Presence Of Wall Motion Abnormalities Research Articles

Mechanical wave velocities by clutter filter wave imaging detects myocardial dysfunction in acute coronary syndrome

Abstract Background/introduction Mechanical waves within the myocardium arising from physiologic events in the cardiac cycle such as the atrial kick (AK), mitral valve closure (MVC) and aortic valve closure (AVC) offer insight to tissue stiffness and can be measured by high frame rate echocardiography. Purpose To investigate the feasibility of measuring mechanical wave velocities in the left ventricle by clutter filter wave imaging (CFWI) and its potential for detecting regional myocardial dysfunction in patients with acute coronary syndrome. Methods We examined 60 patients (66±9 years of age, 72% male) with acute coronary syndrome by high frame rate echocardiography after revascularisation, imaging the left ventricle from the parasternal long axis view and three apical projections. Intrinsic mechanical waves generated by the AK, MVC and AVC were analysed off-line by CFWI of all walls using custom software (PyMWI) on 2000 frames of in-phase and quadrature component data per view extracted from a Vivid E95 scanner. Results We analysed a total number of 2372 waves recorded with a frame rate of 1180 (1134-1199) frames per second. The feasibility for measuring AK waves was high in all regions (mean 89%), but lower for the MVC and AVC waves with significant variability between regions (mean 44% and 46%, respectively; p<0.001). Feasibility declined from basal to apical segments for all waves (p=0.0001). Mean mechanical wave velocity was slowest for the AK wave at 2.5 (2.0-3.0) m/s, faster for the AVC wave at 5.1 (3.5-6.3) m/s and fastest for the MVC wave at 6.6 (4.9-8.6) m/s (p=0.0001). Basal AK wave velocity was faster in patients with basal wall motion abnormalities compared to those without (2.7 vs. 2.0 m/s, p=0.0004) and could detect the presence of wall motion abnormalities adjusting for age, gender and parameters of diastolic function (univariable OR 3.4, 95% CI 1.5-7.7, p<0.01; multivariable OR 4.4, 95% CI 1.4-14.1, p=0.01). Basal AK wave velocity detected wall motion abnormalities with an AUC of 0.78 with cut-off speeds of 2.3 m/s and 3.0 m/s, both correctly classifying 73% of cases (sensitivity/specificity 81%/68% and 43%/89%, respectively). Mechanical wave velocities of other waves and in other regions were not consistently and only weakly associated with echocardiographic parameters of systolic and diastolic function. Conclusion(s) Mechanical wave velocities by CFWI detects myocardial dysfunction in acute coronary syndrome. Elevated basal AK wave velocity was independently associated with myocardial dysfunction where AK wave velocity ≥2.3 m/s provided a good sensitivity and ≥3.0 m/s a good specificity for detecting regional wall motion abnormalities. The feasibility of measuring the AK wave was good, whereas MVC and AVC waves had lower feasibility and were inadequate for assessment of myocardial function. Feasibility variations between AK and MVC/AVC waves suggest differences in wave propagation dynamics or intrinsic wave properties.Illustration Clutter Filter Wave ImagingRisk of myocardial dysfunction

Three-dimensional anatomic features of the mitral valve that predict systolic anterior motion occurring during dobutamine stress echocardiography.

Left ventricular outflow tract obstruction related to systolic anterior motion (SAM) of the mitral valve is a common complication of dobutamine stress echocardiography (DSE). However, the mechanisms underlying SAM have not been fully characterized. The objective of the present study was to use three-dimensional echocardiography to identify anatomic features of the mitral valve that predispose to SAM during DSE. We retrospectively evaluated consecutive patients included prospectively in our database and who had undergone 3D echocardiography (including an assessment of the mitral valve) before DSE. Patients who had developed SAM during DSE (the SAM+ group) were matched 2:3 with patients who did not (the SAM- group). One hundred patients were included (mean age: 67±10). Compared with SAM- patients (n=60), SAM+ patients (n=40) had a lower mitral annular area, a smaller perimeter, and a smaller diameter (p<.01 for all, except the anteroposterior diameter). The SAM+ group had also a narrower mitral-aortic angle (126±12° vs. 139±11° in the SAM- group; p<.01) and a higher posterior mitral leaflet length (1.4±.27cm vs. 1.25±.29, respectively; p<.01). Furthermore, the mitral annulus was more spherical, more flexible, and more dynamic in SAM+ patients than in SAM- patients (p<.05 for all). In a multivariate analysis of anatomic variables, the mitral-aortic angle, the mitral annular area, and posterior leaflet length were independent predictors of SAM (p ≤ .01 for all). In a multivariate analysis of standard echo and hemodynamic variables, the presence of wall motion abnormalities at rest (p<.01) was an independent predictor of SAM. SAM during DSE is multifactorial. In addition to the pharmacologic effects of dobutamine on the myocardium, 3D echocardiographic features of the mitral valve (a smaller mitral annulus, a narrower mitral-aortic angle, and a longer posterior leaflet) appear to predispose to SAM.

The Society for Cardiovascular Magnetic Resonance Registry at 150,000

ObjectivesTo summarize the status of the SCMR Registry at 150,000 exams. BackgroundCardiovascular magnetic resonance (CMR) is increasingly utilized to evaluate expanding cardiovascular conditions. The SCMR Registry is a central repository for real-world clinical data to support cardiovascular research, including those relating to outcomes, quality improvement, and machine learning. The SCMR Registry is built on a regulatory-compliant, cloud-based infrastructure that houses searchable content and Digital Imaging and Communications in Medicine (DICOM) images. MethodsThe processes for data security, data submission, and research access are outlined. We interrogated the Registry and present a summary of its contents. ResultsData were compiled from 154,458 CMR scans across 20 United States sites, containing 299,622,066 total images (~100 terabytes of storage). The human subjects had an average age of 58 years (range 1 month to >90 years old), were 44% female, 72% Caucasian, and had a mortality rate of 8%. The most common indication was cardiomyopathy (27%), and most frequently used current procedural terminology (CPT) code was 75561 (35%). Macrocyclic gadolinium-based contrast agents represented 89% of contrast utilization after 2015. Short-axis cines were performed in 99% of scans, short-axis LGE in 66%, and stress perfusion sequences in 30%. Mortality data demonstrated increased mortality in patients with left ventricular ejection fraction (LVEF) < 35%, the presence of wall motion abnormalities, stress perfusion defects, and infarct late gadolinium enhancement (LGE), compared to those without these markers. There were 456,678 patient-years of all-cause mortality follow-up, with a median follow-up time of 3.6 years. ConclusionsThe vision of the SCMR Registry is to promote evidence-based utilization of CMR through a collaborative effort by providing a web mechanism for centers to securely upload de-identified data and images for research, education, and quality control. The Registry quantifies changing practice over time and supports large-scale real-world multicenter observational studies of prognostic utility. Condensed AbstractThe SCMR Registry is a central regulatory-compliant cloud-based repository for real-world clinical data and DICOM images for multicenter cardiovascular research, including outcomes-based data. The Registry contains 299,622,066 DICOM images and 456,678 patient-years follow-up. Data compiled from 154,458 CMR scans across 20 US sites demonstrated cardiomyopathy as the most common indication and 89% macrocyclic gadolinium contrast utilization after 2015. There was an overall mortality rate of 8%, with higher rates in those with LVEF<35%, abnormal wall motion, ischemia presence, or infarct LGE. The Registry aims to promote evidence-based CMR utilization through a collaborative effort to positively impact cardiovascular outcomes.

Detection of unrecognized myocardial infarction by preprocedural transthoracic echocardiography in patients undergoing elective percutaneous coronary intervention.

Previous studies showed that unrecognized myocardial infarction (UMI) identified on cardiac magnetic resonance (CMR) was related to worse prognosis. We aimed to investigate the efficacy of preprocedural transthoracic echocardiography (TTE) to detect the presence of UMI in patients undergoing percutaneous coronary intervention (PCI). A total of 138 patients with chronic coronary syndrome (CCS) and preserved left ventricular ejection fraction (LVEF) without history of myocardial infarction or revascularization were retrospectively studied. UMI was evaluated with pre-PCI late gadolinium enhancement (LGE)-CMR. TTE and two-dimensional speckle-tracking echocardiography (2D-STE) were performed before PCI. All patients were divided into two groups according to the presence or absence of UMI, and clinical and echocardiographic findings were compared between these two groups. UMI was detected in 43 patients (31.2%). Multivariable logistic regression analysis revealed that higher SYNTAX score, the presence of wall motion abnormalities (WMAs) and lower global longitudinal strain (GLS) were independent predictors of the presence of UMI. Furthermore, GLS provided incremental efficacy for the detection of UMI over abnormal Q waves, SYNTAX score and WMAs. Preprocedural TTE in combination with 2D-STE could help identify patients with UMI regardless of the presence or absence of ECG findings and WMAs.

Takotsubo cardiomyopathy in locally advanced rectosigmoid junction cancer: a case report

Background. takotsubo cardiomyopathy (tcm) occurs more frequently in cancer patients than in the general population. The triggers for tcm in cancer patients include not only the inflammatory state of the cancer itself, but also the significant emotional stress of a cancer diagnosis and the physical stress associated with invasive diagnostic and treatment procedures.Case presentation. We describe the case of a 54-yearold woman with histologically verified rectosigmoid junction cancer (cT4bcN2M0) complicated by acute intestinal obstruction. In the early postoperative period, a sudden drop in blood pressure, t-wave inversion and Qt-interval prolongation on ecg, decrease in the left ventricle contractility and presence of wall motion abnormalities on echocardiography (ecHo), as well as an increase in biomarkers of myocardial damage were initially regarded as acute coronary syndrome, which was subsequently excluded according to the findings of coronary angiography, which did not reveal coronary artery obstruction. taking into account the rapid and complete inverse dynamics of changes, acute myocardial infarction without coronary artery obstruction and acute myocarditis were excluded. Ultimately, the diagnosis of takotsubo cardiomyopathy was established.Conclusion. this case report indicates that cancer can be a trigger for the development of tcm; therefore, the assessment of cardiological status and timely detection of cardiac complications in cancer patients during cancer treatment is extremely important and is aimed at increasing the overall survival in this category of patients.

Echocardiographic wall motion abnormalities and mortality reported in 492,338 individuals

Abstract Background The prevalence of abnormal regional left ventricular function in the setting of myocardial ischaemia is incompletely studied, along with the relative frequency of individual wall motion abnormalities (WMA). We examined the prevalence and distribution of regional WMA in adults being investigated with echocardiography, and the association with mortality. Methods Routinely acquired echocardiographic reporting data and individually linked survival profiles were extracted from the Australia-wide, multicentre National Echocardiography Database of Australia. By applying natural language processing (NLP) to the cardiologist’s report of left ventricular (LV) function, we examined global and regional LV dysfunction. Results 492,338 (age 61.9± 17.9) individuals (255,697 men aged 60.5±17.1 and 236,341 women aged 60.9±18.3 years) could be evaluated. 57,180 (17.6%) individuals were reported to have abnormal wall motion (39,346 men aged 69.0+/-13.4 yrs and 17,834 women, 71.3+/-14.3 yrs). The presence of a WMA was associated with increased left atrial volumes (LAVi: 55.5±36.4 vs 40.9±27.5 ml/m2 for women) , impaired LVEF (50.8±15.1% vs 61.1±12.2% for women), impaired diastolic function (E` 6.64±2.21 vs 8.25±2.86 cm/s for women), and higher pulmonary artery pressure (eRVSP 36.2±11.5 vs 32.5±10.7 mmHg) . Most, but not all individuals had a history of myocardial infarction with or without revascularisation. An inferior WMA was the commonest, with 18,638 WMA reported (4.7%), followed by apical WMA (19,682; 3.4%), lateral WMA (16,976; 2.9%), septal WMA (15,722; 1.7%) and anterior WMA in 9,432 (1.6%). In men, long-term all-cause mortality for WMA was 40.5% (compared to 23.3% without), and in women 42.7% (vs 20.5%). These WMA observations were magnified in those &amp;gt;65 years and with impaired systolic function. The presence of akinesis/dyskinesis/aneurysm of any wall fared worse than hypokinesis (OR 1.34 CI:1.22-1.44 P&amp;lt; 0.001 for Inferior WMA). Females with a WMA had less mortality (OR 0.80 CI: 0.74 – 0.85; P, 0.001), and any revascularisation was protective (OR 0.76 CI 0.46 – 0.69 P&amp;lt;0.001). Conclusion WMA are reported in men at greater than twice more frequently than women, and overall contribute almost a fifth of echocardiographic reports. The presence of a WMA is associated with impaired LV systolic and diastolic function, signs of increased LV filling pressure and pulmonary pressure, and high long-term mortality that is partially ameliorated by revascularisation. Prognosis is affected by the presence, extent and severity of WMA.

Abstract 072: Risk Factors for Developing Ischemic Strokes While Taking Non‐Vitamin K Antagonist Oral Anticoagulants

Introduction Over the past decade, non‐vitamin K antagonist oral anticoagulants (NOACs) have replaced warfarin as the initial strategy for stroke prevention in non‐valvular atrial fibrillation. However, ischemic strokes occurring in patients taking NOACs are becoming increasingly more frequent. In this study, we aimed to determine the clinical, echocardiographic, and neuroimaging markers associated with developing ischemic strokes in patients taking NOACs for atrial fibrillation. Methods Among atrial fibrillation patients on NOACs with and without ischemic stroke, brain MRIs were reviewed for the presence of neuroimaging markers of small vessel disease. Transthoracic echocardiography reports were reviewed to obtain left atrial volumes, presence of left ventricular hypertrophy, ejection fractions, and presence of wall motion abnormalities. Clinical and radiologic variables with significant differences between groups were entered into a multivariable regression model to determine predictors of ischemic stroke. In the ischemic stroke group, a Cox regression analysis was constructed to determine predictors of ischemic stroke recurrence during follow‐up. Results 112 patients with ischemic stroke and 94 controls (free of ischemic stroke) were included in the study. The mean age (77±9 years vs. 74±11 years, p = 0.13) and proportion of patients with CHA2DS2‐VASc&gt;2 were similar between controls and ischemic stroke patients (82% vs. 83%, p = 0.86). The variables that were significantly different between groups included apixaban use, dabigatran use, prior cerebrovascular events, hemoglobin A1c (HbA1c), left ventricular hypertrophy, left atrial volume index, and severe white matter hyperintensities. After multivariable adjustment, prior cerebrovascular events (aOR 23.86, 95% CI [6.02–94.48]), HbA1c levels (aOR 2.36, 95% CI [1.39–3.99]), left ventricular hypertrophy (aOR 2.73, 95% CI [1.11–6.71]) and left atrial volume index (aOR 1.05, 95% CI [1.01–1.08]) increased the risk of stroke, whereas apixaban use appeared to decrease the risk (aOR 0.38, 95% CI [0.16–0.92]). Among patients with ischemic stroke, there were 103 survivors, 82 (80%) of which had follow‐up data. The median follow‐up duration for these patients was 2.6 (0.5–4.7) years. Of these 82 patients, 11 (13%) experienced an ischemic stroke during the follow‐up period. Malignancy was associated with ischemic stroke recurrence (aHR 4.90, 95% CI [1.35–18.42]) after adjustment for age and chronic renal failure. Conclusion Prior cerebrovascular events, diabetes, left ventricular hypertrophy, and left atrial size are associated with the development of ischemic stroke among NOAC users. Future studies should aim to investigate nonpharmacological stroke prevention strategies in patients with the vascular risk factors and echocardiographic risk markers identified in the present study.

Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-centre study

BackgroundStress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines.MethodsData on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level.ResultsStress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384–1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually.ConclusionThis study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning.

Practical role of preoperative echocardiography in low-risk non-cardiac surgery.

Due to increased needs to reduce non-fatal as well as fatal cardiac events, preoperative echocardiography remains part of routine clinical practice in many hospitals. Data on the role of preoperative echocardiography in low-risk non-cardiac surgery (NCS) other than ambulatory surgeries do not exist. We aimed to investigate the role of preoperative echocardiography in predicting postoperative adverse cardiovascular events (CVEs) in asymptomatic patients undergoing low-risk NCS. The study population was derived from a retrospective cohort of 1,264 patients who underwent elective low-risk surgery at three tertiary hospitals from June 1, 2021, to June 30, 2021. Breast, distal bone, thyroid, and transurethral surgeries were included. Preoperative examination data including electrocardiography, chest radiography, and echocardiography were collected. The primary outcome was a composite of postoperative adverse CVEs including all-cause death, myocardial infarction, cerebrovascular events, newly diagnosed or acutely decompensated heart failure (HF), lethal arrhythmia such as sustained ventricular tachycardia/fibrillation, and new-onset atrial fibrillation within 30 days after the index surgery. Preoperative echocardiography was performed in 503 patients (39.8%), most frequently in patients with breast surgery (73.5%), followed by transurethral (37.7%), distal bone (21.6%), and thyroid surgeries (11.9%). Abnormal findings were observed in 5.0% of patients with preoperative echocardiography. Postoperative adverse CVEs occurred in 10 (0.79%) patients. Although a history of previous HF was an independent predictor of postoperative CVE occurrence (adjusted odds ratio, aOR: 17.98; 95% confidence interval, CI: 1.21-266.71, P = 0.036), preoperative echocardiography did not significantly predict CVE in multivariate analysis (P = 0.097). However, in patients who underwent preoperative echocardiography, the presence of abnormal echocardiographic findings was independently associated with development of CVE after NCS (aOR: 23.93; 95% CI: 1.2.28-250.76, P = 0.008). In particular, the presence of wall motion abnormality was a strong predictor of postoperative adverse CVE. In real-world clinical practice, preoperative echocardiography was performed in substantial number of patients with potential cardiac risk even in low-risk NCS, and abnormal findings were independently associated with postoperative CVE. Future studies should identify patients undergoing low-risk NCS for whom preoperative echocardiography would be helpful to predict adverse CVE.

Reperfusion Injury-Related Intramyocardial Hemorrhage

Myocardial reperfusion injury is defined as the death of cardiomyocytes as a direct result of one or more events initiated by reperfusion. These events could be inflammation, oxidative stress, calcium overload, neurohumoral activation, cytotoxicity of anaerobic metabolites, etc. Intramyocardial hemorrhage as a consequence of ischemia–reperfusion injury during acute myocardial infarction and subsequently is frequent and portends worse prognosis. Animal studies have demonstrated that intramyocardial hemorrhage does not occur with ST-elevation myocardial infarction unless myocardium is reperfused with blood. Magnetic resonance imaging is the technique of choice for its detection but has limited availability in emergencies and is expensive. Echocardiography can be used for indirect myocardial tissue characterization. Echocardiography coupled with myocardial contrast imaging is increasingly being used for detecting hemorrhage in infarcted segments. In the presence of wall motion abnormality, increased segmental echogenicity, significantly increased wall thickness underlying hypermobile endocardium, and neocavitations within the myocardium are the characteristic features. Occasionally, extensive wall splitting and formation of pseudotumor due to large hematoma are the striking features of intramyocardial hemorrhage. Intramyocardial hemorrhage in acute myocardial infarction can occur during early phase, following reperfusion and during remodeling process. There is no definite echocardiographic imaging method to assess reperfusion hemorrhage in vivo, but signal-void cavity-like or cystic appearance within the myocardium in the setting of myocardial infarction is highly suggestive. Detecting hypointense area of hemorrhage could be complicated by low-intensity echoes emanating from the normal myocardium. Echocardiography should be performed in every patient before and after reperfusion therapy and serially till discharge. There are no studies comparing the diagnostic yield of echocardiography compared to magnetic resonance imaging. Those with obvious myocardial hematoma need special attention with regard to antiremodeling agents, dual antiplatelet therapy, and possibly surgery. A majority of patients with significant intramural hemorrhage end up having reduced left ventricular function, adverse remodeling, true or pseudo-aneurysms, and even heart failure although spontaneous resorption has also been reported.

Regional wall motion abnormalities predict culprit lesions in patients presenting with acute chest pain

Abstract Background Current ESC guidelines for non-ST-segment elevation myocardial infarction suggest the utilization of echocardiography in patients with inconclusive initial electrocardiography and cardiac enzymes. Besides detection of alternative pathologies associated with chest pain, echocardiography can screen for wall motion abnormalities (WMA) as sign of myocardial necrosis. Purpose We evaluated the ability of the assessment of regional WMA, detected via transthoracic echocardiography, to predict the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Methods In this prospective single-centre observational cohort study, we included consecutive patients presenting to the emergency department of our University Hospital with acute chest pain, suggestive of an acute coronary syndrome, between December 2018 and August 2020. Patients with ST-elevation myocardial infarction, hemodynamic instability, or known coronary artery disease were excluded. As part of initial workup, patients received bedside echocardiography for the assessment of regional WMA by a dedicated study physician, blinded to all patients' characteristics. The primary endpoint was defined as the presence of culprit lesions as detected in subsequent invasive coronary angiography, requiring coronary revascularization therapy. Logistic regression analysis was performed in different models adjusted for traditional cardiovascular risk factors, cardiac biomarkers as well as established risk scores. Area under the receiver operating characteristics curve (AUC) was calculated to assess a potential improvement in the prediction of culprit lesions. Results Overall, 657 patients (age 58.06±18.04 years, 53% male) were included in our study. WMA were detected in 76 patients (11.6%). Patients with WMA were older (66.92±13.85 vs. 56.90±18.21 years, p&amp;lt;0.001), had significantly higher Troponin-levels (18.5 [6.0; 91.5] vs. 6.0 [6.0; 15.0], p&amp;lt;0.001) and higher blood pressure (139.0±19.29 vs. 135.1±19.21, p=0.04). WMA were significantly more frequent in patients reaching the primary endpoint (26.2% vs. 7.6%, p&amp;lt;0.001). In multivariable regression analysis, the presence of WMA was associated with 3-fold increased odds of the presence of culprit lesions (3.41 [1.99–5.86], p&amp;lt;0.001). Adding WMA to a multivariable model containing the TIMI risk score, cardiac biomarkers and traditional risk factors significantly improved the AUC for prediction of obstructive coronary artery disease (0.777 to 0.804, p=0.009). Conclusion WMA strongly and independently predict the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Our results suggest that routine bedside echocardiography for assessment of WMA in emergency department may improve diagnostic algorithms in suspected acute coronary syndrome. Funding Acknowledgement Type of funding sources: None.

Myocardial edema, interstitial expansion and clinical correlates in takotsubo syndrome: a cardiac magnetic resonance tissue mapping study

Abstract Funding Acknowledgements Type of funding sources: None. Background takotsubo syndrome (TTS) is an acute heart failure syndrome characterized by transient systolic dysfunction, widespread myocardial edema and not trivial rate of in-hospital complications. Tissue mapping by cardiac magnetic resonance (CMR) imaging provides measure of myocardial interstitial expansion. Few studies to date comprehensively examined native T1, T2 and extracellular volume (ECV) quantification by CMR in TTS. Purpose to describe T1 and T2 mapping findings by cardiac magnetic resonance (CMR) imaging in a cohort of TTS patients and control subjects. Methods we performed CMR imaging with native T1 and T2 mapping assessment as well as ECV and late gadolinium enhancement (LGE) imaging in n = 14 TTS patients at a median of 4 (3, 7) days after the acute event. Control group consisted of n = 14 healthy individuals with no known prior acute cardiac events. Extracellular-volume (ECV) fraction estimate was derived from native and post-contrast T1 of myocardium and blood pool corrected for hematocrit as reported in literature. All mapping measurements were performed in the interventricular septum from the mid-short-axis view. Results median age of the study population was 72 years, 84% female. Typical apical ballooning was present in 72% of the patients, atypical in 28%, with median left ventricular ejection fraction (LVEF) of 45%; mid interventricular septum was involved in all patients based on the presence of wall motion abnormalities at hospital admission. Median native T1, T2 and ECV were 1078 msec vs 965 msec, 55 msec vs 47 msec and 29% vs 25% in TTS and controls respectively (p &amp;lt; 0.001 for all). A significant direct correlation was found between T2 and both native T1 and ECV in TTS (r = 0.759, p = 0.002 and r = 0.630, p = 0.018 respectively) but not in controls. Moreover, in TTS patients, native T2 inversely correlated with LVEF as assessed at hospital admission (r=-0.563, p = 0.037), whereas non-significant trends were observed between admission LVEF and both native T1 and ECV. No LGE was detected neither in TTS patients nor in controls. Conclusions myocardial edema, as signified by increased T2, is a prominent feature of TTS, likely driving interstitial expansion and increase of native T1 and ECV in the acute phase. Correlation of T2 with LVEF on admission suggests that CMR-based parametric assessment of myocardial edema could contribute to better characterize disease severity in TTS.

Predictors of coronary artery disease in cardiac arrest survivors: coronary angiography for everyone? A single-center retrospective analysis.

ObjectiveTo identify predictors of coronary artery disease in survivors of cardiac arrest, to define the best timing for coronary angiography and to establish the relationship between coronary artery disease and mortality.MethodsThis was a single-center retrospective study including consecutive patients who underwent coronary angiography after cardiac arrest.ResultsA total of 117 patients (63 ± 13 years, 77% men) were included. Most cardiac arrest incidents occurred with shockable rhythms (70.1%), and the median duration until the return of spontaneous circulation was 10 minutes. Significant coronary artery disease was found in 68.4% of patients, of whom 75% underwent percutaneous coronary intervention. ST-segment elevation (OR 6.5, 95%CI 2.2 - 19.6; p = 0.001), the presence of wall motion abnormalities (OR 22.0, 95%CI 5.7 - 84.6; p < 0.001), an left ventricular ejection fraction ≤ 40% (OR 6.2, 95%CI 1.8 - 21.8; p = 0.005) and elevated high sensitivity troponin T (OR 3.04, 95%CI 1.3 - 6.9; p = 0.008) were predictors of coronary artery disease; the latter had poor accuracy (area under the curve 0.64; p = 0.004), with an optimal cutoff of 170ng/L. Only ST-segment elevation and the presence of wall motion abnormalities were independent predictors of coronary artery disease. The duration of cardiac arrest (OR 1.015, 95%CI 1.0 - 1.05; p = 0.048) was an independent predictor of death, and shockable rhythm (OR 0.4, 95%CI 0.4 - 0.9; p = 0.031) was an independent predictor of survival. The presence of coronary artery disease and the performance of percutaneous coronary intervention had no impact on survival; it was not possible to establish the best cutoff for coronary angiography timing.ConclusionIn patients with cardiac arrest, ST-segment elevation, wall motion abnormalities, left ventricular dysfunction and elevated high sensitivity troponin T were predictive of coronary artery disease. Neither coronary artery disease nor percutaneous coronary intervention significantly impacted survival.

P1686 Inverted biventricular takotsubo syndrome: early onset in heart transplanted patient

Abstract Introduction Takostubo syndrome (TTS) is supposed to be a disturbances of myocardial microcirculation and increased catecholamine concentration (ie, epinephrine, norepinephrine, and dopamine), could be responsible of microvascular spasms or myocyte involvement. Catecholamine increased is related to sympathetic overactivity caused by stress but also as inotropic drugs. A 39-year-old women underwent heart transplant due to rheumatic heart disease, status post mitral valve repair, in New York Heart Association Class IV heart failure despite optimal therapy. The donor was a 36-year-old young women without significant past medical history. The echocardiogram before explantation was normal and palpation of the epicardial coronary arteries did not reveal any gross pathology, areas of atheromatous disease, or calcium. An orthotopic heart transplantation was carried out using the bicaval technique without any complication. The postoperative course was in post-surgery intensive care unite with the patient on mechanical ventilation and inotropic support. Within the first 24-hours, changes in T wave were observed and the echocardiography revealed normal left ventricle (LV) size, LV systolic function was mildly reduced (Ejection Fraction 45- 50%), presence of wall motion abnormalities characterized by akinesia of the basal septum, dyskinesia of the basal segment of the lateral wall and hypokinesia of the basal segments of the other walls and akinesia of the basal segments of the right ventricle (RV) suggesting TTS. Because of the donor’s age and risk profile, epicardial coronary artery disease was not considered to be the causing factor of the wall motion abnormality, coronary catheterization plus biopsy was done 7 days later with no evidence of coronary obstruction and biopsy result showed 1R rejection. The echocardiogram performed in the same day showed complete recovery of the wall motion abnormalities while the global strain was still low for the basal segments either for LV or RV. The rest of the hospitalization was uneventful and she was discharged after 10 days from heart transplant and the echocardiographyic study showed an additional improvement of the global strain for both ventricle but not complete recovery. Conclusion This is a rare case of TC that happened the first day after heart transplant, when the heart is denervated. We hypothesized that the present case of TTS was more related to the drug inotropic support and by epinephrine released by suprarenal medulla rather than endogenous catecholamines released locally by the systemic nervous. Figure 1. First echocardiographic exam during the acute phase of TTS, LV GLS was – 6.5% and RV free wall GLS -4%. After 7 days the LV GLS was -9.1% and RV free wall was -7.6%. After 3 weeks the LV GLS was – 10.5% and the RV free wall was – 11%. Abstract P1686 Figure.

Abstract WP263: Wall Motion Abnormalities on Transthoracic Echocardiography in the Setting of Ischemic Stroke Reflect Underlying Cardiac Disease and May Warrant an Ischemic Cardiac Evaluation

Background and Purpose: Patients with acute ischemic stroke (AIS) are at a heightened risk of cardiovascular events. We hypothesize that wall motion abnormalities (WMA) on transthoracic echocardiography (TTE) in the setting of AIS reflect underlying heart disease rather than reversible cardiac strain caused by the stroke. Methods: Data was abstracted from a single center prospective AIS database over 18 months and included all patients with acute ischemic stroke who underwent a TTE. The presence of WMA was abstracted from the TTE report. Univariate analyses and predefined multivariable models were performed to determine factors associated with WMA, including demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, atrial fibrillation, congestive heart failure, coronary heart disease, and smoking), NIHSS score, cardiac markers (positive troponin, ECG evidence of prior myocardial infarction, ejection fraction), and insular location of infarct. Results: We identified 1044 patients who met the inclusion criteria; 139 (13.3%) had evidence of WMA, of which only 23 patients had no history of heart disease or ECG evidence of prior myocardial infarction. Among these 23 patients, 12 had a follow up TTE after the stroke and WMA persisted in 92.7% (11/12) of patients. On fully adjusted models, factors associated with WMA are older age (OR per SD 1.03, 95% CI 1.001-1.05; p=0.009), congestive heart failure (OR 4.44, 95% CI 2.39-8.33, p&lt;0.001), history of coronary artery disease or ECG evidence prior myocardial infarction (OR 27.03, 95% CI 14.93-50.0, p&lt;0.001), and elevated serum troponin levels (OR 2.00, 95% CI 1.06-3.75, p=0.031). Conclusion: In AIS patients, WMA on TTE may reflect underlying cardiac disease and warrant further cardiovascular evaluation particularly in those without known history of cardiac disease. Future studies are needed to investigate the cost-effectiveness of this approach.

Incidence, Predictors, and Outcomes of New-Onset Left Ventricular Systolic Dysfunction After Orthotopic Liver Transplantation

Adverse cardiovascular events after liver transplantation (LT) are relatively common and are a significant source of early mortality. Although new-onset systolic dysfunction after LT is a reported phenomenon, there is little data regarding its incidence, risk factors, and outcomes. This single-center retrospective study included all adult patients from January 2002 to March 2015 with deceased-donor LT and available preoperative transthoracic echocardiograms (TTEs). In total, 1,760 patients were included in the study, 602 (34.2%) of whom had a postoperative TTE. The primary end point was development of new-onset cardiomyopathy, defined as a new left ventricular ejection fraction (LVEF) of <40% within 180days of transplant. Sixty-nine (11.4%) of the patients who received post-LT TTE had a reduction in LVEF to <40% within 6 months. Clinical parameters of donor and recipient did not show significant impact on development of post-LT LV systolic dysfunction (LVSD). Presence of wall motion abnormalities (P = .004) on preoperative TTE was predictive of development of post-LT LVSD. These patients did not have longer hospitalizations, but they had worse survival. Post-LT LV systolic dysfunction occurs at higher rates than previously suspected and may develop more frequently in patients with underlying cardiac structural abnormalities, which appear to adversely affect post-LT survival.

Electrocadiographic Scoring Helps Predict Left Ventricular Wall Motion Abnormality Commonly Observed after Subarachnoid Hemorrhage

Background: Cardiac wall motion abnormality (WMA) is a common complication in patients with subarachnoid hemorrhage (SAH) and is one determinant of their prognosis. The aim of this study was to examine whether the electrocardiography (ECG) findings at admission could predict WMA commonly observed after SAH. Materials and methods: We studied 161 SAH patients with SAH who were hospitalized in our institution between April 2007 and November 2010. We performed bedside 2-dimensional transthoracic echocardiography and 12-lead surface ECG within 24hours of SAH onset. Each of the following ECG changes was scored as having 1 point: ST elevation, ST depression and T wave inversion. We summed up the points in every patient and compared with WMA evaluated by echocardiography. Results: The study subjects were classified into 2 groups based on the presence of WMA. Multivariate analysis revealed that ST elevation, ST depression and T wave inversion were strong independent predictors of WMA. Receiver operating characteristic curve determined that the threshold value to predict WMA was 4 points (sensitivity 86.5%, specificity 83.1%, AUC 0.94, P < .0001). Conclusions: In conclusion, a novel ECG score may well predict WMA after SAH which may associate with an increased risk of mortality.

Stroke : Highlights of Selected Articles

<i>Stroke</i> : Highlights of Selected Articles

The utility of global longitudinal strain in the identification of prior myocardial infarction in patients with preserved left ventricular ejection fraction

Prior myocardial infarction (MI) is associated with increased mortality and is prevalent in certain high risk patient groups. Electrocardiogram may be used in diagnosis, however, sensitivity is limited, thus non-invasive imaging techniques may improve diagnosis. We investigated whether global longitudinal strain (GLS) and longitudinal strain parameters are reduced in patients with prior MI but preserved left ventricular ejection fraction (LVEF). The study included 40 clinical patients with prior MI occurring >3 months previously (defined as subendocardial hyperenhancement on late Gadolinium enhancement imaging) with LVEF ≥ 55% and 40 controls matched for age and LVEF. GLS, global longitudinal strain rate (GLSR) and early diastolic longitudinal strain rate (GLSRe) were measured from cine imaging feature tracking analysis. Presence of wall motion abnormality (WMA) and minimum systolic wall thickening (SWT) were calculated from cine imaging. GLS was −17.3 ± 3.7% in prior MI versus −19.3 ± 1.9% in controls (p = 0.012). GLSR was −88.0 ± 33.7%/s in prior MI versus −103.3 ± 26.5%/s in controls (p = 0.005). GLSRe was 76.4 ± 28.4%/s in prior MI versus 95.5 ± 26.0%/s in controls (p = 0.001). GLS accurately identified prior MI [AUC 0.662 (95% CI 0.54–0.785) p = 0.012] whereas WMA [AUC 0.500 (95% CI 0.386–0.614) p = 1.0] and minimum SWT [AUC 0.609 (95% CI 0.483–0.735) p = 0.093] did not. GLS, GLSR and GLSRe are reduced in prior MI with preserved LVEF. Normal LVEF and lack of WMA cannot exclude prior MI. Prior MI should be considered when reduced GLS, GLSR or GLSRe are detected by non-invasive imaging.

Changes in left ventricular function after spontaneous coronary artery dissection.

Spontaneous healing of spontaneous coronary artery dissection (SCAD) and left ventricular ejection fraction (LVEF) recovery is frequently observed clinically. However, LVEF on presentation and follow-up imaging has not been described. We hypothesize that LV dysfunction improves at follow-up after initial SCAD presentation. We included patients with nonatherosclerotic SCAD prospectively followed at Vancouver General Hospital, who had baseline assessment of LVEF and wall-motion abnormality (WMA) during their index presentation. A subset of these patients had repeat assessment of their ventricular function at follow-up. We compared the baseline LVEF and WMA with follow-up assessments and correlated to long-term cardiovascular outcomes. We included 277 SCAD patients who had baseline ventricular assessment performed. The average age was 52.4 ± 9.4 years, and 90.3% were female. All presented with myocardial infarction (24.2% STEMI, 75.8% NSTEMI). At baseline, the mean LVEF was 55.6% ± 9.1% and 72/277 (26.0%) had LVEF <50%. The presence of WMA was observed in 237/277 (85.6%) cases. Of 164 patients with repeat assessments, the baseline LVEF was 54.6% ± 9.2%, with improvement to 60.7% ± 7.2% at follow-up (P < 0.001). Baseline LVEF of <50% was observed in 29.9%, but only 6.7% had LVEF <50% at follow-up (P < 0.001). Baseline WMA was observed in 87.2% but decreased to 44.5% at follow-up (P < 0.001). Multivariable analysis showed that presentation with STEMI (odds ratio [OR]: 2.71, P = 0.001), troponin I >50 µg/L (OR: 1.02, P = 0.005), and SCAD involvement of the LAD (OR: 2.5, P = 0.002) were independent predictors of baseline LVEF <50%. In our large, prospectively followed SCAD cohort, the majority of patients presented with WMA and had relatively normal LVEF. Over half had subsequent normalization of WMA and LVEF on follow-up assessment.