Myocardial Wall Motion Research Articles

MyoFold: Joint myocardial tissue composition and wall motion quantification via a highly folded sequence.

This study aims to develop and evaluate a novel cardiovascular MR sequence, MyoFold, designed for the simultaneous quantifications of myocardial tissue composition and wall motion. MyoFold is designed as a 2D single breathing-holding sequence, integrating joint T1/T2 mapping and cine imaging. The sequence uses a 2-fold accelerated balanced SSFP (bSSFP) for data readout and incorporates electrocardiogram synchronization to align with the cardiac cycle. MyoFold initially acquires six single-shot inversion-recovery images, completed during the diastole of six successive heartbeats. T2 preparation (T2-prep) is applied to introduce T2 weightings for the last three images. Subsequently, over the following six heartbeats, segmented bSSFP is performed for the movie of the entire cardiac cycle, synchronized with an electrocardiogram. A neural network trained using numerical simulations of MyoFold is used for T1 and T2 calculations. MyoFold was validated through phantom and in vivo experiments, with comparisons made against MOLLI, SASHA, T2-prep bSSFP, and the conventional cine. In phantom studies, MyoFold exhibited a 10% overestimation in T1 measurements, whereas T2 measurements demonstrated high accuracy. In vivo experiments revealed that MyoFold T1 had comparable accuracy to SASHA and precision similar to MOLLI. MyoFold demonstrated good agreement with T2-prep bSSFP in myocardial T2 measurements. No significant differences were observed in the quantification of left-ventricle wall thickness and function between MyoFold and the conventional cine. MyoFold presents as a rapid, simple, and multitasking approach for quantitative cardiovascular MR examinations, offering simultaneous assessment of tissue composition and wall motion. The sequence's multitasking capabilities make it a promising tool for comprehensive cardiac evaluations in clinical settings.

Myocardial motion in acute ischemia: revealing invisible deformation by echocardiography.

Echocardiography has been used clinically to assess regional myocardial wall motion for the diagnosis of acute myocardial ischemia or stress-induced ischemia, but it is often difficult to distinguish hypokinetic motion from normal motion. Myocardial wall motion is affected by loading conditions as well as intrinsic contractility, making it challenging to define a normal range of wall motion. Therefore, hypokinesis is usually diagnosed by comparing target areas with other areas of myocardium considered normal (relative hypokinesis). Myocardial strain analysis by tissue Doppler echocardiography and speckle-tracking echocardiography has enabled objective and quantitative evaluation of regional myocardial wall motion. Peak systolic strain decreases during acute ischemia, but subtle and invisible myocardial motion, such as early systolic lengthening (ESL) and postsystolic shortening (PSS), also occurs, and the analysis of these subtle motions can improve the diagnostic accuracy of ischemia. However, the diagnosis of ischemic myocardium by strain analysis is not widely performed in clinical practice at this time due to several limitations. This article reviews the features of myocardial motion during acute ischemia, the mechanisms of ESL and PSS, the diagnosis of ischemic myocardium using strain analysis, and current approaches and future challenges to overcome the limitations in the detection of relative hypokinesis. This article also explains the use of ESL and PSS to detect myocardial ischemic memory that remains after brief ischemia.

Abstract 17765: Stress Myocardial Blood Flow is Abnormal During Acute Takotsubo Syndrome

Introduction: Coronary microvascular dysfunction (CMD) is a proposed mechanism for takotsubo syndrome (TS). Therefore, we performed cardiac magnetic resonance imaging (CMR) with quantitative stress/rest perfusion and T2 mapping during acute TS and at 6-month post recovery. AIM: Quantitate stress/rest myocardial blood flow (MBF) in acute/recovery TS and compare basal with apical MBF. Methods: TS diagnosed by internationally accepted criteria. Each patient underwent acute and 6-month recovery CMR with automated in-line quantification of global/regional MBF, cine imaging, T2-mapping, and late gadolinium enhancement (LGE) imaging. Normal rest and stress MBF are 0.8-1.0 and > 2.0 ml/min/g, normal myocardial perfusion reserve (MPR) is > 2.4. Results: Acute and recovery studies were performed on 7 patients, all women, average age 63 + 8.5 years. CMR was performed within 72 hours of TS diagnosis. Initial versus (vs) follow-up EF: 40.3% vs 67.1%, left ventricular (LV) mass: 108.7 grams vs 86.3 grams. Acute studies demonstrated hypokinesis in the mid-apical segments with corresponding myocardial edema, LGE was absent in all patients. Myocardial edema and wall motion abnormality normalized at recovery. During acute TS, rest and stress MBF were 1.14 and 2.58 ml/min/g (base) vs 0.96 and 1.73 ml/min/g (apex). While at recovery, rest-stress MBF were 1.14 and 3.12 ml/min/g at base versus 1.09 and 2.76 ml/min/g at apex (Figure). MPR improved from acute to recovery: 2.14 vs 2.74 (global), 2.25 vs 2.84 (base), and 1.85 vs 2.64 (apex); p = 0.126; 0.035; 0.012 respectively (Figure). Conclusion points: Resting MBF is normal during acute TS in both basal and apical LV segments despite typical apical ballooning consistent with stunned myocardium. MPR is more abnormal in apical than base segments during acute TS, returning to normal at recovery. Myocardial edema might contribute to apical CMD during acute TS.

Abstract 17867: Inward Displacement: A Novel CMR Technique for Quantification of Myocardial Wall Motion in Patients With Myocardial Infarction

Introduction: Inward displacement (InD) is a novel parameter which quantifies myocardial wall motion (WM) by measuring the distance travelled by endocardial tracked points towards their corresponding center of the left ventricle in systole, calculated from 3 LAX views obtained during CMR. Hypothesis: InD using CMR is capable of obtaining global quantifiable measurement of WM abnormalities in patients with myocardial infarction (MI) as defined by Late Gadolinium Enhancement (LGE). Methods: We compared patients with history of MI documented by LGE CMR.Studies were acquired in a 1.5 T Siemens Aera (Siemens, Erlangen Germany) scanner with an 18-channel body array coil; Multi-planar ECG-gated cine CMR was obtained using a balanced steady-state free precession readout and LGE images were acquired using an IR prepped sequence 10 min after Gadolinium contrast injection. Offline analysis using automated endocardial LV contour detection was conducted for each of the LAX series and manual corrections were performed as required. InD was measured in mm and expressed as a percentage. Values were compared between MI patients and normal subjects, and analyzed using a Medis Suite workstation (Medis Medical Imaging BV, Leiden, The Netherlands). Results: We analyzed 646 segments in 38 patients of which 9 had past history of myocardial infarction. Global InD for healthy subjects was 28% vs 19% SEM 0.97, as compared to patients with MI (p:< 0.00001). Conclusions: InD is capable of quantification of abnormal motility in subjects with myocardial infarction, therefore producing an objective measure of LV segmental WM abnormalities, further studies are warranted.

Stress-Mediated Abnormalities in Regional Myocardial Wall Motion in Young Women with a History of Psychological Trauma.

Psychosocial stress has been associated with the development and progression of atherosclerotic cardiovascular disease (CVD). Previously, we reported subtle differences in global longitudinal strain in somatically healthy women with a psychiatric diagnosis of borderline personality disorder (BPD). This study aimed to investigate the impact of BPD on segmental myocardial wall motion using speckle tracking echocardiography (STE) analysis. A total of 100 women aged between 18 and 38 years were included in this study. Fifty patients meeting the diagnostic criteria for BPD were recruited from the Department of Psychiatry (LWL-University Hospital Bochum) and compared with fifty age-matched healthy control subjects without previous cardiac disease. Laboratory tests and STE were performed with segmental wall motion analysis. The BPD group had a higher prevalence of risk factors for CVD, with smoking and obesity being predominant, when compared with the control group. Other cardiovascular parameters such as blood pressure, glucose, and cholesterol levels were also elevated, even though not to pathological values. Moreover, in the STE analysis, the BPD group consistently exhibited decreased deformation in nine myocardial wall regions compared with the control group, along with a shift toward higher values in the distribution of peak pathological segments. Additionally, significantly higher values of free thyroxine concentration and thyroid's secretory capacity were observed in the BPD group, despite falling within the (high-) normal range. BPD is associated with chronic stress, classical risk factors, and myocardial wall motion abnormalities. Further exploration is warranted to investigate the relationship between high-normal thyroid metabolism, these risk factors, and myocardial function in BPD patients. Long-term follow-up studies would be valuable in confirming the potential for predicting adverse events.

Role of speckle-tracking echocardiography in diagnosis and further prognosis of coronary heart disease

Echocardiography is one of the first-line methods of detection and evaluation of coronary artery disease, which helps clinicians in the diagnostic and prognostic evaluation of this disease. However, visual assessment of abnormal left ventricular myocardial wall motion is not always appropriate in detecting less severe or transient myocardial ischemia and in making an accurate differential diagnosis. Speckle-tracking echocardiography is a widely available non-invasive tool that can easily and quickly provide clarifying information and significantly extend the standard echocardiographic study, as the method allows you to identify subtle myocardial damage and local areas of ischemia that correspond to the pattern of coronary disease, and obtain an objective report in the form of simple visual scheme, very easy to use for differential diagnosis and treatment. Therefore, this method, which is increasingly used in various manifestations of coronary insufficiency and is convenient to use both at rest and with stress echocardiography, has proved efficient results in terms of predicting coronary heart disease, quantitative interpretation of emerging or persistent ischemia, assessment of the clinical course and outcome, and left ventricular remodeling. In this review, we have attempted to reflect the currently available findings that demonstrate the significance of speckle-tracking echocardiography for the evaluation and follow-up of coronary heart disease, including some congenital anomalies of the coronary arteries, and to touch on the main achievements and discoveries in the use of two-dimensional and three-dimensional deformation parameters and their potential application for a wider introduction into clinical practice.

Deep Learning Synthetic Strain: Quantitative Assessment of Regional Myocardial Wall Motion at MRI.

To assess the feasibility of a newly developed algorithm, called deep learning synthetic strain (DLSS), to infer myocardial velocity from cine steady-state free precession (SSFP) images and detect wall motion abnormalities in patients with ischemic heart disease. In this retrospective study, DLSS was developed by using a data set of 223 cardiac MRI examinations including cine SSFP images and four-dimensional flow velocity data (November 2017 to May 2021). To establish normal ranges, segmental strain was measured in 40 individuals (mean age, 41 years ± 17 [SD]; 30 men) without cardiac disease. Then, DLSS performance in the detection of wall motion abnormalities was assessed in a separate group of patients with coronary artery disease, and these findings were compared with consensus results of four independent cardiothoracic radiologists (ground truth). Algorithm performance was evaluated by using receiver operating characteristic curve analysis. Median peak segmental radial strain in individuals with normal cardiac MRI findings was 38% (IQR: 30%-48%). Among patients with ischemic heart disease (846 segments in 53 patients; mean age, 61 years ± 12; 41 men), the Cohen κ among four cardiothoracic readers for detecting wall motion abnormalities was 0.60-0.78. DLSS achieved an area under the receiver operating characteristic curve of 0.90. Using a fixed 30% threshold for abnormal peak radial strain, the algorithm achieved a sensitivity, specificity, and accuracy of 86%, 85%, and 86%, respectively. The deep learning algorithm had comparable performance with subspecialty radiologists in inferring myocardial velocity from cine SSFP images and identifying myocardial wall motion abnormalities at rest in patients with ischemic heart disease.Keywords: Neural Networks, Cardiac, MR Imaging, Ischemia/Infarction Supplemental material is available for this article. © RSNA, 2023.

Detecting obstructive coronary artery disease with machine learning: rest-only gated single photon emission computed tomography myocardial perfusion imaging combined with coronary artery calcium score and cardiovascular risk factors.

The rest-only single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has low diagnostic performance for obstructive coronary artery disease (CAD). Coronary artery calcium score (CACS) is strongly associated with obstructive CAD. The aim of this study was to investigate the performance of rest-only gated SPECT MPI combined with CACS and cardiovascular risk factors in diagnosing obstructive CAD through machine learning (ML). We enrolled 253 suspected CAD patients who underwent the 1-stop rest-only SPECT MPI and computed tomography (CT) scan due to stress test-related contraindications. Myocardial perfusion and wall motion were assessed using quantitative perfusion SPECT + quantitative gated SPECT (QPS + QGS) automated quantification software. The Agatston algorithm was used to calculate CACS. The clinical data of patients, including cardiovascular risk factors, were collected. Based on feature selection and clinical experience, 8 factors were identified as modeling variables. Subsequently, patients were divided randomly into 2 groups: the training (70%) and test (30%) groups. The performance of 8 supervised ML algorithms was evaluated in the training and test groups. Obstructive CAD was diagnosed by coronary angiography in 94 (37.2%, 94/253) patients. In the training group, the area under the receiver operator characteristic (ROC) curve (AUC) of the random forest was the highest, and the AUCs of Logistic, extreme gradient boosting (XGBoost), support vector machine (SVM), and adaptive boosting (AdaBoost) were all above 0.9. In the test group, the AUC of recursive partitioning and regression trees (Rpart) was the highest (0.911). Rpart and Naïve Bayes had the highest accuracy (0.840). Rpart had a sensitivity and specificity of 0.851 and 0.821, respectively; Naïve Bayes had a sensitivity and specificity of 0.809 and 0.893, respectively. Next was Logistic, with an accuracy of 0.827, a sensitivity of 0.872, and a specificity of 0.750. The random forest and XGBoost algorithms also had high accuracy, which was 0.813 for each algorithm. Rest-only SPECT MPI combined with CACS and cardiovascular risk factors using an ML algorithm to detect obstructive CAD is feasible. Among the algorithms validated in the test group, Rpart, Naïve Bayes, XGBoost, Logistic, and random forest are all highly accurate for diagnosing obstructive CAD. The application of ML in resting MPI and CACS may be used for screening obstructive CAD.

584 AN UNUSUAL CASE OF A STRESSED HEART

Abstract A 53-year-old woman was admitted to our emergency department complaining severe stabbing and oppressive retrosternal pain radiating posteriorly to left scapulae and left arm The onset was followed by general malaise, nausea, vomiting which she attributed to a period of intense emotional stress. She denied common cardiovascular risk factors, but in 2019 had a suspected acute coronary syndrome with subsequent finding of normal coronary artery at angiography in another institute. Her past medical history included severe asthma on multiple drug therapy with regular follow-up. Physical exam was normal. Electrocardiogram (ECG) showed subtle diphasic-negative T wave in anterior leads with mild ST depression in V4-V5, with patient still symptomatic. Lab examinations showed significantly increased troponins levels (hsTnI 664 ng/L, reference < 34 ng/L) with other lab values within normal range. A transthoracic echocardiogram at the bedside revealed mildly reduced systolic function with hypo-akinesis of the mid-apical anteroseptal and anterior left ventricular myocardial wall. Therefore, acute coronary syndrome was suspected and heparin and aspirin at a loading dose were administered. Still symptomatic, the patient was admitted in the ICU. In the same day a left heart catheterization revealed normal aspect of epicardial coronary arteries and ventriculography showed preserved basal and apical myocardial wall motion but hypo-akinesis of mid-cavitary walls, suggesting a possible mid-ventricular variant of Takotsubo syndrome (Figure 1). The patient was still symptomatic for stabbing chest pain after coronarography. To rule out the suspicion of acute aortic syndrome and pulmonary embolism, she also underwent a contrast-enhanced chest CT scan, that was fortunately normal. During her hospital stay, the patient had no arrhythmic and hemodynamic complications. Peak troponin level was 5027 ng/L. At serial ECGs, she developed diffuse deep T-wave inversion and a mild prolonged QT interval. Echocardiogram was repeated after 4 days showing complete normalization of left ventricular wall motion and restored ejection fraction also. From the traditional “apical ballooning” Takotsubo Syndrome with apical akinesia and basal hypercontractility, different variants have been described. The mid-ventricular variant, seen in our patient was found in only 14.6% of the cases in the International Takotsubo Registry, followed by basal “reverse” and focal variants (2.2% and 1.5%, respectively).

Feasibility of prehospital identification of non-ST-elevation myocardial infarction by ECG, troponin and echocardiography

BackgroundPrehospital identification and selection of treatment strategy in patients with suspected non-ST-elevation myocardial infarction (NSTEMI) is challenging. The aim of this study was to evaluate the feasibility and diagnostic accuracy...

A Case Report of Constrictive Pericarditis: Step by Step Surgical Treatment of the Disease, Complications and Long-Term Outcomes

Constrictive pericarditis (CP) is a chronic inflammation often characterized by chronic fibrosis, scaring, pericardial calcification, and associated with diastolic dysfunction, decreased cardiac output, and chronic heart failure. Early diagnosis of constrictive pericarditis is difficult due to absence of typical cardiopulmonary signs. In this case report, we present, a 20-years-old male. His initial disease and complains began with an increased size of the abdomen. Ultrasound showed a severe ascites with unknown cause for a long time. Only after a chest computed tomography and echocardiography was diagnosed constrictive pericarditis. Echocardiography confirmed the diagnosis of constrictive pericarditis, pericardial thickening and hyperechogenicity with abnormal myocardial wall motion, severe tricuspid valve insufficiency and moderate mitral valve insufficiency.MRI findings: irregular pericardial thickening with a maximum thickness of 4mm mostly effecting the right ventricle. Considering liver failure and, as a consequence, the presence of coagulopathy, it was decided to perform pericardectomy without the use of a heart-lung machine and without correction of valvular pathology. After the intervention, the patient retained severe tricuspid valve insufficiency and moderate mitral valve insufficiency, while the functional parameters of the liver progressively improved. Considering the unfavorable prognosis of the patient with tricuspid valve failure 3 weeks after pericardectomy, it was decided to perform mitral and tricuspid valve repair with the use of heart-lung machine, which was successfully done. The patient was discharged in satisfactory condition. At out-patient visit 42 days after the last surgical procedure the patient showed improvement of symptoms, normal sinus rhythm at examination, echocardiography found no signs of mitral valve failure and a minor residual tricuspid valve failure. Liver tests returned to normal on the 10-15th day.

Assessment of the relationship between regional wall motion abnormality score revealed by parametric imaging and the extent of LGE with CMR

The aim of this study was to assess the relationship between left ventricular (LV) regional myocardial wall motion abnormality (WMA), revealed by visual interpretation of cardiac magnetic resonance (CMR) cine images together with the computed wall motion parametric image, and the transmural scar extent, as assessed by Late gadolinium Enhancement (LGE), in 40 patients. Each cine CMR short-axis loop was processed to compute a parametric image where each pixel represents the amplitude of the Hilbert transform of videointensity over time. Two expert radiologists blindly interpreted the cine CMR images in combination with the corresponding parametric image to assign a WMA score for each of the 16 myocardial sectors in which the LV myocardium was subdivided. Such score was compared per sector to the level of transmural scar extent obtained by LGE images.A total of 592 myocardial segments were analyzed. A significant decrease in regional wall motion was observed in sectors with LGE transmural hyperenhancement > 75% of tissue, as well as a correlation between parametric image amplitude and peak radial and circumferential strain, computed by feature tracking. The results showed a reduction in prediction error Lambda of WMA from LGE of 65%, and of LGE from WMA of 63%. In particular, the estimated probability of correct prediction of WMA from LGE was 76%, while that of LGE from WMA was 75%.The interpretation of myocardial viability by LGE images combined with the WMA information, derived from cine CMR and parametric images, could improve the clinical decision making process.

Intraoperative myocardial infarction and refractory cardiogenic shock during major hepatectomy: a case report

BackgroundMyocardial infarction (MI) complicated by cardiogenic shock during non-cardiac surgery is a rare but fatal complication. The management of intraoperative MI is challenging.Case presentationA 77-year-old hypertensive man with good functional capacity was scheduled for hepatectomy. After the start of liver resection, the electrocardiogram monitor showed ST depression, and the patient developed refractory cardiogenic shock. Transesophageal echocardiography revealed severe hypokinesis of the anteroseptal wall. The surgery was suspended, and an intra-aortic balloon pump was placed following immediate abdominal closure. Coronary angiography revealed severe stenosis of the left main coronary trunk, and percutaneous coronary intervention (PCI) was performed. Myocardial wall motion improved, and blood pressure stabilized. Two days after PCI, hepatectomy, which had been suspended, was successfully completed.ConclusionsOnce intraoperative MI has occurred, early diagnosis and multidisciplinary approaches are important to manage the difficult clinical situation.

Multimodality Imaging in Ischemic Chronic Cardiomyopathy.

Ischemic chronic cardiomyopathy (ICC) is still one of the most common cardiac diseases leading to the development of myocardial ischemia, infarction, or heart failure. The application of several imaging modalities can provide information regarding coronary anatomy, coronary artery disease, myocardial ischemia and tissue characterization. In particular, coronary computed tomography angiography (CCTA) can provide information regarding coronary plaque stenosis, its composition, and the possible evaluation of myocardial ischemia using fractional flow reserve CT or CT perfusion. Cardiac magnetic resonance (CMR) can be used to evaluate cardiac function as well as the presence of ischemia. In addition, CMR can be used to characterize the myocardial tissue of hibernated or infarcted myocardium. Echocardiography is the most widely used technique to achieve information regarding function and myocardial wall motion abnormalities during myocardial ischemia. Nuclear medicine can be used to evaluate perfusion in both qualitative and quantitative assessment. In this review we aim to provide an overview regarding the different noninvasive imaging techniques for the evaluation of ICC, providing information ranging from the anatomical assessment of coronary artery arteries to the assessment of ischemic myocardium and myocardial infarction. In particular this review is going to show the different noninvasive approaches based on the specific clinical history of patients with ICC.

Changing Paradigms in the Diagnosis of Ischemic Heart Disease by Multimodality Imaging.

Coronary artery disease (CAD) represents the most common cardiovascular disease, with high morbidity and mortality. Historically patients with chest pain of suspected coronary origin have been assessed with functional tests, capable to detect haemodynamic consequences of coronary obstructions through depiction of electrocardiographic changes, myocardial perfusion defects or regional wall motion abnormalities under stress condition. Stress echocardiography (SE), single-photon emission computed tomography (SPECT), positron emission tomography (PET) and cardiovascular magnetic resonance (CMR) represent the functional techniques currently available, and technical developments contributed to increased diagnostic performance of these techniques. More recently, cardiac computed tomography angiography (cCTA) has been developed as a non-invasive anatomical test for a direct visualisation of coronary vessels and detailed description of atherosclerotic burden. Cardiovascular imaging techniques have dramatically enhanced our knowledge regarding physiological aspects and myocardial implications of CAD. Recently, after the publication of important trials, international guidelines recognised these changes, updating indications and level of recommendations. This review aims to summarise current standards with main novelties and specific limitations, and a diagnostic algorithm for up-to-date clinical management is also proposed.

Myocardial Strain-Based on Regional Wall Motion Abnormalities Index : A Prognostic Marker of Incident Heart Failure. Cardiovascular MRI study from the Multi-Ethnic Study of Atherosclerosis (MESA)

Although several studies have investigated the prognostic value of the LV global circumferential strain for predicting the risk of heart failure (HF), very few studies have assessed the prognostic value of myocardial strain-based Regional Wall Motion Abnormalities (RWMA) index assessed by CMR tagging in asymptomatic individuals without a history of CVD. To assess the long-term prognostic value of myocardial strain and the RWMA index measured by tagged MRI for the prediction of CV events in the Multi-Ethnic Study of Atherosclerosis (MESA). Participants of the MESA who underwent a baseline CMR study including cardiac-tagged MRI using HARP were analysed. The AHA classification with 16-segments was used for strain data. RWMA score was defined by the number of segments with regiona strain > −16% (cut-off defined by survival tree method). Cox proportional hazard models were used to evaluate the association between RWMA index and incident HF. The survival tree method was used to determine the best cut-off to transform the RWMA score into a binary variable. Among the 1506 participants (age 63.3 ± 9.4 years, 54.6% men), 91 incident HFs were observed after a mean follow-up of 15.9 ± 3.1 years. RWMA score was associated with HF (HR 1.58, 95%CI [1.07-2.49], P = 0.002). Using an optimal cut-off to predict incident HF, RWMA > 66% of total myocardium was also associated with HF (HR 2.43, 95%CI [1.72-3.41], P < 0.001). After adjustment for traditional HF risk factors (age, male, ethnicity, BMI, hypertension, diabetes, dyslipidemia, smoking and hypercholesterolemia), higher RWMA score and RWMA > 66% were both independently associated with HF (HR 1.57, 95%CI [1.02-2.32], P = 0.038 and HR 1.67, 95%CI [1.03-2.94], P = 0.002; respectively) ( Table 1 ). In a multi-ethnic population, RWMA index assessed by cardiac-tagged MRI is independently associated with incident HF.

To what extent are perfusion defects seen by myocardial perfusion SPECT in patients with left bundle branch block related to myocardial infarction, ECG characteristics, and myocardial wall motion?

IntroductionWe investigated if uptake pattern on myocardial perfusion SPECT (MPS) in patients with left bundle branch block (LBBB) is related to myocardial fibrosis, myocardial wall motion, and electrocardiography (ECG) characteristics. MethodsTwenty-three patients (9 women) with LBBB, examined with MPS and cardiac magnetic resonance (CMR), were included. Tracer uptake on MPS was classified by visual interpretation as typical LBBB pattern (Defect+, n = 13) or not (Defect−, n = 10) and quantitatively. CMR images were evaluated for wall thickness and for myocardial wall motion both by visual assessment and by regional myocardial radial strain from feature tracking, and for presence and location of myocardial fibrosis. ECGs were analyzed regarding QRS duration and the presence of strict criteria for LBBB. ResultsWall thickness was slightly lower in the septum compared to the lateral wall in Defect+ patients (5.6 ± 1.1 vs 6.0 ± 1.3 mm, P = 0.03) but not in Defect− patients (5.6 ± 1.0 vs 5.6 ± 0.9 mm, P = 0.84). Defect+ patients showed a larger proportion of dyskinetic segments in the septum and hyperkinetic segments in the lateral wall compared to Defect− patients (P = 0.006 and P = 0.004, respectively). Decreased myocardial radial strain was associated with decreased tracer uptake by MPS (R = 0.37, P < 0.001). Areas of fibrosis did not match areas with uptake defect on MPS. No differences in ECG variables were seen. ConclusionThe heterogeneous regional tracer uptake in some patients with LBBB is related to underlying regional myocardial dyskinesia, wall thickening, and wall thickness rather than stress-induced ischemia, myocardial fibrosis, or specific ECG characteristics.

Incremental value of myocardial wall motion and thickening to perfusion alone by gated SPECT myocardial perfusion imaging for viability assessment in patients with ischemic heart failure

PurposeThe objective of this study was to assess the incremental value of myocardial wall motion and thickening compared with perfusion alone obtained from gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in diagnosing myocardial viability in patients with ischemic heart failure. MethodsEighty-three consecutive patients with ischemic heart failure who underwent both 99mTc-MIBI gated SPECT MPI and 18F-FDG positron emission tomography (PET) myocardial metabolic imaging were retrospectively enrolled. SPECT/PET myocardial viability was defined as the reference standard. Segmental myocardial perfusion, wall motion, and thickening were measured by an automated algorithm from gated SPECT MPI. Univariate and stepwise multivariate analysis were conducted to establish an optimal multivariate model for predicting hibernating myocardium and scar. ResultsAmong the 1411 segments evaluated, 774 segments had normal perfusion and 637 segments had decreased perfusion. The latter were classified by 18F-FDG PET into 338 hibernating segments and 299 scarred segments. The multivariate regression analysis showed that the model that combined myocardial perfusion uptake with wall motion and thickening scores had the optimal predictive efficiency to distinguish hibernating myocardium from scar in the segments with decreased perfusion. The model had the largest C-statistic (0.753 vs 0.666, P < 0.0001), and the global chi-square was increased from 53.281 to 111.234 when compared with perfusion alone (P < 0.001). ConclusionsAssessment of myocardial wall motion and thickening in addition to conventional perfusion uptake in the segments with decreased perfusion enables better differentiation of hibernating myocardium from scar in patients with ischemic heart failure. Considering wide availability and high cost-effectiveness, regional myocardial function integrated with perfusion on gated SPECT MPI has great promise to become a clinical tool in the assessment of myocardial viability.

Aortic stenosis: correlation of prenatal echocardiography to postmortem histology

Abstract Background Foetal aortic stenosis (AS) is a challenging congenital heart disease considering its potential to progress during the course of pregnancy. Especially at midgestation, it remains extremely difficult to distinguish the cases that end up biventricular from the cases that will develop into an hypoplastic left heart syndrome. Purpose To test the hypothesis that the degree of myocardial maturation is a possible predictor of biventricular outcome, we present 4 cases of foetal AS with a varying degree of severity and uniquely correlate differences in myocardial function based on prenatal echocardiography to their post-mortem histopathologic maturation. Methods We selected 4 cases with midgestational AS from our tertiary foetal cardiology service between 2018–2020. Speckle tracking recordings of the cardiac four-chamber view were performed during routine foetal echocardiography to quantify myocardial wall motion as a marker for myocardial function. Three cases decided to terminate the pregnancy and donated the cardiac specimen. Immunohistochemical labelling (ICH) against key markers for myocardial maturation (troponin-I, N-cadherin, connexin-43, MLC2A, MLC2V and α-SMA) and fibrosis (Sirius Red) were compared with 2 normal foetal cardiac specimens. Results Two cases with critical AS presented extremely decreased global and segmental longitudinal strain (GLS and SLS) values (GLS −2% and −0.9%) in the left ventricle (LV), indicating an impaired myocardial wall deformation. Post-mortem ICH showed overt endocardial fibro-elastosis (EFE) and pathological fibrosis patterns in the subendocardial layer which was remarkably spatially correlated to the EFE. The cardiomyocytes were disorganised with reduced expression of troponin-I and disturbed expression of connexin-43. The remaining 2 cases had normal LV appearance on foetal echocardiography, showing a mild reduction in left ventricular GLS and SLS (GLS −11.8% and −14.2%). Post-mortem ICH of 1 of these cases showed mild EFE with a milder fibrosis pattern. Cardiomyocytes were less disorganised but also showed a disturbed expression of connexin-43. The 4th case continued the pregnancy and had a biventricular outcome. Conclusions This is a unique case series showing that myocardial function correlates with high extent to histology. The degree of the reduction in myocardial function corresponded with the amount of pathological fibrosis patterns and disorganisation of the cardiomyocyte network. Myocardial wall motion on foetal echocardiography seems to hold promise as a possible marker for cardiac maturation. Funding Acknowledgement Type of funding sources: None. Speckle tracking and fibrosis patterns

The total amount of CRP within the first 72 h after STEMI is crucial for the outcome

Abstract Background The CAMI-1 study dealt with the depletion of CRP by apheresis in patients with acute myocardial infarction (AMI). CRP, the prototype human acute phase protein, has been known as a marker of poor prognosis in AMI and independently predicts 30-day mortality. Methods 66 STEMI patients were enrolled following complete coronary revascularization (2–12 h after AMI). 32 patients received CRP apheresis, whereas 34 patients treated by standard protocols served as controls. CRP apheresis started 24±12 h and 48±12 h after onset of symptoms. A specific CRP adsorber removed ≤79% of the original CRP. 6000 ml of plasma was treated via peripheral venous access. Primary endpoint was myocardial infarction size as determined by Cardiac Magnetic Resonance Imaging (CMR) 3–9 days after STEMI. Results Aphereses sessions were well tolerated with no relevant side effects. The expected peak CRP level after AMI can be calculated precisely with 2–3 CRP quantifications during the first 24h after the onset of symptoms (CRP gradient). The regression coefficient for this analysis is 0.91. This mathematical step allows for the comparison of the CRP-apheresis group and the controls on the basis of their individual CRP gradients. The mean CRP gradient does not differ between both groups, whereas the mean area under the curve (AUC) of CRP within the first 72 h after AMI does. Thus, there was no bias in CRP kinetics between the two groups. The AUC of CRP is a significant indicator for infarct size (p=0.002), LVEF (p&amp;lt;0.001), circumferential strain (p&amp;lt;0.001), longitudinal strain (p=0.021). Therefore, the aphereses patients performed significantly better at all endpoints than the controls. The CRP apheresis significantly reduced myocardial damage by a reduction of the AUC of CRP. To our surprise, two apheresis patients had an infarct size of 0%. Conclusions For the first time we find an unequivocal association between myocardial infarct size and the AUC of CRP. The results show a significant beneficial effect of CRP apheresis on myocardial infarction size and wall motion. Selective CRP apheresis is now being further evaluated as a therapeutic approach in the treatment of acute myocardial infarction in a registry (CAMI registry). Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Pentracor GmbH