Color Doppler Myocardial Imaging Research Articles

Imaging Techniques for the Assessment of Myocardial Perfusion

Abstract One of the most significant causes of heart failure is coronary heart disease and subsequent left ventricular dysfunction. The prognosis and perioperative mortality are influenced by left ventricular function, which is also an important predictor marker following revascularization. The evaluation of myocardial perfusion is of utmost importance in patients who present several symptoms before choosing cardiac catheterization as treatment. The evaluation of myocardial perfusion and myocardial viability leads to superior diagnostic and treatment algorithms, thus resulting in an important improvement in the outcomes of patients with coronary artery disease. Color Doppler myocardial imaging, single-photon emission computed tomography (SPECT), contrast perfusion echocardiography, positron emission computed tomography (PET) and magnetic resonance imaging (MRI) are currently used methods for assessing myocardial perfusion. This review aims to summarize the benefits and disadvantages of each of these techniques.

Assessing pre-clinical ventricular dysfunction in obese children and adolescents: the value of speckle tracking imaging

Obesity has become a major health problem worldwide. Cardiovascular abnormalities have been described not only in obese adults but also in obese children and adolescents. The aim of the present study was to investigate left and right, systolic and diastolic ventricular dysfunction in obese paediatric patients without comorbidities using 2D speckle tracking longitudinal strain. Doppler echocardiogram was performed on 50 obese children and adolescents with body mass index (BMI) above the 95th percentile (OG) and 46 non-obese sex- and age-matched controls (CG). Systolic and diastolic functions of both ventricles were investigated through conventional Doppler echocardiography. Tissue Doppler imaging (TDI), colour Doppler myocardial imaging (CDMI), and two-dimensional (2D) speckle tracking were also used to analyse ventricular performance in both groups. Left-ventricular (LV) ejection fraction was similar between groups (68.2 ± 6.2 vs. 68.3 ± 5.3, P = 0.931). Left-ventricular diastolic parameters did not differ between groups, except for a lower mitral A wave (61.6 ± 13.0 vs. 51.9 ± 10.0 cm/s, P > 0.001) and higher E/A ratio (1.8 ± 0.5 vs. 2.1 ± 0.4, P = 0.007) in the controls. Left-ventricular global strain was lower in the OG by both methods (CDMI: 22.0 ± 2.8 vs. 24.6 ± 2.7%, P = 0.020; 2D speckle tracking: 18.4 ± 1.6 vs. 20.4 ± 1.7%, P < 0.001). In multivariate analysis, 2D longitudinal global strain correlated negatively with BMI, r = -0.433, p = 0.002. Although EF was not different between the two groups, LV 2D speckle tracking longitudinal strain was lower in the obese group, even in the absence of other comorbidities, indicating that obesity effects on LV function is an early finding in obesity.

Analysis of Right Atrial Function in Obese Pediatric Patients

Background : Left atrial enlargement and right and left ventricular dysfunction have been described in obese Patients. A number of studies have also described atrial dysfunction in obese children and adolescents. Objective: The aim of the present study was to investigate right atrial dysfunction in obese pediatric patients and Compare echocardiography findings between these patients and non-obese controls. Methods : Doppler echocardiography was performed on 50 obese pediatric patients (mean BMI=29.8 kg/m2) and 46 lean healthy controls. Systolic and diastolic function in both ventricles was investigated through conventional Doppler echocardiography. Right atrial function was evaluated using Color Doppler Myocardial Imaging (CDMI). Results: No differences were detected between groups with regard to left ventricular ejection fraction. The S wave of the free Wall of the right ventricle was similar in both groups (13.8 ± 1.7 vs. 13.7 ± 1.6, p=0.655). The e’/A’ ratio in the right Ventricle was significantly lower in the obese patients (0.9 ± 0.4 vs.1.2 ± 0.3, p=0.007). CDMI analysis of the right atrium and inter-atrial septum showed significantly lower, strain and strain rate in obese patients (82.6 ± 29.8 vs. 98.6 ± 38.7, p=0.020; 3.9 ± 1.0 vs. 4.4 ± 1.2, p<0.001; 50.9 ± 25.0 vs. 81.1 ± 21.6, p<0.001; and 2.2 ± 1.0 vs. 3.3 ± 0.8, p<0.001, respectively). Conclusion: The findings of the present study suggest incipient right atrial dysfunction, which may be secondary to an incipient impairment of myocardial relaxation in the right ventricle in obese children (BMI above 95th percentile).

Patients with hypertrophic cardiomyopathy at risk for paroxysmal atrial fibrillation: advanced echocardiographic evaluation of the left atrium combined with non-invasive P-wave analysis

The maintenance of sinus rhythm is crucial for the functional capacity of patients with hypertrophic cardiomyopathy (HCM). Using a multimodality approach, we attempted to identify potential predictors of paroxysmal atrial fibrillation (PAF) in HCM patients. Thirty HCM patients (17 males, mean age 57.9 ± 13.6) with at least one documented PAF episode and 32 age- and sex-matched HCM control patients as well as 25 healthy volunteers were studied in sinus rhythm. Study subjects underwent 2D echocardiography including a colour Doppler myocardial imaging evaluation of the left atrium (LA). Additionally, an orthogonal electrocardiogram was acquired; P-wave duration, maximum, and mean energies were calculated for each subject at each orthogonal lead and the composite vector axis using the Morlet wavelet analysis. Compared with HCM controls, in HCM-PAF patients, LA antero-posterior diameter was significantly enlarged (LADAP: 46.1 ± 5.9 vs. 40.0 ± 4.7 mm, P < 0.001), peak strain rate of the LA lateral wall in the reservoir phase was significantly decreased (LAT peak SR-S: 1.93 ± 0.51 vs. 2.55 ± 0.83 s(-1), P < 0.01), and P-wave duration in the Z-lead was significantly prolonged (P-durZ: 106.9 ± 24.6 vs. 86.2 ± 14.3 ms, P < 0.001). Cut-off values and areas under the curve (AUCs) for individual parameters were 42.0 mm, 2.32 s(-1), and 98.8 ms and 0.81, 0.74, and 0.78, respectively. A multivariable model combining LADAP, LAT peak SR-S and P-durZ had an AUC of 0.90, a sensitivity of 0.87, and a specificity of 0.91 for identifying PAF patients. P-wave duration combined with LA antero-posterior diameter and myocardial deformation indices resulted in a higher power for discriminating HCM-PAF patients, when compared with individual parameters derived from either wavelet analysis or 2D echocardiography.

Can Left Atrial Strain and Strain Rate Imaging Be Used to Assess Left Atrial Appendage Function?

Background: The aim of this study was to evaluate the efficiency of left atrial strain (S) and strain rate (SR) imaging in assessing left atrial appendage (LAA) function. Methods: We studied 78 consecutive patients (35 females and 43 males; mean age 38 ± 15 years) referred for transesophageal echocardiography (TEE). LAA late emptying velocity (LAA-EV) was calculated. Real-time color Doppler myocardial velocity imaging (MVI) data were recorded from the LAA by TEE and the lateral wall of the left atrium (LA) by transthoracic echocardiography. Longitudinal S and SR were measured in the mid portion of the lateral LA wall and lateral LAA wall during the contractile period. LAA late systolic velocity (LSV) and LA-LSV were obtained from Doppler analysis. Results: A significant positive correlation was detected between LAA-EV and MVI parameters (for LAA-S, r = 0.88, p < 0.001; for LAA-SR, r = 0.84, p < 0.001; for LAA-LSV, r = 0.83, p < 0.001; for LA-S, r = 0.84, p < 0.001; for LA-SR, r = 0.79, p < 0.001, and for LA-LSV, r = 0.70, p < 0.001). In addition, a significant positive correlation was detected between LAA-S and LA-S (r = 0.85, p < 0.001). Conclusion: We suggest that LA-S and LA-SR imaging is a beneficial method to evaluate LAA functions noninvasively.

The Heart in Friedreich Ataxia

Background— This cross-sectional study provides a practical approach for the clinical assessment of Friedreich ataxia (FA) cardiomyopathy (FA-CM). Methods and Results— A comprehensive cardiac assessment, including standard echocardiography, color Doppler myocardial imaging, cardiac magnetic resonance imaging, ECG, and exercise stress testing, was performed in 205 FA patients. To assess myocardial hypertrophy in FA-CM, the end-diastolic interventricular septal wall thickness (IVSTd) was found to be the best echocardiographic parameter compared with cardiac magnetic resonance imaging–determined left ventricular mass. With the use of this parameter, 4 groups of patients with FA-CM could be defined. Patients with normal values for IVSTd (31.7%) were classified as having no FA-CM. Patients with an IVSTd exceeding the predicted normal IVSTd were classified as having mild FA-CM (40%) if IVSTd exceeded the normal value by &lt;18% or as having intermediate FA-CM (16.1%) if IVSTd exceeded the normal value by ≥18%. Patients with ejection fraction &lt;50% were classified as having severe FA-CM (12.2%). In addition to increased myocardial mass, severe FA-CM was further characterized by dilatation of the left ventricle, reduced systolic strain rate of the posterior wall, and ECG abnormalities. Regional myocardial function correlated negatively with FA-CM groups. Younger patients had a tendency for more advanced FA-CM. Importantly, no clear correlation was found between FA-CM groups and neurological function. Conclusions— We provide and describe a readily applicable clinical grouping of the cardiomyopathy associated with FA based on echocardiographic IVSTd and ejection fraction data. Because no distinct interrelations between FA-CM and neurological status could be determined, regular follow-up of potential cardiac involvement in FA patients is essential in clinical practice. Clinical Trial Registration— https://www.clinicaltrials.gov . Unique identifier: NCT00905268.

Oral Abstract: Understanding the physio-pathology of myocardial mechanics * Friday 9 December 2011, 14:00-15:30 * Location: Kaposvar

Purpose: To evaluate the relationship between atrial contraction, mitral valve closure (MVC) and left ventricular isovolumic contraction. The horse is an ideal model to investigate this mechanism because of the low resting heart rate (25–45 bpm) and long atrioventricular (AV) interval. Methods: Five unsedated horses instrumented with pacing leads in the right atrium and right ventricle were evaluated during sinus rhythm (SR), ventricular pacing without preceding atrial contraction (VP) and dual-chamber pacing at AV delays ranging from 150 to 350 ms, programmed in a random sequence at a constant rate of 40 bpm. Color Doppler myocardial imaging was performed at high frame rates (>100 fps). Modified right parasternal four-chamber views were recorded for simultaneous measurements of MVC by anatomical M-mode and tissue Doppler-based left ventricular pre-ejectional peak velocity spikes and their timing. Results: During SR (AV interval 330–520 ms) and long AV intervals (300 and 350 ms), MVC occurred 12±37 ms after the onset of QRS. Two positive pre-ejectional velocity peaks were present. The first peak was identified as recoil of the left ventricle during atrial relaxation. This peak (2.5±1.1 cm/s) consistently preceded MVC (linear mixed model; P=0.84) by 44±18 ms. The second peak (4.8±1.3 cm/s) was called left ventricular isovolumic contraction and occurred after MVC. This suggests MVC caused by atrial contraction, followed by a true isovolumic contraction. However, during short AV intervals (150 and 200 ms) and VP, MVC occurred significantly later (P=0.002) at 125±5 ms after the onset of QRS. Only one pre-ejectional peak was present and the end of this peak coincided with MVC (linear mixed model; P=0.76). Peak velocity (9.2±2.4 cm/s) was remarkably higher than during SR and long AV intervals (P=0.009). These findings suggest MVC caused by left ventricular myocardial motion, resulting in a high pre-ejectional velocity peak as this contraction is not isovolumic. Conclusions: This study demonstrates the important influence of the atrioventricular interaction on mitral valve closure and pre-ejectional myocardial motion. Depending on the atrioventricular delay, mitral valve closure can be atrio- or ventriculogenic, resulting in high pre-ejectional velocities if the left ventricle is not in a true isovolumic state.

Color Doppler myocardial imaging demonstrates reduced diastolic tissue velocity in growth retarded fetuses with flow redistribution

ObjectivesIn fetuses suffering from intrauterine growth retardation with cerebroplacental redistribution (IUGR CPR), the diastolic heart function may be particularly susceptible to hypoxemia as described in postnatal pathological conditions. Using the newly introduced ultrasound technique, color Doppler myocardial imaging (CDMI), we investigated the correlation between diastolic tissue velocities and diastolic blood flow velocities and compared diastolic myocardial tissue velocities in fetuses with IUGR CPR and normal fetuses. Study designPeak early and active atrial tissue velocities (E’ and A’) were acquired from both ventricular free walls in 18 fetuses with IUGR CPR and 42 normal fetuses. In 35 normal fetuses, blood flow across the atrio-ventricular valves was also recorded. Umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV) flows were obtained in all fetuses. Nonparametric tests were used for statistical analysis. ResultsThere was a tendency towards increased E’ and A’ with fetal age in normal pregnancies. No correlation between tissue velocity and blood flow velocity was established. IUGR CPR fetuses had significantly lower E’ and A’, but when indexing to heart length, only A’ remained significantly lower. E’/A’ ratio was increased in the left ventricle but unchanged in the right. ConclusionCDMI is easily applicable during standard fetal echocardiography and provides new information on the diastolic properties of the fetal myocardium. In fetuses with IUGR CPR, diastolic tissue velocities are abnormal and especially A’ may be a marker of diastolic dysfunction.

Assessment of the left atrial longitudinal myocardial function by Assessment of the left atrial longitudinal myocardial function by the strain and strain rate echocardiography in patients with rheumatic mitral stenosis*

To evaluate the regional left atrial (LA) myocardial functions and time to peak deformations by the longitudinal strain (S) and strain rate (Sr) echocardiography in isolated mitral stenosis (MS) patients for 3 LA periods (contractile, reservoir, and conduit periods). Materials and methods: Included in the study were 30 MS patients and 30 healthy controls. Longitudinal peak S and Sr indices, time to peak S and time to peak Sr, and systolic and diastolic velocities were measured from the color Doppler myocardial imaging data, for each LA period. Results: For all 3 periods, all of the segment S values and most of the segment Sr values were significantly lower in the patients than in the controls (P < 0.0001 and P < 0.05, respectively). There were no significant differences between the groups in terms of velocities. Time to peak S in the contractile and conduit periods was significantly higher in the patients than in the controls, in most of the segments (P < 0.05). Time to peak Sr was significantly higher in the patients than in the controls, in all of the periods in all of the segments (P < 0.05) except for mid-septal segments. Conclusion: This study demonstrated that LA longitudinal myocardial functions were impaired in MS patients with S/Sr echocardiography. Our study is the first to demonstrate prolonged time to peak S/Sr of the LA in rheumatic MS. This condition might be an additional factor in the deterioration of regional LA myocardial function in MS patients.

SEGMENTAL COLOR DOPPLER MYOCARDIAL IMAGING DERIVED PRE-EJECTION VELOCITIES ARE NOT CLINICALLY USEFUL IN THE ASSESSMENT OF POST-INFARCTION SCAR TRANSMURALITY

The presence of a velocity in isovolumic contraction phase (Vivc) evaluated using tissue Pulse wave Doppler myocardial imaging (PWDMI) correlates with a transmural extent of scar after myocardial infarction. The possible clinical usefulness of Vivc evaluated using color Doppler myocardial imaging (CDMI) in detection of a scar after myocardial infarction extent in patients with coronary heart disease (CHD) and low LV systolic function remains to be clarified. 57 patients with CHD (average LVEF 33.5±5%), examined echocardiographicaly (17-segment LV model, 689 segments evaluated) and by cardiac magnetic resonance. All segments were scanned for Vivc presence using CDMI. Vivc presence/absence was correlated with signs of a scar after MI in all segments and in akinetic segments separately. We found significantly larger values of wall thickness (8.2±2,2 vs. 7.1±1.9, p<0.0001), significantly lower values of average late enhancement (LE) extent (1.32±1.78 vs. 1.66±1.98, p=0.041) and LE/wall thickness ratio (20.1±29.8 vs. 29.6±36.7, p=0.008) in segments with present Vivc. Vivc presence in a segment with an abnormal wall motion had a sensitivity of 72.9% and a specificity of 35.7% in recognizing a segment without a transmural scar (LE/ wall thickness ratio ≤75%). Vivc absence in a segment with an abnormal wall motion had a sensitivity of 72.7% and a specificity of 41.2% in recognizing a segment with a transmural scar (LE/wall thickness ratio ≥75%). Isovolumic velocities evaluation assessed using color Doppler myocardial imaging is not applicable in a real-world clinical setting. The presence or absence of a velocity pattern during LV isovolumic contraction is not useful in in the assessment of a post-infarction scar transmurality.

Evaluation of contractile function and inotropic reserve with tissue velocity, strain and strain rate imaging in streptozotocin-induced diabetes

The aim of the present study was to evaluate left ventricular (LV) function and contractile reserve (CR) with Doppler myocardial imaging (DMI) in a small animal model for type 1 diabetes. Cardiac function was assessed in anaesthetized Wistar rats 6 and 8 weeks after injection of 60 mg/kg of streptozotocin. At 6 weeks of diabetes, colour DMI echocardiography was performed at rest and during incremental dosages of dobutamine (5, 10, 20 microg/kg/min). Left ventricular fractional shortening was decreased after 8 weeks of follow-up [36 +/- 5 (D) vs. 41 +/- 4% (C); P = 0.049]. After 6 weeks of diabetes, DMI measurements were reduced in the diabetic rats in the inferolateral wall at rest [systolic velocity: 2.5 +/- 0.4 (D) vs. 4.4 +/- 0.3 (C) cm/s; P < 0.001; systolic strain rate: 12.2 +/- 3.4 (D) vs. 17.4 +/- 3.2 (C) 1/s; P = 0.012] and during inotropic stimulation [delta velocity (cm/s): 0.2 +/- 0.1 (D) vs. 0.5 +/- 0.3 (C)/5 microg dobutamine; P = 0.002; delta strain rate (1/s): 1.4 +/- 0.9 (D) vs. 3.3 +/- 2.2 (C)/5 microg dobutamine; P = 0.049]. Furthermore, the intraventricular delay in time-to-peak systolic strain was larger in diabetes [20 +/- 18 (D) vs. 10 +/- 7 (C) ms; P= 0.01]. Systolic mitral annular velocity was also lower in the diabetic rats at rest [2.7 +/- 0.4 (D) vs. 3.5 +/- 0.4 (C) cm/s; P < 0.001] and in response to dobutamine [delta velocity (cm/s): 0.1 +/- 0.1 (D) vs. 0.3 +/- 0.2 (C)/5 microg dobutamine; P = 0.013]. In experimental diabetes, a reduction in radial and longitudinal LV function and CR can be detected with DMI before the onset of a reduced global LV function.

Comparison of Pulsed Wave and Color Doppler Myocardial Velocity Imaging in Healthy Dogs

Tissue velocity imaging (TVI) is increasingly used in small animal cardiology. Tissue velocity of the myocardial wall can be measured by pulsed wave (PW) or color Doppler (CD) imaging methods. Currently, the same reference ranges are used for PW TVI and CD TVI methods. However, if and how both methods correlate, and whether they can be used interchangeably, have not been assessed in small animals. To compare the results of PW TVI and CD TVI measurements. Seventy-one healthy dogs. Longitudinal myocardial velocity profiles were recorded from the 4-chamber left apical view. Peak maximal systolic (S), early (E), and late diastolic (A) velocities were measured off-line in a blinded fashion in the septal and lateral left ventricular wall by PW TVI and CD TVI. Differences between peak PW TVI and CD TVI waves were analyzed by a paired t-test. Regression analysis and Bland-Altman difference plots also were used to assess agreement between methods. There was a significant correlation between PW TVI and CD TVI (P < .001). However, S, E, and A waves measured by PW TVI were significantly higher than the CD TVI values (P < .001). Peak systolic and diastolic PW velocities were approximately 2.20 cm/s higher than corresponding mean CD TVI velocities. PW TVI measurements are significantly higher compared with CD TVI measurements. Theses differences are clinically relevant. These methods should not be used interchangeably, and different reference ranges for PW TVI and CD TVI should be used.

The influence of pulmonary regurgitation on regional right ventricular function in children after surgical repair of tetralogy of Fallot

Pulmonary regurgitation after repair of tetralogy of Fallot (TOF) results in right ventricular (RV) dysfunction with significant late morbidity and mortality. The aim was to assess the influence of pulmonary regurgitation on regional RV function. In 48 asymptomatic children (age 11.1 +/- 3.3 years) with repair of TOF, peak systolic strain rate (SR) and end-systolic strain (epsilon) were acquired using colour Doppler myocardial imaging. RV indices were quantified by magnetic resonance imaging. Echocardiography and exercise capacity was also performed. Forty complete data sets were analysed. An inverse linear relationship was demonstrated between the degree of pulmonary regurgitation and right ventricle end-systolic epsilon (r = -0.53, P < 0.01) as well as a correlation with peak systolic SR (r = -0.35, P < 0.01). A correlation existed between peak VO(2) and peak systolic SR (r = 0.51, P = 0.001) and end-systolic epsilon (r = 0.33, P < 0.05). In asymptomatic children after repair of TOF, pulmonary regurgitation is associated with impaired regional systolic RV deformation indices. Regional strain and SR may be an early indicator of RV dysfunction in patients with post-TOF and pulmonary regurgitation.

Early Left Ventricular Structural Myocardial Alterations and Their Relationship with Functional and Electrical Properties of the Heart in Myotonic Dystrophy Type 1

Conduction disturbances and arrhythmias characterize the cardiac feature of myotonic dystrophy type 1 (MD1), and a myocardial involvement has been suggested as part of the cardiac disease. The aim of the study was to investigate the role of novel ultrasonic techniques, such as integrated backscatter (IBS) and color Doppler myocardial imaging (CDMI), in the assessment of the subclinical functional and structural myocardial involvement in patients with MD1. Thirty-one patients with MD1 (MD1 group) without known heart failure were evaluated and compared with 31 healthy, age-matched controls. In all patients, 19 conventional and 28 new echocardiographic parameters (14 tissue Doppler, 10 CDMI, and 4 IBS indexes) were analyzed. In regard to ultrastructural left ventricular (LV) properties, a significantly higher IBS echointensity was found at the septum level in the MD1 group, with a statistically significant correlation with MPI (myocardial performance index) (r = 0.34; P = .05) and PR interval duration (r = 0.40; P = .05). In regard to LV systolic function, the MD1 group showed an early alteration of systolic function compared with controls, evidenced by a significant higher MPI and lower peak strain, strain rate, and cyclic variation index (CVI). In regard to LV diastolic function, the MD1 group showed an early alteration of diastolic function compared with controls, evidenced by lower tissue Doppler imaging, E/A, and E/A strain rate, with a statistically significant inverse correlation to the muscular disability rating scale. On receiver operating characteristic curve analysis, MPI and CVI showed the highest discriminating ability to differentiate the hearts of patients with MD1 from healthy subjects. Highly sensitive ultrasonic techniques can detect early functional and structural alterations of the LV myocardium in patients with MD1.

New Echocardiographic Techniques in the Evaluation of Left Ventricular Mechanics in Subclinical Thyroid Dysfunction

The new echocardiographic techniques for the study of physiopathological intramyocardial phenomena include video densitometry (VD), integrated backscatter (IBS), and color Doppler myocardial imaging (CDMI). Being more independent from cardiac load and from rotational and translational heart motion, these new sensible, noninvasive techniques such as CDMI and IBS show a real incremental value in comparison with conventional echocardiography and allow to detect subtle functional and textural abnormalities of intramural myocardium, partially undetectable by conventional two-dimensional Doppler echocardiography. Subclinical thyroid dysfunction (STD), both in its hypo- and hyperthyroidism form, has a relatively high prevalence in general population (9-15% with a lower percentage of adult males), hence it could be very useful to study more deeply heart involvement in these physiopathological conditions and understand the complex relationship between thyroid and heart. The use of these new ultrasonic techniques in subclinical hypothyroidism helps to detect the early simultaneous involvement of both cardiac cycle phases, which causes a decrease of intramyocardial contractility and an impairment of both active and passive phases of diastole. In subclinical hyperthyroidism, these new ultrasonic techniques permitted to discover more complex and different early cardiac abnormalities of both systolic and diastolic phases.

Systolic myocardial velocity alterations in the growth‐restricted fetus with cerebroplacental redistribution

Intrauterine growth restriction (IUGR) is associated with cerebroplacental redistribution (CPR), fetal stress and poor outcome, all of which may be related to dysfunction of the fetal myocardium. The aim of this study was to specifically assess myocardial function in IUGR fetuses with CPR in comparison with normal fetuses using color Doppler myocardial imaging (CDMI). CDMI was used to evaluate and compare myocardial velocities in the left and right ventricles in normal fetuses and in IUGR fetuses with CPR. Peak systolic tissue velocities (S') were acquired from both ventricular free walls in 20 IUGR fetuses (gestational age at scan ranged from 26 + 1 to 34 + 6 weeks, with serial measurements obtained in nine) and 42 normal fetuses (35 at week 28, with the remaining seven undergoing serial scans every 4 weeks, ranging from 18 + 6 to 39 + 1 weeks). Umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV) flows were also recorded. Left and right S' increased with gestational age in normal pregnancy. Fetuses with IUGR and CPR had lower left ventricular S' than normal fetuses (mean, 2.41 (95% CI, 1.96-2.86) cm/s vs. 3.30 (95% CI, 3.05-3.55) cm/s; P = 0.0006). This reduction in S' correlated with the grade of UA flow abnormality (P = 0.0002). Fetuses with reversed diastolic UA flow had significantly lower left S' (mean, 2.0 (95% CI, 1.4-2.6) cm/s; P = 0.001) than normal fetuses. There was no correlation between left S' and MCA pulsatility index (P = 0.37) in the IUGR-CPR group, but there was a reduction in S' approaching statistical significance in fetuses with reversed DV flow in comparison to those without it (P = 0.09). Right S' was similar in the two study groups and did not correlate with worsening UA flow class. All fetuses with a left S' below 1.6 cm/s and reversed UA flow died in the perinatal period. CDMI facilitates acquisition of fetal myocardial ventricular S'. The combination of IUGR and CPR is associated with a reduced left ventricular S', especially in those with reversed UA flow. In this subgroup a left S' below 1.6 cm/s seemed to predict mortality in the perinatal period.

Atrial and ventricular function in thalassemic patients with supra-ventricular arrhythmias.

The aims of this study were to evaluate through Color Doppler Myocardial Imaging (CDMI) echocardiography if atrial or ventricular myocardial alterations could be detectable in patients with thalassemia major (THAL) and if these alterations could be considered as predictive elements for supra-ventricular arrhythmic events. Twenty-three patients with THAL underwent clinical and electrocardiographic evaluation; patients were grouped in THAL1 (9 with supra-ventricular arrhythmias) and THAL2 (14 without arrhythmias); 12 healthy subjects were considered as control group (C). We examined through conventional 2D Color Doppler echocardiography some morphological and functional parameters regarding left ventricular (LV) systolic and diastolic function, and through CDMI the velocities at mitral annulus level, the regional LV and left atrial (LA) strain and strain rate. All THAL patients had LV dimension (p<0.05), LA area (p<0.01) and E/Em ratio (p<0.001) to be significantly higher than controls. The mitral annulus longitudinal velocities were significantly lower in THAL1 than in THAL2 (p<0.001); the E/Em ratio was higher in THAL1 than THAL2 (p<0.001). The THAL1 showed a lower systolic strain rate of atrial wall than THAL2 and C (p<0.05). The multiple regression highlighted a significantly inverse correlation among E/Em and atrial strain (p<0.02). CDMI showed both THAL subgroups had subtle systolic and diastolic left ventricular myocardial alterations, which could represent the onset of developing “iron cardiomyopathy” and are related to supra-ventricular arrhythmia. Monitoring these parameters in the THAL patients could contribute to decisions about follow-up and therapy.

197 REFRACOTRY SPONTANEOUS BACTERIAL PERITONITIS: A RETROSPECTIVE STUDY OF THE UNIVERSITY OF CHICAGO EXPERIENCE

Background and Aim: Cardiac dysfunction in cirrhosis is a problem of the ‘blind side of the heart’. Without firm diagnostic criteria, the exact prevalence of cirrhotic cardiomyopathy remains unknown. We evaluate left ventricle (LV) standard echocardiographic (Echokg) and colour Doppler myocardial imaging (DMI) pattern of cirrhotic patients (pts) with the aim to assess correlation with Child–Pugh score. Patients and Methods: 58 of pts (27 males, 31 females, age 53.6±11.6 years) with liver cirrhosis of various etiology and 21 healthy controls (14 males, 7 females, age 49.0±12.0 years) were studied. Cirrhosis stage was evaluated by Child–Pugh scoring. All subjects had undergone 2D and colour DMI. Results: No clear differences between standard Echokg parameters depicting LV systole and diastole were noticed. Slight increase of LV and left atrium size was observed in the cirrhotic pts as compared with controls (Fisher exact test: p = 0.0489 and p = 0.0015, respectively). Also weak correlation of EF and E, A waves with cirrhosis score was found (Spearman correlation: CEF = 0.32109, p = 0.0039; CE = 0.22771, p = 0.0436; CA = 0.41774, p = 0.0001). Meanwhile cirrhotic pts had markedly decreased septal and mean Ea which further deteriorated depending on cirrhosis score (Spearman correlation: CEa mean= −0.78686, p< 0.0001; CEa septal= −0.78176, p< 0.0001). Filling pressure (E/Ea) was upgraded in the cirrhotic pts (Spearman correlation: CE/Ea= 0.65457, p< 0.0001), that was more pronounced in the Child– Pugh C group (controls vs C: 0.084 vs 0.17). Longitudinal systolic function estimated by mean strain (S) and strain rate (SR) was decreased in the cirrhotic pts compared with controls (Spearman correlation: CS = −0.54209, p< 0.0001; CSRS = −0.46828, p< 0.0001). S and SR were positively correlated with diastolic septal and mean mitral anular Ea (Pearson correlation: CS and Ea septal = 0.493, p< 0.0001; CS and Ea mean = 0.451, p< 0.0001; CSR and Ea septal = 0.540, p< 0.0001; CSR and Ea mean = 0.508, p< 0.0001). Conclusions: DMI indices might be a useful tool in predicting cardiac dysfunction in cirrhotic patients. Following parameters mean and septal annulus Ea, filling pressure E/Ea and mean longitudinal strain and strain rate may therefore represent the best available screening test to diagnose the cirrhotic cardiomyopathy syndrome.

Quantification of Regional Left and Right Ventricular Deformation Indices in Healthy Neonates by Using Strain Rate and Strain Imaging

Color Doppler myocardial imaging (CDMI) allows the calculation of local longitudinal or radial strain rate (SR) and strain (epsilon). The aims of this study were to determine the feasibility and reproducibility of longitudinal and radial SR and epsilon in neonates during the first hours of life and to establish reference values. Data were obtained from 55 healthy neonates (29 male; mean age, 20 +/- 14 hours; mean birth weight, 3,174 +/- 374 g). Apical and parasternal views quantified regional longitudinal and radial SR and epsilon in differing ventricular wall segments. Values at peak systole, early diastole, and late diastole were calculated from the extracted curves. CDMI data acquired at 300 +/- 50 frames/s were analyzed offline. Three consecutive cardiac cycles were measured during normal respiration. The timing of specific systolic or diastolic regional events was determined. Multiple comparisons between walls and segments were made. Left ventricular (LV) longitudinal deformation showed basal differences compared with apical segments within one specific wall. Right ventricular (RV) longitudinal deformation was not homogeneous, with significant differences between basal and apical segments. Longitudinal epsilon values were higher in the RV free basal and middle wall segments compared with the left ventricle. In the RV free wall apical segment, longitudinal SR and epsilon were maximal. LV systolic SR and epsilon values were higher radially compared with longitudinally (radial peak systolic SR midportion, 2.9 +/- 0.6 s(-1); radial peak systolic epsilon, 53.8 +/- 19%; longitudinal peak systolic SR midportion, -1.8 +/- 0.5 s(-1); longitudinal peak systolic epsilon, -24.8 +/- 3%; P < .01). Longitudinal systolic epsilon and SR interobserver variability values were 1.2% and 0.7%, respectively. Ultrasound-based SR and epsilon imaging is a practical and reproducible clinical technique in neonates, allowing the calculation of regional longitudinal and radial deformation in RV and LV segments. These regional SR and epsilon indices represent new, noninvasive parameters that can quantify normal neonate regional cardiac function. Independent from visual interpretation, they can be used as reference values for diagnosis in ill neonates.

Doppler Myocardial Imaging Compared to Standard Two-Dimensional and Doppler Echocardiography for Assessment of Diastolic Function in Patients With Systemic Amyloidosis

Cardiac amyloidosis (AL) is characterized by early impairment of diastolic function with preservation of systolic function, as assessed by standard measures, until very late in the disease process> Role of diastolic color Doppler myocardial imaging (cDMI), that is diastolic color Doppler myocardial velocity imaging (MVI) and strain rate imaging (SRI), to assess distolic dysfunction in this population remains unclear. 238 patients with biopsy proven systemic primary (AL) amyloidosis and 39 age and sex-matched controls have been enrolled. Left ventricular diastolic cDMI measures were compared in patients and healthy subjects, to test if such diastolic dysfunction occurs before longitudinal left ventricular systolic dysfunction. Compared to Diastolic longitudinal, radial, and circumferential DMI, standard pulsed wave tissue Doppler imaging (PW-TDI) of the mitral annulus was the most accurate technique to detect early diastolic dysfunction in patients with AL. However, systolic longitudinal peak cDMI measures outperformed all of the diastolic measures, including PW-TDI, in separating patients with systemic AL, but no evidence of cardiac involvement on standard 2D and Doppler evaluation, from controls. Even when compared to diastolic cDMI measurements, standard PW-TDI of the mitral annulus was the most accurate diastolic measure to detect early left ventricular dysfunction in patients with AL amyloidosis. However, no diastolic measure approached the accuracy of longitudinal systolic cDMI measurements in identifying ventricular dysfunction in AL patients with normal standard 2D and Doppler examinations, compared to controls.