Wall Motion Index Research Articles

Right and left bundle branch block as predictors of long‐term mortality following myocardial infarction

Patients with acute myocardial infarction (MI) with bundle branch block (BBB) have a poor prognosis, but distinction between left (L)- and right (R)-sided BBB is seldom made in epidemiological studies. We studied long-term mortality associated with RBBB and LBBB in the TRAndolapril Cardiac Evaluation (TRACE) study. TRACE screened consecutive patients presenting with an MI and recorded clinical, electro- and echo-cardiographic variables. Subsequently, deaths were recorded during a minimum follow-up of 15 years. In total, 6676 consecutive patients with MI were hospitalized at 27 centres in Denmark. Of these, 533 (8%) had BBB, of whom 260 (4%) had RBBB and 273 (4%) had LBBB. Overall, 5196 (78%) patients died, 256 (94%) with LBBB and 235 (90%) with RBBB compared with 4705 (77%) of those without BBB (P < 0.001). In multivariable analyses, hazard ratios (HRs) of RBBB and LBBB were 1.23 [95% confidence interval (CI), 1.07-1.42] and 1.05 (95% CI, 0.91-1.20), respectively. There was interaction between each type of BBB and left ventricular (LV) systolic function (P = 0.02). Right BBB was associated with a worse prognosis in patients with reduced LV systolic function [HR = 1.31 with wall motion index (WMI) ≤ 1.5 (95% CI, 1.11-1.55] while LBBB had a poor prognosis in patients with preserved LV systolic (HR if WMI > 1.5, 1.70; 95% CI, 1.12-2.57). Right BBB was a predictor of increased mortality in patients with reduced LV systolic function, whereas LBBB was a marker of increased mortality in patients with preserved LV systolic function.

531 IMPACT-CABG trial: Implantation of CD133+ stem cells in patients undergoing coronary bypass surgery, analysis of security, feasibility and efficacy for the first five open-labeled patients

Cellular transplantation is a novel strategy to improve ischemic myocardium healing. Bone marrow CD133+ cells are distinct early progenitor group of hematopoietic stem cells that possess high engraftment, pluripotent and angiogenic capacity and appear valuable for cardiac repair by promoting neovascularization, cardiomyogenesis and inhibition of apoptosis. The aim is to report the feasibility, security and beneficial effects of intramyocardial injection of CD133+ stem cells. We report herein the 6 month follow-up on the first 5 patients treated in an open labeled fashion in the IMPACT-CABG study. This is a randomized-controlled phase II clinical trial aiming to assess the safety and effects of intramyocardial injections of autologous CD 133+ selected stem cells in coronary artery bypass grafting (CABG) patients with chronic ischemic cardiomyopathy (left ventricular ejection fraction (LVEF) below 45%). Cardiac function and myocardial viability was assessed by stress echocardiography and magnetic resonance imaging (MRI) before and 6 months after surgery. Bone marrow aspiration and cell selection, using the CliniMACS system, are performed the morning of the surgical procedure and cells are injected intramyocardially after completion of the distal anastomosis before weaning from cardiopulmonary bypass. Five males, mean age 65 ± 10 years, underwent CABG for 3 ± 1 bypasses. A total of 10 millions CD133+ cells were injected in 15 sites (total cell suspension volume 2.0 ml). Post-operative course was uneventful for each patient. There was no peri-operative complication related to this protocol, and no Major Adverse Cardiac Event (MACE) defined as cardiac death, myocardial infarction, repeated coronary revascularization or sustained ventricular arrhythmias. Pre- and 6 months post-operative LVEF were 34.0 ± 2.2 and 39.0 ± 11.9 respectively (P = ns). Moreover, MRI studies suggested that LV end-diastolic and end-systolic volumes decreased after cell implantation compared to baseline. Echocardiographic regional wall motion index for all patients in the ischemic stem cell-injected territories improve at 6 months of follow-up in all patients compared to baseline. The NYHA functional class improved for every patient from class III to class I. This work represents the first Canadian experience with CD133+ stem cells for the treatment of chronic ischemic cardiomyopathy and relies on state-of-the-art methods for assessing myocardial functional recovery and viability. These encouraging results support the safety and feasibility of intramyocardial injections of CD 133+ cells in addition to CABG. IMPACT-CABG trial with further double-blind randomization between CD 133+ cells vs. placebo will test the beneficial impact of this approach.

Isolated Coronary Artery Bypass Graft Combined With Bone Marrow Mononuclear Cells Delivered Through a Graft Vessel for Patients With Previous Myocardial Infarction and Chronic Heart Failure: A Single-Center, Randomized, Double-Blind, Placebo-Controlled Clinical Trial

This study aimed at examining the efficacy of bone marrow mononuclear cell (BMMNC) delivery through graft vessel for patients with a previous myocardial infarction (MI) and chronic heart failure during coronary artery bypass graft (CABG). Little evidence exists supporting the practice of BMMNC delivery through graft vessel for patients with a previous MI and chronic heart failure during CABG. From November 2006 to June 2009, a randomized, placebo-controlled trial was conducted to test the efficacy and safety of CABG for multivessel coronary artery disease combined with autologous BMMNCs in patients with congestive heart failure due to severe ischemic cardiomyopathy. Sixty-five patients were recruited, and 60 patients remained in the final trial and were randomized to a CABG + BMMNC group (n = 31) and a placebo-control group (i.e., CABG-only group, n = 29). All patients discharged received a 6-month follow-up. Changes in left ventricular ejection fraction from baseline to 6-month follow-up, as examined by magnetic resonance imaging, were of primary interest. The overall baseline age was 59.5 ± 9.2 years, and 6.7% were women. After a 6-month follow-up, compared with the placebo-control group, the CABG + BMMNC group had significant changes in left ventricular ejection fraction (p = 0.029), left ventricular end-systolic volume index (p = 0.017), and wall motion index score (p = 0.011). Also, the changes in the distance on the 6-min walking test as well as B-type natriuretic peptide were significantly greater in the CABG + BMMNC group than in the control group. In summary, patients with a previous MI and chronic heart failure could potentially benefit from isolated CABG (i.e., those who received CABG only) combined with BMMNCs delivered through a graft vessel. (Stem Cell Therapy to Improve Myocardial Function in Patients Undergoing Coronary Artery Bypass Grafting [CABG]; NCT00395811).

Transmural Myocardial Strain Gradient: A New and Robust Quantitative Index of Left Ventricular Wall Motion Based on Myocardial Strain Imaging

Peak strain has been promising as an index of wall motion but it is sometimes susceptible to the image quality. We investigated the feasibility of a novel index, transmural myocardial strain gradient (TMSG), derived from myocardial strain M-mode imaging (TDI-Q, Toshiba) for quantifying regional systolic wall motion. We measured transmural myocardial strain distribution at the left ventricular lateral, posterior, inferior, septal, anteroseptal and anterior walls in the basal and midventricular short-axis images using TDI-Q. Twenty normals (35 ± 3 years) and 35 consecutive patients (63 ± 9 years) with coronary artery disease (CAD, 19 patients with old myocardial infarction, 4 patients with acute myocardial infarction, 12 patients with angina pectoris) were studied. Peak strain, endocardial- and epicardial-half strain and TMSG ((peak strain, - epicardial strain)/distance between peak and epicardial points) were obtained. Coefficient of variation (CV) of each index was calculated. In control subjects, the best reproducibility of the variables was obtained for TMSG with the smallest CV (11.6%) (27.8%, 28.1%, and 35.5%, respectively for CV of peak strain, endocardial- and epicardial-half strain). All segments in control subjects and normal segments in CAD patients showed no significant difference in TMSG (15.1 ± 1.8 vs. 15.1 ± 1.6%/mm, P = ns). TMSG was the lowest for akinetic segments and highest for the normal segments (P < 0.001). TMSG was more robust than simple strain values to quantitatively assess wall motion. This could successfully identify subtle regional differences in wall function.

Intérêt de la mesure du temps de décélération diastolique par Doppler transthoracique dans l’évaluation du phénomène de no-reflow au cours de l’infarctus du myocarde antérieur traité par angioplastie primaire

Aims To assess the value of coronary flow measurement by transthoracic Doppler technique in the detection of “no-reflow” phenomenon. Methods Fourteen patients with first anterior wall infarction treated by successful (TIMI3) primary percutaneous angioplasty and left descending coronary artery stenting were investigated. Myocardial perfusion following PCI was assessed by (i) ST-segment resolution, (ii) MRI-detected microvascular obstruction (early hypoenhancement), (iii) coronary flow pattern measurement by transthoracic Doppler technique. Results Sustained impairment of myocardial perfusion following PCI was observed in a large proportion of the cohort (36% by MRI, 43% by ST regression analysis). Patients with a diastolic deceleration time inferior to 482 ms had higher troponin and CK peak value, higher wall motion index score, lower ST resolution and lower LVEF assessed by MRI. The concordance of the three methods was 80%. Conclusion The measurement of diastolic deceleration time by transthoracic Doppler technique is a reliable technique to identify microvascular obstruction following PCI in acute anterior STEMI. A DDT inferior to 482 ms is associated with sustained “no-reflow” phenomenon.

Myocardial Perfusion Grade After Late Infarct Artery Recanalization Is Associated With Global and Regional Left Ventricular Function at One Year

Background— Whether myocardial perfusion grade (MPG) following late recanalization of infarct-related arteries (IRAs) predicts left ventricular (LV) function recovery beyond the acute phase of myocardial infarction (MI) is unknown. Methods and Results— The Total Occlusion Study of Canada-2 enrolled stable patients with a persistently occluded IRA beyond 24 hours and up to 28 days post-MI. We studied the relationship between the initial MPG and changes in LV function and volume as well as the change in MPG from immediate post-percutaneous coronary intervention (PCI) to 1 year in 139 PCI patients with thrombolysis in myocardial infarction grade 3 epicardial flow post-PCI and with paired values grouped into impaired or good MPG groups (MPG 0/1 or MPG 2/3). MPG 0/1 patients were more likely to have received thrombolytic therapy and to have a left anterior descending IRA. They had lower blood pressure and LV ejection fraction (LVEF) and a higher heart rate and systolic sphericity index at baseline. Changes in the MPG 0/1 and MPG 2/3 groups from baseline to 1 year were LVEF, 3.3±9.0% and 4.8±8.9% ( P =0.42); LV end-systolic volume index (LVESVI), −1.1±9.2 and −4.7±12.3 mL/m 2 ( P =0.25); LV end-diastolic volume index (LVEDVI), 0.08±19.1 and −2.4±22.2 mL/m 2 ( P =0.67); and SDs/chord for infarct zone wall motion index (WMI), 0.38±0.70 and 0.84±1.11 ( P =0.01). By covariate-adjusted analysis, post-PCI MPG 0/1 predicted lower WMI ( P &lt;0.001), lower LVEF ( P &lt;0.001), and higher LVESVI ( P &lt;0.01) but not LVEDVI at 1 year. Of the MPG 0/1 patients, 60% were MPG 2 or 3 at 1 year. Conclusions— Preserved MPG is present in a high proportion of patients following late PCI of occluded IRAs post-MI. Poor MPG post-PCI frequently improves MPG over 1 year. MPG graded after IRA recanalization undertaken days to weeks post MI is associated with LV recovery, indicating that MPG determined in the subacute post-MI period remains a marker of viability. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00025766.

Perfusion defects on real-time myocardial contrast echocardiography predict higher mortality in patients with end-stage renal disease – A 3-year follow-up

Aim: The aim of this study was to assess the prognostic significance of myocardial contrast echocardiography (MCE) in patients with end-stage renal disease (ESRD) on a 3-year follow-up and to compare the value of MCE with demographic, clinical, and laboratory parameters. Methods: Fifty-eight ESRD patients on regular dialysis were prospectively screened for coronary artery disease (CAD) using perfusion assessment on real-time MCE. We analyzed the following end points during the 3-year follow-up: death, cardiovascular complications, and combined end point, which consisted of adverse cardiac events mentioned above. All features were compared between the two groups with and without perfusion disturbances on MCE. Results: No adverse events related to MCE administration have been observed. Twenty-seven (47%) patients with ESRD demonstrated perfusion defects on MCE. The patients with perfusion defects on MCE comparison with those without perfusion disturbances were older (p = 0.008) and had lower ejection fraction (EF) (p = 0.0001) and higher wall motion index (WMSI) (p = 0.0001). After the 3-year follow-up, the incidence of death (p = 0.00018), cardiovascular end points, revascularizations [both percutaneous coronary intervention (PCI) and coronary artery bypass grafts (CABG) p = 0.0016 and p = 0.004, respectively], and composite end point (p = 0.0015) was significantly higher in patients with perfusion defect on MCE. Conclusions: In patients with ESRD, MCE appears to be a safe and useful tool for risk stratification. MCE facilitates decision for coronary angiography.

The First Clinical Pilot Study of Intravenous Adrenomedullin Administration in Patients With Acute Myocardial Infarction

Adrenomedullin (AM) is a 52-amino-acid vasodilator peptide that was originally isolated from human pheochromocytoma. In the previous experimental study with rat ischemia/reperfusion model, AM reduced infarct size and inhibited myocyte apoptosis. AM also suppressed the production of oxygen-free radicals. The present study was designed to evaluate the feasibility of intravenous administration of AM in patients with acute myocardial infarction. We studied 10 patients with first acute myocardial infarction [male to female ratio: 9 to 1, age: 65 ± 9 (mean ± SD) years, peak creatine phosphokinase level: 4215 ± 1933 (SD) U/L], who were hospitalized within 12 hours of symptom onset. Proceeding reperfusion therapy, AM infusion was initiated and continued at concentration of 0.0125-0.025 μg·kg·min for 12 hours. Follow-up coronary angiography and left ventriculography were performed at 3 months. Cardiac magnetic resonance was examined at 1 month and 3 months after AM therapy. During infusion of AM, hemodynamics kept stable except 2 patients. Wall motion index in the infarct area at 3 months was significantly improved compared with that at baseline, and infarct size evaluated by cardiac magnetic resonance was significantly decreased at 3 months. In conclusion, intravenous administration of AM, which possesses a variety of potential cardiovascular protective actions, can be adjunctive to percutaneous coronary intervention.

Persistence of the prognostic importance of left ventricular systolic function and heart failure after myocardial infarction: 17‐year follow‐up of the TRACE register

Left ventricular systolic function and presence of heart failure (HF) are important prognostic factors and dictate future therapeutic strategies after myocardial infarction (MI). We evaluated persistence of the prognostic importance of left ventricular dysfunction and HF in consecutive MI patients screened for entry in the Trandolopril Cardiac Evaluation Registry (TRACE) study. The study population comprised 6676 MI patients screened for entry into the TRACE study, a double-blind, randomized, parallel group, placebo-controlled study of trandolapril vs. placebo in patients with left ventricular dysfunction after MI. In unadjusted analysis, patients with reduced left ventricular function and HF continued to show increased mortality. Landmark analysis and Cox proportional-hazards models showed that wall motion index (WMI) was a significant prognostic factor until 10 years of follow-up with hazard ratios ranging between 0.74 [confidence interval (CI) 0.71-0.78] and 0.90 (CI 0.82-0.98) associated with a 12% improvement in left ventricular ejection fraction (0.4 WMI units). The prognostic significance of HF persisted for 8 years with hazard ratios between 1.47 (CI 1.21-1.78) and 2.62 (95% CI 2.30-2.98) for the first 8 years. When assessed during the index MI, WMI and HF carry prognostic information for up to 10 years.

Predictors of contractile recovery after revascularization in patients with anterior myocardial infarction who received thrombolysis

Identification of viable myocardium after myocardial infarction has gained paramount importance with the current progress in coronary revascularization. To explore the prognostic power of certain patient characteristics to predict myocardial contractile recovery after revascularization in patients presenting with acute anterior ST elevation myocardial infarction (STEMI) who received thrombolytic therapy. Seventy-three consecutive patients presenting with first acute anterior STEMI who had received thrombolytic therapy and had significant coronary stenosis or occlusion of the infarct-related artery amenable for revascularization were enrolled. All patients underwent echocardiographic assessment of regional wall motion and left ventricular ejection fraction. Patients underwent coronary revascularization by either percutaneous angioplasty or surgical bypass. Echocardiography was repeated two to three months following revascularization. Patients were classified into two groups: group 1 had evidence of contractile recovery after revascularization at follow-up echocardiography and group 2 had no such evidence of recovery. Predictors of contractile recovery after revascularization included a shorter time from symptom onset to the institution of thrombolytic therapy, a lower baseline wall motion score index, the presence of grade 3 collaterals to the infarct-related artery and the use of beta-blockers. Instead, the presence of diabetes mellitus and a totally occluded infarct-related artery predicted poor contractile recovery. Myocardial contractile recovery after revascularization in patients presenting with first acute anterior STEMI may be predicted by the absence of diabetes, a shorter time from symptom onset to thrombolytic therapy, the use of beta-blockers, a lower initial wall motion index score and the presence of collaterals to the infarct-related artery.

Practical considerations for a method of rapid cardiac function analysis based on three-dimensional speckle tracking in a three-dimensional diagnostic ultrasound system.

The purpose of this study was to validate the accuracy of our novel 3D speckle tracking method by using numerical data, and to demonstrate the rapid processing of this method by using data obtained from human subjects. In order to create a method that can rapidly assess cardiac function in regional heart wall segments, a 3D speckle tracking algorithm was created that focuses on data quality and performance. Prototype application software based on this algorithm was written to evaluate cardiac wall motion and to calculate indices such as strain. Time series 3D image data were generated for artificial numerical models that simulate the shape of the left ventricle and exhibit various types of motion. We compared observed values returned by the algorithm with expected values yielded by the models. This software was also applied to volume data of the human heart acquired by a 3D ultrasound system. Measurement of the indices was evaluated by using an error ratio that was a residual between an expected value and estimated one divided by the expected value. The average error ratio of the time series volumes was less than 5% for all indices, and no individual error ratio was more than 10% for numerical models. The process was complete within 0.5s per frame for human heart volumes. This application software can provide good estimates of various wall motion indices. The results are similar to data from numerical models, and are provided quickly enough for routine clinical usage.

Quantitative Evaluation of Regional Left Ventricular Function Using Three-Dimensional Speckle Tracking Echocardiography in Patients With and Without Heart Disease

Although 2-dimensional (2D) speckle tracking echocardiography has been shown to be useful in the assessment of regional left ventricular function, it is limited by the assumption that speckles can be tracked frame-to-frame within the imaging plane, even though the cardiac motion is 3-dimensional (3D). Our goal was to evaluate new 3D-speckle tracking echocardiographic (STE) software by (1) comparing the regional wall motion measurements against 2D-STE images, and (2) testing its ability to identify regional wall motion abnormalities. The 2D images and real-time 3D data sets (Toshiba) obtained from 32 subjects were analyzed to measure segmental radial and longitudinal displacements and rotation, as well as the radial, longitudinal, and circumferential strains. The intertechnique comparisons included regression and Bland-Altman analyses. Additionally, cardiac magnetic resonance images (Siemens 1.5 T) acquired the same day were reviewed by an expert who classified the segments as normal or abnormal. The values of each 3D-STE index were compared between the normal and abnormal segments. The 3D-STE and 2D-STE indexes did not correlate well (r = 0.16 to 0.76) and showed wide limits in intertechnique agreement (2 SD: 5 to 6 mm for displacements, 14 degrees rotation, 17% to 52% strains) despite only minimal biases, indicating that these 2 techniques are not interchangeable. In normal segments, 3D-STE showed greater displacements, reflecting the out-of-plane motion component; smaller SDs, indicating tighter normal ranges; and a gradual decrease in radial and longitudinal displacement and a reversal in rotation from the base to the apex. In the abnormal segments, all 3D-STE indexes were reduced, reaching significance for 5 of 6 indexes. In conclusion, this is the first study to evaluate the new 3D-STE technique for measurement of regional wall motion indexes. Our findings have demonstrated its superiority over 2D-STE.

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

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

Left ventricular contractile function after distal protection in primary percutaneous coronary intervention

Coronary intervention (PCI) may result in an increased infarct size. We evaluated the effect of distal protection during PCI for ST-segment elevation myocardial infarction (STEMI) on myocardial function. Patients with STEMI were randomly referred within 12 h for PCI with (N = 312) or without distal protection (N = 314). Left ventricular (LV) contractile function was assessed with echocardiography 8 months after PCI. Global LV myocardial wall motion index (WMI) was calculated as the average wall motion score of all myocardial segments. The occurrence of death, nonfatal re-infarction, and stroke 8 months after PCI were also recorded. The occurrence of death, nonfatal re-infarction, and stroke 8 months after PCI was 7.1% after distal protection and 5.7% after conventional treatment (p = 0.17). WMI improved by 4.1% at 8 months in patients treated with distal protection compared to patients receiving conventional PCI (p < 0.01). In myocardium supplied by a culprit artery treated by distal protection regional LV function was 9-11% higher than myocardial regions treated conventionally ( p < 0.02). Routine use of distal protection during primary PCI is associated with a significant improvement in LV contractile function, with no detectable impact on intermediate term clinical outcome.

Abstract 2664: Clinical Outcome and Left Ventricular Contractile Function After Distal Protection in Primary Percutaneous Coronary Intervention The Drug Elution and Distal Protection in ST-Elevation Myocardial Infarction (DEDICATION) Trial

Objective Embolization of material from an infarct-related lesion during percutaneous coronary intervention (PCI) may result in an increased infarct size. We evaluated the effect of distal protection during PCI for ST-segment elevation myocardial infarction (STEMI) on clinical outcome and myocardial function. Methods and results Patients with STEMI were randomly referred within 12 hours for PCI with (n = 312) or without distal protection (n = 314). Left ventricular (LV) contractile function was assessed with echocardiography 8 month after PCI. Global LV myocardial wall motion index (WMI) was calculated as the average wall motion score of all myocardial segments. Major adverse cardiac and cerebral events (MACCE) 8 months after PCI was 7.1 % after distal protection and 5.7 % after conventional treatment (p = 0.17). WMI improved by 4.1% at 8 months in patients treated with distal protection compared to patients receiving conventional PCI (p&lt;0.01). In myocardium subtended by culprit coronary vessels treated with distal protection regional LV function was 9 –11% higher than myocardial regions treated conventionally (p&lt;0.02). Conclusion Routine use of distal protection during primary PCI is associated with a significant improvement in LV contractile function, with no detectable impact on intermediate term clinical outcome.

Chronic obstructive pulmonary disease in patients admitted with heart failure

Chronic obstructive pulmonary disease (COPD) is an important differential diagnosis in patients with heart failure (HF). The primary aims were to determine the prevalence of COPD and to test the accuracy of self-reported COPD in patients admitted with HF. Secondary aims were to study a possible relationship between right and left ventricular function and pulmonary function. Prospective substudy. Systematic screening at 11 centres. Consecutive patients (n = 532) admitted with HF requiring medical treatment with diuretics and an episode with symptoms corresponding to New York Heart Association class III-IV within a month prior to admission. Forced expiratory volume in 1 s (FEV(1)) and forced vital capacity (FVC) were measured by spirometry and ventricular function by echocardiography. The diagnosis of COPD and HF were made according to established criteria. The prevalence of COPD was 35%. Only 43% of the patients with COPD had self-reported COPD and one-third of patients with self-reported COPD did not have COPD based on spirometry. The prevalence of COPD in patients with preserved left ventricular ejection fraction (i.e. LVEF >or=45%) was significantly higher than in patients with impaired LVEF (41% vs. 31%, P = 0.03). FEV(1) and FVC were negatively correlated with right ventricular end-diastolic diameter and tricuspid annular plane systolic excursion and FVC positively correlated with systolic gradient across the tricuspid valve. Chronic obstructive pulmonary disease is frequent in patients admitted with HF and self-reported COPD only identifies a minority. The prevalence of COPD was high in both patients with systolic and nonsystolic HF.

C-Terminal Provasopressin (Copeptin) is Associated With Left Ventricular Dysfunction, Remodeling, and Clinical Heart Failure in Survivors of Myocardial Infarction

Background Acute myocardial infarction (AMI) is associated with left ventricular (LV) dysfunction and clinical heart failure. Arginine vasopressin is elevated in heart failure and the C-terminal of provasopressin (Copeptin) is associated with adverse outcome post-AMI. The aim of this study was to describe the association between Copeptin with LV dysfunction, volumes, and remodeling and clinical heart failure post-AMI. Methods and Results We studied 274 subjects with AMI. Copeptin was measured from plasma at discharge and subjects underwent echocardiography at discharge and follow-up (median 155 days). Subjects were followed for clinical heart failure for a median of 381 days. Remodeling was assessed as the change (Δ) in LV volumes between echo examinations. Copeptin correlated directly with wall motion index score (WMIS) and inversely with LV ejection fraction (LVEF) at discharge (WMIS, r = 0.276, P < .001; LVEF, r = −0.188, P = .03) and follow-up (WMIS, r = 0.244, P < .001; LVEF, r = −0.270, P < .001) and with ventricular volumes at follow-up (LVEDV, r = 0.215, P = .002; LVESV, r = 0.299, P < .001). Copeptin was associated with ventricular remodeling; ΔEDV; r = 0.171, P = 0.015, ΔESV; r = 0.186, P = .008. Subjects with increasing LVESV had higher levels of Copeptin (median 6.30 vs. 5.75 pmol/L, P = .012). Subjects with clinical heart failure (n = 30) during follow-up had higher Copeptin before discharge (median 13.55 vs. 5.80, P < .001). In a Cox proportional hazards model, Copeptin retained association with clinical heart failure. Kaplan-Meier assessment revealed increased risk in subjects with Copeptin >6.31 pmol/L. Conclusions Copeptin is associated with LV dysfunction, volumes, and remodeling and clinical heart failure post-AMI. Measurement of Copeptin may provide prognostic information and the AVP system may be a therapeutic target in post-MI LV dysfunction.

Quantitative assessment of left ventricular systolic wall thickening using multidetector computed tomography

Background Multidetector computed tomography (MDCT) of the heart provides both anatomical and functional information. The objective of this study was to evaluate the accuracy of quantitative assessment of left ventricular contractile function in relation to two-dimensional transthoracic echocardiography (TTE). Materials and methods Sixty-four patients with known or suspected coronary artery disease underwent ECG-gated 64-slice MDCT and TTE. Regional left ventricular contractile function was measured by percent systolic wall thickening (SWT) in 16 myocardial segments using MDCT, and compared with visual evaluation of wall motion score (WMS) by TTE. Global SWT by MDCT was calculated as the mean SWT of all myocardial segments and compared with wall motion index (WMI) by TTE. Results Eight hundred and eleven segments (81%) were classified as normokinetic, 142 (14%) as hypokinetic, 41 (4%) as akinetic and 5 (0.5%) as dyskinetic by TTE. A significant inverse linear trend was found between regional SWT by MDCT and WMS by TTE ( p < 0.001). Sensitivity and specificity for the identification of regional abnormalities of contractile function were 76% and 78%, respectively. A linear correlation between global SWT by MDCT and WMI by TTE was found ( r = −0.8, p < 0.001). Sensitivity and specificity for the identification of WMI > 1.5 using global SWT was 91% and 94%, respectively. Conclusion Quantification of systolic wall thickening by MDCT provides functional information, which is well correlated to visual assessment of global left ventricular contractile function by TTE.

Wall motion index, estimated glomerular filtration rate and mortality risk in patients with heart failure or myocardial infarction: A pooled analysis of 18,010 patients

This study was designed to assess whether the prognostic significance of estimated glomerular filtration rate (eGFR) and left ventricular ejection fraction (LVEF) interact in populations with heart failure (HF) and myocardial infarction (MI). Patients were recruited from four screening registers (N=18,010) including patients admitted with HF or MI. Ten years follow-up was recorded and formal testing for interactions between eGFR and LVEF with respect to outcome was done. Twelve-thousand-and-ninety patients died. A significant interaction (P=0.010) was found and each parameter became relatively more important when the value of the other was low. eGFR and LVEF were reparameterized to categorical variables and we observed that chronic kidney disease stage II was associated with a decreased (Hazard ratio (HR): 0.79 (95% Confidence Interval: 0.72-0.86)) and chronic kidney disease stages IV (HR: 1.60 (1.45-1.91) and V (HR: 1.91 (1.45-2.52) were associated with an increased mortality risk with an additive effect of left ventricular systolic dysfunction (LVSD). The prognostic significance of eGFR and LVEF is synergistic in patients with HF or MI and the impact of one parameter is inversely related to the level of the other. Statistical interactions are scale dependent and the relationship between chronic kidney disease stages I to V and mortality risk is J-shaped with an additive effect of LVSD.

Prognostic importance of a short deceleration time in symptomatic congestive heart failure☆

A restrictive transmitral filling (RF) pattern predicts increased mortality in heart failure (HF) with reduced left ventricular (LV) systolic function. We performed a combined evaluation of LV function and RF for prognosis in patients with HF with and without systolic dysfunction. Doppler echocardiography was performed in 972 patients with symptomatic HF. RF was considered present when deceleration time (DT) was <or=140 ms and non-RF when >140 ms. A DT >240 ms was defined as delayed relaxation. During a median of 51 months the unadjusted all-cause mortality rates were significantly increased among patients with RF vs. the non-RF group (1- and 4-year mortality was 25% and 54% vs. 17% and 43%). In a multivariable model, RF was a significant predictor of all-cause mortality (hazard ratio (HR)=2.0, 95% confidence interval (CI):1.5-2.6) whereas delayed relaxation was without prognostic importance (HR=0.9, CI:0.5-1.6). Repeating the multivariable model in subgroups of wall motion index (WMI) showed that RF was a strong predictor of mortality independent of WMI. For patients with LVEF of at least 50%, HR for RF was 2.0 (CI:1.1-3.4; p=0.02) and interaction between LVEF and RF was not significant. In a heterogeneous population hospitalised for symptomatic HF a restrictive transmitral filling pattern, defined as shortened deceleration time, during hospitalisation is an ominous prognostic sign independent of LV systolic function.