Diffuse Left Ventricular Hypokinesis Research Articles

Left ventricular shape in idiopathic dilated cardiomyopathy and cardiomyopathy with or without only mild ventricular dilatation

Left ventricular (LV) dilatation and diffuse LV hypokinesia have been considered characteristic features of “congestive” cardiomyopathy, as originally described by Goodwin et al. 1 Since the mid-1970s, the term congestive cardiomyopathy has been increasingly replaced by “dilated cardiomyopathy.” Recently, Keren et al 2 called attention to an entity they designate “mildly dilated congestive cardiomyopathy,” defined as end-stage heart failure of unknown etiology occurring with neither typical hemodynamic findings of restrictive cardiomyopathy nor significant LV dilatation. They stated, “some of the patients in this series actually had cardiac dimensions within normal limits.” We undertook the present echocardiography study to: (1) ascertain whether mildly dilated or nondilated congestive cardiomyopathy does in fact exist in our population, and (2) compare LV shape in such patients with those in patients with typical dilated cardiomyopathy and in normal subjects.

Response of heart rate to atropine and left ventricular function in Chagas' heart disease

Chagasic patients may have a normal or abnormal response of heart rate to atropine. To determine if this response to atropine is related to the degree of left ventricular dysfunction, we studied 33 patients with a positive complement fixation test for Chagas' disease. Eleven subjects, with atypical chest pain and negative complement fixation test, were used as controls (sero-negative). Left ventricular wall motion and the left ventricular volumes were determined by ventricular cineangiography. Coronary arteriography was also performed. The sero-negative subjects had normal left ventricular wall motion and the left ventricular diastolic volume was 88 ± 24 ml/m 2. The response of heart rate to atropine was 50 ± 8 (mean ± SD) (range 40–65 beats/min). On the basis of the response to atropine, the chagasic patients were divided into groups with a normal response (> 40 beats/min) and those with an abnormal response (< 40 beats/min). Sixty five per cent of those with a normal response had left ventricular apical aneurysms. The left ventricular end-diastolic volume was not significantly different from the sero-negative subjects (96 ± 26 ml/m 2). Six patients (30%) had a left ventricular diastolic volume between 110 and 140 ml/m 2. Sixty two per cent of those chagasic subjects with an abnormal response had diffuse left ventricular hypokinesis, and the left ventricular end-diastolic volume was 192 ± 49 ml/m 2 ( P < 0.01). The response of heart rate and the left ventricular diastolic volume were inversely correlated in the chagasic patients ( r = −0.88, P < 0.01). Our results indicate that myocardial damage and the degree of left ventricular dilatation are more severe in chagasic patients with an abnormal response of their heart rate to atropine. Furthermore, the inverse correlation between these two variables is highly indicative of a relationship between the response of heart rate to atropine and the degree of left ventricular dysfunction.

Complete evaluation of the cardiovascular lesions in 24 patients with Takayasu's aortitis using four-image, intravenous digital subtraction angiography

We studied the entire distribution of cardiovascular lesions with the use of intravenous digital subtraction angiography (DSA) in 24 patients having Takayasu's sortitis. The aorta, its branches, pulmonary vessels, and left ventricle were assessed by neck (anteroposterior), abdominal (anteroposterior), and chest (right and left anterior oblique) images. DSA showed multiple arterial lesions (n = 24) including proximal renal artery stenoses (n = 4), pulmonary arterial stenoses (n = 4), inferior-superior mesenteric arterial anastomoses (n = 3), brachiocephalic arterial aneurysms (n = 2), aortic root aneurysm (n = 1), diffuse left ventricular hypokinesis (n = 1), subclavian steal phenomenon (n = 1), and right aortic arch (n = 1). The incidence of total occlusion was highest in the right subclavian artery (n = 12). Average percent luminal stenosis (mean ± S.D.) over the aorta and its branches tended to be smaller in patients with prior corticosteroid therapy (17.3 ± 14.6%) than in those without (22.0 ± 9.8%), but the difference was not significant. DSA (four-series) was useful in assessing the whole disease spectrum and often revealed subclinical lesions in this disease.

Sarcoidosis: a pattern of clinical and morphological presentation.

The diagnosis of cardiac sarcoidosis, particularly when there is no overt systemic involvement, is frequently delayed because of its varied manifestations. Focal left ventricular wall motion abnormalities were recognised in five patients with sarcoidosis. Three patients showed abnormal regional wall motion in the basal portion of the ventricular septum and free wall with sparing of the apex. The angiographic appearances supported the echocardiographic findings which were atypical of ischaemic heart disease. The remaining two patients both had diffuse left ventricular hypokinesia, with a focal abnormality that was most pronounced in the anteroapical region; this pattern is often seen with coronary disease. The recognition by echocardiography or angiography of focal abnormalities of wall motion affecting the basal portion of the ventricular septum should suggest the possibility of myocardial sarcoidosis even in the absence of recognised systemic manifestations.

Progression of hypertrophic cardiomyopathy into a hypokinetic left ventricle: Higher incidence in patients with midventricular obstruction

The development of segmental or generalized left ventricular hypokinesia is an unusual occurrence in patients with hypertrophic cardiomyopathy. To determine the incidence and possible pathophysiologic mechanisms responsible for this process, the serial clinical and laboratory data of 62 patients with the diagnosis of hypertrophic cardiomyopathy were analyzed. During a mean follow-up period of 8 years (range 2 to 21), 5 patients (Group A) developed left ventricular hypokinesia, whereas the remaining 57 patients (Group B) continued to exhibit the clinical and laboratory findings of hypertrophic cardiomyopathy. Three patients developed a dilated left ventricle with generalized hypokinesia; two other patients had segmental left ventricular wall motion abnormalities. None of these five patients who developed left ventricular hypokinesia had fixed coronary artery disease. The mean age, sex, mean duration of follow-up, presence of coronary myocardial bridges and angina pectoris, and an interventricular gradient were all similar in Groups A and B. Midventricular obliteration was seen in 4 (80%) of the 5 patients in Group A and in 4 (7%) of the 57 patients in Group B (p less than 0.001). Findings from this study reveal that segmental or generalized left ventricular hypokinesia can develop in patients with hypertrophic cardiomyopathy in the absence of fixed coronary artery disease. Such hypokinesia can occur after an acute myocardial infarction or it can develop gradually without clinical or electrocardiographic evidence of infarction. Patients with the mid-ventricular obliteration variant of hypertrophic cardiomyopathy are at a higher risk of developing segmental or diffuse left ventricular hypokinesia.

The value of echocardiographic regional wall motion abnormalities in detecting coronary artery disease in patients with or without a dilated left ventricle

To evaluate the usefulness of echocardiographic regional wall motion abnormalities (RWMA) in detecting coronary artery disease (CAD) in patients with left ventricular (LV) sysfunction and a normal-sized or dilated left ventricle, 103 patients were studied by two-dimensional echocardiography (2DE) and cardiac catheterization. In 60 patients (group I) who had LV dysfunction and a dilated left ventricle by echo (patients with dilated cardiomyopathy), RWMA were detected in 44 patients and 38 (86%) of them had significant CAD, usually two- or three-vessel obstruction; of the 16 patients with dilated cardiomyopathy (DCM) and diffuse LV hypokinesis, eight (50%) had evidence of CAD. Thus the presence of RWMA by 2DE had an 83% sensitivity, a 57% specificity, and a 77% predictive accuracy in detecting CAD in patients with DCM and thus in distinguishing ischemic from idiopathic DCM. In 43 patients with LV dysfunction but normal LV size (group II), the sensitivity, specificity, and predictive accuracy of RWMA in detecting significant CAD was 95%, 100%, and 95%, respectively. We conclude that the detection of RWMA by 2DE is highly suggestive of significant CAD in patients with LV dysfunction and normal-sized or dilated left ventricle; the finding, however, of diffuse LV hypokinesis does not exclude CAD in these patients, especially when the left ventricle is dilated.

Torsade de pointes associated with elevated N-acetylprocainamide levels

N-acetylprocainamide (NAPA), the major metabolite of procainamide, has been shown to have separate antiarrhythmic and side effects from procainamide.l Torsade de pointes, a type of polymorphous ventricular tachycardia characterized by “twisting” of ventricular complexes around the isoelectric line and usually associated with QT prolongation,2 has been reported to occur with administration of procainamide.3 However, only recently has it been associated with NAPA.* Because procainamide is such a widely used antiarrhythmic agent, this association has important clinical implications. The following case confirms this association of torsade de pointes with NAPA. A 57-year-old black man was admitted to the St. Louis Veterans Administration Medical Center on June 21, 1982, with a diagnosis of biventricular heart failure. There were no symptoms or history suggestive of coronary artery disease or cardiac arrhythmias. He was taking no medications. The admission ECG showed sinus rhythm, right bundle branch block, and a QT interval of 0.46 second. Two-dimensional echocardiography showed marked fourchamber enlargement and severe diffuse left ventricular hypokinesis. He improved on treatment with digoxin, furosemide, and hydralazine. On June 25, however, he had a cardiopulmonary arrest, with a slow idioventricular rhythm but no ventricular tachycardia. He was intubated and stabilized but required mechanical ventilation. A

Correlation of 99mTc-pyrophosphate myocardial accumulation with left ventricular wall motion abnormalities.

Reports have indicated that myocardial accumulation of 99mTc-pyrophosphate occurs in the absence of a recent myocardial infarction. An attempt was made to determine if myocardial accumulation, in the absence of a recent infarction, may be associated with left ventricular wall motion abnormalities. 51 patients undergoing elective left ventriculography had 99mTc-pyrophosphate cardiac scans 24-28 h prior to the procedure. 33 (33/51) patients had myocardial accumulation; all 33 had left ventrcular wall motion abnormalities. Localized myocardial accumulation occurred in 21 (21/33) patients; 19 of the 21 had localized left ventricular wall motion abnormalities corresponding to the area of myocardial accumulation. 12 (12/33) patients had diffuse myocardial accumulation; 4 had diffuse left ventricular hypokinesis and 8 had localized myocardial dysfunction. 18 (18/51) patients had no myocardial accumulation of the radionuclide; 9 had normal wall motion in all areas and 9 had localized dysfunction. The data strongly suggest that myocardial accumulation of 99mTc-pyrophosphate in the absence of a recent myocardial infarction is associated with a left ventricular wall motion abnormality.

Small vessel disease of the heart resulting in myocardial necrosis and death despite angiographically normal coronary arteries

A 46 year old man who had undergone cardiac transplantation 1 year previously had progressive congestive heart failure without evidence of cardiac rejection. Cardiac catheterization and angiography revealed a reduced ejection fraction and cardiac output caused by diffuse left ventricular hypokinesia, but the epicardial coronary arteries were widely patent. The transit time of injected contrast material across the coronary arterial tree was greatly slowed. Within a few days cardiogenic shock and death occurred. The large epicardial coronary vessels were grossly patent at autopsy, although nonstenosing arteriosclerotic plaques were identifiable histologically. However, intramyocardial vessels showed severe arteriosclerotic narrowing, resulting in multiple, diffuse microinfarcts.

Clinical utility of gated cardiac blood pool imaging in congestive left heart failure

Our experience with gated cardiac blood pool imaging in the evaluation of congestive left-sided heart failure was reviewed in 82 patients. Ventricular contraction patterns, right and left ventricular size, and regional wall motion were evaluated from technetium-99m-albumin gated blood pool scans obtained in anterior and left anterior oblique projections. Patterns of ventricular function shown by scan were classified as follows: normal right and left ventricular size and contraction, normal left ventricular size with right ventricular enlargement, left ventricular volume overload, diffuse left ventricular hypokinesis, regional left ventricular asynergy, left ventricular aneurysm and hypertrophic cardiomyopathy. In 34 of 36 patients who underwent cardiac catheterization, the pattern of left ventricular dysfunction revealed by scan agreed with the findings on left ventriculography. Left ventricular end-diastolic diameters were significantly (p < 0.001) increased in patients with heart failure due to previous myocardial infarction, congestive cardiomyopathy, left ventricular volume overload and left ventricular pressure overload. Right ventricular diameters were increased predominantly among patients with congestive cardiomyopathy and mitral stenosis. Clinically, gated cardiac imaging was useful for (1) diagnostic screening prior to cardiac catheterization; (2) determination of the potential for improvement with surgical operation; and (3) prognostication from the severity of left ventricular dysfunction.

Striking Electrocardiographic Changes Associated with Pheochromocytome: Masquerading as Ischemic Heart Disease

A patient with pheochromocytoma presented striking electrocardiographic changes mimicking ischemic heart disease at one time and acute pulmonary embolism at other times. Diffuse left ventricular hypokinesia was demonstrated in the presence of normal coronary arteries. Following removal of the pheochromocytoma, the electrocardiographic abnormalities disappeared.

Clinical experience with left main coronary artery stenosis.

We report the clinical features and the results of investigation and surgery in 20 patients with significant left main coronary artery stenosis. All had moderate to severe angina; 8 had pain at rest. Three had dyspnoea as a major symptom. The electrocardiogram was abnormal in 17, with evidence of previous myocardial infarction in 10. Of the 11 patients exercised, 8 developed chest pain. Nine patients had a normal left ventriculogram. At coronary angiography all patients had major disease elsewhere in addition to the left main coronary artery stenosis. There were no deaths or major complications associated with this investigation. One patient was unsuitable for surgery because of diffuse left ventricular hypokinesia, one had a fatal myocardial infarction while awaiting operation, and there was one preoperative death. Sixteen of the 17 surgical survivors are free from angina. There has been a significant improvement in the maximum exercise capacity in the 10 patients who had pre- and postoperative exercise tests.

Severe alcoholic cardiomyopathy reversed with abstention from alcohol

In a chronic alcoholic with a severe congestive cardiomyopathy the angiographic and hemodynamic evidence of left ventricular dysfunction was completely reversed after 1 year of abstinence. At the time of initial presentation two of the traditional hallmarks of a poor prognosis were present, namely, a long exposure to alcohol before the onset of symptoms and severe diffuse left ventricular dilatation and hypokinesis (ejection fraction 14.9 percent). Yet, today, 18 months later he is asymptomatic, receiving no medications and has normal left ventricular function. A reexamination of prognostic factors in alcoholic cardiomyopathy may be indicated.

Scintiphotographic Evaluation of Patients with Suspected Left Ventricular Aneurysm

Twenty-two patients with a history of myocardial infarction and suspected of having a left ventricular aneurysm were evaluated by routine clinical studies, gated cardiac blood pool scanning, and contrast left ventriculography. Thirteen patients were found to have a localized left ventricular aneurysm and nine demonstrated diffuse left ventricular hypokinesis on contrast angiography. The patients with localized left ventricular aneurysms could not be separated from those with diffuse left ventricular hypokinesis on the basis of the routine clinical evaluation including the chest roentgenogram or the finding of ST-segment elevation in the electrocardiogram. Scintiphotographic studies identified the nine with diffuse hypokinesis and twelve of the thirteen with a localized left ventricular aneurysm. In one patient with a calcified left ventricular aneurysm filled with clot, the cardiac blood pool scan showed an area of akinesis which corresponded to that seen on contrast angiography, but the aneurysm could not be detected. In nineteen of the patients in whom adequate measurements were obtained, left ventricular end-diastolic volume and ejection fraction by both contrast angiography and gated cardiac blood pool scintiphotography demonstrated a good correlation, r = 0.92 and 0.87, respectively. There was also a good correlation between the extent of left ventricular akinesis seen on contrast angiography and gated scintiphotography, r = 0.97. This study demonstrates that biplane gated cardiac blood pool scans are useful in differentiating patients with localized left ventricular aneurysms from those with diffuse left ventricular hypokinesis.