Prognostic value of three dimensional-vena contracta area in patients with secondary mitral regurgitation

Background Effective regurgitant orifice area (EROA) is an important quantitative measurement for mitral regurgitation (MR) grading. Yet, the accuracy of this method is limited in patients with secondary mitral regurgitation (SMR). Three-dimensional (3D) color Doppler echocardiography allows for the direct assessment of the vena contracta area (VCA). The prognostic value of 3D-VCA in patients with secondary MR has not been investigated. Purpose The aim of the present study was to assess the association between 3D-VCA and prognosis of patients with SMR. Methods A total of 218 patients (69% men, median age 74 years) with significant SMR were retrospectively analyzed. 3D-VCA was measured offline with dedicated software, from restored 3D color Doppler full volume datasets of the mitral valve (Figure 1). The population was divided according to the American College of Cardiology expert recommendation for the grading of severe MR (VCA ≥50 mm2 and VCA <50 mm2). Patients were followed up for the combined end point of all-cause mortality or heart failure hospitalization. Results Of the total population, 63% had an ischemic etiology, 60% had atrial fibrillation and 25% cardiac resynchronization therapy. Patients with 3D-VCA ≥50 mm2 needed more diuretic therapy, had a larger left ventricle and atrium, and had more post-procedural residual MR. A total of 82% of patients underwent MitraClip device implantation, 17% had mitral valve repair and 1% had mitral valve replacement. During a median follow-up of 28 months, 130 (60%) met the combined end point (101 (46%) patients died and 81 (37%) were hospitalized due to heart failure). When dividing the population according to the cut-off of 3D-VCA, patients with a 3D-VCA≥50 mm2 had a worse prognosis compared with their counterparts (Figure 2). In a multivariable Cox regression analysis, 3D-VCA≥50 mm2 remained independently associated with the composite endpoint of all-cause mortality or heart failure hospitalization (HR=1.454, 95% CI 1.020–2.072, p=0.038). Conclusion In patients with SMR, a 3D-VCA ≥50 mm2 was independently associated with a combined endpoint of death or heart failure hospitalization. FUNDunding Acknowledgement Type of funding sources: None. Figure 1. Method of 3D-VCA measurement Figure 2. Kaplan-Meier survival curve

Utilizing Intraoperative Navigated 3D Color Doppler Ultrasound in Glioma Surgery

BackgroundIn glioma surgery, the patient’s outcome is dramatically influenced by the extent of resection and residual tumor volume. To facilitate safe resection, neuronavigational systems are routinely used. However, due to brain shift, accuracy decreases with the course of the surgery. Intraoperative ultrasound has proved to provide excellent live imaging, which may be integrated into the navigational procedure. Here we describe the visualization of vascular landmarks and their shift during tumor resection using intraoperative navigated 3D color Doppler ultrasound (3D iUS color Doppler).MethodsSix patients suffering from glial tumors located in the temporal lobe were included in this study. Intraoperative computed tomography was used for registration. Datasets of 3D iUS color Doppler were generated before dural opening and after tumor resection, and the vascular tree was segmented manually. In each dataset, one to four landmarks were identified, compared to the preoperative MRI, and the Euclidean distance was calculated.ResultsPre-resectional mean Euclidean distance of the marked points was 4.1 ± 1.3 mm (mean ± SD), ranging from 2.6 to 6.0 mm. Post-resectional mean Euclidean distance was 4.7. ± 1.0 mm, ranging from 2.9 to 6.0 mm.Conclusion3D iUS color Doppler allows estimation of brain shift intraoperatively, thus increasing patient safety. Future implementation of the reconstructed vessel tree into the navigational setup might allow navigational updating with further consecutive increasement of accuracy.

Insights into Functional Mitral Regurgitation Using Transillumination Rendering

Case 1. An 82-year-old man with history of ischemic cardiomyopathy and multiple admissions due to acute decompensated heart failure was evaluated for moderate to severe secondary MR due to atrial dilation (atrial functional MR). TTE showed severe biatrial enlargement with a left atrial volume of 117mL and a left atrial volume index of 65.5ml/m2. It also showed LV of normal size, left ventricular LVIDd of 4.5cm and LVEF of 55%. En face view revealed two central jets arising from the coaptation gaps between posterior mitral leaflet indentations (P1/P2 and P2/P3) (Panel A). (Panel B) Transillumination rendering on 3D TEE, highlighted two distinct coaptation gaps between posterior mitral leaflet scallops. Case 2. A 63-years-old woman with medical history of ischemic cardiomyopathy and heart failure with reduced ejection fraction (35%) was evaluated for moderate to severe secondary MR. TTE showed the LV dilation with LVIDd of 5.7cm. TEE revealed severe eccentric MR. (Panel C) 3D color Doppler TEE imaging of the mitral valve showed a severe regurgitant jet, originated in-between P2 and P3 posterior scallops. (Panel D) Transillumination rendering on 3D TEE, view from left atrium, in systole highlighted the coaptation gap. (Panel E) 3D color Doppler TEE imaging showed residual mild MR after a mitral clip was deployed grasping the medial aspect of P2 and A2 scallops covering the coaptation defect. (Panel F) Transillumination rendering on 3D TEE, view from LV, showed complete resolution of the coaptation gap between posterior scallops after clip deployment.

Thyroid Multimodal Ultrasound Evaluation—Impact on Presurgical Diagnosis of Intermediate Cytology Cases

Fine needle aspiration (FNA) is recommended as the final evaluation in diagnosing thyroid nodules. Intermediate cytology is observed in about 15%–25% of the FNA results and has divergent recommendations: follow-up or surgery, either hemi- or total thyroidectomy. The present study aimed to assess the benefit of multimodal ultrasound (US) evaluation in clarifying the attitude in cases with intermediate cytology on FNA. Sixty-four successive cases with Bethesda III or IV cytology results were evaluated using two-dimensional B-mode US (2B), qualitative strain elastography, as well as planar and volumetric (3D) color Doppler using both a linear multifrequency probe and a linear volumetric probe (Hitachi Preirus Machine, Hitachi Inc. Japan). The analyzed nodules were all categorized as low, intermediate, or high risk, based on the following US criteria: taller-than-wide shape, marked hypoechogenicity, irregular borders, inhomogeneity, microcalcifications, or the presence of suspicious adenopathy. Elastographic criteria included stiff lesions, while volumetric Doppler criteria included moderate and marked perinodular vascularization, as suspicious for malignancy. The gold standard for the analysis was the result of the pathology report after thyroidectomy. Our results showed that the prevalence of cancer was 25% (16 cases). In five cases, borderline follicular neoplasia was identified, group which requires watchful waiting. These lesions were also considered as malignant in the final analysis, with a total number of 21 neoplasm cases. Sixteen of the 21 malignant nodules presented with high stiffness, while 15/21 had increased perinodular vascularization. Eight of the 21 cases displayed both important stiffness and perinodular vascularization. Cancer prevalence increased both with severity of stiffness (9.0%–15.0%–66.6%–80.0%) and intensity of vascularization in the adjacent perinodular parenchyma (18.2%–27.7%–35.29%–50.0%). Combining the use of grayscale US, elastography, and 3D Doppler in the evaluation of intermediate cytology cases showed a sensitivity of 85.7%, a specificity of 88.3%, and an accuracy of 90.3% in detecting thyroid cancer cases. We can conclude that the identification of highly suspicious US characteristics observed in 2B, qualitative elastography, and volumetric Doppler increases the risk of malignancy.