Midventricular Segments Research Articles

MID-VENTRICULAR TAKOTSUBO CARDIOMYOPATHY MIMICKING ACUTE CORONARY SYNDROME

Takotsubo cardiomyopathy can mimic potentially fatal cardiovascular conditions on presentation. The mid-ventricular variant presents with akinesis of the mid-ventricular segments and hyperkinesis of the base and apex. A 54 year old woman with history of hypertension and hyperlipidemia presented

Left Ventricular Pressure-Strain–Derived Myocardial Work at Rest and during Exercise in Patients with Cardiac Amyloidosis

Left ventricular pressure-strain-derived myocardial work index (LVMWI) is a novel, noninvasive method for left ventricular (LV) function evaluation in relation to LV pressure dynamics. LV global longitudinal strain (LVGLS) has proven benefit for diagnosis and risk stratification in patients with cardiac amyloidosis (CA), but LVGLS does not adjust for loading conditions. The aim of the present study was to characterize LVMWI at rest and during exercise in patients with CA. A total of 155 subjects were retrospectively included. These subjects comprised 100 patients with CA and 55 healthy control subjects. All patients had previously undergone comprehensive two-dimensional echocardiographic examinations at rest. Furthermore, a subgroup 27 patients with CA and 41 control subjects was examined using semisupine exercise stress echocardiography. Patients with CA had significantly lower LVGLS, LVMWI, and LV myocardial work efficiency (LVMWE) than control subjects (P<.0001 for all). The reduction in LV myocardial performance was more pronounced in the basal segments, which led to significant alterations in the average apical-to-basal segmental ratios between patients with CA and control subjects (LVGLS, 2.6 [1.9 to 4.1] vs 1.3 [1.2 to 1.5]; LVMWI, 2.6 [1.7 to 3.8] vs 1.3 [1.1 to 1.5]; LVMWE, 1.1 [1.0 to 1.3] vs 1.0 [1.0 to 1.1]; P<.0001 for all). The average increase in LVMWI from rest to peak exercise was 1,974mm Hg% (95% CI, 1,699 to 2,250mm Hg%; P<.0001) in control subjects and 496mm Hg% (95% CI, 156 to 835mm Hg%; P<.01) in patients with CA. The absolute numeric LVGLS increase was 5.6% (95% CI, 3.9% to 7.3%; P<.0001) in control subjects and only 1.2% (95% CI, -0.9% to 3.3%; P=.26) in patients with CA (between groups, P<.0001) from rest to peak exercise. The LVMWI increase in patients with CA was mediated by improvement in the apical segments (P<.0001), whereas there was no significant LVMWI alterations in the midventricular or basal segments. LVMWE remained stable during exercise in control subjects (Δ -0.6%; 95% CI, -2.5% to 1.2%; P=.50) but decreased significantly in patients with CA (Δ -2.5%; 95% CI, -4.8% to -0.2%; P<.05). Patients with CA have significantly reduced magnitude of LVMWI compared with healthy control subjects. With exercise, the differences are even more pronounced. Even though LVMWI increased with exercise, LVMWE decreased, suggesting inefficient myocardial energy exploitation in patients with CA.

P1384 Longitudinal strain in basal, midventricular and apical segments in aortic stenosis and mitral regurgitation and the relationship to pulmonary capillary wedge pressure at exercise

Abstract Funding Acknowledgements Supported by the Danish Heart Foundation Background Two dimensional speckle tracking provide reproducible regional and global assessment of left ventricular (LV) function. Valvular heart disease imposes both pressure overload (aortic stenosis (AS) and volume overload (mitral regurgitation (MR) on the LV. Despite high prevalence of valvular heart disease, little is known about the relationship between longitudinal strain (LS) measures and exercise hemodynamics in the pressure over loaded LV AS and the volume over loaded LV in MR. Purpose To describe the relationship between segmental LS in AS and MR according to normal or increased pulmonary capillary wedge pressure with exercise. Methods In a cross-sectional study patients with asymptomatic AS (aortic valve area &amp;lt;1 cm2 and peak velocity &amp;gt;3.5 m/s) and patients with primary MR (effective regurgitant orifice &amp;gt; 0.30 cm2) underwent echocardiography and stress test in semi-supine position with invasive hemodynamic assessment using a Swan-Ganz catheter. Echocardiograms were performed at rest on a Vivid 9 (GE, Horten, Norway) and stored for offline analysis. Semi-automatic software (Echopac version 202, GE) was used for LS analysis and recorded using an 18-segment model of the LV followed by segmentation into basal (BAS), midventricular (MID) and apical (API) segments. Semi-supine stress test was performed with increase in workload every third minute until exhaustion; at maximum exercise, pulmonary capillary wedge pressure was measured (maxPCWP). Patients were grouped according to maxPCWP &amp;gt; 28 mmHg (group 1) or ≤ 28 mmHg (group 2). Results are shown as mean ± SD, student’s t-test was used for continues data and pearsons chi-squared test was used for categorical data. Results Thirty-five patients with AS (age 73 ± 7.0 years, 74% men), and in 44 patients with MR (age 64 ± 8.8 years, 77% men) were studied. Patients with AS had a global LS of -18.8 ± 3.3% vs. -21.5 ± 3.3% in MR patients (p = 0.001). Basal, midventricular and apical LS was -14.5%±2.2%, -18.4 ± 2.9% and -26.3 ± 5.5% in AS patients and -18.4 ± 2.6%, -21.9 ± 2.9% and -26.7 ± 5.1% in MR patients (p &amp;lt; 0.001, p &amp;lt; 0.001 and 0.442, respectively). The proportion of AS patients that were in group 1(n = 23) were higher than the proportion of MI patients that were in group 1 (n = 19, 66 % vs 42%, p = 0.046). Patients in group 1 had lower LS in all segments (BAS: -15.7 ± 2.8% vs -17.7 ± 3.1%, MID: -19.3 ± 2.9% vs. -21.6 ± 3.4%, API: -26.0 ± 5.0% vs -27.8 ± 5.4%) but only BAS and MID segments were statistically significant(p = 0.005 and p = 0.002, respectively). In both AS and MR, patients in group 1 had lower segmental LS, but only MID LS in MR patients was statistically significant (-20.9%±2.5% vs -22.7 ± 2.9%, p = 0.030). Conclusion In patients with AS or MR PCWP above 28 mmHg with exercise was associated with lower LS in BAS and MID segments. This implies that in both pressure and volume overload resting LV function is depressed when patients have abnormally elevated filling pressure with exercise. Abstract P1384 Figure. Longitudinal strain

P184 Broken heart complications

Abstract Introduction Patients with persistent chest discomfort or other symptoms suggestive of ischaemia and ST segment elevation in two contiguous leads on electrocardiography should be prompt managed to revascularization and emergent angiography for percutaneous intervention in two hours is the preferred reperfusion strategy. Purpose Our aim is to show the importance of differential diagnosis in a patient with an initial diagnosis of ST segment elevation myocardial infarction (STEMI). Clinical case We present a case of 67 years old women with a past medical history of dyslipidemia and polymyalgia rheumatica, treated with rosuvastatin 10mg id and prednisolone 5 mg id. The patient was admitted to emergency department complaining of chest pain with 3 hours of evolution that started after a period of nausea and vomiting. Physical examination showed slight tachypnea with 22 breath per minute, blood pressure 93/40 mmHg, heart rate 110 beats per minute, oxygen saturation in room air 90%, heart sounds with a systolic murmur II/VI and lung crackles in inferior lobes, with no peripheral oedema. Electrocardiography showed sinus rhythm and ST segment elevation in DI, DII and V2-6. Patient was treated with aspirin 300mg, ticagrelor 180mg, furosemide 40mg, oxygen therapy and was scheduled for emergent coronariography. This procedure revealed no significant coronary lesions and ventriculography identified apical ballooning, diagnosing takotsubo myocardiopathy. Clinical condition starts to deteriorate, and an echocardiography identified akinetic apical and midventricular segments and hyperkinetic basal segments with systolic anterior motion of mitral valve, significant mitral regurgitation and left ventricular outflow tract obstruction (LVOTO) with an intraventricular gradient superior to 60 mmHg. Adequate hemodynamic monitoring and heart rate control allowed a substantial clinical improvement. Two days later a cardiac magnetic ressonance was done, confirmed the diagnosis and identified an apical thrombus. The patient was later discharged stable with oral hypocoagulation with anti-vitamin K antagonist. Discussion and Conclusion Takotsubo cardiomyopathy is a unique cardiac syndrome characterized by transient systolic dysfunction witch often mimics acute coronary syndromes (ACS). After exclusion of an ACS, echocardiography is of primordial importance in the assessment of these patients. Left heart failure with pulmonar oedema, mitral regurgitation, LVOTO and thrombus formation were all complications that were present in this clinical case and established the indication to proper therapeutic attitudes. Abstract P184 Figure.

P5287Influence of contrast and spatial resolution on myocardial strain results using feature tracking MRI

Abstract Background Feature tracking is a new post-processing algorithm for calculating myocardial strain from cardiac magnetic resonance (CMR) cine images. Quantification of myocardial deformation promises to detect myocardial abnormalities early in the course of disease. However, no uniform standards for image acquisition and processing are available. Purpose Analysing the influence of spatial resolution and contrast agent on quantitative myocardial strain results. Methods Seventy-five patients in sinus rhythm were prospectively enrolled and underwent a standardised CMR exam using a 1.5 Tesla scanner. For feature tracking analysis, steady-state free-precession (SSFP) cine images in long and short axes were acquired in 3 variants: 1. Native standard cine (spatial resolution 1.4x1.4x8mm3). 2. Native cine with lower spatial resolution (2.0x2.0x8mm3). 3. Standard cine equal to variant 1 but acquired 5 minutes after i.v.-administration of 0.2mmol/kg body weight gadoteracid. Group A consisted of 50 patients with normal left ventricular ejection fraction, no regional wall motion abnormality and no evidence of fibrosis based on Late Gadolinium Enhancement. Group B comprised 25 patients with evidence of infarct-like myocardial scar in the analyzed planes. Using dedicated feature tracking software, circumferential, longitudinal and radial strain were calculated as mean of the six midventricular myocardial segments for group A. For group B, the analysis focused on the infarcted segments. Results Figure 1 summarises the strain results, given as mean standard deviation. (The p-values stem from paired t-tests (group A) and Wilcoxon tests (group B), respectively. Significance is highlighted by *). In group A, circumferential and radial strain decreased significantly after Gadolinium administration, while longitudinal strain increased significantly with lower spatial resolution. In group B, circumferential, longitudinal and radial strain results of the infarcted segments increased significantly with lower spatial resolution, while Gadolinium had no statistically significant influence on strain results. Figure 1 Conclusion Quantitative myocardial strain results obtained by CMR feature tracking are significantly influenced by spatial resolution and Gadolinium administration. Standardised image acquisition seems fundamental for reliable and comparable CMR strain analysis.

P1775Outcomes in patients with left ventricular non-compaction phenotype and normal left ventricular ejection fraction

Abstract Introduction Left ventricular non-compaction (LVNC) is a rare cardiomyopathy with a progressive clinical course, resulting in symptoms such as heart failure, cardiac arrhythmias, or thrombo-embolic events. Little is known about the natural course of disease, in particular in individuals with normal LV ejection fraction (EF) at diagnosis. In this study, we aim to evaluate the outcome of this group of patients. Methods 48 LVNC patients with normal LV EF at diagnosis (defined as ≥50% by Simpson) were retrospectively analysed followed-up for median duration of 3656 days (2017–4965). All outcome data and conventional echocardiographic parameters were obtained; and in 27 patients, LV and right ventricular (RV) global longitudinal strain (GLS) were also determined using TomTec Image Arena (v.4.6). Results Mean age was 25.5 years. Median LVEF was 58.5% [IQR: 52.75 - 65.25]). The localization of non-compacted segments displayed a typical distribution with apical and inferolateral midventricular segments most frequently involved. Although LVEF was normal at baseline, median LV GLS was 16.8% (IQR: 20.0 - 14.2) and RV GLS was 18.7% (23.3–15.6). Furthermore, only 30 patients (73.2%) had a normal diastolic function, while others showed impaired relaxation (19.5%; n=8) or restrictive filling pattern (7.3%; n=3). During follow-up, LVEF decreased slightly from the initial visit (59%, [53.3–65.0]) to last follow-up (56%, [53.0–61.8], p=0.0009), and LV end-systolic and end-diastolic volumes increased (p=0.009 and 0.001, respectively). The other echocardiographic parameters did not show any significant changes. During follow-up, 3 patients (7.7%) died, 5 (12.8%) were hospitalized for heart failure, 3 (7.7%) had a thromboembolic event, 5 (12.8%) a syncope, 3 (8.1%) a non-sustained ventricular tachycardia, 9 (22.5%) a supraventricular tachycardia, and 14 (35.9%) suffered other complications during follow-up. The change in LVEF and LV volumes during follow-up was not significantly associated with outcome. Conclusion Patients presenting with a LVNC phenotype and normal LVEF did not display a completely normal LV function as revealed by LV strain and LV diastolic function. LVEF decreased slightly during follow-up, but was surprisingly stable in most patients. Nevertheless, a significant number of individuals experienced a clinically relevant event. Hence, a LVNC phenotype is important even in individuals with normal LVEF and such patients should be followed-up regularly.

4D modelling of fluid mechanics in the zebrafish embryonic heart.

Abnormal blood flow mechanics can result in pathological heart malformation, underlining the importance of understanding embryonic cardiac fluid mechanics. In the current study, we performed image-based computational fluid dynamics simulation of the zebrafish embryonic heart ventricles and characterized flow mechanics, organ dynamics, and energy dynamics in detail. 4D scans of 5days post-fertilization embryonic hearts with GFP-labelled myocardium were acquired using line-scan focal modulation microscopy. This revealed that the zebrafish hearts exhibited a wave-like contractile/relaxation motion from the inlet to the outlet during both systole and diastole, which we showed to be an energy efficient configuration. No impedance pumping effects of pressure and velocity waves were observed. Due to its tube-like configuration, inflow velocities were higher near the inlet and smaller at the outlet and vice versa for outflow velocities. This resulted in an interesting spatial wall shear stress (WSS) pattern where WSS waveforms near the inlet and those near the outlet were out of phase. There was large spatial variability in WSS magnitudes. Peak WSS was in the range of 47.5-130dyne/cm2 at the inflow and outflow tracts, but were much smaller, in the range of 4-11dyne/cm2, in the mid-ventricular segment. Due to very low Reynolds number and the highly viscous environment, intraventricular pressure gradients were high, suggesting substantial energy losses of flow through the heart.

Cardiac magnetic resonance feature tracking for quantifying right ventricular deformation in type 2 diabetes mellitus patients

To determine the feasibility of deformation analysis in the right ventricle (RV) using cardiovascular magnetic resonance myocardial feature tracking (CMR-FT) in type 2 diabetes mellitus (T2DM) patients. We enrolled 104 T2DM patients, including 14 with impaired right ventricular ejection fraction (RVEF) and 90 with preserved RVEF, and 26 healthy controls in this prospective study. CMR was used to determine RV feature-tracking parameters. RV strain parameters were compared among the controls, patients with preserved and reduced RVEF. Binary logistic regression was used to predict RV dysfunction. Receiver operating characteristic analysis was used to assess the diagnostic accuracy. The agreement was tested by Bland–Altman analysis. Compared with controls, longitudinal and circumferential global peak strain (PS) and PS at mid-ventricular, apical slices were significantly decreased in T2DM patients with or without reduced RVEF (p < 0.05). Within the T2DM patients, the global longitudinal PS (GLPS) and the longitudinal PS at mid-ventricular segments were significantly reduced in the reduced RVEF group than in preserved RVEF groups (p < 0.05). GLPS was an independent predictor of RV dysfunction (odds ratio: 1.246, 95% CI: 1.037–1.496; p = 0.019). The GLPS demonstrated greater diagnostic accuracy (area under curve: 0.716) to predict RV dysfunction. On Bland-Altman analysis, global circumferential PS and GLPS had the best intra- and inter-observer agreement, respectively. In T2DM patients, CMR-FT could quantify RV deformation and identify subclinical RV dysfunction in those with normal RVEF. Further, RV strain parameters are potential predictors for RV dysfunction in T2DM patients.

Impact of apical foreshortening on deformation measurements: a report from the EACVI-ASE Strain Standardization Task Force.

Foreshortening of apical views is a common problem in echocardiography. It results in an abnormally thick false apex and a shortened left ventricular (LV) long axis. We sought to evaluate the impact of foreshortened (FS) on LV ejection fraction (LVEF) and layer-specific 2D speckle tracking based segmental (S) and global (G) longitudinal strain (LS) measurements. We examined 72 participants using a GE Vivid E9 system. FS apical views were collected from an imaging window one rib-space higher than the optimal images. Ejection fraction as well as layer-specific GLS and SLS measurements were analysed by GE EchoPAC v201 and TomTec Image Arena 4.6 and compared between optimal and FS images. On average, LV long axis was 10% shorter in FS images than in optimal images. FS induced a relative change in LVEF of 3.3% and 6.9% for GE and TomTec, respectively (both, P < 0.001). Endocardial GLS was 9.0% higher with GE and 23.2% with TomTec (P < 0.001). Midwall GLS measurements were less affected (7.8% for GE and 14.1% for TomTec, respectively, both P < 0.001). Segmental strain analysis revealed that the mid-ventricular and apical segments were more affected by foreshortening, and endocardial measurements were more affected than midwall. Optimal image geometry is crucial for accurate LV function assessment. Foreshorhening of apical views has a substantial impact on longitudinal strain measurements, predominantly in the apex and in the endocardial layer. Our data suggest that measuring midwall strain might therefore be the more robust approach for clinical routine use.

Metal Artifact Reduction in Cardiovascular MRI for Accurate Myocardial Scar Assessment in Patients With Cardiac Implantable Electronic Devices.

OBJECTIVE. An important application of late gadolinium enhancement (LGE) cardiac MRI is accurate assessment of myocardial scar before ablation. However, this is often limited in patients with cardiac implantable electronic devices (CIEDs) because of metal device-induced artifacts. The purpose of this study was to determine whether a modified wideband inversion recovery (IR) LGE MRI technique decreases artifact volume to allow the assessment of myocardial scar. SUBJECTS AND METHODS. Fifty patients (17 women and 33 men; mean age ± SD, 61 ± 12 years; mean ejection fraction ± SD, 35.9% ± 13.3%) with CIEDs underwent cardiac MRI using conventional and modified wideband IR LGE techniques before ablation. The volume of device-induced artifact was quantified and stratified by tertiles on mild, moderate, and severe. Ordinal logistic regression analysis assessed the association between artifact volume on conventional and wideband images adjusted for patients' demographics. RESULTS. Conventional LGE MRI resulted in device-induced hyperintense artifacts that obscured ventricular segments in 32 of 50 (64%) cases. Wideband LGE MRI significantly reduced severe artifact volume (p < 0.0001) and completely resolved all mild and most moderate artifacts. Overall, wideband techniques resulted in a 56% reduction in total artifact volume for the cohort (p < 0.0001). The wideband LGE MRI sequence minimized artifacts in the most commonly obscured segments on the conventional LGE MRI sequence, with persistent artifacts in seven, eight, and four of 32 cases at the basal anterior, midventricular anterior, and midventricular anteroseptal segments, respectively. CONCLUSION. The modified wideband IR technique completely resolves mild and moderate device-induced hyperintense artifacts and significantly reduces the volume of severe artifact to allow accurate identification of myocardial scar in patients with CIEDs before ablation.

Differential Effects of Isoproterenol on Regional Myocardial Mechanics in Rat Using Three-Dimensional Cine DENSE Cardiovascular Magnetic Resonance

The present study assessed the acute effects of isoproterenol on left ventricular (LV) mechanics in healthy rats with the hypothesis that β-adrenergic stimulation influences the mechanics of different myocardial regions of the LV wall in different ways. To accomplish this, magnetic resonance images were obtained in the LV of healthy rats with or without isoproterenol infusion. The LV contours were divided into basal, midventricular, and apical regions. Additionally, the midventricular myocardium was divided into three transmural layers with each layer partitioned into four segments (i.e., septal, inferior, lateral, and anterior). Peak systolic strains and torsion were quantified for each region. Isoproterenol significantly increased peak systolic radial strain and circumferential-longitudinal (CL) shear strain, as well as ventricular torsion, throughout the basal, midventricle, and apical regions. In the midventricle, isoproterenol significantly increased peak systolic radial strain, and induced significant increases in peak systolic circumferential strain and longitudinal strain in the septum. Isoproterenol consistently increased peak systolic CL shear strain in all midventricular segments. Ventricular torsion was significantly increased in nearly all segments except the inferior subendocardium. The effects of isoproterenol on LV systolic mechanics (i.e., three-dimensional (3D) strains and torsion) in healthy rats depend on the region. This region dependency is also strain component-specific. These results provide insight into the regional response of LV mechanics to β-adrenergic stimulation in rats and could act as a baseline for future studies on subclinical abnormalities associated with the inotropic response in heart disease.

REVERSE TAKOTSUBO FROM IATROGENIC STRESS INDUCED CARDIOMYOPATHY

Reverse Takotsubo is a version of stress cardiomyopathy in which the base and midventricular segments of the left ventricle are akinetic. This is opposite of the classically described Takotsubo cardiomyopathy in which there is apical ballooning from systolic dysfunction of the apex. A 63 year old

Speckle Tracking Analysis of Left Ventricular Systolic Function Following Traumatic Brain Injury: A Pilot Prospective Observational Cohort Study.

Systolic dysfunction and reduction in left ventricular ejection fraction (LVEF) has been documented after traumatic brain injury (TBI). Speckle tracking is an emerging technology for myocardial strain assessment which has been utilized to identify subclinical myocardial dysfunction, and is most commonly reported as global longitudinal strain (GLS). We examined myocardial strain and regional strain patterns following moderate-severe TBI. We conducted a prospective cohort study of moderate-severe TBI patients (Glasgow Coma Scale≤12) and age/sex-matched controls. Transthoracic echocardiography was performed within the first day and 1 week following TBI. Myocardial function was assessed using both GLS and LVEF, and impaired systolic function was defined as GLS >-16% or LVEF ≤50%. Regional strain patterns and individual strain trajectories were examined. Thirty subjects were included, 15 patients with TBI and 15 age/sex-matched controls. Among patients with adequate echocardiographic windows, systolic dysfunction was observed in 2 (17%) patients using LVEF and 5 (38%) patients using GLS within the first day after TBI. Mean GLS was impaired in patients with TBI compared with controls (-16.4±3.8% vs. -20.7±1.8%, P=0.001). Regional myocardial examination revealed impaired strain primarily in the basal and mid-ventricular segments. There was no improvement in GLS from day 1 to day 7 (P=0.81). Myocardial strain abnormalities are common and persist for at least 1 week following moderate-severe TBI. Speckle tracking may be useful for the early diagnosis and monitoring of systolic dysfunction following TBI.

Joint cardiac and respiratory motion estimation for motion-corrected cardiac PET-MR

Respiratory and cardiac motion can strongly impair cardiac PET image quality and tracer uptake quantification. Standard gating techniques can minimize these motion artefacts but suffer from low signal-to-noise ratio because only a small percentage of the total data is utilized. Motion correction approaches have been proposed to overcome this problem but require accurate knowledge of such physiological motion. Here we present a joint PET-MR motion estimation approach which combines complimentary dynamic image information from simultaneously acquired MR and PET to ensure improved cardiac and respiratory motion estimation for motion-corrected image reconstruction (MCIR) of PET images. A 3D triple-echo Dixon MR scan is used both for calculation of MR-based attenuation correction (AC) maps and estimation of physiological motion. PET listmode data is obtained simultaneously to the MR acquisition which is used for a joint motion estimation and reconstruction of the final MCIR PET. In a first step, dynamic cardiac and respiratory motion resolved 4D MR and PET images are reconstructed. These image series are used in a joint image registration to estimate non-rigid cardiac and respiratory motion fields. In a second step, the motion fields are utilized in a MR MCIR to obtain cardiac and respiratory resolved dynamic MR-based AC maps. In the last step, the non-rigid motion fields and the dynamic AC maps are applied in a PET MCIR to obtain the final motion-corrected PET images. PET-MR data has been obtained in six patients without any known heart disease. Motion amplitudes were between 5.6 and 16 mm, with higher values in the basal compared to the mid-ventricular and apical segments. The proposed joint PET-MR motion estimation provided more accurate motion estimation than using either modality separately. The underestimation of PET uptake due to respiratory and cardiac motion artefacts in the AC maps was up to 17%. The average increase in uptake values using MCIR was 23% ± 10% (p < 0.0001), with values of 28% ± 11% (p < 0.0001) for basal, 21% ± 8% (p < 0.0001) for mid-cavity and 17% ± 7% (p < 0.0001) for apical segments. With the proposed scheme we could ensure high PET image quality and improve local PET uptake quantification by up to 30%. Attenuation correction and motion information was obtained from the same PET-MR raw data, which was obtained during free-breathing to minimize scan times and to increase patient comfort.

Three-dimensional echocardiography for the assessment of left ventricular geometry and papillary muscle morphology in hypertrophic cardiomyopathy

BackgroundHypertrophic cardiomyopathy (HC) is characterized by left ventricular (LV) hypertrophy and associated with papillary muscle (PM) abnormalities. The aim of this study was to evaluate the utility of three-dimensional echocardiography (3DE) for the geometric assessment of LV hypertrophy and PM morphology.MethodsThe study included 24 patients with an established diagnosis of HC and 31 healthy controls. 3DE was performed using an iE33 or EPIQ 7C ultrasound system with an X5-1 transducer. QLAB software was used for the 3D analysis of LV wall thickness (LVWT) and PM morphology and hypertrophy; the number and cross-sectional area (CSA) of anterolateral and posteromedial PMs; and the presence of bifid or accessory PMs.ResultsPatients with HC had a larger LVWT compared to controls in all segments (p < 0.001), and LVWT was largest in the midventricular septal segment (2.12 ± 0.68 cm). The maximum LVWT followed a spiral pattern from the LV base to the apex. The CSA of both anterolateral and posteromedial PMs was larger in patients with HC than in controls (1.92 vs. 1.15 cm2; p = 0.001 and 1.46 vs. 1.08 cm2; p = 0.033, respectively). The CSA of the posteromedial PM was larger in patients with LVOT obstruction than in those without (2.64 vs 1.16 cm2, p = 0.021).Conclusions3DE allows the assessment of LV geometry and PM abnormalities in patients with HC. 3DE demonstrated that the maximum hypertrophy was variable and generally located in a spiral from the LV base to the apex.

Is there a relationship between increased aortic stiffness and segmental left ventricular deformation in elite athletes? (Insights from the MAGYAR-Sport Study).

Introduction Myocardial contractility of the left ventricle (LV) is related to arterial distensibility. Sport activity is frequently associated with changes in both LV and arterial functions. This study aimed to find correlations between three-dimensional speckle-tracking echocardiography-derived segmental LV deformation parameters and echocardiographically assessed aortic stiffness index (ASI) in athletes. This study comprised 26 young elite athletes (mean age: 26.7±8.4 years, nine men). Results Among segmental circumferential strains (CSs), only that of apical anterior (r = 0.40, p = 0.05), septal (r = 0.47, p = 0.01), inferior (r = 0.59, p = 0.001), lateral (r = 0.44, p<0.05), and midventricular anteroseptal (r = 0.44, p<0.05) segments correlated with ASI, whereas LV-CS of the midventricular anterior segment showed a correlation tendency. Only longitudinal strain of basal anteroseptal (r = -0.46, p < 0.05) and inferoseptal (r = -0.57, p < 0.01) segments showed correlations with ASI, whereas that of the basal anterior segment had only a tendency to correlate. Some segmental multidirectional strains also correlated with ASI. Conclusions Correlations could be demonstrated between increased aortic stiffness and circular function of the apical and midventricular LV fibers and longitudinal motion of the basal septum and LV anterior wall (part of LV outflow tract) in maintaining circulation in the elite athletes.

Regional wall motion abnormalities during early diastole in patients with hypertensive left ventricular hypertrophy: a Doppler tissue echocardiographic study.

To investigate left ventricular wall motion asynchrony in patients with hypertensive heart disease, we measured regional myocardial velocity in hypertensive patients with left ventricular hypertrophy and in normotensive individuals using tissue Doppler imaging. The endocardial velocity and the myocardial velocity gradient were measured in the basal and mid segments of the septal and posterior walls. The dilating velocity of the left ventricular cavity were determined for the basal and mid ventricular segments of left ventricle. The peak myocardial velocity gradient was significantly lower in the hypertensive group than in the control group for all regions. The peak endocardial velocity during early diastole in the mid ventricular septum was significantly lower in the hypertensive group (Hypertensive vs Controls; 3.8 +/- 1.3 vs 5.1 +/1.6 cm/s, P < 0.05), whereas the peak endocardial velocity at the other three sites were similar in the two groups. The peak dilating velocity was significantly lower in the hypertensive group only in the mid portion of the left ventricle (Hypertensive vs Controls; 7.2 +/- 2.4 vs 9.8 +/- 1.3 s(-1), P < 0.005). These results suggest that there were regional wall motion abnormalities and nonuniformity during the early diastolic phase in the hypertensive hearts with left ventricular hypertrophy.

Quantification of myocardial deformation in children by cardiovascular magnetic resonance feature tracking: determination of reference values for left ventricular strain and strain rate

BackgroundThe objective assessment of global and regional cardiac function in children has shown to be clinically relevant but is challenging to conduct. Cardiovascular magnetic resonance (CMR) has emerged as a valuable diagnostic modality especially in patients with cardiomyopathy or congenital heart disease. However, data on the normal cardiac deformation in children assessed by CMR is lacking at present. Thus, the aim of this study was to provide reference values for cardiac strain and strain rate in children and adolescents derived from CMR feature tracking (FT) measurements.MethodsIn this binational study, eighty children and adolescents (age 0.4–18.0 years, 41 male, 39 female) free from cardiac diseases from two centers underwent CMR in 1.5 T whole-body scanners in supine position. Global peak radial, circumferential and longitudinal systolic strains as well as the corresponding early peak diastolic strain rates were assessed applying FT on short axis as well as 3- and 4-chamber views of standard cine steady-state free precession images.ResultsThe difference between genders yielded no significance for all assessed strains. Yet, all strains showed a significant parabolic relation to age and an even stronger one to body surface area (BSA). Therefore, BSA-specific reference values were determined using a polynomial regression model. The apical cardiac segments featured significant higher peak circumferential but lower peak radial systolic strains than the midventricular and basal segments (all p < 0.001).ConclusionsThe assessment of cardiac deformation by CMR-FT is feasible in children. This is the first CMR study providing specific reference values for FT-derived strain and strain rate in the pediatric age range.

Strain and strain rate echocardiography in children with Wilson's disease.

SummaryObjectiveThis study aimed to evaluate strain and strain rate echocardiography in children with Wilson’s disease to detect early cardiac dysfunction.MethodsIn this study, 21 patients with Wilson’s disease and a control group of 20 age- and gender-matched healthy children were included. All the patients and the control group were evaluated with two-dimensional (2D) and colour-coded conventional transthoracic echocardiography by the same paediatric cardiologist using the same echocardiography machine (Vivid E9, GE Healthcare, Norway) in standard precordial positions, according to the American Society of Echocardiography recommendations. 2D strain and strain rate echocardiography were performed after the ECG probes of the echocardiography machine were adjusted for ECG monitoring. Longitudinal, transverse and radial strain, and strain rate were assessed from six basal and six mid-ventricular segments of the left ventricle, as recommended by the American Society of Echocardiography.ResultsLeft ventricular wall thickness, systolic and diastolic diameters, left ventricular diameters normalised to body surface area, end-systolic and end-diastolic volumes, cardiac output and cardiac index values were within normal limits and statistically similar in the patient and control groups (p < 0.05).Global strain and strain rate: the patient group had a statistically significant lower peak A longitudinal velocity of the left basal point and peak E longitudinal velocity of the left basal (VAbasR) point, and higher global peak A longitudinal/circumferential strain rate (GSRa) compared to the corresponding values of the control group (p < 0.05).Radial strain and strain rate: end-systolic rotation [ROT (ES)] was statistically significantly lower in the patient group (p < 0.05). Longitudinal strain and strain rate: end-systolic longitudinal strain [SLSC (ES)] and positive peak transverse strain (STSR peak P) were statistically significantly lower in the patient group (p < 0.05).Segmental analysis showed that rotational strain measurement of the anterior and lateral segments of the patient group were statistically significantly lower than the corresponding values of the control group (p < 0.05). Segmental analysis showed statistically significantly lower values of end-systolic longitudinal strain [STSR (ES)] of the basal lateral (p < 0.05) and end-systolic longitudinal strain [SLSC (ES)] of the basal septal segment (p < 0.05) in the patient group.End-systolic longitudinal strain [SLSC (ES)] and positive peak transverse strain (STSR peak P) were statistically significantly lower in the patient group (p < 0.05). Segmental analysis showed statistically significantly lower values of endsystolic longitudinal strain [SLSC (ES)] of the mid-anterior and basal anterior segments (p < 0.05), end-systolic longitudinal strain [STSR (ES)] measurements of the posterior and mid-posterior segments, end-systolic longitudinal displacement [DLDC (ES)] of the basal posterior, mid-posterior and mid-antero-septal segments in the patient group.ConclusionCardiac arrhythmias, cardiomyopathy and sudden cardiac death are rare complications but may be seen in children with Wilson’s disease due to copper accumulation in the heart tissue. Strain and strain rate echocardiography is a relatively new and useful echocardiographic technique to evaluate cardiac function and cardiac deformation abnormalities. Our study showed that despite normal systolic function, patients with Wilson’s disease showed diastolic dysfunction and regional deformation abnormalities, especially rotational strain and strain rate abnormalities.

Impaired Left Ventricular Longitudinal Function in Idiopathic Pulmonary Arterial Hypertension Children

Abstract Background: Pulmonary arterial hypertension is associated with right ventricular dilation and failure. As a result, left ventricular geometry is affected by shifting of the interventricular septum towards the left ventricle. Aim of the study: The aim of the study was to assess the effect of chronic right ventricular pressure overload on left ventricular longitudinal function and synchronicity in idiopathic pulmonary arterial hypertension children, using speckle-tracking echocardiography. Material and methods: We prospectively evaluated 13 children (5 with idiopathic pulmonary arterial hypertension and 8 sex- and age-matched controls) using conventional and speckle-tracking echocardiography and clinical status (WHO functional class). Left ventricular longitudinal strain curve was generated for 17 segments and global left ventricular longitudinal peak systolic strain was calculated. Dyssynchrony index of the left ventricle was determined calculating the standard deviation of time to peak-systolic strain for 12 left ventricular, 6 basal and 6 midventricular segments, from short axis views. Results: Strain imaging showed significantly decreased global left ventricular longitudinal strain and increased dyssynchrony index in idiopathic pulmonary arterial hypertension patients as compared with controls (−16.80 ± 2.94 vs. −21.50 ± 1.60, p = 0.003, and 53.80 ± 16.72 vs. 22.25 ± 6.18, p=0.0001, respectively). There was a significant correlation between left ventricular longitudinal strain, dyssynchrony index and right ventricular fractional area changes (r = −0.66, p = 0.013, and r = −0.72, p = 0.005, respectively), right ventricular myocardial performance index (r = 0.86, p = 0.0001, and r = 0.93, p = 0.000, respectively), and LV eccentricity index (r = 0.82, p=0.001, and r = 0.93, p = 0.000, respectively) in the study population as a whole. Conclusions: Left ventricular longitudinal systolic strain and synchronicity are impaired in idiopathic pulmonary arterial hypertension children with normal left ventricular ejection fraction.