Wall Motion Disorders Research Articles

Two-dimensional speckle tracking imaging to assess the hazards of left ventricular function and ventricular wall motion disorders in children with pre-excitation syndrome and the efficacy of radiofrequency ablation treatment.

Our study aimed at analyzing the echocardiographic multi-indicator evaluation of the risk of Wolff-Parkinson-White syndrome (WPW) on the left ventricular function and ventricular wall motion disorders, as well as the effect of radiofrequency ablation treatment. The clinical data of 55 WPW patients treated with radiofrequency (RF) ablation at the Children's Hospital of Nanjing Medical University between January 2018 and December 2022 were retrospectively analyzed and included in the observation group, while other 50 healthy children were included in the control group during the same time. We analyzed the echocardiographic indices of the patients, assessed the effects of the disease on left ventricular myocardial function and ventricular wall motion disorders, and evaluated the effects of radiofrequency ablation treatment on the myocardium of the left ventricle. The echocardiographic parameters were analyzed to assess the effect of the disease on left ventricular myocardial function and ventricular wall dyskinesia. Of the 55 patients with pre-excited syndrome, 20 had type A bypass and 35 had type B bypass. Ten patients had pre-excited dilated cardiomyopathy with significant enlargement of the left ventricular cavity, reduced left ventricular systolic function, and a significant impairment of ventricular wall motion; the other 5 patients had basal segmental septal motion incoordination. Compared to the control group, patients with left ventricular end-diastolic diameter (LVEDD) (42.9±5.0 mm vs. 39.2±3.0 mm), peak strain dispersion (PSD) (38.8±15.3 ms vs. 21.7±2.2 ms), maximum peak time difference (MPTD) (200.2±92.8 ms vs. 89.5±9.8 ms) and interventricular mechanical delay (IVMD) (36.2±13.7 ms vs. 21.2±2.1 ms) before RF ablation were increased. Left ventricular ejection fraction (LVEF) (57.1±9.1% vs. 65.9±2.6%), E/A (1.1±0.2 vs. 1.8±0.2) and global longitudinal strain (GLS) (-18.7±2.2% vs. -22.4±0.5%) decreased, with statistically significant differences (p<0.05). All 55 patients had a successful procedure, and all postoperative echocardiographic parameters were found to be improved, compared to the preoperative period. The results of the postoperative review after 3 months showed differences in E/A, PSD, MPTD, and IVMD compared to the healthy group, suggesting that left ventricular diastolic function and synchrony had not fully returned to normal. Echocardiography can better evaluate myocardial motion and function in patients with Wolff-Parkinson-White syndrome and monitor the effect and progress of disease treatment, and has high clinical application value.

Usefulness of Cardiac Magnetic Resonance Imaging in Patients with Neuromuscular Dystrophies (Duchenne/Becker Muscular Dystrophy)

Background: Cardiac magnetic resonance imaging (CMR) is commonly used in patients with Duchenne (DMD) and Becker (DMB) Neuromuscular Dystrophies. Late gadolinium enhancement (LGE) identifies areas of middle, subepicardial, or subendocardial wall fibrosis, and volumetric left ventricular ejection fraction (LVEF) is considered the gold standard in the diagnosis and prognosis of these dystrophies. Myocardial fibrosis occurs in patients with neuromuscular dystrophies. Objectives: The purposes of our study were to determine the presence of cardiac fibrosis using CMR, to determine neuromuscular and cardiac involvement, and to evaluate the cardiovascular outcomes of these patients. Material y métodos: A descriptive cross-sectional study of 16 consecutive patients was conducted from March 2021 to July 2022 in the Cardiac Imaging Service of Diagnóstico Médico and CEMET- Tucumán. Results: A total of 16 patients were evaluated, 100% of them with confirmed diagnosis of DMD/DMB by laboratory, enzymes and genetic tests. Mean age was 19 years. All patients had severe stage of the Vignos Scale and were under neurological treatment. All patients were also treated with beta-blockers or angiotensin-converting enzyme inhibitors. CMR revealed severe LVEF impairment &lt;35% in 4 patients, segmental or global left ventricular (LV) wall motion disorders in 8 patients, and variable distribution pattern (diffuse, mesocardial, subendocardial and subepicardial patterns) of LGE in 12 patients. Non-compacted myocardium was observed in 6, and mild pericardial effusions in 2 patients. Conclusion: CMR should be included as a screening method in patients with neuromuscular dystrophies. Its contribution to clinical, echocardiographic and therapeutic staging is of utmost importance

Right Ventricular Volume and Function Assessment in Congenital Heart Disease Using CMR Compressed-Sensing Real-Time Cine Imaging.

Background and objective: To evaluate the reliability of compressed-sensing (CS) real-time single-breath-hold cine imaging for quantification of right ventricular (RV) function and volumes in congenital heart disease (CHD) patients in comparison with the standard multi-breath-hold technique. Methods: Sixty-one consecutive CHD patients (mean age = 22.2 ± 9.0 (SD) years) were prospectively evaluated during either the initial work-up or after repair. For each patient, two series of cine images were acquired: first, the reference segmented multi-breath-hold steady-state free-precession sequence (SSFPref), including a short-axis stack, one four-chamber slice, and one long-axis slice; then, an additional real-time compressed-sensing single-breath-hold sequence (CSrt) providing the same slices. Two radiologists independently assessed the image quality and RV volumes for both techniques, which were compared using the Wilcoxon test and paired Student’s t test, Bland–Altman, and linear regression analyses. The visualization of wall-motion disorders and tricuspid-regurgitation-related signal voids were also analyzed. Results: The mean acquisition time for CSrt was 22.4 ± 6.2 (SD) s (95% CI: 20.8–23.9 s) versus 442.2 ± 89.9 (SD) s (95% CI: 419.2–465.2 s) for SSFPref (p < 0.001). The image quality of CSrt was diagnostic in all examinations and was mostly rated as good (n = 49/61; 80.3%). There was a high correlation between SSFPref and CSrt images regarding RV ejection fraction (49.8 ± 7.8 (SD)% (95% CI: 47.8–51.8%) versus 48.7 ± 8.6 (SD)% (95% CI: 46.5–50.9%), respectively; r = 0.94) and RV end-diastolic volume (192.9 ± 60.1 (SD) mL (95% CI: 177.5–208.3 mL) versus 194.9 ± 62.1 (SD) mL (95% CI: 179.0–210.8 mL), respectively; r = 0.98). In CSrt images, tricuspid-regurgitation and wall-motion disorder visualization was good (area under receiver operating characteristic curve (AUC) = 0.87) and excellent (AUC = 1), respectively. Conclusions: Compressed-sensing real-time cine imaging enables, in one breath hold, an accurate assessment of RV function and volumes in CHD patients in comparison with standard SSFPref, allowing a substantial improvement in time efficiency.

Trauma, a Matter of the Heart—Molecular Mechanism of Post-Traumatic Cardiac Dysfunction

Trauma remains a leading global cause of mortality, particularly in the young population. In the United States, approximately 30,000 patients with blunt cardiac trauma were recorded annually. Cardiac damage is a predictor for poor outcome after multiple trauma, with a poor prognosis and prolonged in-hospitalization. Systemic elevation of cardiac troponins was correlated with survival, injury severity score, and catecholamine consumption of patients after multiple trauma. The clinical features of the so-called “commotio cordis” are dysrhythmias, including ventricular fibrillation and sudden cardiac arrest as well as wall motion disorders. In trauma patients with inappropriate hypotension and inadequate response to fluid resuscitation, cardiac injury should be considered. Therefore, a combination of echocardiography (ECG) measurements, echocardiography, and systemic appearance of cardiomyocyte damage markers such as troponin appears to be an appropriate diagnostic approach to detect cardiac dysfunction after trauma. However, the mechanisms of post-traumatic cardiac dysfunction are still actively being investigated. This review aims to discuss cardiac damage following trauma, focusing on mechanisms of post-traumatic cardiac dysfunction associated with inflammation and complement activation. Herein, a causal relationship of cardiac dysfunction to traumatic brain injury, blunt chest trauma, multiple trauma, burn injury, psychosocial stress, fracture, and hemorrhagic shock are illustrated and therapeutic options are discussed.

Single breath-hold compressed sensing real-time cine imaging to assess left ventricular motion in myocardial infarction

PurposeTo evaluate the reliability of a real-time compressed sensing (CS) cine sequence for the detection of left ventricular wall motion disorders after myocardial infarction in comparison with the reference steady-state free precession cine sequence. Materials and MethodsOne hundred consecutive adult patients referred for either initial work-up or follow-up by cardiac magnetic resonance (CMR) in the context of myocardial infarction were prospectively included. There were 77 men and 23 women with a mean age of 63.12±11.3 (SD) years (range: 29–89 years). Each patient underwent the reference segmented multi-breath-hold steady-state free precession cine sequence including one short-axis stack and both vertical and horizontal long-axis slices (SSFPref) and the CS real-time single-breath-hold evaluated sequence (CSrt) providing the same slices. Wall motion disorders were independently and blindly assessed with both sequences by two radiologists, using the American Heart Association left ventricle segmentation. Paired Wilcoxon signed-rank test was used to search for differences in wall motion disorders conspicuity between both sequences and receiver operating characteristic curve (ROC) analysis was performed to assess the diagnosis performance of CSrt sequence using SSFPref as the reference method. ResultsEach patient had at least one cardiac segment with wall motion abnormality on SSFPref and CSrt images. The 1700 segments analyzed with SSFPref were classified as normokinetic (360/1700; 21.2%), hypokinetic (783/1700; 46.1%), akinetic (526/1700; 30.9%) or dyskinetic (31/1700; 1.8%). Sensitivity and specificity of the CS sequence were 99.6% (95% CI: 99.1–99.9%) and 99.7% (95% CI: 98.5–100%), respectively. Area under ROC of CSrt diagnosis performance was 0.997 (95% CI: 0.993–0.999). ConclusionCS real-time cine imaging significantly reduces acquisition time without compromising the conspicuity of left ventricular -wall motion disorders in the context of myocardial infarction.

Management and prognostic of right ventricular extended myocardial infarction: About a Moroccan experience

Myocardial infarction can affect any myocardial territory, however, the isolated right ventricle infarction is exceptional. It is often biventricular with a high mortality of about 30% compared to that of isolated LV (6%). Assess the prevalence of acute myocardial infarction extended to RV, and study the epidemiological, clinical, diagnostic, therapeutic and prognostic. Retrospective and descriptive study conducted in the Cardiology department in CHU Ibn-Rochd in Casablanca. It was conducted on patients admitted in ICU for acute MI extended to the RV, in the period January 2016 to June 2018. Of the 360 patients, who suffered a myocardial infarction in acute phase, 22 patients (6% of all AMI, 23% inferior MI) had an acute MI extended to RV. The average age of our patients was 61 years ranging from 53 to 70 years, with a male predominance. The majority of our patients (81%) have more than 03 cardiovascular risk factors. Chest pain with in physical examination: the jugular turgor, hypotension and bradycardia were the most common clinical signs in our patients. The ECG showed an ST-elevation in right leads (V3R, V4R) and in the inferior territory (DII, DIII and AvF) in all our patients. Dilatation of right cavities and wall motion disorders were the most frequent echocardiographic abnormalities (63% of patients). The most frequent complications were hemodynamic instability (46%) and rhythmic complications (36%). From the therapeutic point, thrombolysis was performed in 18 patients, which 6 patients received an additional angioplasty after failed thrombolysis. Ten patients required vascular filling, and inotropic drugs were used in 4 of our patients. Mortality in our series was 10%. Our series underscores the value of nearly management of patients admitted to the acute phase of MI extended to RV, and the considerable contribution of thrombolysis as a means of revascularization and its positive impact on prognosis.

Upoređivanje nalaza magnetne rezonance i ultrazvuka srca kod kongenitalnih i stečenih srčanih bolesti

Objective: Nowadays, non-invasive methods are emerging in the evaluation of cardiovascular diseases. The aim of this study was to determine the diagnostic performance of cardiac magnetic resonance (CMR) imaging and cardiac ultrasound imaging (Echo) in cardiac patients diagnosed with Echo previously. Methods: In a total of 32 various cardiac patients with Echo findings including congenital and acquired heart pathologies who applied to our clinic were included in the study. The distribution of cardiac pathologies including valve dysfunctions, right and left ventricular wall lesions and movement disorders, atrioventricular hypertrophy, septal defect, pericardial effusion-mass, additional congenital or acquired vascular pathologies and additional thoracic pathology, age and gender correlations were determined. The CMR and Echo findings were compared statistically. Results: It was found that 12 (37.5%) of the individuals were female, 20 (62.5%) were male, aged between 6 and 80 years with an average age of 29.9 years. The cardiac parameters were positive in 27 (84.4%) patients according to Echo and were positive in 22 (68.8%) patients according to CMR. There was no statistically significant correlation between CMR and Echo for cardiac pathology detection rates (p &gt; 0.05). However, only 18 out of 22 patients who were positive on CMR were positive on Echo. CMR was superior in detecting congenital cardiac pathologies. Conclusion: Echo has a diagnostic advantage and in general, CMR and Echo findings overlap in cases with valve dysfunctions, ventricular wall motion disorders, and hypertrophy, whereas we found that Echo findings were insufficient for diagnosis of congenital heart pathologies.

Cardiac stress after electroconvulsive therapy and spontaneous generalized convulsive seizures: A prospective echocardiographic and blood biomarker study

AimKnowledge about cardiac stress related to seizures in electroconvulsive therapy (ECT) and spontaneously occurring generalized convulsive seizures (GCS) is limited. The aim of the present study was to analyze cardiac function and circulating markers of cardiac stress in the early postictal period after ECT and GCS. MethodsPatients undergoing ECT in the Department of Psychiatry, Psychotherapy and Psychosomatics and patients undergoing diagnostic video-EEG monitoring (VEM) in the Department of Neurology were prospectively enrolled between November 2017 and November 2018. Cardiac function was examined twice using transthoracic echocardiography within 60 min and >4 h after ECT or GCS. Established blood markers (troponin T high-sensitive, N-terminal pro brain natriuretic peptide) of cardiac stress or injury were collected within 30 min, 4 to 6 h, and 24 h after ECT or GCS. In the ECT group, the troponin T values were also correlated with periprocedural heart rate and blood pressure values. Because of organizational or technical reasons, the measurement was not performed in all patients. ResultsTwenty patients undergoing ECT and 6 patients with epilepsy with a GCS during VEM were included. Postictal echocardiography showed no wall motion disorders and no change in left ventricular and right ventricular functions. Four of 17 patients displayed a transient increase in high-sensitive cardiac troponin T 4–6 h after the seizure (3 patients with ECT-induced seizure). None of these 4 patients had signs of an acute cardiac event, and periprocedural blood pressure or heart rate peaks during ECT did not significantly differ in patients with and without troponin T elevation. ConclusionsSigns of mild cardiac stress can occur in some patients following ECT or GCS without clinical complications, probably related to excessive catecholamine release during the seizure.

Compressed sensing real-time cine imaging for assessment of ventricular function, volumes and mass in clinical practice.

This study was conducted in order to evaluate the accuracy of a compressed sensing (CS) real-time single-breath-hold cine sequence for the assessment of left and right ventricular functional parameters in daily practice. Cardiac magnetic resonance (CMR) cine images were acquired from 100 consecutive patients using both the reference segmented multi-breath-hold steady-state free precession (SSFP) acquisition and a prototype single-breath-hold real-time CS sequence, providing the same slice number, position, and thickness. For both sequences, the left (LV) and right ventricular (RV) ejection fractions (EF) and end-diastolic volumes (EDV) were assessed as well as LV mass (LVM). The visualization of wall-motion disorders (WMD) and signal void related to mitral or tricuspid regurgitation was also analyzed. The CS sequence mean scan time was 23 ± 6 versus 510 ± 109s for the multi-breath-hold SSFP sequence (p < 0.001). There was an excellent correlation between the two sequences regarding mean LVEF (r = 0.995), LVEDV (r = 0.997), LVM (r = 0.981), RVEF (r = 0.979), and RVEDV (r = 0.983). Moreover, inter- and intraobserver agreements were very strong with intraclass correlations of 0.96 and 0.99, respectively. On CS images, mitral or tricuspid regurgitation visualization was good (AUC = 0.85 and 0.81, respectively; ROC curve analysis) and wall-motion disorder visualization was excellent (AUC ≥ 0.97). CS real-time single-breath-hold cine imaging reduces CMR scan duration by almost 20 times in daily practice while providing reliable measurements of both left and right ventricles. There was no clinically relevant information loss regarding valve regurgitation and wall-motion disorder depiction. • Compressed sensing single-breath-hold real-time cine imaging is a reliable sequence in daily practice. • Fast CS real-time imaging reduces CMR scan time and improves patient workflow. • There is no clinically relevant information loss with CS regarding heart valve regurgitation or wall-motion disorders.

The prognosis of Different Types of Reciprocal ST-segment Depression (R-ST-D) on Electrocardiograms in Acute Myocardial Infarction

Summary Background We investigated how to define the culprit coronary artery according to different reciprocal ST-segment depression (R-ST-D) types on electrocardiograms in ST-segment elevation acute myocardial infarction (STEMI), as well as the high-risk factors. Methods To analyze the prognosis of different R-ST-D types to define the culprit coronary artery and high-risk factors, 967 patients with STEMI were included and divided into four groups according to STEMI infarction sites and R-ST-D type: group I (type I), without R-ST-D (n = 143); group II (type II), R-ST-D less than or equal to the amplitude of ST-segment elevation (n = 664); group III (type III), R-ST-D greater than or equal to the amplitude of ST-segment elevation (n = 93); and group IV (type IV), the amplitudes of R-ST-D and ST-segment elevation were both elevated (n = 67). Results The incidence of type II was the highest at 68.7%, followed by that of type I, which was mainly due to anterior descending branch stenosis. Type IV was mainly caused by complete occlusion of multiple vessels including the anterior descending branch and circumflex branch and/or right coronary artery. Type III was always related to a higher incidence of malignant complications, ventricular wall motion disorders, and ejection fraction index ≤50% compared with types I and II (p Conclusion Different high-risk stratifications of R-ST-D in patients with STEMI, especially type III and IV, can be used as objective independent indices to predict and assess the culprit coronary artery and life-threatening prognosis.

0236 : Epidemiological profile and prognostic factors of right myocardial infarction

Myocardial infarction can affect any myocardial territory, however, the isolated right ventricle infarction is exceptional. It is often biventricular with a high mortality of about 30% compared to that of isolated LV (6%). To study the features epidemiological, clinical, diagnostic, therapeutic and prognostic of it. Retrospective and descriptive study conducted in the Cardiology department of UH Ibn Rochd of Casablanca. It was conducted on 13 patients admitted for acute MI extended to the RV, in the period April 2013 to March 2014. The average age of our patients was 58 years ranging from 39 to 71 years, with a male predominance (77% VS 13%). The majority of our patients (85%) have more than 03 cardiovascular risk factors. Chest pain with in physical examination: the jugular turgor, hypotension and bradycardia were the most common clinical signs in our patients. The ECG showed an ST-elevation in right leads (V3R, V4R) and in the lower area (DII, DIII and AvF) in all our patients. Dilatation of right cavities and wall motion disorders were the most frequent echocardiographic abnormalities (69% of patients). The most frequent complications were hemodynamic instability (54%) and rhythmic complications (38%). From the therapeutic point, thrombolysis was performed in 10 patients, which 06 received an additional angioplasty after failed thrombolysis. 07 patients required vascular filling, and inotropic drugs were used in 05 of our patients. Mortality in our series was 23%. Our series underscores the value of an early management of patients admitted to the acute phase of MI extended to RV, and the considerable contribution of thrombolysis as a means of revascularization and its positive impact on prognosis.

The right ventricle: always normal in normal subjects?

Right ventricular (RV) structure and function serve as important indicators of a wide spectrum of heart diseases such as congenital heart disease, pulmonary hypertension, hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy/disease (ARVC/D) [1–3]. Over the past years cardiac magnetic resonance imaging (CMR) has proven itself as the preferred imaging modality of choice to evaluate RV anatomy, structure, texture, motion and function [4–9]. In the study by Quick et al. [10], published in the current issue of the Netherlands Heart Journal, a quantitative analysis of normal variations in RV wall motion was evaluated in healthy subjects using CMR. The study population consisted of 65 consecutive patients referred for the evaluation of cardiac function by 3 Tesla-CMR. All subjects were shown to be free of heart disease based on the currently available guidelines for CMR. Balanced steady-state free-precession images were obtained and regional RV wall motion was evaluated and classified based on a standardised segmental model for the right ventricle. In 59 out of 65 subjects (>90 %) wall motion abnormalities of the right ventricle were observed. Wall motion abnormalities were predominantly seen in the apico-lateral segments (72 %) when compared with the medio-lateral (24 %) and infero-lateral segments (4 %). Dyskinesia was the most frequent wall motion disorder (62 %), followed by hypokinesia (21 %) and bulging (17 %). The authors concluded that RV wall motion abnormalities are common in subjects supposed to be normal, indicating that one should be aware of the notion that non-pathological wall motion disorders can easily be mistaken for a pathological regional wall motion abnormality, particularly in patients with ARVC where –according to the authors- to date, clear wall motion criteria are lacking. The study is certainly very interesting in the sense that the right ventricle in normal subjects does not always appear normal when visualised by CMR. Especially, regional wall motion abnormalities are predominantly seen in the apico-lateral segments. However, the study warrants the following three comments. First, also acknowledged by the authors, the study was based on a small patient population. As a result, the description of normal variations in RV morphology as observed by CMR are not necessarily absolute and should only be regarded as hypothesis-generating for studying larger patient samples. Second, according to the authors, there is supposedly no in-depth knowledge on RV motion in healthy subjects. This is an obvious understatement as already in 2004 Pennell’s group (London, UK) showed that CMR demonstrated good inter-study reproducibility for RV function parameters in 20 healthy subjects, in 20 patients with heart failure, and in 20 patients with hypertrophy, suggesting that CMR is reliable for serial RV assessment [11]. In 2008, Youssef et al. [12] showed in 21 healthy subjects that the strain-encoding CMR technique allowed for rapid quantification of RV regional function with low intra- and inter-observer variability, permitting accurate quantification of regional strain in patients with RV dysfunction. Rather recently, Von Knobelsdorff-Brenkenhoff et al. [13], in nine healthy subjects, showed that fast-gradient echo cine imaging of the RV at 7 Tesla-CMR was feasible and provided good image quality; RV dimensions and function were comparable with steady-state free-precession at 1.5 Tesla-CMR as gold standard. Doesch et al. [14] showed in 20 healthy subjects that CMR-derived measurement of the tricuspid annular plane systolic excursion with a reference point outside the ventricle (TAPSEout) might be used for screening RV motion; however, the detection of subtle changes in RV function requires the 3D volumetric CMR approach. Third, and most importantly, Quick et al. [10] rather firmly state, that -particularly in ARVC patients- ‘to date clear wall motion criteria are lacking’. However, the revised ARVC/D diagnostic Task Force Criteria, already dating from 2010, incorporate clear CMR-defined cut-off values for RV ejection fraction and RV end-diastolic volume for ARVC [3, 15]. More specifically, the 2010 ARVC/D Task Force Criteria include the following parameters for CMR: 1) regional RV akinesia or dyskinesia or dyssynchronous RV contraction, 2) ratio of RV end-diastolic volume to BSA ≥110 mL/m2 (male) or ≥100 mL/m2 (female), or RV ejection fraction ≤40 %. Used in this way, CMR-derived RV ejection fraction can help in distinguishing ARVC/D from both normal subjects and/or from the physiological cardiac adaptation in athletes [3, 15]. To summarise, despite the above-mentioned critical comments, the study by Quick et al. [10] is a valuable contribution to our understanding of CMR-derived RV function in normal subjects. The study clearly shows that RV wall motion abnormalities may occur both in normal subjects and in diseased patients, in particular those with ARVC. Fortunately, CMR-derived parameters, as defined by the 2010 ARVC/D Task Force Criteria, may provide a major discriminatory role.

Evaluation and classification of right ventricular wall motion abnormalities in healthy subjects by 3-tesla cardiovascular magnetic resonance imaging.

BackgroundRight ventricular (RV) shape and function serves as an indicator in several types of heart disease such as arrhythmogenic right ventricular dysplasia (ARVD). However, there is no in-depth knowledge of RV motion, even in healthy subjects. The aim of our study was to provide a quantitative analysis of normal variations in RV wall motion in healthy subjects by cardiac magnetic resonance imaging (CMRI).Material and methodsThe study population consisted of 65 consecutive patients referred for the evaluation of cardiac function by 3 Tesla CMR. Balanced steady-state free-precession images were obtained and areas of disordered RV wall motion were evaluated and classified based on a standardised segmental model for the right ventricle.ResultsIn 59 patients (90.8 %) wall motion abnormalities (WMA) of the right ventricle were evident. WMA were predominately detected in the apicolateral segments (72 %) compared with mediolateral (24 %, P < 0.001) and inferolateral segments (4 %, P < 0.001). Dyskinesia was the most frequent wall motion disorder (62.4 %), followed by hypokinesia (20.8 %) and bulging (16.8 %). The mean WMA diameter in the transverse plane (6.4 ± 1.9 mm) was significantly shorter compared with the diameter in the horizontal long-axis (8.1 ± 3.6 mm, P = 0.002) and short-axis plane (10.7 ± 4.6 mm).ConclusionWMA of the right ventricle are common. Therefore, one should be aware that these nonpathological wall motion disorders can easily be mistaken for a pathological regional wall motion contraction, particularly in ARVD where to date, clear wall motion criteria are lacking.

Whole-body MRI and MRA for evaluation of the prevalence of atherosclerosis in a cohort of subjectively healthy individuals

ObjectivesTo assess the prevalence of cardiovascular findings in asymptomatic individuals by means of 1.5-T whole-body magnetic resonance imaging and angiography.MethodsA cohort of 138 individuals (118 men, 20 women) with a mean age of 54 years (SD ± 7.55) was referred to whole-body MRI at 1.5-T, including contrast-enhanced whole-body MR angiography (MRA) and cardiac MRI. A total of 2,065/2,070 vessel segments (99.8%) and cardiac function were evaluated.ResultsApproximately one-fourth of the participating individuals had vascular abnormalities. In 17 subjects (12.3% of all subjects) significant luminal narrowing was observed in at least one vascular segment. Luminal narrowing (mild to severe) was observed in 1 (0.7% of all subjects respectively) of the renal arteries, 7 (5.0%) of the carotid arteries, and 3 (2.2%) of the pelvic and upper leg arteries, and in 17 segments (12.3%) of arteries in the lower leg.In cardiac function and perfusion imaging, wall motion disorders were observed in six patients (4.3%), with additional delayed enhancement and isolated delayed enhancement present in two cases. Functional parameters differed from reference values in 55 cases.ConclusionsEven in an asymptomatic cohort of middle-aged predominantly male individuals, atherosclerotic disease is not uncommon and is detectable by whole-body MRI.Main Messages In middle-aged predominantly male individuals, atherosclerotic disease is not uncommon. Even in an asymptomatic collective, approximately one fourth had vascular abnormalities. Using whole-body MR angiography (MRA), 99.8% of 2,070 vessel segments could be evaluated.

Discinergia ventricular esquerda reversível identificada por potenciação pós-extrassistólica em miocardiopatia chagásica crônica não é causada por hibernação miocárdica

INTRODUCAO: A alteracao regional da mobilidade segmentar do ventriculo esquerdo e marcador precoce de miocardiopatia chagasica cronica. Demonstramos recentemente que a discinergia em algumas regioes ventriculares pode ser revertida pela potenciacao pos-extrassistolica. Apesar de angiografia coronaria normal, pacientes com miocardiopatia chagasica apresentam falhas de perfusao, corroborando a hipotese de que a hibernacao miocardica pode ser responsavel pelas anormalidades de mobilidade segmentar revertidas durante a potenciacao pos-extrassistolica. METODO: Vinte e dois pacientes consecutivos portadores de miocardiopatia chagasica foram submetidos a angiografia coronaria, ventriculografia e cintilografia miocardica com talio-201 com o protocolo estresse-redistribuicao-reinjecao para avaliacao da perfusao dos segmentos do ventriculo esquerdo demonstrando potenciacao pos-extrassistolica. RESULTADOS: Nao foram observadas obstrucoes coronarias significativas nos pacientes avaliados. Potenciacao pos-extrassistolica ocorreu em pelo menos um segmento ventricular esquerdo em 14 dos 22 pacientes, sendo observada em segmentos ventriculares com diminuicao de mobilidade de moderada a intensa, mas nao em segmentos com discinesia. Esses pacientes apresentaram melhora da media da pontuacao de mobilidade segmentar de 1,49 ± 0,73 para 1,36 ± 0,76 do batimento basal ao batimento pos-extrassistolico (P < 0,05). Nessas areas, a perfusao miocardica era normal ou apenas levemente prejudicada e sem demonstracao de isquemia com exercicio ou estresse farmacologico. CONCLUSAO: Estes resultados nao corroboram a hipotese de miocardio hibernante causado por disturbio de perfusao microvascular na miocardiopatia chagasica.

Transient left ventricular apical ballooning after physical exercise

A 43-year-old woman with mild hypertension and type-2 diabetes mellitus was presented to the coronary care unit because of ongoing chest pain and associated dyspnea after physical exercise. On arrival, her ECG disclosed ST-segment elevations in the precordial leads. The emergent cardiac catheterization failed to demonstrate coronary artery disease. The prompt performed transthoracic echocardiogram demonstrated systolic dysfunction with apical ballooning. Akinetic segments were irrespective of coronary artery anatomy. Laboratory tests revealed only slightly elevated cardiac enzymes: we observed a significant discrepancy between the extent of akinesis and the minimal increase in cardiac necroenzymes. The patient was medically managed and discharged in stable condition, with follow-up at 4 weeks demonstrating nearly total recovery of cardiac function and total resolution of wall motion disorder. Her clinical presentation is consistent with that of tako-tsubo cardiomyopathy, a syndrome that is characterized by transient apical regional wall motion abnormalities in the absence of epicardial coronary artery disease. Main precipitating factor is thought to be the cathecolamin excess due to emotional or physical stress, subarachnoid heamorrhage, phaeochromocytoma or cocaine use. The authors report the first physical exercise induced tako-tsubo syndrome in the Hungarian medical literature.

Silent Myocardial Ischemia

Silent myocardial ischemia is defined as objective documentation of myocardial ischemia in the absence of angina or anginal equivalents. Since its original description in the 1970s, it has undergone intensive investigation, and its clinical significance is now well established. This review will serve as an update on the pathophysiology, detection, prevalence, prognosis, and treatment of silent ischemia in both asymptomatic patients and those with angina, whether stable or unstable. ### Pain Studies No discussion of silent ischemia is complete without consideration of the cardiac pain mechanism. Although much has been learned about this subject, much is still uncertain. The afferent fibers that run in the cardiac sympathetic nerves are usually thought of as the essential pathway for the transmission of cardiac pain (Figure 1). The atria and ventricles are abundantly supplied with sympathetic sensory innervation; from the heart, the sensory nerve endings connect to afferent fibers in cardiac nerve bundles, which in turn connect to the upper 5 thoracic sympathetic ganglia and the upper 5 thoracic dorsal roots of the spinal cord. Within the spinal cord, impulses mediated by this sympathetic afferent route probably converge with impulses from somatic thoracic structures onto the same ascending spinal neurons. This would be the basis for cardiac pain referred to the chest, wall, arm, back etc. In addition to this “convergence-projection theory,” the contribution of vagal afferent fibers must be acknowledged for an explanation of cardiac pain referred to the jaw and neck. How these vagal fibers are activated remains unclear. Furthermore, somatic localization of ischemic pain cannot predict the site of myocardial ischemia (anterior, inferior, or lateral) from one patient to the next. Figure 1. Mechanisms of cardiac pain. From Droste and Roskamm (used with permission).4 The actual “trigger” that stimulates the sensory nerve endings remains elusive. If a chemical pain stimulus is involved, …

Diagnosis of arrhythmogenic right ventricular cardiomyopathy by Fourier analysis of gated blood pool single-photon emission tomography

To evaluate the diagnostic performance of Fourier phase analysis of gated blood pool single-photon emission computed tomography (GBP SPECT) in arrhythmogenic right ventricular (RV) cardiomyopathy, 18 patients with confirmed arrhythmogenic RV cardiomyopathy underwent GBP SPECT and x-ray cineangiography. Results were compared with data obtained with GBP SPECT in 10 control subjects. This 3-dimensional method demonstrated good correlation with cineangiography for measurements of RV enlargement and extent of the disease; RV and left ventricular segments were analyzed with the same accuracy. Tomographic abnormalities were significant decreased RV ejection fraction, RV dilatation, nonsynchronized contraction of the ventricles, increased RV contraction dispersion, presence of segmental RV wall motion disorders and/or phase delays, and occasionally regional left ventricular abnormalities. RV-delayed phase areas were always present in our population. A scoring system with RV criteria was proposed to diagnose RV disease. Because Fourier analysis of GBP SPECT provides ventricular morphologic information for the right ventricle with the same accuracy as for the left ventricle, it may replace planar radionuclide studies. Therefore, this method is helpful in patients with a strong clinical suspicion of arrhythmogenic RV cardiomyopathy, and should be used as a screening method before right ventriculography.

Hierarchy of levels of ischemia-induced impairment in regional left ventricular systolic function in man.

We tested the hypothesis that different subsets of ischemia-induced wall motion disorders are characterized by specific patterns of abnormal regional left ventricular systolic function. Regional contraction was quantitatively assessed from two-dimensional echocardiograms by an automated integrative analysis considering the time course of wall motion during the entire contraction sequence in 20 patients with chronic myocardial infarction, in 13 patients with impending myocardial infarction (less than 2 hr after the onset of symptoms), and in nine patients during transient myocardial ischemia. Wall motion abnormalities were detected in all patients by the integrative analysis. In contrast, the sensitivity for detecting wall motion abnormalities was 80% during chronic infarction, 77% during impending infarction, and 56% during transient ischemia if only end-diastolic and end-systolic frames were compared for assessment of overall regional systolic function. There were distinct differences in the time course of abnormal wall excursion between the three groups. Chronic infarction was characterized by a monophasic contraction pattern, with abnormal synergy in regional contractile events occurring predominantly during early systole. In contrast, transient ischemia caused predominantly mid-to-late systolic abnormal synergy followed by late systolic shortening corresponding to a polyphasic contraction pattern. During impending infarction, an intermediate temporal contraction pattern was present with both early and mesosystolic abnormal synergy.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of phase-angle histograms from equilibrium radionuclide studies: Correlation with semiquantitative grading of wall motion

Quantitative wall motion assessment from gated radionuclide left ventriculograms using phase analysis was studied in 14 subjects (6 normal volunteers and 8 patients with previous acute myocardial infarction). The standard deviation and skewness of the phase-angle histograms were determined from both global and segmental left ventricular (LV) regions of interest (septal, apical and posterolateral). Studies were performed at rest, after administration of atropine and after combined administration of phenylephrine and atropine. Both the standard deviation and skewness showed significant correlations with semiquantitative wall motion scoring. From the global analyses, the highest correlations were found after atropine administration (r = 0.86, p < 0.001 for standard deviation and r = 0.72, p < 0.001 for skewness). Nevertheless, deterioration in global wall motion scores correlated poorly with directional changes in standard deviation (r = 0.06, difference not significant) or skewness (r = 0.33, p < 0.05). No significant correlation between skewness or change in skewness and wall motion scores were found with the segmental analyses. The maximal correlation between segmental standard deviation and segmental wall motion grading was again noted after atropine administration (r = 0.68, p < 0.001), but deterioration in grading did not correlate with similar deterioration of the standard deviation (r = −0.05, difference not significant). Based on 90% confidence limits for normal standard deviation and skewness, an abnormal standard deviation (>14.5) identified 13 of 28 wall motion disorders (sensitivity 46%), whereas an abnormal skewness (>1.4) identified 1 of 28 wall motion disorders (sensitivity 4%). In conclusion, the presently implemented methods of phase-angle analysis in clinical use are insensitive in characterizing wall motion disorders. This limitation is most profound in the assessment of directional changes in wall motion.