Introduktion: Vid ekokardiografi används ultraljudsvågor med frekvens över 20 000Hz. Ultraljudssändare med piezoelektriska kristaller används för att generera ljudvågor som skickas ut i kroppen, reflekteras och sedan återvänder till kristallerna för att skapa en ultraljudsbild. Ejektionsfraktionen uttrycker hur stor del av den diastoliska volymen som pumpas ut i kroppen under systole och är en viktig parameter vid bedömning av den globala systoliska funktionen. Den rekommenderade metoden Simpsons biplan jämförs med Philips automatiska funktion a2Dq, som utgår ifrån speckle tracking principen, för bedömning av ejektionsfraktionen. Material och metod: 32 hjärtfriska testpersoner mellan 20–43 år inkluderades i tvärsnittsstudien. Apikala 4- och 2-kammarbilder insamlades ifrån testpersonerna och användes för beräkning av ejektionsfraktionen. Den manuella metoden Simpsons biplan grundas på operatörens utlinjering av endokardiet. Den automatiska funktionen a2Dq utgår ifrån 53 hjärtmodeller och placerar en region of interest automatiskt. Den semiautomatiska funktionen används genom att operatören modifierar region of interest men inte längden av vänsterkammaren. Resultat: Resultatet visade att det inte förelåg någon signifikant skillnad i mätvärdena av ejektionsfraktionen mellan de tre mätprinciperna. Den semiautomatiska och manuella metoden som är operatörsberoende hade likvärdiga mätresultat. Den automatiska funktionen erhöll totalt 6 mätvärden som hamnade utanför normalgränserna. Diskussion: Automatiska funktioner för bedömning av ejektionsfraktionen utvecklas snabbt och kräver utvärderingar. Automatiska mätningar har påvisats vara fördelaktiga då de inte är så tidskrävande som den manuella Simsons biplanmetoden. Tidsaspekten framhävs i de flesta studier dock på bekostnad av säkra mätresultat. Observationerna i denna studie påvisar att den automatiska funktionen inte är säker nog för användning. Konklusion: Enligt observationer ifrån denna studien rekommenderas att den automatiska funktionen ifrån Philips inte används. / Introduction: Ultrasound are soundwaves with frequencies above 20 000Hz. Piezoelectric crystals are used to generate sound waves that can be transmitted into the tissue and reflected back to the crystals to obtain an ultrasound image. The ejection fraction expresses how much blood the left ventricle pumps out with each contraction and is an important parameter for assessment of the hearts global systolic function. The recommended method Simpson´s biplane to assess ejection fraction is compared with Philips automatic function a2Dq, which is based on the principle of speckle tracking. Material and method: The study population included 32 tests subjects with age between 20-43 years old. The test subjects had no records of earlier heart pathologies. Apical 4- and 2-chamber images were collected for the purpose to measure the ejection fraction. The manual method Simpson´s biplane is based on the sonographers manual tracking of the endocardial border. The automatic function a2Dq is based on 53 heart models with different anatomy and physiology and applies a region of interest automatically along the endocardial border. The semi-automatic function allows the sonographer to adjust the region of interest but not the length of the chamber. Result: The result showed that there was no significant difference in the measured values of ejection fraction between the three different techniques. The semi-automatic and Simpson´s biplane method showed equivalent results. The automatic function showed a wide variance of measurements which resulted with a total of 6 measurement ended up below the normal values for ejection fraction. Discussion: Automatic functions for assessing the ejection fraction rapidly develops and requires validations. Automatic functions have shown to be advantageous as the are not as time-consuming as the manual Simpson´s biplane method. In most studies, however, the time aspect is emphasized at the expense of correct measurements results. The observations in this study show that the automatically function a2Dq from Philips are not providing correct measurements. Conclusion: According to observations in this study, it´s recommended that the automatic function from Philips shouldn’t be used.

Klaffvitier är några av de vanligaste hjärtsjukdomarna och studier visar att fysisk aktivitet är en viktig del av den kliniska diagnostiken speciellt för individer med symtomfri problematik. Fysisk aktivitet leder hos en del individer till typiska symtom för klaffvitium och ger således möjlighet till förbättrad gradering av klaffvitier jämfört med i vila. Syftet med studien är att ekokardiografiskt studera eventuell förändring av trikuspidalisklaffunktion i vila och efter lättare fysisk ansträngning, samt undersöka hypotesen om trikuspidalisinsufficiens samt tryckgradienten över trikuspidalisklaffen förändras i samband med denna typ av diagnostik. Sexton deltagare inkluderas vid anamnes på andfåddhet eller ansträngningsutlösta hjärtbesvär samt även fynd av trikuspidalisinsufficiens i samband med ordinarie undersökningstillfälle. Även de med känd trikuspidalis-insufficiens sedan tidigare inkluderades. Efter ordinarie ekokardiografisk undersökning som individerna var remitterade till fick inkluderade deltagare utföra ett cykeltest på ergometercykel under sex minuter med en lättare belastning. Ultraljudsbilder på hjärtat samlades in direkt efter avslutad ansträngning. Två variabler, tryckgradient före respektive efter ansträngning över trikuspidalisklaffen, analyserades enligt dess differens och därefter analyserades differenserna i förhållande till nollhypotesen. Medianvärden av variablerna jämfördes i Wilcoxons teckenrangtest och med Spearmans rangkorrelation studerades förhållandet mellan stigande hjärtfrekvens samt tryckgradient vid fysisk ansträngning. Studien visade att tryckgradienten hos trikuspidalis-insufficiensen förändrades vid utförande av lättare fysisk ansträngning hos individer med ansträngningsutlösta hjärtbesvär samt att denna form av undersökning i anslutning till ordinarie undersökningstillfälle kan vara av värde bland individer med anamnes på ansträngningsutlösta hjärtbesvär. / Valvular heart disease are one of the most common heart diseases and previous studies have shown that exercise is an important part of the clinical diagnostics, especially in asymphtomatic individuals. In some cases, exercise lead to typical symptoms of valvular heart disease and improved grading compared to rest. The aim of the present study was to analyze tricuspid valvular function in rest compared to exercise and examine whether or not tricuspid regurgitation and pressure gradient over the tricuspid valve will alter after exercise. Sixteen participants was included with anamnesis of dyspnea or cardiac symptoms related to exercise as well as findings of tricuspid regurgitation during the echocardio-graphic examination. Individuals with known tricuspid regurgitation were also included. After the transthoracic echocardiographic examination, included individuals performed a bicycle test for six minutes with light workload. Additional ultrasound images of the heart was collected immediately after finished bicycle test. Two variables, pressure gradient over the tricuspid valve before and after right exercise, were analyzed according to its difference and then the differences were analyzed relative to the zero hypothesis. Median values of the variables were compared in Wilcoxon's signed-rank test and Spearman's rank correlation analyzed the relationship between increasing heart rate and pressure gradient under the influence of exercise. This study has shown that the pressure gradient of the tricuspid regurgitation changes in the performance of light exercise in individuals with history of dyspnea or cardiac symptoms related to exercise. It also showed the value of an exercise test in adherence to the echocardiographic examination in this group of individuals.

Hintergrund: Die funktionelle Mitralklappeninsuffizienz (fMI) tritt häufig sekundär bei Patienten im fortgeschrittenen Stadium der Linksherzinsuffizienz auf. Zur Quantifizierung der fMI werden von den Leitlinien der European Association of cardiovascular Imaging (EACVI) bisher vorwiegend 2D-echokardiographische Methoden, insbesondere die 2D Proximal Isovelocity Surface Area (PISA) als Teil einer semiquantitativen Evaluation zur Schweregrad-Einteilung empfohlen. Allerdings weisen diese Verfahren aufgrund des asymmetrischen Querschnitts des Regurgitationsjets und der proximalen Konvergenz bei fMI deutliche Limitationen in der Quantifizierung auf. Der Unterscheidung einer moderaten von einer schweren fMI kommt eine entscheidende Rolle zu, weil diese Abgrenzung den Zugang zur interventionellen oder chirurgischen Therapie beschränkt. Für die 3D-echokardiographischen Methoden bestehen bislang weder Leitlinienempfehlungen noch feste Grenzwerte zur Unterscheidung von moderater und schwerer fMI. Fragestellung/Hypothese: Das Ziel der Arbeit liegt in einem umfassenden Vergleich der bestehenden 2D- und 3D-echokardiographischen Methoden zur Quantifizierung der fMI. Mithilfe dieser Daten sollen die Unterschiede der verschiedenen Verfahren herausgearbeitet, die Vorteile der 3D Methoden belegt und an der weiteren Validierung der 3D-Methoden mitgewirkt werden. Darüber hinaus sollen Grenzwerte zur Unterscheidung von moderater und schwerer fMI für die unterschiedlichen Verfahren berechnet werden. Material und Methoden: Bei allen Patienten, die für eine perkutane interventionelle Mitralklappentherapie zwischen 01.01.2015 und 31.12.2018 im Herzzentrum Dresden vorgesehen waren, wurden sukzessive 2D- und 3D-Datensätze mit und ohne Farbdoppler anhand eines standardisierten Untersuchungsablauf mittels transösophagealer Echokardiographie durch erfahrene Fachärzte akquiriert. Aus diesem Kollektiv im „Dresdner Register Perkutane Mitralklappentherapie“ wurden anhand von Ausschlusskriterien 105 Patienten mit symptomatischer fMI in die endgültige Analyse eingeschlossen. Die klinischen Charakteristika und Begleiterkrankungen der Patienten wurden erhoben und mit dem Gesamtkollektiv verglichen. Die echokardiographischen Studienparameter wurden entsprechend der Empfehlungen der EACVI bestimmt und als Mittelung aus dreifacher Messung berechnet. Die Analyse der 3D Datensätze wurde offline mit der Multiplanaren Rekonstruktionsmethode durchgeführt. Anschließend erfolgte ein Vergleich der unterschiedlichen Verfahren nach der Bland-Altman-Methode. Für die untersuchten Verfahren wurden außerdem mittels einer Receiver-Operating-Characteristic-Analyse Grenzwerte zur Unterscheidung von moderater und schwerer fMI generiert, welche auf der Einteilung des Schweregrades nach dem Grenzwert des bisherigen Standardverfahrens, der effektiven Regurgitationsfläche (EROA) nach 2D PISA von ≥ 0,2 cm², basieren. Ergebnisse: In den durchgeführten Untersuchungen konnten die 2D Methoden eine akzeptable Validität und gute Reproduzierbarkeit der Messungen belegen. Allerdings wiesen sowohl die EROA 2D PISA als auch die biplanen Vena Contracta Weiten (VCW) eine größere Messvariabilität als die 3D-basierten Verfahren auf. Die 3D-Methoden, insbesondere die 3D hemielliptische PISA, konnten geringere Messungenauigkeiten aufgrund einer besseren Approximation der asymmetrischen Regurgitationsfläche als die 2D-Verfahren belegen. Die 3D VCA konnte durch die direkte Messung in der planimetrischen Aufsicht bei asymmetrischem Querschnitt der Regurgitationsfläche bei fMI valide und reproduzierbare Werte erreichen, die sich auch beim Vorliegen exzentrischer oder multipler Regurgitationsjets stabil zeigten. Für die 3D VCA konnte ein Grenzwert von 0,42 cm² zur Unterscheidung einer moderaten von einer schweren fMI generiert werden. Mittels eines direkten Vergleichs der beiden anatomischen Regurgitationsflächen (AROA) konnte erstmals gezeigt werden, dass beide Approximationen der AROA trotz Bestimmung aus unterschiedlichen Bilddatensätzen analoge Werte messen. Dabei besitzen beide AROA-Verfahren eine sehr gute Validität und eine geringe Messabweichung insbesondere für große Beträge der Regurgitationsfläche. Außerdem konnte ein Grenzwert von 0,21 cm² für beide AROAs zur Unterscheidung von moderater und schwerer fMI vorgeschlagen werden. Schlussfolgerungen: Die 2D-echokardiographischen Verfahren zeichnen sich durch eine unkomplizierte, ubiquitär verfügbare Bestimmbarkeit und eine große Anzahl an beschreibenden Studien aus. Die größere Messvariabilität der 2D Methoden besteht aufgrund der suboptimalen geometrischen Näherung mittels der hemisphärischen (2D PISA) oder elliptischen (VCW) Approximation. Die 3D-Verfahren hingegen weisen eine durchweg höhere Messgenauigkeit als die 2D Methoden auf. Am Beispiel der hemielliptischen 3D PISA-Methode zeigt sich, dass mittels einer verbesserten, aber auch aufwendigeren Approximation der asymmetrischen Form der proximalen Konvergenz eine höhere Messgenauigkeit erreicht werden kann. Im Rahmen von Studien wurde mittels (semi-)automatischer Software eine weniger benutzerabhängige Messung der 3D PISA entwickelt. Momentan stellt die 3D VCA aufgrund der exzellenten Reproduzierbarkeit sowie der validen Messung der Regurgitationsfläche die robusteste Methode zur Quantifizierung der fMI dar. Die 3D VCA weist die geringste Unterschätzung der Regurgitationsfläche im Vergleich zu unabhängigen Vergleichsmethoden (MRT; quantitativer Doppler) auf. Darüber hinaus überzeugt der im Rahmen dieser Studie kalkulierte Grenzwert zur Schweregrad-Einteilung der fMI nach 3D VCA mit einer sehr hohen Reliabilität und kann somit bei vergleichbaren Werten wie in früheren Studien zur Bestätigung eines Grenzwerts für die 3D VCA beitragen. Die AROA ist durch die planimetrische Bestimmung der Regurgitationsfläche unabhängig von geometrischen Annahmen und ist somit weniger anfällig für Fluss-bedingte Phänomene. In dieser Arbeit konnte erstmals die universelle und reproduzierbare Bestimmbarkeit der AROA anhand unterschiedlicher Bilddatensätze belegt werden. Bei bisher geringer Datenlage stellt die AROA eine vielversprechende Methode zur Quantifizierung der schweren fMI dar, die noch in weiteren Studien validiert werden muss. In Zukunft wären eine Integration der im Rahmen dieser Arbeit und diverser weiterer Studien belegten 3D-Verfahren in die Schweregrad-Einteilung bei fMI sinnvoll. Es wird deswegen eine zweistufige Beurteilung als Screening mittels 2D PISA und biplaner VCW im TTE und anschließend eine Bestimmung der 3D VCA zusammen mit bereits etablierten Parametern (retrograder Pulmonalvenenfluss; Regurgitationsfraktion) im TEE zur semiquantitativen Schweregrad-Einschätzung vorgeschlagen. Die 3D-echokardiographischen Methoden stellen eine Weiterentwicklung mit Zugewinn an Validität und Messgenauigkeit im Vergleich zu den bestehenden 2D-echokardiographischen Verfahren dar.:Danksagung 3 Inhaltsverzeichnis 4 Tabellenverzeichnis 6 Abbildungsverzeichnis 7 Abkürzungsverzeichnis 10 1. Einleitung 12 1.1 Epidemiologie der Mitralklappeninsuffizienz 12 1.2 Morphologie und Anatomie der Mitralklappe 12 1.3 Ätiologie und Verlaufsformen der MI 12 1.4 Pathophysiologie der funktionellen Mitralklappeninsuffizienz 13 1.4.1 Ischämische Kardiomyopathie (ICM) 14 1.4.2 Nicht-ischämische Kardiomyopathie (nICM) 15 1.4.3 Isolierte linksatriale Dilatation bei Vorhofflimmern 16 1.5 Hämodynamische Auswirkungen bei ausgeprägter MI 16 1.6 Klinik der symptomatischen MI 17 1.7 Diagnostik der MI 18 1.7.1 Echokardiographische Beurteilung bei fMI 18 1.7.2 Echokardiographische Quantifizierung der fMI 20 1.7.3 Magnet-Resonanz-Tomographie zur Quantifizierung der MI 25 1.8 Prognose bei fMI 26 1.9 Therapie der fMI 27 1.9.1 Chirurgische Therapieverfahren 27 1.9.2 Perkutane, interventionelle Therapieverfahren 30 1.10 Ziele der Arbeit 33 2. Material und Methoden 34 2.1 Studiendesign und Datenakquisition 34 2.2 Parameter der Patientencharakteristika und Vergleichsgruppe 36 2.3 Echokardiographische Methodik 37 2.3.1 Technische Voraussetzungen der Echokardiographie 37 2.3.2 Echokardiographische Bildakquisition 37 2.3.3 Analyse 3D-Zoom-Datensatz für fMI-Ätiologie & AROA nach Morphe 37 2.3.3 Analyse 2D-Doppler-Datensätze mit PISA- und VCW-Verfahren 39 2.3.4 Analyse 3D-Doppler-Datensätze mit PISA-Methoden 41 2.3.5 Analyse 3D-Doppler-Datensätze mit VCW, VCA & AROA ohne Farbe 43 2.3.6 Analyse 2D-&3D-Datensätze linksventrikuläre Volumina und Funktion 46 2.4 Statistische Methoden und Analysen 47 3. Ergebnisse 51 3.1 Charakteristika des Patientenkollektivs 51 3.2 Deskriptive Statistik der echokardiographischen Methoden 55 3.2.1 Regurgitationsflächen 57 3.2.2 Regurgitationsvolumina 60 3.3 Vergleich der Zusammenhänge der Methoden anhand von Korrelationen 62 3.3.1 Regurgitationsflächen 62 3.3.2 Regurgitationsvolumina 67 3.4 Vergleich echokardiographischer Methoden mittels Bland Altman-Verfahren 69 3.4.1 Regurgitationsflächen 71 3.4.2 Regurgitationsvolumina 81 3.5 Graduierung fMI mittels ROC-Analyse anhand Schweregrad nach 2D PISA 84 3.5.1 Regurgitationsflächen 85 3.5.2 Regurgitationsvolumina 88 4. Diskussion 90 4.1 Charakteristika des Patientenkollektivs 90 4.2 2D-Methoden 95 4.2.1 2D PISA 95 4.2.2 2D VCW und 3D VCW 97 4.2.3 Biplane 2D VCA und biplane 3D VCA 99 4.3 3D-Methoden 101 4.3.1 3D PISA-Methoden 102 4.3.2 3D VCA-Methode 108 4.3.3 AROA-Methoden 113 4.4 Limitationen 118 4.4.1 Limitationen der Bilderfassung 118 4.4.2 Messfaktoren 120 4.4.3 Doppler-bedingte Faktoren 121 4.4.4 Spezielle Charakteristika der fMI 122 4.4.5 Systematische Einschränkungen 123 4.5 Zusammenfassung 124 4.6 Summary 127 Anhang 130 Literaturverzeichnis 133 / Background: Functional mitral valve regurgitation (fMR) secondarily occurs in patients with advanced stages of ischemic or dilated cardiomyopathy. Quantification of fMR is mainly conducted by echocardiography. The guidelines of the European Association of Cardiovascular Imaging (EACVI) recommend 2D echocardiographic methods, especially the 2D Proximal Isovelocity Surface Area (PISA) for the quantification of fMR. However, due to the asymmetric cross section of both the regurgitation jet and the proximal convergence in fMR, these methods exhibit clear limitations in quantification. The discrimination between moderate and severe fMR poses an important distinction, because severe symptomatic fMR represents an indication for interventional or surgical therapy. For 3D echocardiographic methods, there are neither recommended guidelines nor fixed thresholds for differentiating moderate from high-grade fMR. Aim and objectives: The purpose of this thesis is a comprehensive comparison of the existing 2D and 3D echocardiographic methods for the quantification of fMR. Based on this data, the aim was to describe the differences between several methods, to prove the advantages of the 3D methods and to contribute to the further validation of the 3D methods. In addition, it was intended to calculate threshold values for the different methods to differentiate between moderate and severe fMR. Material and methods: In all patients scheduled for percutaneous interventional mitral valve therapy at the Dresden Heart Center between January 1, 2015 and December 31, 2018, successive 2D and 3D data sets with and without color Doppler were acquired by experienced specialists using a standardized examination procedure based on transthoracic (TTE) and transesophageal echocardiography (TEE). From this collective in the 'Dresden Register Percutaneous Mitral Valve Therapy' 105 patients with symptomatic fMR were included in the final analysis based on exclusion criteria. The clinical characteristics and concomitant diseases of the patients were assessed and compared to the overall collective. The echocardiographic study parameters were determined according to the recommendations of the EACVI and calculated as an average of three repeated measurements. The analysis of the 3D data sets was performed offline using the Multiplanar Reconstruction Method. Subsequently, we performed the comparison of the different procedures using the Bland-Altman method. Furthermore, threshold values for the differentiation of moderate and severe fMR were generated for the investigated methods according to the preexisting limit value of the previous standard method of effective regurgitation area (EROA) according to 2D PISA from ≥ 0.2 cm² by means of a Receiver Operating Characteristic (ROC). Results: In the presented investigations the 2D PISA method convinced with a good temporal resolution of the data sets and prove stable measured values. However, the EROA 2D PISA showed the greatest measurement variability of all methods, which was attributed to a suboptimal geometric approximation of the asymmetric proximal convergence using a hemispherical model. Despite this limitation, the EROA 2D PISA was utilized as a reference method, since this procedure has been investigated in numerous studies analogous to our measurement methodology and is recommended by the EACVI guidelines for distinguishing moderate and severe fMR. The 2D and 3D Vena Contracta Width (VCW) also demonstrated moderate validity and reproducibility, especially as an average from determination in 2 planes (biplane VCW). Moreover, the vena contracta methods showed stable measurements even with eccentric jets. The 3D methods, on the other hand, substantiated lower measurement inaccuracies due to a better approximation of the asymmetric regurgitation surface than the 2D methods. The 3D PISA methods showed the lowest absolute measurement variability of all methods. Despite good results in previous studies, the 3D hemielliptic PISA exhibited the strongest mean deviation compared to the other methods. The 3D VCA was able to achieve valid and reproducible values in particular by direct measurement in planimetric top view with asymmetrical cross section of the regurgitation surface at fMR. Therefore, the 3D VCA could account for stable results even in the presence of eccentric or multiple regurgitation jets. For the 3D VCA a threshold value of 0.42 cm² was generated to distinguish a moderate from a severe fMR. With this data it was proven for the first time that the anatomical regurgitation area (AROA) produces analogous values by determination from different image data sets. The method shows a very good validity with low measurement error. In addition, a limit value of 0.21 cm² for AROA was proposed to distinguish between moderate and severe fMR. Conclusion: Despite a wide range of echocardiographic methods, the EACVI guidelines mainly recommend 2D echocardiographic procedures as part of a semi-quantitative evaluation for classification of severity for fMR. The 2D methods are characterized as uncomplicated, ubiquitously available technology, and many descriptive studies exist. However, they show an underestimation of the regurgitation area and larger measurement inaccuracy than the 3D methods probably due to suboptimal geometric approximations of the asymmetric shape of regurgitation area and proximal convergence. The 3D PISA with improved, but complex approximation of the surface of proximal convergence nevertheless performs an indirect determination of the regurgitation surface, which is more susceptible to flow-related interference in acquisition and measurement. However, some former studies presented approaches to enable a less user-dependent measurement of the 3D PISA using (semi-)automatic software. In previous studies, the 3D VCA was able to demonstrate the smallest underestimation of the regurgitation area compared to independent comparison methods such as MRI or thermodilution. At present, the 3D VCA is the most robust method for quantifying fMR due to its excellent reproducibility and valid measurement of the regurgitation area despite demanding determination. The threshold value for the severity classification of fMR according to 3D VCA, determined by this study, is in a comparable range to values from previous studies and can therefore possibly contribute to confirm a general threshold value for the 3D VCA. Due to the planimetric determination of the regurgitation area, AROA does not require geometric assumptions and is less susceptible to flow-related impact. However, AROA is strongly dependent on the image quality of the data sets and shows a higher measurement inaccuracy for small amounts of the regurgitation area. With little data available so far, AROA represents a promising method for quantifying severe fMR, which still needs to be validated in further studies. In the future, it would be desirable to integrate the 3D methods substantiated in this work and in numerous studies into the severity classification of fMR. There could be a two-tiered assessment, screening by 2D PISA and biplanar VCW in the TTE and then a determination of the 3D VCA together with already established parameters (retrograde pulmonary venous flow; regurgitation fraction) in the TEE for semi-quantitative severity assessment. The 3D echocardiographic methods represent a further development with increased validity and measurement accuracy compared to the existing 2D echocardiographic methods.:Danksagung 3 Inhaltsverzeichnis 4 Tabellenverzeichnis 6 Abbildungsverzeichnis 7 Abkürzungsverzeichnis 10 1. Einleitung 12 1.1 Epidemiologie der Mitralklappeninsuffizienz 12 1.2 Morphologie und Anatomie der Mitralklappe 12 1.3 Ätiologie und Verlaufsformen der MI 12 1.4 Pathophysiologie der funktionellen Mitralklappeninsuffizienz 13 1.4.1 Ischämische Kardiomyopathie (ICM) 14 1.4.2 Nicht-ischämische Kardiomyopathie (nICM) 15 1.4.3 Isolierte linksatriale Dilatation bei Vorhofflimmern 16 1.5 Hämodynamische Auswirkungen bei ausgeprägter MI 16 1.6 Klinik der symptomatischen MI 17 1.7 Diagnostik der MI 18 1.7.1 Echokardiographische Beurteilung bei fMI 18 1.7.2 Echokardiographische Quantifizierung der fMI 20 1.7.3 Magnet-Resonanz-Tomographie zur Quantifizierung der MI 25 1.8 Prognose bei fMI 26 1.9 Therapie der fMI 27 1.9.1 Chirurgische Therapieverfahren 27 1.9.2 Perkutane, interventionelle Therapieverfahren 30 1.10 Ziele der Arbeit 33 2. Material und Methoden 34 2.1 Studiendesign und Datenakquisition 34 2.2 Parameter der Patientencharakteristika und Vergleichsgruppe 36 2.3 Echokardiographische Methodik 37 2.3.1 Technische Voraussetzungen der Echokardiographie 37 2.3.2 Echokardiographische Bildakquisition 37 2.3.3 Analyse 3D-Zoom-Datensatz für fMI-Ätiologie & AROA nach Morphe 37 2.3.3 Analyse 2D-Doppler-Datensätze mit PISA- und VCW-Verfahren 39 2.3.4 Analyse 3D-Doppler-Datensätze mit PISA-Methoden 41 2.3.5 Analyse 3D-Doppler-Datensätze mit VCW, VCA & AROA ohne Farbe 43 2.3.6 Analyse 2D-&3D-Datensätze linksventrikuläre Volumina und Funktion 46 2.4 Statistische Methoden und Analysen 47 3. Ergebnisse 51 3.1 Charakteristika des Patientenkollektivs 51 3.2 Deskriptive Statistik der echokardiographischen Methoden 55 3.2.1 Regurgitationsflächen 57 3.2.2 Regurgitationsvolumina 60 3.3 Vergleich der Zusammenhänge der Methoden anhand von Korrelationen 62 3.3.1 Regurgitationsflächen 62 3.3.2 Regurgitationsvolumina 67 3.4 Vergleich echokardiographischer Methoden mittels Bland Altman-Verfahren 69 3.4.1 Regurgitationsflächen 71 3.4.2 Regurgitationsvolumina 81 3.5 Graduierung fMI mittels ROC-Analyse anhand Schweregrad nach 2D PISA 84 3.5.1 Regurgitationsflächen 85 3.5.2 Regurgitationsvolumina 88 4. Diskussion 90 4.1 Charakteristika des Patientenkollektivs 90 4.2 2D-Methoden 95 4.2.1 2D PISA 95 4.2.2 2D VCW und 3D VCW 97 4.2.3 Biplane 2D VCA und biplane 3D VCA 99 4.3 3D-Methoden 101 4.3.1 3D PISA-Methoden 102 4.3.2 3D VCA-Methode 108 4.3.3 AROA-Methoden 113 4.4 Limitationen 118 4.4.1 Limitationen der Bilderfassung 118 4.4.2 Messfaktoren 120 4.4.3 Doppler-bedingte Faktoren 121 4.4.4 Spezielle Charakteristika der fMI 122 4.4.5 Systematische Einschränkungen 123 4.5 Zusammenfassung 124 4.6 Summary 127 Anhang 130 Literaturverzeichnis 133

complex has been further divided into , , and . is considered to be the least virulent fungi of the complex. Candida endocarditis is uncommon but is associated with a very high mortality rate. Prosthetic or previously damaged valves act as common targets, but native, structurally normal valves are seldom affected. We hereby present a case of endocarditis involving a native aortic valve in an immunocompetent 55-year-old male who was successfully treated with surgical valve replacement and antifungal therapy.

No description available.

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No description available.

Cardiac rehabilitation (CR) exercise training, which traditionally involves the prescription of moderate intensity continuous exercise, can slow the progression of heart disease and improve cardiorespiratory fitness (CRF). Cardiac function is typically investigated using calculations of ejection fraction (EF) from echocardiography, yet EF measures do not provide information about the unique twisting motion of the heart. Novel measures of cardiac function, such as LV twist, myocardial performance index (MPI) and global longitudinal strain (GLS), may provide additional information about changes in LV mechanics associated with exercise training for individuals with coronary artery disease (CAD). The aims of this study were to investigate the changes in cardiac function, using both standard and novel measures, at baseline (0 weeks; T1), post-initial training (4 weeks; T2), and post-training (12 weeks; T3) in response to either stair climbing-based high intensity interval training (STAIR) or traditional moderate intensity continuous training (TRAD). We recruited 16 individuals with CAD (61±7years; 1W) and randomized them into TRAD and STAIR groups (n=8/group). Standard (CRF and EF), and novel (LV twist, MPI, GLS), measures of cardiovascular function were assessed at all three timepoints. CRF improved in both groups, after 4 and 12 weeks (STAIR: T1:22.1±4.2, T2:24.7±4.9, T3:25.4±5.2 and TRAD: T1:22.8±2.5, T2:25.2±4.9, T3:26.0±5.0 mL/kg/min; P<0.005) of CR exercise. We observed an increase in apical rotation (P=0.01) and LV twist (P=0.03), but no changes in either traditional (EF P=0.15), or novel (MPI P=0.19; GLS P=0.81) measures of cardiac function over time, in either group. It is possible that the relatively short training period (12 weeks) was not sufficient to result in significant changes in cardiac function, despite improvements in CRF. Future research should assess both standard and novel indices of cardiac function over longer exercise training periods to determine the ideal indices for tracking changes over time with interventions in this population. / Thesis / Master of Science (MSc) / Cardiac rehabilitation exercise is an important part of recovery after a heart attack, and it has been shown to improve heart function measured using standard ultrasound assessments. Studies have suggested that novel measures of heart function may be more sensitive in comparison to these standard ultrasound measures, yet these novel measures have not been examined in individuals completing stair-climbing based high intensity cardiac rehabilitation exercise training. This work examined the changes in both novel and standard ultrasound measures of heart function after either stair climbing-based high intensity interval training or traditional moderate intensity exercise training in individuals who have heart disease. While this study found that both stair climbing based high intensity interval training and traditional cardiac rehabilitation both resulted in increases in cardiorespiratory fitness after 12 weeks of training, no changes were observed in any of the standard measures of heart function. Supporting the concept that novel measures of heart function might be more sensitive, as some training associated changes were observed in the novel measures of heart function.

Thesis (M. Tech.) -- Central University of Technology, Free State, 2010 / This main aim of this study was to assess patients in a general cardiology practice in order to determine the systolic and diastolic profiles of these patients. The aim was also to determine what effect life style and risk factors may have on the echocardiographic variables measured during such an examination. The specific aim of this study was the importance of not only examining the systolic function but the necessity to also examine the diastolic profile of patients. Life-style plays an important role, with the main culprit being obesity. Obesity was the single most important factor that affected the diastolic profile of patients seen in this study. With obesity a combination of other risk factors related to obesity was observed. Most abnormalities found due to these risk factors were associated with diastolic changes in the left ventricle. Echocardiography is routinely used in daily practice, but the diagnostic value of this tool can be enhanced if proper analyses of the systolic as well as the diastolic profiles are determined. Many cardiologists only measure the systolic function of the heart as an indication of the well- being of the left ventricle, although in this study it was proven that systolic function did not alter with ageing or with changes in the risk profile. Hundred-and-twelve patients, divided into three age groups, were evaluated in this study. Both systolic and diastolic variables were measured and analysed for abnormalities. None of these patients had systolic function abnormalities, although they had detectable anatomic changes due to ageing, obesity and hypertension. Several abnormalities were found on the diastolic profile of these patients. Muscle thickness increased due to obesity and hypertension and even with ageing, but with no significant abnormalities in the systolic function of the heart. There was a slight increase in the circumferential shortening of the left ventricle and that both the septal and longitudinal functions decreased with ageing. It is noteworthy that even where the systolic function remained normal in ageing subjects, their diastolic profiles changed significantly. Assessment of left ventricular function required a meticulous and systematic approach. In this study forty- one percent of patients visiting this general practice had abnormalities of their diastolic function although their systolic function was normal. It was found that with ageing, especially in the older age group, important abnormalities occur in their diastolic profile. The most common changes were that the E- peak velocity decreased and that the Apeak velocity of the trans-mitral flow increased. It seemed that passive filling decreased with ageing but that active filling increased simultaneously, causing the cardiac output to remain constant in older subjects. This is important to know because diseases affecting the atrium may have a profound effect on the cardiac output of older patients, even if they have normal systolic function, (due to the decreased passive filling they need their active filling or atrial contraction to support a normal cardiac output). An important marker will be to look at the ratio of the E/A- velocities in older patients to determine the ratio of active against passive filling. Other than that, a relatively new tool in echocardiography called tissue Doppler was used to determine what happened to the muscle with ageing. Here it was demonstrated that the different layers of the left ventricle acted differently with ageing. Results showed that the longitudinal fibres weakened with ageing although the circumferential fibres remained unchanged or even strengthened with ageing. It was apparent in this study that the traditional use of only systolic function may not be adequate when evaluating relative asymptomatic patients presenting at a general cardiology practice. It is important to also evaluate the diastolic profiles of these patients in order to scientifically quantify their heart health, even in asymptomatic patients. It is important to routinely evaluate the diastolic profile of patients so that early detection of these diastolic variables can be detected and timely consideration for its treatment can be given by their cardiologist. It is also important to take note of the significance of the obesity problem and the effect it has on the heart’s health. In conclusion, this study emphasizes the importance of the echocardiographic evaluation of diastolic cardiac function in addition to routine systolic evaluation in asymptomatic patients. This will enable the clinician to detect abnormalities early and tailor therapy accordingly. Lifestyle related risk factors, especially obesity, also have significant effects on diastolic cardiac function.

Atrial fibrillation (AF) is the most common arrhythmia seen in clinical practice. In cardiac surgery, one-third of the patients experience episodes of AF during the first postoperative days (postoperative AF), and patients with preoperative AF (concomitant AF) can be offered ablation procedures in conjunction with surgery, in order to restore ordinary sinus rhythm (SR). The aim of this work was to study the relation between postoperative AF and inflammation; the long-term consequences of postoperative AF on mortality and late arrhythmia; and atrial function after concomitant surgical ablation for AF. In 524 open-heart surgery patients, C-reactive protein (CRP) serum concentrations were measured before and on the third day after surgery. There was no correlation between levels of CRP and the development of postoperative AF. All 1,419 patients with no history of AF, undergoing primary aortocoronary bypass surgery (CABG) in the years 1997–2000 were followed up after 8.0 years. The mortality rate was 191 deaths/1,000 patients (19.1%) in patients with no AF and 140 deaths/419 patients (33.4%) in patients with postoperative AF. Postoperative AF was an age-independent risk factor for late mortality, with a hazard ratio (HR) of 1.56 (95% CI 1.23–1.98). Postoperative AF patients had a more than doubled risk of death due to cerebral ischaemia, myocardial infarction, sudden death, and heart failure compared with patients without AF. All 571 consecutive patients undergoing primary CABG during the years 1999–2000 were followed-up after 6 years. Questionnaires were obtained from 91.6% of surviving patients and an electrocardiogram (ECG) from 88.3% of all patients. In postoperative AF patients, 14.1% had AF at follow-up, compared with 2.8% of patients with no AF at surgery (p&lt;.001). An episode of postoperative AF was found to be an independent risk factor for development of late AF, with an adjusted risk ratio (RR) of 3.11 (95% CI 1.41–6.87). Epicardial microwave ablation was performed in 20 open-heart surgery patients with concomitant AF. Transthoracic echocardiography was performed preoperatively and at 6 months postoperatively. At 12 months postoperatively 14/19 patients (74%) were in SR with no anti-arrhythmic drugs. All patients in SR had preserved left and right atrial filling waves (A-waves) and Tissue velocity echocardiography (TVE) showed preserved atrial wall velocities and atrial strain. In conclusion, postoperative AF is an independent risk factor for late mortality and later development of AF. There is no correlation between the inflammatory marker CRP and postoperative AF. Epicardial microwave ablation of concomitant AF results in SR in the majority of patients and seems to preserve atrial mechanical function.