Global Wall Motion Abnormalities Research Articles

1232 Acute myocarditis: prognostic role of speckle tracking echocardiography and cardiac magnetic resonance

Abstract Background Myocarditis is an inflammatory disease of the myocardium predominantly caused by infection with subsequent immunological response. Cardiac magnetic resonance (CMR) is the currently best imaging modality to confirm a suspected diagnosis of myocarditis. Conventional echocardiography can detect regional or global wall motion abnormalities but it could also be negative. Speckle tracking echocardiography can help to identify subtle systolic dysfunction, in patients with myocardits and apparently negative echocardiogram. Purpose the aim of this study was to identify cardiac imaging parameters predictive of cardiovascular events in patients with acute myocarditis. Methods a prospective study was carried out using 76 patients with acute myocarditis. Cardiological evaluation including echocardiogram and CMR with quantitative analysis of edema and delayed enhancement (DE) was performed in all patients at the hospital admission. In 43 patients we assessed multilayer 2D speckle tracking analysis measuring GLS at three levels (mid-wall layer, endocardial and epicardial) and mechanical dispersion (MD). We assessed cardiovascular events during hospitalization in all patients (arrhythmias, heart failure, cardiogenic shock, syncope). Results we found significant higher value of DE mass in patients with cardiovascular events compared to patients without cardiovascular events (20,23 ± 11,47gr vs 11,58 ± 9,54gr; p = 0,021). GLS and multilayer strain at each level was significantly lower in patients with events than in patients without events (GLS epicardial -16,29 ± 1,76% vs -14,54 ± 2,19%; p = 0,013; GLS mid-wall -18,22 ± 1,94% vs -16,27 ± 2,48%; p = 0,013; GLS endocardial -19,83 ± 1,91% vs -17,81 ± 2,65%; p = 0,011). MD was significantly higher in patients with cardiovascular events (48.50 ± 15.79 ms vs 34.12 ± 6.22ms; p < 0,001). Logistic regression analysis showed that DE is a good predictor of events (ROCarea 0,81-OddsRatio 1,09). Also GLS seems to be predictive of events (GLS epicardial: ROC area 0,72-OddsRatio 1,57; GLS mid wall: ROC area 0,73-OddsRatio 1,52; GLS endocardial: ROC area 0,72-OddsRatio 1,48). With segmental analysis, inferior and lateral walls seemed to be more predictive of events. Segment 9 had a good predictability in all layers (epicardial: ROCarea 0,8-OddsRatio 1,69; mid wall: ROCarea 0,83- OddsRatio 1,77; endocardial: ROC area 0,82-OddsRatio 1,69). MD was a slight predictor of events with ROC area < 0,7. Conclusions Speckle tracking echocardiography could be used in addiction to cardiac magnetic resonance to get more information about prognosis and events risk stratification in patients with acute myocarditis.

MR imaging of arrhythmogenic right ventricular dysplasia: What the radiologist needs to know.

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is an inherited heart muscle disease that predominantly affects the right ventricle. Clinical manifestations are related to severe ventricular arrhythmia that may lead to sudden death, mostly in young patients. Magnetic resonance imaging (MRI), included in the new diagnostic criteria since 2010, aims to detect segmental and global wall motion abnormalities, reduced ejection fraction, right ventricular dilatation and right ventricular diastolic/systolic dysfunction. An MRI assessment of the right ventricle is often challenging, partly because the MRI diagnostic criteria have some limitations, and also because it requires a significant learning curve due to the low prevalence of the disease. Therefore, this article aims to review the pathophysiology of the disease, the cardiac MRI protocol, images of the various stages of this affection as well as the differential diagnosis.

Clinical and echocardiographic profile and outcomes of peripartum cardiomyopathy: the Philippine General Hospital experience

BackgroundPeripartum cardiomyopathy (PPCM) is a rare disease entity of unknown aetiology. High rates of mortality or poor overall clinical outcome are reported in women with this condition. Certain characteristics are...

Automatic assessment of regional and global wall motion abnormalities in echocardiography images by nonlinear dimensionality reduction

Identification and assessment of left ventricular (LV) global and regional wall motion (RWM) abnormalities are essential for clinical evaluation of various cardiovascular diseases. Currently, this evaluation is performed visually which is highly dependent on the training and experience of echocardiographers and thus is prone to considerable interobserver and intraobserver variability. This paper presents a new automatic method, based on nonlinear dimensionality reduction (NLDR) for global wall motion evaluation and also detection and classification of RWM abnormalities of LV wall in a three-point scale as follows: (1) normokinesia, (2) hypokinesia, and (3) akinesia. Isometric feature mapping (Isomap) is one of the most popular NLDR algorithms. In this paper, a modified version of Isomap algorithm, where image to image distance metric is computed using nonrigid registration, is applied on two-dimensional (2D) echocardiography images of one cycle of heart. By this approach, nonlinear information in these images is embedded in a 2D manifold and each image is characterized by a point on the constructed manifold. This new representation visualizes the relationship between these images based on LV volume changes. Then, a new global and regional quantitative index from the resultant manifold is proposed for global wall motion estimation and also classification of RWM of LV wall in a three-point scale. Obtained results by our method are quantitatively evaluated to those obtained visually by two experienced echocardiographers as the reference (gold standard) on 10 healthy volunteers and 14 patients. Linear regression analysis between the proposed global quantitative index and the global wall motion score index and also with LV ejection fraction obtained by reference experienced echocardiographers resulted in the correlation coefficients of 0.85 and 0.90, respectively. Comparison between the proposed automatic RWM scoring and the reference visual scoring resulted in an absolute agreement of 82% and a relative agreement of 97%. The proposed diagnostic method can be used as a useful tool as well as a reference visual assessment by experienced echocardiographers for global wall motion estimation and also classification of RWM abnormalities of LV wall in a three-point scale in clinical evaluations.

Acute regional myocarditis with normal ventricular wall motion diagnosed by two-dimensional speckle tracking imaging

Acute regional myocarditis with normal ventricular wall motion diagnosed by two-dimensional speckle tracking imaging

Prevalence and Prognostic Significance of Wall-Motion Abnormalities in Adults Without Clinically Recognized Cardiovascular Disease

Left ventricular wall motion (WM) abnormalities have recognized prognostic significance in patients with coronary or other heart diseases; however, whether abnormal WM predicts adverse events in adults without overt cardiovascular disease has not been assessed. Our objective was to determine whether echocardiographic WM abnormalities predict subsequent cardiovascular events in a population-based sample. Participants (n=2864, mean age 60+/-8 years, 64% women) without clinically evident cardiovascular disease in the second Strong Heart Study examination who had complete echocardiographic WM assessment were studied. Echocardiographic assessment revealed that 5% of participants (n=140) had focal hypokinesia, and 1.5% (n=42) had WM abnormalities. Relationships between WM abnormalities and fatal and nonfatal cardiovascular events (including myocardial infarction, stroke, coronary artery disease, and heart failure; n=554) and cardiovascular death (n=182) during 8+/-2 years follow-up were examined. In Cox regression, after adjustment for age, gender, waist/hip ratio, systolic blood pressure, and diabetes mellitus, segmental WM abnormalities were associated with a 2.5-fold higher risk of cardiovascular events and a 2.6-fold higher risk of cardiovascular death (both P<0.0001). In similar multivariable models, global WM abnormalities were associated with a 2.4-fold higher risk of cardiovascular events (P=0.001) and a 3.4-fold higher risk of cardiovascular death (P=0.003). Echocardiographic left ventricular WM abnormalities in adults without overt cardiovascular disease are associated with 2.4- to 3.4-fold higher risks of cardiovascular morbidity and mortality, independent of established risk factors.

Discordance between echocardiographic and MRI findings in two cases of acute myocarditis mimicking myocardial infarction

Two male adolescents were admitted due to chest pain influenced by the respiratory movements. A lobar pneumonia caused by Mycoplasma pneumoniae, was radiographically and serologically diagnosed in the first patient (a 15-year-old boy) and a febrile diarrhea of unidentified etiology, despite repetitive stool cultures and serological assessments in the second one (a 19-year-old male). Both patients combined the aforementioned infectious conditions with outstanding thoracic pain the previous hours before admission, markedly elevated cardiac enzymes and ST-segment elevation in the inferior and left precordial leads with a normal coronary angiogram, thus composing a clinical setting highly indicative of acute myocarditis. Surprisingly however, the echocardiogram performed in both patients failed to reveal any regional or global wall motion abnormalities or even diastolic dysfunction and remained absolutely normal throughout their 3-month follow-up period. Cardiac MRI within 7 days, using T2-weighted and gadolinium-enhanced T1-weighted images demonstrated extensive focal contrast enhancement, consistent with acute inflammatory myocardial involvement. It can therefore be concluded that contrast MRI is a more sensitive method than the echocardiogram for the diagnosis of acute focal myocarditis.

Endomyocardial Fibrosis and Intracardiac Thrombus Occurring in Idiopathic Hypereosinophilic Syndrome

Case Report A 59-year-old woman was examined to investigate weakness, fatigue, and abdominal pain. Clinical examination revealed vitiligo, raised jugular venous pressure, bilateral pleural effusion, splenomegaly, and mild peripheral edema. Laboratory studies showed an absolute eosinophilia level of 10%, thrombocytopenia, and abnormally elevated liver enzyme levels. A triphasic abdominal CT scan (not shown) revealed a nonenhancing thrombus in both ventricular cavities, a small pericardial effusion, and bilateral pleural effusion. Cardiac MRI was requested to exclude the presence of a pericardial mass suggested by the findings of transthoracic echocardiography performed on the same day as the CT. ECG-gated cardiac MRI was performed on a 1.5-T scanner (Sonata, Siemens). Multiple sequences were obtained, including singleshot and retrospective gated balanced gradient-echo (true fast imaging with steady-state precession [FISP]) cine; fat-suppressed HASTE; unenhanced and enhanced T1weighted gradient-echo; and delayed, enhanced viability (inversion recovery prepared turbo fast low-angle shot) obtained after a 10min delay following IV administration of double-dose gadolinium (0.2 mmol/kg). No pericardial mass was identified. The endocardium of both ventricles was more intense than the deeper myocardium on true FISP (Fig. 1A) and HASTE (Fig. 1B) sequences and showed intense linear hyperenhancement on the delayed viability sequences (Fig. 1C). Extensive nonenhancing thrombus was present in both ventricles (Fig. 1D). Both right and left ventricles showed qualitatively normal function on cine sequences, with no regional or global wall motion abnormalities. Large bilateral pleural effusions and a small pericardial effusion were present. After cardiac MRI, coronary angiography was performed and found no significant coronary artery disease in any vessel. Ventriculography revealed apical obliteration of both ventricles. A right ventricular biopsy was also performed; however, pathologic examination of the obtained specimens revealed mainly thrombus with some necrotic tissue. Despite the biopsy results, a diagnosis of endomyocardial fibrosis secondary to IHES was made on the basis of the imaging, clinical, and laboratory findings. The MRI findings of increased signal intensity and contrast enhancement not corresponding to a vascular territory involving the endocardium of both ventricles, together with the unremarkable coronary angiography findings, excluded prior infarction from coexistent ischemic heart disease. Because Loeffler’s syndrome more commonly affects the left ventricle in isolation, this syndrome was considered less likely than IHES. Unfortunately, despite corticosteroid and hydroxyurea therapy, the patient’s condition continued to decline and she died from septicemia 4 weeks after initial presentation.

Computer-aided diagnosis via model-based shape analysis: Automated classification of wall motion abnormalities in echocardiograms 1

Shape analysis of endocardial contour sequences from echocardiograms can provide classification of wall motion abnormalities (WMA). We previously reported on active appearance motion models (AAMM) for automated detection of endocardial contours in sequences of echocardiograms. The shape analysis of AAMM renders eigenvariations of shape/motion, including typical normal and pathologic endocardial contraction patterns. A set of stress echocardiograms (single-beat four-chamber and two-chamber sequences with expert-verified endocardial contours) of 129 infarct patients was split randomly into training (n = 65) and testing (n = 64) sets. AAMMs were generated from the training set and AAMM shape coefficients (ASCs) were extracted for all sequences and statistically related to regional/global visual wall motion scoring (VWMS) and volumetric parameters. Linear regression showed clear correlations between ASCs and VWMS. Discriminant analysis showed good prediction by ASCs of both segmental (74% correctness) and global WMA (90% correctness). Volumetric parameters correlated poorly to regional VWMS. 1) ASCs show promising accuracy for automated WMA classification. 2) VWMS and endocardial border motion are closely related; with accurate automated border detection, automated WMA classification should be feasible. 3) ASC shape analysis allows contour set evaluation by direct comparison to clinical parameters.

2-D echocardiography prediction of adverse events in ED patients with chest pain

The objective of this study was to establish the efficacy of two-dimensional (2-D) echocardiography (echo) in predicting adverse cardiac events in patients presenting to the ED with possible acute coronary syndrome (ACS). Patients 25 years of age or older having symptoms consistent with ACS and a non-diagnostic electrocardiogram (ECG) were evaluated with 0-, 3-, 6-, and 9-hour creatine kinase -MB (CK-MB) assays and continuous 12-lead ECG ST-segment monitoring. Patients with normal serial CK-MB assays and no ECG changes after 9 hours had a resting 2-D transthoracic echo performed. A positive 2-D echo was defined as segmental or global wall motion abnormalities. Patients were followed up after 6 months to identify adverse events resulting from ACS. Of the 1112 patients receiving an echo, 18 had positive studies. None had adverse events on follow-up. Of the 1094 patients with a negative 2-D echo, 15 had adverse events (2 acute myocardial infarctions, 2 coronary artery bypass graftings, and 11 percutaneous transluminal coronary angioplasties). Resting 2-D echo did not predict cardiac adverse events in patients with possible ACS and non-diagnostic serial 12-lead ECG and normal serial CK-MB at the end of a 9-hour evaluation. (Am J Emerg Med 2003;21:106-110. Copyright 2003, Elsevier Science (USA). All rights reserved.)

Echocardiographic wall motion abnormalities in hypertensive patients with electrocardiographic left ventricular hypertrophy: the LIFE Study.

There is limited information on correlates of left ventricular wall motion (WM) abnormalities in ambulatory patients with hypertension and ECG left ventricular hypertrophy by Cornell voltage-duration product and/or Sokolow-Lyon voltage criteria. Therefore, we assessed the prevalence and the correlates of echocardiographic global and segmental left ventricular WM abnormalities in 942 hypertensive patients with hypertrophy enrolled in the Losartan Intervention For End-point reduction in hypertension (LIFE) echo substudy. Patients were separated into groups of those with normal WM or those with segmental or global WM abnormalities. Segmental and global WM abnormalities were mostly of mild degree and were detected in 7% and 6% of the study sample. Compared with subjects with normal motion, those with WM abnormalities were mostly men and had higher prevalences of self-reported coronary heart disease, ECG signs of myocardial infarction, ST-strain pattern, and higher Cornell voltage-duration product, echo-left ventricular mass, and albuminuria, but lower total and high-density lipoprotein cholesterol. Blood pressure was similar among groups. No significant differences were found between patients with global or segmental WM abnormalities. Only half of patients with WM abnormalities had a history or ECG signs of coronary heart disease. Independent correlates of WM abnormalities were higher albuminuria and Cornell voltage-duration product, male gender, and echo-left ventricular hypertrophy, but lower cholesterol. In a subanalysis restricted to patients with WM abnormalities, those with evident cardiovascular disease had a higher prevalence of ST-strain pattern than those with subclinical WM abnormalities, but other clinical, ECG, or echocardiographic parameters were indistinguishable between the 2 groups. Thus, in hypertensives with ECG left ventricular hypertrophy, WM abnormalities, mostly of mild degree, occurred in one eighth of the patients and were associated with male gender, left ventricular hypertrophy, and albuminuria. No significant differences were found between patients with global or segmental wall motion abnormalities.