Segmental Wall Motion Score Research Articles

Circumferential strain acquired by CMR early after acute myocardial infarction adds incremental predictive value to late gadolinium enhancement imaging to predict late myocardial remodeling and subsequent risk of sudden cardiac death.

Late adverse myocardial remodeling after acute myocardial infarction (AMI) is strongly associated with sudden cardiac death (SCD). Cardiac magnetic resonance (CMR) performed early after AMI can predict late remodeling and SCD risk with moderate accuracy. This study assessed the ability of CMR-measured circumferential strain (CS) to add incremental predictive information to late gadolinium enhancement (LGE). Patients with an AMI and LVEF < 50% were screened for inclusion. A total of 27 patients, totaling 432 myocardial segments, prospectively underwent CMR 7±5days after percutaneous coronary intervention (PCI). LGE, microvascular obstruction (MVO), and myocardial CS were measured for each segment. The primary endpoint was late segmental adverse remodeling defined as segmental wall motion score (WMS) > 1 measured by echocardiography 3months after PCI. A total of 141 segments experienced the primary endpoint at 3months. The mean LGE volume was higher in these segments, but LGE was also present in many segments with normal WMS (40±28 versus 20±26%, p<0.01). Segments that met the primary endpoint also showed greater impairment of CS. Segments with both LGE > 17% and impaired CS >- 7.2% on CMR were more likely to experience late adverse remodeling (73%) as compared to segments with neither (9%, p<0.001) or one abnormal parameter (36%, p<0.001). CS >- 7.2% also added incremental accuracy to LGE > 17% for predicting late adverse remodeling (AUC 0.81 from 0.70, p<0.001). When performed early after AMI, LGE is a moderate predictor of late remodeling and CS is a powerful predictor of late myocardial remodeling. When combined, they can predict late remodeling, a surrogate of SCD, with high accuracy.

Assessment of myocardial ischemia by strain dobutamine stress echocardiography and cardiac magnetic resonance perfusion imaging before and after coronary artery bypass grafting.

Following coronary artery bypass grafting (CABG), testing for myocardial ischemia by noninvasive imaging is often hampered by false-positive results. The aim of this study was to find test parameters with the best potential to identify myocardial ischemia in post-CABG patients. Fifty-two consecutive patients scheduled for CABG, underwent both dobutamine stress echocardiography (DSE) and cardiac magnetic resonance first-pass perfusion imaging (CMR-FPPI) with adenosine vasodilation, before and 8-10months after the surgical revascularization. A pathologic biphasic stress response (PBR) expresses the presence of contractile reserve during low-dose dobutamine that decreases to hypo- or akinesia provoked by high-dose dobutamine. During DSE, potential PBR, segmental wall-motion score (WMS) as well as peak-systolic longitudinal strain (PLS) at peak-dose dobutamine were assessed. Post-CABG, there was still a relatively high prevalence of ischemia-positive segments evaluated by deformation imaging, but the number of such segments was significantly lower by PBR (20% and 22%) compared with peak-dose strain and WMS (62% and 77%, respectively; P<.05). The use of PBR instead of peak-dose WMS and strain could reduce the number of false-positive test results post-CABG. Among all imaging modalities tested, PBR by WMS and strain may be useful parameters for identifying patients with the need for new revascularization. We furthermore found that DSE may be interpreted as positive when revealing at least three ischemia-positive segments. The sensitivity of these test modalities for detecting coronary restenosis needs to be determined in further studies on a cohort of symptomatic post-CABG patients.

Using of Two Dimensional Speckle Tracking Echocardiography to Predict Major Adverse Events and Segmental Function Recovery in Patients with Acute Myocardial Infarction and Preserved Ejection Fraction

The aim is to investigate whether strain by 2D speckle tracking echocardiography in patients with acute myocardial infarction (AMI) and preserved ejection fraction (EF≧40%) would predict prognosis and segmental function recovery or not. Ninety patients (average age 60.7±12.3 y/o) with new-onset AMI and EF≧40% were enrolled. Echocardiographies were performed after admission (average 3.3 days) and 12 months after percutaneous coronary intervention. Segmental function recovery was defined as a decrease of ≧1 grade in segmental wall motion score. The global peak longitudinal strain (GLS), circumferential strain (CS), and radial strain (RS) were calculated via EchoPAC, version 11.0 (GE Vingmed). During follow-up (mean 23.4±12.1months), 20 patients had adverse events including 6 deaths, 3 strokes, 15 revascularizations for culprit vessels. In the multivariate Cox proportional hazard regression model for adverse events, using the forward stepwise method, only female (hazard ratio 4.65 [95% CI =1.49-14.52]) and GLS (hazard ratio 1.16 [95% CI =1.03-1.3]) were independent predictors (p < 0.05). Receiver operating characteristic curve analyses for segmental function recovery showed the area under the curves was 0.75 and optimal cut-off value of –12.5% had 67% sensitivity and 76% specificity. Global longitudinal strain by 2D speckle tracking echocardiography provided important prognostic information and could predict segmental function recovery in patients with AMI and preserved EF.

Impact of pre-infarction angina on angiographic and echocardiographic outcomes in patients with acute anterior wall myocardial infarction managed by primary percutaneous coronary intervention

Abstract Objectives To assess the impact of angina prior to first attack of acute anterior wall ST-segment elevation myocardial infarction (STEMI) on immediate angiographic and echocardiographic outcomes after primary percutaneous coronary intervention (PPCI). Methods A total of 100 patients with acute anterior wall STEMI managed by PPCI were included (50 patients with pre-infarction angina (PIA) and 50 patients without). Patients were observed for angiographic outcome (coronary collateral grade, final TIMI and TMP flow grade) and echocardiographic outcome. Results Baseline patient characteristics were similar in both groups. PIA group had more patients with grade 3 coronary collaterals (p = 0.006), more patients with TIMI 3 flow grade after PPCI (p = 0.0002), less patients with TMP 0 flow grade (p = 0.013). The group with no PIA had more advanced Killip class at presentation (p = 0.015). No difference was present between both groups regarding post-PPCI LV ejection fraction (p = 0.255), LV end diastolic dimensions (p = 0.553), LV end systolic dimensions (p = 0.908), segmental wall motion score index (p = 0.214). Conclusions For patients suffering from a first attack of acute anterior wall STEMI, pre-infarction angina is associated with a better Killip class at presentation, better TIMI flow grade after PPCI, less incidence of TMP 0 flow grade.

The Impact of Coronary Flow Grade after Primary PCI on Global Longitudinal Left Ventricular Strain as Measured by Speckle Tracking Compared to Two-Dimensional Echo

The Impact of Coronary Flow Grade after Primary PCI on Global Longitudinal Left Ventricular Strain as Measured by Speckle Tracking Compared to Two-Dimensional Echo Aim: Identify the impact of coronary flow on GLPS after primary percutaneous coronary intervention (PCI). Background: Left ventricular global longitudinal peak systolic strain (GLPS) was previously demonstrated to be related to outcome after acute myocardial infarction, however its relation to myocardial epicardial flow and microvascular flow were not studied before. Methods: We compared the left ventricular function in 75 consecutive patients admitted to coronary care unit with first acute ST segment elevation myocardial infarction (STEMI) using: speckle tracking derived GLPS and two dimensional echo. Then we assessed the relation between GLPS and myocardial flow. Results: Mean global longitudinal left ventricular strain was -13.26 ± 2.97% in TIMI flow 3 group of patients compared to -11.807 ± 1.08% in Thrombolysis in myocardial infarction (TIMI II) group. (p-value=0.01876). With longitudinal strain improved as better coronary flow was established as determined by TIMI myocardial perfusion (TMP) grades. There was no statistically significant difference between ejection fraction percent and segmental wall motion score index in patients with TIMI II or TIMI III flow. Conclusion: GLPS can detect early and minor changes in longitudinal LV function due to ischemia in absence of any appreciable abnormalities recognized on two dimensional echocardiographic examination. In addition the degree of change of GLPS is strongly correlated to the degree of epicardial and microvascular flow

Novel mouse model of left ventricular pressure overload and infarction causing predictable ventricular remodelling and progression to heart failure.

Mouse surgical models are important tools for evaluating mechanisms of human cardiac disease. The clinically relevant comorbidities of hypertension and ischaemia have not been explored in mice. We have developed a surgical approach that combines transverse aortic constriction and distal left anterior coronary ligation (MI) to produce a gradual and predictable progression of adverse left ventricular (LV) remodelling that leads to heart failure (HF). Mice received either sham, MI alone, transverse aortic constriction alone or HF surgery. Infarct size and LV remodelling were evaluated by serial 2-D echocardiograms. Transverse aortic constriction gradients were measured by the Doppler velocity-time integral ratio between constricted and proximal aortic velocities. At 4weeks, hearts were weighed and analysed for histology and brain natriuretic peptide, a molecular marker of HF. Echocardiographic analysis of segmental wall motion scores showed similarly small apical infarct sizes in the MI and HF groups at day1 postsurgery. MI alone showed little change in infarct size over 4weeks (0.26±0.02 to 0.27±0.04, P=0.77); however, HF mice showed infarct expansion (0.25±0.06 to 0.39±0.09, P<0.05). HF mice also showed LV remodelling with increases in LV volumes (1day=36.5±5.2mL, 28days=89.1±16.0mL) versus no significant changes in the other groups. Furthermore, systolic function progressively deteriorated in the HF group only (ejection fraction, 1day=55.6±3.6%, 28days= 17.6±4.1%, P<0.05) with an increase of brain natriuretic peptide by 3.5-fold. This surgical model of pressure overload in the setting of a small infarction causes progressive deterioration of cardiac structural and functional properties, and provides a clinically relevant tool to study adverse LV remodelling and heart failure.

Rest myocardial perfusion disturbance is related to inflammation but not to fibrosis inexperimental chronic chagas cardiomyopathy

Purpose: Myocardial perfusion disturbance is a common finding in human chronic Chagas cardiomyopathy (CC), but its underlying tissue changes and pathophysiologic mechanisms are unclear. We aimed at investigating the histologic changes related to the myocardial perfusion changes detected in an experimental model of CC in hamsters. Methods: Female Syrian hamsters (n=34) were infected with 35.000 or 100.000 trypomastigotes forms of T. cruzi Y-strain and were submitted to in vivo imaging 6 to 10 months afterwards. High-resolution rest Sestamibi-Tc-99m-SPECT imaging was used for detection of myocardial perfusion defects (MPD), defined as segments with uptake <50% of the maximum pixel uptake value on polar maps analysis. The segmental and global left ventricular (LV) function was assessed by using 2D-Echocardiogram. Ex vivo histologic analysis included quantitation of fibrosis (picrosirius red) and inflammatory infiltrate. A 13-segment model of LV segmentation was used for all imaging analyses and histologic topographic correlations. Results: MPD were found in 17 (50%) of the infected animals. No transmural scar was detected in segments with MPD. The subgroup of animals with MPD, in comparison to animals without MPD, showed: 1) reduced LV ejection fraction (65±21 and 81±9%, respectively, p<0.01); 2) larger inflammatory infiltrate (172.8±89 and 111.5±54 nuclei/mm2; p=0.04); 3) higher segmental wall motion score (1.44±0.5 and 1.04±0.05%; p=0.003); 4) but similar extent of fibrosis (8.4±3.9; 6.6±3.2%; p=0.06). There was a significant association between regional MPD and abnormal wall motion (p<0,001). The segments with MPD (n=57) as compared to the segments with normal perfusion (n=487) showed larger extent of inflammatory infiltrate (175.8±145.0 and 111.6±69.2 nuclei/mm2, respectively; p=0.001), higher segmental wall motion score (1.65±0.6 and 1.1±0.4; p<0.0001) and comparable extent of fibrosis (10.5±18.6 and 7.4±6.2%; p=0.37). Conclusions: Rest MPD in experimental CC is topographically correlated to inflammatory changes that are intense enough to be associated to wall motion impairment. The fact that these derangements are not due to fibrosis opens the possibility that therapeutic interventions aimed at reducing the degree of myocardial inflammation and/or hypoperfusion may favorably impact on the natural history of this model of experimental CC.

Quantification of left ventricular longitudinal strain by two-dimensional speckle tracking: a comparison between expert and non-expert readers

The study aimed to examine whether global and segmental longitudinal strain (LS) using speckle tracking echocardiography could improve the interpretation of wall motion (WM) asynergy for expert and non-expert readers compared to visual assessment by 2-dimensional echocardiography (2DE). Using the 17 left ventricular segments model, both segmental and global LS were assessed by automatic function imaging in 20 patients with ischemic heart disease (61.0 ± 9.9 years, 70 % are male) and 20 normal controls (57.7 ± 16.9 years, 75 % are male). Global and segmental WM score was calculated by 2DE visual analysis using the same model. Both modalities were analyzed by two expert and two non-expert readers. Inter- and intra-observer agreement was calculated between all readers. Complete WM analysis of 680 segments was performed in 94.1 and 81 % by expert and non-expert readers respectively. Analysis of LS was completed in 96.3 and 95 % by both readers respectively. WM score by expert readers was correlated well with global LS by both expert and non-expert readers (R = 0.81, P < 0.0001, R = 0.79, P < 0.0001) while by the non-expert readers it was correlated fairly (R = 0.58, P < 0.01, R = 0.57, P < 0.01 respectively). Inter and intra-observer agreements between the expert readings were excellent in both techniques while the non-expert readings showed better agreement for LS than WM score. The mean difference between expert and non-expert readers was higher for WM score than LS (2.4 ± 2.9, -1.5 ± 1.6). Assessment of LS using 2D speckle tracking echocardiography showed better inter and intra-observer agreement than the visual analysis of WM regardless of the experience level. This may help to improved the quantification of WM asynergy by non-expert readers.

Value of Three-Dimensional Speckle-Tracking Longitudinal Strain for Predicting Improvement of Left Ventricular Function After Acute Myocardial Infarction

Identification of patients with reversible left ventricular (LV) dysfunction has important prognostic implications after acute myocardial infarction (AMI). This study aimed to determine the value of LV segmental and global longitudinal strains assessed with 3-dimensional (3D) speckle-tracking analysis in predicting improvement of LV function after AMI. One hundred fifty-three patients (80% men, 59 ± 11 years old) with AMI and treated with primary percutaneous coronary intervention underwent 3D echocardiography. LV segmental and global 3D longitudinal strains were assessed with speckle-tracking analysis using a novel dedicated software. At 6-month follow-up, improvement in segmental LV function was defined as a decrease of ≥1 grade in segmental wall motion score. Improvement in global LV function was defined as an absolute improvement ≥5% in LV ejection fraction. Segments with functional improvement at follow-up showed a significantly higher baseline 3D longitudinal strain compared to segments without improvement (-16.4 ± 4.0% vs -7.6 ± 3.5%, p <0.001). A cut-off value of -11.1% for segmental 3D longitudinal strain had 92% sensitivity and 91% specificity in predicting functional improvement. In addition, 67 patients (44%) showed an improvement in global LV function at 6-month follow-up. These patients showed significantly higher baseline global 3D longitudinal strain compared to patients without improvement (-16.7 ± 2.1% vs -13.3 ± 2.6%, p <0.001). Global 3D longitudinal strain provided incremental value over clinical and conventional echocardiographic variables in predicting global LV function improvement (c-statistic improved from 0.64 to 0.71 to 0.84). In conclusion, longitudinal strain assessed by 3D speckle-tracking analysis is an important predictor for segmental and global LV function improvement after AMI.

Contrast Echocardiography Improves Interobserver Agreement for Wall Motion Score Index and Correlation with Ejection Fraction

The wall motion score index (WMSI) is a surrogate for left ventricular ejection fraction (LV-EF), which becomes unreliable in poor echo windows. The value of contrast LV opacification (LVO) for WMSI assessment is not well known. We sought to compare interobserver agreement for WMSI and the correlation between the LVO-WMSI and LV-EF using two-dimensional second harmonic (SH) and LVO echocardiography. The study comprised 100 consecutive patients (57 ± 13 years, 85% males). Two independent physicians assessed LV segmental quality and wall motion for both the SH and LVO studies according to a 17-segment model. Systolic wall motion was defined as: normokinesia, hypokinesia (systolic inward endocardial motion <7 mm), akinesia, and dyskinesia. LV-EF was assessed from the LVO images according to the biplane modified Simpson's method. Of the 1,700 analyzed segments, 453 (26.6%) were poorly visualized with SH imaging, and 173 (10.2%) with LVO (P < 0.0001). The two observers agreed on segmental wall motion score in 1,299 segments (agreement 76%, Kappa 0.60) with SH imaging and in 1,491 segments (agreement 88%, Kappa 0.78) with LVO. Interobserver correlation (r(2) ) was 0.86 for the SH-WMSI and 0.93 for the LVO-WMSI. The limits-of-agreement for interobserver LVO-WMSI (mean difference -1.0%± 6.8%, agreement -14.6%, 12.6%) was lower than that for SH-WMSI (mean difference -2.3%± 10.1%, agreement -22.5, 17.9). The LVO-WMSI correlated well with LV-EF (r(2) = 0.71). LV-EF could be estimated according to the formula 1.01 - 0.32 × WMSI. Echo-contrast improves interobserver agreement for wall motion scoring and the WMSI. The LVO-imaged WMSI correlates well with LV-EF.

Predictors of right ventricular function as measured by tricuspid annular plane systolic excursion in heart failure

IntroductionTricuspid Annular Plane Systolic Excursion (TAPSE) has independent prognostic value in heart failure patients but may be influenced by left ventricular (LV) ejection fraction. The present study assessed the association of TAPSE and clinical factors, global and regional LV function in 634 patients admitted for symptomatic heart failure.Methods & ResultsTAPSE were correlated with global and regional measures of longitudinal LV function, segmental wall motion scores and measures of diastolic LV function as measured from transthoracic echocardiography.LV ejection fraction, wall motion index scores, atrio-ventricular annular plane systolic excursion of the mitral annulus were significantly related to TAPSE. Septal and posterior mitral annular plane systolic excursion (β = 0.56, p < 0.0001 and β = 0.35, p = 0.0002 per mm, respectively) and non-ischemic etiology of heart failure (β = 1.3, p = 0.002) were independent predictors of TAPSE, R2 = 0.28, p < 0.0001. The prognostic importance of TAPSE was not dependent of heart failure etiology or any of the other clinical factors analyzed, pinteraction = NS.ConclusionTAPSE is reduced with left ventricular dysfunction in heart failure patients, in particular with reduced septal longitudinal motion. TAPSE is decreased in patients with heart failure of ischemic etiology. However, the absolute reduction in TAPSE is small and seems to be of minor importance in the clinical utilization of TAPSE whether applied as a measure of right ventricular systolic function or as a prognostic factor.

The role of platelets CD40 ligand (CD154) in acute coronary syndromes

Background Despite of the proof of the biological function of CD154 on platelets, there has been little information about its role either in patients with stable angina or in those with acute coronary syndrome (ACS). Objective This study aimed to investigate the expression of CD154 on platelets and its role in ACS. Methods The study included 50 patients with ACS (24 patients with acute myocardial infarction (AMI) and 26 patients with unstable angina (UA)), 20 patients with stable angina (SA) and 18 healthy volunteers. CD154 and CD62 expression on platelets were analyzed by flow cytometry. Their relations to the clinical and laboratory data were assessed in the studied group. Results Patients with AMI and UA had higher levels of platelets CD154 and CD62 as compared to those with SA and among patients with AMI, UA and SA versus healthy volunteers. Platelets CD154 showed significant positive correlations with the studied pro-inflammatory markers (Ox-LDL, CRP and fibrinogen), segmental wall motion score and the studied risk factors. There were significant negative correlations between platelet CD154 and serum nitric oxide among patients. Conclusions CD154 may be used as a marker of thrombo-embolic events. Nitric oxide may have an anti-atherogenic effect. There is an association between platelet activation and severity of coronary artery disease among patients with ACS.

1104 Characterization of left ventricular remodeling using contrast echocardiography in patients with anterior ST elevation myocardial infarction treated with primary percutaneous coronary intervention

Eur J Echocardiography Abstracts Supplement, December 2006 vided as a surrogate marker for LV-EF. Unfortunately, there are only few data on the relation between the WMSI and LV-EF. In addition, poor non-contrast enhanced echo windows can make the WMSI (and LV-EF) unreliable. The value of contrast imaging for WMSI assessment was not investigated before . Aim of the study: To compare segmental wall motion and WMSI interobserver agreement in patients who underwent both two-dimensional second harmonic (SH) and contrast left ventricular opacification (LVO) echocardiography. Methods: The study comprised 100 consecutive patients (mean age 57±13 years, 85% males) who underwent both SH and SonoVue LVO echocardiography for clinical evaluation of LV function. Two independent physicians assessed segmental quality and wall motion for both the SH and LVO studies according to a 17-segment model. Systolic wall motion was defined as (1) normokinesia, (2) hypokinesia (systolic inward endocardial motion <7 mm), (3) akinesia, and (4) dyskinesia. LV-EF was assessed from the LVO images according to the biplane modified Simpson’s method by a third blinded physician. Results: Of the 1,700 analyzed segments, 453 (26.6%) were poorly visualized with SH imaging, and 173 (10,2%) with LVO imaging (p<0.0001). The two independent observers agreed on segmental wall motion score in 1,299 of the 1,700 segments (agreement 76%, Kappa 0.60) with SH imaging and in 1,491 of the 1,700 segments (agreement 88%, Kappa 0.78) with LVO imaging. Interobserver correlation (R 2) was 0.86 for the SH-imaged WMSI and 0.93 for the LVO-imaged WMSI. The limits of agreement for interobserver LVO-imaged WMSI (mean relative difference -1.0%±6.8%, agreement -14.6%, 12.6%) were lower than those for SH-imaged WMSI (mean relative difference -2.3%±10.1%, agreement -22.5, 17.9). The LVO-imaged WMSI correlated well with LVO-imaged LV-EF (R 2=0.71). LV-EF could be estimated according to the formula 1.01-0.32xWMSI. Conclusion: Echo contrast improves interobserver agreement for wall motion and WMSI scoring. The LVO-imaged WMSI correlates well with LVOimaged LV-EF.

Quantitative Estimation of Left Ventricular Ejection Fraction from Mitral Valve E-Point to Septal Separation and Comparison to Magnetic Resonance Imaging

This study tested the hypothesis that the mitral valve E point-to-septal separation (EPSS) can be used to quantify the left ventricular (LV) ejection fraction (EF) on a continuous scale rather than simply as "normal" or "reduced." After excluding 5 patients with mitral valve prostheses, asymmetric septal hypertrophy, or significant aortic insufficiency, EPSS was measured in 42 patients by 3 independent observers on a cardiac magnetic resonance image identical to the echocardiographic parasternal long-axis view. In each patient, the reference standard LVEF was calculated from the magnetic resonance short-axis cross-sectional stack images by Simpson's rule and ranged from 11% to 72%. For all 42 patients, linear regression revealed the relation magnetic resonance imaging (MRI) LVEF = 75.5 - 2.5. EPSS (millimeters). Correlation between EPSS and the MRI LVEF for the 3 observers agreed closely, ranging from r = 0.78 to r = 0.82 (SEE 9 to 10), with similar regression coefficients. After blinded segmental wall motion scoring of the gated magnetic resonance cine images of the left ventricle in each patient, correlations, SEEs, and regression coefficients were found to be very similar in the 21 patients with the most homogenous wall motion, compared with the 21 patients with the most heterogenous wall motion. In conclusion, clinically useful quantitative prediction of the LVEF as a continuous variable can be obtained from the EPSS with a simple linear regression equation in a substantial portion of patients and may be a useful adjunct for assessment of LV function.

Off-Pump, In Situ Internal Thoracic Artery Grafting: A Durable Treatment for Single-Vessel Coronary Artery Disease

The value of off-pump in situ left internal thoracic artery to left anterior descending coronary artery bypass grafting in single-vessel coronary artery disease was assessed by long-term angiographic and clinical data. One-hundred three randomly selected patients (87 male, 16 female; mean age, 57.4 +/- 10.5 years) underwent postoperative angiographic control after an average postoperative period of 4.8 +/- 2.9 years (up to 8.2 years; a total of 490 patient-years). Fifty-five patients (52%) were asymptomatic, whereas 31 (30%) had anginalike chest pain. Ninety-seven patients (94.2%) were in New York Heart Association class I or II. Five-year angina-free survival was 81% +/- 5%. Of 103 left internal thoracic arteries assessed, 99 were patent (overall patency, 96.1%). All four cases having occluded grafts had mild native vessel stenoses (<80%) before operation. The patency rate was 99% +/- 1% at 3 years, and 93% +/- 4% at 5 years. The left ventricular segmental wall motion score of the left anterior descending coronary arterial distribution improved from 4.1 +/- 1.1 to 3.7 +/- 0.9 (p = 0.001). Consequently, 15 patients (15%) underwent secondary revascularization (11 interventional and 4 surgical) 4.8 +/- 2.1 years after the primary operation. The most frequent indication for interventional revascularization was atherosclerotic progression in systems other than left anterior descending artery. The cases with graft occlusion were treated surgically. Five-year freedom from interventional or surgical repeat revascularization was 91% +/- 4%. In addition to the well-documented safety and reliability, off-pump in situ left internal thoracic artery grafting is also a durable treatment for isolated left anterior descending artery disease, in both clinical and angiographic terms.

Off-Pump Coronary Artery Bypass Grafting: Long-Term Angiographic Results

Although short-term results of off-pump coronary artery bypass grafting are well documented, late postoperative data are still scarce. This report provides an analysis of late postoperative control angiograms. 265 patients (231 males, 34 females; mean age: 54 +/- 10) underwent postoperative angiographic control, after an average postoperative period of 4.2 +/- 2.3 years (up to 9 years, a total of 1110 years). A total of 385 distal anastomoses on 258 internal mammary arteries (IMAs) and 127 saphenous vein grafts (SVGs) were evaluated. The primary operation was single bypass in 156 cases (62%), double bypass in 98 (34%), and triple or more bypass in 11 (4%). Out of 258 IMAs, 241 were patent (93%), while SVG patency was 65% with 82 patent grafts out of 127 (p < 0.0001). The patency in the lateral branches (62%) and right coronary system (64%) were similar. The variables associated with graft occlusion were hypercholesterolemia (p = 0.02), poor left ventricular performance (p = 0.03), reoperation (p = 0.01), target coronary vessel caliber less than 1.5 mm (p < 0.0001), poor native coronary vessel quality (p = 0.0003) and low-grade stenosis (p = 0.02). In the poor left ventricle group, the left ventricular segmental wall motion score was improved (p = 0.004). Consequently, 47 patients underwent secondary revascularization (35 PTCA and 12 CABG). The leading indication was native coronary artery disease progression, frequently in the circumflex system, followed by graft failure. The cases with native vessel disease progression were referred to PTCA/stenting, while those with LAD graft occlusion were treated surgically. Probably the best candidates for OPCAB are those having target vessels of good caliber and quality, and high-grade stenoses. Postoperative lipid-lowering therapy seems to be prudential.

Autotransplantation of unmanipulated bone marrow into scarred myocardium is safe and enhances cardiac function in humans.

Stem cell transplants into damaged myocardium may have the potential to improve cardiac function. We investigated the safety of transplanting unmanipulated autologous bone marrow into infarcted myocardium of patients undergoing coronary bypass surgery and assessed its efficacy to improve cardiac function. Fourteen patients with one or more areas of transmural myocardial infarction were studied. Autologous bone marrow was obtained by sternal bone aspirate at the time of surgery, diluted in autologous serum at a ratio of 1:2, and then injected 1 cm apart into the mid-depth of the left ventricular scar. There were no deaths, no perioperative myocardial infarctions, and no significant ventricular arrhythmias. Dobutamine stress echocardiography demonstrated overall improvement in the global and regional left ventricular function 6 weeks and 10 months after surgery. Of 34 infarcted left ventricular segments, 11 were injected with bone marrow alone, 13 were revascularized with a bypass graft alone, and 10 received bone marrow transplantation and a bypass graft in combination. Only the left ventricle segmental wall motion score of the areas injected with bone marrow and receiving a bypass graft in combination improved at low dose and at peak dobutamine stress. These findings suggest that transplantation of unmanipulated autologous bone marrow into scar tissue of the human heart is safe and enhances cardiac function only when used in combination with myocardial revascularization. This benefit can be seen after 6 weeks of the bone marrow transplant and is maintained after 10 months of follow-up.

Effects of surgery for postinfarction ventricular tachycardia on parameters of left ventricular function

Heart failure is the leading cause of death in patients after surgery for ventricular tachycardia. This study examines the effects of antiarrhythmic surgery on 4 parameters of left ventricular (LV) function. Global ejection fraction, segmental wall motion score, homogeneity of contraction, and diastolic function were measured in 32 patients by technetium-99m radionuclide ventriculography. Ejection fraction was measured from the left anterior oblique image. Wall motion score was assessed semiquantitatively for 11 LV segments from 3 projections. Homogeneity of contraction was expressed as the SD of the LV phase analysis curve during systole from the left anterior oblique image. Diastolic function was expressed in terms of peak and mean first time derivative of the action potential (dV/dt) of the LV function curve. Subgroup analyses were performed to distinguish the effects of aneurysmectomy, coronary artery bypass grafting, and changes in angiotensin converting enzyme inhibitor therapy. Mean systolic function improved after surgery (ejection fraction 22% vs 32%, p <0001; wall motion score 20 vs 13, p <0.0001; phase analysis 18 vs 12, p <0.03). Mean diastolic function also improved (peak dV/dt 0.83 ± 0.32 vs 1.49 ± 0.39, p = 0.006; mean dV/dt 0.41 ± 0.15 vs 0.76 ± 0.27, p = 0.006). Improvements were not confined to those who had aneurysmectomy or coronary bypass grafting and were not explained by changes in vasodilator therapy. Thus, antiarrhythmic surgery does not inherently damage LV function. Significant improvements were observed in most patients. Failure to improve indicated a poor longer term prognosis.

Utilidad de las nuevas técnicas de imagen, segundo armónico y contraste en la visualización del borde endocárdico. Análisis de la reproducibilidad en la valoración de la contracción segmentaria

This study sought to determine if newer techniques significantly improve endocardial border definition in suboptimal acoustic windows, and the reproducibility of the evaluation of wall motion abnormalities according to the different techniques and degrees of expertise. We studied a total of 20 consecutive patients with poor ultrasound window, to assess, if the use of tissue harmonic imaging (2H) or contrast with second harmonic (Levovist ; 4 g i.v.), (2HC) improves endocardial border visualization. In order to analyze inter and intraobserver reliability with the different techniques, four observers with different degrees of expertise were each asked to assess the segmental wall motion score of 31 consecutive echocardiograms. The quality of the image was clearly superior with 2H and 2HC compared with 2D. This difference was larger in apex and lateral endocardial border from 0.9 and 1 to 1.5 and 1.64 (p < 0.001) with 2H. 2HC was found to slightly but significantly improve the endocardial definition in apex compared with 2H (1.64 vs 1.81; p = 0.016). The percentage of segments assessed for interobserver variability significantly improve with 2H and 2HC (2D = 50%, 2H = 75% and 2HC = 95%). Interobserver agreement with the different techniques between the experienced observers did not statistically differ. The less experienced observer presented a significantly lower interobserver reliability than those with experience, and did not improve with 2H and 2HC. a) Native tissue harmonic imaging and second harmonic imaging with contrast (Levovist ) significantly improves endocardial border visualization; b) the newer imaging techniques significantly improve performance (percentage of evaluated segments) without decreasing reliability, and c) experience in assessing wall motion is the main factor in interobserver agreement.

Myocardial perfusion and oxygen consumption in reperfused noninfarcted dysfunctional myocardium after unstable angina: Direct evidence for myocardial stunning in humans

OBJECTIVESTo positively establish the diagnosis of myocardial stunning in patients with unstable angina and persistent wall motion abnormalities after reperfusion by coronary angioplasty.BACKGROUNDAlthough myocardial stunning is thought to occur in several clinical conditions, definite proof of its existence in humans is still lacking, owing to the difficulty of measuring myocardial blood flow (MBF) in absolute terms.METHODSWe studied 14 patients with unstable angina due to proximal left anterior descending coronary artery disease who presented persistent anterior wall motion abnormalities despite revascularization of the culprit lesion by percutaneous coronary angioplasty (PTCA) and who did not have clinical evidence of necrosis. Dynamic positron emission tomography (PET) with [13N]-ammonia and [11C]-acetate was performed 48 h after PTCA to determine absolute MBF and oxygen consumption (MVO2). Regional wall thickening and regional cardiac work were determined using two-dimensional echocardiography. Improvement of segmental wall motion abnormalities was followed for a median of 4 months (1.5 to 14 months).RESULTSAs judged from the changes in segmental wall motion score, regional dysfunction was spontaneously reversible in 12/14 patients and improved from 2.2 ± 0.3 to 1.2 ± 0.3 at late follow-up (p < 0.001). With PET, [13N]-ammonia MBF was similar among dysfunctional and remote normally contracting segments (85 ± 29 vs. 99 ± 20 ml·min−1·100g−1, p = not significant [n.s.]), thus demonstrating a perfusion-contraction mismatch. Despite the reduced contractile function, dysfunctional myocardium presented near normal levels of MVO2(6.5 ± 4.2 vs. 8.0 ± 1.9 ml·min−1·100g−1, p = n.s.). Consequently, the regional myocardial efficiency (regional work divided by MVO2) of the dysfunctional myocardium was found to be markedly decreased as compared with normally contracting myocardium (6 ± 6% vs. 26 ± 6%, p < 0.001).CONCLUSIONSThis study demonstrates that human dysfunctional myocardium capable of spontaneously recovering contractile function after unstable angina endures a state of perfusion-contraction mismatch. These data for the first time provide unequivocal direct evidence for the existence of acute myocardial stunning in humans.