Three‐Dimensional Contrast Echocardiography in Assessing Left Ventricular Diverticulum

Congenital left ventricular (LV) diverticulum is a rare malformation that can be alone or in association with other congenital abnormalities. Since the several complications have been reported in association with LV diverticulum, as cardiac rupture, heart failure, and endocarditis, patients with LV diverticulum who are managed with conservative treatment would require regular checkups to ascertain the absence of such complications. We report a case of LV diverticulum in a 47‐year‐old man. He took the serial three‐dimensional contrast echocardiography, which was reliable and readily available tool for defining LV diverticulum and monitoring the presence of complications.     

Emerging Role of Three‐Dimensional Speckle Tracking Strain for Accurate Quantification of Left Ventricular Dyssynchrony

A case was 53‐year‐old female with dilated‐phase hypertrophic cardiomyopathy. She was classified as New York Heart Association functional class III heart failure despite receiving optimal medical therapy. The electrocardiogram taken showed intraventricular conduction delay with a QRS width of 194 msec. The left ventricular (LV) end‐diastolic and systolic volumes, and ejection fraction (EF) were 101 mL, 68 mL, and 32%, respectively. The patient showed no significant mechanical LV dyssynchrony as evidenced by two‐dimensional (2D) speckle tracking radial strain, which is defined as the time difference between anterior‐septum and posterior wall, of 105 msec (<130 msec). Three‐dimensional (3D) speckle tracking radial strain was performed for more detailed LV mechanical dyssynchrony analysis. An especially important finding for 3D speckle tracking radial strain analysis was that the average time‐to‐peak strain of 5 septum segments at 3 different LV levels (basal‐anterior‐septum, basal‐septum, mid‐anterior‐septum, mid‐septum, apical‐septum) was significantly shorter than that of 5 posterolateral segments at 3 different LV levels (basal‐posterior, basal‐lateral, mid‐posterior, mid‐lateral, apical‐lateral). This time difference between septum and posterolateral wall was 216 msec (204 msec vs. 420 msec), which was considered to indicate significant LV mechanical dyssynchrony (≥130 msec). 12 months after cardiac resynchronization therapy (CRT), EF had improved to 47%, while end‐systolic and diastolic volumes had decreased to 88 mL and 47 mL, respectively, so that the patient was classified as a responder. In conclusions, a newly developed 3D speckle tracking strain can provide a comprehensive evaluation of “true” LV mechanical dyssynchrony from pyramidal 3D data sets acquired in the same beat, thus yielding more accurate information than previously possible with the 2D speckle tracking system.     

Study of Left Ventricular Rotation and Torsion in the Acute Phase of ST-Elevation Myocardial Infarction by Speckle Tracking Echocardiography

Background: The mechanics of the complex left ventricular (LV) myocardial fiber architecture may accurately be assessed by speckle tracking echocardiography (STE). The role of STE to assess LV mechanical dysfunction in the setting of ST segment elevation myocardial infarction (AMI) is still poorly studied. Patients and Methods: 29 consecutive patients (55 ± 13 years) presenting with AMI underwent STE within 72 hours of admission. Reperfusion was achieved with thrombolysis in 15 patients and with primary percutaneous coronary intervention in 14. LV rotational and torsion data were registered during peak systole. Standard Doppler data included LV ejection fraction (EF), mitral inflow deceleration time (DT), and conventional E/A ratio. E/E' ratio (mitral inflow E velocity/tissue Doppler E velocity) was calculated as a marker of LV filling pressure. Twelve subjects with clinically indicated but negative dobutamine stress echocardiogram served as Controls. Results: Peak systolic torsion was not only significantly lower in AMI compared with Controls (13.3 ± 7.6 vs. 21.8 ± 6.1; P < 0.01), it was also lower in subjects with LVEF <40% (5.0 ± 2.9) compared with those who had LVEF >40% (10.6 ± 6.6; P < 0.02). Torsion had a modest but significantly positive linear relation (R = 0.6; P < 0.05) with DT, not with E/E' or LVEF. Conclusion: LV systolic torsion is decreased in AMI and more markedly decreased in patients with LVEF <40%. The most significant linear relationship between DT and torsion may possibly indicate that the LV mechanical dysfunction is also associated with altered filling dynamics. (Echocardiography 2010;27:45-49)     

The Impact of Mitral Stenosis on Left Atrial Function Assessed by Two‐Dimensional Speckle Tracking Echocardiography

Aims: The aim of this study is to investigate the effect of mitral stenosis (MS) on left atrial (LA) function using two‐dimensional speckle tracking echocardiography (2DSTE). Methods and Results: The study subjects consisted of 52 patients with asymptomatic MS and 52 control subjects. LA function was assessed using prototype speckle tracking software and manual tracking method. Maximal LA volume (LAVmax) and minimal LA volume (LAVmin) and LA volume before atrial contraction (LAVpre‐a) were measured. Using these volumes, LA reservoir, conduit and booster pump fuction parameters were calculated. Indexed LAVmax, LAVmin, and LAVpre‐a measurements via speckle tracking were highly correlated with manual tracing methods in both groups. Expansion index (67.8 ± 36.4 vs. 148.3 ± 44.2), diastolic emptying index (37.7 ± 12.9 vs. 58.0 ± 8.5), passive emptying (37.3 ± 14.1 vs. 70.4 ± 10.4) and passive emptying index (13.3 ± 6.3 vs. 41.3 ± 10.6) were decreased significantly in MS patients (P < 0.001). In contrast active emptying index (62.6 ± 4.1 vs. 29.5 ± 10.1) increased in MS group (P < 0.001) while active emptying (28.1 ± 13.0 vs. 28.3 ± 6.9) remained same among both groups. Conclusions: This is the first study relating LA volumes and function assessed by 2DSTE to MS. 2D speckle tracking analysis of LA volume is relatively easy and provides more detailed information regarding the changes in LA volumes during the cardiac cycle.     

Cardiac Resynchronization Therapy as Rescue Therapy in End‐Stage Heart Failure: Illustration by Three‐Dimensional Speckle Tracking Strain Echocardiography

We report the case of a 73‐year‐old man admitted for refractory heart failure following implantation of a dual‐chamber pacemaker. Three‐dimensional (3D) echocardiography with speckle tracking area strain identified severe left ventricular (LV) dysfunction and LV dyssynchrony following right ventricular pacing. As the patient's clinical condition rapidly worsened despite optimal medical treatment, a cardiac resynchronization therapy (CRT) pacemaker was successfully implanted as rescue therapy. Symptoms rapidly regressed and echocardiographic assessment following CRT demonstrated an immediate improvement in LV systolic function, confirmed at 9‐month follow‐up with evidence of reverse remodeling. New imaging technologies such as 3D echocardiography with speckle tracking area strain may help to identify and follow up patients who will benefit from CRT as rescue therapy.