Basal Anterior Septum Research Articles

Is myocardial fibrosis appropriately assessed by calibrated and 2D strain derived integrated backscatter?

AimsIncreased collagen content of the myocardium modifies tissue reflectivity and integrated backscatter (IBS) indexes are suggested as markers of myocardial fibrosis (MF). We sought to assess the correlation between calibrated (c) IBS and bidimensional (2D) strain derived IBS with left ventricular (LV) MF in patients with severe aortic stenosis (AS).Methods and resultsWe made a prospective observational cohort study including 157 patients with severe AS referred for surgical aortic valve replacement (AVR), with complete preoperative transthoracic echocardiography, cardiac magnetic resonance (CMR) and endomyocardial biopsy (EMB) obtained from the anterior basal septum at the time of surgery. Two groups of 30 patients were specifically evaluated, with and without late gadolinium enhancement (LGE) at CMR. IBS was obtained at QRS peak from both parasternal long axis (PLAX) and apical-three-chamber (AP3C) views and measured in decibels (dB). Whole-cardiac cycle IBS at basal anterior septum was obtained from 2D longitudinal strain. Correlation analysis of reflectivity indexes was performed with global and segmental (anterior basal septum) values of native T1 and extracellular volume (ECV), and EMB collagen volume fraction (CVF) (Masson´s Trichrome). IBS values were compared in both group of patients (LGE + vs. LGE –). 60 patients (74 [36–74] years, 45% male) with high gradient (mean gradient: 63 ± 20mmHg), normal flow (45 ± 10mL/m2) AS and preserved left ventricular ejection fraction (60 ± 9%) were included. Basal septum cIBS was − 17.45 (–31.2–10.95) and − 9.17 ± 9.45dB from PLAX and A3C views, respectively. No significant correlations were found between IBS and both non-invasive CMR tissue characterization and CVF: median MF of 9.7(2.1–79.9)%. Acoustic indexes were not significantly different according to the presence of pre-operative LGE.ConclusionIn this group of patients with classical severe AS, IBS reflectivity indexes are of no added value to discriminate the presence of MF.Graphical

Assessment of cardiac involvement in patients recovered from corona virus disease-19 (COVID-19) infection using magnetic resonance imaging

Abstract Background Cardiac sequelae after recovery from COVID-19 infection has not been well-established. Recent studies have used cardiac magnetic resonance (CMR) imaging to assess myocardial involvement or ongoing myocarditis in patients with prior COVID-19 infection. Objectives The primary objective of this study was to identify the CMR imaging findings in adult COVID-19 recovered patients. Methods This was a single-center retrospective observational cohort study of adult COVID-19 recovered patients who underwent cardiac magnetic resonance imaging. Patient demographics, CMR findings, blood marker results, and treatment received were obtained. Results Of the 77 included patients, 42 (54.55%) were male, and the median age was 45 years. Only 6 patients had completely normal scans, making the prevalence of an abnormal CMR 92.21% (95% CI 83.5%–96.5%). All those with an abnormality demonstrated late gadolinium enhancement (LGE), and of these, 64 (90%) had preserved left ventricular ejection fraction (LVEF). Thirty-four patients (44%) had evidence of myocardial edema. Among patients with myocardial edema and LGE, the median numbers of involved segments were 4 (range 1–16) and 7 (range 1–15), respectively. Myocardial edema was most frequently found in the mid inferolateral segment (53%), followed by the basal inferior septum, basal anterior septum, and basal inferolateral segments (each with 41%). Meanwhile, late gadolinium enhancements were most commonly located in the basal inferior septum (75%), mid inferior septum (80%), and basal anterior septum (73%). Conclusion Cardiac involvement, particularly edema and late gadolinium enhancement, affecting multiple myocardial segments were observed in a considerable number of patients recovered from COVID-19. Funding Acknowledgement Type of funding sources: None.

Linear late gadolinium enhancement in the basal anterior septum and lateral wall may represent the contrast enhancement of vessels: A CMR and CCTA comparison study

BackgroundThe purpose of this paper was to verify that the linear high-intensity signal on late gadolinium enhancement-cardiac magnetic resonance (LGE-CMR) may represent the contrast enhancement of vessels rather than scars or fibrosis, and to assess whether this linear high-intensity signal will affect the quantification of myocardial fibrosis in patients with hypertrophic cardiomyopathy (HCM). MethodsA total of 58 patients who underwent both coronary computed tomography angiography (CCTA) and LGE-CMR in our hospital were ultimately enrolled. The definitions of positive linear LGE (LLGE+) were as follows: (1) LLGE in the basal anterior septum or lateral wall, and (2) LLGE observable at 10 mm or more. All other patients were regarded as negative LLGE (LLGE-). In LLGE+ patients, the length of the LLGE located in the anterior septum and lateral wall was compared with the length of the septal perforator artery and the circumflex artery on CCTA, respectively. For nine patients with HCM, the LGE% was measured before and after removal of LLGE. ResultsAmong the 58 patients, 40 showed LLGE+ and 18 showed LLGE-. For patients with LLGE in the anterior septum, there was a strong correlation between LLGE and anterior septal perforator arteries in length (r=0.887, p<0.001). For patients with LLGE in the lateral wall, LLGE also correlated well with the circumflex arteries in length (r=0.962, p<0.001). In nine patients with HCM, the LGE% decreased significantly after the removal of LLGE [9.50 (7.70 – 17.35)% vs. 8.80 (6.20 – 15.55)%, p<0.05]. ConclusionsThe LLGE in the anterior septum and lateral wall may represent contrast enhancement of the anterior septal perforator artery and the circumflex artery, respectively. This LLGE may overestimate the extent of myocardial fibrosis in patients with HCM.

Cardiac MRI in the Assessment of Cardiac Injury and Toxicity From Cancer Chemotherapy

During the past 30 years, there has been a significant decrease in cancer mortality rates, predominantly attributable to improvements in treatment options.1 However, survivors are at increased risk of premature cardiac disease,2 both because of the overlap in risk factors for cancer and cardiovascular disease3 and the cardiotoxic effects of cancer chemotherapy. Two chemotherapeutic agent classes that are commonly associated with cardiotoxicity are the anthracyclines and tyrosine kinase inhibitors, both of which can cause left ventricular (LV) dysfunction and heart failure (HF).4,5 Mechanisms of cardiac injury from cancer therapy have been summarized elsewhere.4,6 Briefly, anthracycline cardiotoxicity has been attributed to reactive oxygen species formation, transcriptional changes in intracellular adenosine triphosphate production in cardiac myocytes, and, more recently, through interaction with cardiac topoisomerase IIβ.4,6 Trastuzumab cardiotoxicity seems to be because of inhibition of cardiomyocyte human epidermal growth factor receptor 2, resulting in ATP depletion and contractile dysfunction.4 Other proposed mechanisms include immune-mediated destruction of cardiomyocytes.4,6 At the tissue level, early anthracycline toxicity has been associated with myocardial inflammation,7–9 vacuolization,9–12 and cell swelling/edema.11,13 These changes seem to occur before myocardial functional abnormalities.11,13 Later stages of toxicity are associated with myocardial fibrosis.14,15 Unfortunately, the use of myocardial biopsy is not feasible for diagnostic purposes in this setting. However, once HF manifests, the 2-year mortality can be as high as 60%.16 This emphasizes the importance of early recognition of cardiac injury and institution of cardioprotective therapy in an effort to prevent development of HF and allow uninterrupted completion of cancer therapy.17 Thus, the diagnosis is dependent on either direct evidence of myocardial damage or functional disturbance. Either signal may be identified …

Peripartum Cardiomyopathy Associated With Left Ventricular Noncompaction Phenotype and Reversible Rigid Body Rotation

A 30-year-old woman presented 1-month postpartum with new-onset biventricular heart failure for which no other contributing cause could be found clinically or on laboratory investigations. Her 2 previous pregnancies were uncomplicated. She was HIV-positive for the preceding 3 years, but had never been on antiretroviral therapy. Initial echocardiography revealed a left ventricular (LV) end-diastolic diameter of 59 mm and LV ejection fraction of 32% (online-only Data Supplement Movies 1 and 2). There was evidence of LV noncompaction involving the apex and midinferior and midlateral walls of the LV that satisfied the Jenni criteria (Figure 1). There was no echocardiographic evidence of other congenital or organic valvular disease. Speckle tracking revealed rigid body rotation (ie, rotation at both the basal and apical levels of the LV occurred in a counterclockwise direction during systole; Figure 2). The patient was treated with furosemide, carvedilol, an angiotensin-converting enzyme inhibitor, and spironolactone. On reevaluation 6 months later, her functional status was New York Heart Association Class 1. Echocardiography revealed that LV ejection fraction was now 48% …

Quantification of regional left ventricular radial strain rate in healthy children by speckle tracking echocardiography: reference values, the effect of ageing and heart rate

ObjectiveThe objectives of this report are as follows: To establish reference values for peak systolic radial strain rate (SrR) in healthy children, and evaluates the relationship between age and SrR,...

Percutaneous balloon mitral valvuloplasty in severe mitral stenosis during pregnancy comparing Inoue versus multitrack balloons: comparative study between Inoue and multitrack balloon mitral valvuloplasty in pregnant females with severe mitral stenosis

This study was designed to evaluate the effect of septal reduction therapies on the conduction system for patients with hypertrophic cardiomyopathy (HCM).Heart block is a potential complication of both catheter-based and surgical procedures to relieve left ventricular outflow tract obstruction in HCM, but it is important to understand the different effects of these treatments on the conduction system.The electrocardiograms and postoperative course of patients who underwent percutaneous alcohol septal ablation or surgical myectomy at Mayo Clinic between 1999 and 2003 were reviewed.For the 58 patients who underwent alcohol septal ablation, 21 (36%) developed right bundle branch block. Six patients (12%) developed complete heart block requiring permanent pacing, three of whom had left bundle branch block before the procedure. Among the 117 patients who underwent surgical septal myectomy, 47 (40%) developed left bundle branch block. Four patients (3%) developed heart block requiring permanent pacing after the procedure, three of whom had right bundle branch block preoperatively.Percutaneous septal ablation selectively produces transmural infarction of the basal mid-septum and adjacent right bundle tissue, whereas surgical myectomy affects the endocardial portion of the basal anterior septum and adjacent left bundle tissue. These observations may help identify patients at risk for complete heart block after septal reduction procedures for HCM.

Early detection of cardiac involvement in Miyoshi myopathy: 2D strain echocardiography and late gadolinium enhancement cardiovascular magnetic resonance.

BackgroundMiyoshi myopathy (MM) is an autosomal recessive distal myopathy characterized by early adult onset. Cardiomyopathy is a major clinical manifestation in other muscular dystrophies and an important prognostic factor. Although dysferlin is highly expressed in cardiac muscle, the effect of dysferlin deficiency in cardiac muscle has not been studied. We hypothesized that early myocardial dysfunction could be detected by 2D strain echocardiography and late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR).MethodFive consecutive MM patients (3 male) in whom we detected the DYSF gene mutation and age-matched healthy control subjects were included. None of the patients had history of cardiac disease or signs and symptoms of overt heart failure. Patients were studied using 2D strain echocardiography and CMR, with 2D strain being obtained using the Automated Function Imaging technique.ResultsAll patients had preserved left ventricular systolic function. However, segmental Peak Systolic Longitudinal Strain (PSLS) was decreased in 3 patients. Global PSLS was significantly lower in patients with MM than in control subjects (p = 0.005). Basal anterior septum, basal inferior septum, mid anterior, and mid inferior septum PSLS were significantly lower in patients with MM than in control subjects (P < 0.0001, < 0.0001, 0.038 and 0.003, respectively). Four patients showed fibrosis by LGE. The reduced PSLS lesion detected by 2D strain tended to be in the same area as that which showed fibrosis by LGE.ConclusionsPatients with MM showed subclinical involvement of the heart. 2D strain and LGE are sensitive methods for detecting myocardial dysfunction prior to the development of cardiovascular symptoms. The prognostic significance of these findings warrants further longitudinal follow-up.

Overlapping Phenotypes

Patient KM is a 26-year-old male in whom a systolic ejection murmur was recently identified on a routine physical examination. As part of his evaluation, he underwent 2-dimensional echocardiography, which revealed asymmetrical left ventricular (LV) hypertrophy with a maximum LV wall thickness of 22 mm in the basal anterior septum and extension of hypertrophy into the posterior septum. His LV ejection fraction was 55%, with a normal cavity size and no evidence of resting LV outflow tract obstruction. In addition, the myocardium was noted to be highly trabeculated from the apex to the midportion of the LV (Figure 1; online-only Data Supplement Movie I). The right ventricle was normal in size and function. He has never developed heart failure …

Alcohol septal ablation versus surgical septal myectomy: Comparison of effects on atrioventricular conduction tissue

This study was designed to evaluate the effect of septal reduction therapies on the conduction system for patients with hypertrophic cardiomyopathy (HCM). Heart block is a potential complication of both catheter-based and surgical procedures to relieve left ventricular outflow tract obstruction in HCM, but it is important to understand the different effects of these treatments on the conduction system. The electrocardiograms and postoperative course of patients who underwent percutaneous alcohol septal ablation or surgical myectomy at Mayo Clinic between 1999 and 2003 were reviewed. For the 58 patients who underwent alcohol septal ablation, 21 (36%) developed right bundle branch block. Six patients (12%) developed complete heart block requiring permanent pacing, three of whom had left bundle branch block before the procedure. Among the 117 patients who underwent surgical septal myectomy, 47 (40%) developed left bundle branch block. Four patients (3%) developed heart block requiring permanent pacing after the procedure, three of whom had right bundle branch block preoperatively. Percutaneous septal ablation selectively produces transmural infarction of the basal mid-septum and adjacent right bundle tissue, whereas surgical myectomy affects the endocardial portion of the basal anterior septum and adjacent left bundle tissue. These observations may help identify patients at risk for complete heart block after septal reduction procedures for HCM.

Subaortic septal bulge simulates hypertrophic cardiomyopathy by angulation of the septum with age, independent of focal hypertrophy. An echocardiographic study

Focal hypertrophy of the basal anterior septum occurs not infrequently in elderly patients and is considered by some to be a significant form of hypertrophic cardiomyopathy; others consider it to be an unimportant anatomic variant associated with an angulated septum, called a septal bulge (SB). We analyzed 94 cases of SB collected prospectively and compared them with 88 patients with extensive hypertrophic cardiomyopathy (≤CM), 20 patients with hypertrophic cardiomyopathy limited to the entire septum (ASH), and 20 age-matched controls. The SB cases were also divided into three groups, with marked, moderate, or no basal septal hypertrophy associated with the occurrence of an SB. All groups of SB patients had increased fractional shortening compared with controls (0.48 ± 0.07 versus controls 0.40 ± 0.07), comparable with HCM (0.48 ± 0.12), and increased left ventricular outflow tract velocity both at rest and especially after amyl nitrite inhalation (3.42 ± 1.35 versus 1.55 ± 0.60 m/sec [controls]). Other features of HCM were not present: normal wall thickness except for the basal septal hypertrophy, no anterior malposition in SB patients, no age-independent reversal of ratio of early to late mitral inflow velocity (E/A), and no decrease in end-diastolic dimension. It is concluded that outflow tract narrowing by an angulated septum is the primary mechanism responsible for the increased outflow tract velocity, rather than the hypertrophic septum. The resultant increase in convective acceleration simulates the dynamics of hypertrophic cardiomyopathy. The focal hypertrophy may be secondary and contributory to the enhanced ventricular dynamics, but it does not appear to be a primary cardiomyopathy. (J Am Soc Echocardiogr 1997;10:545-55.)

Development and determinants of dynamic obstruction to left ventricular outflow in young patients with hypertrophic cardiomyopathy.

To study the development of dynamic subaortic obstruction in young patients with hypertrophic cardiomyopathy (HCM), serial echocardiograms were retrospectively analyzed in a group of 26 consecutive children with this disease who showed no evidence of dynamic outflow obstruction at their initial evaluation (age, 11 +/- 3 years). After a follow-up of 3-12 years (mean, 7 +/- 3 years), seven of the 26 patients (27%) developed echocardiographic evidence of subaortic obstruction, i.e., marked systolic anterior motion (SAM) of the mitral valve with mitral-septal apposition and increased left ventricular outflow tract systolic velocities (3.8 +/- 0.3 m/sec; range, 3.1-4.5). Patients who developed SAM had smaller transverse dimension of the left ventricular outflow tract and more anteriorly displaced mitral valve when initially evaluated than did patients without development of SAM (outflow tract dimension, 19.1 +/- 4 versus 24.6 +/- 4 mm; mitral valve position index, 1.07 +/- 0.2 versus 0.73 +/- 0.3; each p less than 0.02). In patients with development of SAM, the already reduced outflow tract dimension decreased further during follow-up, and the mitral valve became even more anteriorly displaced within the left ventricular cavity. These developmental alterations in outflow tract size were associated with increases in left ventricular wall thickness, particularly of the basal anterior septum (11.0 +/- 8 mm; 72 +/- 33%) compared with control patients with HCM who did not develop SAM (3.0 +/- 3 mm; 17 +/- 10%; p less than 0.05). Development of subaortic obstruction in young patients with HCM results from a process of dynamic remodeling of left ventricular geometry over several years and is characterized by progressive narrowing of the outflow tract with anterior displacement of the mitral valve and disproportionate thickening of the basal anterior ventricular septum.