Analysis Of Wall Motion Abnormalities Research Articles

Cardiac exercise imaging using a 3-tesla magnetic resonance-conditional pedal ergometer: Preliminary results in healthy volunteers and patients with known or suspected coronary artery disease.

Cardiac magnetic resonance imaging (CMR) remains underutilized as an exercise imaging modality, mostly because of the limited availability of MR-compatible exercise equipment. This study prospectively evaluates the clinical feasibility of a newly developed MR-conditional pedal ergometer for exercise CMR METHODS: Ten healthy volunteers (mean age 44 ± 16 years) and 11 patients (mean age 60 ± 9 years) with known or suspected coronary artery disease (CAD) underwent rest and post-exercise cinematic 3T CMR. Visual analysis of wall motion abnormalities (WMA) was rated by 2 experienced radiologists, and volumes and ejection fractions (EF) were determined. Image quality was assessed by a 4-point Likert scale for visibility of endocardial borders. Median subjective image quality of real-time cine at rest was 1 (interquartile range [IQR] 1-2) and 2 (IQR 2-2.5) for post-exercise real-time cine (p = 0.001). Exercise induced a significant increase in heart rate (62 [62-73] to 111 [104-143] bpm, p < 0.0001). Stroke volume and cardiac index increased from resting to post-exercise conditions (85 ± 21 to 101 ± 19 mL and 2.9 ± 0.7 to 6.6 ± 1.9 L/min/m2, respectively; both p < 0.0001), driven by a reduction in end-systolic volume (55 ± 20 to 42 ± 21 mL, p < 0.0001). Patients (2/11) with inducible regional WMA at high-resolution postexercise cine imaging revealed significant coronary artery stenosis in subsequently performed invasive coronary angiography. Exercise-CMR using our newly developed 3T MR-conditional pedal ergometer is clinically feasible. Imaging of both cardiac response and myocardial ischemia, triggered by dynamic stress, is rapidly conducted while the patient is near their peak heart rate.

P1400 Improving ischemia diagnosis: 3D speckle-tracking stress echocardiography

Abstract Background 2D stress echocardiography (SE) is based in the visual analysis of wall motion abnormalities and it requires a trained operator. This operator-dependence has promoted the search for a semiautomatic method to reduce SE limitations and improve test accuracy. The aim of this study was to evaluate the value of 3D speckle tracking (3DSTE) in SE in patients with chest pain. Methods 44 consecutive patients with chest pain and pathological findings on CCTA (&amp;gt;50% stenosis or high calcium score (&amp;gt;400 HU) with undetermined severity) were included. These patients underwent SE with acquisition of 3DSTE at rest and at peak stress. Results Mean age was 63.9 ± 9.9 years. 90% were men. The images of the 44 patients were processed with automatic tracking and manual corrections. 11 patients developed inducible ischaemia during SE. Patients with ischaemic response showed significant reductions in 3D area strain (AS) compared to resting values. The 33 patients without inducible ischaemia showed, however, a significant increase in this parameter. Results are shown in table 1. Conclusion 3D area strain SE could help to identify patients with inducible ischemia. However, further studies are need to confirm these data. Ischemia + (n = 11) Ischemia - (n = 33) P 2D LVEF rest 57.2; 5.5 61.4; 6.0 0.04 2D LVEF peak stress 56.9; 11.7 70.0; 9.0 &amp;lt;0.01 3D LVEF at rest 54.3; 6.9 64.3; 9.7 0.17 3D LVEF peak stress 51.9; 22.5 66.0; 8.6 0.17 AS rest 38.3; 5.1 40.4; 5.7 0.29 AS peak stress 37.2; 11.3 43.6; 7.2 0.03 LVEF: left ventricle ejection fracion; AS: area strain.

Coronary reserve in Dobutamine stress echocardiography: Feasibility study and determination of a pathological threshold for myocardial ischemia in the LAD territory

The evaluation of the coronary flow velocity reserve (CFVR) in the left anterior descending coronary artery (LAD) during a Dobutamine stress echocardiography (DSE) is few realized in current practice. A threshold < 2 would be in favor of myocardial ischemia according to some studies. The main purposes of this study are to analyze the feasibility of the CFVR and to search for a pathological threshold in order to make it a complementary tool in the non-invasive detection for myocardial ischemia in the LAD territory. One hundred and ninety-six consecutive patients referred for detection of myocardial ischemia with contrast-enhanced DSE were evaluated in the GHPSJ from July 2017 to July 2018. CFVR was calculated as a ratio of the distal LAD diastolic peak velocity at rest and peak of stress. The result of the echocardiography was rendered only on the analysis of wall motion abnormalities as a standard reference. The feasibility of CFVR is 94.9%. The pathological threshold of CFVR is ≤ 2.1 (sensitivity of 84.2%, specificity of 70%). The CFVR is altered at 1.87 ± 0.52 in the positive DSE in the LAD territory vs. 2.67 ± 0.91 in the normal ones ( P < 0.001). No significant difference was found between the diabetic and non-diabetic populations ( P = 0.194). The coronary reserve is a non-invasive feasible technique in current practice, sensitive, allowing to add a quantitative criterion to the detection of a myocardial ischemia during a DSE even in non-echogenic patients who needed contrast agent. ( Figure 1 , Cut off value of CFVR).

Three-Dimensional Echocardiography for the Preoperative Assessment of Patients With Left Ventricular Aneurysm

Surgical ventricular reconstruction has been proposed as a treatment option in heart failure patients with left ventricular (LV) aneurysm. The feasibility of this procedure has some limitations, and extensive preoperative evaluation is necessary to give the correct indication. For this purpose, magnetic resonance imaging (MRI) is currently considered the gold standard, providing accurate quantification of LV shape, size, and global and regional function together with the assessment of myocardial scar and mitral regurgitation severity. The aim of this study was to evaluate the accuracy of real-time three-dimensional echocardiography (RT3DE) as a potential alternative to MRI for this evaluation. A total of 52 patients with ischemic cardiomyopathy and LV aneurysm underwent a comprehensive analysis with two-dimensional echocardiography, RT3DE, and MRI. Excellent correlation (r=0.97, p<0.001) and agreement were found between RT3DE and MRI for quantification of LV volumes, ejection fraction, and sphericity index; in a segment-to-segment comparison, RT3DE was shown to be accurate also for the analysis of wall motion abnormalities (k=0.62) and LV regional thickness (k=0.56) as a marker of myocardial scar. In contrast, two-dimensional echocardiography significantly underestimated these variables. Furthermore, mitral regurgitant volume assessed by RT3DE showed excellent correlation (r=0.93) with regurgitant volume measured by MRI, without significant bias (=-0.7 mL/beat). In the management of heart failure patients with LV aneurysm, RT3DE provides an accurate and comprehensive assessment, including quantification of LV size, shape, global systolic function, regional wall motion, and myocardial scar together with precise evaluation of the severity of mitral regurgitation.

The post–myocardial infarction scarred ventricle and congestive heart failure: The preeminence of magnetic resonance imaging for preoperative, intraoperative, and postoperative assessment

Magnetic resonance imaging (MRI), with its ability to precisely define myocardial anatomy, echoes the teachings of one of cardiac surgery’s most distinguished pioneers. Since the 1990s, several studies have demonstrated the preeminence of cardiac magnetic resonance (CMR) for analysis of wall motion abnormalities after myocardial infarction (MI). Both cine-MRI to determine precise scar location and the late enhancement technique to assess the transmural extension of infarcted myocardium illustrate the utility of CMR. CMR is the preeminent method of assessing left ventricular remodeling and aneurysmal progression after MI. Moreover, thrombus formation; the site, depth, and extension of the scarred myocardial wall; precise localization of asynergic areas; disorganization of the mitral apparatus; and estimation of left ventricular volume and performance are all circumstances in which CMR has proved more accurate than other techniques. In our opinion, a complete MRI evaluation of cardiac function is paramount before deciding how to appropriately treat patients after MI. The core problem with ischemic congestive heart failure (CHF) is the undue demand put on the residual viable left ventricular myocardium. As noted by Klein and colleagues more than 40 years ago, ‘‘When the myocardium in the aneurismal area functions improperly, or has been replaced by fibrosis in 20%–25% of the surface area of the left ventricle, the extent of shortening required of the remaining functioning heart begins to exceed physiological limits.’’ This was later confirmed by McKay and associates, who showed that left ventricular dilatation occurs when the asynergic (dyskinetic or akinetic) left ventricular circumference exceeds 40%.

Abstract 4230: Comparison of Dobutamine-atropine Stress Echocardiography and Magnetic Resonance for Detection of Obstructive Coronary Artery Disease by Assessing Wall Motion and Myocardial Perfusion Abnormalities

Background: The analysis of wall motion abnormalities (WMA) with dobutamine stress echocardiography or magnetic resonance is an established method for the detection of myocardial ischemia. Contrast echocardiography has been demonstrated a useful technique for evaluating myocardial perfusion (MP). We test the hypothesis that combination of MP and WMA would improve the diagnosis of coronary artery diseasen (CAD). Objective: To compare the diagnostic accuracy of dobutamine stress real-time myocardial contrast echocardiography (RTMCE) and gadolinium-enhanced magnetic resonance imaging (G-MRI) for detecting CAD by analyzing left ventricular WMA and MP. Methods: We prospectively studied 46 patients (23 males, mean age 58±8 years) referred for coronary angiography, RTMCE and MRI within a maximum interval of two weeks. Protocol used in RTMCE and G-MRI was four-stage dobutamine protocol (10 – 40 mcg/kg/min), with injection of atropine as required to reach 85% of age-adjusted target heart rate. Patients underwent first dobutamine stress RTMCE and then G-MRI using the same doses of dobutamine and atropine. RTMCE was performed using low-mechanical index imaging combined with intravenous commercially available contrast agent (Definity, Bristol-Myers Squibb). Positivity for the stress test was defined as new or worsening WMA or reversible perfusion defects in &gt;2 contiguous segments. Quantitative coronary angiography (QCA) was performed in all patients. CAD was defined as the presence of lesion &gt;50 % in at least one coronary artery territory. Results: All patients tolerated well dobutamine stress. In five patients G-MRI was not performed (2 because of claustrofobia, 1 because patient did not fit in MRI, 2 because of extensive ischemia by dobutamine RTMCE). A total of 41 patients underwent dobutamine RTMCE, G-MRI and QCA. The sensitivity, specificity, and accuracy to detect CAD by dobutamine RTMCE were 74%, 89% and 80% for the analysis of wall motion, 83%, 89% and 85% for the analysis of MP and 65%, 83% and 73% for dobutamine stress G-MRI. C onclusion: RTMCE seems to have better performance for detecting angiographically significant CAD than G-MRI using dobutamine stress. The analysis of MP increases sensitivity to RTMCE without changing specificity.

A comparison of wall motion analysis and systolic left ventricular long axis function during dobutamine stress echocardiography.

To compare long-axis function and wall motion analysis for the detection of significant coronary artery stenoses in patients with single and multivessel disease. We performed dobutamine stress echocardiography in 67 subjects, 14 with normal coronary anatomy, and 53 with significant coronary disease. A blunted increase in mean long-axis shortening of <0.25 cm was the best discriminator for coronary artery disease (sensitivity 85%, specificity 81%). Using this threshold, long axis function gave a sensitivity of 88% and specificity 89% for the detection of coronary artery disease in patients with normal resting wall motion while wall motion abnormality analysis had a sensitivity 73% and specificity 94%. Of 26 patients with a resting wall motion abnormality, 14 (54%) had multivessel disease. Long axis function detected multivessel disease in 12 of these (sensitivity 86%) compared with nine (sensitivity 64%) for wall motion analysis. Long axis function provides a promising, quantitative adjunct to wall motion analysis for the detection of coronary ischaemia using dobutamine stress echocardiography in patients with single and multivessel disease and with resting wall motion abnormalities.

901-27 Regional Wall Motion Analysis by Dobutamine Stress Echocardiography in Heart Transplant Recipients with Normal Coronary Angiographic Findings: Comparison with Intravascular Ultrasound

Coronary angiography (ANGlO) is still the reference method for diagnosis of coronary allograft vasculopathy (CAV). To investigate, if normal ANGlO excludes CAV, 42 patients (P, 51 ± 7 yrs, 49 ± 22 months after heart transplantation) were studied prospectively by ANGlO, intravascular ultrasound (IVUS, quantitative analysis of degree and extension of intimal hyperplasia; modified Stanford grading, grades 1–6) and dobutamine stress echocardiography (DSE, 5–40 mcg/kg/min, 5 min stages). Regional wall motion abnormalities (WMA) were assessed qualitatively (2-D-echo, 16 segment model) and quantitatively (M-Mode, systolic wall thickening of septum (IVS) and LV posterior wall (LPW). P with allograft rejection ( &gt; grade lA ISHLT) were excluded from analysis. ANGlO was completely normal in 33 P; these P were allocated according to mean IVUS grading (mean, 4.1 coronary segments per P): groupl, mild-to-moderate intimal hyperplasia (mean grade &lt; 3.5), n = 20; group2, marked-to-severe intimal hyperplasia (mean IVUS grade ≥ 3.5), n = 13. No groupl P had WMA at rest, 2/20 P developed WMA during DSE (6/320 segments). In group2, WMA at rest were found in 6/13P (26/208 segmentsl. During DSE, WMA increased in these 6P and newly developed in 6 P (total. WMA in 12/13 group2 P in 72/208 segments during DSE). Mean systolic thickening of IVS (group2 vs. 1: rest, 23 vs. 33%, p &lt; 0.01; max. DSE, 32 vs. 62%, P &lt; 0.01) and LPW (rest, 38 vs. 58%, P &lt; 0.01, max. DSE, 65 vs. 96%, p &lt; 0.01) were signif. smaller in group2 than groupl. In total, in 15/33 P with normal ANGlO, evidence of CAY was found (IVUS ≥ 3.5 and WMA at DSE, n = 12; IVUS ≥ 3.5 only, n = 1; WMA at DSE alone, n = 2). A normal ANGlO does not rule out CAV WMA during DSE are associated with marked to severe intimal changes as assessed by IVUS. These changes appear to preceede ANGlO changes. Analysis of WMA by DSE is a feasible noninvasive method for early detection of CAV Costly and invasive ANGlO, in particular when performed without IVUS, may be not necessary at regular annual intervals in heart transplant recipients with normal DSE findings.

Prognostic Significance of Regional Wall Motion Abnormality in Patients With Prior Myocardial Infarction: A Prospective Correlative Study of Two-Dimensional Echocardiography and Angiography

In this pilot study of 50 consecutive patients with prior myocardial infarction, the results of two-dimensional echocardiographic and angiographic analysis of wall motion abnormalities were correlated, and their prognostic significance was determined. There was overall good agreement (88%) between the two methods. In general, the greater the left ventricular dysfunction, the worse was the prognosis. The 3-year survival was significantly reduced for patients with a left ventricular wall motion score index of 2.5 or greater (P = 0.024). These findings were essentially similar to the reduced survival rate associated with decreased angiographic ejection fractions (less than 40%). This study suggests that two-dimensional echocardiography, a noninvasive and relatively inexpensive technique, can provide prognostic information in patients with prior myocardial infarction.

Prevalence of Spontaneous Coronary Thrombolysis and its Relation to Left Ventricular Function

The prevalence of spontaneous recanalisation (SR) of the infarct-affected coronary artery and the subsequent effect on left ventricular and functional reserve was assessed in 50 patients 35 ± 10 days after acute myocardial infarction and compared to control patients without angiographic evidence of SR but with permanent coronary occlusion. The clinical characteristics of both groups were similar. None of the patients in either group received thrombolytic therapy. The prevalence of SR at the time of the study was 44% versus 56% permanent occlusion. The degree of residual stenosis in the SR group varied widely, from < 50% to subtotal. Neither radionuclide global left ventricular ejection fraction and left ventricular functional reserve nor cineangiographic analysis of wall motion abnormalities 35 ± 10 days post-infarction could significantly separate the SR group from patients with permanent coronary occlusion, comparable in variables such as age, history and site of infarction. Patients with inferior wall infarction, however, revealed a tendency to SR-related preservation of left ventricular function. In patients with anterior infarction no such trend was detectable. We conclude that SR occurs too late to salvage a significant amount of myocardium at risk and thus to limit infarct size when compared to permanent occlusion of the infarct-affected vessel.

Two dimensional echocardiographic analysis of wall motion abnormalities during handgrip exercise in patients with coronary artery disease

Studies were made of the feasibility and value of two dimensional echocardiography in detecting left ventricular asynergy during handgrip exercise in 45 patients with suspected coronary artery disease. Resting echocardiography revealed normal wall motion in 32 patients, and in 17 of these handgrip exercise induced abnormal wall motion. All 17 patients had significant stenoses in the coronary arteries. However, only 65 percent of patients with coronary artery disease whose resting two dimensional echocardiogram revealed normal wall motion showed abnormal wall motion during handgrip exercise. The left ventricular wall visualized in the short axis plane was divided into 5 segments, and a total of 225 segments were analyzed. Of 49 segments with exercise-induced asynergy, 46 (94 percent) reflected significant stenosis in the perfusing coronary artery. In particular, 16 (89 percent) of 18 segments with exercise-induced akinesia reflected stenosis of greater than 90 percent. Resting or exercise two dimensional echocardiography (or both) was able to diagnose multivessel disease with a predictability of 92 percent. It is concluded that two dimensional echocardiography combined with handgrip exercise has high specificity in detecting coronary artery disease and would be useful for predicting severely stenotic or multivessel coronary arterial lesions.

Analysis of Wall Motion Abnormalities of the Heart and Great Vessels by Computer Generated Cine-Radionuclide-Equilibrium Study

Cardiac wall motion was evaluated in 54 patients by ECG-gated blood pool scintigraphy (GBPS) and computer assisted cine-radionuclide-equilibrium study (CRES). The cine format in CRES enhances the subtle aspects of great vessel and cardiac chamber motion and volume abnormalities. An off-line system using a general purpose computer permitted CRES to be initiated in smaller nuclear medicine facilities without large financial investiments.

Improved Myocardial Infarct Localization by Combination of Scintigraphy and Ventricular Wall Motion Evaluation

Localization of acute myocardial infarcts can be done directly by imaging 99mTc pyrophosphate in the infarcted myocardium, or indirectly by analysis of wall motion abnormalities. Combining these modalities improves the sensitivity and specificity of the study. Forth-nine consecutive abnormal studies were analyzed in which both wall motion and static images were obtained with a single injection of pyrophosphate. At least 50% of the acute infarcts were better localized (or additional information obtained) by combining the modalities.