Regional Wall Motion Score Research Articles

Two-Dimensional Speckle-Tracking Echocardiography to Monitor Left Ventricular Function After Percutaneous Coronary Intervention

Background: Conventional 2 D Doppler echocardiographic parameters are inadequate for evaluation and monitoring Left ventricle systolic function recovery of patients with ischemic heart disease (IHD) treated by Percutaneous coronary intervention (PCI). Hence, New strain imaging parameters are studied by using 2 D speckle Tracking Echocardiography. The aim is to compare the conventional echocardiographic parameters (Left ventricle ejection fraction, Wall motion score index, regional wall motion score) with speckle tracking echocardiographic parameters (Global longitudinal strain, Regional longitudinal strain) in patients with ischemic heart disease undergo Percutaneous Coronary Intervention (PCI).Method and patient: A prospective Interventional Hospital Based study enrolled 50 patients who had ischemic heart disease (IHD), Percutaneous coronary intervention (PCI) was done for them at IbN Al-Bittar Cardiac Surgery Center from October 2014 to April 2015. Both conventional echocardiographic parameters (Left ventricle ejection fraction, Wall motion score index, regional wall motion score according to coronary artery territory) and Speckle tracking echocardiographic parameters (Global longitudinal strain, Regional longitudinal strain according to coronary artery territory) done for them pre PCI, one day post PCI, and one month post PCI.Result: Regarding conventional echocardiographic parameters: Global LVEF pre PCI 52.34±90% , one month post PCI was (54.00±6.9), there was no significant difference statistically (P value 0.79), also Wall motion score index ,Regional wall motion score according to coronary artery territory were (1.22±0.25,1.44±1.52) respectively, one month post PCI were (1.98±0.26,1.40±0.58) respectively where there's no significant differences statistically (P value 0.25,0.22) respectively.Regarding speckle tracking parameters :Global Longitudinal strain for all patients pre PCI was (-14.30±3.54%) ,one day post PCI was (-14.78±3.81%) ;there was no significant differences (p value 0.77).After one month Global Longitudinal Strain was (-16.38±4.15%) where this consider highly significant differences (p value 0.001).Regional Longitudinal Strain according to the coronary artery territory pre PCI was (-14.49±4.47%),post one day post PCI was (-15.08±4.92%) where there's no significant differences (p value 0.10), while one month post PCI was (-17.70±5.27%),this was highly significant different statistically (0.001).Only in STEMI patients there was significant difference one day post PCI(P value 0.041 for Global LS,0.016 for Regional LS).Conclusions: In all IHD groups (STEMI, NSTEMI ∕UA, chronic stable angina) Speckle Tracking Echocardiographic parameters (Global Longitudinal Strain and Regional longitudinal strain) more reliable and effective than conventional echocardiographic parameters (Global LWEF,WMSI, RWMS) for monitoring improvement in LV systolic function post Percutaneous coronary intervention.

Complementary Value of Tissue Doppler Imaging in Dobutamine Stress Echocardiography: A Prospective Cohort Study

Introduction: In patients with Coronary Artery Diseases (CAD), the presence of viable myocardium predicts the recovery of Left Ventricular (LV) systolic function after revascularisation. The identification of myocardial viability during dobutamine stress echocardiography is subjective and with observer bias. Tissue Doppler Imaging (TDI) echocardiography has opened new possibilities for non-invasive quantification of myocardial function by directly interrogating myocardial velocity with high temporal and spatial resolution. Aim: To determine the baseline regional myocardial and mitral annular Maximum Systolic Velocities (MSV) in patients with LV dysfunction and to compare the MSV values in viable and nonviable myocardium. Materials and Methods: In this prospective Cohort study, TDI of regional and annular LV myocardial velocities was performed at the baseline (at rest) in 352 patients with CAD and LV dysfunction who were referred for Dobutamine stress Echocardiography. Viability assessment by 2 Dimensional (2D) methods was done simultaneously using routine Dobutamine stress protocol. Patients were grouped in two groups based on the presence or absence of viability with 2D stress echocardiography. TDI velocities were compared in the two groups of patients with and without myocardial viability. Measurements of regional wall thickness, Ejection Fraction(EF) and Wall Motion Score Index (WMSI) were done to assess the regional and global LV function in these patients. Those patients who underwent revascularisation were subsequently assessed for functional recovery by 2D and TDI echocardiography before discharge from the hospital. Analyses were conducted using Statistical Package for Social Sciences(SPSS) version 16.0. Results: Among 352 patients studied (124 females and 228 males), mean age 58 years (range 36 to 75 years). A total of 243 patients (69%) with viable myocardium as per 2D echocardiography had higher cut-off Baseline Regional Maximum Systolic Velocity (BRMSV) >0.03 m/s and baseline mitral annular systolic velocity >0.06 m/s with high sensitivity and specificity compared to patients with severe contractile dysfunction and non-viable myocardium. Conclusion: Tissue doppler parameters like regional myocardial systolic and mitral annular velocities have shown significantly higher cut-off values in those patients with ischaemic and viable myocardium compared to non-viable myocardium.

Diagnostic Performance of On-Site Computed Tomography Derived Fractional Flow Reserve on Non-Culprit Coronary Lesions in Patients with Acute Coronary Syndrome.

The role of coronary computed tomography angiography (CCTA) derived fractional flow reserve (CT-FFR) in the assessment of non-culprit lesions (NCL) in patients with acute coronary syndrome (ACS) is debated. In this prospective clinical study, a total of 68 ACS patients with 89 moderate (30-70% diameter stenosis) NCLs were enrolled to evaluate the diagnostic accuracy of on-site CT-FFR compared to invasive fractional flow reserve (FFRi) and dobutamine stress echocardiography (DSE) as reference standards. CT-FFR and FFRi values ≤ 0.80, as well as new or worsening wall motion abnormality in ≥2 contiguous segments on the supplying area of an NCL on DSE, were considered positive for ischemia. Sensitivity, specificity, positive, and negative predictive value of CT-FFR relative to FFRi and DSE were 51%, 89%, 75%, and 74% and 37%, 77%, 42%, and 74%, respectively. CT-FFR value (β = 0.334, p < 0.001) and CT-FFR drop from proximal to distal measuring point [(CT-FFR drop), β = -0.289, p = 0.002)] were independent predictors of FFRi value in multivariate linear regression analysis. Based on comparing their receiver operating characteristics area under the curve (AUC) values, CT-FFR value and CT-FFR drop provided better discriminatory power than CCTA-based minimal lumen diameter stenosis to distinguish between an NCL with positive and negative FFRi [0.77 (95% Confidence Intervals, CI: 0.67-0.86) and 0.77 (CI: 0.67-0.86) vs. 0.63 (CI: 0.52-0.73), p = 0.029 and p = 0.043, respectively]. Neither CT-FFR value nor CT-FFR drop was predictive of regional wall motion score index at peak stress (β = -0.440, p = 0.441 and β = 0.403, p = 0.494) or was able to confirm ischemia on the territory of an NCL revealed by DSE (AUC = 0.54, CI: 0.43-0.64 and AUC = 0.55, CI: 0.44-0.65, respectively). In conclusion, on-site CT-FFR is superior to conventional CCTA-based anatomical analysis in the assessment of moderate NCLs; however, its diagnostic capacity is not sufficient to make it a gatekeeper to invasive functional evaluation. Moreover, based on its comparison with DSE, CT-FFR might not yield any information on the microvascular dysfunction in the territory of an NCL.

Patients with Moderate Non-Culprit Coronary Lesions of Recent Acute Coronary Syndrome.

Fractional flow reserve (FFR) measurement was compared to dobutamine stress echocardiography (DSE) instable angina (SA) with stable coronary lesion (s) (SCL (s) ) in a few trials; however, similar comparisons in patients with acute coronary syndrome (ACS) with non-culprit lesion (s) (NCL (s) ) are lacking. Our objectives were to prospectively evaluate the diagnostic performance of FFR with two different cutoff values (< 0.80 and < 0.75) relative to DSE in moderate (30%-70% diameter stenosis) NCLs (ACS group) and to compare these observations with those measured in SCLs (SA group). One hundred seventy-five consecutive patients with SA (n = 86) and ACS (n = 89) with 225 coronary lesions (109 SCLs and 116 NCLs) were enrolled. In contrast to the ACS cohort in SA patients, normal DSE was associated with higher FFR values compared to those with abnormal DSE (P = 0.051 versus P = 0.006). In addition, in the SA group, a significant correlation was observed between DSE (regional wall motion score index at peak stress) and FFR (r = -0.290; P = 0.002), whereas a similar association was absent (r = -0.029; P = 0.760) among ACS patients. In the SA group, decreasing the FFR cutoff value (< 0.80 versus < 0.75) improved the concordance of FFR with DSE (70.6% versus 81.7%) without altering its discriminatory power (area under the curve; 0.68 versus 0.63; P = 0.369), whereas in the ACS group, concordance remained similar (69.0% versus 71.6%) and discriminatory power decreased (0.62 versus 0.51; P = 0.049), respectively. In conclusion, lesion-specific FFR assessment may have different relevance in patients with moderate NCLs than in patients with SCLs.

Accuracy of global and regional longitudinal strain at peak of dobutamine stress echocardiography to detect significant coronary artery disease

Dobutamine stress echocardiography (DSE) is sensitive but subjective diagnostic tool to detect inducible ischemia. Nowadays, speckle tracking allows an objective quantification of regional wall function. We aimed to investigate the feasibility and accuracy of global (GLS) and regional longitudinal strain (RLS) during DSE to detect significant coronary stenosis (SCS). We conducted a prospective observational multicenter study including patients undergoing DSE for suspected SCS. 50 patients with positive DSE underwent coronary angiography. Besides visual regional wall motion score index (WMSI), GLS and RLS were determined at rest and at peak stress by Automated Function Imaging. DSE GLS feasibility was 96%. Among 35 patients with SCS, 12 patients were affected by multivessel disease, 18 had stenosis of left anterior descending artery (LAD), 18 of left circumflex (LCX) and 15 of right coronary artery (RCA). At peak stress, both GLS reduction (p = 0.037) and WMSI worsening (p = 0.04) showed significant agreement with coronary angiography for detecting SCS. When single lesion was considered, peak stress GLS and LAD RLS were lower in the obstructed LAD regions than in normo-perfused territories (17.4 ± 5.5 vs. 20.5 ± 4.4%, p = 0.03; 17.1 ± 7.6 vs. 21.6 ± 5.5%, p < 0.02, respectively). Furthermore, the addition of RLS to regional WMSI was able to improve accuracy in LAD SCS prediction (AUC 0.68, p = 0.037). Conversely, in presence of LCX or RCA SCS, LS was less accurate than WMSI at peak stress. In conclusion, DSE strain analysis is feasible and may improve prediction of LAD SCS, whereas regional WMSI assessment performs better in presence of SCS of LCX and RCA.

Direct comparisons of left ventricular volume and function by simultaneous cardiac magnetic resonance imaging and gated 13N-ammonia positron emission tomography

Hybrid PET/MRI is useful for the simultaneous evaluation of both -ammonia PET and MRI data. The aim of the current study was to compare the accuracy of gated -ammonia PET with MRI for the measurement of left ventricular volumes and function in patients with coronary artery disease (CAD), using simultaneous acquisitions on a hybrid PET/MRI system. Fifty-one consecutive patients with suspected CAD who underwent -ammonia PET/MRI were enrolled in this study. End-diastolic volume (EDV), end-systolic volume (ESV), and left ventricular ejection fraction (LVEF) were simultaneously evaluated using both gated -ammonia PET and cine MRI. Regional wall motion was visually scored on a 4-point scale using a 17-segment model for both methods. The correlations between each EDV (R = 0.99, P < 0.001), ESV (R = 0.98, P < 0.001), and LVEF (R = 0.99, P = 0.001) measured by gated -ammmonia and MRI were very high. These high correlations were also observed in postmyocardial infarction patients. Furthermore, the regional wall motion scores determined on gated -ammonia PET and MRI showed an agreement of 89.0% with a kappa value of 0.82 ± 0.02. EDV, ESV, LVEF, and regional wall motion measured by gated -ammonia PET were highly correlated with those measured by MRI.

P1404 Additional power of automated longitudinal strain during dobutamine stress echo for detecting inducible ischemia in left anterior descending artery stenosis

Abstract Background Dobutamine stress echo (DSE) is a sensitive but subjective test of inducible ischemia. Speckle tracking allows now a quantitative assessment of regional wall motion, even during DSE. Purpose To investigate the feasibility and accuracy of global and regional longitudinal strain during DSE to detect significant CAD. Methods This is a prospective, observational study, including 88 patients undergoing DSE for suspected CAD. Thirthy-three patients with negative DSE were excluded from analysis. The remaining 50 patients (82% males, mean age 66.3 ± 8.2 years) with positive DSE underwent subsequent invasive coronary angiography (CA). Besides visual regional wall motion score index (WMSI), global longitudinal strain (GLS) and regional longitudinal strain (RLS) were determined at rest, at peak stress and at early recovery by a dedicated software (Automated Function Imaging) incorporated in a quoad-screen of the echo machine and activated by automatic quantification. Obstructive CAD was defined as &amp;gt;70% stenosis or intermediate stenosis combined with fractional flow reserve &amp;lt;0.80. Results The feasibility of DES regional longitudinal strain was 100% (n = 50/50) in the pooled population. Fifteen patients did not show coronary stenosis whereas obstructive CAD was detected in 35 patients (12 with multi-vessel disease). Among these patients, 18 patients had left anterior descending artery (LAD) stenosis, 18 left circumflex coronary artery (LCX) stenosis and 15 right coronary artery (RCA) stenosis. GLS reduction at peak stress (k = 0.253, p = 0.037) and WMSI increase at peak stress (k = 0.217, p = 0.04) showed mild but significant agreement with CA for detecting significant coronary stenosis, whereas the agreement of GLS at recovery (k=-0.087, p = 0.518) was poor. When single lesion territory was considered, GLS at peak stress (17.4 ± 5.5 vs 20.5 ± 4.4%, p = 0.034) and LAD longitudinal strain (= average of 8 myocardial segments: middle and apical posterior septum, basal, middle and apical anterior septum, basal, middle and apical anterior wall) at peak stress showed significantly lower values in the obstructed LAD regions than the territories perfused by non-obstructed coronary arteries (17.1 ± 7.6 vs 21.6 ± 5.5% p = 0.021). Conversely, in presence of significant LCX or RCA stenosis, visual regional wall motion of LCX and RCA territories were higher at peak stress (WMSI LCX = 1.80 ± 0.65 in presence of LCX stenosis vs. 1.38 ± 0.44 in absence of stenosis, p &amp;lt; 0.01; WMSI RCA = 1.89 ± 0.52 in presence of RCA stenosis vs. 1.42 ± 0.42 in absence of stenosis, p = 0.002), but RLS at peak stress showed a trend to increase, without achieving the statistical significance (RLS RCA: p = 0.128, RLS LCX: p = 0.103). Conclusion AFI-based strain quantitative analysis appears to be highly feasible during DSE. It appears also to be more accurate than the visual wall motion for the detection of myocardial ischemia in presence of LAD while the accuracy is suboptimal in patients with LCX and RCA stenosis.

Left Ventricular Filling Pressure as a Useful Marker of Myocardial Injury Following Elective Percutaneous Coronary Intervention

AbstractBackground: Advances in Percutaneous Coronary Inter-vention (PCI) techniques have improved patient outcome. However, occurrence of myonecrosis after elective PCI has been extensively debated.Aim of Study: We investigated the value of the ratio of early transmittal velocity to tissue Doppler mitral annular early diastolic velocity (E/E') in detecting the occurrence of peri-procedural myocardial injury in patients undergoing elective PCI.Patients and Methods: Sixty two patients undergoing elective PCI were recruited prospectively. All participants had EF% >50% and sinus rhythm. E/E' ratio was measured immediately before, and within 24 hours after PCI. CK-MB and cardiac troponin (cTn) were measured in the same day after successful PCI to diagnose myocardial injury.Results: The cohort age was 56.7±9.7 year, and consisted of forty four (71%) males, 49 (27.4%) had ³ two risk factors for CAD, 60% were symptomatic before PCI. Thirty (48.4%) patients had regional wall motion abnormalities (regional Wall Motion Score Index (WMSI): 0.74±0.29). Myocardial injury was diagnosed by elevated cTn in 39 (62.9%) patients. Patients with predilation showed reduction of LVEDP as estimated by D E/E' (8.9±2.9 Vs. 7.9±3.2, p<0.001). Pearson correlation analysis revealed that the E/E' correlated negatively with LV EF% (r=–26, p<0.03), positively with CK-MB and cTn level after PCI (r=.51, p<0.0001), NYHA functional class (r=.72, p<0.001), the number of risk factors, and number of vessel diseased and the number of vessel treated with PCI (r=36, pConclusion: These data suggest that the tissue Doppler derived-index of LV filling pressure (E/E') may be a useful indicator for predicting early myocardial injury after successful PCI. Patients with an elevated E/E' after PCI may need more careful and closer follow-up.

Left ventricular thrombus formation in myocardial infarction is associated with altered left ventricular blood flow energetics.

AimsThe main aim of this study was to characterize changes in the left ventricular (LV) blood flow kinetic energy (KE) using four-dimensional (4D) flow cardiovascular magnetic resonance imaging (CMR) in patients with myocardial infarction (MI) with/without LV thrombus (LVT).Methods and resultsThis is a prospective cohort study of 108 subjects [controls = 40, MI patients without LVT (LVT− = 36), and MI patients with LVT (LVT+ = 32)]. All underwent CMR including whole-heart 4D flow. LV blood flow KE wall calculated using the formula: , where ρ = density, V = volume, v = velocity, and was indexed to LV end-diastolic volume. Patient with MI had significantly lower LV KE components than controls (P < 0.05). LVT+ and LVT− patients had comparable infarct size and apical regional wall motion score (P > 0.05). The relative drop in A-wave KE from mid-ventricle to apex and the proportion of in-plane KE were higher in patients with LVT+ compared with LVT− (87 ± 9% vs. 78 ± 14%, P = 0.02; 40 ± 5% vs. 36 ± 7%, P = 0.04, respectively). The time difference of peak E-wave KE demonstrated a significant rise between the two groups (LVT−: 38 ± 38 ms vs. LVT+: 62 ± 56 ms, P = 0.04). In logistic-regression, the relative drop in A-wave KE (beta = 11.5, P = 0.002) demonstrated the strongest association with LVT.ConclusionPatients with MI have reduced global LV flow KE. Additionally, MI patients with LVT have significantly reduced and delayed wash-in of the LV. The relative drop of distal intra-ventricular A-wave KE, which represents the distal late-diastolic wash-in of the LV, is most strongly associated with the presence of LVT.

Clinical characteristics of occluded culprit arteries and collaterals in patients with non-ST-segment elevation myocardial infarction and impact on clinical outcomes.

The presence of an occluded culprit artery or collaterals in non-ST-segment elevation myocardial infarction (NSTEMI) is relatively common; however, limited data are available regarding their clinical significance. The aim of the current study was to determine the clinical characteristics of occluded culprit arteries and coronary collaterals in patients with NSTEMI and their impact on patient outcomes. A total of 345 patients diagnosed with NSTEMI via coronary angiography between February 2006 and May 2013 were evaluated in the present study. Patient demographics, procedural characteristics and clinical outcomes of patients were analyzed according to the presence of an occluded culprit artery and coronary collaterals. A total of 78 (22.6%) and 166 patients (48.1%) exhibited an occluded artery and coronary collaterals, respectively. The left anterior descending artery is a more common location of culprit arteries in patients with NSTEMI with patent artery (NSTEMIPA) and distal parts of the artery are more common location of culprit arteries in patients with NSTEMI with occluded arteries (NSTEMIOA). Patients with NSTEMIOA exhibited higher peak creatine kinase-MB (CKMB) and troponin-I levels compared with patients that had NSTEMIPA. The presence of coronary collaterals is associated with a lower mean left ventricular ejection fraction, higher regional wall motion score index and extensive coronary artery disease. However, the clinical outcomes of patients with collaterals did not differ, irrespective of the presence of an occluded culprit artery or coronary collaterals. In the current study, ~25% of patients with NSTEMI had an occluded culprit coronary artery whereas 50% of patients with NSTEMI had coronary collaterals. The presence of an occluded artery and/or coronary collaterals did not affect clinical outcomes. Further studies are required to evaluate the long-term prognostic impact of an occluded artery and collaterals.

Myocardial stunning-induced left ventricular dyssynchrony on gated single-photon emission computed tomography myocardial perfusion imaging.

Myocardial stunning provides additional nonperfusion markers of coronary artery disease (CAD), especially for severe multivessel CAD. The purpose of this study is to assess the influence of myocardial stunning to the changes of left ventricular mechanical dyssynchrony (LVMD) parameters between stress and rest gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). A total of 113 consecutive patients (88 males and 25 females) who had undergone both stress and rest Tc-sestamibi gated SPECT MPI were retrospectively enrolled. Suspected or known patients with CAD were included if they had exercise stress MPI and moderate to severe myocardial ischemia. Segmental scores were summed for the three main coronary arteries according to standard myocardial perfusion territories, and then regional perfusion, wall motion, and wall thickening scores were measured. Myocardial stunning was defined as both ischemia and wall dysfunction within the same coronary artery territory. Patients were divided into the stunning group (n=58) and nonstunning group (n=55). There was no significant difference of LVMD parameters between stress and rest in the nonstunning group. In the stunning group, phase SD and phase histogram bandwidth of contraction were significantly larger during stress than during rest (15.05±10.70 vs. 13.23±9.01 and 46.07±34.29 vs. 41.02±32.16, P<0.05). Phase SD and phase histogram bandwidth of relaxation were also significantly larger during stress than during rest (21.21±13.91 vs. 17.46±10.52 and 59.03±37.82 vs. 52.38±36.89, P<0.05). Both systolic and diastolic LVMD parameters deteriorate with myocardial stunning. This kind of change may have incremental values to diagnose CAD.

Attenuation correction in myocardial perfusion imaging affects the assessment of infarct size in women with previous inferior infarct.

Myocardial perfusion imaging is a well-established diagnostic tool in patients with known or suspected coronary artery disease. Numerous clinical trials have shown that attenuation correction (AC) in single photon emission computed tomography (SPECT) improves the diagnostic accuracy of myocardial perfusion imaging over non-AC SPECT, differentiating between scar and attenuation artifacts. We have previously shown that attenuation artifacts produce an overestimation of the size of inferior infarcts in the male population. It is assumed that women are less affected by inferior attenuation artifacts than men. The aim of this study is to evaluate the role of AC in the assessment of infarct size in female patients with a history of myocardial inferior infarct. We studied a population of 66 consecutive women, with a history of previous inferior myocardial infarct, by SPECT/computed tomography (CT) with 370+370 MBq of technetium-99m labeled compounds by a 2-day stress-rest protocol. Both AC and uncorrected gated-SPECT/CT studies were reconstructed after scatter and motion correction by ordered-subset expectation maximization iterative reconstruction and resolution recovery. The coregistration of the transmission and emission scans was verified for all patients; any misalignment was realigned manually. Uncorrected and corrected SPECT images were analyzed by software QPS/QGS package using a 17-segment model. For each segment, perfusion and wall motion were quantified using a five-point score according to the American Society of Nuclear Cardiology guidelines. Summed stress, summed rest score (SRS), and summed difference score of the inferior left ventricle wall (inferior, inferoseptal, inferolateral, and apical inferior segments) were calculated. A linear correlation was used to assess the relationship between perfusion and the regional wall motion score as determined by uncorrected gated-SPECT. The results of quantitative analysis of non-AC and CT-AC SPECT images, respectively, were as follows: summed stress score: 9.47±5.01 and 6.58±4.77% (P<0.001); SRS was 6.05±5.02 and 4.14±4.12% (P<0.001); the summed difference score was 2.92±2.74 and 2.52±2.63% (P=NS), respectively. The correlation between corrected and uncorrected SRS and the regional summed wall motion score of the same segment was R=0.31 versus R=0.34. In the female population, like in men, attenuation artifacts affect the calculation of the infarct size of the inferior wall, with overestimation of the infarct size in uncorrected images. The AC regional perfusion score (SRS) better correlates with the regional wall motion score of the inferior wall in women with previous inferior infarct.

Impaired myocardial microcirculation in the flow-glucose metabolism mismatch regions in revascularized acute myocardial infarction

BackgroundIn successfully revascularized acute myocardial infarction (AMI), microvascular function in a myocardial flow-glucose metabolism mismatch pattern has not been reported. We aimed to elucidate myocardial flow reserve (MFR) and myocardial viability in mismatch segments. Methods18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) and adenosine stress 13N-ammonia PET were performed in eighteen AMI patients to evaluate myocardial glucose metabolism, myocardial blood flow (MBF), and MFR. Infarct segments were classified into 3 groups: normal (preserved resting MBF), mismatch (preserved FDG uptake but reduced resting MBF), and match (reduced FDG uptake and resting MBF). Regional wall motion score (WMS) was assessed immediately after reperfusion and recovery periods. ResultsMFR in the mismatch group was significantly lower than that in non-infarct-related segments (1.655 ± 0.516 vs 2.282 ± 0.629, P < .01) and similar to that in the match group (1.635 ± 0.528, P = .999). WMS in the mismatch group was significantly improved (3.07 ± 0.48 vs 2.07 ± 1.14, P = .003); however, in recovery periods, WMS in the mismatch group was significantly higher than that in the normal group (1.05 ± 1.04, P < .01). ConclusionsIn successfully revascularized AMI, microvascular function is impaired despite preserved myocardial glucose metabolism in mismatch segments.

Speckle tracking echocardiography in acute lupus myocarditis: comparison to conventional echocardiography

Aims Lupus myocarditis occurs in 5–10% of patients with systemic lupus erythematosus (SLE). No single feature is diagnostic of lupus myocarditis. Speckle tracking echocardiography (STE) can detect subclinical left ventricular dysfunction in SLE patients, with limited research on its utility in clinical lupus myocarditis. We report on STE in comparison to conventional echocardiography in patients with clinical lupus myocarditis.Methods and results A retrospective study was done at a tertiary referral hospital in South Africa. SLE patients with lupus myocarditis were included and compared to healthy controls. Echocardiographic images were reanalyzed, including global longitudinal strain through STE. A poor echocardiographic outcome was defined as final left ventricular ejection fraction (LVEF) <40%. 28 SLE patients fulfilled the criteria. Global longitudinal strain correlated with global (LVEF: r=-0.808; P=0.001) and regional (wall motion score: r=0.715; P<0.001) function. In patients presenting with a LVEF =50%, global longitudinal strain (P=0.023), wall motion score (P=0.005) and diastolic function (P=0.004) were significantly impaired vs controls. Following treatment, LVEF (35–47% (P=0.023)) and wall motion score (1.88–1.5 (P=0.017)) improved but not global longitudinal strain. Initial LVEF (34%; P=0.046) and global longitudinal strain (-9.5%; P=0.095) were lower in patients with a final LVEF <40%.Conclusions This is the first known report on STE in a series of patients with clinical lupus myocarditis. Global longitudinal strain correlated with regional and global left ventricular function. Global longitudinal strain, wall motion score and diastolic parameters may be more sensitive markers of lupus myocarditis in patients presenting with a preserved LVEF =50%. A poor initial LVEF and global longitudinal strain were associated with a persistent LVEF <40%. Echocardiography is a non-invasive tool with diagnostic and prognostic value in lupus myocarditis.

Global longitudinal strain from resting echocardiogram is associated with long-term adverse cardiac outcomes in patients with suspected coronary artery disease.

Measuring myocardial strain using two-dimensional speckle tracking echocardiography has emerged as a new tool to identify subclinical ventricular dysfunction. Abnormal strain has been shown to have superior sensitivity compared with dobutamine stress echocardiography for viability assessment; however, there is a paucity of data regarding the prediction of long-term major adverse cardiac events. We compared the prognostic ability of both global longitudinal strain (GLS) from resting echocardiograms to regional wall motion score index (WMSI) from stress echocardiograms in their ability to predict long-term major adverse cardiac events. Patients referred for stress echocardiography, who also underwent coronary angiography within 3 months of stress echo (n=122), were enrolled. Patients with reduced ejection fractions (<40%) were excluded. Patients were followed for a median of 3.4 years for major adverse cardiac events, readmissions and repeat cardiac testing. Patients with abnormal GLS (GLS <16.8%) from the resting echocardiogram obtained as part of the exercise echocardiogram experienced a significantly shorter time to major adverse cardiac events (p=0.026), first cardiovascular hospitalization and repeat cardiac testing (p=0.0011) compared to those with normal GLS. Abnormal GLS appears to be a better predictor than abnormal WMSI in predicting major adverse cardiac events (p=0.174) and time to first cardiovascular hospitalization or repeat cardiac testing (p=0.0093). GLS may be a better predictor of long-term major adverse cardiac events, readmissions and repeat cardiac testing than WMSI in patients undergoing stress echocardiography.

Feasibility of Using Multiplane Stress Imaging to Add Measurement of LV Ejection Fraction Response to Exercise to Regional Wall Motion Scoring During Stress Echo

Multiplane 4D imaging probes not only increase accuracy of stress echo by reducing image acquisition time whilst maintaining orthogonal triplane views, but also have the potential to add a biplane ejection fraction (LVEF) measurement to the standard regional wall motion scoring. Methods: We prospectively studied 67 consecutive patients undergoing a treadmill stress echocardiogram using a Bruce protocol. Multiplane images of the left ventricle were obtained at rest and post exercise using a GE Vivid 9 scanner and a 4D multiplane probe. All studies were performed by a single senior sonographer. The time taken to obtain the images post exercise was recorded and the LVEF measured off line using EchoPac™ BT12 software and Simpson's biplane method. Results: We included 67 patients (52 male, 15 female) over 12 months, ranging in age from 28 to 85 years, (63 ± 11 years, mean ± SD). The patients’ sizes varied with BSA ranging from 1.53–2.38 m2 (mean 1.92m2). Images suitable for standard regional wall motion scoring were obtained in 95%, within 35 ± 9 seconds, and the LVEF was measurable in 100% of these patients. Conclusion: Left ventricular ejection fraction response to exercise could be measured using multiplane 4D imaging in all patients with suitable stress echo images. Whilst the clinical utility of this will depend on the context in which it is used the results do suggest that it is feasible to incorporate this into standard stress echo protocols and may add important information to regional wall motion scoring.

Extracorporeal Cardiac Shock Wave Therapy(CSWT) in Patients with Severe Coronary Artery Disease(CAD) Unsuitable for Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Graft Surgery (CABG) Guided by Echocardiography

To test the effectiveness and feasibility of extracorporeal CSWT in patients (pts) with severe CAD unsuitable for PCI and CABG. 51 pts were enrolled. They were 35 men and 16 women aged from 41 to 89 years old (67.5 +10.9). Extracorporeal CSWT was performed with the application of 100 shocks/spot at 0.09 millijoules/mm2 (mJ/mm2) energy flux density for 3-9 spots each time with three times per week at each series for three series at 1, 5, 9 weeks. The location and depth of CSWT application were based on thallium 201 myocardial perfusion scan findings guided by echocardiography. The exercise tolerance, thallium 201 myocardial perfusion scan and echocardiography were followed up 6 months later. These 51 patients received 1500 to 7500 low intensity shock waves during entire treatment course with an average of 4682 + 1293 shock waves. Exercise duration with Bruce protocol increased from 304 + 148 seconds before CSWT to 350 + 115 seconds after 6 months (p< 0.0174). The CCS angina score was decreased from 2.9 before CSWT to 2.0 after 6 months (P< 0.001). 39(76%) pts had perfusion improvement by thallium 201 myocardial perfusion scan. Echocardiographic study showed left ventricular (LV) end-diastolic dimension and volume were decreased significantly from 55.0 + 8.5 mm and 152.2 + 57.2 mm3 to 53.1 + 8.1 mm and 140.5 +52.8 mm3 after 6 months (P=0.0185, P= 0.0232). LV systolic dimension decreased from 36.8 + 8.8 mm before CSWT to 34.6 + 9.2 mm after 6 months (P =0.006). LV systolic volume changed from 62.5 + 37.8 mm3 to 55.0 + 38.5 mm3 (P= 0.0282). LV ejection fraction increased from 60.0 + 12.6% before CSWT to 63.5 + 12.7% after 6 months. (P =0.032). Regional wall motion score index was decreased from 1.30 + 0.36 before CSWT to 1.21 + 0.30 after 6 months (P= 0.0024). No side effects related to CSWT were found. Our study demonstrated that echocardiography can be used as a guide for performing extracorporeal CSW. And CSWT can improve angina symptoms, increase exercise duration and improve myocardial perfusion, left ventricular remodeling, myocardial wall motion and finally improve left ventricular ejection fraction. Our study also demonstrated that CWST is safe and effective. This kind of therapy can be applied to the pts of severe CAD with refractory angina unsuitable for PCI or CABG.

Comparative clinical implications of admission electrocardiographic findings for patients with non-ST-segment elevation myocardial infarction

Early risk stratification is crucial for appropriate management using invasive strategies in non-ST elevation myocardial infarction (NSTEMI), and electrocardiography (ECG) has been widely used for risk stratification. However, ECG findings in NSTEMI vary, and there is a need to define the clinical characteristics and outcomes according to ECG.We analyzed the admission ECGs of 345 NSTEMI patients who underwent coronary angiography from 2006 to 2013. Demographics, procedural characteristics, and clinical outcomes were analyzed.The ST-segment depression, T-wave inversion, and no ECG change groups included 114, 90, and 141 patients, respectively. The ST-segment depression group trended toward older, nonsmoking, and female, with a lower body mass index (BMI) and a higher incidence of comorbidities, than the no ECG change group. The ST-segment depression group also had a higher Killip class, a lower left ventricular ejection fraction, a higher regional wall motion score index (RWMSI), and 3-vessel coronary artery disease angiographically, than the no ECG change group. Patients with T-wave inversion trended toward older, female, lower BMI, less smoking, lower creatine kinase MB, and more left anterior descending (LAD) artery involvement, than the no ECG change group. In clinical outcomes, the ST-segment depression group had a higher mortality rate at 30 days and 12 months after the index procedure than the no ECG change group, whereas the T-wave inversion group showed similar clinical outcomes.Patients with ST-segment depression have a greater burden of comorbidities with risk factors and worse clinical outcomes, whereas patients with T-wave inversion have an intermediate number of risk factors but similar outcomes, compared with the no ECG change group. Further study is necessary to evaluate the prognostic impact of the baseline ECG on admission.

Impact of glycemic status on left ventricular systolic function in patients with acute coronary syndrome

Background: Diabetes mellitus (DM) and left ventricular systolic dysfunction (LVSD) commonly coexist; increasing morbidity and mortality among patients. The aim of this study is to detect the correlation between the glycemic status of patients presenting by acute coronary syndrome (ACS) and left ventricular global and regional systolic function. Method: The study included 510 patients presenting by ACS and referred for coronary angiography. In addition to routine laboratory tests, Glycated hemoglobin (HbA1C) level, as a marker of chronic glycemic status, was measured. Every patient was subjected to transthoracic echocardiographic study with accurate evaluation of left ventricular systolic function by both m-mode and biplane Simpson's method, in addition to calculation of regional wall motion score index (RWMSI). The whole study population was divided into two groups; diabetic and non-diabetic based on cutoff point of HbA1C value 6.5%. The non-diabetic group was subdivided into two groups; high risk and low risk based on cutoff point of HbA1C value 5.7% Results: Sixty four percent of the studied population had DM. The mean HbA1C level was 7.6 ± 2.2%. The mean left ventricular ejection fraction (LVEF) was 54 ± 11 and mean RWMSI was 1.3 ± 0.3. There was significant negative correlation between the HbA1C level and the LVEF (r = -0.101, p < 0.022). There was significant positive correlation between HbA1C level and RWMSI (r = 0.109, p < 0.014). The non-diabetic high risk group had lower LVEF and higher RWMSI than the low risk group (p < 0.041 and p < 0.002 respectively). Conclusion: Chronic hyperglycemia in patients with uncontrolled DM may be a risk factor for developing LVSD in patients presenting by ACS. Glycated hemoglobin level may predict LVSD in patients with ACS. Non-diabetic patients who are at higher risk of developing DM have higher incidence of LVSD.

Different contribution of extent of myocardial injury to left ventricular systolic and diastolic function in early reperfused acute myocardial infarction

BackgroundWe sought to investigate the influence of the extent of myocardial injury on left ventricular (LV) systolic and diastolic function in patients after reperfused acute myocardial infarction (AMI).MethodsThirty-eight reperfused AMI patients underwent cardiac magnetic resonance (CMR) imaging after percutaneous coronary revascularization. The extent of myocardial edema and scarring were assessed by T2 weighted imaging and late gadolinium enhancement (LGE) imaging, respectively. Within a day of CMR, echocardiography was done. Using 2D speckle tracking analysis, LV longitudinal, circumferential strain, and twist were measured.ResultsExtent of LGE were significantly correlated with LV systolic functional indices such as ejection fraction (r = -0.57, p < 0.001), regional wall motion score index (r = 0.52, p = 0.001), and global longitudinal strain (r = 0.56, p < 0.001). The diastolic functional indices significantly correlated with age (r = -0.64, p < 0.001), LV twist (r = -0.39, p = 0.02), average non-infarcted myocardial circumferential strain (r = -0.52, p = 0.001), and LV end-diastolic wall stress index (r = -0.47, p = 0.003 with e’) but not or weakly with extent of LGE. In multivariate analysis, age and non-infarcted myocardial circumferential strain independently correlated with diastolic functional indices rather than extent of injury.ConclusionsIn patients with timely reperfused AMI, not only extent of myocardial injury but also age and non-infarcted myocardial function were more significantly related to LV chamber diastolic function.