. TABLE 11. X2 and P value comparing 3D-TTE and 2D-TEE.
Parameter
LAA Visualization
Observed (O) 3D-TTE 100%
Expected (E) 2D TEE
(O-E)
(O-E)2
(OE)2/E
100%
0
0
0
Sub-optimal Quality Good Quality
8
1
7
49
49
92
99
7
49
0.49
Thrombus seen
48
75
27
729
9.72
Thrombus not seen
52
25
27
729
29.16
Results
X2 = ∑ (O-E) 2/E= 21.10 and P value =0.001
Conclusion:
There is no significant statistical difference between expected (2D-TEE) and observed (3D-TTE) results
82
Results Comparison between 2D-TTE and 2D-TEE in LAA visualization (table 8, 11-figure 37):
LAA could be adequately visualized by 2D-TTE in 70 patients (70% of the total group of patients). LAA was visualized in all the 56 examined patients (100%) by 2D-TEE. In patients with diagnostic image quality, LAA was visualized in 40 patients (58%) by 2D –TTE and in 55 patients (98.2) by 2D-TEE.
In patients with sub- optimal image quality, LAA was visualized in 30 patients (42%) by 2D –TTE and in 1 patient (1.8) by 2D-TEE.
CHI-SQURED test showed that there is significant statistical difference between expected (2D-TEE) and observed (2D-TTE) results; X 2= 10 and P value = 0.350 i.e. 2D-TEE is better than 2DTTE in LAA thrombus visualization. Table 12. X2 and P value comparing 2D-TTE and 2D-TEE. Observed (O) 2D-TTE
Expected (E) 2D -TEE
(OE)
(OE)2
LAA Visualization
70
100%
-30
900
9
Sub-optimal Quality
42
1
41
1681
1681
Good Quality
58
99
-41
1681
17
Thrombus seen
45
75
-30
900
12
Thrombus not seen
55
25
30
900
36
Parameter
Results
(OE)2/E
X2 = ∑ (O-E) 2/E =10 and P Value =0.350
There Is Significant Statistical Difference Between Conclusion:
Expected (2d-Tee) And Observed (2d-Tte) Results. 83
Results CASE (1). Male patient aged 35 years old, presented with dyspnea III, expectoration and palpitation. He was on digoxin and diuretics but no anticoagulation. No history of embolic manifestation. He had rheumatic mitral stenosis and AF. 2D-TTE
Figure 38.2D-TTE, apical four chambers (4CH) view showing: Tight M.S and dilated LA with smoky echo shadows inside it.
Figure 39. 2D-TTE parasternal long axis (PSLAX) view, showing: M.S dilated LA with swirling echo shadows in the left atrium. 84
Results
2D-TEE
Figure 40.2D-TEE showing dilated LA with swirling LAA.
3D-TTE
Figure 41.3D-TTE; PSLAX view showing LA and LAA thrombus.
85
Results CASE (2). 28 years old house wife, presented with: dyspnea III, productive cough. She was on digoxin ,warfarin and diuretics. She had history of cerebral stroke three years ago (2009) that resolved without disability. She had rheumatic mitral stenosis and mitral regurge and was in AF. 2D-TTE
Figure 42. 2D-TTE apical 4 CH view with RHD, severe M.S and moderate MR. 2D-TEE
Figure 43. 2D-TEE: left atrium is dilated with thrombus inside.
86
Results
Figure 44. 2D-TEE: dilated LA and LAA with a thrombus inside.
3D-TTE
Figure 45. 3D-TTE; PSLAX showing: dilated LA and LAA with a thrombus inside.
87
Results CASE (3). Male patient, aged 42 years, smoker, no history of HTN or DM and no previous cardiac history, presented by cerebral stroke. He was in sinus rhythm. Echocardiography was done to exclude cardiac source of emboli. 2D-TTE: no intracardiac masses or thrombi. Both TEE and 3D-TTE and showed no thrombi. 2D-TEE
Figure 46.2D-TEE for a case of cerebral stroke. No intra atrial masses. 3D-TTE
Figure 47. 3D-TTE PSALX view; for a case of cerebral stroke. No intra atrial masses or thrombi. 88
Results CASE (4). Female patient aged 26 years old, presented with atypical chest pain and dyspnea III. She was on digoxin. INR was 1.6 on warfarin 3mg. She had restrictive cardiomyopathy and she was in AF. 2D-TTE
Figure 48.2D-TTE apical 4CH view showing small LV cavity. Marked LV hypertrophy i.e. Septum & post wall= 2.4 cm hugely dilated RA about 10 cm in diameter with a smoky echo shadow in side.
Figure 49.2D-TTE parasternal short axis view showing: hugely dilated RA about 10 cm in diameter with a smoky echo shadow inside. 89
Results
2D-TEE
Figure 50. 2D-TEE Showing hugely dilated RA with a thrombus in side. 3D-TTE
Figure 51.3D-TTE apical 4 CH view; showing hugely dilated RA with a thrombus inside.
90
MASTER TABLE
MS MS MS MS MS DCM MS MS MS MS MS MS MS IHD MS MS MS MS DCM MS MS MS MS MS MS
70 66 60 54 57 40 62 58 53 67 62 60 61 55 67 78 54 65 39 58 65 70 66 60 54 91
Y N Y N Y Y N Y Y N Y N Y Y N Y Y N Y Y Y N N Y Y
D * S * S D * S D * D * S D * D S * S D D * * S D
T * A * T T * A T * T * T T * T A * A T T * * A T
* Y * Y Y Y * Y Y Y * N * * Y Y * Y * * Y * Y * *
* D * D D D * D D D * * * * D D * D * * D * D * *
* T * T T T * T T T * A * * T T * T * * T * T * *
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
D D D S D D D D D D D S D D D D D S D D D D D D D
CONTENT
QUALITY
LAA
VISULIZ.
3D-TTE DATA
CONTENT
QUALITY
VISULIZ.
5 4 3.5 4.8 5.2 5.1 3.5 4 5.6 4 5.3 3.3 5.4 5.4 3.8 5.6 3.9 4 4.2 5 5.2 4 3.4 4.3 5.3
LAA
1.2 1.4 2 1.1 0.9 2.4 1.7 1.4 1.6 1.9 1.2 2 1.8 2.3 2 1.5 1.6 1.2 3 0.7 2 1.7 1.9 1.7 1,9
CONTEAT
SINUS AF SINUS AF AF SINUS SINUS AF AF SINUS AF SINUS AF SINUS AF AF SINUS AF AF SINUS SINUS AF SINUS AF SINUS
TEE DATA
QUALITY
N N N N N N 1 N N N N N N N N N N N 1 N N N N N N
VISULIZ.
RHYTHM
III III III III III II III III III III III III III III II III III II III II III III II III III
LAA
PREVIOUS EMBOLI
M M F M F M F M F M F M F M M F M F M M F M F M M
LA DIAMETE R EF%
NYHA
20 23 34 25 25 54 44 32 27 29 36 31 23 52 22 26 38 3N 45 29 37 29 39 22 2N
MVA
SEX
1 2 3 4 5 6 7 8 9 1N 11 12 13 14 15 16 17 18 19 2N 21 22 23 24 25
PATHOLOGY
AGE
2D-TTE DATA
NO.
CLINICAL DATA
T T A T T T A T T A A A T A T T A T A A T A T A T
MASTER TABLE 26 27 28 29 3N 31 32 33 34 35 36 37 38 39 4N 41 42 43 44 45 46 47 48 49 5N 51 52 53 54 55
49 34 25 25 54 44 32 27 29 36 31 23 39 48 26 38 3N 45 29 37 29 39 22 38 2N 53 34 25 25 54
M F M F F M M F M F F F M M F M F M M F M F M M M M F M F M
III III III III IV III III III II III III III III IV III III III III II III III III III III II III III III III III
N N N N N 1 N N N N N N N N N N N N N N N N N N N N N N N N
AF AF SINUS SINUS AF AF AF AF SINUS AF SINUS AF SINUS AF AF SINUS AF SINUS AF SINUS AF SINUS AF AF SINUS AF AF AF SINUS SINUS
HTN MS MS MS DCM MS MS MS MS MS MS MS MS IHD MS MS MS DCM MS MS MS MS MS MS MS DCM MS MS MS MS
3 1.7 2 1.8 2.5 1.8 1.12 1.7 1.9 2 2.2 1.7 0.8 2.7 1.4 1 1.5 2.9 2 1.8 1.3 1 1 0.8 1.4 2.7 1.8 1.2 1.9 1.4
5.2 4.3 4.1 3.8 4 5.1 4.7 4.9 3.7 5.2 4 3.8 5.3 4.5 5.5 5.6 5 4.3 5.3 4 5.4 4.2 3.9 5.4 3.9 5.8 4.6 4.6 5.9 5
57 70 62 58 34 67 62 60 61 55 67 78 54 65 76 58 65 45 66 60 54 57 70 62 58 40 67 62 60 61 92
Y Y N Y N Y N Y Y Y Y N Y Y Y Y Y N Y N Y Y Y Y Y Y N Y Y Y
D S * S * D * D S D D * D S D S D * D * S D S S D D * D S D
T A * A * T * A A T A * T A T T A * T * T A A T A T * A T T
Y Y * Y * * Y Y * * Y Y * * Y * Y * * Y * Y * Y * * Y Y Y Y
D D * D * * D D * * D D * * D * D * * D * D * D * * D D D *
T T * T * * A T * * A T * * T * T * * T * T * T * * T T A *
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
D D D D D D D D D D D S D D D D D D D D D D D D D D D D D D
T T A T A A A T A A A T A A T A T A A T A T A T A A T T A A
MASTER TABLE 56 57 58 59 6N 61 62 63 64 65 66 67 68 69 7N 71 72 73 74 75 76 77 78 79 8N 81 82 83 84 85
44 32 27 29 47 31 23 39 22 26 38 3N 45 29 37 29 39 22 5N 23 34 25 25 54 44 53 27 51 36 31
M M F M F F F M M F M F M M F M F M M M F M F F M M F M M M
II III IV II III III III IV III III III III III II III III III III S III III III III III III III IV II III III
N N N N 1 N N N N N N N N N N N N N N N N N N N N N N N 1 N
AF SINUS AF AF SINUS SINUS SINUS SINUS AF AF AF AF AF SINUS SINUS AF SINUS AF AF AF SINUS AF SINUS SINUS AF AF AF SINUS AF SINUS
DCM MS MS MS IHD MS MS MS MS MS MS MS MS MS MS MS MS MS DCM MS MS MS MS MS MS MS MS HTN MS MS
2 2 1.8 1.23 2.4 0.7 2 2 1.9 1.8 1.4 1.4 1.9 1,5 1.4 1.4 1.8 2 2.5 1.8 1.9 1.4 1.9 1.5 1.9 1.4 1.9 3 0.9 0.8
4.7 4.8 5 5.2 5.3 3.9 4.2 3 3.9 5.6 4.4 5.4 4.8 4 5.2 4.3 5.1 3.5 5 4.3 5.4 5 5.2 5.4 6 5.4 A 5.9 6.7 5.7
38 67 78 54 65 76 58 65 70 66 60 54 57 70 62 58 53 67 33 60 61 55 67 78 54 65 76 58 65 70 93
N N Y Y Y Y Y N Y Y N Y N N Y Y Y N Y Y Y N Y Y N Y Y Y N Y
* * D S D D S * S D * D * * D S D * D D S * S D * S D S * D
* * A T T A A * A T * T * * T A T * T A T * T T * T A T * T
Y * * * Y Y * * Y * * Y * * Y * * Y * Y Y Y * Y * Y Y * Y Y
D * * * D S * * D * * D * * D * * D * D D D * D * D D * D D
T * * * T A * * T * * T * * A * * T * A T A * T * T T * A T
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
D S D D D S D D D D D D D D D D D D D D D D D D D D D D S D
T A A T T A T A T T A T A A A A A T A A T A T T A T T A A T
MASTER TABLE 86 87 88 89 9N 91 92 93 94 95 96 97 98 99 100 TOTA L
M F N D S T A *
23 39 22 26 5N 3N 45 29 37 49 39 22 34 25 25
F M M F M F M M M M M F F M M M=6 0 F=40
III III II III III II III III II III III III III III III II=17 III=7 8 IV=5
N N N N N N N N N N N N N N N 4
AF SINUS AF SINUS AF AF AF SINUS SINUS AF SINUS AF SINUS AF SINUS AF=55 SINUS=4 5
MS MS MS MS IHD MS MS MS MS IHD MS RCM MS MS MS MS=85 DCM=7 IHD=5 HTN=2 RCM=1
1.6 1.7 1.5 2 3 2 1.7 1.7 1.9 2 0.8 2 2 1.9 1.7
5 4.6 5.6 4 5.4 3.8 3.6 5.6 4 4.2 4 5.2 5 4.1 3
66 60 54 57 70 62 58 53 67 62 60 61 55 67 78
MALE FEMALE NOT SEEN DIAGNOSTIC SUB OPTIMAL THROMBUS ABSENT T NOT DONE 94
Y Y Y N Y Y N Y N Y Y Y Y Y N Y=70 N=30
S D S * S D * D * S D S S D * D=4 0 S=30
* * A Y T Y * Y T Y A Y * Y T Y * Y T Y A Y T Y T Y A Y * * T=32 Y=56 A=38 *=44
* D D D D D D D D D D D D D * D=5 5 S=1
* Y T Y A Y T Y T Y A Y A Y T Y A Y T Y T Y T Y A Y T Y * Y T=42 Y=100 A=14
D D D D D D D D D D D D D D S D=9 2 S=8
A T A T T A A T A T T T A T A T=48 A=52
DISCUSSION.
Discussion
DISCUSSION
The present gold standard for the evaluation of LAA is TEE. Detection of LAA thrombi in patients with atrial fibrillation is important for identification of individuals at increased risk of cardiac source of emboli 157,158
21,
. The previously reported data suggest that the total duration of time
spent in atrial fibrillation prior to cardioversion may strongly influence the outcome of patients regarding the success of cardioversion and recurrence of atrial fibrillation.159, 160 In patients with no thrombus identified in LAA by TEE, cardioversion can be safely performed, decreasing the time required for anticoagulation and thus potentially improving the success of cardioversion and reducing the risk of hemorrhage.3 Although TEE is safe and can be performed relatively rapidly, it carries the risks of a semi-invasive procedure. Appropriate preparation of the patient, adequate sedation and esophageal probe placement are required with its attendant risks.161, 162 The present study investigated the feasibility of an alternative approach for visualization of LAA by utilizing transthoracic 3D-TTE echocardiography. In the study population; the 3D-TTE and 2D images were obtained as part of echocardiographic evaluation and at the time of image acquisition specific effort was made to focus on LAA visualization.
95
Discussion In contrast to 2D, 3D-TTE can provide unconventional and multiple views from any number of different vantage points163, 164. This is a definite advantage when visualizing structures with complex shape and structure such as the LAA. In comparison to TEE, 3D-TTE is completely non-invasive, and the studies can be easily and quickly performed at the point of care. In this study; full volume wide-angled 3D images were obtained to cover a wider area of interest. The spatial relationships of the various structures were easily identified in these images. Since LAA tends to lie in more than one plane, 3D-TTE is ideal in imaging its complex structure. The main limitations of the 3D technique are related to breath hold and to ECG gating. A significant irregularity in the cardiac rhythm and changes in transducer position or setting can result in motion artifacts. Since 3D-TTE is a transthoracic technique, patients with technically difficult 2D (body habitus, chronic lung disease) will be technically difficult for 3D-TTE as well.157 In this study; 100 adult patients (60% males, 40% females), age range 20–54 years; mean age 30 years (± 7.75) were included. 85% of patients had rheumatic mitral stenosis, 7% had dilated cardiomyopathy, 5% had ischaemic heart disease, 2% had hypertensive heart disease and one case with restrictive cardiomyopathy.55% of the total populations were in atrial fibrillation; while the remaining 45% were in sinus rhythm. They were refereed to our department for echocardiographic examination for evaluation of mitral valve pathology, evaluation of intracardiac masses and for exclusion of cardiac source of cerebral stroke.
96
Discussion Comparing 2D-TTE and TEE: 2D-TTE was done for 100 patients. LAA was seen in 70 patients (70%) with good quality in 40 patients and suboptimal in the other 30 patients. 32 patients had thrombus in their LAA while the other 38 patients were free. TEE was done only for 56 patients of the total population of the study. LAA was seen in all of them (100%) with good quality in 55 patients and sub-optimal in one case. LAA Thrombus was seen in 42 cases (75%) while the other 14 patients (25%) were free. There is significant statistical difference between 2D-TEE and 2D-TTE: X2 = 10 and P value = 0.35 i.e. TEE is better than 2D-TTE in LAA thrombus visualization. Comparing 3D-TTE and 2D-TTE: On 3D-TTE, an attempt was made to visualize the LA and LAA and to focus on the presence or absence of a clot. LAA was visualized by 3DTTE in 100 patients with good diagnostic image quality in 92 of them and sub optimal quality in 8 patients .Thrombus was seen in 48 cases and not seen in 52 patients. The inter observer agreement between the two reviewers was 100%. By CHI-SQUARED test there was significant statistical difference between the 3D-TTE and the 2D-TTE: X2 = 32.62 and P value = 0.618 i.e. 3D-TTE is better than 2D-TTE in LAA thrombus visualization.
97
Discussion Comparing 3D-TTE and 2D-TEE: An echo dense mass consistent with thrombus was noted in LAA by both 2D-TEE and 3D-TTE in 42 patients. All patients with LAA thrombus had enlarged LA (> 4.0 cm in parasternal long-axis by 2D) and enlarged LAA by TEE. One patient was noted to have a large echo density on 2D-TTE, 3D-TTE and 2D-TEE within the right atrium, consistent with a thrombus. The 44 patients, in whom 2D-TEE was not performed, there was LAA thrombus noted by 3DTTE in 6 of them while the remaining 38 patients were free. CHI-SQURED test showed that there is no significant statistical difference between 2D-TEE and 3D-TTE: X2 = 21.10 and P value = 0.001 i.e. concordance between 3D-TTE and TEE detection of LAA thrombus was high. 3D-TTE was equal to TEE in visualizing individual LAA lobes. The acquisition of 3D-TTE images is non-invasive and took approximately 5 minutes per patient compared to TEE examination which is semi-invasive and consumed 20– 30 minutes A major limiting factor for image quality was patient’s body habitus. In the group of patients with 2D images that had diagnostic image quality, 3D-TTE was superior to 2D in visualizing LAA. In the patients who had undergone TEE, 3D-TTE results were correlated extremely well with the TEE findings regarding LAA size and presence of LAA thrombus. 98
Discussion In the agreement of the present study; the study done by Agoston, et al
167
who obtained 3D-TTE images in 204 consecutive patients referred for
routine 2D or TEE. They performed wide-angled acquisition from parasternal and apical views. Tom Tec system (4D Cardio-view, RT 1.2) was used to visualize LAA from multiple vantage points. They found that LAA was adequately visualized by 3D-TTE in 139 of 204 (68.1%) patients. 3D-TTE visualization was dependent on image quality, suboptimal in 100 and diagnostic in 104 patients. Overall, LAA was visualized in 93 (45.5%) patients by 2D compared to 139 (68.1%) by 3DTTE (P < 0.0001). In 100 patients with suboptimal image quality by 3D-TTE, LAA visualization was 16% by 2D and 35% by 3D-TTE, whereas in 104 patients with diagnostic images, LAA was visualized in 77 (74%) by 2D and in all 104 (100%) patients by 3D-TTE (P < 0.0001).167 In 37 patients referred for transoesophageal echocardiography (TEE), live three-dimensional echocardiography (3D-TTE) visualized left atrial appendage (LAA) in 34 patients with diagnostic image quality. Eight patients with LAA thrombi on TEE had thrombi detected by 3D-TTE as well. All patients with LAA thrombus had enlarged LA by both 2D and TEE. 167 They concluded that 3D-TTE is a promising technique in evaluation of LAA with and without thrombi. In patients with good quality transthoracic images 3D-TTE may be used as a screening tool in assessment of LAA. 167 Also in concordant with the present study is Karakus, et al157 study that compared the utility of combined two-dimensional (2D) transthoracic echocardiography (TTE) and three-dimensional (3D) TTE versus 2D
99
Discussion transesophageal echocardiography (TEE) in evaluation of the left atrium (LA) and LA appendage (LAA) for clot. 92 patients underwent 2DTTE, 3DTTE, and 2DTEE. An additional 20 patients, in whom TEE could not be performed, underwent 2DTTE and 3DTTE. Results were that LA and LAA could be visualized in all patients. Of 92 patients studied, 74 had no thrombus and 7 had thrombus in the LAA by all modalities. 11 patients (9 with atrial fibrillation) had a suspected thrombus by 2DTEE, but 3DTTE cropping clearly showed these to be prominent pectinate muscles which were seen in short axis on 2DTEE as rounded echo dense masses and therefore mimicked thrombi. These 9 patients with AF underwent successful cardioversion without any complications. 157 Of the 20 patients in whom TEE could not be performed, 19 had no thrombus in the LA/LAA and 1 had a clot in the LAA. These 19 patients underwent successful cardioversion without complications. 157 They concluded that combined 2DTTE and 3DTTE has comparable accuracy to TEE in evaluating the LA and LAA for thrombus. In some patients TEE, but not 3DTTE, may misdiagnose pectinate musculature as thrombus. 157 Yodwut
et al
168
assessed the feasibility of using 3-dimensional
echocardiography in the detection of left atrial appendage (LAA) thrombi compared to TEE in a study included 27 patients who required TEE for evaluation of LAA thrombi. Two dimensional (2D) echocardiography and 3D echocardiography were performed on the same day as TEE by different operators. The 3D echocardiography evaluation of the left atrium (LA) clot
100
Discussion was evaluated off-line by 3 experienced cardiologists. The definite diagnosis for LAA thrombi was by a consensus of at least 2 of the 3. The correlation between the results of 3D and TEE were analyzed as sensitivity and specificity. They found that the sensitivity and specificity of LAA thrombi by 3D were 45.4 % and 87.5 % with a positive predictive value (PPV) and negative predictive value (NPV) of 71.4% and 70% respectively when compared to TEE. For those with sinus rhythm (8 patients), the sensitivity, specificity, PPV and NPV were all 100%, with the power of the test also 100%. 168 They concluded that the power of 3D echocardiography is inferior to TEE in detecting LAA thrombi. However in sinus rhythm when the image quality was not limited by irregular rhythm, the results of positive LAA thrombi were equal to TEE. 168
101
SUMMERY AND CONCLUSION.
SUMMERY AND CONCLUSION
SUMMERY
Aim of the study: to compare the utility of combined twodimensional
transthoracic
echocardiography
(2D-TTE)
and
three-
dimensional (3D-TTE) versus 2D transesophageal echocardiography (TEE) in evaluation of the left atrium (LA) and LA appendage (LAA) for clot. Patients and methods: 100 patients with age range from 20 to 54 years, of both sex referred to our departement for routine transthoracic echocardiography and transesophageal echocardiography were included in the study. GE Vivid 7® Pro Color Ultrasound System was used for 2D-TTE, 2D-TEE and 3D-TTE examinations. By 2D Transthoracic Echocardiography; LA diameter was taken in the parasternal long axis view in M-mode, visualization of LA thrombus and the LA was examined in standard parasternal long axis, apical, subcostal and parasternal short axis views with different angulation. Using transesophageal Echocardiography; The LA was scanned, the LA appendage was visualized and LA thrombus was diagnosed by the presence of well-defined echogenic intracavity mass. With Three Dimensional Transthoracic Echocardiography; LAA was examined and focus was placed on the presence or absence of a clot. Statistical analysis: by CHI-SQUARED test which was applied for comparison of imaging results.
102
SUMMERY AND CONCLUSION
Results: by 2D-TTE LAA was seen in 70 patients (70%) with good quality in 40 patients (58%) and sub optimal quality in 30 patients (42%). 32 patients had thrombus in their LA and LAA. Of them; 11 patients (35%) had rheumatic mitral stenosis with a small MVA 5cm, 3 patients (7%) had impaired left ventricular i.e. EF < 40% and 6 patients (17%) had dilated LV i.e. LVED > 6cm. 2D-TEE was done only for 56 patients. LAA was seen in the all 56 patients (100%) with good quality in 55 patients (98.2 %) and sub optimal quality in one case (1.8%). Thrombus was seen in 42 cases (75%) while the other 14 patients (25%) had no thrombi. The 44 patients in whom 2D-TEE was not performed; combined 2DTTE and 3DTTE examination showed LA/LAA thrombus in 6 patients while the remaining 38 patients showed none. There is significant statistical difference between 2D-TEE and observed 2D-TTE. CHI-SQUARED test: X2 = 10 and P value =0.350 i.e. 2D-TEE is better than 2D-TTE in LAA thrombus visualization.
On 3D-TTE, an attempt was made to visualize the LA and LAA and to focus on the presence or absence of a clot. 3D-TTE and 2D images were analyzed by two independent reviewers for LAA visualization and further stratified based on image quality. The inter observer agreement between the two reviewers was 100%. By CHI-SQUARED test there was significant statistical difference between the 3D-TTE and the 2D-TTE results. X2 =32.62 and P value =0.6182 i.e. 3D-TTE is better than 2D-TTE in LAA thrombus visualization.
103
SUMMERY AND CONCLUSION
We find that LAA was visualized by 3D-TTE in 100% patients with good diagnostic image quality in 92% of them and sub-optimal quality in 8%. Thrombus was present in 48% of cases. All patients with LAA thrombus had enlarged LA (>4.0 cm in parasternal long-axis by 2D) and enlarged LAA by TEE. An echo dense mass consistent with thrombus was noted by 2D-TEE in 42 patients and this thrombus was also noted by 3D-TTE. One patient was noted to have a large echo density on 2D-TTE and 3D-TTE and 2D-TEE within the right atrium, consistent with a thrombus. The 44 patients, in whom 2DTEE was not performed, there was no thrombus noted by 2D-TTE and 3DTTE in 38 of them
CHI-SQURED test showed that there is no significant statistical difference between 2D-TEE and 3D-TTE: X2 = 21.10 and P value = 0.001 i.e. concordance between 3D-TTE and TEE detection of LAA thrombus by was high.
104
SUMMERY AND CONCLUSION
CONCLUSION AND RECOMMENDATIONS
The present study concluded that visualization of LAA by 3D-TTE echocardiography is feasible in a large number of patients. The acquired volume of 3D information can be sliced to obtain multiple views of the structure of interest. 3D-TTE is relatively safe, rapid and easy to apply. In patients with good acoustic windows and good quality transthoracic images, 3D-TTE may be used as a screening tool in assessment of LAA especially in patients contraindicated to TEE e.g. unconscious patients. For patients scheduled for 2D-TEE for the evaluation of LAA thrombus, a combined 2D-TTE and 3D-TTE should be attempted first. If the LAA is well visualized by both 2D-TTE and 3D-TTE, then in this group of patients it may not be necessary to perform a 2D-TEE. However, if the LA is not well visualized from the transthoracic approach, then a 2D-TEE would be warranted. This study suggests that combined 2DTTE and 3DTTE has comparable accuracy to TEE in evaluating the LA and LAA for a thrombus. Further studies in larger number of patients are needed to establish the clinical diagnostic role of 3D-TTE in evaluation of LAA thrombus and to determine the exact role of combined 2DTTE and 3DTTE in evaluating the LAA for thrombi.
105
SUMMERY AND CONCLUSION
Figure 52. Suggested algorithm for LAA evaluation for thrombus starting with 2D- TTE. 106
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ARABIC SUMMERY
الملخص العربي
المـلـــخـص الـعــربـــي الهدف من الدراسة :تيدف الدراسة الى المقارنة بين الموجات فوق الصوتية ثنائية األبعاد
والموجات فوق الصوتية ثالثية األبعاد عمى القمب عبر الصدر وبين الموجات فوق الصوتية ثنائية األبعاد عمى القمب باسخدام منظار المرئ وذلك في تقييم وجود جمطة في األذين األيسر وزائدتو. المرضى و طرق البحث :لقد اشتممت الدراسة عمى مائة مريض تراوحت أعمارىم بين 02و
45عاما من كال الجنسين حيث أجريت ليم الفحوصات السابقة باستخدام جياز شركة جنرال الكترك لمموجات الصوتية. وقد تم باستخدام الموجات فوق الصوتية ثنائية األبعاد عمى القمب قياس قطر األذين األيسر وفحص أي جمطات موجودة بو باستخدام األوضاع المختمفة مثل الوضع القمي والمحوري الطويل ومن فوق وأسفل القص وذلك من زوايا متعددة ،وكذلك استخدمت الموجات فوق الصوتية باستخدام منظار المرئ في فحص األذين األيسر وزائدتو وقد تم تشخيص وجود جمطة بوجود كتمة واضحة المعالم ومولدة لمصدى داخل تجويفو. أما الموجات فوق الصوتية ثالثية األبعاد عمى القمب عبر الصدر فقد تم بيا فحص زائدة
األذين األيسر مع التركيز عمى وجود جمطة من عدمو بداخميا واستخدمت معادلة مربع كاي في التحميل االحصائي لمقارنة نتائ تصوير المرضى . النتائج :تمت رؤية زائدة األذين األيسر باستخدام الموجات فوق الصوتية ثنائية األبعاد
عمى القمب عبر الصدر في 02مريضا وذلك بجودة جيدة في 52منيم وجودة أقل في 02مريضا .وقد وجدت الجمطة في 00مريضا عانوا من ضيق شديد بالصمام الميترالي ومن اتساع األذين األيسر باكثر من 4سم ومن ىبوط بوظائف األذين األيسر ألى أقل من %52وكذلك من تمدد األذين األيسر حيث يصل بعد األذين االنبساطي الى أكثر من 6سم . وقددد فحددص 46مريضدا باسددتخدام الموجددات فددوق الصددوتية عمددى القمددب بمنظددار المددرئ وكانددت نسبة رؤية زائدة األذين األيسر %022و بجودة عالية بنسبة بمغت % 0،89و جدودة أقدل بنسدبة بمغدت %9،0وقد وجدت الجمطة في %04من الحاالت بينما خمت النسبة المتبقية( )%04منيا. 1
الملخص العربي ول ددم يخض ددع 55مريض ددا لفح ددص الموج ددات بالمنظ ددار نظد د ار لرفض دديم أو نظد د ار لوج ددود موان ددع الجرائو مثل حاالت صعوبة البمع ،تصمب المرئ ،دوالي المرئ والمرضى الغائبون عدن الدوعي .وقدد فحص ىؤالء المرضى فقط باستخدام الموجات الفوق صوتية عمى القمب عبر الصدر بنوعييا ثنائي و ثالثي األبعاد. وقددد وجددد ف دارق احصددائي بددين نتددائ الموجددات ثنائيددة األبعدداد عبددر الصدددر وتمددك باسددتخدام منظار المرئ حيث كانت قيمة مربع كاي 02وقيمة معامل االحتمال .2304 وقد تم التركيز عمى وجود جمطة من عدمو في فحص األذين األيسر وزائدتو .وقام مراجعان بتقييم الصور ثنائية وثالثية األبعاد وكانت نسبة التوافق بينيما ، %022وقد أشار مربع كاي الدى عددم وجددود فددارق بددين الموجددات الفددوق صددوتية ثنائيددة األبعدداد عبددر الصدددر وثالثيددة األبعدداد حيددث كددان مربددع كاي 00وقيمة االحتمال .23609 بمغت نسبة رؤية زائدة األذين األيسر %022بالموجات ثالثية األبعاد وذلدك بجدودة عاليدة فدي
%80من الحاالت وجودة اقدل فدي %9مدن الحداالت وقدد شدوىدت جمطدة األذيدن األيسدر فدي %59مدن الحاالت. وكددان جميددع المرضددى الدذين بيددم جمطددات فددي األذيددن األيسددر يتميددزون باتسدداع فددي قطددر األذيددن األيسر بأكثر من 5سم باستخدام الموجات الفوق الصوتية ثنائيدة األبعداد عمدى القمدب مدن الجيدة ذات المحددور الطويددل المجدداورة لمقددص وكددذلك كانددت ال ازئ ددة كبي درة فددي الموج دات الثنائيددة باسددتخدام منظددار المرئ. وقد وجدت جمطة في األذين األيسدر فدي 50مدريض تمدت رؤيتيدا مدن خدالل الموجدات الفدوق صددوتية ثنائيددة األبعدداد باسددتخدام منظددار المددرئ والموجددات ثالثيددة األبعدداد ،وقددد احتددوى األذيددن االيمددن لمريض واحد عمى جمطة تم تصويرىا بطرق التصوير الثالثة. إن التوافددق بددين الموجددات الفددوق صددوتية ثالثيددة األبعدداد عمددى القمددب والموجددات الفددوق صددوتية باستخدام منظار المرئ في اكتشاف جمطات األذين األيسر يعد توافقا كبي ار حيث بمغ مربدع كداي 00302 وقيمة االحتمال . 23220
2
الملخص العربي
االستنتاج و التوصيات لق ددد خمص ددت ى ددذه الد ارس ددة إل ددى أن رؤي ددة زاائ دددة األذي ددن األيس ددر باس ددتخدام الموج ددات الف ددوق الصددوتية ثالثيددة األبعدداد عمددى القمددب ممكنددة فددي عدددد كبيددر مددن المرضددى حيددث تتميددز بكونيددا طريقددة سريعة وسيمة التطبيق. ففي المرضى الذين يتمتعدون بنافدذة جيددة لمفحدص يمكدن اسدتخدام ىدذه الموجدات كدأداة مسد ل ازئدددة األذيددن األيسددر خاصددة فددي اولئددك الددذين ال يمكددن فحصدديم عددن طريددق الموجددات فددوق الصددوتية باسددتخدام منظددار المددرئ ومددن الممكددن اسددتخدام الموجددات الفددوق صددوتية ثنائيددة و ثالثيددة األبعدداد عبددر الصدر في بدء فحص المرضى المقرر فحصيم عن طريق المنظار و ذلك في حالة الرؤية الجيدة. تتميز الموجات فوق الصوتية الثالثية األبعاد بدقة مقاربة لمموجات الفوق الصوتية باسدتخدام منظددارالمرئ فددي تقيدديم األذيددن األيسددر و زائدتددو مددن حيددث و جددود جمطددات ولكننددا نحتدداج الددى اجددراء دراسات أخرى عمى عدد أكبر مدن المرضدى لتحديدد الددور و االسدتخدام االكمينيكدي ليدذه الموجدات فدي تقييم و جود جمطة األذين األيسر.
3
الملخص العربي
جامعة طنطا. كلية الطب. قسم أمراض القلب واألوعية الدموية.
هقــارًـة بني املىجات فىق الصىتٍة ثٌائٍة األبعاد باستخذام
هٌظار املرئ على القلب واملىجات فىق الصىتٍة ثٌائٍة و ثالثٍة األبعادعلى القلب فى تقٍٍن زائذة األرٌي األٌسر رسالة مقدمة الى كلية الطب -جامعة طنطا. ايفاءا جزئيا لشرط الحصول على درجة الماجستير في أمراض القلب واألوعية الدموية.
مقدمة من الطبيب:
حموذ أمحذ اجلىهري الرببري بكالوريوس الطب و الجراحة. طبيب مقيم بقسم طب القلب و األوعية الدموية. جامعة طنطا.
املشـــــــرفىى : األستاذ الدكتور: أحـوـذ حموـذ زغـلـىل دروٌـش أستاذ القلب واألوعية الدموية كلية الطب جامعة طنطا
األستاذ الدكتور:
األستاذ الدكتور:
ساهٍة حموىد شرف الذٌي
سهــام فهوـً بـذر
أستاذ القلب واألوعية الدموية كـلـيـة الـطــــب جامعة طنطــــا
أستاذ القلب واألوعية الدموية كـلـيـة الـــطــب جامعة طنطــــا 3122
