Segmental Wall Motion Analysis Research Articles

Stress-Mediated Abnormalities in Regional Myocardial Wall Motion in Young Women with a History of Psychological Trauma.

Psychosocial stress has been associated with the development and progression of atherosclerotic cardiovascular disease (CVD). Previously, we reported subtle differences in global longitudinal strain in somatically healthy women with a psychiatric diagnosis of borderline personality disorder (BPD). This study aimed to investigate the impact of BPD on segmental myocardial wall motion using speckle tracking echocardiography (STE) analysis. A total of 100 women aged between 18 and 38 years were included in this study. Fifty patients meeting the diagnostic criteria for BPD were recruited from the Department of Psychiatry (LWL-University Hospital Bochum) and compared with fifty age-matched healthy control subjects without previous cardiac disease. Laboratory tests and STE were performed with segmental wall motion analysis. The BPD group had a higher prevalence of risk factors for CVD, with smoking and obesity being predominant, when compared with the control group. Other cardiovascular parameters such as blood pressure, glucose, and cholesterol levels were also elevated, even though not to pathological values. Moreover, in the STE analysis, the BPD group consistently exhibited decreased deformation in nine myocardial wall regions compared with the control group, along with a shift toward higher values in the distribution of peak pathological segments. Additionally, significantly higher values of free thyroxine concentration and thyroid's secretory capacity were observed in the BPD group, despite falling within the (high-) normal range. BPD is associated with chronic stress, classical risk factors, and myocardial wall motion abnormalities. Further exploration is warranted to investigate the relationship between high-normal thyroid metabolism, these risk factors, and myocardial function in BPD patients. Long-term follow-up studies would be valuable in confirming the potential for predicting adverse events.

Non-Obstructive Coronary Artery Disease due to COVID-19 Infection: St-Segment Elevation due to Endothelial Dysfunction

The ongoing inflammatory process in COVID infection is reported to cause acute cardiac injury either due to direct cytotoxicity or oxidative stress injury to myocytes. Hypercoagulability and endothelial dysfunction are the two main events resulting in the transient thrombotic process. Objective: To assess the coronary artery occlusion in COVID infected patients presenting with ST-elevation myocardial injury. Methods: A descriptive case series study was conducted on 52 patients presenting with ST-elevation myocardial infarction along with COVID infection. Data was collected regarding demographic profile, Troponin levels, COVID PCR, changes in ECG, Echocardiographic findings and coronary arteries were assessed angiographically. Data were analyzed using SPSS software and various percentages were calculated. Results: Of all the 52 patients studied, 46 patients (88%) tested positive for COVID -19 on RT-PCR done via nasopharyngeal swab. Other 6 patients tested negative initially but they had findings on their CXR and HRCT suggestive of interstitial pneumonia. All the patients were in age group 30-60 years with 32 patients (62%) being males and 20 being females (38%). None of the patients previously had any history of angina or myocardial infarction. Inflammatory markers were raised in about 43 patients (82.7%). ECG showed ST segment elevation in anterior leads in 35 patients (67%) and in inferior leads in 9 patients (17%) and in lateral leads in 2 patients (3.8%). Qualitative Troponin I test was positive in all the patients, whereas, about 41 patients (78%) had Quantitative Troponin I test in high probability range. About 50 patients (96%) had Ejection Fraction greater than 45% and normal segmental wall motion analysis. The coronary arteries were reported to be normal or recanalized in 40 patients (76%) and mild-moderate disease in single or two vessels are present in rest of the 12 patients. None of the patients had shown culprit artery severe disease or clot burden on angiograms. Conclusions: Acute Cardiac injury in previously asymptomatic patients may be related to the pro-thrombotic state created by COVID-19 infection resulting in endothelial dysfunction and mimicking ST-elevation myocardial injury raising Troponin levels indicated by raised D-Dimers and CRP level. The auto-recanalization of the coronary arteries and normal echocardiographic findings, are good prognostic factors for the post cardiac injury rehabilitation.

Transthoracic Echocardiography to Assess Post-Resuscitation Left Ventricular Dysfunction After Acute Myocardial Infarction and Cardiac Arrest in Pigs

One of the main causes of out-of-hospital cardiac arrest is acute myocardial infarction (AMI). After successful resuscitation from cardiac arrest, approximately 70% of patients die before hospital discharge due to post-resuscitation myocardial and cerebral dysfunction. In experimental models, myocardial dysfunction after cardiac arrest, characterized by an impairment in both left ventricular (LV) systolic and diastolic function, has been described as reversible but very little data are available in cardiac arrest models associated with AMI in pigs. Transthoracic echocardiography is the first-line diagnostic test for the assessment of myocardial dysfunction, structural changes and/or AMI extension. In this pig model of ischemic cardiac arrest, echocardiography was done at baseline and 2-4 and 96 hours after resuscitation. In the acute phase, the examinations are done in anesthetized, mechanically ventilated pigs (weight 39.8 ± 0.6 kg) and ECG is recorded continuously. Mono- and bi-dimensional, Doppler and tissue Doppler recordings are acquired. Aortic and left atrium diameter, end-systolic and end-diastolic left ventricular wall thicknesses, end-diastolic and end-systolic diameters and shortening fraction (SF) are measured. Apical 2-, 3-, 4-, and 5-chamber views are acquired, LV volumes and ejection fraction are calculated. Segmental wall motion analysis is done to detect the localization and estimate the extent of myocardial infarction. Pulsed Wave Doppler echocardiography is used to record trans-mitral flow velocities from a 4-apical chamber view and trans-aortic flow from a 5-chamber view to calculate LV cardiac output (CO) and stroke volume (SV). Tissue Doppler Imaging (TDI) of LV lateral and septal mitral anulus is recorded (TDI septal and lateral s', e', a' velocities). All the recordings and measurements are done according to the recommendations of the American and European Societies of Echocardiography Guidelines.

Cardiomyopathy in Duchenne Muscular Dystrophy: Current Value of Clinical, Electrophysiological and Imaging Findings in Children and Teenagers.

Progressive cardiomyopathy (CMP) is one main cause of death in DMD. This cross-sectional assessment of different cardiac diagnostic procedures focusses on preterm diagnosis of cardiac dysfunction. 39 male DMD patients aged 6-20 years were included. 6 patients were still ambulatory, 21 patients received corticosteroid therapy. All patients were investigated by ECG, Holter ECG and heart rate variability (HRV), B-type natriuretic peptide (BNP), echocardiography (TTE), tissue Doppler Imaging (TD) and magnetic resonance imaging (MRI) with Late Gadolinium enhancement (LE) and segmental wall motion analysis (WMA). 56% of the patients showed repolarization abnormalities and 76% altered HRV. Subnormal ventricular function was found in 25% by TTE and in 34% by MRI. TD differed from normal controls only in the apical septum. In MRI 89% of the patients showed different distribution and intensity of LE and WM restriction. The extent of LE was less in patients after steroid treatment (p<0.05). MRI with segmental LE- and WM-analysis seems to be superior to TTE and TD in exploring regional distribution and severity of damage of the myocardium. ECG and HRV abnormalities are common in DMD-patients but not tightly predictive for segmental and global left ventricular dysfunction. Targeted treatment of CMP in DMD needs prospective evaluation. A timely cardiac MRI is the most sensitive investigation for the identification of early myocardial changes in DMD which is a prerequisite for early interventions and therapeutic strategies.

Improvement of regional and global left ventricular function in magnetic resonance imaging after recanalization of true coronary chronic total occlusions.

Successful recanalization of true chronic total occlusion (CTO) has been linked to a decrease in cardiac mortality. We evaluated the effect of CTO recanalization on LVEF and regional wall motion using paired cardiac magnetic resonance imaging (cMRI) studies. 43 patients underwent contrast enhanced cMRI prior to and 9 months after successful recanalization of a true CTO defined as thrombolysis in myocardial infarction flow 0 and duration of occlusion of more than 3 months. Regional wall motion was analyzed using the AHA model. For each segment the wall thickness (WT) was measured over the duration of one heart cycle and segmental wall thickening (SWT) was calculated. Left ventricular ejection fraction (LVEF) and volumes were measured. LVEF significantly increased by 2.4 ± 6.0% (p = 0.01). The increase was confined to patients with baseline LVEF below the median of 49.3% (4.1 ± 7.0%, p = 0.01) compared to 0.6 ± 4.0 (p = 0.48) in patients with baseline LVEF higher than the median. Segmental wall motion analysis was performed in 706 myocardial segments. SWT significantly increased in segments within the perfusion territory of the CTO vessel (5.1 ± 30.4%, p = 0.01), especially in dysfunctional segments at baseline with SWT(init) <45% (13.3 ± 24.3%, p < 0.001). In addition, SWT significantly increased in segments of non-CTO vessels (4.1 ± 32.1%, p < 0.01). In conclusion, in patients with successful recanalization of CTO left ventricular ejection fraction and regional wall motion are significantly improved, especially in patients with decreased LVEF and in dysfunctional segments.

Abstract 15086: Transendocardial CD34+ Cell Transplantation Improves Left Ventricular Segmental Wall Motion in Patients With Ischemic Cardiomyopathy

Introduction: We investigated the effects of transendocardial transplantation of CD34+ stem cells on left ventricular segmental wall motion in patients with ischemic cardiomyopathy (ICM). Methods: We performed transendocardial CD34+ cell transplantation in 31 ICM patients with NYHA class III heart failure and LVEF &lt;40%. Peripheral blood CD34+ cells were mobilized by G-CSF, collected via apheresis, and injected transendocardially in the areas of hibernating myocardium as defined by electromechanical mapping (unipolar voltage ≥9 mV and linear shortening &lt;6%). Left ventricular segmental wall motion analysis was evaluated with TomTec software using a 17-segment model of the left ventricle. Of 31 patients enrolled, 85% were male, their age was 57±6 years; their creatinine, bilirubin and NT-proBNP levels were 89±22 μmol/L, 17±9 μmol/L, and 3,322±3,411 pg/mL respectively. The average Syntax score was 27.9±10.5 and the average number of injected CD34+ cells was 90.6±7.5 million. Patients were followed for 6 months and good clinical response was defined as an increase of left ventricular ejection fraction (LVEF) ≥5%. Results: During follow-up, we found a significant improvement in LVEF (from 27.1±6,6% to 34.7±10.9%; P=0.001), left ventricular end-systolic diameter (from 5.3±0.7 cm to 4.9±0.9 cm; P=0.04), and left ventricular end-systolic volume (from 152±45 mL to 135±44 mL; P=0.03). Left ventricular segmental wall motion analysis showed significantly improved myocardial longitudinal strain in injected segmentes as opposed to noninjected segments (2.4±8.3 vs. -0.9±6.1; P=0.05). We also established a correlation between improvement in myocardial strain and clinical response to cell therapy: responders demonstrated a significant improvement in longitudinal strain in injected segments, but non-responders did not (6.29±8.1 vs. -3.4±5.1; P=0.007). No difference was seen between responders and nonresponders with regards to myocardial strain of noninjected segments (2.4±8.4 vs. -0.97±6.1; P=0.59). Conclusions: Intramyocardial CD 34+ cell transplantation appears to improve left ventricular segmental wall motion in patients with ischemic cardiomyopathy.

An atypical case of inverted Tako-Tsubo syndrome: case report and review of the literature

Dr. Vicidomini, Dr. Zanobetti, Dr. Innocenti: A 69-yearold Caucasian woman was admitted to our emergency department (ED) for an acute and initial episode of substernal chest pain radiating to the left arm, which had lasted about 1 h, associated with dyspnea and diaphoresis. She had a past medical history of depression and first stage primary biliary cirrhosis. She was taking chronic low-dose sotalol therapy (80 mg PO bid) for a prior episode of supraventricular tachycardia. She had an otherwise normal heart, and was without cardiovascular risk factors. At admission, she denied any recent emotional or stressful event. The first EKG recorded 10 min after the ED admission showed mild ST-segment depression in the precordial leads V5 and V6 (Fig. 1), without significant changes in the inferior, posterior and right precordial leads. The first blood sample analysis exhibited normal values of Troponin-I (cTn-I: 0.10 lg/L, normal range: 0–0.15 lg/L) and CK-MB (1.1 ng/ml, normal range: 0.5–3.6 ng/ml). The patient, fully asymptomatic, was admitted to our intensive observation unit. Based on our protocol, a second blood chemistry control was performed 6 h after the initial results. An elevated cTn-I value of 3.31 lg/L with normal CK-MB value (1.0 ng/ml) was observed. The EKG registered at the same time as the laboratory blood tests showed T-wave inversion in the precordial leads from V1 to V4 (Fig. 2), not present in the first tracing,and a small QT dispersion with a QT interval a bit longer than previous EKG. Trans-thoracic echocardiography showed normal left ventricular internal dimensions; the segmental wall motion analysis revealed akinesis of the basal anterior wall and the entire interventricular septum associated with hypokinesis of the inferior wall basal segments. Posterolateral basal segments and all mid-ventricular and apical segments appeared hyperkinetic.

Assessement of left ventricular systolic strain in patients with mitral valve replacement by speckle tracking echocardiography

Objective To assess left ventricular systolic strain in patients with mitral valve replacement (MVR) by speckle tracking echocardiography. Methods Two-dimensional images were acquired from the apical four-chamber view, two-chamber view and long-axis of the left ventricular view in 30 MVR patients (MVR group) and 30 healthy subjects matched by age and gender(control group), and then were analysed off line to evaluate left ventricular systolic strain. The maximum systolic longitudinal strain(LS) of myocardial segments and global longitudinal strain(GLS) were measured in apical views. Left ventricular ejection fraction(LVEF) was calculated using Simpson's method. The correlation between GLS and LVEF was analyzed using Pearson's method. Results Compared with the control group, LS of corresponding segment and GLS in MVR group decreased significantly (P 0.05). There was a good linear positive correlation between GLS and LVEF in patients (r = 0.710, P <0.01). Conclusions Speckle tracking eehoeardiography is available for measuring left ventricular systolic strain and estimating global systolic function in patients with MVR. Bull's-eye strain map, created by speckle tracking imaging, can achieve an accurate real-time segmental wall motion analysis. Key words: Echocardiography; Mitral valve stenosis; Heart valve prosthesis implantation; Ventricular function, left; Speckle tracking imaging

Untersuchung der regionalen und globalen linksventrikulären Funktion mit der Dual-Source-Computertomografie im Vergleich zur Magnetresonanztomografie

To determine regional and global left ventricular (LV) functional parameters and to perform segmental wall thickness (SWT) and motion (WM) analysis of dual-source CT (DSCT) with optimized temporal resolution versus MRI. 30 patients with known or suspected CAD, non-obstructive HCM, DCM, ARVCM, Fallot Tetralogy, cardiac sarcoidosis and cardiac metastasis underwent DSCT and MRI. The DSCT and MR images were evaluated: end-systolic (ESV), end-diastolic LV (EDV) volumes, stroke volume (SV), ejection fraction (EF), and myocardial mass (MM) as well as LV wall thickening and segmental WM applying the AHA model were obtained and statistically analyzed. The mean LV-EDV (r = 0.96) and ESV (r = 0.98) as well as LV-EF (r = 0.97), SV (r = 0.83), and MM (r = 0.95) correlated well. Bland Altman analysis revealed little systematic underestimation of LV-EF (-1.1 +/- 7.8 %), EDV (-0.3 +/- 18.2 ml), SV (-1.3 +/- 16.7 ml) and little overestimation of ESV (1.1 +/- 7.8 ml) and MM (12.8 +/- 14.4 g) determined by DSCT. Systolic reconstruction time points correlated well (DSCT 32.2 +/- 6.7 vs. MRI 35.6 +/- 4.4 % RR-interval). The LV wall thickness obtained by DSCT and MRI showed close correlation in all segments (Ø diff 0.42 +/- 1 mm). In 413 segments (89 %) WM abnormalities were equally rated, whereas DSCT tended to underestimate the degree of wall motion impairment. DSCT with optimized temporal resolution enables regional and global LV function analysis as well as segmental WM analysis in good correlation with MRI. However, the degree of WM impairment is slightly underestimated by DSCT.

Accelerated 4D Dobutamine Stress MR Imaging with k-t BLAST: Feasibility and Diagnostic Performance

To prospectively determine feasibility and diagnostic performance (with angiography as reference standard) of k-space and time (k-t) broad-use linear acquisition speed-up technique (k-t BLAST) cine imaging during dobutamine stress for identification of inducible cardiac wall motion abnormalities. The study was conducted according to standards of the Charité and Virchow-Klinikum Ethics Committee. Patients gave written consent. Dobutamine stress magnetic resonance (MR) imaging was conducted in 65 patients (mean age, 63 years +/- 9 [standard deviation]; 49 men) with conventional cine steady-state free precession (SSFP). Accelerated four-dimensional (4D) k-t BLAST single-breath-hold imaging with complete left ventricular (LV) coverage was also performed at rest and during stress. For the cine SSFP and accelerated cine techniques, duration of imaging at rest and LV end-diastolic volume and ejection fraction were assessed. Segmental agreement for resting and inducible wall motion abnormalities was determined. In a subgroup (n = 40), direct comparison between SSFP and accelerated cine was performed for coronary stenosis detection. A paired Student t test was used to assess significance of continuous variables. Pearson correlation was used to test correlation between the techniques. Sensitivity, specificity, and diagnostic accuracy were calculated (standard definitions). For quantitative measurement of agreement, Cohen kappa was applied. For accelerated cine, imaging duration at rest was shortened by 40%. Correlations between cine SSFP and accelerated cine for LV parameters were 135 mL +/- 37 versus 129 mL +/- 31 (r = 0.89) for end-diastolic volume and 59% +/- 8 versus 58% +/- 7 (r = 0.95) for ejection fraction. kappa Values for segmental wall motion at rest and stress ranged from 0.77 to 0.91. Sensitivity, specificity, and diagnostic accuracy for coronary stenosis (>or=50%) detection based on arterial territory were 82%, 87%, and 86%, respectively, for cine SSFP and 82%, 86%, and 85%, respectively, for accelerated cine imaging. Accelerated 4D k-t BLAST wall motion imaging at rest and at dobutamine stress is rapid and feasible; LV measurements were nearly identical between the imaging approaches. Segmental wall motion analysis at rest and at stress show excellent agreement and reliable depiction of myocardial territories supplied by coronary arteries with 50% or more luminal narrowing.

Echocardiographic analysis of segmental left ventricular wall motion at rest and after exercise in horses with and without heart disease

An echocardiography was performed on 23 healthy warmblood horses and on 12 warmblood horses with cardiac diseases at rest and after treadmill or lungeing exercise. The B-mode technique was used, and the left ventricular wall motion was analyzed visually. The left ventricle was divided into 6 equally sized myocardial segments, 3 of them in the region of the interventricular septum, and the other 3 in the region of the left ventricular rear wall (“6-segment model”). The kinetic of each segment was determined using a kinetic score system. A normokinetic wall motion was defined with a kinetic index of 1. To the authors' knowledge, the current study is the first to present a visual qualitative method for assessment of the healthy equine heart with regard to the myocardial left ventricular wall motion at rest and after exercise under standardized conditions. First, reference values for the left ventricular myocardial kinetics were established in healthy horses. Subsequently, horses with cardiac diseases of differing severity were examined, and the diagnostic value of the method was evaluated. In contrast with human cardiology, the healthy equine heart is characterized by several deviating wall motion patterns. The majority of the healthy horses (52%) showed a normokinetic wall motion of all 6 segments at rest and a normokinetic concentrically increased hypertrophy after exercise. In 9 healthy horses, however, the middle septal segment (at the papillary muscle level) was characterized by a hypokinesia (kinetics index = 2) at rest. In 5 of these horses, the hypokinesia was not observed after exercise. The kinetic wall motion score was 1.1 ± 0.2 at rest in the healthy horses. In the horses with cardiac disorders, the score was 1.5 ± 0.4 at rest. In all healthy horses, the middle septal segment (at the papillary muscle level) was characterized by a hypokinesia (kinetics index = 2; n = 5) or akinesia (kinetics index = 3; n = 3) at rest. After standardized treadmill exercise, the wall motion score of the healthy horses was 1.12 ± 0.16 and the score of the horses with cardiac disorders was 1.52 ± 0.4. In contrast to human cardiology, the mid-septal segment showed a hypokinesia (kinetics index: 2) and an akinesia (kinetics index: 3) in two healthy horses after exercise. In all horses with low-grade and moderate cardiac disorder, an atypical wall motion pattern was observed after exercise. In all horses with high-grade cardiac disorder, an atypical motion pattern was documented in 5 out of 6 segments. An exercise test was not performed on the latter group.

Guiding and optimization of resynchronization therapy with dynamic three-dimensional echocardiography and segmental volume--time curves: a feasibility study.

To assess a new approach for guiding and hemodynamic optimization of resynchronization therapy, using three-dimensional (3D) transthoracic echocardiography. Resynchronization therapy for heart failure provides the greatest hemodynamic benefit when applied to the most delayed left ventricular (LV) site. Currently, the ideal LV pacing site is selected according to acute invasive hemodynamic assessment and/or tissue Doppler imaging. A total of 16 patients with advanced heart failure and an implanted biventricular pacemaker were included in this study. Transthoracic apical LV images at equidistant intervals were obtained using a prototype, fast-rotating second harmonic transducer to reconstruct 3D LV datasets during sinus rhythm (SR), right ventricular (RV) apical and biventricular pacing mode. A semi-automated contour analysis system (4D LV analysis, TomTec, Germany) was used for segmental wall motion analysis and identification of the most delayed contracting segment and calculation of global LV function. Data acquisition duration was 10 s and analyzable 3D images were obtained in 12 patients. Of these patients, data during SR were available in 9 and during biventricular pacing in 11. The greatest contraction delay during SR was found in the anterior and antero-septal segments in five of nine patients. Biventricular pacing resulted in reduction of the contraction delay in seven of eight patients. The global LV function did not change significantly. 3D echocardiography with appropriate analytic software allows detection of the most delayed LV contracting segment and can be used to select the optimal pacing site during resynchronization therapy.

Magnetic resonance imaging evaluation of myocardial perfusion and viability in congenital and acquired pediatric heart disease

This study examined the feasibility and potential clinical utility of magnetic resonance imaging (MRI) evaluation of myocardial perfusion (first-pass contrast enhancement) and viability (myocardial delayed enhancement) in 30 patients with congenital and acquired pediatric heart disease. Good agreement was found between MRI evaluation of myocardial perfusion and viability and analysis of segmental wall motion as well as coronary angiography (n = 10) and single photon emission computed tomography (n = 6).

Comparison of real-time coherent contrast imaging to dipyridamole thallium-201 single-photon emission computed tomography for assessment of myocardial perfusion and left ventricular wall motion

Real-time coherent contrast imaging (CCI) echocardiography has the ability to evaluate wall motion and myocardial perfusion simultaneously, but its clinical applicability in the diagnosis of coronary artery disease (CAD) remains to be determined. This study examines the level of agreement between real-time CCI echocardiography and thallium-201 single-photon emission computed tomography (SPECT) following stress vasodilation. Forty-two patients with known or suspected CAD underwent real-time CCI using octafluoropropane-filled microspheres infusion before and after dipyridamole and thallium-201 injections. The apical 4- and 2-chamber views were each divided into 6 segments to assess wall motion and perfusion. Real-time CCI and SPECT were interpreted independently. Thirty-eight patients successfully completed tests, and 4 had suboptimal contrast images. Each vascular territory was classified as normal or abnormal by CCI perfusion, wall motion, and SPECT at baseline and at stress. Of the 114 territories (3 in each of the 38 patients), 3 (3.5%) were not analyzed; however, all territories corresponding to the left anterior descending artery were suitable for analysis. Concordance between CCI echocardiography and thallium-201 SPECT perfusion for left anterior descending, left circumflex, and right coronary artery territories were 91%, 86%, and 69%, respectively; between CCI perfusion and wall motion, the correlations were 93%, 93%, and 91%, respectively. When CCI perfusion and wall motion analysis were combined, their concordance to thallium-201 SPECT uptake improved to 94%, 89%, and 79%, respectively. In conclusion, real-time CCI echocardiography agrees very closely with thallium-201 SPECT in assessing myocardial perfusion following vasodilatory stress. Assessment of myocardial perfusion, in addition to segmental wall motion analysis, during stress echocardiography may be a significant contribution to the noninvasive evaluation of patients with ischemic heart disease.

Assessment of myocardial perfusion during pharmacologic contrast stress echocardiography

We believe that using MCE simultaneously with a dipyridamole stress protocol and thallium-201 SPECT for the detection of coronary artery disease is safe and found that a single triggered intermittent imaging protocol is easier and less time consuming than dual triggering. The location of these perfusion abnormalities correlated well with thallium-201 SPECT, especially if segmental wall motion analysis and perfusion were used together.

New method of on-line quantification of regional wall motion with automated segmental motion analysis

We have recently developed an automated segmental motion analysis (A-SMA) system, based on an automatic “blood-tissue interface” detection technique, to provide real-time and on-line objective echocardiographic segmental wall motion analysis. To assess the feasibility of A-SMA in detecting regional left ventricular (LV) wall motion abnormalities, we performed 2-dimensional echocardiography with A-SMA in 13 healthy subjects, 22 patients with prior myocardial infarction (MI), and 9 with dilated cardiomyopathy (DCM). Midpapillary parasternal short-axis and apical 2- and 4-chamber views were obtained to clearly trace the blood-tissue interface. The LV cavity was then divided into 6 wedge-shaped segments by A-SMA. The area of each segment was calculated automatically throughout a cardiac cycle, and the area changes of each segment were displayed as bar graphs or time-area curves. The systolic fractional area change (FAC), peak ejection rate (PER), and filling rate (PFR) were also calculated with the use of A-SMA. In the control group, a uniform FAC was observed in real time among 6 segments in the short-axis view (60% ± 10% to 78% ± 9%), or among 5 segments in either the 2-chamber (59% ± 12% to 75% ± 16%) or 4-chamber view (58% ± 13% to 72% ± 12%). The variations of FAC, PER, and PFR were obviously decreased in infarct-related regions in the MI group and were globally decreased in the DCM group. We conclude that A-SMA is an objective and time-saving method for assessing regional wall motion abnormalities in real time. This method is a reliable new tool that provides on-line quantification of regional wall motion. (J Am Soc Echocardiogr 2001;14:892-901.)

Regional Patterns of Left Ventricular Systolic Dysfunction After Subarachnoid Hemorrhage: Evidence for Neurally Mediated Cardiac Injury

Although left ventricular (LV) dysfunction has been described after subarachnoid hemorrhage (SAH), its pathophysiology, regional distribution, and reversibility remain uncertain. To test the hypothesis that regional wall motion patterns in SAH patients do not match the typical patterns observed in coronary artery disease, a segmental wall motion analysis was performed in 30 SAH patients with LV dysfunction. Both regional (n = 21) and global (n = 9) wall motion patterns were observed. Preservation of apical function relative to the base was observed in 17 (57%) of the 30 patients. Many of the wall motion patterns were atypical of coronary artery disease but correlated with the distribution of the myocardial sympathetic nerve terminals. Five subjects had follow-up echocardiograms with resolution of LV dysfunction in all cases. In conclusion, a previously unreported, apex-sparing pattern of LV dysfunction is described, providing indirect evidence for a neurally mediated mechanism of cardiac injury. Limited data indicate that LV dysfunction in SAH patients is potentially reversible. (J Am Soc Echocardiogr 2000;13:774-9.)

Validation of global and segmental left ventricular contractile function using gated planar technetium-99m sestamibi myocardial perfusion imaging

Objectives. The purpose of this study was to test the hypothesis that segmental wall motion analysis determined from gated planar technetium-99m sestamibi myocardial imaging is reproducible and agrees well with echocardiographic data.Background. Teehnetium-99m sestamibi is a new radiopharmaceutical recently approved for myocardial perfusion imaging. Its advantages include a dosimetry that allows use of a dose 10 to 15 times higher than that of thallium-201. as a result, myocardial counts are markedly improved and images can be collected in a gated mode to potentially allow assessment of global and segmental ventricular function. However, the reprodecibility and accuracy of technetium-99m sestamibi imaging for measurement of global and segmental left ventricular function have not been evaluated or compared with those of a standard ventricular function technique, such as echocardiography.Methods. We studied 136 patients referred for clinical technetium-99m sestamibi imaging, One-day rest-stress planar technetium-99m sestamibi protocols were used, gating the stress images. After technetium-99m sestamibi imaging, all patients had standard rest two-dimensional echocardiography. Global and segmental technetium-99m sestamibi and echocardiographic left ventricular contraction was graded qualitatively as normal or abnormal a four-point grading system.Results. Interobserver and intraobserver agreement was extremely high for global and segmental technetium-99m sestemibi wall motion analysis, with absolute agreements ranging from 0.92 to 1.00 and corresponding kappa values of 0.74 to 1.00 (p < 0.00001). Agreement with global and segmental echocardiographic wall motion was similarly very high, with absolute agreements ranging from 0.93 to 1.00 and corresponding kappa values of 0.75 to 1.00 (p < 0.00001).Conclusions. Gated technetium-99m sestamibi cardiac imaging provides information with regard to rest global and segmental left ventricular systolic function that is highly reproducible and agrees very well with results of two-dimensional echocardiography.

Quantitation of global and regional left ventricular function by cine magnetic resonance imaging during dobutamine stress in normal human subjects.

Magnetic resonance imaging (MRI) provides high-resolution images of the heart. However, physical exercise during MRI is difficult due to space restriction and motion artefacts. To evaluate the feasibility of MRI during stress conditions, dobutamine was used as an alternative to exercise. Haemodynamics, ventricular volumes and wall thickening were measured at rest and during peak dobutamine infusion (15 micrograms.kg-1 x min-1) in 23 normal human subjects. To calculate left ventricular volumes, eight short-axis views were obtained encompassing the left ventricle from base to apex. At six levels, percent systolic wall thickening (%WTh) was measured in 18 segments (20 degrees intervals). Heart rate, systolic and diastolic blood pressures, stroke index, cardiac output and left ventricular ejection fraction increased significantly during dobutamine infusion (all P values < 0.001). In addition, %WTh increased significantly (P < 0.001) during dobutamine compared to the control state at all levels except in the apical and low-left ventricular levels. Both in control conditions and during dobutamine, segmental wall motion analysis showed the highest %WTh at the posterolateral area and the lowest %WTh at the septal region (P < 0.05). MRI clearly identifies wall motion dynamics and provides calculations of segmental wall thickening and haemodynamic parameters. Dobutamine is a useful stress agent by virtue of its safety, operator control and its effects which resemble physical exercise.

Prognostic value of biventricular function in hypotensive patients after cardiac surgery as assessed by transesophageal echocardiography

In patients after cardiac surgery, hypotension, defined as a mean arterial pressure less than 65 mmHg despite adequate filling pressures and positive inotropic medication, poses a problem. In addition, it is often difficult to determine whether these patients have suffered irreversible myocardial injury or if they are likely to recover. In this study, left and right ventricular function, as assessed by transesophageal echocardiography (TEE), was related to mortality both (1) quantitatively, using fractional area change (FAC), and (2) qualitatively, using a segmental wall motion analysis, which assigned a score to myocardial wall segments, in order to determine whether this technique can be used to predict survival. Mortality rate was very high in patients with biventricular and especially right ventricular failure (FAC < 35%). Left and right ventricular wall motion abnormality indices were significantly better in survivors compared to nonsurvivors, but no distinct cut-off value could be determined. A wall motion index derived from only 6 segments at the mid-papillary muscle level was found to be as reliable as one based on 16 segments of the entire left ventricle. Thus, TEE provided information about the degree of left and right ventricular dysfunction by using a single cross-section at the papillary muscle level. It identified patients at high risk of death, ie, those with compromised right and biventricular function.