Echocardiographic Left Ventricular Wall Motion Research Articles

Plasma brain natriuretic peptide level on admission predicts long-term outcome in patients with non-traumatic subarachnoid hemorrhage

IntroductionNon-traumatic subarachnoid hemorrhage (SAH) is a type of stroke that still has a high mortality rate. Some patients with SAH have electrocardiography (ECG) abnormalities or asymptomatic left ventricular apical ballooning, and requires intervention by cardiologists. However, the impact of cardiac abnormalities after SAH onset remains unclear. We investigated whether ECG abnormalities, myocardial damage, sympathetic nervous activity or echocardiographic left ventricular wall motion abnormalities (WMA) could provide additional risk stratification in patients with SAH. MethodsWe studied 118 SAH patients (78 women, age 63 ± 15) without a history of heart disease. Neurological grade (Hunt and Kosnik Grade) and clinical factors were evaluated. A standard 12-lead ECG, echocardiography and blood samples were obtained within 48 h after SAH onset. ECG abnormalities were defined as abnormal Q wave, ST elevation, giant T-wave inversion or QT prolongation. ResultsTwenty of 118 patients (17%) died during the follow-up (35 ± 31 months). Death was significantly associated with higher age (p < 0.0001), neurological grade (p < 0.0001), elevated BNP level (p < 0.0001), increased plasma norepinephrine levels (p < 0.0001) and WMA (p = 0.0070), while ECG abnormalities were not significantly associated. Neurological grade (p < 0.0001), age (p = 0.0047) and BNP (p = 0.0014, hazard ratio 1.0255 for each 1 pg/mL increase in BNP, 95%CI 1.0088 to 1.0499) were independently associated with death. Patients with BNP ≥ 96.6 had a higher risk of death (log- rank p < 0.0001). ConclusionPlasma BNP might provide an additional risk stratification in patients with non-traumatic SAH that requires intervention by cardiologists for both its prevention management after onset.

Role for MicroRNA-21 in Atrial Profibrillatory Fibrotic Remodeling Associated With Experimental Postinfarction Heart Failure

Atrial tissue fibrosis is often an important component of the atrial fibrillation (AF) substrate. Small noncoding microRNAs are important mediators in many cardiac remodeling paradigms. MicroRNA-21 (miR-21) has been suggested to be important in ventricular fibrotic remodeling by downregulating Sprouty-1, a protein that suppresses fibroblast proliferation. The present study examined the potential role of miR-21 in the atrial AF substrate resulting from experimental heart failure after myocardial infarction (MI). Large MIs (based on echocardiographic left ventricular wall motion score index) were created by left anterior descending coronary artery ligation in rats. Changes induced by MI versus sham controls were first characterized with echocardiography, histology, biochemistry, and in vivo electrophysiology. Additional MI rats were then randomized to receive anti-miR-21 (KD21) or scrambled control sequence (Scr21) injections into the left atrial myocardium. Progressive left ventricular enlargement, hypocontractility, left atrial dilation, fibrosis, refractoriness prolongation, and AF promotion occurred in MI rats versus sham controls. Atrial tissues of MI rats showed upregulation of miR-21, along with dysregulation of the target genes Sprouty-1, collagen-1, and collagen-3. KD21 treatment reduced atrial miR-21 expression levels in MI rats to values in sham rats, decreased AF duration from 417 (69-1595; median [Q1-Q3]) seconds to 3 (2-16) seconds (8 weeks after MI; P<0.05), and reduced atrial fibrous tissue content from 14.4 ± 1.8% (mean ± SEM) to 4.9 ± 1.2% (8 weeks after MI; P<0.05) versus Scr21 controls. MI-induced heart failure leads to AF-promoting atrial remodeling in rats. Atrial miR-21 knockdown suppresses atrial fibrosis and AF promotion, implicating miR-21 as an important signaling molecule for the AF substrate and pointing to miR-21 as a potential target for molecular interventions designed to prevent AF.

Electrocardiographic markers predict left ventricular wall motion improvement in patients with acute myocardial infarction receiving thrombolysis

In patients with ST-elevation myocardial infarction (STEMI) treated with fibrinolysis, prediction of early left ventricular wall motion changes is important for prognosis. In 106 patients with STEMI treated with thrombolysis, we analyzed the degrees of total and maximal ST-segment resolution at 3 hours and changes in sums of T-wave amplitudes in leads with ST elevation 3 and 48 hours after thrombolysis as the predictors of the echocardiographic left ventricular wall motion score index (WMSI) improvement. Wall motion score index improvement was best predicted by total ST-segment resolution of more than 44% in anterior infarctions (sensitivity, 81%; specificity, 62%) and more than 59% in nonanterior infarctions (sensitivity, 100%; specificity, 42%) and by difference in sums of T-wave amplitudes between electrocardiograms at 48 hours and baseline less than -28 mm (sensitivity, 68%; specificity, 76%). In STEMI, the total ST-segment resolution 3 hours and T-wave changes at 48 hours after thrombolysis are the reliable predictors of the left ventricular WMSI improvement.

The Reliability of Echocardiographic Left Ventricular Wall Motion Index to Identify High‐Risk Patients for Multicenter Studies

To study whether the use of echocardiographic left ventricular (LV) wall motion index (WMI) is a dependable parameter for identifying patients with LV dysfunction to be enrolled in multicenter trials. Videotaped echocardiographic examinations from 200 randomly selected patients that were screened for inclusion into the DIAMOND-CHF and DIAMOND-MI trials were reevaluated by an external expert echocardiographer. WMI was calculated using the 16-segment LV model. The external echocardiographer systematically found lower values of WMI than the core laboratory. The average difference in WMI was 0.18 (SD: 0.33) in the DIAMOND-CHF trial and 0.09 (SD: 0.33) in the DIAMOND-MI trial. The difference in WMI exceeded 0.33 in 34% of the patients in both trials. The cutoff value for inclusion into the DIAMOND trials was WMI < or = 1.2. There was an agreement on WMI dichotomized to below or above 1.2 in 82% of the patients in both trials (kappa coefficient 0.66 for the DIAMOND-CHF and 0.55 for the DIAMOND-MI). Despite substantial interlaboratory variation in WMI in individual patients and a systematic lower WMI score by the external echocardiographer there was an acceptable overall agreement for identifying patients with severe impairment of LV function. This not only underscores the value of LV-WMI as a useful tool for selecting high-risk patients to be included in multicenter studies but also serves to warn against the use of rigid cutoff values for WMI in the treatment of individual patients.

Abciximab improves 6-month clinical outcome after rescue coronary angioplasty

Background Few data are available concerning the effects on clinical outcome and left ventricular function of abciximab administration in patients undergoing rescue percutaneous transluminal coronary angioplasty (PTCA) after failed thrombolysis for acute myocardial infarction. The aim of the study was to investigate such effects. Methods Eighty-nine consecutive patients referred to our laboratory from other hospitals for rescue PTCA within 24 hours from the onset of chest pain were prospectively randomized before the procedure to abciximab treatment (44 patients) or placebo (45 patients). No significant differences in baseline characteristics were observed between the 2 groups. Study end points were the occurrence of major adverse cardiac events (MACE) such as death, reinfarction, congestive heart failure, target lesion revascularization, or recurrent ischemia at 30-day and 6-month follow-up and the occurrence of periprocedural bleeding. Results Mean time from symptom onset to reperfusion was 8.5 ± 5.4 hours; rescue PTCA was successful in 96% of patients. The incidence of major, moderate, and minor bleeding was similar in the 2 groups. At 30-day follow-up, the echocardiographic left ventricular wall motion score index showed a significantly higher improvement in the abciximab group versus the placebo group (P <.001). At 6-month follow-up, the incidence of MACE was 11% in the abciximab group versus 38% in the placebo group (P =.004). Abciximab administration (P =.003) and cardiogenic shock (P =.005) were the only independent predictors of the occurrence of MACE at multivariable analysis. Conclusion Treatment with abciximab during rescue PTCA positively affects clinical outcome at 6-month follow-up without increasing periprocedural bleeding. (Am Heart J 2002;143:334-41.)

Thallium-201 Myocardial Imaging at Rest in Male Orienteers and Other Endurance Athletes

During the period 1979 to 1992, 16 sudden unexpected cardiac deaths were known to have occurred in young Swedish orienteers. Autopsy indicated myocarditis to be the most frequent finding, most often combined with extensive myocardial fibrosis. The aim of the present investigation was to explore whether young male orienteers show a higher frequency than other young elite endurance athletes (controls) in the occurrence of Thallium-201 myocardial perfusion defects at rest, suggestive of fibrosis evoked by myocarditis. Thallium-201 perfusion abnormalities at rest were more frequently found in the controls than in the orienteers (26% vs. 12%, p=0.03). Uneven Tl-201 perfusion was associated with left ventricular mass (r=0.32, r=0.24, p<0.01, p=0.02) and body weight (r=0.30, r=0.31, p<0.01, p=0.03) in orienteers and controls, respectively. Echocardiographic left ventricular wall motion abnormalities were found in 11 athletes (9 orienteers and 2 controls) but only two displayed an abnormal Thallium-201 perfusion scan at rest. Perfusion abnormalities at rest did not occur more frequently in the orienteers but were commonly found in both groups of apparently healthy athletes making it futile to discern abnormals from normals. Thallium-201 perfusion aberrations were not associated with left ventricular wall motion abnormalities obtained by echocardiography.

Influence of reversible segmental left ventricular dysfunction on heart period variability in patients with one-vessel coronary aetery disease

Objectives. This study evaluated the relation between reversible segmental left ventricular dysfunction and frequency domain measures of heart period variability in patients with coronary artery disease.Background. Heart period variability is frequently reduced in patients with coronary artery disease. However, the mechanisms of this reduction are still unclear. Methods. Echocardiographic left ventricular wall motion and frequency domain measures of heart period variability were evaluated in 32 patients with one-vessel coronary artery disease before and 16 to 24 days after successful percutaneous transluminal coronary angioplasty. Of these, 12 patients (Group A) had normal and 20 patients (Group B) had abnormal regional wall motion. A control group of 15 healthy subjects (Group C) underwent 24-h Holter recording twice at 2-week intervals to check for spontaneous variations.Results. At baseline, low and high frequency power were lower in Group B than in Groups A and C, whereas no difference was detectable in ultra low and very low frequency and total power. After coronary angioplasty, regional wall motion and frequency domain measures of heart period variability were unchanged in Group A. In Group B the mean (±SD) summed segment score improved from 17.1 ± 3.6 to 12.8 ± 2.0 (p < 0.01), and mean low and high frequency power (logarithmic units) increased from 6.14 ± 0.23 to 6.35 ± 0.34 (p < 0.01) and from 5.43 ± 0.32 to 5.68 ± 0.52 (p < 0.01), respectively. Furthermore, low and high frequency power, lower at baseline in Group B than in the other two groups, were comparable in the three groups after coronary angioplasty.Conclusions. This study demonstrates that segmental left ventricular dysfunction is involved in determining sympathovagal imbalance in patients with one-vessel coronary artery disease; the reversal of left ventricular dysfunction by successful coronary angioplasty improves the heart period power spectrum. Thus, alterations in cardiac geometry influence the discharge of afferent sympathetic mechanoreceptors, contributing to the derangement in autonomic control of heart rate.

Clinical application of coronary sinus retroperfusion during high risk percutaneous transluminal coronary angioplasty

Objectives. This study was designed to determine the efficacy of synchronized coronary sinus retroperfusion of arterial blood in reducing myocardial ischemia associated with the performance of high risk coronary angioplasty.Background. Previous animal and clinical work has demonstrated the efficacy of this technique in supporting ischemic myocardium.Methods. Twenty-one patients were randomized to alternately receive coronary sinus retroperfusion support during either the second or the third coronary angioplasty balloon inflation, after an initial unsupported brief control inflation. Myocardial ischemia was assessed by the extent of echocardiographic left ventricular wall motion abnormality, quantified ST segment deviation and hemodynamic and anginal variables during balloon inflations performed with and without coronary sinus retroperfusion support. Regional wall motion score was defined as hyperkinesia (−1), normokinesia (0), hypokinesia (+1), akinesia (+2) and dyskinesia (+3).Results. A reduction in the echocardiographic left anterior descending regional wall motion score in retroperfusion-supported (1.7 ± 2.1) versus unsupported (2.7 ± 1.6) inflations (p < 0.05) was noted. Twelve-lead electrocardiographic monitoring revealed no additional ST segment deviation during supported (173 ± 95 s) compared with unsupported (129 ± 87 s) angioplasty inflations despite a significantly longer duration of supported inflations (p < 0.004). Mean and peak systolic coronary sinus pressures differed during supported inflations (21 ± 6 and 44 ± 13 mm Hg) versus unsupported inflations (10 ± 4 and 16 ± 5 mm Hg) (p < 0.001). There was no difference in hemodynamic or anginal variables.Conclusions. A reduction in ischemia as defined by wall motion abnormality during retroperfusion-supported compared with unsupported angioplasty balloon inflations was documented. No additional ST segment deviation occurred during retroperfusion-supported compared with unsupported balloon inflations despite a significantly longer duration of supported inflations. No difference in hemodynamic or anginal variables was noted.

Emergency room infusion of intravenous streptokinase in acute myocardial infarction: Feasibility, safety, and hemodynamic consequences

Between September 1, 1986, and December 31, 1987, sixty-four consecutive patients younger than 70 years, with early (less than 4 hours) symptoms and signs of myocardial infarction, were treated with 1.5 million units streptokinase intravenously in the emergency room (ER group) before admission to the coronary care unit. Data from these patients were compared in retrospect to those of 66 consecutive patients with myocardial infarction who were treated with intravenous streptokinase in the coronary care unit (CCU group) before September 1, 1986. Time between first symptoms and initiation of fibrinolytic therapy was significantly shorter in the ER group: 114 ± 53 minutes vs 150 ± 56 minutes in the CCU group ( p < 0.001). The incidence of in-hospital complications was similar in both groups. However, left ventricular stroke work index during the stay in the coronary care unit was 50 ± 19 gm/m 2 in the ER group vs 42 ± 14 in the CCU group ( p = 0.02). Also the echocardiographic left ventricular wall motion score at 48 hours after admission tended to be better in the ER group: 6.7 ± 4.0 compared to that in the CCU group (7.6 ± 4.5; p = 0.29). In conclusion, infusion of intravenous streptokinase in the emergency room is feasible and safe and results in a significant time gain leading to a better hemodynamic profile. Within the hospital the emergency room is the ideal place for intravenous fibrinolytic therapy in eligible patients with acute myocardial infarction.

Dissociation between two-dimensional echocardiographic left ventricular wall motion and myocardial salvage in early experimental acute myocardial infarction in dogs

This study was designed to evaluate whether the effects of coronary reperfusion with or without a pharmacologic agent could be detected in the early hours after infarction by 2-dimensional (2-D) echocardiography applied in a manner analogous to its clinical use. Proximal left anterior descending coronary occlusion was performed in 24 dogs, and the dogs were then randomized into 3 groups. In group 1 (n = 8), coronary occlusion was maintained for 6 hours; in group 2 (n = 8), coronary occlusion was maintained for 2 hours and was followed by 4 hours of reperfusion; in group 3 (n = 8), 2 hours of coronary occlusion were followed by 4 hours of reperfusion but methylprednisolone (30 mg/kg intravenously) was also administered 15 minutes after coronary occlusion. At 6 hours, 2-D images were obtained through the closed chest wall and the percentage of the left ventricular wall motion abnormalities was determined at 4 short-axis levels. The mass at risk was defined by in vivo Monastral blue injection and infarction by triphenyltetrazolium chloride staining. The mass of necrosis was 74 +/- 4% (mean +/- standard error of the mean) of the mass at risk in group 1 and was smaller in groups 2 and 3, 44 +/- 6% and 35 +/- 4%, respectively (p less than 0.01). Percent necrosis of the left ventricle was 22 +/- 3% in group 1, 15 +/- 3% in group 2 (difference not significant) and 10 +/- 2% in group 3 (p less than 0.05 vs group 1).(ABSTRACT TRUNCATED AT 250 WORDS)