Left Ventricular Myocardial Segments Research Articles

Multinational experience with next-generation sequencing: opportunity to identify transthyretin cardiac amyloidosis and Fabry disease.

Sarcomeric hypertrophic cardiomyopathy (HCM) must be differentiated from phenotypically similar conditions because clinical management and prognosis may greatly differ. Patients with unexplained left ventricular hypertrophy require an early, confirmed genetic diagnosis through diagnostic or predictive genetic testing. We tested the feasibility and practicality of the application of a 17-gene next-generation sequencing (NGS) panel to detect the most common genetic causes of HCM and HCM phenocopies, including treatable phenocopies, and report detection rates. Identification of transthyretin cardiac amyloidosis (ATTR-CA) and Fabry disease (FD) is essential because of the availability of disease-specific therapy. Early initiation of these treatments may lead to better clinical outcomes. In this international, multicenter, cross-sectional pilot study, peripheral dried blood spot samples from patients of cardiology clinics with an unexplained increased left ventricular wall thickness (LVWT) of ≥13 mm in one or more left ventricular myocardial segments (measured by imaging methods) were analyzed at a central laboratory. NGS included the detection of known splice regions and flanking regions of 17 genes using the Illumina NextSeq 500 and NovaSeq 6000 sequencing systems. Samples for NGS screening were collected between May 2019 and October 2020 at cardiology clinics in Colombia, Brazil, Mexico, Turkey, Israel, and Saudi Arabia. Out of 535 samples, 128 (23.9%) samples tested positive for pathogenic/likely pathogenic genetic variants associated with HCM or HCM phenocopies with double pathogenic/likely pathogenic variants detected in four samples. Among the 132 (24.7%) detected variants, 115 (21.5%) variants were associated with HCM and 17 (3.2%) variants with HCM phenocopies. Variants in MYH7 (n=60, 11.2%) and MYBPC3 (n=41, 7.7%) were the most common HCM variants. The HCM phenocopy variants included variants in the TTR (n=7, 1.3%) and GLA (n=2, 0.4%) genes. The mean (standard deviation) ages of patients with HCM or HCM phenocopy variants, including TTR and GLA variants, were 42.8 (17.9), 54.6 (17.0), and 69.0 (1.4) years, respectively. The overall diagnostic yield of 24.7% indicates that the screening strategy effectively identified the most common forms of HCM and HCM phenocopies among geographically dispersed patients. The results underscore the importance of including ATTR-CA (TTR variants) and FD (GLA variants), which are treatable disorders, in the differential diagnosis of patients with increased LVWT of unknown etiology.

Two-dimensional speckle tracking imaging cardiac motion-based quantitative evaluation of global longitudinal strain among patients with coronary Heart Disease and functions of left ventricular ischemic myocardial segment.

To investigate two-dimensional speckle tracking imaging (2D-STI)-based quantitative evaluation of the influences of different levels of coronary artery stenosis on left ventricular functions and its clinical diagnostic values, 120 patients with coronary heart disease (CHD) were divided into control group (30 cases), mild stenosis group (30 cases), moderate stenosis group (30 cases), and severe stenosis group (30 cases) according to coronary angiography (CAG) results. They underwent routine ultrasound examination and 2D-STI examination. Receiver operating characteristic (ROC) curves were drawn to evaluate the sensitivity and specificity of different levels of coronary artery stenosis. Global longitudinal strain (GLS) of left ventricular myocardium among patients in moderate and severe stenosis groups remarkably declined (P < 0.05). Global radial strain (GRS) and global circular strain (GCS) among patients in severe stenosis group dramatically reduced (P < 0.05). ROC curves revealed that available GLS=-17.2 was the cut-off value for screening moderate coronary stenosis. The sensitivity, specificity, and area under the curve (AUC) amounted to 57.3%, 58.4%, and 0.573, respectively. GLS, GRS, and GCS could be used to screen severe coronary stenosis. When GLS=-16.5 was the cut-off value for screening severe coronary stenosis, sensitivity, specificity, and AUC amounted to 84.3%, 82.5%, and 0.893, respectively. With the aggravation of stenosis, left ventricular systolic function of CHD patients was impaired more significantly. 2D-STI technique could be adopted for the quantitative evaluation of left ventricular strain of patients with coronary stenosis and provided a new method for early clinical diagnosis of CHD.

CMR feature tracking in patients with dilated cardiomyopathy: patterns of myocardial strain and focal fibrosis

BackgroundThere is a paucity of data on cardiovascular magnetic resonance feature tracking (CMR-FT) in patients with dilated cardiomyopathy (DCM). We aimed at describing global and segmental myocardial strain patterns and...

Severe Impairment of Left Ventricular Regional Strain in STEMI Patients Is Associated with Post-Infarct Remodeling.

Background: Measures of global left ventricular (LV) systolic function have limitations for the prediction of post-infarct LV remodeling (LVR). Therefore, we tested the association between a new measure of regional LV systolic function—the percentage of severely altered strain (%SAS)- and LVR after acute ST-elevation myocardial infarction (STEMI). As a secondary objective, we also evaluated the association between %SAS and clinical events during follow-up. Methods: Of 177 patients undergoing echocardiography within 24 h from primary percutaneous coronary angioplasty, 172 were studied for 3 months, 167 for 12 months, and 10 died. The %SAS was calculated by dividing the number of LV myocardial segments with ≥−5% peak systolic longitudinal strain by the total number of segments. LVR was defined as the increase in end-diastolic volume >20% at its first occurrence compared to baseline. Results: LVR percentage was 10.2% and 15.8% at 3 and 12 months, respectively. Based on univariable analysis, a number of clinical, laboratory, electrocardiographic and echocardiographic variables were associated with LVR. Based on multivariable analysis, %SAS and TnI peak remained associated with LVR (for %SAS 5% increase, OR 1.226, 95% CI 1.098–1.369, p < 0.0005; for TnI peak, OR 1.025, 95% CI 1.004–1.047, p = 0.022). %SAS and LVR were also associated with occurrence of clinical events at a median follow-up of 43 months (HR 1.02, 95% CI 1.0–1.04, p = 0.0165). Conclusions: In patients treated for acute STEMI, acute %SAS is associated with post-infarct LVR. Therefore, we suggest performing such evaluations on a routine basis to identify, as early as possible, STEMI patients at higher risk.

Left ventricular remodeling following septal myectomy in hypertrophic obstructive cardiomyopathy

ObjectivesThe purpose of this study is to determine whether or not left ventricular remodeling can be induced after septal myectomy in patients with obstructive hypertrophic cardiomyopathy, and if so, how it occurs, using gated cardiac computed tomography. MethodsFifty patients with hypertrophic obstructive cardiomyopathy who underwent septal myectomy along the septal band between March 2016 and July 2020 were retrospectively reviewed. Recent consecutive 19 patients underwent postoperative cardiac computed tomography. In these patients, volumes of the septal band and thickness of 17 left ventricular myocardial segments were measured to determine the changes after surgery. ResultsThe resection volume predicted by preoperative computed tomography and the actual resection volume were 6.7 ± 3.3 mL and 6.4 ± 2.7 mL. In-hospital mortality was 0%. Moderate or greater mitral valve regurgitation and systolic anterior motion decreased from 56% to 6% and 86% to 6%, respectively. Median preoperative ventricular septal thickness and left ventricular outflow tract pressure gradient at rest decreased from 20.0 mm (interquartile range, 17.0-24.0 mm) and 74.0 mm Hg (interquartile range, 42.5-92.5 mm Hg) to 14.0 mm (interquartile range, 11.5-16.0 mm) and 15.5 mm Hg (interquartile range, 12.1-21.5 mm Hg), respectively. Postoperative computed tomography confirmed a reduction in septal band volume of 5.7 ± 2.8 mL. Total left ventricular myocardial volume was reduced by 12.9 ± 8.8 mL, which exceeded the volume reduction of the resected septal band. All segments except the basal inferior and basal inferolateral regions showed a significant decrease in wall thickness by a median of 6.4%. ConclusionsProperly performed septal myectomy may induce remodeling of the entire left ventricle, not just the resected area.

Early echocardiographic predictors of unfavorable yearly prognosis in patients with acute myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Objective to determine the most informative in the prognostic plan echocardiographic indices in patients with acute myocardial infarction and diabetes mellitus. Methods A retrospective analysis of outcomes of 97 diabetic patients with acute myocardial infarction (AMI), with lesions of two or more coronary arteries was performed. All patients received conventional basic therapy comprising, acetylsalicylic acid, clopidogrel, beta-blocker, an ACE inhibitor, statins, and insulin therapy on a stationary phase for a minimum of 2 weeks, followed by a transition to oral antidiabetics. According to the 12 month follow depending on the outcomes two groups were established: favorable prognosis n = 46 and unfavorable prognosis n = 51, having one or more of the following complications: death, reinfarction (nonfatal), development or progression of heart failure. Results Differences in echocardiographic parameters, characterizing myocardial hypertrophy of left ventricular (LV) were revealed between patients with different outcomes of AMI. Thus, patients with adverse outcome were characterized by a significant increase of LV mass (from 191.2 ± 35.7g to 255.7 ± 46.2 g, p = 0.004) and LV posterior wall thickness (from 8.7 ± 1.04mm to 10.6 ± 1.37mm, p = 0.004) in dynamics. Moreover, a smaller LV ejection fraction (LVEF) was observed in the group with an unfavorable outcome (both initially and in dynamics), as well as large LV end-diastolic volume and end-systolic volume. Single-factor analysis has shown, that EF &amp;lt;40%, LV aneurysm, the involvement of the apical LV myocardial segments at any location were echocardiography predictors of poor outcome. In the group of patients with unfavorable course of AMI, the index of left atrium (LA) increased from 35.8 ± 3.8mm to 37.3 ± 1.8mm (p = 0.04), which is significantly higher than in the second group, where the LA index was 33.8 ± 3.2mm and 34.2 ± 2.9mm (p = 0.7). In the first group, the right ventricle (RV) remained practically unchanged (22.3 ± 2.7mm and 22 ± 3.5 mm, respectively, p = 0.89), while in the second group the size of the RV decreased from 23.2 ± 3.9mm to 20.7 ± 2.9mm (p = 0.38). Initially, when comparing between groups, p = 0.38) and after 1 month p = 0.5). The negative role of pressure in the pulmonary artery (PA) in patients with AMI was also demonstrated. The systolic pressure in the PA index in the group with a favorable outcome in the dynamics significantly decreased, in contrast to the group with an unfavorable outcome (from 19.9 ± 4.5 mmHg to 16.2 ± 2.6 mmHg, p = 0.03 and from 22.1 ± 5.7mmHg to 18.0 ±3.6 mmHg, p = 0.15, respectively). Conclusion AMI with a high risk of adverse 12-month outcomes, characterized by the following echocardiographic signs: engagement apical segments of the LV regardless of the localization of myocardial infarction, reduced LVEF, as well as increased PA pressure, combined with the increase in the size of RV.

384 Morpho-functional analysis of subvalvular apparatus in mitral valve prolapse and response to dipyridamole stress echocardiography. A pilot study

Abstract Aims Myocardial fibrosis has been found in papillary muscles (PM) and basal segment of left ventricular (LV) inferior-lateral wall in patients with mitral valve prolapse (MVP), which may be due to stretch from valve. Moreover, ST-segment depression is common in patients with MVP, despite low prevalence of epicardial coronary artery disease, and it is attributed to microvascular dysfunction or myocardial stretch. Longitudinal strain (LS) correlates with myocardial fibrosis, while dipyridamole stress echocardiography (DSE) identifies microvascular dysfunction. We aimed at assessing morphology and function of PM and left ventricular walls at rest and during DSE by LS, and at determining prevalence of microvascular dysfunction in patients with MVP. Methods and results Seven consecutive patients with MVP (age 55.4 ± 15.7 years, 57% female) and LV ejection fraction 64 ± 5% underwent DSE. Length and LS of PM were measured at rest and retrospectively compared with those of patients with ischaemic heart disease (n = 8, age 67.1 ± 10.1 years, 37% female) and healthy controls (n = 8, age 39.6 ± 13.3 years, 50% female). LS of PM and LV was also determined at rest and during stress in MVP. Length of PM did not differ among groups, but in MVP, posterior PM was longer than the anterior PM (24 ± 3.8 vs. 20.6 ± 3.6 mm, P = 0.028). Significant difference in resting PM LS was found among groups (overall P = 0.04), with PM LS value in MVP (16.7 ± 7.1%) intermediate between ischaemic (14.2 ± 3.2%) and controls (20.5 ± 2.7%). No difference was found between rest and stress LS of PM in MVP. Global LS tended to increase in MVP during DSE compared to rest (23.1 ± 3.8% vs. 21.1 ± 2.6%, respectively, P = 0.07), while no significant difference between rest and stress LS was found in every LV myocardial segments. Nevertheless, in MVP, LS of LV inferior-lateral wall tended to improve under DSE in patients with mild regurgitation (19.7 ± 4.6 vs. 14.2 ± 5 at rest), but to decrease (16 ± 6.1 vs. 20.3 ± 2.3 at rest) in patients with severe mitral regurgitation (P = 0.006 for interaction). ST-segment depression was elicited by DSE in 29% of MVP. No significant difference in echocardiographic parameters was found between patients with and without ST-segment depression. Conclusions In MVP, sub-valvular apparatus may have peculiar morpho-functional features. DSE does not alter LS of PM, neither of LV walls, except for inferior-lateral wall, which impairs in severe mitral regurgitation. Prevalence of microvascular dysfunction is comparable to that of the general population.

Myocardial Deformation Assessed by MR Feature Tracking in Groups of Patients With Ischemic Heart Disease.

Global myocardial strain assessments have been shown to provide useful measures of contractility in many diseases, but whether feature tracking (FT)-derived strain at rest can differentiate ischemic myocardium from infarcted and remote myocardium in patients with coronary artery disease (CAD) remains unclear. To evaluate the performance of magnetic resonance imaging FT-derived strain in the detection of regional myocardial deformation in ischemic, infarcted, and apparent normal myocardium in CAD. Retrospective POPULATION: A total of 109 patients with CAD. Steady-state free-precession rest cine, T1-weighted saturation-recovery fast gradient echo stress/rest perfusion, and two-dimensional phase-sensitive inversion recovery breath-hold late gadolinium enhancement (LGE) tests were performed at 3.0 T. Based on perfusion and LGE images, left ventricular (LV) myocardial segments of CAD patients were categorized into ischemic, infarcted, and negative groups. The FT longitudinal (LS) and circumferential strain (CS) of normal subjects and the three CAD groups were calculated. Z-scores of each segment of CAD patients were calculated. χ2 testing, analysis of variance (ANOVA), and Kruskal-Wallis tests. Z-scores were used to compare the strain between CAD groups. There were significant differences in global LS (GLS) and CS (GCS) between healthy controls (GLS: -19.0% ± 1.4%, GCS, -20.9% ± 1.8%), ischemia (GLS: -17.4% ± 2.1%, GCS, -19.6% ± 1.9%), infarction (GLS: -16.4% ± 1.9%, GCS, -17.8% ± 1.9%), and negative patients (GLS: -17.7% ± 1.4%, GCS, -20.9% ± 2.4%) (all P < 0.05). There were significant differences in regional LS and CS between ischemic (LS, -16.1% ± 5.0%, CS, -18.7% ± 5.0%), infarcted (LS, -14.8% ± 5.2%, CS, -15.3% ± 4.8%), and negative segments (LS, -17.6% ± 5.2%, CS, -19.8% ± 4.8%) (all P < 0.05). The differences in the z-scores of regional LS and CS between the ischemic, infarcted, and negative segments were also significant (all P < 0.05). FT-derived rest strain indices of the LV myocardium of CAD patients were higher compared to healthy controls and varied between ischemic, infarcted, and negative segments. 4 TECHNICAL EFFICACY: Stage 5.

Left and right ventricular strain using fast strain-encoded cardiovascular magnetic resonance for the diagnostic classification of patients with chronic non-ischemic heart failure due to dilated, hypertrophic cardiomyopathy or cardiac amyloidosis

AimsTo compare the ability of left ventricular (LV) and right ventricular (RV) strain measured by fast-strain encoded cardiovascular magnetic resonance (CMR) (fast-SENC) with LV- and RV-ejection fraction for the diagnostic classification of patients with different stages of chronic heart failure (stages A-D based on American College of Cardiology/American Heart Association guidelines) due to non-ischemic cardiomyopathies.MethodsOur study population consisted of 276 consecutive patients who underwent CMR for clinical reasons, and 19 healthy subjects. Wall motion score index and non-infarct related late gadolinium enhancement (LGE), LV ejection fraction (LVEF) and RV ejection fraction (RVEF) and global LV- and RV-longitudinal (GLS) and circumferential strain (GCS) based on fast-SENC acquisitions, were calculated in all subjects. The percentage of LV and RV myocardial segments with strain ≤ − 17% (%normal LV and RV myocardium) was determined in all subjects.ResultsLVEF and RVEF, LV-GLS, LV-GCS, RV-GLS, RV-GCS and %normal LV- and RV myocardium depressed with increasing heart failure stage (p < 0.001 for all by ANOVA). By multivariable analysis, %normal LV and RV myocardium exhibited closer associations to heart failure stages than LVEF and RVEF (rpartial = 0.79 versus rpartial = 0.21 for %normal LV myocardium versus LVEF and rpartial = 0.64 versus rpartial = 0.20 for %normal RV myocardium versus RVEF, respectively). Furthermore, %normal LV and RV myocardium exhibited incremental value for the identification of patients (i) with subclinical myocardial dysfunction and (ii) with symptomatic heart failure, surpassing that provided by LVEF and RVEF (ΔAUC = 0.22 for LVEF and ΔAUC = 0.19 for RVEF with subclinical dysfunction, and ΔAUC = 0.19 for LVEF and ΔAUC = 0.22 for RVEF with symptomatic heart failure, respectively, p < 0.001 for all). %normal LV myocardium reclassified 11 of 31 (35%) patients judged as having no structural heart disease by clinical and imaging data to stage B, i.e., subclinical LV-dysfunction.ConclusionsIn patients with non-ischemic cardiomyopathy, %normal LV and RV myocardium, by fast-SENC, enables improved identification of asymptomatic patients with subclinical LV-dysfunction. This technique may be useful for the early identification of such presumably healthy subjects at risk for heart failure and for monitoring LV and RV deformation during pharmacologic interventions in future studies.

Multi-parametric assessment of left ventricular hypertrophy using late gadolinium enhancement, T1 mapping and strain-encoded cardiovascular magnetic resonance

AimTo evaluate the ability of single heartbeat fast-strain encoded (SENC) cardiovascular magnetic resonance (CMR) derived myocardial strain to discriminate between different forms of left ventricular (LV) hypertrophy (LVH).Methods314 patients (228 with hypertensive heart disease (HHD), 45 with hypertrophic cardiomyopathy (HCM), 41 with amyloidosis, 22 competitive athletes, and 33 healthy controls) were systematically analysed. LV ejection fraction (LVEF), LV mass index and interventricular septal (IVS) thickness, T1 mapping and atypical late gadolinium enhancement (LGE) were assessed. In addition, the percentage of LV myocardial segments with strain ≤ − 17% (%normal myocardium) was determined.ResultsPatients with amyloidosis and HCM exhibited the highest IVS thickness (17.4 ± 3.3 mm and 17.4 ± 6 mm, respectively, p < 0.05 vs. all other groups), whereas patients with amyloidosis showed the highest LV mass index (95.1 ± 20.1 g/m2, p < 0.05 vs all others) and lower LVEF compared to controls (50.5 ± 9.8% vs 59.2 ± 5.5%, p < 0.05). Analysing subjects with mild to moderate hypertrophy (IVS 11–15 mm), %normal myocardium exhibited excellent and high precision, respectively for the differentiation between athletes vs. HCM (sensitivity and specificity = 100%, Area under the curve; AUC%normalmyocardium = 1.0, 95%CI = 0.85–1.0) and athletes vs. HHD (sensitivity = 83%, specificity = 75%, AUC%normalmyocardium = 0.85, 95%CI = 0.78–0.90). Combining %normal myocardial strain with atypical LGE provided high accuracy also for the differentiation of HHD vs. HCM (sensitivity = 82%, specificity = 100%, AUCcombination = 0.92, 95%CI = 0.88–0.95) and HCM vs. amyloidosis (sensitivity = 83%, specificity = 100%, AUCcombination = 0.83, 95%CI = 0.60–0.96).ConclusionFast-SENC derived myocardial strain is a valuable tool for differentiating between athletes vs. HCM and athletes vs. HHD. Combining strain and LGE data is useful for differentiating between HHD vs. HCM and HCM vs. cardiac amyloidosis.

Radiation-Induced Myocardial Fibrosis in Long-Term Esophageal Cancer Survivors.

Radiation-induced cardiac toxicity is a potential lethal complication. The aim of this study was to assess whether there is a dose-dependent relationship between radiation dose and myocardial fibrosis in patients who received neoadjuvant chemoradiation (nCRT) for esophageal cancer (EC). Forty patients with EC treated with a transthoracic esophagectomy with (n = 20) or without (n = 20) nCRT (CROSS study regimen) were included. Cardiovascular magnetic resonance imaging (1.5 Tesla) for left ventricular (LV) function, late gadolinium enhancement, and T1 mapping were performed. Extracellular volume (ECV), as a surrogate for collagen burden, was measured for all LV segments separately. The dose-response relationship between ECV and mean radiation dose per LV myocardial segment was evaluated using a mixed-model analysis. Seventeen nCRT and 16 control patients were suitable for analysis. The mean time after treatment was 67.6 ± 8.1 (nCRT) and 122 ± 35 (controls) months (P = .02). In nCRT patients, we found a significantly higher mean global ECV of 28.2% compared with 24.0% in the controls (P < .001). After nCRT, LV myocardial segments with elevated ECV had received significantly higher radiation doses. In addition, a linear dose-effect relation was found with a 0.136% point increase of ECV for each Gy (P < .001). There were no differences in LV function measures and late gadolinium enhancement between both groups. Myocardial ECV was significantly higher in long-term EC survivors after nCRT compared with surgery only. Moreover, this ECV increase was linear with the radiation dose per LV segment, indicating radiation-induced myocardial fibrosis.

Cardioprotective strategy in ST-elevation acute myocardial infarction patients after reperfusion with percutaneous coronary intervention

Abstract Objectives Reperfusion may cause no-reflow phenomenon. Both microvascular obstruction (MVO) and intramyocardial hemorrhage (IMH) have been recognized as poor prognostic factors in myocardial infarction (MI) patients. The aim of the study was to evaluate hypothesis whether cardioprotective strategy prevent IMH in MI patients after primary percutaneous coronary intervention (PCI). Methods This multicenter open-label randomized clinical trial enrolled 143 patients with first acute anterior ST-elevation MI (STEMI) reperfused within 6 h after symptoms onset. Cardiac magnetic resonance (CMR) was performed to assess left ventricular (LV) function and microvascular injury in 23 patients within the first week (3.5±1.2 days) after STEMI. Nine patients were randomized into soluble intravenous form of quercetin (Q) group and 14 - to the control group. Q infusions were started before PCI and used during the next 5 days. MVO was visualized using early gadolinium enhancement (EGE) and IMH was detected by using T2-WI. Results The study groups did not differ in terms of demographic characteristics, time to admission and main clinical data. Initially, the number of LV myocardial segments with edema was similar - 7.8±1.7 in patients of Q subgroup versus 6.8±1.8 in patients of the control subgroup (p=0.245). However, patients of the Q subgroup tended to have greater number of segments with gadolinium accumulation and higher value of the transmural index (7.7±1.2 compared to 6.2±1.5; p&amp;lt;0.05) according to the late gadolinium enhancement (Area at Risk, gray zone of AMI). According to gadolinium enhancement MVO was detected in more than 90% patients of both groups, but IMH rate was higher in the control group (53.3 vs 11.1%; p=0.03). Additionally, Q limited final infarct size assessed by CK-MB AUC 18% compare to control group (p&amp;lt;0.021). Conclusion Detection of MVO and IMH by CMR can accurately demonstrate the severity of myocardial injury. Intravenous Q can decrease the rate of IMH additionally to infarct size limitation. Further investigations are needed to confirm our results and to determine whether prevention of IMH can impact on better prognosis. Funding Acknowledgement Type of funding source: None

Contrast Echocardiography with a Quantitative Assessment of Myocardial Perfusion in Patients with Previous Q-Wave Myocardial Infarction

To assess possibilities of contrast echocardiography with quantitative evaluation of myocardial perfusion in patients with previous Q-wave myocardial infarction. We examined 15 men (42-72 years) with coronary artery disease and previous myocardial infarction, and pathological Q-wave in 2 or more ECG leads. Quantification of left ventricular (LV) myocardial perfusion was performed by calculating of the ultrasound signal tissue intensity from the LV myocardial segments during intravenous administration of the ultrasound contrast agent (SonoVue). The Tissue intensive curve (TIC) analysis was done in the end-diastolic period before and on the fourth cardiac cycle after applying the "flash". Changes in the intensity of myocardial perfusion (A4, dB) was estimated as the difference between the intensity values of the ultrasound signal in the myocardial segment during the period of filling the contrast bubbles on 4-th cardiac cycle and before applying the «flash». Measurements were performed in 16 segments of the LV. A contrast cardiac magnetic resonance imaging (contrast MRI) was performed in order to verify the LV scar. Fibrotic changes of 50% of myocardial wall or more were considered as signs of post-infarction scar. The dynamics of perfusion and scar presence in 240 myocardial segments were evaluated. The median A4 was 1 dB (range, -20 to 10 dB). MRI revealed 82 of 240 segments with the large-focal scar. The effectiveness of the diagnostic test (quantitative contrast perfusion echocardiography with A4 assessment) to detect myocardial scar was investigated. ROC curve analysis showed good model quality, AUC=0,787 (0,730-0,837); sensitivity 82.9%; specificity 75.3%; p&lt;0.01. The cut-off point for A4 was -1. A new approach to quantitative contrast assessment of perfusion allows to identify perfusion disorders with high efficiency in patients with previous Q-wave myocardial infarction.

P1488Single wave mitral inflow pattern caused by left ventricular diastolic dyssynchrony in patients with heart failure

Abstract Background Mitral E and A waves could fuse to form a single wave in tachycardia. Patients with heart failure (HF) occasionally show single wave mitral inflow despite of non-tachycardiac condition. Purpose To investigate mechanisms of single wave mitral inflow in HF patients with sinus rhythm and normal heart rate. Methods A total of 60 HF patients, including 20 single wave (SW), 20 impaired relaxation (IR) and 20 pseudonormalized (PN) mitral inflow patterns were retrospectively enrolled. All the patients were in sinus rhythm under 85 bpm. Patients with bundle branch blocks and first-degree heart block were excluded. We compared basic echo measurements, magnitude of left ventricular (LV) diastolic dyssynchrony, isovolumic relaxation time (IRT) and BNP levels among 3 groups. Diastolic dyssynchrony was determined as standard deviation of interval between aortic valve closure and peak early diastolic wave of longitudinal strain across 16 LV myocardial segments using 2D speckle tracking echocardiography. Results There was no significant difference in heart rate among 3 groups. Patients with SW showed significantly large magnitude of diastolic dyssynchrony (4.1±1.1) compared to those with IR (2.7±0.7) and PN (2.9±0.9ms), respectively. Likewise, IRT of SW (7.1±2.7) was longer than IR (3.2±0.8) and PN (2.4±0.9ms). BNP level in patients with IR (153±111) was significantly lower than those with SW (558±432) and PN (523±263pg/ml). Representative cases Conclusion HF patients with SW could be caused by LV diastolic dyssynchrony and their BNP levels are comparable to those with PN.

Treatment of Active Cardiac Sarcoidosis with TNF Alpha Inhibitors

Background Cardiac sarcoidosis (CS) is associated with significant morbidity and mortality including progressive heart failure and sudden cardiac death. High-dose steroid immunosuppression remains standard of care for CS but there is a lack of randomized clinical trial data. As a result, there remains significant treatment variability among specialized centers. TNF alpha inhibitors are widely used for other inflammatory diseases and are generally well tolerated. However, little data, if any, exists regarding their utility in CS. TNF alpha inhibitors are particularly attractive given the potential adverse effects of chronic glucocorticoid based immunosuppression. The purpose of this study was to explore the effectiveness of TNF alpha inhibitors in active CS. Methods We performed a retrospective analysis of patients with metabolically active CS (defined by increased FDG avidity by cardiac PET imaging) who were treated with TNF alpha inhibitors. All patients underwent follow up PET imaging. Disease activity was quantified by the number of left ventricular (LV) myocardial segments with FDG avidity (based on a 17 segment model of the LV). Adverse events related to therapy was also recorded. Results Nine patients treated with TNF alpha inhibitors were included in this analysis. Eight Patients received the TNF alpha inhibitor, infliximab, one patient received adalimumab. Eight of the nine patients had previously received prednisone for CS; four transitioned from prednisone to infliximab due to adverse effects of steroid use; three transitioned because of continued active CS despite steroid therapy; one patient exhibited recurrent cardiac FDG avidity after prednisone discontinuation and another declined steroid treatment. The number of LV myocardial segments with active CS decreased from 8.6 +/- 3.6 to 1.9 +/- 3.5 (p=0.001) after a mean treatment duration of 7 months of infliximab that represents a decline of FDG avid LV segments by 72%. There was no significant change in LV ejection fraction (45 +/- 15% to 50 +/- 11% after therapy, p=NS). Six of the nine patients had complete resolution of active CS, and two had partial improvement. One patient experienced pancytopenia felt possibly related to infliximab; no other obvious adverse events were observed. Conclusions In this retrospective cohort, TNF alpha inhibition lead to significant improvement in disease activity based on FDG PET imaging. Most patients demonstrated complete resolution of active CS with minimal adverse effects. Further investigation into the use of TNF alpha inhibitors for treating active CS is warranted.

Changes in left ventricular shape and morphology in the presence of heart failure: a four-dimensional quantitative and qualitative analysis.

The presence and progression of heart failure (HF) are associated with cardiac remodelling, defined as cellular, molecular and interstitial changes which occur after injury and manifest as changes in left ventricular (LV) size, mass, geometry and function. This research study was designed to investigate the changes to LV morphology and shape which occur in the presence of heart failure using three-dimensional (3D) modelling and analysis of cardiac-gated CT scans from both healthy individuals and patients classified with HF. A number of quantitative and qualitative strategies were applied to cardiac CT scans of HF patients and healthy controls (n = 7) in order to analyse changes to LV size, shape and structure and to examine LV remodelling in the different classes of HF. Three-dimensional wireframe representations of endocardial and epicardial borders were created, three-dimensional computer stereolithography models of the inner LV cavity and myocardial wall segments were generated and three-dimensionally printed and a number of clinical LV dimension and shape indices were measured. All data were analysed using one-way ANOVA with post hoc Tukey method for multiple comparisons for significant variables. Results of most significance included abnormalities in LV mass and end-systolic dimensions and significantly increased septal wall thickness among mid-range ejection fraction cases. Also of importance were significant increases in both dimension-based and volumetric sphericity index measures in all HF cases. Three-dimensional printed models provided qualitative information as to changes in inner LV cavity and myocardial wall morphology across the cardiac cycle for healthy and HF cases and validated quantitative findings. Findings from this study can successfully be applied to motivate the research and development of new HF treatment strategies and devices as well as for the development of a realistic cardiac simulator system.

The Use of Two-Dimensional Strain Measured by Speckle Tracking in the Identification of Incipient Ventricular Dysfunction in HIV-Infected Patients on Antiretroviral Therapy, Untreated HIV Patients and Healthy Controls.

BackgroundMost cardiovascular abnormalities in patients infected with the human immunodeficiency virus (HIV) have been associated with myocardial damage directly caused by the virus. Some cases, however, may be associated with adverse effects from antiretroviral therapy (ART). New ventricular function assessment techniques are capable of detecting early changes in the cardiac function of HIV-infected patients using or not using ART. The usefulness of these techniques has been little employed in these patients.ObjectivesTo investigate the potential influence of antiretroviral therapy (ART) on the occurrence of subclinical left ventricular systolic dysfunction evaluated by myocardial strain rate analysis using two-dimensional speckle tracking echocardiography (2-D Echo) in treated HIV patients compared to untreated patients and healthy individuals.MethodsSixty-eight HIV-infected patients with no cardiovascular symptoms, normal left ventricular (LV) ejection fraction (> 0.55 on 2-D Echo) were divided into three groups: 11 patients not using antiretroviral therapy (NT), 24 using protease inhibitor (PI) and 33 using non-nucleoside reverse transcriptase inhibitor (NNRTI). We also studied 30 normal non-HIV infected individuals (Ctrl). Demographic, clinical, biochemical and anthropometric data were collected. Preliminary transthoracic echocardiography included study of myocardial strain using two-dimensional speckle tracking. We studied strain and strain rate in the seventeen left ventricular (LV) myocardial segments in the longitudinal, circumferential and radial axes. Statistical analysis of the data was done with IBM SPSS - version 20 for Windows. Upon analysis of the data, namely the normality of independent variables in the different groups and the homogeneity of the variances between the groups, Kruskal-Wallis’ non-parametric test was done, followed by Dunn’s multiple comparison tests to test the significance of the differences between the values measured in the study groups. A significance level of 5% was adopted for decision-making on statistical tests.ResultsThe mean age of HIV patients was 40 ± 8.65 years and the mean age of controls was 50 ± 11.6 years (p < 0.001). Median LV global longitudinal strain (GLS) of NT patients (-17.70%), PI patients (-18.27%) and NNRTIs (-18.47%) were significantly lower than that of the Ctrl group (-20.77%; p = 0.001). There was no significant difference in mean SLG between treated patients (PI, NNRTI) and untreated (NT) patients. No significant differences were observed in mean circumferential and radial strain, nor on circumferential and radial strain rates between the NT, PI, NNRTI and Ctrl groups.ConclusionThe data suggest that HIV patients present, on myocardial strain measured by speckle tracking, signs of early LV systolic dysfunction that seem to be unrelated to the presence of ART. The prognostic significance of this condition in these patients deserves further studies.

The function of the left ventricular myocardial segments assessed by velocity vector imaging in patients with a myocardial infarction before and after coronary artery bypass

Rationale: Velocity vector imaging is a non-invasive technique to analyze left ventricle (LV) fibers and determine the depth and area of an ischemic injury and the response to revascularization. Aim : To assess LV functional parameters in patients with non Q-wave myocardial infarction and Q-wave myocardial infarction using velocity vector imaging before and in the early postoperative period after coronary bypass grafting. Methods : We analyzed the strain (S) and strain rate (SR) of longitudinal, circular and radial fibers in 252 LV segments in 14 patients with non Q-wave myocardial infarction (group I) and in 252 segments in 14 patients with Q-wave myocardial infarction (group II) before and at day 12 after coronary bypass grafting. Results : General analysis of the fibers from all LV segments, as well as a detailed analysis of each segment was performed by velocity vector imaging. The general analysis showed the following: the function of longitudinal fibers in group I was characterized by a low S parameter (-15.2 ± 7.4%) and normal SR (-1.04 ± 0.6 s-1); in group II – a low S (-12.7 ± 6.4%) and SR (-0.80 ± 0.4 s-1). The deformation characteristics of the circular fibers were reduced in both groups (group I: S -17.1 ± 8.9%, SR 1.23 ± 0.7 s-1; group II: S -14.02 ± 8.3%, SR -0.98 ± 0.6 s-1). The radial fibers had normal S values (group I: 29.1 ± 19.9%, group II: 25.9 ± 19.7%), high SR value in group I (1.73 ± 1.0 s-1) and normal SR in group II (1.35 ± 0.6 s-1). After coronary bypass surgery, the group II demonstrated an improvement in the SR of longitudinal (-0.91 ± 0.5 s-1, p = 0.001) and circumferential (-1.11 ± 0.5 s-1, p = 0.001) fibers, whereas the S of radial fibers deteriorated (21.7 ± 8.9%, p = 0.0004). In group I, radial fiber SR became normal (1.39 ± 0.6 s-1, p = 0.0004). A detailed analysis of the LV identified 10 groups of segments depending on the changes S and/or SR. Revascularization had an impact on all segments in patients of both groups. The segments with combined changes in S and SR improved its function. The segments with changes only in S or only in SR reduce their function, which is considered as a step to harmonic contraction. Conclusion : General analysis of LV fibers shows the impact of myocardial infarction, and the detailed analysis helps to identify the impact of revascularization.

Left Ventricular Non-Compaction: Mid-myocardial Distribution of Late Gadolinium Enhancement in Compacted Segments

Background: Cardiovascular Magnetic Resonance (CMR) with Late Gadolinium Enhancement (LGE) is a proven method for detecting myocardial fibrosis. Previous CMR studies described the distribution of LGE in patients with LVNC; however, it still remains unclear. The purpose of the study was to describe the distribution of LGE in patients meeting cardiovascular magnetic resonance criteria for Left Ventricular Non-Compaction (LVNC). Methods: We retrospectively enrolled 15 patients adult patients (11 males and 4 females; mean age, 42 ± 13 years) considered to meet standard CMR criteria for LVNC. For each patient, cine and contrast-enhanced CMR images were analyzed to evaluate LV systolic function and the prevalence and ex-tent of LGE. The presence or absence of LGE was qualitatively determined for each left ventricular myocardial segment. Results: The mean NC/C ratio was 4.6 ± 0.9. The areas of non-compaction were most commonly observed at the apex, the anterior and the lateral walls, mainly on their apical and mid-cavity segments. LGE was present in 11 of the 15 patients (73%). LGE was observed most frequently in the ventricular septum commonly on basal and mid-cavity segments. The distribution of LGE was midmyocardial (n=42; 67%), subepicardial (n=11; 18%), transmural (n=6; 10%) and subendocardial (n=3; 5%), in total of 62 LGE (+) left ventricular segments. No association was found between LGE and non-compaction at left ventricular segmental level (phi coefficient 0,021; p= 0.191). Conclusion: LGE was most often observed in the ventricular septum with mid-myocardial distribution. Distribution of LGE in patients with LVNC is observed in both non-compacted and compacted segments with prevalence of compacted zones. This maintenance the concept that LVNC is a diffuse process including both non-compacted and morphologically normal segments.

The coronary arterial anatomy of the 17-segment model using 3-Tesla cardiac magnetic resonance imaging

AimTo analyze the correspondence of the 17 left ventricular myocardial segments with each coronary artery by using late gadolinium contrast enhanced cardiovascular magnetic resonance (CMR) imaging. Material and methodsA total number of 58 patients with known or suspected ischemic heart disease were enrolled in this study. Those patients were scheduled for CMR and conventional coronary angiography. The correspondence between the coronary artery distribution and the supplied myocardium was assessed according to the 17-segment model. ResultsThe segments 1, 2, 3, 7, 8, 13, 14 and 17 were totally specific for LAD, segments 6 and 12 were totally specific for LCX, and segment 10 was specific for RCA. There was overlap between LAD and RCA for segments 9 and 15. There was overlap between LCX and RCA for segments 4, 5 and 11. The segment 16 was shared by the all territories (LAD, LCX and RCA) with slight LCX predominance. ConclusionsOur study concluded that the LAD territory on CMR bases is larger than the American Heart Association (AHA) proposed 17-segment model.