Midventricular Level Research Articles

Experimental and clinical studies ot prediction of response to cardiac resynchronization therapy by real-time three-dimensional echocardiography and speckle tracking imaging

Objective To investigate new parameters to predict the response to cardiac resynchronization therapy (CRT) by using real-time three-dimensional echocardiography (RT3DE) and speckle tracking imaging(STI). Methods Twenty-one adult beagle dogs were divided into three groups:group A (CRT group, n =10) ,group B (heart failure group, n =7) and group C (control group, n =4).Seventy patients who accepted CRT and were followed up 6 months after CRT were enrolled. Response to CRT was defined as a ≥15％ decrease in left ventricular end-systolic volume. RT-3DE parameters were the dispersion of time to minimum regional volume for 16 segments (Tmsv16-SD) ,and the ratio of Tmsv16-SD to R-R interval (SDI). STI parameters were the ratios of standard deviation of the time to peak radial and circumferential strain at midventricular level to R-R interval (Trs-6SD,Tcs-6SD). Results In experimental study,Tmsv-16SD, Trs-6SD, Tcs-6SD had negative relationship with left veutricular ejection fraction (r were - 0. 86, - 0.75, - 0.83 respectively, all P ＜0.01 ). Trs-6SD was the strongest predictor to CRT. A cut-off value of Trs-6SD≥12.2％ was able to predict response to CRT with a sensitivity of 83.3％ and a specificity of 100％. Clinical studies found SDI was the strongest predictor to CRT. A cut-off value of SDI≥6.55％ was able to predict response to CRT with a sensitivity of 80. 0％ and a specificity of 81.8％.Conclusions RT-3DE and STI can assess left ventricular dyssynchrony, and are promising methods to predict the response to CRT. Key words: Echocardiography, real-time three-dimensional; Speckle tracking imaging; Cardiac resynchronization therapy; Ventricular function, left

Identification and further differentiation of subendocardial and transmural myocardial infarction by fast strain-encoded (SENC) magnetic resonance imaging at 3.0 Tesla

To investigate whether subendocardial and transmural myocardial infarction can be identified and differentiated using the peak circumferential and longitudinal strains measured by fast strain-encoded (SENC). Nineteen patients with ischemic heart diseases underwent imaging with fast SENC and late gadolinium enhancement (LGE) MRI at 3 T. Fast SENC measurements were performed in three short-axis slices (basal, mid-ventricular and apical levels) and one long-axis view (four-chamber) to assess peak longitudinal and circumferential systolic strains. All patients showed myocardial infarction with an average of 7 positive LGE segments. A total of 304 segments for longitudinal strains (LS) and 114 segments for circumferential strains (CS) could be analysed. Positive LGE segments showed lower peak CS and LS compared with the no LGE segments (P < 0.0001 for both). Segments with subendocardial infarction showed reduced CS and LS compared with the no LGE segments (P < 0.0001 for both). There was a significant difference in CS between subendocardial and transmural infarct segments (P = 0.03), but no significant difference in LS between them (P = 0.64). Fast SENC can identify old myocardial infarction and differentiate subendocardial from transmural infarction.

Epicardial adipose tissue thickness predicts descending thoracic aorta atherosclerosis shown by multidetector computed tomography

Human epicardial adipose tissue (EAT) is a type of visceral adipose tissue functioning as an endocrine organ by secreting hormones and adipocytokines which have an important role in the atherosclerotic process. In this study, we aimed to assess the relationship between EAT measured by dual source multidetector computed tomography (MDCT) and descending thoracic aorta (DTA) atherosclerosis. A total of 148 patients who underwent MDCT for the evaluation of coronary artery disease were enrolled in this study. Thickness of the EAT was measured on contrast enhanced multiplanar reformat images with parasternal short axis view at basal, mid-ventricular and apical levels and horizontal long axis view. The atherosclerotic plaque was scored from 0 to 4 points by the percentage of the luminal surface at the cross sectional area of proximal, mid and distal segments of descending aorta. Among the study population, 84 (56.8%) were male and age was (mean ± standart deviation) 56.9 ± 11.7 years. In patients with critical coronary atherosclerosis, DTA atherosclerosis had a significant relationship with EAT (P = 0.012). Multivariate linear regression analysis revealed that in addition to critical coronary stenosis, age and total epicardial fat thickness were associated with aortic atherosclerosis (β value, 0.058 and 0.035; t value, 4.74 and 2.28, respectively; P < 0.05) after adjustment for traditional cardiovascular risk factors. In this study we demonstrated that atherosclerotic plaque burden of DTA was associated with the amount of EAT thickness among patients with suspected CAD shown by MDCT. Further large scale prospective studies are needed to address the interaction of EAT as well as the mediators of inflammation and adipocytokines with the development of atherosclerotic plaques in aorta and effects on cardiovascular outcomes.

120 Comparison and reproducibility of standard and high temporal resolution myocardial tissue tagging in patients with severe aortic stenosis

ObjectivesThe aim of this study was to compare and assess the reproducibility of left ventricular (LV) circumferential peak systolic strain (PeakEcc) and strain rate (SR) measurements using standard and high...

130 Comparison of harmonic phase imaging with local sine wave modelling for the assessment of circumferential myocardial strain using tagged cardiovascular magnetic resonance images

IntroductionAssessment of myocardial strain promises to become an important quantitative tool in early diagnosis of cardiac disease and treatment monitoring. Advances in image processing software have facilitated rapid and clinically...

OP-029: EPICARDIAL ADIPOSE TISSUE THICKNESS PREDICTS DESCENDING THORACIC AORTA ATHEROSCLEROSIS SHOWN BY MULTIDETECTOR COMPUTED TOMOGRAPHY

Human epicardial adipose tissue (EAT) is a type of visceral adipose tissue functioning as an endocrine organ by secreting hormones and adipocytokines which have an important role in the atherosclerotic process. In this study, we aimed to assess the relationship between EAT measured by dual source multidetector computed tomography (MDCT) and descending thoracic aorta (DTA) atherosclerosis. A total of 148 patients who underwent MDCT for the evaluation of coronary artery disease were enrolled in this study. Thickness of the EAT was measured on contrast enhanced multiplanar reformat images with parasternal short axis view at basal, mid-ventricular and apical levels and horizontal long axis view. The atherosclerotic plaque was scored from 0 to 4 points by the percentage of the luminal surface at the cross sectional area of proximal, mid and distal segments of descending aorta. Among the study population, 84 (56.8%) were male and age was (mean ± standart deviation) 56.9 ± 11.7 years. In patients with critical coronary atherosclerosis, DTA atherosclerosis had a significant relationship with EAT (P = 0.012). Multivariate linear regression analysis revealed that in addition to critical coronary stenosis, age and total epicardial fat thickness were associated with aortic atherosclerosis (β value, 0.058 and 0.035; t value, 4.74 and 2.28, respectively; P < 0.05) after adjustment for traditional cardiovascular risk factors. In this study we demonstrated that atherosclerotic plaque burden of DTA was associated with the amount of EAT thickness among patients with suspected CAD shown by MDCT. Further large scale prospective studies are needed to address the interaction of EAT as well as the mediators of inflammation and adipocytokines with the development of atherosclerotic plaques in aorta and effects on cardiovascular outcomes.

Comparison and reproducibility of standard and high temporal resolution myocardial tissue tagging in patients with severe aortic stenosis

Objectives The aim of this study was to compare and assess the reproducibility of left ventricular (LV) circumferential peak systolic strain (PeakEcc) and strain rate (SR) measurements using standard and high temporal resolution myocardial tissue tagging in patients with severe aortic stenosis (AS). Background Myocardial tissue tagging with cardiac magnetic resonance (CMR) can be used to quantify strain and SR, however, there are little data on the reproducibility. Diastolic SR may be of particular interest as it may be the most sensitive marker of diastolic dysfunction often occurring early in the course of disease. Methods Eight patients with isolated severe AS without obstructive coronary artery disease were prospectively enrolled. They underwent CMR in a 1.5T scanner (Siemens Avanto) on two separate occasions, median interval 12 days. Complementary tagged (CSPAMM) images were acquired with both a single breath-hold (SBH: temporal resolution 42 ms), and a multiple brief expiration breath-hold (MBH: high temporal resolution 17 ms) sequence. Mid-wall PeakEcc was measured in the LV at mid-ventricular level with HARP Version 2.7 (Diagnosoft, USA). SR was calculated from the strain data; SR=Ecc2-Ecc1/Time2-Time1. PeakEcc, peak systolic and diastolic SR were read from curves of strain and SR against time. The MBH SR curves were filtered with a moving average (MA) to reduce noise sensitivity, results from a sample width of three and five were examined. Differences between SBH and MBH were assessed using Wilcoxon signed-rank test as not all measures were normally distributed. Reproducibility assessments were carried out on all techniques. Results PeakEcc was significantly higher with MBH vs SBH, but reproducibility was slightly worse. Results are summarised in Abstract 120 table 1. Systolic SR was approximately equal with all techniques although MBH using MA of five led to a borderline significant reduction. Diastolic SR was higher when measured with MBH although only significant using MA of three. Systolic and diastolic SR measures were more reproducible with MBH compared with SBH, except for the diastolic SR using MA of three, which was substantially worse. Strain and SR curves for the same patient are shown in Abstract 120 figure 1. Conclusions It is likely than SBH may be adequate or even superior to MBH for assessment of PeakEcc. The increased temporal resolution of MBH may be advantageous for examining systolic and diastolic SR; a MA of five for diastolic SR may be the preferred method for quantification given the improved reproducibility of this measure.

Right ventricular strain in patients with tetralogy of Fallot

Background Left ventricular (LV) circumferential strain shows cardiac dysfunction earlier than ejection fraction. However, measuring right ventricle strain is technically challenging due to the thin RV wall and complex morphology. Also, the predominant RV strain is longitudinal, whereas the predominant LV strain is circumferential. We recently validated a feature tracking algorithm for evaluation of left ventricular strain. Based on that work, we hypothesized that feature tracking would provide accurate and reproducible RV strain metrics for use in longitudinal evaluation of repaired TOF patients. Methods Forty patients and sixteen normal controls were evaluated. All patients had pulmonary regurgitant fraction > 30% with no residual obstruction. We dichotomized the TOF patients by RVEF ( 55%) for analysis. CMR image analysis included routine volumetry. Circumferential LV and longitudinal RV strain were calculated using the previously validated feature tracking algorithm. The average strain at the mid-ventricular level was used for comparison. Means were compared using student’s t-test and variances were compared with the Lev1:med test. Results All images yielded interpretable LV circumferential and RV longitudinal strain curves. All control subjects had normal biventricular ejection fraction. They had mean longitudinal right ventricular strain = -21+/-5%. The mean RV strain of patients with TOF and normal EV was -19 +/- 12%, not statistically different than normal. However, the variance in the strain as group was 2.5x higher than controls (p 55%) have markedly variable strain with increased dispersion in regional strain values. TOF patients with

Normal Values for Left Ventricular Volume in Infants and Young Children by the Echocardiographic Subxiphoid Five-Sixth Area by Length (Bullet) Method

Left ventricular (LV) end-diastolic volume (LVEDV) can be estimated by the formula (5/6) x area x length, or the "bullet" method. The aim of this study was to determine the range of normal LVEDV values in infants and young children (aged 0-3 years) by the subxiphoid bullet method. Echocardiograms from 100 normal subjects aged ≤ 3 years were retrospectively analyzed. Subjects with systemic disease, abnormal body size, cardiovascular disease, or nondiagnostic subxiphoid images were excluded. Measurements of LV short-axis cross-sectional diastolic area at the midventricular level and LV length were made offline from subxiphoid images. LVEDV was indexed to body surface area (BSA) to the powers of 1.0 and 1.38. Relationships between indexing methods, age, and gender were explored. The median age was 0.98 years (range, 0-2.9 years), the median weight was 9.5 kg (range, 3.1-16.0 kg), and the median BSA was 0.45 m(2) (range, 0.21-0.66 m(2)). The mean LVEDV/BSA(1.38) was 70.4 ± 9.1 mL/m(2.6), with an excellent correlation between LVEDV and BSA(1.38) (r = 0.96, P < .01). There was no residual relationship between LVEDV/BSA(1.38) and BSA (r = 0.06, P = NS) and no significant relationship between LVEDV/BSA(1.38) and age (r = 0.10, P = NS) or LVEDV/BSA(1.38) and gender. The normal range for LVEDV by the subxiphoid echocardiographic bullet method is reported for newborns, infants, and young children. LVEDV should be indexed to BSA(1.38), which is consistent with the known relationship between LV size and body size. In children aged ≤ 3 years, these data can be used to calculate Z scores for LVEDV by the subxiphoid bullet technique independent of age or gender.

Comprehensive cardiovascular magnetic resonance of myocardial mechanics in mice using three-dimensional cine DENSE.

BackgroundQuantitative noninvasive imaging of myocardial mechanics in mice enables studies of the roles of individual genes in cardiac function. We sought to develop comprehensive three-dimensional methods for imaging myocardial mechanics in mice.MethodsA 3D cine DENSE pulse sequence was implemented on a 7T small-bore scanner. The sequence used three-point phase cycling for artifact suppression and a stack-of-spirals k-space trajectory for efficient data acquisition. A semi-automatic 2D method was adapted for 3D image segmentation, and automated 3D methods to calculate strain, twist, and torsion were employed. A scan protocol that covered the majority of the left ventricle in a scan time of less than 25 minutes was developed, and seven healthy C57Bl/6 mice were studied.ResultsUsing these methods, multiphase normal and shear strains were measured, as were myocardial twist and torsion. Peak end-systolic values for the normal strains at the mid-ventricular level were 0.29 ± 0.17, -0.13 ± 0.03, and -0.18 ± 0.14 for Err, Ecc, and Ell, respectively. Peak end-systolic values for the shear strains were 0.00 ± 0.08, 0.04 ± 0.12, and 0.03 ± 0.07 for Erc, Erl, and Ecl, respectively. The peak end-systolic normalized torsion was 5.6 ± 0.9°.ConclusionsUsing a 3D cine DENSE sequence tailored for cardiac imaging in mice at 7 T, a comprehensive assessment of 3D myocardial mechanics can be achieved with a scan time of less than 25 minutes and an image analysis time of approximately 1 hour.

126 Speckle tracking echocardiography as a potential diagnostic method for acute myocarditis: A pilot comparaison to cardiac MRI

Cardiac MRI is the current gold standard for diagnosis of acute myocarditis (AM) but is often not available in the emergency setting. Ultrasound imaging using new imaging modalities such as STE is a potential alternative. Our aim was to test whether speckle tracking echocardiography (STE) can assist in the diagnostic of AM. Patients admitted for AM (n = 10), defined as acute chest pain, elevated troponin, normal coronary angiogram and presence of epicardial delayed enhancement (EDE) with cardiac MRI, and control patients (n = 10) were studied. For each patient, left parasternal short axial views were acquired in 2D mode at basal, mid-ventricular and apical levels and divided into a 16-segment model. Circumferential strain (CS) and radial strain (RS) were automatically calculated for each segment (n = 320) using a dedicated workstation. Time to peak of CS was measured for each segment and expressed as degrees of RR cycles (= 360°). In patients with AM, segments were categorized as with or without EDE. Mean CS and time to peak were higher in patients with AM as compared to control patients (−15.3 ± 2.5% vs. −20.8 ± 1.4% and 50 ± 23° vs. 5 ± 10°, p < 0,05; respectively), whereas RS was similar (42.8 ± 12.7% and 55.7 ± 13.4%; p = 0,07). In patients with AM, cardiac segments with EDE had a lower CS and delayed time to peak as compared to segments with no delayed enhancement (−6.4 ± 8.2% vs. −16.7 ± 7.1%, 23 +/− 27° vs. 4 +/− 11°; respectively; p < 0.05), but similar RS values (37.7 ± 16.8% vs. 38.4 ± 15.9%, respectively; p = 0.86). CS ≥ −9% or time-to-peak of CS > 30° in at least two segments identified patients with AM with a specificity of 90%, a sensitivity of 100% and an accuracy of 95%. This pilot study suggests that STE may be useful in the diagnosis of AM, particularly when using a composite index of CS value≥ −9% or time-to-peak of CS > 30° in at least two segments.

Myocarditic Appearance of Arrhythmogenic Right Ventricular Cardiomyopathy

A 48-year-old man presented with syncope due to tachycardia of left ventricular origin and was electrically cardioverted to sinus rhythm. There was no medical history of cardiac disease or family history of sudden cardiac death. Resting electrocardiography displayed epsilon waves (Figure, A). Coronary angiography revealed unobstructed arteries. Transthoracic echocardiography (Movies I and II) showed normal left ventricular dimensions with mild systolic dysfunction. The right ventricle was mildly dilated, with reduced systolic function but no regional wall-motion abnormalities or aneurysms. The right ventricular outflow tract measured 41 mm. Figure. A, Epsilon waves. B, Short-axis image at midventricular level. Late enhancement of the right ventricular border of the septum is seen, extending into epicardium of the anterior and inferior …

Role of pericardium in the maintenance of left ventricular twist

BackgroundThe role of pericardium in left ventricular (LV) twist has not been directly investigated. We sought to determine the role of pericardium in maintenance of LV twist function in an...

Dobutamine stress echocardiography for assessing the role of dynamic intraventricular obstruction in left ventricular ballooning syndrome

BackgroundDynamic intraventricular obstruction has been observed in patients with left ventricular ballooning syndrome (LVBS) and has been hypothesized as a possible mechanism of the syndrome. The aim of this study was to assess the prevalence and significance of dynamic intraventricular obstruction in patients with LVBS.Methods and ResultsDobutamine stress echocardiography was carried out in 22 patients with LVBS (82% apical), all women, aged 68 ± 9 years. At baseline 1 patient had a > 30 mmHg LV gradient; during stress a LV gradient > 30 mm Hg developed in 6/21 patients (28%) and was caused by systolic anterior motion of the mitral valve in the 3 patients with severe gradient (mean 116 ± 29 mmHg), who developed mitral regurgitation and impaired apical wall motion and by obstruction at mid-ventricular level in the other 3 with a moderate gradient (mean 46 ± 16 mmHg). Compared with patients without obstruction those with obstruction had a greater mean septal thickness (11.6 ± .6 vs 9.8. ± 3, p < .01), a higher prevalence of septal hypertrophy (71% vs 7%, p < .005) and a higher peak wall motion score index (1.62 ± .4 vs 1.08 ± .4, p < .01).ConclusionSpontaneous or dobutamine-induced dynamic LV obstruction is documented in 32% of patients with LVBS, is correlated with the presence of septal hypertrophy and may play a role in the development of LVBS in this subset of patients. In those without septal hypertrophy a dynamic obstruction is rarely induced with dobutamine and is unlikely to be a major pathogenetic factor of the syndrome.

Circumferential myocardial strain in cardiomyopathy with and without left bundle branch block.

BackgroundCardiac resynchronization therapy (CRT) has been shown to decrease mortality in 60-70% of advanced heart failure patients with left bundle branch block (LBBB) and QRS duration > 120 ms. There have been intense efforts to find reproducible non-invasive parameters to predict CRT response. We hypothesized that different left ventricular contraction patterns may exist in LBBB patients with depressed systolic function and applied tagged cardiovascular magnetic resonance (CMR) to assess circumferential strain in this population.MethodsWe determined myocardial circumferential strain at the basal, mid, and apical ventricular level in 35 subjects (10 with ischemic cardiomyopathy, 15 with non-ischemic cardiomyopathy, and 10 healthy controls). Patterns of circumferential strain were analyzed. Time to peak systolic circumferential strain in each of the 6 segments in all three ventricular slices and the standard deviation of time to peak strain in the basal and mid ventricular slices were determined.ResultsDyskinesis of the anterior septum and the inferior septum in at least two ventricular levels was seen in 50% (5 out of 10) of LBBB patients while 30% had isolated dyskinesis of the anteroseptum, and 20% had no dyskinesis in any segments, similar to all of the non-LBBB patients and healthy controls. Peak circumferential strain shortening was significantly reduced in all cardiomyopathy patients at the mid-ventricular level (LBBB 9 ± 6%, non-LBBB 10 ± 4% vs. healthy 19 ± 4%; both p < 0.0001 compared to healthy), but was similar among the LBBB and non-LBBB groups (p = 0.20). The LBBB group had significantly greater dyssynchrony compared to the non-LBBB group and healthy controls assessed by opposing wall delays and 12-segment standard deviation (LBBB 164 ± 30 ms vs. non-LBBB 70 ± 17 ms (p < 0.0001), non-LBBB vs. healthy 65 ± 17 ms (p = 0.47)).ConclusionsSeptal dyskinesis exists in some patients with LBBB. Myocardial circumferential strain analysis enables detailed characterization of contraction patterns, strengths, and timing in cardiomyopathy patients with and without LBBB.

Hypertrophic cardiomyopathy associated with left ventricular apical aneurysm

MOTS CLES Cardiomyopathie hypertrophique ; Echo-doppler A 38-year-old man was admitted to the cardiology emergency department for palpitations. He had been diagnosed 3 years earlier with hypertrophic cardiomyopathy and was receiving chronic treatment with beta-blockers and low-dose aspirin. Physical examination was unremarkable. Electrocardiogram showed right bundle branch block associated with diffuse abnormal ST-segment changes (Fig. 1). Troponin I was increased slightly, at 0.11 ng/mL (normal < 0.05). Transthoracic echocardiographic examination revealed concentric left ventricular hypertrophy with maximal midventricular thickening without significant left ventricular obstruction and a large apical aneurysm (Video 1). Coronary angiography was normal. The left ventricular cine-angiogram showed midcavitary obliteration at end-systole and a large aneurysm (Video 2). Late gadolinium enhancement cardiac magnetic resonance imaging found transmural fibrosis of the apex and confirmed maximal left ventricular wall thickening at the midventricular level (Video 3, Fig. 2). Exercise testing did not produce arrhythmias. Treatment with a vitamin K antagonist was

Heterogeneous contraction of the left ventricle demonstrated by 2-dimensional strain imaging.

Tissue Doppler imaging (TDI) is useful in quantifying regional myocardial function, but has a significant limitation of Doppler angle dependency. The recently developed 2-dimensional strain imaging (2DS), based on speckle tracking imaging (STI) technology, enables us to evaluate myocardial function independent of ultrasound beam direction. The aim of this study was to assess the mode of contraction of the left ventricle. Circumferential, radial and longitudinal strains were measured in 18 segments (anteroseptal, anterior, anterolateral, inferolateral, inferior and inferoseptal walls at the base, mid-ventricle and apex) from apical and short-axis views using 2DS in 24 healthy subjects (mean age, 33±5years). We divided the left ventricle into 2 sites: septum (anterior, anteroseptal and inferoseptal walls) and free walls (anterolateral, inferolateral and inferior walls). We then compared the mode of contraction between the septum and free walls. At the base and mid-ventricular levels, circumferential strain was larger in the septum (-22.6±3.6 vs. -18.3±4.1% and -24.1±4.8 vs. -18.4±5.7%, respectively; p<0.0001 each), and radial strain was larger in the free walls (33.4±12.4 vs. 38.7±14.5% and 37.8±12.6 vs. 43.0±11.6%, respectively; p<0.001 each) at the basal and mid-ventricular levels, whereas both were relatively homogeneous at the apex. The longitudinal strain did not differ among walls. Heterogeneous contraction is seen in the left ventricle. The septum mainly contracts circumferentially, whereas the free walls contract radially. 2DS is helpful in understanding the mode of 3-dimensional myocardial contraction.

The influence of fat thickness on the human epicardial bipolar electrogram characteristics: measurements on patients undergoing open-heart surgery

Reference values exist for endocardial but not for epicardial (EPI) substrate mapping in cases of cardiomyopathy-associated ventricular tachycardia. We sought to establish such values for EPI electrogram voltage, including areas with overlying fat. Ten patients (six males) undergoing cardiac surgery were studied. After opening the pericardium, the distal bipole of an electrophysiology catheter was placed tangential to the EPI surface to obtain an electrogram recording. The bipole was tangentially rotated 90 degrees and the higher of the two amplitudes (mV) was taken as the local amplitude. Recordings were taken from normal left and right ventricular myocardium (n = 26 data points each), over thick (> or = 0.5 cm) fat at both ventricular bases (n = 16) and thin (<0.5 cm) fat at the mid-ventricular level (n = 32). A total of 100 recordings (mean 10/patient) were analysed. Four patients underwent valvular surgery, three bypass surgery, and three combined procedures. Mean age was 61.7 +/- 10.4 years and mean left ventricular ejection fraction was 46 +/- 12%. Electrogram amplitude was inversely related to EPI fat thickness. Over thick fat, 31% of recordings were <0.5 mV. Human EPI electrogram amplitude varies by ventricular chamber and significantly by EPI fat thickness. A cut-off of 0.5 mV to define 'scar' will include normal areas with thick overlying fat. EPI substrate maps should include data on EPI fat thickness for higher specificity.

Stress-induced cardiomyopathy following cephalosporin-induced anaphylactic shock during general anesthesia

Anaphylaxis may be caused by various agents during general anesthesia. Sympathetic discharge may occur during anaphylaxis, which can trigger transient cardiomyopathy. We describe a case of stress-induced cardiomyopathy that occurred in association with an anaphylactic reaction during general anesthesia. A 32-year-old female undergoing laparoscopic enucleation of an ovarian cyst developed a severe anaphylactic reaction after cephalosporin infusion during general anesthesia. Her vital signs responded favourably to immediate resuscitative maneuvers, but cardiovascular collapse reappeared with transient ventricular tachycardia shortly after her transfer to the intensive care unit. ST-segment elevation appeared in electrocardiographic leads V(2)-V(6) and echocardiography showed diffuse regional wall motion abnormalities in the midventricular level. Increased MB fractions of creatine kinase and troponin T levels indicated myocardial necrosis, but cardiac catheterization demonstrated normal coronary arteries. Management was supportive and she was discharged 2 days after the onset of anaphylactic symptoms, without sequelae. A diagnosis of stress-induced cardiomyopathy of a midventricular type following anaphylaxis was made on the basis of the clinical features and the findings of cardiac evaluations. Transient, reversible left-ventricular dysfunction is a recently recognized phenomenon that may occur in the setting of anaphylactic reactions during the perioperative period.

Abstract 4691: Endomyocardial Dysfunction in Patients with Severe Aortic Regurgitation and Preserved Ejection Fraction: A Speckle Tracking Echocardiographic Study

Potential myocardial dysfunction may be present in patients with significant aortic regurgitation (AR) and preserved left ventricular ejection fraction (LVEF). Newly developed software for speckle tracking imaging (STI) allows separate analysis of endo- and epimyocardial strain. The aim of this study was to assess the relationship between endo- and epimyocardial radial strain (RS) distribution and AR severity in identifying the potential myocardial dysfunction in patients with significant AR and LVEF&gt;50%, and its correlation with postoperative LV function. We studied 47 patients with AR and 26 control subjects. Degree of AR was classified according to standard echocardiographic criteria as moderate in 16 and severe in 23 patients. STI was analyzed with the new software (Toshiba Medical Systems, Tokyo, Japan). For STI analysis, an endocardial and epicardial border line were each manually traced at end-systole on a short-axis B-mode image at the mid-ventricular level; peak RS of total, endomyocardium, and epicardium were automatically calculated. Endomyocardial RS was reduced in patients with severe AR compared to control subjects and patients with moderate AR (Figure ). Postoperative changes in LVEF were well correlated with the ratio of baseline endomyocardial RS to epimyocardial RS (n=21, r=−0.69, p&lt;0.001). Endomyocardial RS was reduced in patients with severe AR. Assessment of STI-derived RS distribution may be useful to identify potential myocardial dysfunction and postoperative LV functional deterioration in patients with severe AR and preserved EF.