Severe Asynergy Research Articles

P22-4 - Two Different Cause of Acute Heart Failure Due to Localized Aortic Dissection

Case 1: A 78-year-old man was admitted to our hospital with chest pain and dyspnea. Chest X ray showed congestive heart failure (CHF). Transthoracic echocardiography (TTE) and plain chest CT revealed severe aortic valve regurgitation (AR) and aortic root dilation without apparent flap. Despite treatment of heart failure CHF was worsened, in order to stabilize his respiratory status, mechanical ventilation was started. We diagnosed cause of his heart failure was acute AR, and then, performed surgical operation. Operation finding showed localized dissection of aortic root which was the cause of acute AR. Case 2: A 66-year-old man was admitted to our hospital with chest pain in a shock state. ECG showed ST elevation in II, III and aVf, and TEE showed severe dilation of right ventricular and severe asynergy of the left ventricular inferior wall. We diagnosed acute myocardial infarction (AMI) with right heart failure, coronary angiogram (CAG) was performed. However CAG did not showed occlusive coronary disease, enhance CT and TEE restudy revealed localized aortic dissection of the sinus of valsalva and dilation of ascending aorta. Operation was performed and the finding showed localized dissection of aortic root which was the cause of AMI and right heart failure. We report these rare cases, two different type of acute heart failure due to local dissection of aortic root.

Prediction of functional recovery after coronary bypass surgery using quantitative gated myocardial perfusion SPECT.

Previous studies have demonstrated that myocardial perfusion imaging using 99m Tc-tetrofosmin at rest allows viability assessment similar to that obtained with 201 T1 imaging and 18 F-fluorodeoxyglucose positron emission tomography ( 18 F-FDG PET). The simultaneous assessment of perfusion and regional function is now available by quantitative gated myocardial perfusion single-photon emission computed tomography (SPECT). This study was designed to evaluate the utility of quantitative values of wall motion and wall thickening, calculated by quantitative gated myocardial perfusion SPECT, for the prediction of functional recovery after coronary bypass grafting (CABG). Fifty-six patients with coronary artery disease scheduled for CABG were included prospectively. All patients underwent 99m Tc-tetrofosmin gated SPECT imaging at rest preoperatively and 3 months after CABG. The myocardium was divided into nine segments and the average quantitative values of regional perfusion (percentage uptake) (%), wall motion (mm) and wall thickening (%) were determined automatically using quantitative gated SPECT (QGS) software. The wall motion score was defined visually using a four-point scale (0, normal; 3, akinesis), and segments with severe asynergy (score of 2 or 3) with patent grafts were assessed. Of 77 segments with severe asynergy, 56 segments showed improved wall motion and 21 segments did not improve after CABG. The area under the receiver operating characteristic curve of wall thickening for the prediction of functional recovery was significantly higher (0.92) than that of the percentage uptake (0.77, P<0.017) or wall motion (0.60, P < 0.0001). When each analysis used the optimal threshold, the wall thickening analysis (? 10%) had a sensitivity of 95% and a specificity of 81%. These values tended to be higher than those of the percentage uptake (sensitivity, 86%; specificity, 67%). The wall motion analysis (? 1.5 mm) had a significantly lower sensitivity of 75% and specificity of 43% than the wall thickening analysis (P = 0.0038 and P = 0.011, respectively). The results indicate that wall thickening, calculated by QGS software, may be more useful than regional perfusion or wall motion analysis for the prediction of functional recovery after CABG. The areas of asynergy with relatively preserved wall thickening may have the potential for improved function despite severely decreased perfusion.

Perfusable tissue index obtained by positron emission tomography as a marker of myocardial viability in patients with ischemic ventricular dysfunction.

In areas of severe asynergy, the clinically important task is to identify functionally recoverable myocardium. Fourteen patients with asynergy were investigated by H2(15O) dynamic positron emission tomography imaging before revascularization. Regional myocardial blood flow (MBF) was determined and the water-perfusable tissue fraction (PTF) for each region of interest and the total anatomical tissue fraction (ATF) were estimated. The PTF/ATF was analyzed as the water perfusable tissue index (PTI). Asynergy was defined as segments with wall motion more than 2SD below than that of a normal population. An increase of >0.8SD in anterior wall segments with asynergy and an increase of >0.6 SD in inferior wall asynergy were defined as significant improvements of wall motion indicative of viable myocardium. Fifteen segments with wall motion abnormalities less than -2SD and 10 control segments were identified; 7 segments recovered and 8 segments did not. MBF was similar in both groups of segments before revascularization (0.78 +/- 0.27 vs 0.73 +/- 0.18 ml min-(-1) x g(-1), NS). The PTI in the recovered segments was significantly higher than that in the unimproved segments (0.734 +/- 0.058 vs 0.592 +/- 0.038, p<0.0001) and was similar to that of the control segments. After revascularization, the PTI correlated with the SD of wall motion (p<0.05, r=0.58). PTI may be a good predictor of contractile recovery after revascularization.

Dobutamine-induced ST-segment elevation in patients without myocardial infarction

During dobutamine stress echocardiography, ST-segment elevation developed in 20 of 372 patients (5%) without previous myocardial infarction and was associated with a transient severe asynergy of the myocardial region corresponding to the site of ST elevation. In 17 of 19 patients, ST-segment elevation was associated with a critical stenosis of the ischemia-related coronary artery, whereas in 2 of 19 patients with no critical lesions of the ischemia-related artery, coronary vasospasm was the most likely mechanism of myocardial ischemia.

Exercise beta-methyl iodophenyl acid (BMIPP) and resting thalium delayed single photon emission computed tomography (SPECT) in the assessment of ischemia and viability.

To clarify the significance of exercise BMIPP (beta-methyl iodophenyl pentadecanoic acid) and resting T1 delayed single photon emission computed tomography (SPECT) in the assessment of ischemia and viability, we studied maximal exercise-loading BMIPP SPECT following rest-injected T1 3 h SPECT in 11 control subjects, 20 patients with effort angina and 38 patients with old myocardial infarction. The left ventricular wall on ECT was divided into 9 segments. BMIPP and T1 uptake were scored as 0 = normal, 1 = reduced, 2 = severely reduced, or 3 = absent. Discordance was defined as when segments with a reduced BMIPP uptake had a better resting T1 uptake. Significant coronary artery stenosis was defined as stenosis of 75% or greater on coronary arteriogram. Left ventricular wall motion was assessed as either normokinesis, hypokinesis, severe hypokinesis, akinesis or dyskinesis on left ventriculogram. When discordance was considered to be a marker of ischemia, the sensitivity and specificity in effort angina and control subjects were 95.2% and 84.6% for patients and 83.9% and 94.4% for diseased vessels, respectively. There were no differences between the sensitivity and specificity in left anterior descending artery (LAD), left circumflex artery (LCx) and right coronary artery (RCA) lesions (83.3%, 95.5% in LAD, 83.3%, 95.5% in LCx, 85.7%, 92.6% in RCA, respectively). All of the patients with old myocardial infarction had reduced exercise BMIPP uptake in infarcted regions. In old myocardial infarction, 35 patients had segments with discordant uptake. Discordance was observed in 75 (91.5%) of 82 segments with hypokinesis, and in 24 (92.3%) of 26 segments with severe hypokinesis. Even among the 36 segments with akinesis or dyskinesis, 25 (69.0%) had discordant uptake. When discordance in the infarcted region was considered to be a marker of viability, regions with severe asynergy showed a high possibility of viability. Thus, discordant uptake on exercise BMIPP and resting T1 delayed SPECT may be a useful marker of ischemia in effort angina and of viability in old myocardial infarction.

Quantitative planar rest-redistribution 201Tl imaging in detection of myocardial viability and prediction of improvement in left ventricular function after coronary bypass surgery in patients with severely depressed left ventricular function.

Although many patients with multivessel coronary artery disease (CAD) and severely depressed left ventricular (LV) function will benefit from coronary artery bypass graft surgery (CABG), surgeons may be reluctant to perform CABG on these patients without evidence of myocardial viability in regions of severe asynergy. We hypothesized that quantitative planar rest-redistribution 201Tl imaging would identify viable myocardium and predict improved regional and global function after revascularization in patients with depressed LV function and CAD. Twenty-one patients (mean LV ejection fraction, 0.27 +/- 0.05) were studied. Regional and global LV functions were evaluated before and 8 weeks after CABG with radionuclide ventriculography. Segments were prospectively classified as showing normal, mildly reduced, or severely reduced viability on the basis of quantitative analysis of defect severity and redistribution on planar resting 201Tl imaging. By 201Tl criteria, 90% of hypokinetic segments were classified with normal or mildly reduced viability. Among akinetic or dyskinetic segments, 20% had normal 201Tl uptake, 53% had mildly reduced viability, and only 27% had severely reduced viability. 201Tl viability criteria identified segments that improved function after CABG. Sixty-two percent of severely asynergic segments with normal viability and 54% with mildly reduced viability improved function after surgery, but only 23% with severely reduced viability improved function (p = 0.002). When only adequately revascularized segments were considered, the predictive value of a positive preoperative viability scan for functional improvement was 73%. The greatest improvement in global LV function after CABG occurred in patients with the greatest number of asynergic segments classified as viable before surgery (p < 0.01). In 10 patients with more than seven viable, asynergic segments, mean LV ejection fraction increased significantly after CABG (0.29 +/- 0.07 to 0.41 +/- 0.11, p = 0.002). In 11 patients with seven or fewer viable, asynergic segments, mean LV ejection fraction remained unchanged after revascularization (0.27 +/- 0.05 to 0.30 +/- 0.08, p = NS). In patients with CAD and severely depressed LV function, preoperative quantitative planar rest-redistribution. 201Tl imaging identifies viability in many asynergic myocardial segments, and these segments frequently improve function after CABG. The presence of numerous asynergic but viable myocardial segments before surgery correlated significantly with improvement in global LV function after bypass surgery.

Functional recovery of hibernating myocardium after coronary bypass surgery: Does it coincide with improvement in perfusion?

To determine the relationship between functional recovery and improvement in perfusion after coronary artery bypass graft surgery (CABG), 49 patients were studied. Radionuclide angiography was performed before, 1 month after, and 6 to 12 months after CABG to evaluate regional wall motion. Exercise thallium-201 myocardial perfusion imaging was done before and 1 month after CABG to assess regional perfusion. Preoperative asynergy was observed in 108 segments, and 74 of them showed an improvement in wall motion 1 month after CABG (segment A). Sixty-six of these segments (89%) were associated with an improvement in perfusion. Eight segments that had not improved 1 month after CABG demonstrated a delayed recovery of wall motion 6 to 12 months after CABG (segment B). However, seven of eight segments (88%) already showed an improvement in perfusion 1 month after CABG. A total of 82 segments exhibited functional recovery after CABG and were considered hibernating segments. In the preoperative study segment B more frequently had areas of akinesis or dyskinesis than segment A (75% vs 34%, p < 0.05). The mean percent thallium-201 uptake in segment B was lower than that in segment A (74% ± 9% vs 83% ± 8%, p < 0.05). Functional recovery of hibernating myocardium usually coincided with an improvement in perfusion. However, delayed functional recovery after reperfusion was observed in some instances. Severe asynergy and severe thallium-201 defects were more frequently observed in these segments with delayed recovery. Hibernating myocardium might remain stunned during those recovery periods.

狭心症および心筋梗塞患者の予後に及ぼす無症候性心筋虚血の臨床的意義

The purpose of this study is to increase understanding of the prognosis of coronary artery disease (CAD) patients whose anginal symptoms have been removed by medical therapy, and to evaluate the prognostic and clinical significance of silent myocardial ischemia (SMI). Cardiac events including cardiac death, acute myocardial infarction, PTCA/CABG and unstable angina were examined in 253 CAD patients who underwent ambulatory Holter monitoring, treadmill exercise testing and coronary angiography. The subjects were classified into two groups: 93 patients with exertional angina (AP) without previous myocardial infarction and 160 patients with old myocardial infarction (MI). SMI was diagnosed by Holter monitoring. Cox's proportional hazard regression model and the survival curves using the Kaplan-Meier method were used to analyze 9 variables in patients with AP, including Holter monitoring parameters, exercise parameters and angiographic findings, and 12 variables in patients with MI, including the same parameters as in AP patients. The cardiac event rate was 19% in patients with AP and 18% in patients with MI. The independent and common predictors of unfavorable outcome in both groups were severe coronary lesion and SMI. The incidence of SMI was 30% in AP patients and 38% in MI patients, the same incidence as reported in previous studies. The cardiac event rate in patients with SMI was higher than in those without SMI for both groups (28% vs 9% and 32% vs 9%; p less than 0.05). However, the most frequent cardiac event was different in the groups with SMI: PTCA/CABG in AP patients and re-infarction in MI patients. The significant predictors of cardiac events in patients with SMI were severe coronary lesion, short exercise duration, severe asynergy and exercise-induced angina in patients with AP and lower ejection fraction and maximum ST depression on Holter monitoring in patients with MI. In conclusion, it was ascertained that SMI is a significant and independent marker of unfavorable outcome in patients with CAD and that the cardiac event rate in patients with SMI was significantly higher than in those without SMI. However, severe complications such as acute myocardial infarction were more frequent in MI patients than in AP patients. Therefore, it was suggested that the use of re-vascularization procedure (PTCA/CABG) should be considered as soon as possible in patients with SMI, regardless of whether anginal symptoms are present or not.(ABSTRACT TRUNCATED AT 400 WORDS)

Early Indium-111 antimyosin scintigraphy for assessment of regional wall motion asynergy on discharge after myocardial infarction

To assess the relation between early Indium-111 monoclonal antimyosin antibody scintigraphy and degree of regional asynergy on discharge, 38 patients with a first acute myocardial infarct were studied (18 anterior, 20 inferoposterior infarctions). In 21 patients thrombolytic therapy was administered. On the first day of myocardial infarction, 80 MBq Indium-111 Antimyosin was injected. Planar images, anterior, lateral and left anterior oblique, were made 24 hours later. Localized myocardial uptake was present in 37/38 patients, and was evaluated for Count Density Index (count density of infarct zone/left lung count density) in the left anterior oblique images, which displayed the infarct zone well. Regional asynergy on discharge was evaluated by cross-sectional echocardiography and defined mild (hypokinesia) or severe (akinesia or dyskinesia). Count density index was significantly lower in 15 patients with mild asynergy, compared with 22 patients with severe asynergy (1.61 +/- 0.25 vs. 2.42 +/- 0.40, p less than 0.001). This difference was present in both patient groups treated with or without thrombolysis. We conclude that early count density index, reflecting the amount of local necrosis, is highly correlated to the ultimate degree of wall motion impairment.

Coronary collaterals assessed with myocardial contrast echocardiography in healed myocardial infarction

The epicardial coronary collateral vessels are visualized with coronary angiography, but this method does not provide significant information about the myocardial perfusion supplied with the collaterals. In this study, myocardial contrast echocardiography (MCE) was performed to assess the coronary collaterals in 29 patients with old myocardial infarction. MCE was performed by intracoronary injection of 2 ml agitated amidotrizoate sodium meglumine. The peak background-subtracted gray level (PGL) in the infarct area was determined from the digitized echocardiographic images obtained before and after injection into the noninfarct and donor artery. PGL was compared with the 3-point coronary angiographic grades of collaterals. PGL in the infarct area was significantly lower in patients with poor collaterals than in patients with moderate to good collaterals (5 ± 4 vs 18 ± 8 U mean ± standard deviation, p < 0.01). PGL in the infarct area was < 10 U in the 3 patients with severe asynergy despite the moderate to good collateral supply, suggesting that activity of the collaterals was not good enough to preserve the wall motion effectively. It is concluded that (1) the degree of MCE enhancement in the infarct area generally corresponded to the collateral grades assessed with coronary angiography, and (2) MCE may provide a measure of the collateral perfusion.

Right bundle-branch block in coronary artery disease: a hemodynamic and angiographic study.

Thirty-four patients with right bundle-branch block (RBBB) and coronary artery disease (CAD) (RBBB was not pre-existent to clinical development of CAD) and 52 consecutive CAD patients without conduction disturbances were studied and compared to verify whether the presence of RBBB implies more severe and extensive left ventricular myocardial damage as well as more severe CAD. The two groups did not differ either in age or in New York Heart Association functional class. The incidence or location of previous myocardial infarction (MI) was not different in the two groups. No significant differences were found in left ventricular volumes or ejection fraction. Higher end-diastolic left ventricular pressure and more severe and diffuse left ventricular wall asynergy were present in RBBB patients. At coronary arteriography, more severe involvement of the right coronary artery in CAD patients without conduction disturbances was the only significant finding. The group of patients with CAD and RBBB without MI showed significantly less involvement of the left anterior descending coronary artery and significantly more severe damage of the inferior wall of the left ventricle than the group with CAD without RBBB and MI. Patients with inferior wall MI and RBBB had more severe asynergy of the posterobasal region of the left ventricle than did patients with inferior wall MI without RBBB. The group of patients with anterior wall MI and RBBB had a higher left ventricular end-diastolic pressure, a lower left ventricular ejection fraction, and a greater extent of myocardial damage compared to similar patients of the control group. The groups with MI and RBBB had the same Gensini's score as similar groups without RBBB. (ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic value of Q waves outside standard precordial lead points in left anterior myocardial infarction undetectable by standard 12-lead electrocardiogram

Body surface potential maps were recorded for 52 patients with solitary anterior myocardial infarction and 57 normal subjects. All patients had pure anterior wall asynergy on a left ventriculogram but no diagnostic Q wave on the standard 12-lead electrocardiogram. Q wave (>30 msec) distributions on the body surface of the patients and normals were compared. The frequency of Q waves in the area above V 1-V 2 and in the right middle chest was significantly higher in patients than in normals. The sensitivity of Q waves for asynergy in leads from both these areas was 19–60%. The positive predictive value was 67–94%. The frequency of Q waves was significantly higher in severe asynergy than in mild asynergy. A combination of two selected unipolar leads from these areas yielded a sensitivity and specificity of 33% and 95%, respectively. With a combination of three leads, these values were 42% and 93% and with four leads 48% and 88%, respectively. The results indicate that several unipolar leads from the area above V 1-V 2 and from the right middle chest in addition to the standard 12-lead electrocardiogram may improve the electrocardiographic diagnostic accuracy of myocardial infarction.

Segmental wall motion abnormalities in dilated cardiomyopathy: Hemodynamic characteristics and comparison with thallium-201 myocardial scintigraphy

This study assessed the hemodynamic characteristics of segmental wall motion abnormality of the left ventricle in patients with dllated cardiomyopathy (DCM) and its relation to the thallium-201 (TI-201) myocardial scintigraphy (MPI). Left ventriculograms and MPI in 23 patients were analyzed by the use of quantitative indexes of regional wall motion and TI-201 uptake based on a mean and a standard deviation of 13 normal subjects. Relative normokinesis in our definition was more frequently seen in the inferior wall than in the anterior wall ( p < 0.01). In contrast, severe asynergy was more often seen in the anterior wall than in the inferior wall ( p < 0.01). There were 11 patients who had relative normokinesis and asynergy together. By means of the index of wall motion, the DCM patients were divided into two groups, one with segmental wall motion abnormality (SWMA) and another with diffuse wall motion abnormality (DWMA). The DWMA group had higher left ventricular end-diastolic pressures ( p < 0.05) and the tendency of large left ventricular end-diastolic volumes than the SWMA group. There was a rough correlation ( r = 0.58) between the quantitative indexes of TI-201 uptake and wall motion at the same region of the left ventricle. Thus, the nonuniformity of the left ventricular wall motion was recognized in the pationts with DCM and more increased preload was shown in the patients with DWMA than in the group with SWMA. Further, the regional asynergy may be related to the localized fibrosis within the left ventricle in DCM, considering the result that the worse TI-201 uptake was roughly accompanied by the more severe asynergy.

Asymmetric distribution of left ventricular asynergy in coronary artery disease and its relation to coronary stenoses

In 100 patients with coronary artery disease (CAD), the prevalence and severity of asynergy was determined for 9 left ventricular (LV) segments by both radionuclide and contrast anglography. The anterior, septal and lateral LV walls had significantly more prevalent and more severe asynergy in the medial segments than in the basal segments. In contrast, the inferior LV wall exhibited equally severe asynergy in both the medial and basal segments. In general, asynergy was most severe in the apical, medial septal, medial inferior and basal inferior LV segments. This asymmetric distribution of LV asynergy could not be explained by the distribution of occlusions or significant stenoses in the arterial tree, which were relatively uniformly distributed among the left anterior descending (32%), left circumflex (29%) and right (26%) coronary arteries. It is postulated instead that the asymmetric distribution of LV asynergy results from asymmetry of the coronary arterial tree supplying the left ventricle and that the prevalence of asynergy in an LV segment is directly related to its vascular distance from the coronary ostia. Unlike the relatively direct supply of the left anterior descending and circumflex arteries to the basal segments of the anterior, septal and lateral LV walls, the arterial supply to the basal inferior wall begins only after the right or dominant circumflex artery has traversed the length of the atrioventricular groove, significantly increasing its susceptibility to the pressure attenuation and occlusive jeopardy of more proximal stenoses.

Is it possible to rule out extensive anterior myocardial infarction in the absence of abnormal Q waves in lead I and aVL? Effect of infero-apical extension of infarction over apex.

To determine whether abnormal Q wave in lead I or aVL may be of use to estimate the size of an extensive anterior myocardial infarction, electrocardiographic and left ventriculographic findings were analyzed in 45 patients with old extensive anterior infarction. All 45 patients had a significant narrowing in the proximal segment of left anterior descending coronary artery (LAD) and severe asynergy in anterolateral segment. The patients were divided into two groups; Group I consisted of 35 cases with less involvement of the inferoapical segment and Group II of 10 cases with remarkable extension of the anterolateral infarction into the inferoapical segment due to occlusion of very long LAD supplying the anterior half of posterior interventricular groove. There were no statistical differences in the extent of anterolateral asynergy, number of abnormal Q waves in precordial leads and left ventricular ejection fraction between the two groups. While abnormal Q wave in lead I or aVL was present in 28 cases (80%) of Group I, it was observed in only 3 cases (30%) of Group II (p less than 0.01). Thus, we can't rule out extensive anterior myocardial infarction even if abnormal Q waves are absent in lead I or aVL, in which abnormal Q waves may be cancelled by loss of electromotive force of inferoapical segment due to extension of the anterior infarction over the apex in cases with extraordinarily long LAD.

Reversal of rest myocardial asynergy during exercise: A radionuclide scintigraphic study

While exercise-induced segmental left ventricular wall motion abnormalities are well described, the phenomenon of improvement in certain asynergic segments during exercise in some patients remains a curiosity. To assess this unexpected finding, results were analyzed in 85 patients with wall motion abnormalities at rest who underwent two view (45 degrees left anterior oblique and anterior) exercise radionuclide ventriculography and exercise thallium-201 myocardial perfusion imaging. Wall motion was scored with a 5 point system (from 3 [normal] to - 1 [dyskinesia]); normalization or increase of 2 or more points with exercise signified improvement. Forty-eight patients (56%) had no change or further deterioration of wall motion at peak exercise, 15 (18%) showed both improvement of wall motion and deterioration and 22 (26%) showed only improvement of wall motion. Wall motion improvement during exercise was found in 57 (20%) of 279 segments with asynergy at rest. Of these 57 segments improving with exercise, 45 (79%) showed mild and 12 (21%) showed severe asynergy at rest. Only seven segments (12%) were associated with pathologic Q waves. Thallium-201 perfusion was normal in 44 segments (77%) while only 6 segments (11%) had reversible and only 7 (12%) had nonreversible thallium-201 defects. 1) wall motion that is abnormal at rest can sometimes improve with exercise; 2) this phenomenon generally occurs in zones without a Q wave or nonreversible thallium-201 defect. Hence, segments with abnormal wall motion at rest that show improvement with exercise appear to represent viable nonischemic segments.

Contractile properties of the left ventricle with aneurysm

Twenty-five patients with an anterior wall acute myocardial infarction (AMI) were studied by 2-dimensional echocardiography (2-D echo) 3 to 5 days after the onset of chest pain, and serially over 3 to 24 months to determine if a particular pattern of contractility may predispose to left ventricular (LV) aneurysm formation. No subject had a prior AMI. In 8 subjects LV aneurysm eventually developed (group I), usually within 2 to 4 weeks of AMI; in 17 patients LV aneurysm did not develop (group II). Percent fractional shortening of the basal and midventricular segments was significantly better in group I subjects than in group II subjects (29 ± 2% vs 20 ± 2%, p < 0.01, respectively, for the basal segment, and 23 ± 1% vs 17 ± 2%, p < 0.02, respectively, for the midventricular segment). Infarct size as determined by peak creatine kinase isoenzyme levels was large in both groups, and there was no statistically significant difference between their mean values (2,099 ± 620 IU vs 1,334 ± 249 IU for groups I and II, respectively). Severe asynergy of the infarcted myocardium was present in all group I subjects and in 9 of 17 group II subjects on the initial 2-dimensional echocardiographic study. These results indicate that LV aneurysm formation depends on a critical imbalance of myocardial forces where strong LV segments cause bulging of weakened ones.

Prognostic value of Q waves, R/S ratio, loss of R wave voltage, ST-T segment abnormalities, electrical axis, low voltage and notching: Correlation of electrocardiogram and left ventriculogram

Data on the correlation of left ventricular segmental wall motion and electrocardiographic findings are, except for Q waves and ST segment elevation, still controversial. Therefore, in addition to Q waves and ST segment elevation, eight features of the electrocardiogram were studied in 265 patients, 61 with normal coronary arteries and 204 with coronary artery disease. Patients with a QRS duration of 0.12 second or greater were excluded. Left ventricular wall motion was assessed in the 30 degrees right anterior oblique and the 60 degrees left anterior oblique projections and analyzed by the Stanford method and a modification of that method, respectively. Asynergy of a particular segment correlated well with the presence of Q waves in the corresponding electrocardiographic lead or leads, but was also found in other segments. There was a significant (p less than 0.001) correlation between the number of leads with Q waves and the degree of extension of asynergy. The R/S ratio in lead V1 and Q waves in lead V6 appeared to be the most informative about the posterior wall. Loss of R wave voltage had a lower predictive value for segmental asynergy than did Q waves in the same lead. Among patients with electrocardiographic findings of an infarct, asynergy was found in 83 to 94%. Patients having Q waves in combination with ST segment elevation manifested more severe asynergy than did patients whose Q waves were not associated with ST elevation. New data are presented for lateral and posterior infarction. Patients having left-axis deviation, low voltage and QRS notching had severe asynergy.(ABSTRACT TRUNCATED AT 250 WORDS)

Sequential changes of left ventricular function after cineangiography in normal heart and coronary artery disease.

To evaluate the effect of contrast material on left ventricular (LV) function, LV pressure and its first derivative were continuously monitored during and after LV cineangiography with Mikro-tip angiocatheters in 15 normal subjects (Group 1) and patients with coronary artery disease (CAD) without LV asynergy (Group 2, n = 10), with mild asynergy (Group 3, n = 12) and severe asynergy (Group 4, n = 13). In all 4 groups, systolic hypotension, decrease of negative dP/dt, and prolonged time constant of LV pressure fall (T) were observed in 30 seconds after dye injection, and all these parameters returned to the control value in 2 minutes. LV end-diastolic pressure (EDP) began to elevate at one minute, reached its peak at 2 minutes, and stayed elevated for 7 minutes. Although significant decrease in LV systolic pressure was seen, indexes of LV contractility, peak positive dP/dt and (dP/dt)/DP40, showed increase in all groups. No different directional changes of these parameters were observed among 4 groups. The degree of LVEDP elevation was parallel to the diastolic elastic stiffness constant (K) in Group 1 (r = 0.64, (p less than 0.05). It is concluded that systolic hypotension and prolonged relaxation are only transient, and elevation of LVEDP after the contrast material injection seems to be the effect of only acute volume overload.

Diagnostic value of electrocardiogram and vectorcardiogram in postinfarction ventricular asynergy

The ability of ECG-VCG to predict the severity of postinfarction LV asynergy was evaluated in 152 patients with previous myocardial infarction who underwent left cineventriculography in the right anterior oblique view. Various ECG and VCG signs were examined in order to predict the existence of severe asynergy in general (dyskinesia or akinesia or severe hypokinesia) and of dyskinesia in particular. In patients with inferior myocardial infarction (Group A) persistent ST segment elevation was the only specific ECG sign (100%) of severe asynergy; it had a poor sensitivity (6.2%). Four frontal VCG signs (presence of terminal bite, y- greater than 0.18 mV, maximum early superior vector along x axis = MESV greater than or equal to 1.3 mV, duration of initial superior forces = DISF greater than 50 msec) increased the sensitivity of the ECG-VCG method to 75.8% while maintaining a 100% specificity. Regarding the diagnosis of dyskinesia, only the ECG sign of persistent ST segment elevation and the VCG sign of y- greater than or equal to 0.3 mV had a 100% specificity. The sensitivity of the ECG-VCG method was 33.3% (16.6% ECG and 16.6% VCG). In patients with anterior myocardial infarction (Group B), concerning the diagnosis of severe asynergy, the ECG signs of sigma ST greater than 3 mm in anterior leads; pathologic Q wave in four or more anterior leads (including D1 and aVL); and the presence of LAH or LAH + RBBB, had a 100% specificity and a good sensitivity (60.5%). The VCG sign of a narrow horizontal QRS loop increased the sensitivity of the ECG-VCG method to 71% while maintaining a 100% specificity. As for the diagnosis of dyskinesia, the ECG signs with a 100% specificity were sigma ST greater than or equal to 5 mm in anterior leads, a pathologic Q wave in more than five anterior leads (including I and a VL) and RBBB + LAH; these variables had a sensitivity of 48.3%. The VCG sign of a narrow horizontal QRS loop increased the sensitivity of the ECG-VCG method to 79.3% while maintaining a 100% specificity. In patients with inferior plus anterior myocardial infarction (Group A + B) the signs mentioned above for each group were evaluated, confirming a 100% specificity. Regarding the diagnosis of severe asynergy, the ECG signs had a sensitivity of 61.3%, while VCG increased the sensitivity of the ECG-VCG method to 90.3%.(ABSTRACT TRUNCATED AT 400 WORDS)