Wall Motion Score Research Articles

Machine Learning Algorithms for Prediction of Survival by Stress Echocardiography in Chronic Coronary Syndromes.

Stress echocardiography (SE) is based on regional wall motion abnormalities and coronary flow velocity reserve (CFVR). Their independent prognostic capabilities could be better studied with a machine learning (ML) approach. The study aims to assess the SE outcome data by conducting an analysis with an ML approach. We included 6881 prospectively recruited and retrospectively analyzed patients with suspected (n = 4279) or known (n = 2602) coronary artery disease submitted to clinically driven dipyridamole SE. The outcome measure was all-cause death. A random forest survival model was implemented to model the survival function according to the patient’s characteristics; 1002 patients recruited by a single, independent center formed the external validation cohort. During a median follow-up of 3.4 years (IQR 1.6–7.5), 814 (12%) patients died. The mortality risk was higher for patients aged >60 years, with a resting ejection fraction < 60%, resting WMSI, positive stress-rest WMSI scores, and CFVR < 3.The C-index performance was 0.79 in the internal and 0.81 in the external validation data set. Survival functions for individual patients were easily obtained with an open access web app. An ML approach can be fruitfully applied to outcome data obtained with SE. Survival showed a constantly increasing relationship with a CFVR < 3.0 and stress-rest wall motion score index > Since processing is largely automated, this approach can be easily scaled to larger and more comprehensive data sets to further refine stratification, guide therapy and be ultimately adopted as an open-source online decision tool.

Left ventricular assessment with artificial intelligence increases the diagnostic accuracy of stress echocardiography.

AimsTo evaluate whether left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS), automatically calculated by artificial intelligence (AI), increases the diagnostic performance of stress echocardiography (SE) for coronary artery disease (CAD) detection.Methods and resultsSEs from 512 participants who underwent a clinically indicated SE (with or without contrast) for the evaluation of CAD from seven hospitals in the UK and US were studied. Visual wall motion scoring (WMS) was performed to identify inducible ischaemia. In addition, SE images at rest and stress underwent AI contouring for automated calculation of AI-LVEF and AI-GLS (apical two and four chamber images only) with Ultromics EchoGo Core 1.0. Receiver operator characteristic curves and multivariable risk models were used to assess accuracy for identification of participants subsequently found to have CAD on angiography. Participants with significant CAD were more likely to have abnormal WMS, AI-LVEF, and AI-GLS values at rest and stress (all P < 0.001). The areas under the receiver operating characteristics for WMS index, AI-LVEF, and AI-GLS at peak stress were 0.92, 0.86, and 0.82, respectively, with cut-offs of 1.12, 64%, and −17.2%, respectively. Multivariable analysis demonstrated that addition of peak AI-LVEF or peak AI-GLS to WMS significantly improved model discrimination of CAD [C-statistic (bootstrapping 2.5th, 97.5th percentile)] from 0.78 (0.69–0.87) to 0.83 (0.74–0.91) or 0.84 (0.75–0.92), respectively.ConclusionAI calculation of LVEF and GLS by contouring of contrast-enhanced and unenhanced SEs at rest and stress is feasible and independently improves the identification of obstructive CAD beyond conventional WMSI.

Clinical outcomes and characteristics of acute myocardial infarction patients with developing fever after percutaneous coronary intervention

The incidence of fever complicating percutaneous coronary intervention (PCI) is rare. However, little is known regarding the cause of fever after PCI. Therefore, this study aimed to determine the clinical characteristics of patients with acute myocardial infarction (AMI), with or without fever, after PCI. We enrolled a total of 926 AMI patients who underwent PCI. Body temperature (BT) was measured every 4 hours or 8 hours for 5 days after PCI. Patients were divided into two groups according to BT as follows: BT&lt;37.7°C (no-fever group) and BT ≥37.7°C (fever group). The 2 years clinical outcomes were compared subsequently. Fever after PCI was associated with higher incidence of major adverse cardiac events (MACE) (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.07-2.28; &lt;i&gt;P&lt;/i&gt;=0.021), all-cause death (HR, 2.32; 95% CI, 1.18-4.45; &lt;i&gt;P&lt;/i&gt;=0.014), cardiac death (CD) (HR, 2.57; 95% CI, 1.02-6.76; &lt;i&gt;P&lt;/i&gt;=0.049), and any revascularization (HR, 1.69; 95% CI, 1.02-2.81; &lt;i&gt;P&lt;/i&gt;=0.044) than without fever. In women, prior chronic kidney disease, lower left ventricular (LV) ejection fraction, higher LV wall motion score index, white blood cell count, peak creatine kinase-myocardial band level, and longer PCI duration were associated with fever after PCI. Procedures such as an intra-aortic balloon pump, extracorporeal membrane oxygenation, continuous renal replacement therapy, central and arterial line insertion, and cardiopulmonary resuscitation were related to fever after PCI. Fever after PCI in patients with AMI was associated with a higher incidence of MACE, all-cause death, CD, and any revascularization at the 2 years mark than in those without fever.

First-in-human pilot trial of combined intracoronary and intravenous mesenchymal stem cell therapy in acute myocardial infarction.

BackgroundAcute ST-elevation myocardial infarction (STEMI) elicits a robust cardiomyocyte death and inflammatory responses despite timely revascularization.ObjectivesThis phase 1, open-label, single-arm, first-in-human study aimed to assess the safety and efficacy of combined intracoronary (IC) and intravenous (IV) transplantation of umbilical cord-derived mesenchymal stem cells (UMSC01) for heart repair in STEMI patients with impaired left ventricular ejection fraction (LVEF 30-49%) following successful reperfusion by percutaneous coronary intervention.MethodsConsenting patients received the first dose of UMSC01 through IC injection 4-5 days after STEMI followed by the second dose of UMSC01 via IV infusion 2 days later. The primary endpoint was occurrence of any treatment-related adverse events and the secondary endpoint was changes of serum biomarkers and heart function by cardiac magnetic resonance imaging during a 12-month follow-up period.ResultsEight patients gave informed consents, of whom six completed the study. None of the subjects experienced treatment-related serious adverse events or major adverse cardiovascular events during IC or IV infusion of UMSC01 and during the follow-up period. The NT-proBNP level decreased (1362 ± 1801 vs. 109 ± 115 pg/mL, p = 0.0313), the LVEF increased (52.67 ± 12.75% vs. 62.47 ± 17.35%, p = 0.0246), and the wall motion score decreased (26.33 ± 5.57 vs. 22.33 ± 5.85, p = 0.0180) at the 12-month follow-up compared to the baseline values. The serial changes of LVEF were 0.67 ± 3.98, 8.09 ± 6.18, 9.04 ± 10.91, and 9.80 ± 7.56 at 1, 3, 6, and 12 months, respectively as compared to the baseline.ConclusionThis pilot study shows that combined IC and IV transplantation of UMSC01 in STEMI patients with impaired LVEF appears to be safe, feasible, and potentially beneficial in improving heart function. Further phase 2 studies are required to explore the effectiveness of dual-route transplantation of UMSC01 in STEMI patients.

Early recruitable coronary collaterals preserve miocardial viability in late presentation infarctions.

Previous studies showed conflicting results regarding the contribution of coronary collateral circulation (CCC) to myocardial perfusion and function in the setting of myocardial infarction (MI). In the primary angioplasty era, the role of CCC in these studies may have been influenced by the effect of early reperfusion. The true impact of CCC could be clarified by studying its effect on nonreperfused patients. The aim of our study was to evaluate the effect of CCC on myocardial viability of late presentation MI. Between 2008 and 2019, we included 167 patients with a late presentation MI who had a complete angiographic occlusion in a major coronary artery in which myocardial viability of the culprit territory was assessed. Patients were divided according to the presence of angiographic early recruited CCC (ERCC) (Rentrop 2-3) or poor CCC (PCC) (Rentrop 0-1). A lower left ventricular ejection function (LVEF) at discharge (54.2 ± 9 vs. 47.9 ± 12; <0.01) and a more severe left ventricular wall motion abnormalities in the culprit territory were observed in PCC patients. The presence of ERCC was the main independent predictor of myocardial viability in late presentation MI (hazard ratio, 4.24; 95% confidence interval, 1.68-10.6; P < 0.001). At follow-up, wall motion score increased significantly (2.05 ± 0.16; P = 0.02) in patients with ERCC but not in PCC patients (0.07 ± 0.16; P = 0.4), and LVEF improvement was significantly higher in ERCC than in PCC patients (9.7 ± 2.6 vs. 3.8 ± 4.2; P = 0.02). The presence of ERCC was the main independent predictor of myocardial viability in late presentation MI.

Advantages of long-term combination pharmacotherapy with a beta-blocker and eplerenone in patients with ST-segment elevation acute coronary syndrome

Aim.To conduct a comparative analysis of the effect of long-term pharmacotherapy (12 months) using a β-blocker (nebivolol) and its combination with eplerenone in patients after ST-segment elevation acute coronary syndrome (STE-ACS) with heart failure with mildly reduced ejection fraction (EF) (HFmrEF) on the structural and functional cardiac parameters.Material and methods. We examined 130 patients with STE-ACS and HFmrEF after successful myocardial revascularization by percutaneous coronary intervention. The mean age of patients was 53,6 [46;57] years. Ten patients withdrew from the study due to personal reasons. Subsequently, patients were randomly divided into 2 treatment groups as follows: 60 patients received nebivolol; 60 patients received nebivolol and eplerenone. Patients were examined at two stages: 1st day of the disease before PCI and 12 months later. All patients underwent a clinical examination, echocardiography, followed by assessment of left ventricular (LV) EF, LV end-diastolic volume index (EDVI), LV endsystolic volume index (ESVI), LV myocardial index (LVMI), LV wall motion score index (WMSI), the ratio of peak early diastolic flow over peak late diastolic flow (E/A), the ratio of early diastolic transmitral flow velocity to the mitral annular velocity (E/e´).Results.Twelve-month pharmacotherapy with nebivolol in patients after STE-ACS showed an increase in LVEF by 7,2% (p&lt;0,05), a decrease in WMSI by 13,0% (p&lt;0,05), an increase in the E/A ratio by 11,1% (р&lt;0,05), decrease in the E/e’ ratio by 7,2% (р&lt;0,05). LV EDVI increased by 4,6% (p&gt;0,05). Twelve-month combined pharmacotherapy with nebivolol and eplerenone showed an increase in LVEF by 16,0% (p&lt;0,01), a decrease in LV ESVI by 17,9% (p&lt;0,05), and a decrease in WMSI by 26,7% (p&lt;0,01), LVMI — by 23,8% (р&lt;0,01). At the same time, LV EDVI decreased by 0,7% (p&gt;0,05). The E/A ratio increased significantly by 22,2% (&lt;0,01), E/e’ decreased by 29,6% (р&lt;0,01). Comparative analysis also found that combination therapy had a more pronounced positive effect on LVEF (p&lt;0,05), ESVI (p&lt;0,05), WMSI (p&lt;0,05), LVMI (p&lt;0,01), as well as diastolic function in the form of a significant increase in E/A (p&lt;0,05) and E/e’ (p&lt;0,01), which recovered to normal values.Conclusion.The advantages of long-term combination pharmacotherapy of nebivolol and eplerenone in HFmrEF patients after STE-ACS on both structural and functional cardiac parameters were established.

Influence of sacubitril/valsartan on hibernating myocardium in patients with chronic heart failure with reduced ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Myocardial viability particularly hibernating myocardium is one of the critical parameters for the assessment of the long-term prognosis of patients with ischemic etiology heart disease. Purpose of the study was to evaluate the influence of angiotensin receptor neprilysin inhibitor - sacubitril/valsartan on hibernating myocardium in patients with ischemic etiology chronic heart failure with reduced ejection fraction. Material and Methods One hundred and twenty patients with chronic heart failure with reduced ejection fraction (EF&amp;lt;40%) were enrolled in the study (mean age 58.2±14.6 years, male=53%). Patients were divided into two groups by sixty. Group I patients were assigned sacubitril/valsartan while Group II were assigned valsartan in addition to the standard treatment. Hibernating myocardium were assessed with echocardiography with dopamine test. All statistical analysis were assessed using STATA software. Results Ejection fraction and the wall motion score has been improved in both groups from baseline (P&amp;lt;0.05), however when we compared two groups, sacubitril/valsartan group tended to have more positive effect on ejection fraction (from 32.2±8.2% to 43.6±12.4% vs. from 31.7±8.0% to 37.2±10.3%, P&amp;lt;0.05) and the wall motion score (from 2.34±0.5 to 1.92±0.4 vs. 2.36±0.6 to 2.15±0.45, P&amp;lt;0.05) compared to valsartan group. Diastolic and systolic wall thickness has been improved in both groups from baseline (P&amp;lt;0.05), however there were not statistically significant changes between groups (P&amp;gt;0.05). When we analyzed by gender there were not significant changes between male and female (P&amp;lt;0.05). Conclusion Sacubitril/valsartan improves myocardial viability in patients with ischemic etiology chronic heart failure with reduced ejection fraction. Further studies with large amount of patients are required to clarify exact mechanisms.

PREDICTION OF MYOCARDIAL VIABILITY ON THE BASIS OF SERUMBNP AND HSTROPONIN I LEVELS IN PATIENTS WITH CORONARYARTERY DISEASEWITH LVSYSTOLIC DYSFUNCTION

Introduction: Coronary artery disease (CAD) is the leading cause of heart failure (HF). Only viable dysfunctional myocardium (hibernation) is potentially recoverable with restoration of adequate perfusion. Cardiac imaging modalities have emerged with the ability to differentiate between myocardial scar and viable myocardium and are now often used to direct therapy decisions including revascularization. Decrease in wall motion score (WMS) and improvement in LV ejection fraction (LVEF) during DSE is considered as a surrogate marker for viability of myocardium. It is largely unknown how cardiac specific biomarkers are released in relation the presence and extent of hibernation in patients with ischemic HF. The objectives of this study are to assess the relationship and interaction of the biomarkers BNP and hs TnI with hibernation in patients with chronic ischemic HF. Materials and methods: It is a single center observational study which is conducted in Department of Cardiology, S.M.S. Medical College, Jaipur. 70 eligible patients with suspected ischemic cardiomyopathy (ICMP) are prospectively recruited into an imaging study using DSE to determine viability of myocardium. The patients also had blood sampling at baseline to determine biomarkers. Results: Mean age (in yrs) of patients is 63.78 ± 10.69 years. No patient is in NYHA I. 25.7 % of patients are in NYHA II (18 patients); 36 patients (51.4%) are in NYHA III and 16 patients (22.8%) are in NYHA IV. On comparison of baseline characteristics among patients with different NYHA class, there is a progressive increase in level of cardiac biomarkers with increase in NYHA class. Both BNP and hs TnI levels are significantly elevated in patients with Improvement in EF &gt;10% as compared with Improvement in EF &lt;10% There is a continuous relationship between increasing degrees of hibernation and increasing BNP and hs Trop I levels. HsTrop I had predicted a positive 56.6% change in Improvement in LVEF. HsTrop I had predicted a positive 52.5% change in decrease in WMS. Conclusion: The current study support the novel concept that the extent of LV hibernation are determinant of serum BNP and hs Trop I elevation in patients with ischemic HF and hs Trop I levels in patients with ischemic HF relate to the degree of hibernation.

Impact of exercise training on myocardial contractile functions assessed by cardiac magnetic resonance in post-myocardial infarction patients

BackgroundImprovement of functional capacity and mortality reduction in post-MI patients were found to be associated with regular exercise training. The cardiac magnetic resonance (CMR) is considered the most accurate non-invasive modality in quantitative assessment of left ventricular (LV) volumes and systolic functions. Our main objective was to investigate the impact of exercise training on LV systolic functions in patients post anterior MI using CMR. 32 patients on recommended medical treatment 4 week after having a successful primary PCI for an anterior MI were recruited, between May 2018 and May 2019. They were divided into two groups, training group (TG): 16 assigned to a 12 week exercise training program and control group (CG): 16 who received medical treatment without participating in the exercise training program. Treadmill exercise using modified Bruce protocol was done to TG before and after the training program in order to record the resting and maximum HR, metabolic equivalent (MET), and calculate HR reserve. CMR was performed for all patients 4 weeks after PCI and was repeated after completion of the study period to calculate ejection fraction (EF), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), and wall motion score index (WMSI).Results100% were males. 6 patients from CG dropped during follow-up, no statistically significant difference between the two groups regarding age, BMI, smoking status, hypertension, diabetes mellitus and dyslipidemia. Using the CMR, the TG showed significant improvement in EF (36.6 ± 14.2% to 43.1 ± 12.4%; P < 0.001) and WMSI (2.03 ± 0.57 to 1.7 ± 0.49; P < 0.001), without statistically significant change in LV volumes. Regarding CG no significant changes in EF, WMSI, LV volumes were found. There was significant improvement in EF and WMSI change before and after study in TG vs. CG [6.5 (2.3–9.0) vs. − 2.0 (− 6.8 to 1.3), P value < 0.001] and [− 0.3 (− 0.5 to 0.1) vs. 0.1 (− 0.1 to − 0.5), P value 0.001] respectively.Conclusions12 weeks of exercise training program in post-MI patients have a favorable impact on LV global and regional systolic functions without adversely affecting LV remodeling (as assessed by CMR).

Two-Dimensional Speckle Tracking Echocardiography as Predictor of Major Adverse Cardiac Events in Patients With Non–ST-Elevation Myocardial Infarction and Unstable Angina

INTRODUCTION: This study was conducted to determine the utility of two-dimensional speckle tracking echocardiography (2D STE) in predicting major adverse cardiac events (MACEs) in patients with non–ST-elevation acute coronary syndrome (NSTE-ACS). METHODOLOGY: This is a prospective cohort study that included 91 patients diagnosed to have NSTE-ACS. In-hospital and 6-month MACEs were evaluated in relation to their baseline echocardiographic parameters, 2D speckle strain, and strain rate analyses. RESULTS: Among the conventional echocardiographic parameters, only left ventricular end systolic diameter (LVESD) and wall motion scores showed significant difference between those with and without outcomes after 6 months. Significant higher wall motion scores (24.06 vs 20.91 P = 0.0320) and LVESD (3.36 vs 2.97 cm, P = 0.0125) were noted among those who had MACE after 6 months. There were no significant differences among the 2D STE strain and strain rate between those patients with and without MACE during their hospital admission. However, after 6-month follow-up, significantly lower mean left ventricular global longitudinal strain (GLS) −14.22% ± 4.45% vs −16.44% ± 4.19%, P = 0.0261) and strain rate (−0.69 ± 0.36 s-1 vs −0.94 ± 0.25 s-1, P = 0.009) were observed among patients with MACE compared with those without. Incidence of reduced GLS strain and strain rate was significantly higher in those with MACE after 6 months. Left ventricular GLS sensitivity and specificity were 64.64% and 61.70%, respectively, at a cutoff value of less than −15.0% for detecting MACE within 6 months. Left ventricular GLS cutoff point less than −12.0%, which detects severe LV dysfunction in previous studies, have a sensitivity of 40% but a high specificity of 82.98% for predicting MACE after 6 months. CONCLUSION: Both LV GLS strain and strain rate can be used to predict major adverse cardiovascular events after NSTE-ACS. KEYWORDS: speckle tracking echocardiography, non–ST-elevation acute coronary syndrome, cardiac events

Takotsubo cardiomyopathy in patients suffering from acute non-traumatic subarachnoid hemorrhage—A single center follow-up study

Takotsubo cardiomyopathy (TTC) is an important complication of subarachnoid hemorrhage (SAH), that may delay surgical or endovascular treatment and may influence patient outcome. This prospective follow-up study intended to collect data on the prevalence, severity, influencing factors and long-term outcome of TTC in patients suffering from non-traumatic SAH. Consecutive patients admitted with the diagnosis of non-traumatic SAH were included. Intitial assessment consisted of cranial CT, Hunt-Hess, Fisher and WFNS scoring, 12-lead ECG, transthoracic echocardiography (TTE), transcranial duplex sonography and collecting laboratory parameters (CK, CK-MB, cardiac troponin T, NT-proBNP and urine metanephrine and normetanephrine). Diagnosis of TTC was based on modified Mayo criteria. TTC patients were dichotomized to mild and severe forms. Follow-up of TTE, Glasgow Outcome Scale assessment, Barthel's and Karnofsky scoring occurred on days 30 and 180. One hundred thirty six patients were included. The incidence of TTC in the entire cohort was 28.7%; of them, 20.6% and 8.1% were mild and severe, respectively. TTC was more frequent in females (30/39; 77%) than in males (9/39; 23%) and was more severe. The occurrence of TTC was related to mFisher scores and WFNS scores. Although the severity of TTC was related to mFisher score, Hunt-Hess score, WFNS score and GCS, multivariate analysis showed the strongest relationship with mFisher scores. Ejection fraction differences between groups were present on day 30, but disappeared by day 180, whereas wall motion score index was still higher in the severe TTC group at day 180. By the end of the follow-up period (180 days), 70 (74.5%) patients survived in the non-TTC, 22 (81.5%) in the mild TTC and 3 (27%) in the severe TTC group (n = 11) (p = 0.002). At day 180, GOS, Barthel, and Karnofsky outcome scores were higher in patients in the control (non-TTC) and the mild TTC groups than in the severe TTC group. Takotsubo cardiomyopathy is a frequent finding in patients with SAH, and severe TTC may be present in 8% of SAH cases. The severity of TTC may be an independent predictor of mortality and outcome at 6 months after disease onset. Therefore, a regular follow-up of ECG and TTE abnormalities is warranted in patients with subrachnoid hemorrhage for early detection of TTC. The study was registered at the Clinical Trials Register under the registration number of NCT02659878 (date of registration: January 21, 2016).

The application of myocardial contrast echocardiography in assessing microcirculation perfusion in patients with acute myocardial infarction after PCI

BackgroundTo evaluate the myocardial microcirculation perfusion of patients with acute ST-segment elevation myocardial infarction (STEMI) with a different index of microcirculatory resistance (IMR) after percutaneous coronary intervention (PCI) by myocardial contrast echocardiography (MCE) and analyse the value of MCE in predicting myocardial perfusion after PCI.MethodsFifty-six patients with acute STEMI who underwent an emergency PCI were selected from October 2018 to October 2019 in our hospital. According to the IMR values measured during PCI treatment, the patients were divided into three groups. Traditional ultrasound and MCE were performed one week after PCI. The left ventricular ejection fraction (LVEF), ventricular wall motion score index (WMSI), A value, β value and A × β value (which refers to the patient’s myocardial blood flow) were measured. The receiver operating characteristic curve was drawn to evaluate the effectiveness of the MCE parameters in the diagnosis of myocardial microcirculation perfusion disorders.ResultsThe results showed that there was no significant difference in the LVEF among the groups. The WMSI in Group 3 was statistically different from that in Groups 1 and 2 (P < 0.05), but there was no statistically significant difference in the WMSI between Groups 1 and 2. Among the three groups, the A value, β value and A × β value were significantly different (P < 0.05). According to Spearman’s correlation analysis, the MCE quantitative parameters (i.e. the A value, β value and A × β value) were negatively correlated with the IMR value (r = −0.523, −0.471, −0.577, P < 0.01).ConclusionsThe A value, β value and A × β value were negatively correlated with the IMR value. Furthermore, MCE could be used to observe the myocardial perfusion in patients with acute STEMI after PCI and may be one of the indicators used to accurately evaluate myocardial microcirculation.

Myocardial Contractile Mechanics in Ischemic Mitral Regurgitation: Multicenter Data Using Stress Perfusion Cardiovascular Magnetic Resonance

BackgroundLeft ventricular (LV) ischemia has been variably associated with functional mitral regurgitation (FMR). Determinants of FMR in patients with ischemia are poorly understood. ObjectivesThis study sought to test whether contractile mechanics in ischemic myocardium underlying the mitral valve have an impact on likelihood of FMR. MethodsVasodilator stress perfusion cardiac magnetic resonance was performed in patients with coronary artery disease (CAD) at multiple centers. FMR severity was confirmed quantitatively via core lab analysis. To test relationship of contractile mechanics with ischemic FMR, regional wall motion and strain were assessed in patients with inducible ischemia and minimal (≤5% LV myocardium, nontransmural) infarction. ResultsA total of 2,647 patients with CAD were studied; 34% had FMR (7% moderate or greater). FMR severity increased with presence (P < 0.001) and extent (P = 0.01) of subpapillary ischemia: patients with moderate or greater FMR had more subpapillary ischemia (odds ratio [OR]: 1.13 per 10% LV; 95% CI: 1.05-1.21; P = 0.001) independent of ischemia in remote regions (P = NS); moderate or greater FMR prevalence increased stepwise with extent of ischemia and infarction in subpapillary myocardium (P < 0.001); stronger associations between FMR and infarction paralleled greater wall motion scores in infarct-affected territories. Among patients with inducible ischemia and minimal infarction (n = 532), wall motion and radial strain analysis showed impaired subpapillary contractile mechanics to associate with moderate or greater FMR (P < 0.05) independent of remote regions (P = NS). Conversely, subpapillary ischemia without contractile dysfunction did not augment FMR likelihood. Mitral and interpapillary dimensions increased with subpapillary radial strain impairment; each remodeling parameter associated with impaired subpapillary strain (P < 0.05) independent of remote strain (P = NS). Subpapillary radial strain (OR: 1.13 per 5% [95% CI: 1.02-1.25]; P = 0.02) and mitral tenting area (OR: 1.05 per 10 mm2 [95% CI: 1.00-1.10]; P = 0.04) were associated with moderate or greater FMR controlling for global remodeling represented by LV end-systolic volume (P = NS): when substituting sphericity for LV volume, moderate or greater FMR remained independently associated with subpapillary radial strain impairment (OR: 1.22 per 5% [95% CI: 1.02-1.47]; P = 0.03). ConclusionsAmong patients with CAD and ischemia, FMR severity and adverse mitral apparatus remodeling increase in proportion to contractile dysfunction underlying the mitral valve.

Rationale and design of the open-label, prospective, randomized study of the efficacy of intravenous versus oral iron deficiency therapy in improving left ventricular systolic function in patients with myocardial infarction (OPERA-MI)

Aim. Iron has a protective effect on cardiomyocytes during hypoxia, while iron deficiency (ID) directly affects its function, disrupting mitochondrial respiration, reducing their contractility and relaxation. Some studies have shown that ID is a predictor of adverse outcomes in patients with acute coronary syndrome (ACS). However, the impact of ID and its treatment, quality of life and prognosis of patients with ID and myocardial infarction (MI) has not been fully established. The study aim is to determine the effectiveness of intravenous ferric carboxymaltose (FCM) compared with oral iron (ferrous sulfate) in relation to left ventricular (LV) systolic function, assessed by echocardiography.Material and methods. This open-label, prospective, randomized study includes 360 patients with or without ID who were hospitalized with acute myocardial infarction (MI). Patients with ID will be randomized (1:1) to intravenous FCM and oral ferrous sulfate therapy. Treatment in groups will be started at the time of hospitalization. Patients without ID will form the control group. The follow-up period for patients will be 1 year. The primary endpoint was a reduction in LV wall motion score index (WMSI) in the FCM group compared to the ferrous sulfate group. The key secondary endpoint is a composite endpoint of cardiovascular death, non-fatal MI and stroke, and hospitalization for decompensated heart failure.Conclusion. The OPERA-MI study will determine the effect of ID treatment with intravenous FCM compared with oral ferrous sulfate on WMSI, which reflects LV systolic function.

Diagnostic accuracy of global longitudinal strain in prediction of severity and extent of coronary artery stenosis in patients with acute coronary syndrome

Background 2 D Speckle tracking echocardiography (STE) is a non-invasive, angle-independent, semiautomatic and objective technique that quantitatively assesses global and regional longitudinal systolic strain and provides a single bull’s eye map for segmental wall strain of the left ventricle. Objectives assessment of the accuracy of global longitudinal strain (GLS) using STE in the detection of resting myocardial ischaemia and its severity compared with visual assessment of wall motion score index by conventional 2 D echo Patients and methods 100 patients who presented with ACS were included. Wall motion score index (WMSI) was calculated in a 16-segment model and compared with GLS assessed in left ventricle 17 segments and calculated automatically by summation of regional longitudinal peak systolic strain (RLS) using STE. Quantitative coronary angiography was performed on clinical indication and significant stenosis was defined as a 70% reduction of the arterial lumen. Results 56 patients (56%) of patients were males with a mean age of 58.3 years. GLS showed a significant positive correlation between ejection fraction (EF) and GLS (p < 0.05), (r value 0.514) and a good significant negative correlation between WMSI and GLS (p < 0.05), (r value 0.593). And a good significant correlation between GLS and both severity of the lesion and the number of affected vessels was found (p < 0.05). ROC curves showed the cut-off point of GLS was (−15.9) for predicting lesion ≥70% with 88.1% sensitivity, 90.2% specificity respectively, Conclusion GLS has higher specificity, sensitivity, and diagnostic accuracy for the detection of the severity of lesion and number of the vessel affected than WMSI.

Pulmonary Congestion During Exercise Stress Echocardiography in Ischemic and Heart Failure Patients.

Lung ultrasound detects pulmonary congestion as B-lines at rest, and more frequently, during exercise stress echocardiography (ESE). We performed ESE plus lung ultrasound (4-site simplified scan) in 4392 subjects referred for semi-supine bike ESE in 24 certified centers in 9 countries. B-line score ranged from 0 (normal) to 40 (severely abnormal). Five different populations were evaluated: control subjects (n=103); chronic coronary syndromes (n=3701); heart failure with reduced ejection fraction (n=395); heart failure with preserved ejection fraction (n=70); ischemic mitral regurgitation ≥ moderate at rest (n=123). In a subset of 2478 patients, follow-up information was available. During ESE, B-lines increased in all study groups except controls. Age, hypertension, abnormal ejection fraction, peak wall motion score index, and abnormal heart rate reserve were associated with B-lines in multivariable regression analysis. Stress B lines (hazard ratio, 2.179 [95% CI, 1.015-4.680]; P=0.046) and ejection fraction <50% (hazard ratio, 2.942 [95% CI, 1.268-6.822]; P=0.012) were independent predictors of all-cause death (n=29 after a median follow-up of 29 months). B-lines identify the pulmonary congestion phenotype at rest, and more frequently, during ESE in ischemic and heart failure patients. Stress B-lines may help to refine risk stratification in these patients. URL: https://www. gov; Unique identifier: NCT03049995.

Sonothrombolysis Promotes Improvement in Left Ventricular Wall Motion and Perfusion Scores after Acute Myocardial Infarction.

ResumoFundamentoDemonstrou-se recentemente que a aplicação de ultrassom de alta energia com microbolhas, técnica conhecida como sonotrombólise, causa a dissolução de trombos intravasculares e aumenta a taxa de recanalização angiográfica no infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAM-CSST).ObjetivoAvaliar o efeito da sonotrombólise nos índices de motilidade e perfusão miocárdicas em pacientes com IAM-CSST, utilizando a ecocardiografia com perfusão miocárdica em tempo real (EPMTR).MétodoUma centena de pacientes com IAM-CSST foram randomizados em dois grupos: Terapia (50 pacientes tratados com sonotrombólise e angioplastia coronária primária) e Controle (50 pacientes tratados com angioplastia coronária primária). Os pacientes realizaram EPMTR para analisar a fração de ejeção do ventrículo esquerdo (FEVE), o índice de escore de motilidade segmentar (IEMS) e o número de segmentos com defeito de perfusão miocárdica, 72 horas após o IAM-CSST e com 6 meses de acompanhamento. Foi considerado significativo p < 0,05.ResultadosPacientes tratados com sonotrombólise apresentaram FEVE mais alta que o grupo Controle em 72 horas (50 ± 10% vs. 44 ± 10%; p = 0,006), e essa melhora foi mantida em seis meses (53 ± 10% vs. 48 ± 12%; p = 0,008). O IEMS foi similar nos grupos Terapia e Controle em 72 horas (1,62 ± 0,39 vs. 1,75 ± 0,40; p = 0,09), mas tornou-se menor no grupo Terapia em 6 meses (1,46 ± 0,36 vs. 1,64 ± 0,44; p = 0,02). O número de segmentos com defeito de perfusão não foi diferente entre os grupos em 72 horas (5,92 ± 3,47 vs. 6,94 ± 3,39; p = 0,15), mas ficou menor no grupo Terapia em 6 meses (4,64 ± 3,31 vs. 6,57 ± 4,29; p = 0,01).ConclusãoA sonotrombólise em pacientes com IAM-CSST resulta na melhora dos índices de motilidade e perfusão ventricular ao longo do tempo.

Thyroid dysfunction and its relation to myocardial performance among patients with acute myocardial infarction

Background: The cardiovascular system is one of the most important targets on which thyroid hormones act, thyroid hormone has a major role in the cardiovascu­lar system function and cardiac hemodynamics. Objectives: The primary aim of our study was to evaluate the prevalence of thyroid dysfunction in patients with acute myocardial infarction and to study the impact of these dysfunctions on in-hospital morbidity and mortality among those subjects. Patients and Methods: This study was conducted on one hundred critically ill patients admitted to the critical care department with the diagnosis of acute myocardial infarction in the period from April 2017 to January 2019. Results: According to thyroid profile, 78 patients (78%) had euthyroid status and the remaining 22 patients (22%) had thyroid dysfunctions which include: 12 patients (54.54%) were euthyroid sick syndrome, 7 patients (13.81%) had subclinical hypothyroidism, 3 patients (13.63%) had subclinical hyperthyroidism. Conclusion: Thyroid dysfunction in association with acute myocardial infarction affect the myocardial performance and this was evident in our study by lower ejection fraction, higher initial killip class, higher wall motion score index, and increased myocardial performance index compared to those with normal thyroid status but it has no impact on the in-hospital mortality.

Global longitudinal strain in acute myocardial infarction and incidence of in-hospital heart failure.

BACKGROUND: Myocardial strain is a good prognostic factor independent of ejection fraction for outcomes in heart failure. We evaluated the prognostic role of global longitudinal strain in acute myocardial infarction to identify the likelihood of in-hospital heart failure. METHODS: Forty participants with acute myocardial infarction were included, ranked according to Killip class, and classified into 2 groups: patients complicated by in-hospital heart failure (Killip class II — IV) on admission or during hospital stay (n = 16) and patients with no clinical evidence of in-hospital heart failure (Killip class I) on admission or during hospital stay (n = 24). All participants underwent reperfusion by percutaneous intervention or fibrinolytic therapy followed by transthoracic echocardiography within 72 hours of admission. RESULTS: There were statistically significant differences between both groups regarding the global longitudinal strain, ejection fraction and the wall motion score index. In patients with mildly reduced ejection fraction, there was a statistically significant difference between both groups regarding the global longitudinal strain and statistically non-significant differences regarding the ejection fraction and wall motion score index. Global longitudinal strain was the only echocardiographic parameter with statistically significant difference between Killip class I and class II. CONCLUSIONS: Global longitudinal strain was superior to ejection fraction and wall motion score index in detection of in-hospital heart failure in Killip class II and in evaluation of myocardial dysfunction in patients with mildly reduced ejection fraction. Global longitudinal strain could be considered as a part of the routine echocardiographic evaluation of acute myocardial infarction for detection of in-hospital heart failure and risk stratification of patients with acute myocardial infarction especially those with mildly reduced ejection fraction and those without overt heart failure (Killip class II).

Correlation between ankle–brachial index, wall motion score index, and SYNTAX score in acute coronary syndrome patients

Abstract Background Ankle–brachial index (ABI) is a noninvasive and cheap measurement that is used to define peripheral arterial disease (PAD). It is used as a marker to predict coronary artery disease (CAD). The SYNTAX score was created to quantify the extent of CAD in patients with multivessel disease. Two-dimensional transthoracic echocardiography (TTE) is a useful method for evaluating left ventricular (LV) volumes and ejection fraction (EF) in CAD patients. The aim of the study is to find the relationship between ABI and wall motion score index (WMSI) in order to better predict the severity of CAD. Patients and Methods One hundred and twenty-five CAD patients were evaluated by echocardiography to calculate WMSI before they underwent coronary angiography to assess the SYNTAX score. ABI measurement was done. Results The study included 54.4% males with a mean age of 55.11 years. Nearly half of them had ST-segment elevation myocardial infarction (STEMI). There was a negative correlation between the SYNTAX score and AKI, a positive correlation between the SYNTAX score and WMSI, and a negative correlation between WMSI and ABI. Predictors of high SYNTAX were ABI &lt;0.9, low left ventricular ejection fraction (LVEF), high WMSI, and multivessel coronary artery affection. Conclusion ABI is a noninvasive test that could predict the severity of CAD. WMSI is an echocardiographic parameter that could be used as an indicator of CAD severity. Combining both ABI and WMSI could help in predicting complex CAD better.