Wall Motion Abnormalities In Patients Research Articles

Prognostic value of transthoracic echocardiography in the evaluation of suspected myocardial infarction

Abstract Introduction Transthoracic bedside echocardiography (TTE) in the emergency department is recommended in patients with suspected myocardial infarction (MI), who do not qualify for early discharge using accelerated protocols. The prognostic value of routine echocardiographic parameters like wall motion abnormalities in patients with suspected MI, has not been evaluated so far. Therefore, our aim was to analyze whether TTE is a suitable risk stratification tool in patients presenting with suspected MI. Methods In a prospective cohort study, 2,719 patients presenting to the emergency department with symptoms indicate of MI were recruited. Patients with ST-segment elevation myocardial infarction (STEMI) and without available TTE were excluded. In the final dataset of 2,086 patients, pathological TTE-findings were defined as the composite of reduced systolic left ventricular(LV) function <50%, regional wall motion abnormalities (WMA) and severe valvular defects. Patients were followed up for up to 5 years to assess all-cause mortality and major adverse cardiac events (MACE), composited of cardiac rehospitalization, revascularization, MI excluding the index events, and death. Kaplan-Meier survival curves were created and compared using the log rank test. Cox-proportional hazard ratios with adjustment for age, sex, cardiovascular risk factors and high-sensitivity troponin were calculated for individual echocardiographic pathological findings. Results Among 2,086 patients 63.7% were male and the mean age was 64 years. Acute myocardial infarction was present in 308 (14.7%). 32.5% showed any pathological TTE-findings: A reduced systolic LV-function was detected in 18.6%, 18.4% had wall motion abnormalities, composed of 7.5% with akinesia and 10.9% with hypokinesia. Severe valvular defects were present in 7.8%. In patients with any pathological TTE-finding the rate of MACE was significantly higher than in patients without pathological findings (p<0.001, Figure 1A): After 5 years, MACE occurred in 320 (29.99%) of patients with a normal TTE, whereas 319 (59.65%) patients with at least one pathology developed MACE after 5 years. Overall mortality as a single component of the combined endpoint occurred in 86 (8.71%) patients with a normal TTE, while in patients with pathologies 152 (30.46%) had died (p<0.001, Figure 1B). Following cox-regression, valvular defects (HR 2,23 (95% CI 1,66-2,78)), highly reduced systolic LV-function <30% (HR 2,51 (95% CI 1,68-3,76)), and akinesia (HR 1,94 (95% CI 1,30-2,91)), were independent predictors of all-cause mortality at five years (Figure 2). Conclusion We describe the value of TTE as prognostic tool in patients with suspected MI and found that patients with pathologies in TTE were at substantially higher cardiovascular risk compared to patients without pathologies. Especially regional akinesia, highly reduced LV-function and severe valvular defects were strong predictors of mortality within 5 years.Kaplan-Meier survival curvesAdjusted cox-proportional hazard ratios

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

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

Inter- and intra-observer variability in the echocardiographic evaluation of wall motion abnormality in patients with ST-elevation myocardial infarction or takotsubo syndrome - A novel approach.

Using existing transthoracic echocardiographic indices to quantify left ventricular wall motion abnormalities (WMAs) can be difficult due to the variations in the location of the abnormalities within the left ventricle, the quality of examinations, and the inter-/intra-observer variability of available indices. This study aimed to evaluate a new approach for measuring the extent of WMA by calculating the percentage of abnormal wall motion and comparing it to the wall motion score index (WMSI). The study also sought to assess inter- and intra-observer variability. The study included 140 echocardiograms from 54 patients presenting with ST-elevation myocardial infarction or Takotsubo syndrome. All patients underwent an echocardiographic examination according to a standard protocol and the images were used to measure the extent of akinesia (proportion akinesia, PrA), akinesia and hypokinesia (proportion akinesia/hypokinesia, PrAH), and WMSI. The inter-observer variability between the two operators was analyzed. The intra-observer analysis was performed by one observer using the same images at least 1 month after the first measurement. The agreement was analyzed using the Pearson correlation coefficient and Bland-Altman plots. Inter- and intra-observer variability for PrA and PrAH were low and comparable to those for WMSI. PrA and PrAH are reliable and reproducible echocardiographic methods for the evaluation of left ventricular wall motion.

Left ventricular longitudinal strain: a useful tool in the evaluation of patients with Takotsubo syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Introduction In contrast with the usual type of Takotsubo syndrome (TS), where apical wall motion abnormality occurs, the less common patterns (mid-ventricular, basal, and focal) are often misdiagnosed. Purpose In this retrospective study we examined the role of global (GLS) and territorial longitudinal strain with speckle tracking in the evaluation of patients with TS. Methods Patients with TS were examined at the echocardiography laboratory of our general hospital, from August 2019 until August 2022. Left ventricular ejection fraction (LVEF) and GLS were calculated and territorial longitudinal strain was assessed. Results Out of 21 patients with TS (19 females), of median age 67.5 years (range 33.0 – 87.0 years), 11 (52.4%) had apical distribution, 6 (28.6%) mid-ventricular, 2 (9.5%) basal and 2 (9.5%) focal. Of those, 3 were excluded from the study due to insufficient echocardiographic image quality. Patients with apical pattern had median LVEF 37% (range 23–51%) and GLS −7.6% (−5.8 to −12.5%), patients with mid-ventricular pattern had median LVEF 40% (35–50%) and GLS −14.2% (−9.3 to −16.5%) and patients with basal pattern had median LVEF 52% (47–56%) and GLS −16.5% (−14.6 to −18.4%). In the first case of focal distribution, wall motion abnormality was found at the anterior septal wall, and LVEF was calculated 46% and GLS −12.8%. In the second case, abnormality was found at the inferoposterior wall and LVEF was calculated 56% and GLS −17.3%. Patients with apical TS had median strain of basal territory −11.7%, mid territory −3.7% and apical territory +3.6%. Patients with mid ventricular TS had median strain of basal territory −10.2%, mid territory −6.5% and apical territory −19.7%. Patients with basal TS had median strain of basal territory −4.3%, mid territory −16.4% and apical territory −29.1%. Conclusion GLS and territorial longitudinal strain reflect the reduction in left ventricular systolic function and the distribution of wall motion abnormalities in patients with TS, which further supports the initial diagnosis.

FOCUS may detect wall motion abnormalities in patients with ACS

BackgroundChest pain is a common presentation to the Emergency Department (ED) with roughly 6 million visits a year. The primary diagnostic modality for the identification of acute coronary syndrome (ACS) is the electrocardiogram (ECG), which is used to screen for electrocardiographic findings representing acute coronary occlusion. It is known that the ischemia generated by an acutely occluded coronary vessel generates a wall motion abnormality which can be visualized by echocardiogram; however, emergency physician-performed focused cardiac ultrasound (FOCUS) currently does not have a formal role in the diagnosis of OMI within the emergency department. PurposeWe sought to define the characteristics of FOCUS performed by emergency physicians of variable training levels in the identification of RWMA in patients presenting to the emergency department with high suspicion for ACS before undergoing cardiac catheterization or formal echocardiography. We also explored whether RWMA was associated with OMI in these patients. MethodsWe performed a structured, retrospective review of adult patients presenting to a large, academic, tertiary care center with suspected ACS from July 1st, 2019, and October 24th, 2020. Patients were included if they underwent FOCUS in the ED during the time-period above for suspected ACS looking for RWMA and FOCUS images were stored and reviewable in our middleware software. The primary outcome was the accuracy, sensitivity, and specificity of FOCUS compared to formal echocardiography for the detection of RWMA. Secondary outcomes were sensitivity of FOCUS compared to formal echocardiography for detection of RWMA in patients with and without cardiac catheterization proven OMI and sensitivity and specificity of FOCUS operators based on training. ResultsFOCUS for RWMA performed by emergency physicians had a sensitivity of 94% (95% CI, 82–98), specificity 35% (95% CI, 15–61), and overall accuracy of 78% (95% CI, 66–87). Of all subjects, 82% underwent urgent or emergency coronary angiography, of which 71% had OMI at the time of coronary angiography of the procedure. FOCUS identified RWMA in 87% of patients with coronary angiography proven OMI. Residents (PGY-1 - PGY-3) (n = 31) were able to detect RWMA with a sensitivity of 86% (95% CI, 64–96), a specificity of 56% (95% CI, 23–85%), and an accuracy of 77 (95% CI, 58–90%). Emergency ultrasound fellows and attendings (n = 34) were able to detect RWMA with a sensitivity of 85% (95% CI, 64–95%), a specificity of 75% (95% CI, 36–96%), and an accuracy of 82% (95% CI, 65–93%). ConclusionsOur retrospective study concludes FOCUS performed by emergency physicians may be used to detect RWMA in patients with high concern for acute coronary syndrome. This may have its greatest utility in patients presenting without STEMI where the ECG is felt to be equivocal, but the clinician has high concern for OMI, in which the presence of RWMA might result in emergent cath lab activation, though this requires further study. The presence of RWMA in such cases may help to rule in OMI as a cause; however, the absence of RWMA should exclude OMI. Further research is necessary to confirm these findings.

Impact of Time Factor on Wall Motion Abnormalities in Patients with STEMI and Underwent Primary PCI

Background: Left ventricular (LV) dysfunction is the single most accurate predictor of death and one of the most common and lethal consequences after ST segment elevation myocardial infarction (STEMI) that has been substantially decreased by primary percutaneous coronary intervention (PCI). This research investigated the impact of duration of ischemia on the severity and improvement of wall motion abnormalities after revascularization and 40-day follow-up.
 Methods: This study was performed on 60 STEMI patients, treated with 1ry PCI and distributed in two groups; group1: 37 patients presented early before 12h and group II: 23 patients presented late after 12h. Echocardiogram (ECHO) was done for ejection fraction (EF) and resting segmental wall motion abnormalities (RSWMA) detection after revascularization within 24 h of hospitalization and follow up after 40 days.
 Results: MI complication showed insignificant difference between both groups. Wall motion score index (WMSI) values in group I were significantly decreased relative to group II during the follow-up period (p=0.001). Major improvement in LV ejection fraction from hospital admission to follow-up (p=0.001) in group I from the beginning of chest pain compared to group II. Correlation between time to wire crossing and WMSI showed significant positive correlation after 40 days in group I (p=0.016) with significant negative correlation with EF after 40 days in group I (p=0.018).
 Conclusions: Ischemic patients with ≤ 12 hours symptoms showed a significant degree of recovery from RWMA on follow up after 40 days.

Short-term Prognostic Value of Admission Cardiac Troponin T, C-Reactive Protein and Echocardiographic Regional Wall Motion Abnormalities in Patients with Acute ST Elevation Myocardial Infarction

Introduction: With increasing burden of Coronary Artery Disease (CAD) and ST-Elevation Myocardial Infarction (STEMI) in India, early risk stratification of patients is as important as making a correct diagnosis. Cardiac Troponin T (cTnT), C-Reactive Protein (CRP) and echocardiographic Regional Wall Motion Abnormalities (RWMA) are used to assess the patients of STEMI at presentation. The short term prognostic importance of these parameters also need to be known. Aim: To study the prognostic values of admission Cardiac Troponin T (cTnT), CRP and echocardiographic RWMA in patients with acute STEMI. Materials and Methods: Fifty patients of STEMI were evaluated from January 2017 to July 2017 by Troponin-T (positive >0.18 ng/mL), CRP (positive >3 mg/l) and echocardiography (positive with presence of RWMA) on day one. The patients were divided into three groups: Group 1: patients with all the three parameters positive, Group 2: patients with all three parameters negative, Group 3: patients with one or two parameters positive. The end points observed were heart failure Left Ventricular Ejection Fraction (LV EF) <40%) assessed by echocardiography at day 28, significant ventricular ectopics (>class II by Lown’s classification) and mortality at day 30 in the groups. Chi-square test for equality of proportions was used to analyse the difference in outcome in the groups. Results: The mean age of patients was 54 years. There were 25 (50%) patients in group 1, 14 (28%) patients in group 2 and 11 (22%) patients in group 3. Twelve (24%) patients had heart failure with 9 (18%) in group 1 and 3 (6%) in group 3 (p<0.05). 9 (18%) patients had significant ventricular ectopics with 8 (16%) patients in group 1 and 1 (2%) patients in group 3 (p<0.05). Mortality was found in 9 (18%) patients with 8 (16%) patients in group 1 and 1 (2%) patients in group 3 (p<0.05). Conclusion: Acute STEMI with high cTnT, CRP and presence of RWMA on echocardiography at admission need more aggressive management and close follow-up.

Accuracy of Emergency Physicians for Detection of Regional Wall Motion Abnormalities in Patients With Chest Pain Without ST‐Elevation Myocardial Infarction

Our aim was to evaluate the accuracy of emergency physicians (EPs) in the detection of regional wall motion abnormalities (RWMAs) using focused cardiac ultrasound (FOCUS) in patients suspected of non-having ST-elevation myocardial infarction. We prospectively enrolled patients with chest pain. Three EPs underwent didactics and hands-on-training, of 3 hours each, by an experienced cardiologist, on detecting RWMAs using 2-dimensional echocardiography. They performed a FOCUS examination to evaluate for RWMAs and recorded the echo images. Our reference standard for the detection of RWMAs was accepted as a blinded cardiologist review of the prerecorded video clips. We calculated the corrected sample size and inter-rater agreement between the EPs (82 and 0.83, respectively). The analysis of the study was performed on 89 patients. Eighty-nine patients with chest pain were screened. Emergency physicians demonstrated the detection of RWMAs with good sensitivity and even excellent specificity: 76.9% (95% confidence interval [CI], 56.4%- 91.0%) and 92.1% (95% CI, 82.4%-97.4%), respectively. The accuracy of FOCUS was 87.6% (95% CI, 79.0%-93.7%). The area under the curve from a receiver operating characteristic curve analysis, which evaluated the EPs' rate of detecting the presence or absence of RWMAs, was 0.845 (95% CI, 0.753-0.913). Our study results suggest that EPs with training in bedside echocardiography can accurately rule in patients with RWMAs in suspected non-ST-elevation myocardial infarction cases.

P362 Antimalarial-induced cardiomyopathy: retrospective case series

Abstract Background Antimalarial drugs chloroquine and hydroxychloroquine represent an important therapeutic option in autoimmune diseases. Rare cases of potentially lethal antimalarial-induced cardiomyopathy (AMIC) have been described. Pattern of minimal changes with wall hypertrophy, followed by restrictive and end-stage dilative cardiomyopathy was proposed in AMIC. Purpose Our aim was to identify patients with definite AMIC and characterize their clinical and imaging findings. Methods Retrospective analysis of admissions to Cardiology department from January 2010 to January 2019 was done to identify patients with definite diagnosis of AMIC based on positive endomyocardial biopsy. Clinical, echocardiographic, and cardiac magnetic resonance (CMR) imaging findings were reviewed if available. Results Three patients with biopsy proven diagnosis of AMIC were identified. Two patients, 62 and 76-year-old females, presented with signs of congestive heart failure, while the third, a 41-year-old man presented with chest pain and cardiac conduction abnormalities necessitating pacemaker implantation. All were treated with chloroquine phosphate. Both females had a history of pacemaker due to atrioventricular block. All had positive troponin and coronary artery disease was excluded. Echocardiography in the first case showed a severely dilated left ventricle (LV) with global hypokinesia and severe systolic dysfunction (LVEF 30%). CMR confirmed dilative cardiomyopathy, furthermore subepicardial late gadolinium enhancement (LGE) of the inferolateral LV wall and of the right ventricle free wall was present. In the second case a restrictive cardiomyopathy pattern was observed with mild biventricular systolic dysfunction and biatrial enlargement. CMR of this case was not available. Echocardiography in the third case showed a normal sized LV with mild diastolic and systolic dysfunction (LVEF 50%), along with septal hypokinesia. CMR showed patchy subepicardial and mid-wall LGE of the septum that was falsely attributed to myocarditis. Additionally, a chemical shift artefact suggestive of myocardial fatty infiltration (Image 1) was visible in the apical septum. After discontinuation of chloroquine two patients improved, while the first patient deteriorated and eventually succumbed to refractory heart failure. Conclusions Our three cases confirm high diversity of cardiac imaging findings in AMIC. Even mild non-specific findings such as LV systolic dysfunction or wall motion abnormalities in patients on antimalarial drugs should therefore be thoroughly investigated. CMR with non-ischaemic LGE pattern may aid in diagnosis, however definite diagnosis is currently possible only with endomyocardial biopsy. Novel imaging techniques, such as T1 mapping, have a potential to increase the diagnostic yield given the known patohistological similarities between AMIC and Anderson-Fabry disease. Abstract P362 Figure. Chemical shift artefact (arrow) in AMIC

Echocardiographic wall motion abnormalities in patients with stroke may warrant cardiac evaluation

BackgroundThe aetiology of wall motion abnormalities (WMA) in patients with ischaemic stroke is unclear. We hypothesised that WMAs on transthoracic echocardiography (TTE) in the setting of ischaemic stroke mostly reflect...

Apparent Declining Prognostic Value of a Negative Stress Echocardiography Based on Regional Wall Motion Abnormalities in Patients With Normal Resting Left Ventricular Function Due to the Changing Referral Profile of the Population Under Study.

Background Cardiology guidelines identify the low-risk response during stress echocardiography as the absence of regional wall motion abnormalities. Methods From 1983 to 2016, we enrolled 5817 patients (age 63±12 years; 2830 males) with suspected coronary artery disease, normal regional, and global left ventricular function at rest and during stress (exercise in 692, dipyridamole in 4291, and dobutamine in 834). Based on timing of enrollment, 4 groups were identified in chronological order of recruitment: years 1983 to 1989, group 1 (n=211); years 1990 to 1999, group 2 (n=1491); years 2000 to 2009, group 3 (n=3285); and years 2010 to 2016, group 4 (n=830). Results There were 240 (4%) events (119 deaths and 121 infarctions) in the follow-up. At 1-year follow-up, the event rate was 0.5% (95% CI, 0.05-0.95), 1.5% (95% CI, -1.18 to 1.82), 1.9% (95% CI, 1.63-2.17), and 1.7% (95% CI, 1.01-2.39; χ2, 9.0; P=0.03) in groups 1 to 4, respectively. At multivariable Cox analysis, independent predictors of future events were age (hazard ratio (HR), 1.05; 95% CI, 1.04-1.07; P<0.0001), male sex (HR, 1.57; 95% CI, 1.20-2.04; P=0.001), diabetes mellitus (HR, 1.78; 95% CI, 1.34-2.37; P<0.0001), smoking habit (HR, 1.40; 95% CI, 1.05-1.85; P=0.02), and ongoing anti-ischemic therapy (HR, 1.50; 95% CI, 1.15-1.97; P=0.003) Conclusions Over the past 3 decades, we observed a progressive decline in the prognostic value of a negative test based on regional wall motion abnormalities, likely reflecting both an increase in risk in patients, as well as a potential decrease in test performance due to concomitant anti-ischemic therapy.

Assessment of Regional Wall Motion Abnormality in Patients with Acute Anteroseptal ST Segment Elevation Myocardial Infarction

Post myocardial infarction (MI) short and long term clinical outcome is largely determined by the size of the infarcted area. It is generally assumed that as the lead involvement in the 12 lead electrocardiography (ECG) is less in anteroseptal ST segment elevation myocardial infarction (AS-STEMI), where ST segment elevation (STE) is limited to leads V1 to V3, myocardial damage is likely to be less. This study was intended to assess regional wall motion abnormality (RWMA) in acute anteroseptal STEMI patients. 90 patients with AS-STEMI admitted in between October 2012 and September 2013, were included. For each patient, a transthoracic echocardiogram (TTE) was performed within 24-48 hours of MI and was interpreted by an independent investigator blinded to the patient’s ECG data.The mean (± SD) age of the patients was 51.57 (± 12.02) years with mean (± SD) age of the patients was 52.58 (± 12.02) years with a range of 23 - 80 years. There were 91.1% male and 8.9% female. The mean (± SD) EF% was 38.80 %( ± 5.78). All the segments of left ventricle, except basal and mid inferolateral segments, were affected in anteroseptal STEMI. So, the term AS-STEMI may be a misnomer, as it implies that only the anteroseptal segments of the left ventricle are involved. This study shows that regional dysfunction in patients with AS-STEMI extends beyond the anteroseptal region and may be it is as much extensive as extensive anterior myocardial infarction. So, any patients with anterior wall involvement should be treated with utmost importance.&#x0D; University Heart Journal Vol. 15, No. 1, Jan 2019; 28-33

The significance of electrocardiographic changes without echocardiographic evidence of segmental wall motion abnormalities in patients undergoing dobutamine stress echocardiography

Ischemic ECG changes during dobutamine stress echocardiography (DSE) have been reported to have low sensitivity and specificity for detecting myocardial ischemia in the absence of wall motion abnormalities on echocardiography. We present a case of a renal transplant candidate with severe multivessel disease who had ST depressions without any wall motion abnormalities on DSE. Certain studies have shown the sensitivity of DSE is lower in patients with left ventricular hypertrophy and/or end stage renal disease, but the significance of ischemic ECG changes with no evidence of wall motion abnormalities in these patients has not been well studied.

Association of left bundle branch block with new onset abnormal wall motion in treated hypertensive patients with left ventricle hypertrophy: the LIFE Echo Sub-study

Aims: We aimed to investigate whether left bundle branch block (LBBB) is related to new-onset left ventricle (LV) wall motion abnormalities during treatment in hypertensive patients with electrocardiographic (ECG) defined left ventricular hypertrophy (LVH).Methods and results: 960 patients with essential hypertension and ECG-LVH participating in the LIFE Echo Sub-study were investigated at baseline and annually with echocardiography, during randomized antihypertensive therapy. After excluding patients with LV wall motion abnormalities at baseline and patients developing new-onset LBBB during study time, we investigated 784 patients. The participants with (n = 32) and without (n = 752) LBBB were similar regarding most baseline variables. Logistic regression models controlling for LV mass index, Framingham risk score, and randomized treatment assignment were used to assess the odds ratio of developing new-onset abnormal LV wall motion on annual follow-up echocardiograms. The likelihood of developing new global LV wall motion abnormalities in patients with LBBB was not higher compared to those without LBBB except at year 5 (p = .002). The likelihood of developing new segmental LV wall motion abnormalities in patients with LBBB was however higher compared to patients without LBBB after 1 year (OR = 3.1, 95% CI = 0.7–14.2, p = .173); 2 years (OR = 6.9, 2.1–22.4, p = .003); 3 years (OR = 5.3, 2.0–14.3, p < .001), 4 years (OR = 4.0, 1.6–10.3, p = .003 and 5 years (OR = 4.1, 1.0–16.2, p = .394) of treatment.Conclusion: Among patients with ECG-LVH, undergoing antihypertensive treatment, the presence of LBBB independently identifies individuals with ∼3- to 7-fold greater odds of developing new segmental abnormal LV wall motion. These findings suggest that LBBB may be a marker for progressive myocardial disease.

Intraoperative assessment of transient and persistent regional left ventricular wall motion abnormalities in patients undergoing coronary revascularization surgery using real time three-dimensional transesophageal echocardiography: A prospective observational study.

To evaluate the feasibility of intraoperative real time three-dimensional echocardiography (RT3DE) for identification and quantification of transient and persistent regional wall motion abnormalities (RWMAs) in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG). A prospective observational study SETTING: Single-center study in an academic tertiary care hospital PARTICIPANTS: A series of 42 patients undergoing elective CABG over a 2-year period were included. After induction of anesthesia, a comprehensive transesophageal echocardiography (TEE) examination was performed to evaluate regional wall motion using two-dimensional wall motion score index (WMSI) and RT3D echocardiographic parameters at three specific time points during the operative phase. The 3D assessment of LV function was based on the quantification of change in LV chamber volume over time from each segment excursion. Patients were divided into two groups and subgroups based on TEE findings. There was significant mechanical dyssynchrony in patients with RWMAs (WMSI>1; systolic dyssynchrony index [SDI]=7.0±3.66) as compared to the patients having normal wall motion (WMSI=1; SDI=2.0±0.95; P=.001). Patients with contractile dysfunction were found to have low values of segmental excursion and high values of negative excursion on parametric imaging. Persistent RWMAs due to hibernating myocardium showed significant resolution of mechanical dyssynchrony after revascularization. Parametric imaging could detect transient RWMAs due to stunning and graft dysfunction. Early activating segments (EAS) on "timing bull's-eye" may represent hypercontractile segments and may influence inotrope administration. The RT3DE is a valuable modality for precise quantification of regional wall motion during revascularization procedure.

Prognostic Impact of Segmental Wall Motion Abnormality in Patients With Idiopathic Dilated Cardiomyopathy.

The clinical impact of left ventricular (LV) segmental wall motion abnormalities (SWMA) in patients with idiopathic dilated cardiomyopathy (IDCM) has not been well elucidated.Among 100 consecutive IDCM patients with follow-up visits, we enrolled 85 after excluding those with left bundle branch block and/or ventricular pacemaker implantation. LV wall motion was assessed using left ventriculography scored for 7 segments according to the American Heart Association classification as follows: 0, normokinesis; 1, hypokinesis; 2, akinesis; and 3, dyskinesis. SWMA were defined as a score dispersion of more than 1 degree among the segments.SWMA was exhibited by 26 patients. Kaplan-Meier curves demonstrated that the patients with SWMA (SWMA+) had a significantly higher cardiac event-free rate than the patients without SWMA (P < 0.001). Cox proportional hazards analysis showed that SWMA+ was an independent predictor of cardiac events (P = 0.03; hazard ratio = 3.38; 95% confidence interval [CI], 1.11-10.8). Furthermore, multiple regression analysis showed that SWMA+ was an independent predictor of decreased LV end-systolic dimension index after optimal pharmacotherapy (β = -0.24; 95%CI, -9.12 to -0.73; P = 0.02).SWMA is common in patients with IDCM and is independently associated with a poor prognosis and less morphometric and functional improvement of LV in response to pharmacotherapy.

Right ventricular strain by MR quantitatively identifies regional dysfunction in patients with arrhythmogenic right ventricular cardiomyopathy

Analysis of regional wall motion of the right ventricle (RV) is primarily qualitative with large interobserver variation in clinical practice. Thus, the purpose of this study was to use feature tracking to analyze regional wall motion abnormalities in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). We enrolled 110 subjects (39 overt ARVC [mutation+/phenotype+] (35.5%), 40 preclinical ARVC [mutation+/phenotype-] (36.3%), and 31 control subjects (28.2%)). Cine steady state free precession cardiac MR was performed with temporal resolution ≤40 ms in the horizontal long axis (HLA), axial, and short axis directions. Regional strain was analyzed using feature tracking software and reproducibility was assessed by means of intraclass correlation coefficient. Dunnett's test was used in univariate analysis for comparisons to control subjects; cumulative odds logistic regression was used for minimally and fully adjusted multivariate models. Strain was significantly impaired in overt ARVC compared with control subjects both globally (P < 0.01) and regionally (all segments of HLA view, P < 0.01). In the HLA view, regional reproducibility was excellent within (intraclass correlation coefficient [ICC] = 0.81) and moderate between (ICC = 0.62) observers. Using a threshold of -31% subtricuspid strain in the HLA view, the sensitivity and specificity for overt ARVC were 75.0% and 78.2%, respectively. In multivariable analysis involving all three groups, subtricuspid strain less than -31% (beta = 1.38; P = 0.014) and RV end diastolic volume index (beta = 0.06; P = 0.001) were significant predictors of disease presence. RV strain can be reproducibly assessed with MR feature tracking, and regional strain is abnormal in overt ARVC compared with control subjects.

Quantifying “normalized” regional left ventricular contractile function in ischemic coronary artery disease

ObjectiveWhen significant coronary lesions are identified by angiography, regional left ventricular (LV) contractile function often plays a role in determining candidacy for revascularization. To improve on current subjective and nonquantitative metrics of regional LV function, we tested a z-score “normalization” of regional strain information quantified from clinically acquired high-resolution LV geometric datasets. MethodsTest subjects (n = 120) underwent cardiac MRI with multiple 3-dimensional strain parameters calculated from tissue tag-plane displacement data. Sixty healthy volunteers contributed strain parameter data at each of 15,300 LV grid points, to form a normal human strain database. Point-specific database comparisons were made in 60 patients who had documented coronary artery disease (CAD), by angiography. Patient-specific, color-coded 3-dimensional LV maps of z-score–normalized contractile function were generated. ResultsBlinded clinical review indicated that 55% (33 of 60) of the patients with CAD had significant regional contractile abnormalities by 1 of 3 “gold-standard” criteria: (1) Q waves on electrocardiography (ECG); (2) infarct on radionuclide single-photon emission computed tomography (SPECT); or (3) akinesia or dyskinesia on echocardiography. Consistency among all gold-standard metrics was found for only 19% (6 of 31) of patients with CAD who had ≥2 available metrics. Blinded MRI-based, multiparametric, strain z-score localization of contractile abnormalities was accurate in 89% (ECG), 97% (SPECT), and 95% (echocardiography). ConclusionsNonsubjective normalization of regional LV contractile function by z-score calculation from a normal human strain database can localize and quantitatively display regional wall motion abnormalities in patients with CAD. This high-resolution localization of regional wall motion abnormalities may help improve the accuracy of therapeutic intervention in patients who have CAD.

Exercise echocardiography and cardiac magnetic resonance imaging to predict outcome in patients with hypertrophic cardiomyopathy†

We have observed that wall motion abnormalities (WMAs) during exercise echocardiography (ExE) are associated to events in hypertrophic cardiomyopathy (HCM). Our objective was to evaluate ExE and cardiac magnetic resonance (CMR) to predict outcome in HCM. ExE and CMR were performed in 148 patients with HCM. During follow-up (7.1 ± 2.7 years), there were 7 hard events (Hard-E) and 26 combined events (Comb-E). Exercise WMAs were observed in 13 patients (8.8%), perfusion defects in 10 (6.8%), and late gadolinium enhancement (LGE) in 48 (32.4%). WMAs were seen in 57% of patients with Hard-E vs. 6% without (P = 0.001) and in 23 and 6% with and without Comb-E (P = 0.005). Perfusion defects were also more frequent in patients with Hard-E than without (43 vs. 5%, P = 0.007) and in patients with Comb-E than without (23 vs. 5%, P = 0.002). LGE (g) was greater in patients with Comb-E than without [median (25th-75th percentile) 0 (0-21.1) vs. 0 (0-9.3) g P = 0.04]. Univariable predictors of Comb-E included NYHA class ≥2, peak double product, ΔWMSI, and CMR data. Peak double product [Hazard ratios (HR) = 0.99, confidence intervals (CI) 95% 0.99-0.99, P = 0.02] and ΔWMSI (HR = 404, CI 95% 12-13681, P = 0.001) remained independent predictors. Peak WMSI correlated with myocardial mass with LGE (r = 0.20, P = 0.02) and with perfusion defect area (r = 0.40, P < 0.001). LGE affecting ≥15% of the left ventricle was observed in 38% of patients with exercise WMAs vs. 12% without (P = 0.009). CMR data are associated to exercise WMAs in patients with HCM. ExE and CMR may help to predict outcome in them.

The value of assessing myocardial deformation at recovery after dobutamine stress echocardiography.

BackgroundThe purpose of this study was to evaluate whether performing an assessment of myocardial deformation using speckle tracking imaging during the recovery period after dobutamine stress echocardiography (DSE) allows detection of significant coronary artery disease (CAD) in patients with chest discomfort.MethodsDSE and coronary angiography were performed in 44 patients with chest discomfort. The mean global longitudinal peak systolic strain (GLS) was measured at rest, at low stress (dobutamine infusion rate of 10 µg/kg/min) and at recovery (5 min after cessation of dobutamine infusion) of DSE using automated function imaging with apical views. Fractional flow reserve (FFR) was also performed in patients with intermediate coronary stenosis. CAD was defined as having a ≥ 70% diameter stenosis on coronary angiography or as having a FFR < 0.8. Patients were divided two groups based on the absence or presence of CAD [CAD (-) group vs. CAD (+) group].ResultsThere were no significant differences in the clinical characteristics and results of conventional echocardiography between the two groups. GLS at recovery was lower in the CAD (+) group than in the CAD (-) group (-18.0 ± 3.4% vs. -21.0 ± 1.9%, p = 0.003). The optimal cutoff of GLS at recovery for detection of CAD was -19% (sensitivity of 70.6%, specificity of 83.3%).ConclusionAssessment of GLS at recovery of DSE is a reliable and objective method for detection of CAD. This finding may suggest that systolic myocardial stunning remains even after recovery of wall motion abnormalities in patients with CAD.