Wall Motion Score Index Research Articles

Coronary flow reserve is related to the extension and transmurality of myocardial necrosis and predicts functional recovery after acute myocardial infarction

Few studies have examined the effect of transmurality of myocardial necrosis on coronary microcirculation. The aim of this study was to examine the influence of cardiac magnetic resonance-derived (GE-MRI) structural determinants of coronary flow reserve (CFR) after anterior myocardial infarction (STEMI), and their predictive value on regional functional recovery. Noninvasive CFR and GE-MRI were studied in 37 anterior STEMI patients after primary coronary angioplasty. The wall motion score index in the left descending anterior coronary artery territory (A-WMSI) was calculated at admission and follow-up (FU). Recovery of regional left ventricular (LV) function was defined as the difference in A-WMSI at admission and FU. The necrosis score index (NSI) and transmurality score index (TSI) by GE-MRI were calculated in the risk area. Baseline (BMR) and hyperemic (HMR) microvascular resistance, arteriolar resistance index (ARI), and coronary resistance reserve (CRR) were calculated at the Doppler echocardiography. Bivariate analysis indicated that the CPK and troponin I peak, heart rate, NSI, TSI, BMR, the ARI, and CRR were related to CFR. Multivariable analysis revealed that TSI was the only independent determinant of CFR. The CFR value of >2.27, identified as optimal by ROC analysis, was 77% specific and 73% sensitive with accuracy of 76% in identifying patients with functional recovery. Preservation of microvascular function after AMI is related to the extent of transmurality of myocardial necrosis, is an important factor influencing regional LV recovery, and can be monitored by noninvasive CFR.

Value of Two-Dimensional Strain Imaging in Prediction of Myocardial Function Recovery After Percutaneous Revascularization of Infarct-Related Artery

Background: Acute myocardial infarction (MI) is often accompanied by impaired regional myocardial systolic function. A novel approach known as two-dimensional speckle tracking echocardiography was used to quantify regional LV function. Objective: The aim of the current study was to evaluate of the role of Speckle Tracking Echocardiography in prediction of left ventricular function recovery after percutaneous coronary intervention to left anterior descending coronary artery in patients with anterior ST segment elevation myocardial infarction with impaired left ventricular ejection fraction. Patients and methods: This study included 50 patients and 15 normal control adult persons. Patients had suffered from first attack of anterior STEMI. They were admitted at the CCU units of Al-Azhar University Hospitals from September 2016 to September 2018 and treated with thrombolytic therapy. Each patient was subjected to conventional transthoracic echocardiography before hospital discharge and before reperfusion. Speckle tracking echocardiography and resting SPECT were done one week after MI. Percutaneous coronary intervention to LAD within one week after MI for patients with demonstrated myocardial viability by resting SPECT. Three months after percutaneous revascularization to LAD, all patients were reevaluated using conventional TTE and strain imaging. The studied population were divided into 2 Groups; group A: 24 patients who showed post-PCI LV function recovery and Group B: 26 patients who did not showed post-PCI LV function recovery. Results: There was statistically significant increase in the prevalence of diabetes mellitus, smoking and dyslipidemia in group B. There was high statistically significant difference between the two groups as regard baseline LVEF (%), baseline wall motion score index (WMSI), mean baseline and follow up WMSI values, baseline number of affected left anterior descending (LAD) segments as assessed by WMSI, baseline and 90 days follow up mean number of affected LAD segments, baseline strain values at both global LV and territorial LAD segments. Control group showed mean territorial LAD strain was - 20.41± 0.61, mean baseline territorial LAD strain of group (A) - 13.20 ± 2.05 and mean baseline territorial LAD strain of group (B) - 8.47 ± 2.12. Regarding mean baseline territorial LAD strain and mean GLS of the LV, Receiver Operating Characteristic curve was done between group A and B for obtaining a cut off value of – 11.3 % and – 11.8 % respectively. Conclusion: LV global and territorial strain measured by 2D STE is a good predictor of LV function recovery in STEMI patients after percutaneous revascularization of infarct–related artery.

MK5 haplodeficiency decreases collagen deposition and scar size during post-myocardial infarction wound repair.

MK5 is a protein serine/threonine kinase activated by p38, ERK3, and ERK4 MAPKs. MK5 mRNA and immunoreactivity are detected in mouse cardiac fibroblasts, and MK5 haplodeficiency attenuates the increase in collagen 1-α1 mRNA evoked by pressure overload. The present study examined the effect of MK5 haplodeficiency on reparative fibrosis following myocardial infarction (MI). Twelve-week-old MK5+/- and wild-type littermate (MK5+/+) mice underwent ligation of the left anterior descending coronary artery (LADL). Surviving mice were euthanized 8 or 21 days post-MI. Survival rates did not differ significantly between MK5+/+ and MK5+/- mice, with rupture of the LV wall being the primary cause of death. Echocardiographic imaging revealed similar increases in LV end-diastolic diameter, myocardial performance index, and wall motion score index in LADL-MK5+/+ and LADL-MK5+/- mice. Area at risk did not differ between LADL-MK5+/+ and LADL-MK5+/- hearts. In contrast, infarct size, scar area, and scar collagen content were reduced in LADL-MK5+/- hearts. Immunohistochemical analysis of mice experiencing heart rupture revealed increased MMP-9 immunoreactivity in the infarct border zone of LADL-MK5+/- hearts compared with LADL-MK5+/+. Although inflammatory cell infiltration was similar in LADL-MK5+/+ and LADL-MK5+/- hearts, angiogenesis was more pronounced in the infarct border zone of LADL-MK5+/- mice. Characterization of ventricular fibroblasts revealed reduced motility and proliferation in fibroblasts isolated from MK5-/- mice compared with those from both wild-type and haplodeficient mice. siRNA-mediated knockdown of MK5 in fibroblasts from wild-type mice also impaired motility. Hence, reduced MK5 expression alters fibroblast function and scar morphology but not mortality post-MI. NEW & NOTEWORTHY MK5/PRAK is a protein serine/threonine kinase activated by p38 MAPK and/or atypical MAPKs ERK3/4. MK5 haplodeficiency reduced infarct size, scar area, and scar collagen content post-myocardial infarction. Motility and proliferation were reduced in cultured MK5-null cardiac myofibroblasts.

Invited Commentary

Invited Commentary

10-Year Outcomes After Left Ventricular Reconstruction: Rethinking the Impact of Mitral Regurgitation

Heart failure with reduced ejection fraction due to a post-infarction anteroseptal aneurysm carries a poor prognosis. Patients with refractory heart failure may be considered for advanced surgery, including left ventricular assist device implantation, heart transplantation and left ventricular reconstruction. The aim of this study was to evaluate outcomes after anintegrated approach of left ventricular reconstruction with concomitant procedures (mitral/tricuspid valve repair, coronary revascularization), and assess risk factors for event-free survival, focusing on left ventricular geometry/function and presence of functional mitral regurgitation (MR). A total of 159 consecutive heart failure patients who underwent left ventricular reconstruction between 2002 and 2011 were included. Mid-term echocardiographic and long-term clinical outcomes were evaluated. Preoperative risk factors were correlated to event-free survival (freedom from mortality, left ventricular assist device implantation, and heart transplantation). Mid-term echocardiography demonstrated decreased indexed left ventricular end-systolic volumes (89 ± 42 mL/m2 preoperatively; 51 ± 18 at mid-term, p < 0.001), and absence of MR ≥ grade 2. Event-free survival was 83% ± 3% at 1-year, 68% ± 4% at 5-year, and 46% ± 4% at 10-year follow-up. Preoperative wall motion score index (WMSI; hazard ratio [HR] 3.1, 95% confidence interval [CI] 1.7-5.8, p < 0.001) and presence of MR ≥ grade 2 (HR 1.9, 95% CI 1.1-3.1, p= 0.014) were independently associated with adverse event-free survival. Event-free survival is favorable in patients with WMSI < 2.5 and significantly worse when WMSI is ≥ 2.5. In both groups, the presence of preoperative MR ≥ grade 2 negatively affects event-free survival, despite successful correction of MR. Risk stratification by preoperative WMSI and MR grade supports the Heart team in choosing the optimal surgical strategy for patients with refractory heart failure.

The evaluation of the effect of coronary collateral formation on left ventricular function by using strain echocardiography

The aim of this study is to compare the strain echocardiography method, that we think, evaluate ventricular functions more accurately, and the other echocardiographic methods in patients with or without angiographically developed collaterals. Non acute coronary syndrome 45 patients with determined occlusion of the left anterior descending artery (LAD) over 90% were included in this study. Collateral vessel devellopping according to Rentrop classification, grade 0-1 patients were determined as Group I (n=24) , grade 2-3 patients determined as Group II (n=21). PW doppler, tissue doppler and strain echocardiography was applied. The peak strain levels in basal anteroseptal, midseptal and apical septal segments were significantly lower in Group I (p=0.04, p=0.01 and p=0.02 respectively). Also €peak I value was significantly lower in Group I (p=0.02). In Group I, postsystolic shortening index (PSSI) was found to be positively correlated with left ventricle end diastolic volume (LVEDV) (r=0.4, p=0.05), left ventricle end systolic volume (LVESV) (r=0.47, p=0.01) and wall motion score index(WMSI) (r=0.64, p=0.001) and negatively correlated with ejection fraction(EF) (r= -0.57, p=0.03) and mitral septal annulus systolic velocity (MSA S) (r= -0.49, p=0.01). In Group II, PSSI was positively correlated with left ventricle end diastolic diamater (LVESD) (r=0.5, p=0.01) and LVESV (r=0.5, p=0.01) and negatively correlated with MSA S (r= 0.45, p=0.03). In patients who have better developed collaterals have better left ventricle functions that were observed both by strain echocardiography and conventional echocardiographic methods.

Diagnostic role of echocardiography in patients admitted to the emergency room with suspect no-ST-segment elevation acute myocardial infarction.

We investigated whether echocardiography may help identify, among patients admitted with a suspect of non-ST-segment elevation acute myocardial infarction (NSTEMI), those with athero-thrombotic coronary artery disease (CAD). We studied consecutive patients admitted with a clinical suspect of first NSTEMI. Echocardiography was assessed within 24 hours from admission. Patients were divided into two groups, according to the results of coronary angiography: 1) patients with obstructive stenosis (≥ 50%) and/or images of thrombosis in one or more coronary arteries (CAD group); 2) patients with no evidence of obstructive coronary arteries (NOCAD group). Of 101 patients enrolled in the study, 53 (52.5%) showed obstructive CAD and 48 (47.5%) NOCAD. At echocardiographic examination, regional wall motion abnormalities were found in 52.8% of patients in the CAD group and 43.7% in the NOCAD group (p=0.43). Left ventricle ejection fraction was 56.4±6.8 vs. 54.7±9.8% (p=0.30) and wall motion score index was 1.16±0.26 vs. 1.21±0.32 (p=0.39) in the two groups, respectively. A multivariable logistic regression independent predictors of obstructive CAD included age, male gender, typical angina, diabetes and hypertension. Our data showed that, in patients with acute chest pain and increased serum troponin T concentration, routine standard echocardiography does not significantly improve the diagnostic accuracy for the presence of obstructive CAD.

Echocardiography assessment of the left ventricular systolic function and regional wall motion abnormalities pre- and post-coronary artery bypass grafting surgery

Background and Objective: Coronary artery disease is a significant global health problem and is a leading cause of disability and death. In this study, the effect of coronary artery bypass graft (CABG) surgery on left ventricular (LV) systolic functions and regional wall motion abnormalities in the 1st week and 3rd month after surgery was evaluated through echocardiographic techniques. Patients and Methods: Fifty patients who underwent elective isolated CABG at Azadi Heart Center were included and studied prospectively from November 2018 to May 2019. Transthoracic two-dimensional echocardiography was used to assess the LV-systolic function (LV ejection fraction [LVEF]) and wall motion score index (WMSI) and abnormalities. Results: Almost all patients had chest pain preoperatively, and 32% and 38% of them were in Canadian Cardiovascular Society (CCS) Class III and IV, respectively. Ninety percent had multivessel disease, and the left anterior descending was the most common vessel affected (86%), complete revascularization was done in all patients using 3–6 grafts, and left internal mammary artery was used in 48 patients (96%). There was no significant improvement in LVEF in the early postoperative period (P = 0.28). On the contrary, there was a highly significant improvement of LVEF lately postoperatively, which was improved from (49.62%–56.92%) at (P ≤ 0.001). As well, there was a substantial improvement of WMSI at lately postoperative (P = 0.026) that changed from (1.204 to 1.12). Conclusions: The present study suggests that CABG has a positive effect on LV systolic functions and regional wall motion abnormalities 3-month post-operatively as confirmed through echocardiographic techniques.

Platelet aggregability and anticoagulant proteins activity during dobutamine stress echocardiography in asymptomatic patients four months after percutaneous coronary intervention

Introduction: Platelets aggregability (PA) and the activation of hemostasis, during myocardial ischemia within physical or mental stress, can be one of many factors that influence the process of stent thrombosis after percutaneous coronary intervention (PCI). Objective: The aim of the study is to investigate the relationship between PA and activity of anticoagulant proteins with myocardial ischemia during dobutamine stress echocardiography (DSE) in asymptomatic patients four months after PCI. Methods: The study population included 74 asymptomatic patients who had successful PCI four months before high-dose dobutamine stress echocardiography (DSE).PA on epinephrine (EPI) and adenosine diphosphate (ADP) were determined by Light Transmission Aggregometry (LTA), together with plasma activity of protein C (PC) and antithrombin (AT) before DSE and at the peak stage of the stress test. Patients were divided into several groups whether they have baseline or induced disturbance of segmental myocardial kinetics or not. All patients were on clopidogrel and aspirin therapy at the time of DSE. Results: There were no statistically significant difference in PA on ADP (47.50% vs. 50.20%; p=0.970) as well as on EPI (59.30% vs. 60.30%, p=0.600) before and at the peak DSE. A statistically significant difference was found in the anticoagulant activity of the AT (84.85% vs. 74.75%, p=0.001) and PC (77.75% vs. 67.60%, p&lt;0.001). Significance of differences in antithrombin and the protein C, refers to the result before and at the peak levels of the test. There was no significant difference in PA and plasma activity of anticoagulant proteins in patients with or without induced myocardial ischemia at the peak of DSE. Patients who had increased wall motion score index (WMSI) at the peak of DSE had higher EPI induced PA (68.60% vs. 54.70% p=0.017) than patients with normal myocardial contractility. Conclusion: There are no changes in the PA before and after DSE, however, plasma activity of anticoagulant proteins decreased at the peak level of the test. Platelet aggregability on EPI significantly increases at the peak of DSE in patients with segmental myocardium hypocontractility.

Usefulness of Triiodothyronine Replacement Therapy in Patients With ST Elevation Myocardial Infarction and Borderline/Reduced Triiodothyronine Levels (from the THIRST Study)

The aim of the study was to investigate whether TH replacement therapy is safe and impact infarct size, left ventricular (LV) volumes and function in patients with acute myocardial infarction (AMI) and low T3 syndrome (LT3S). Thirty-seven AMI/LT3S patients were randomly treated or untreated with liothyronine (T3) therapy (maximum dosage 15 mcg/m2/die) in addition to standardized treatment (T3-treated group, n = 19; untreated group, n = 18). TH and thyroxine (TSH) during hospital stay and at 1-month and 6 months were evaluated. At discharge and at 6 months LV volumes, ejection fraction, wall motion score index (WMSI) and infarct extent were measured by cardiac MR. T3-treated patients had a significant increase in fT3 (p = 0.003 and p <0.001) at discharge and 1-month. These patients had no signs or symptoms of hyperthyroidism or arrhythmias. At follow-up, there was a significant reduction in WMSI in both groups (T3-treated group: Δ = -0.12, p = 0.001; untreated group: Δ = -0.04, p = 0.04) and the difference value (discharge/follow-up) was significantly higher in T3-treated group than in untreated group (mean difference between groups = 0.08, 95% confidence interval [CI]: 0.01 to 0.15, p = 0.05). Also, stroke volume increased significantly in the T3-treated group (Δ = 3.4, 95% CI: 0.8 to 6, p <0.01) at follow-up. In conclusion, this is the first pilot experience in which T3 replacement therapy resulted safe and able to improve regional dysfunction in patients with STEMI/LT3S.

【論文摘要】急性心肌梗塞合併代謝症候群患者執行心肺運動介入之效果－個案報告

背景與目的：代謝症候群(metabolic syndrome)是引發冠心症的重要因子，然而，具有代謝症候群的急性心肌梗塞患者，其發病嚴重程度較高，且代謝症候群合併急性心肌梗塞患者之再狹窄比例、重大心血管事件及死亡率的比例較高。許多文獻提出中等與高強度運動訓練可以降低代謝症候群相關因子，也能改進心肺適能。但運動訓練針對具有代謝症候群的急性心肌梗塞患者，是否能降低代謝症候群等因子且提升心肺耐力，以期降低冠心症再發生率，需進一步探討。方法：本文藉由美國物理治療學會建議之「個案處理模式(patient/client management model, CMM)」，進行個案評估、介入與成效評量。結果：為期18週共36次，每次30分鐘之心肺運動介入，主要的運動模式為腳踏車與跑步機之有氧運動訓練，運動強度則是依據症狀限制最大運動測試報告結果訂定目標心率為40～60%至60～80%之心率儲備量。個案於期中及期末，心肺耐力部分之症狀限制最大運動負荷從4.6代謝當量（正常值的50.1%）進步至6.4（正常值的70.1%）及6.5（正常值的71.1%）代謝當量，六分鐘行走測試部分從499 m（正常值的80.0%）進步到558 m（正常值的90.3%）與607 m（正常值的97.8%）；心臟功能部分之心臟超音波檢查，左心室射出分率從43.5%增加至66.8%，左心室功能正常比例從38%增加至94%，左心室室壁動作指數(wall motion score index, WMSI)從2降低至1.06，另外代謝症候群因子之血液檢查之三酸甘油酯、低密度膽固醇、糖化血色素皆有下降，高密度膽固醇有上升現象，身體基本測量體重期初為96.2 kg，期中下降到94.4 kg，在期末減少至93.8 kg，身體質量指數(body mass index, BMI)由33.9 kg/m^2降至33.0 kg/m^2，腰圍期初106 cm，期中為104 cm，在期末為101.5 cm，共減少了4.5 cm。結論：個案於9週心肺運動介入後，在心肺耐力、血液及超音波檢查、身體基本測量方面已有成效，而於第18週後的評估結果於心肺耐力及身體基本測量部分僅有些微進步。臨床意義：本個案為具有代謝症候群的急性心肌梗塞接受經皮氣球擴張冠狀動脈支架成型術治療，利用個案處理模式與國際健康功能與身心障礙分類(International Classification of Functioning, Disability and Health, ICF)分析個案問題，經由實證醫學設定個案心肺運動介入計畫，可增進個案心肺耐力，改善代謝症候群相關因子。

Effects of Trypanocidal Treatment on Echocardiographic Parameters in Chagas Cardiomyopathy and Prognostic Value of Wall Motion Score Index: A BENEFIT Trial Echocardiographic Substudy

Serial echocardiographic studies in chronic Chagas cardiomyopathy are scarce. The aims of this study were to evaluate whether therapy with benznidazole modifies the progression of cardiac impairment and to identify baseline echocardiographic parameters related to prognosis. A prospective substudy was conducted in 1,508 patients with chronic Chagas cardiomyopathy randomized to benznidazole or placebo, who underwent two-dimensional echocardiography at enrollment, 2years, and final follow-up (5.4years). Left ventricular (LV) ejection fraction, LV wall motion score index (WMSI), indexed left atrial volume, and chamber dimensions were collected and correlated to all-cause death and a composite hard outcome using univariate and multivariate analyses. At enrollment, most patients had normal chamber dimensions, and 70.5% had preserved LV ejection fractions. During follow-up, all chamber dimensions increased similarly in both treatment arms. LV ejection fraction was comparably reduced (55.7±12.7% to 52.1±14.6% vs 56.3±12.7% to 52.8±14.1%) and LV WMSI similarly increased (1.31±0.41 to 1.49±0.03 and 1.27±0.38 to 1.51±0.03) for the benznidazole and placebo groups, respectively (P>.05). A higher baseline LV WMSI was identified in subjects who died compared with those alive at final echocardiography (1.76±0.517 vs 1.271±0.393, P<.0001). There was a significant (P<.0001) graded increase in the risk for the composite outcome with worsening LV WMSI (hazard ratios, 2.27 [95% CI, 1.69-3.06] and 6.42 [95% CI, 4.94-8.33]) and also of death (hazard ratios, 2.45 [95% CI, 1.62-3.71] and 8.99 [95% CI, 6.3-12.82]) for 1<LV WMSI<1.5 and LV WMSI>1.5, respectively. Both LV WMSI and indexed left atrial volume remained independent predictors in multivariate analysis. Trypanocidal treatment had no effect on echocardiographic progression of chronic Chagas cardiomyopathy over 5.4years. Despite normal global LV systolic function, regional wall motion abnormalities and indexed left atrial volume identified patients at higher risk for hard adverse clinical outcomes.

Layer-specific strain in dipyridamole stress echo: A new tool for the diagnosis of microvascular angina.

Dipyridamole stress echocardiography (DSE) represents a fundamental test in patients with suspected coronary artery disease (CAD). The diagnosis of microvascular disease is still challenging. We aimed to determine the diagnostic value of left ventricular (LV) layer-specific longitudinal (LS) and circumferential strain (CS) by Speckle Tracking in detecting CAD during DSE and to study if they can help in discriminate between a negative echo and a suspected microvascular angina. We enrolled 66 patients with known or suspected CAD. All underwent standard DSE. We identified 3 groups according to the result of DSE (36 negative DSE, 19 positive DSE, 11 indicatives for microvascular disease). Wall motion score index, global LV LS and CS (global longitudinal strain [GLS] and global circumferential strain [GCS]), and layer-specific LV LS and CS were measured at rest and peak stress. The Delta between rest and peak stress values was calculated. GLS increased after injection in negative DSE and microvascular disease while reducing in positive DSE. Endocardial GCS and transmural GCS values were stable in microvascular disease while increasing significantly in negative DSE, helping in the diagnosis. The specific analysis of endocardial LS showed the most powerful difference between healthy and macrovascular CAD patients, both for LS and CS. Global circumferential strain can be a new valuable added tool in the echocardiographic diagnosis of microvascular disease. Endocardial GLS is the best indicator of an altered wall deformation in the presence of macrovascular ischemia.

The Prognostic Value of Coronary Flow Velocity Reserve in Two Coronary Arteries During Vasodilator Stress Echocardiography

Vasodilator stress echocardiography (SE) allows combined evaluation of regional wall motion and Doppler coronary flow velocity reserve (CFVR) of both the left anterior descending coronary artery (LAD) and the right coronary artery (RCA). The aim of this study was to prospectively assess the prognostic correlates of LAD and RCA CFVR on SE. A total of 1,365 patients with known or suspected coronary artery disease underwent dipyridamole SE with combined evaluation of CFVR in both the LAD and the RCA. Ischemia was present on SE in 263 patients (19%). CFVR was abnormal (≤2.0) in 545 patients (40%): 172 in the LAD only, 149 in the RCA only, and 224 in both the LAD and the RCA. During a median follow-up period of 20months, 44 deaths and 98 myocardial infarctions occurred. In the overall population, LAD CFVR ≤ 2.0 (hazard ratio [HR], 3.93) and inducible ischemia (HR, 2.74) were multivariate prognostic predictors. In the subset with ischemia on SE, CFVR did not add to peak wall motion score index (HR, 2.23). In patients without ischemia on SE, age (HR, 1.04), anti-ischemic therapy at the time of testing (HR, 1.6) and LAD CFVR≤2.0 (HR, 10.8) were independent prognostic indicators. In patients without ischemia on SE and LAD CFVR >2.0, the 4-year event rate was 4% in those with RCA CFVR > 2.0 and 18% in those with RCA CFVR ≤ 2.0 (P<.0001). Ischemia on SE with high peak wall motion score index identifies a high-risk subset regardless of the underlying CFVR response. Absence of ischemia on SE is associated with intermediate risk, and LAD CFVR is essential to identify a truly low-risk subset. RCA CFVR is less useful than LAD CFVR but may have a role for further risk stratification in patients without ischemia and normal LAD CFVR.

DUAL IMAGING OF REGIONAL WALL MOTION AND LV ELASTANCE CALCULATED SIMULTANEOUSLY DURING STRESS ECHOCARDIOGRAPHY: A LARGE SCALE VALIDATION STUDY IN AN INTERNATIONAL MULTICENTER TRIAL

The peak stress/rest ratio of LV elastance (systolic arterial pressure/endsystolic volume) is load-independent meaning LV contractile reserve (LVCR). "Weak” heart (blunted LVCR) shows worse outcome than a "strong” heart (preserved LVCR), and prognostic impact of LVCR outperforms stress-EF. We sought to assess feasibility, positivity rate and relative diagnostic value of RWMA+LVCR in prospective, multicenter, international, effectiveness study. We enrolled 1249 patients (age 60.8±10.8 years, 765 males) referred to stress echocardiography (SE) (known or suspected coronary artery disease)-24 laboratories, six countries (Italy, Brazil, Russia, Serbia, Hungary, Bulgaria). Majority of patients (n=1100) underwent exercise stress with semi-supine ergometer (n=1079), upright bicycle (n=14), treadmill (n=7) exercise, 149 patients (11,9%) underwent dobutamine SE. All underwent dual imaging SE (standard evaluation of Wall Motion Score Index (WMS, 17-segment model). each segment from 1=normal to 4=dyskinetic)+simultaneous LVCR assessment with stress/rest ratio of LV force (systolic blood pressure by cuff sphygmomanometer/end-systolic volume from 2D). All readers passed the upstream quality control reading-RWMA. Methods used for LV calculations: Simpson biplane (preferred), single-plane (second choice), Teichholz (when the former two were not of acceptable quality). Previously established abnormal values of LVCR were <2.0 for exercise and dobutamine. Coronary angiographic verification done in 368 patients, 81,8% (n=301) displaying 1+ vessel disease (significant= ≥50% stenosis). LVCR was measured in 1237/1249 patients (feasibility=99%), no additional imaging time, and extra-analysis time of <3 min/patient. Positivity rate=33.8% for RWMA, 63.8%-LVCR, and 68.9% when either of two criteria was considered. WMSI poorly correlated with LVCR (n=1237, r=0.29, p<0.001). “Weak heart” with reduced LVCR was more often found with inducible RWMA, abnormal (≤5%) increase in EF during stress or underlying CAD (Figure). In selected population of 368 patients with coronary angiography, sensitivity=37% (95% CI 31% -42%) for RWMA, 73% (95% CI 66%-77%) for LVCR, 77% (95% CI 71%-81%) for combined criteria, whereas specificity was 80% (95% CI 69%-87%) for RWMA, 32% (95% CI 24%-45%) for LVCR and 32% (95% CI 22%-42%) for combined criteria. During exercise or dobutamine SE, simultaneous dual imaging of RWMA and LVCR is highly feasible, does not add complexity or extra-imaging time to the standard protocol, minimally increases analysis time, increasesing the positivity rate of RWMA alone, with good sensitivity and poor specificity for CAD identification. A “weak heart” with blunted LVCR targets subclinical myocardial disease, which may be independent from physiologically critical epicardial coronary artery stenosis which are the primary determinant of RWMA.

Early Predictors of Left Ventricular Remodeling after Primary Percutaneous Coronary Intervention

AbstractBackground: Successful primary Percutaneous Coronary Intervention (PCI), has reduced the mortality of patients with Acute Myocardial Infarction (AMI). However, the increased survival rate resulted in the increased incidence of Left Ventricular (LV) remodeling. Ventricular remodeling is a predictor of heart failure and for this reason it assumes a negative prognostic value.Aim of the Study: Was to assess the percentage of LV remodeling and to identify at discharge early predictors of LV remodeling after primary PCI.Material and Methods: We included 152 patients diag-nosed as acute STEMI and underwent successful primary PCI. All patients were examined by transthoracic echocardi-ography at discharge and 6 months later. LV remodeling defined as increase in Left Ventricular End Diastolic Volume Index (LVEDVI) >20%. Patients were grouped into two groups: Group I (with LV remodeling) and Group II (without LV remodeling). The following factors affecting LV remodeling were evaluated: Infarct Related Artery (IRA), number of vessels affected, use of thrombus aspiration, type of stent used, post PCI TIMI flow, time to reperfusion, Wall Motion Score Index (WMSI) and cardiovascular risk factors.Results: Patients with an increase in LVEDVI >20% who were considered to have LV remodeling (Group I) were 49 patients (32.2%). Anterior MI was significantly more in GroupI patients (89.8%) vs. (44.7%) in Group II patients (p-value= 0.00). Left Anterior Descending (LAD) artery affection was significantly more in Group I (89.8%) vs. (45.6%) in GroupII (p-value=0.00). Ejection fraction noticed to be significantly greater at baseline in Group II (51±6.81%) vs. (41.4±6.59%) in Group I (p-value=0.00) while Group I patients had signif-icant higher WMSI (1.66±0.19) vs. (1.28±0.17) in Group II (p-value=0.00).Conclusions: LV remodeling occurred in 32.2% of patients. Patients with ECG diagnosis as (anterior MI), WMSI (>1.5), ejection fraction (£45%), and LAD as an IRA were at higher risk for LV remodeling (p 1.5) and LAD as an IRA were the only independent predictors for LV remodeling after primary PCI (relative risk; 3.2 and 2.6 respectively).

Usefulness of Cardiac Magnetic Resonance Imaging in Patients With Acute Spontaneous Coronary Artery Dissection

Cardiac magnetic resonance (CMR) has significant diagnostic and prognostic utility in myocardial infarction evaluation. However, its application in spontaneous coronary artery dissection (SCAD) is not described. Patients with confirmed SCAD who had CMR performed within 8 days of the index SCAD were reviewed. Clinical variables including demographics and medical history were recorded. CMR indexes, including myocardial delayed enhancement (MDE), microvascular obstruction, perfusion defects, left ventricular ejection fraction, and wall motion score index were measured. A total of 18 patients (all women, mean age 47.1 years) were included. Overall burden of atherosclerotic risk factors was low; 3 had a previous SCAD. Two patients underwent CMR before coronary angiography, whereas the others received CMR thereafter. Mean time between SCAD diagnosis and CMR completion was 2.7 days (range 0 to 8). Mean left ventricular ejection fraction and wall motion score index were 56.1% and 1.27, respectively. A total of 15 patients had MDE consistent with myocardial infarction in the SCAD distribution(s) identified on coronary angiography, with 8 patients having concomitant microvascular obstruction. Ten patients had transmural MDE. At follow-up (mean 386 days), all patients were alive; extracoronary vascular abnormalities were identified in 14; 6 had recurrent chest pain; and 2 had recurrent SCAD. Both patients with recurrent SCAD had no unique features on CMR to predict a future event. In conclusion, CMR provided significant value in clarifying the diagnosis and assessing for adverse sequelae after acute SCAD. Further studies are needed to determine its role in SCAD prognostication.

Clinical characteristics of occluded culprit arteries and collaterals in patients with non-ST-segment elevation myocardial infarction and impact on clinical outcomes.

The presence of an occluded culprit artery or collaterals in non-ST-segment elevation myocardial infarction (NSTEMI) is relatively common; however, limited data are available regarding their clinical significance. The aim of the current study was to determine the clinical characteristics of occluded culprit arteries and coronary collaterals in patients with NSTEMI and their impact on patient outcomes. A total of 345 patients diagnosed with NSTEMI via coronary angiography between February 2006 and May 2013 were evaluated in the present study. Patient demographics, procedural characteristics and clinical outcomes of patients were analyzed according to the presence of an occluded culprit artery and coronary collaterals. A total of 78 (22.6%) and 166 patients (48.1%) exhibited an occluded artery and coronary collaterals, respectively. The left anterior descending artery is a more common location of culprit arteries in patients with NSTEMI with patent artery (NSTEMIPA) and distal parts of the artery are more common location of culprit arteries in patients with NSTEMI with occluded arteries (NSTEMIOA). Patients with NSTEMIOA exhibited higher peak creatine kinase-MB (CKMB) and troponin-I levels compared with patients that had NSTEMIPA. The presence of coronary collaterals is associated with a lower mean left ventricular ejection fraction, higher regional wall motion score index and extensive coronary artery disease. However, the clinical outcomes of patients with collaterals did not differ, irrespective of the presence of an occluded culprit artery or coronary collaterals. In the current study, ~25% of patients with NSTEMI had an occluded culprit coronary artery whereas 50% of patients with NSTEMI had coronary collaterals. The presence of an occluded artery and/or coronary collaterals did not affect clinical outcomes. Further studies are required to evaluate the long-term prognostic impact of an occluded artery and collaterals.

Speckle tracking imaging as a predictor of left ventricular remodeling 6 months after first anterior ST elevation myocardial infarction in patients managed by primary percutaneous coronary intervention.

Acute myocardial infarction (AMI) remains a leading cause of morbidity and mortality worldwide. LV remodeling is an important factor in the pathophysiology of advancing heart failure (HF).Aim of the workTo evaluate the value of speckle tracking imaging as a predictor of left ventricular remodeling 6 months after first anterior STEMI in patients managed by primary PCI.MethodologyEighty-five patients with first acute anterior STEMI underwent primary PCI. Patients were followed up for 6 months. Echocardiographywas done within 48 h [1] Standard transthoracic 2D echocardiographic examination: LV internal dimensions and volumes, Left Ventricular EF, and Wall Motion Score Index: [2] LV peak systolic global longitudinal strain and Torsion dynamics were assessed. Echocardiography was repeated at 6 months LV volumes and EF were calculated. LV remodeling was defined as an increase in LV EDV ≥ 20% 6 months after infarction as compared to baseline data. Patients were then classified into Group I: did not develop LV remodeling. Group II: developed LV remodeling. Both groups were studied to determine predictors of LV remodeling.ResultsAt baseline echocardiographic evaluation there was no statistically significant difference between both groups regarding both LVEDD and LVEDV, while there was statistically significant increase in both LV ESD and LV ESV, with statistically significant lower Ejection Fraction, in LV remodeling group. There was also statistically significant higher LV peak systolic GLS values in LV remodeling group, the best cut-off value was >−12.5 (Sensitivity 87%, Specificity 85%) and LV torsion was also statistically significantly lower in the LV remodeling group, with the best cut-off value for LV torsion was <9.5°, [Sensitivity 91%, Specificity 85%].Independent predictors of LV remodeling after AMI: baseline WMSI > 1.8, baseline LV EF < 40, GLS > −12.5%, LV torsion < 9.5°, CK-MB > 500 U/L, baseline Thrombus grade > 4 and total ischemic time.ConclusionAverage peak systolic GLS and LV torsion at echocardiography done early after myocardial infarction are independent predictors of LV remodeling after anterior STEMI and can be used to predict occurrence of LV remodeling after 6 months.

Coronary Sinus Reducer implantation improves symptoms, ischaemia and physical capacity in patients with refractory angina unsuitable for myocardial revascularisation: a single-centre experience.

The aim of this study was to evaluate the clinical efficacy of Coronary Sinus Reducer implantation in alleviating angina symptoms and improving objective ischaemia parameters and indices of physical capacity. Patients with refractory angina (Canadian Cardiovascular Society [CCS] class 3-4) were treated with the Reducer. Baseline and follow-up evaluation consisted of clinical assessment including completion of the Seattle Angina Questionnaire (SAQ) and CCS class evaluation, and objective assessment by treadmill exercise test, dobutamine echocardiography and six-minute walk test (6MWT). Overall, 48 patients (40 male) were enrolled. No periprocedural or long-term adverse events were recorded. CCS class diminished from a mean of 3.4±0.5 at baseline to 2.0±1 (p<0.001), and all domains of the SAQ improved significantly following Reducer implantation. Mean exercise duration increased from 03:43±01:30 to 04:36±02:18 min:sec (p=0.025) and 6MWT distance increased from 299.9±97.9 m to 352.9±75.3 m (p=0.002). Ejection fraction (EF%) at stress increased from 51.0±10 to 56.5±10 (p=0.004), and wall motion score index improved from 1.58±0.4 to 1.37±0.3 (p=0.004). Reducer implantation for the treatment of refractory angina is a simple and safe procedure which significantly alleviates symptoms of angina and improves objective ischaemia parameters and indices of physical function.