Left Ventricular Wall Motion Abnormalities Research Articles

Effects of Left Ventricular Wall Motion Abnormality on Global and Regional Diastolic Function of the Left and Right Ventricles at Rest and After Stress.

BackgroundDiastolic dysfunction precedes systolic dysfunction in patients with coronary artery disease. The aim of the study was to evaluate the effects of left ventricular (LV) wall motion abnormality (WMA) on diastolic LV and right ventricular (RV) function at rest and after stress.MethodsFifty-nine subjects, 15 with LV-WMA (abnormal group) and 44 without (normal group), underwent dobutamine stress echocardiography (DSE) studies, in addition to evaluation of LV and RV diastolic function before and after DSE.ResultsResting mitral flow parameters were similar. DSE increased peak A-wave velocities in both groups, and mitral color slope only in normal subjects. After DSE, E-wave peak velocities and mitral color slope were higher in normal subjects, P < 0.05. At rest and after DSE systolic and diastolic pulmonary vein velocities were similar in both groups; however, DSE increased these velocities only in normal subjects, P < 0.05. Regional E-wave peak velocities of LV were higher at rest in normal subjects, P < 0.05. Both LV and RV, regional peak E-wave velocities were not affected by DSE. After DSE, regional A-wave peak velocities increased in all (P < 0.01), except at the lateral region (P = 0.07). DSE increased trans-tricuspid velocities in both groups, P < 0.05. Resting A-wave velocities were higher in normal subjects, P < 0.01.ConclusionsGlobal LV early diastolic filling parameters were not affected by LV-WMA at rest. LV-WMA blunted the response after stress. RV E-wave velocities increased after DSE, and were not affected by LV-WMA. LV-WMA reduced regional LV-E’ velocities at rest but not the reserve. A-wave velocities were not affected by WMA and increased after DSE.

Left ventricular involvement in arrhythmogenic right ventricular cardiomyopathy - a cardiac magnetic resonance imaging study.

BACKGROUNDFew studies evaluated left ventricular (LV) involvement in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). The aim of this study is to determine the frequency, clinical presentation, and pattern of LV involvement in ARVD/C (LV-ARVD/C).METHODSWe retrospectively evaluated the cardiac magnetic resonance (CMR) in 202 patients referred between 2008 and 2012 to our institution, and we determined the presence or the absence of CMR criteria in the revised task force criteria 2010 for the diagnosis of ARVD/C. A total of 21 patients were diagnosed with ARVD/C according to the revised task force criteria 2010. All included patients had no previous history of myocarditis, acute coronary syndrome, or any other cardiac disease that could interfere with the interpretations of structural abnormalities. The LV involvement in ARVD/C was defined by the presence of one or more of the following criteria: LV end-diastolic volume (LVEDV; >95 mL/m2), LV ejection fraction (LVEF; <55%), LV late enhancement of gadolinium (LVLE) in a non-ischemic pattern, and LV wall motion abnormalities (WMAs). In the follow-up for the occurrence of cardiac death, ventricular tachycardia (VT) was obtained at a mean of 31 ± 20.6 months.RESULTSA total of 21 patients had ARVD/C. The median age was 48 (33–63) years. In all, 11 patients (52.4%) had LV-ARVD/C. The demographic characteristics of patients with or without LV were similar. There was a higher frequency of left bundle-branch block (LBBB) VT morphology in ARVD/C (P = 0.04). In CMR, regional WMAs of right ventricle (RV) and RV ejection fraction (RVEF; <45%) were strongly correlated with LV-WMAs (r = 0.72, P = 0.02, r = 0.75, P = 0.02, respectively). RV late enhancement of gadolinium (RVLE) was associated with LV-WMs and LVLE (r = 0.7, P = 0.03; r = 0.8, P = 0.006). LVLE was associated with LV-WMAs, LVEF, and LVEDV (r = 0.9, P = 0.001; r = 0.8, P = 0.001; r = 0.8, P = 0.01).CONCLUSIONLV involvement in ARVD/C is common and frequently associated with moderate to severe right ventricular (RV) abnormalities. The impact of LV involvement in ARVD/C on the prognosis needs further investigations.

Two cases of abnormal left ventricular wall motion like a reversed takotsubo myopathy induced by different mechanisms

Two cases of abnormal left ventricular wall motion like a reversed takotsubo myopathy induced by different mechanisms

Advanced Echocardiography for the Critical Care Physician: Part 2

This article is the second part of a series that describes practical techniques in advanced critical care echocardiography and their use in the management of hemodynamic instability. Measurement of left ventricular function and segmental wall motion abnormalities, evaluation of left ventricular filling pressures, assessment of right-sided heart function, and determination of preload sensitivity, including passive leg raising, are discussed. Video examples help to demonstrate techniques described in the text.

Takotsubo and surroundings. Step by step postpartum stress-induced cardiomyopathy shows its facet. A peculiar case of atypical takotasubo in the peripartum period

Takotsubo syndrome is an acquired cardiomyopathy with transient and reversible left ventricular dysfunction that can mimic an acute coronary syndrome. It is characterized by ECG abnormalities, including minimal ST-segment elevation and T-wave changes, mild troponin elevation, typical left ventricular regional wall motion abnormalities (apical ballooning) and atypical forms (midventricular or reverse apical ballooning) without significant coronary artery stenosis. Its etiology and pathophysiology remain unclear. The sympathetic system seems to play a central role: its exaggerated response to emotional or physical stress triggers may induce microvascular dysfunction and catecholamine-induced cardiotoxicity due to cyclic AMP-mediated calcium overload. We report our experience highlighting the possible pathophysiological and clinical overlap of emotional-triggered catecholamine cardiotoxicity, arterial hypertension and physiological cardiovascular overload in pregnancy describing an atypical case of takotsubo cardiomyopathy with diffuse left ventricular hypokinesia at onset and subsequent evolution to apical ballooning.

Left and Right Ventricular Wall Motion Abnormalities In Thalassemia Major Patients

IntroductionLeft ventricular (LV) and right ventricular (RV) wall motion abnormalities can be detected through a qualitative analysis of cine magnetic resonance (MR) images. Moreover, MR is the gold standard technique for the evaluation of myocardial iron overload (MIO), biventricular global systolic function and myocardial fibrosis. We investigated the relationships between LV movement abnormalities and MIO, LV function and myocardial fibrosis as well as between RV motion and function in thalassemia major (TM) patients. MethodsCMR was performed in 1092 TM patients (537 male; 30.6±8.5 years) enrolled in the Myocardial Iron Overload in Thalassemia Network. Cine images were acquired to evaluate wall motion and to quantify biventricular volumes and ejection fraction (EF). For MIO assessment, a T2* multislice approach was used. To detect myocardial fibrosis, late gadolinium enhanced (LGE) images were acquired. For the LV the 16-segment model of the AHA/ACC was taken into account during image analysis: wall motion, T2* value and presence/absence of enhancing area were evaluated for each segment. ResultsAbnormal motion of LV was found in 66 (6%) patients (60 hypokinetic and 6 dyskinetic). Table 1 shows the comparison between TM patients with normal and abnormal LV motion. Patients with abnormal LV motion were older and had significantly lower global T2* value and significantly higher number of segments with T2*<20 ms. Left volumes and mass indexed by body surface area were significantly higher in patients with abnormal LV motion while the EF was significantly lower. LGE areas were detected in 196 patients (18%) and were predominantly located in the mid-ventricular septum. There was a significant correlation between LGE and abnormal LV motion.Table 1Abnormal LV motionNormal LV motionPAge33.1 ± 8.330.4 ± 8.50.014Sex (M/F)37/29500/5260.248Global heart T2* (ms)22.5 ± 14.730.4 ± 8.50.001N. of segments with T2* < 20 ms8.6 ± 7.54.6 ± 6.1<0.0001Global heart T2* <20 ms, N (%)38 (57.6)376 (36.6)0.001LV end-diastolic volume index (ml/m2)99.0 ± 24.587.5 ± 18.9<0.0001LV end-systolic volume index (ml/m2)49.3 ± 18.734.0 ± 11.6<0.0001LV mass index (g/m2)66.3 ± 14.158.4 ± 13.3<0.0001LV ejection fraction (%)51.1 ± 9.161.7 ± 6.6<0.0001LGE, N (%)34 (51.5)162 (15.8)<0.0001Abnormal motion of the RV was found in 35 (3.2%) patients (29 hypokinetic, 5 dyskinetic and 1 akynetic). Table 2 shows the comparison between TM patients with normal and abnormal RV motion. Patients with abnormal RV motion were older and they were more frequently males. Right volumes were significantly higher in patients with abnormal RV motion while the EF was significantly lower.Table 2Abnormal RV motionNormal RV motionPAge33.9 ± 5.930.5 ± 8.60.013Sex (M/F)27/8510/5470.001RV end-diastolic volume index (ml/m2)110.4 ± 48.283.4 ± 19.2<0.0001RV end-systolic volume index (ml/m2)61.5 ± 29.632.5 ± 11.4<0.0001RV ejection fraction (%)44.9 ± 10.161.4 ± 7.7<0.0001Abnormal LV motion was not correlated with abnormal RV motion. Seventeen patients showed movement abnormalities in both ventricles. ConclusionsMovement abnormalities in the left ventricle were not really frequent in TM patients but were associated with age, MIO, LV dilation and dysfunction, and myocardial fibrosis. Movement abnormalities in the right ventricle were less frequent compared to the left ventricle, but were associated with age, sex , RV dilation and dysfunction. Disclosures:No relevant conflicts of interest to declare.

Right Ventricular Myocardial Performance Index Derived from Tissue Doppler Echocardiography Is Useful in Differentiating Apical Ballooning Syndrome from Cardiomyopathy Due to Left Anterior Descending Coronary Artery Disease

Apical ballooning syndrome (ABS) and obstructive coronary artery disease of the left anterior descending coronary artery (LAD) can both result in similar left ventricular apical wall motion abnormalities. The right ventricle may more likely be involved in ABS, and its careful evaluation may help differentiate the two conditions. Therefore, the aim of this study was to determine the roles of echocardiographic measures of right ventricular (RV) function, namely, Doppler tissue imaging-derived RV index of myocardial performance (RIMP), RV basal free wall systolic excursion velocity (RV S'), and tricuspid annular plane systolic excursion, indifferentiating ABS from obstructive LAD disease. A total of 80 patients with new extensive apical left ventricular wall motion abnormalities on echocardiography who underwent coronary angiography were identified retrospectively. Patients with insufficient echocardiographic data were excluded (n= 17). Admission clinical and echocardiographic data were compared between patients with obstructive disease of the LAD (LAD group; n= 46) and those with normal coronary arteries (ABS group; n= 17). The ABS group had significantly greater RIMP (1.03 ± 0.22 vs 0.44 ± 0.18, P < .001). In predicting ABS, RIMP > 0.74 had sensitivity of 94%, specificity of 94%, positive predictive value of 84%, and negative predictive value of 98%, with excellent discriminatory ability (area under the receiver operating characteristic curve, 0.96 ± 0.03). Other measures of RV function (i.e., tricuspid annular plane systolic excursion and RV S') were similar between the two groups. Doppler tissue imaging-derived RIMP may help differentiate ABS from obstructive LAD disease with high accuracy. This easily obtainable measurement may offer a noninvasive tool to differentiate these two conditions.

CMR reference values for left ventricular volumes, mass, and ejection fraction using computer‐aided analysis: The Framingham Heart Study

To determine sex-specific reference values for left ventricular (LV) volumes, mass, and ejection fraction (EF) in healthy adults using computer-aided analysis and to examine the effect of age on LV parameters. We examined data from 1494 members of the Framingham Heart Study Offspring cohort, obtained using short-axis stack cine SSFP CMR, identified a healthy reference group (without cardiovascular disease, hypertension, or LV wall motion abnormality) and determined sex-specific upper 95th percentile thresholds for LV volumes and mass, and lower 5th percentile thresholds for EF using computer-assisted border detection. In secondary analyses, we stratified participants by age-decade and tested for linear trend across age groups. The reference group comprised 685 adults (423F; 61 ± 9 years). Men had greater LV volumes and mass, before and after indexation to common measures of body size (all P = 0.001). Women had greater EF (73 ± 6 versus 71 ± 6%; P = 0.0002). LV volumes decreased with greater age in both sexes, even after indexation. Indexed LV mass did not vary with age. LV EF and concentricity increased with greater age in both sexes. We present CMR-derived LV reference values. There are significant age and sex differences in LV volumes, EF, and geometry, whereas mass differs between sexes but not age groups.

Elevated left ventricular filling pressure estimated by E/E′ ratio after exercise predicts development of new-onset atrial fibrillation independently of left atrial enlargement among elderly patients without obvious myocardial ischemia

ObjectiveTo determine whether elevated left ventricular (LV) filling pressure estimated by raised Doppler E velocity to tissue Doppler E′ velocity ratio (E/E′) after exercise is associated with increased risk of new-onset atrial fibrillation (AF) in non-ischemic elderly patients. BackgroundPrognostic importance of exercise induced LV diastolic dysfunction remains uncertain. Patients and methodsWe studied 147 elderly patients (73±5 years) who underwent treadmill stress echocardiography. Patients with exercise induced LV wall motion abnormality were not included. Doppler and tissue Doppler measurements were done before treadmill exercise and immediately after the post-stress image acquisition, and E/E′ ratio was measured. Raised E/E′ was defined as E/E′≥15, and left atrial (LA) enlargement was defined as LA volume index≥34ml/m2. Using Cox proportional hazards regression analysis, predictor of new-onset AF was determined. Using Kaplan–Meier analysis, we evaluated association between raised post-exercise E/E′ or LA enlargement with new-onset AF. ResultsDuring the follow-up period (median=67 months), there were 25 new-onset AF. Cox proportional hazards regression analysis demonstrated that male gender [hazard ratio (HR) 3.294; p=0.0117], LA enlargement (HR 3.576; p=0.0017), and raised post-exercise E/E′ (HR 3147; p=0.0068) were the best predictors of new-onset AF. Kaplan–Meier survival plot demonstrated that patients with both LA enlargement and raised post-exercise E/E′ developed new-onset AF most frequently. There was no significant difference in outcome between patients with isolated raised post-exercise E/E′ or isolated LA enlargement. ConclusionsRaised E/E′ ratio after exercise provides significant prognostic information for predicting new-onset AF in non-ischemic elderly patients. This prognostic value of raised post-exercise E/E′ is independent of and incremental to the LA enlargement.

Novel cardiovascular findings in association with a POMT2 mutation: three siblings with α-dystroglycanopathy

Dystroglycanopathies are a genetically heterogeneous subset of congenital muscular dystrophies that exhibit autosomal recessive inheritance and are characterized by abnormal glycosylation of α-dystroglycan. In particular, POMT2 (protein O-mannosyltransferase-2) mutations have been identified in congenital muscular dystrophy patients with a wide range of clinical involvement, ranging from the severe muscle-eye-brain disease and Walker-Warburg syndrome to limb girdle muscular dystrophy without structural brain or ocular involvement. Cardiovascular disease is thought to be uncommon in congenital muscular dystrophy, with rare reports of cardiac involvement. We describe three brothers aged 21, 19, and 17 years with an apparently homozygous POMT2 mutation who all presented with congenital muscular dystrophy, intellectual disabilities, and distinct cardiac abnormalities. All three brothers were homozygous for a p.Tyr666Cys missense mutation in exon 19 of the POMT2 gene. On screening echocardiograms, all siblings demonstrated significant dilatation of the aortic root and depressed left ventricular systolic function and/or left ventricular wall motion abnormalities. Our report is the first to document an association between POMT2 mutations and aortopathy with concomitant depressed left ventricular systolic function. On the basis of our findings, we suggest patients with POMT2 gene mutations be screened not only for myocardial dysfunction but also for aortopathy. In addition, given the potential for progression of myocardial dysfunction and/or aortic dilatation, longitudinal surveillance imaging is recommended both for patients with disease as well as those that have normal baseline imaging.

Vasospasm of Atherosclerotic Coronary Arteries Precipitates Acute Ischemic Myocardial Damage in Myocardial Infarction–Prone Strain of the Watanabe Heritable Hyperlipidemic Rabbits

This study tested the hypothesis that vasospasm can trigger coronary plaque injury and acute ischemic myocardial damage. Myocardial infarction-prone strain of the Watanabe heritable hyperlipidemic rabbits received an intravenous bolus of ergonovine maleate (0.45 µmol/kg) during intravenous infusion of norepinephrine (12 nmol/kg per minute) to provoke coronary spasm in vivo. After this treatment, coronary angiography demonstrated vasospasm, and the ECG showed ischemic abnormalities (ST depression/elevation and T-wave inversion) in 77% of animals (23/30). These changes normalized after nitroglycerin injection. In rabbits that demonstrated these ECG findings for >20 minutes, echocardiograms showed left ventricular wall motion abnormality. Serum levels of heart-type fatty acid-binding protein, cardiac troponin-I, and myoglobin increased markedly 4 hours after spasm provocation. In coronary lesions of myocardial infarction-prone strain of the Watanabe heritable hyperlipidemic rabbits with provoked coronary spasm, we observed intimal injury in 60.9% in the form of endothelial cell protrusions (39.1%), denudation (30.4%), and macrophage extravasation (56.5%). Plaque disruption with luminal thrombus, however, was only seen in 2 of 23 animals (8.7%), and mural microthrombus was rarely observed (4.3%). These observations show that provocation of vasospasm in myocardial infarction-prone strain of the Watanabe heritable hyperlipidemic rabbits associates with subsequent ischemic myocardial damage. Although treatment with spasmogens altered aspects of plaque morphology, for example, endothelial protrusion and macrophage emigration, thrombosis was rare in these animals with chronic atherosclerotic disease.

Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is characterized by transient left ventricular apical wall motion abnormalities, chest pain with electrocardiographic changes, and modest myocardial enzymatic release mimicking acute coronary syndrome, but without significant coronary artery disease. TC is an increasingly recognized type of acquired cardiomyopathy occurring commonly after a recent stressful event, in particular emotional stress, and is relatively common in middle-aged and older women. The pathogenetic mechanism remains unknown. Catecholamine surge related to emotional distress seems to play a major role in the pathogenesis of this cardiomyopathy, rendering TC a type of neurocardiological disorder that manifests as acute but reversible heart failure. Clinicians should consider this syndrome in the differential diagnosis of patients presenting with clinical findings suggestive of acute coronary syndrome, especially in postmenopausal women with a recent history of acute emotional or physical stress.

Acute phase myocardial edema was related to recovery process of regional left ventricular wall motion abnormality in takotsubo cardiomyopathy

Background: Takotsubo cardiomyopathy (TC, stress cardiomyopathy, apical ballooning syndrome) is characterized by transient reversible systolic dysfunction of the apical and/or mid segments of the left ventricular (LV). However, the recovery process of LV systolic dysfunction is not known in detail. Methods: We retrospectively evaluated 40 consecutive patients (38 women, 2 men) who were diagnosed as TC in our hospital between June 2007 and October 2012. Main outcome was complete recovery of LV wall motion. Clinical characteristics of early recovery group (n=16; LV wall motion recovered completely within 7 days) and late recovery group (n=24; abnormal LV wall motion remained after 7 days) were compared. Then, we recorded cardiovascular magnetic resonance imaging (CMR) within three days after hospitalization in 27 of 40 patients to evaluate an acute phase histological change of the diseased myocardium. Results: A stressful trigger could be identified in 26 patients (mental: 10, physical: 16). Average LV ejection fraction (LVEF) evaluated by left ventriculography was 50%. There were no statistically significant differences about age, coronary risk factor, laboratory data, QTc in electrocardiogram, and LVEF between two groups. Regional myocardial edema (high intensity in T2-weighted images of CMR) could be identified in 5 of 9 patients (56%) in early recovery group and 18 of 18 patients (100%) in late recovery group (P<0.05). ![Figure][1] Figure 1. Regional myocardial edema on CMR Conclusions: Acute phase myocardial edema detected by CMR images may relate to recovery process of LV wall motion abnormality in TC patients. [1]: pending:yes

Different impacts of statin treatment on development of ischemic heart failure after acute myocardial infarction in patients with or without renal dysfunction

Purpose: It remains unclear whether statin treatment benefits the patients with heart failure in terms of clinical outcomes Also there is a controversy whether patients with renal dysfunction (RD) develops ischemic heart failure (IHF) after acute myocardial infarction (AMI) more easily than those without RD. The aim of this study was to evaluate the effectiveness of statin treatment on IHF in patients with RD. Methods: A total of 36,580 patients with AMI were enrolled in nationwide AMI registry between November 2005 and February 2012. Of these, eligible 6,835 AMI patients (65.3±12.9 years, 74% Men) with (n=2,209) or without RD (n=4,626) were extracted and divided into two subgroups according to statin treatment (statin group: n=5,133, non-statin group: n=1,702). Primary end point was development of IHF assessed by follow-up echocardiography. IHF was defined by reduced left ventricular ejection fraction (<50%) and wall motion abnormality in territories consistent with coronary angiographic findings. Results: Baseline characteristics were not significantly different between groups. In COX proportional regression analysis, RD was an independent predictor of IHF (HR 1.482, 95% CI 1.340-1.640, p <0.0001) along with advanced age. In Kaplan-Meier analysis, non-statin group showed more IHF development in patients with RD than without at short- and long-term follow-up (p <0.0001 by log-rank test). However, statin group showed no difference between patients with and without RD at short-term follow-up and late development of IHF after AMI (p <0.0001 by log-rank test). ![Figure][1] Conclusions: Statin treatment of AMI patients with renal dysfunction may prevent early development of IHF. Large randomized controlled trials and future investigations of how to reduce late one are warranted. [1]: pending:yes

Dobutamine-Induced Myocardial Ischemia and ST-Segment Elevation in Collateral-Dependent Myocardium

In patients with obstructive coronary artery disease, electrocardiographic (ECG) ST-segment elevation (STE) is frequently seen during dobutamine stress echocardiography (DSE) in leads overlying previous transmural left ventricular (LV) myocardial infarction. The mechanism of occasional STE during DSE in LV region with inducible myocardial ischemia and no previous myocardial infarction has not been well delineated. We retrospectively identified 28 adults (age 51 to 83 years [69 ± 8]; 82% men) with STE (>1 mm at ≥80 ms after J point in ≥2 contiguous leads without pathologic Q waves) and inducible myocardial ischemia in the same territory during DSE. STE occurred in inferior (n = 16), inferolateral (n = 8), anterior (n = 1), lateral (n = 2), or anterolateral (n = 1) leads and was associated with ischemic symptoms in 17 patients (61%). Inducible LV wall motion abnormality developed in LV segments corresponding to ECG STE in all patients. Coronary arteriography (within 1 week of the index DSE) showed severe luminal narrowing in the major epicardial coronary artery supplying the region with DSE STE and ischemia (90% to 99% in 9 patients [32%] and 100% in 19 patients [68%]). The ischemic region was supplied by ipsilateral (n = 4 [14%]), contralateral (n = 21 [75%]), or both ipsilateral and contralateral (n = 3 [11%]) collateral branches. In conclusion, dobutamine-induced ECG STE in LV segments with normal baseline wall motion is a highly reliable marker of viable collateral-dependent myocardium.

Diffuse ST-elevation following J-wave presentation as an uncommon electrocardiogram pattern of Tako-Tsubo cardiomyopathy

BackgroundTako-Tsubo cardiomyopathy (TTC) is characterized by symptoms, ECG changes with elevated cardiac markers mimicking acute myocardial infarction, left ventricular (LV) wall motion abnormalities in the apical region with preserved function of base, and normal coronary arteries. Usual ECG anomalies heralding TTC are ST-elevation in anterior leads, QT prolongation and negative T-waves. MethodsWe report the unusual case of TTC with an uncommon ECG presentation: J wave in inferior leads followed by diffuse ST-elevation. ResultsAn 82-year-old woman was admitted for dyspnea and chest pain following exacerbation of chronic obstructive pulmonary disease. ECG showed J-wave in inferior leads followed by diffuse ST-elevation. The patient was monitored in intensive care unit and treated with diuretics. Both ECG and echocardiography anomalies gradually recovered. ConclusionsDiffuse ST-elevation following J-waves may be considered as a possible ECG pattern of presentation in case of TTC.

Cardiac involvement in Becker muscular dystrophy: role of cardiovascular magnetic resonance

We report the case of a 40-year-old male known carrier of the Becker muscular dystrophy (BMD) who presented with fatigue in the outpatient clinic. Echocardiographic examination revealed a regional inferior left ventricular (LV) wall motion abnormality (Supplementary data online, Movie S1 ). A cardiovascular magnetic resonance imaging study (CMR) was indicated, showing …

Triple occurrence of Takotsubo cardiomyopathy

A 51 year-old woman after a quarrel with her husband and with no previous cardiovascular history was admitted to hospital with a suspicion of anterior myocardial infarction (MI) in 2005. She was suffering from chest pain; ECG documented ST-segment elevation in the V1–V3 leads and a positive troponin I level (2.8 ng/dL) was documented. An echocardiogram revealed akinesia of apical and mid-wall segments of left ventricular (LV) anterior wall and intraventricular septum with an ejection fraction (EF) of 45% (Fig. 1A, B). An urgent coronary angiography demonstrated no coronary artery disease (CAD). We observed full recovery with no LV contraction abnormalities at one-month follow-up. The subsequent focal type of Takotsubo cardiomyopathy (TTC) was diagnosed. Three years later, she presented with an inverse-type of TTC after knee surgery due to chest pain, ST-segment abnormalities in ECG and an increased troponin level (5.3 ng/dL). An echocardiogram and ventriculography revealed akinesia of all basal and mid-wall LV segments with an EF of 38% (Fig. 1C, D). We observed again a full clinical recovery with no LV wall motion abnormalities. A third hospitalisation, following a panic attack, occurred in 2009. The patient was referred for invasive diagnostics due to chest discomfort, ST-segment depression in ECG and a troponin I level of 1.1 ng/dL. Echocardiography and coronarography results were similar to those from the second episode (Fig. 1E, F). Therefore, a third occurrence of TTC was subsequently recognised. The most recent echocardiography showed normal LV contraction with an EF of 68% and normal longitudinal peak systolic strain for all LV regions (Fig. 1G, H). TTC, first described in 1990, usually affects postmenopausal women and is proceeded by psychological or physical stress. TTC mimics acute MI due to angina chest pain, ST-segment elevation pattern in ECG and a positive troponin level. However, obstructive CAD is in the majority of cases excluded. TTC, which is sometimes also known as apical ballooning syndrome, is predominantly characterised by transient, reversible, regional systolic dysfunction involving the LV apex and mid-ventricle with hyperkinesis of the basal LV segments. Case reports from the last 2 decades have also shown different faces of TTC concerning atypical TTCs such as inverse TTC with basal wall motion abnormalities, mid-segment TTC with akinesia presentation of all LV mid-segment and hyperkinesias of the basal and apical regions of LV, and focal TTC with regional wall motion disturbances. We here present a unique case of three TTC episodes in one patient after different stress events.

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.

Tako-Tsubo cardiomyopathy or allergic acute coronary syndrome: that is the question

We read with great interest the article by Fassio et al. [1] which provided a detailed review on Kounis syndrome (allergic acute coronary syndrome). The authors approached the issue both from the cardiologist’s and the allergist’s view. Authors report that initial descriptions of Kounis syndrome were focused on patients with ‘‘angiographycally’’ normal coronary arteries and acute release of allergic mediators (histamine or leukotrienes); the prognosis of these patients is good, with the left ventricular function normalizing over 3 days to several weeks [2]. However, we recently reported a case (a 70-year-old woman) of transient apical ballooning (Tako-Tsubo syndrome) [3], with mild ST-elevation in anterior leads and increased troponin-I levels [1.09 ng/ml (n.v. 0.03)], triggered by administration of antibiotics (cephalosporin) in a patient with history of asthma and allergy. Tako-Tsubo syndrome is characterized by acute onset of chest symptoms, ECG changes with elevated cardiac markers mimicking acute myocardial infarction, left ventricular wall motion abnormalities in the apical region with preserved function of base, and normal coronary arteries [4]. Those affected are typically older women presenting after a stressful trigger, either emotional or physical. According to authors’ opinion, could there be a link between Kounis syndrome’s variant with ‘‘angiographycally’’ normal coronary arteries and Tako-Tsubo syndrome triggered by administration of drugs in patient with history of asthma and allergy?