Subclinical left ventricular systolic impairment in steady state young adult patients with sickle-cell anemia

Chronic volume overload in sickle-cell anemia (SCA) is associated with left ventricular (LV) enlargement and hypertrophy. The effect of the disease on LV systolic function remains debated. The aim of our study was to investigate LV systolic function in SCA patients using 2D speckle-tracking imaging. We compared 30 steady state asymptomatic adult SCA patients (17 women, mean age 24.7 ± 5.1 years) with 30 age and sex-matched healthy subjects (17 women, mean age 25.0 ± 4.9 years). In addition to conventional echocardiographic parameters including LV ejection fraction (LVEF) and LV mass index (LVMi), global longitudinal strain (GLS) and strain rate (GLSR) were measured. GLS (?17.9 ± 2.0 vs. ?19.7 ± 2.5 %, p = 0.004) and GLSR (?0.92 ± 0.09 vs. ?1.07 ± 0.17 s^?1, p < 0.0001) values were lower in SCA patients while LVEF values (60.1 ± 3.8 vs. 61.7 ± 4.7 %, p = 0.30) were not different. LVMi was increased in SCA patients (100.7 ± 23.5 vs. 72.4 ± 15.2 g/m², p = 0.0001) and GLSR was significantly lower in the subgroup of patients with LV hypertrophy (?0.88 ± 0.09 vs. ?0.96 ± 0.08 s^?1, p = 0.02). In SCA patients LVMi was correlated to GLS (r = 0.58, p = 0.001) and GLSR (r = 0.45, p = 0.015) pleading in favor of a pathological LV remodeling. Asymptomatic SCA patients exhibited a subclinical alteration of LV systolic function. Myocardial dysfunction appears to be linked to the degree of LV hypertrophy. 2D speckle-tracking imaging might be useful for long-term follow-up and to study the natural course of LV dysfunction in SCA patients.     

The impact of high-normal blood pressure on left ventricular mechanics: a three-dimensional and speckle tracking echocardiography study

To assess the presence of subclinical left ventricular myocardial dysfunction in subjects with high-normal blood pressure (BP) and untreated arterial hypertension, using three-dimensional (3D) echocardiography strain analysis. This cross-sectional study included 49 subjects with optimal BP, 50 subjects with high-normal BP, and 50 newly diagnosed untreated hypertensive patients matched by gender and age. All the subjects underwent 24 h blood pressure monitoring and complete two-dimensional and 3D echocardiography examination. The enrolled subjects were grouped according to 24 h systolic BP values, dividing the subjects with optimal BP from those with high-normal BP and the hypertensive patients (cut-off values were 120 and 130 mmHg, respectively). 3D global longitudinal strain was significantly lower in the high-normal BP group and the hypertensive patients, in comparison with the optimal BP group (?20.5 ± 3.3 vs. ?18.7 ± 2.8 vs. ?17.6 ± 2.7 %, p < 0.001). Similar results were obtained for 3D global circumferential strain (?18.6 ± 3 vs. ?17.1 ± 2.9 vs. ?16 ± 2.5 %, p < 0.001), as well for 3D global radial strain (49.4 ± 9.5 vs. 44.7 ± 8.1 vs. 43.5 ± 7.8 %, p = 0.002), and global area strain (?31.2 ± 4.8 vs. ?28.7 ± 4.2 vs. ?27.1 ± 4.5 %, p < 0.001). LV twist was increased in the hypertensive patients in comparison with the high-normal and the optimal BP groups (10.1° ± 2.4° vs. 10.8° ± 2.6° vs. 13.8° ± 3.1°, p < 0.01), whereas untwisting rate significantly and gradually decreased from the optimal BP group, across the high-normal BP group, to the hypertensive patients (?135 ± 35 vs. ?118 ± 31 vs. ?102 ± 27°/s, p < 0.001). 3D echocardiography revealed that the subjects with high-normal BP suffered subclinical impairment of LV mechanics similar as the hypertensive patients.     

Assessment of left atrial functional parameters using a novel dedicated analysis tool for real-time three-dimensional echocardiography: validation in comparison to magnetic resonance imaging

Real-time three-dimensional echocardiography (RT3DE) is superior to two-dimensional echocardiography in assessing left atrial (LA) parameters, but to date algorithms developed for the left ventricle were applied due to a lack of dedicated LA software. In addition, no data are available on RT3DE assessment of active atrial contraction. The aim of this study was to validate a novel RT3DE analysis tool specifically dedicated to evaluate the LA. Cardiac magnetic resonance imaging (MRI) served as standard of reference. Fifty-five patients scheduled for pulmonary vein isolation underwent cardiac MRI and RT3DE. On ultrasound image datasets, a dynamic polyhedron model of the LA was generated from which LA maximum and minimum volumes (LA_max and LA_min), passive atrial emptying fraction (LAEF), and active atrial ejection fraction (LAEF_true) were derived and compared to values obtained from cardiac MRI. High intraclass correlations between RT3DE and MRI were found for LA_max (r = 0.94, p < 0.001), LA_min (r = 0.95, p < 0.001), LAEF (r = 0.92, p < 0.001), and LAEF_true (r = 0.87, p < 0.001). Similarly, Bland–Altman analysis revealed narrow limits of agreement for LA_max (?28.6 to 14.1 ml), LA_min (?26.8 to 12.4 ml), LAEF (?11.2 to 14.9 %), and LAEF_true (?10.6 to 6.8 %). LA_max, LA_min and LAEF_true were measured significantly (p < 0.05) lower by RT3DE (111 ± 38 ml vs. 118 ± 39 ml, 73 ± 38 ml vs. 80 ± 41 ml, and 23 ± 14 % vs. 27 ± 14 %, respectively). Interobserver and intraobserver RT3DE measurements correlated closely. RT3DE using a novel dedicated software tool is valid, accurate and reproducible for assessing LA dimensional and functional parameters. This study corroborates previous reports and extends its validity to the assessment of active LA contraction.     

Left atrial remodelling in patients undergoing transcatheter aortic valve implantation: a speckle-tracking prospective, longitudinal study

Aortic stenosis (AS) results in several left ventricular (LV) disturbances as well as progressive left atrial (LA) enlargement and dysfunction. Transcatheter aortic valve implantation (TAVI) reverses LV remodelling and improves overall systolic function but its effect on LA function remains undetermined. The aim of this prospective, longitudinal study was to investigate the effects of TAVI on LA structure and function. We studied thirty-two patients with severe symptomatic AS who underwent TAVI, using standard and 2-dimensional speckle-tracking echocardiography before, at 40-day and at 3-month follow-up. Following TAVI, mean transvalvular gradient decreased (p < 0.001). Both LA area index and LA volume index decreased at 40-day follow-up (16.2 ± 6.4 vs. 12.5 ± 2.9 cm²/m², and 47.3 ± 12.0 vs. 42.8 ± 12.5 mL/m², respectively, p < 0.05) and values remained unchanged at 3 months. The reduction of LA size was accompanied by a significant increase in global peak atrial longitudinal strain (14.4 ± 3.9 vs. 19.1 ± 4.7 %, p < 0.001) and in global peak atrial contraction strain (8.4 ± 2.5 vs. 11.0 ± 4.1 %, p < 0.05) at 3-month follow-up. LA stiffness measurements significantly decreased 3 months after TAVI (0.93 ± 0.59 vs. 0.65 ± 0.37, respectively, p < 0.001). Trans-aortic mean gradient change and pre-procedural LA volume were identified as predictors of global peak atrial longitudinal strain increase (β = ?0.41, β = ?0.35, respectively, p < 0.0001) while pre-procedural LA volume and trans-aortic mean gradient change as predictor of LA volume index reduction 3 months after TAVI (β = ?0.37, β = ?0.28, respectively, p < 0.0001). TAVI is associated with significant recovery of LA structure and function suggesting a reverse cavity remodelling. Such functional recovery is primarily determined by the severity of pre-procedural valve stenosis.     

Impact of right ventricular dyssynchrony on left ventricular performance in patients with pulmonary hypertension

Pulmonary hypertension has been associated with right ventricular (RV) dyssynchrony which may induce left ventricular (LV) dysfunction and dyssynchrony through ventricular interdependence. The present study evaluated the influence of RV dyssynchrony on LV performance in patients with pulmonary hypertension. One hundred and seven patients with pulmonary hypertension (age 63 ± 14 years, systolic pulmonary arterial pressure 60 ± 19 mmHg) and LV ejection fraction (EF) >35 % were evaluated. Ventricular dyssynchrony was assessed with speckle tracking echocardiography and defined as the standard deviation of the time to peak longitudinal strain of six segments of the RV (RV-SD) and the LV (LV-SD) in the apical 4-chamber view. Mean RV-SD and LV-SD assessed with longitudinal strain speckle tracking echocardiography were 51 ± 28 and 47 ± 21 ms, respectively. The patient population was divided according to the median RV-SD value of 49 ms. Patients with RV-SD ≥49 ms had significantly worse NYHA functional class (2.7 ± 0.7 vs. 2.3 ± 0.7, p = 0.004), RV function (tricuspid annular plane systolic excursion: 16 ± 4 vs. 19 ± 4 mm, p < 0.001), LVEF (50 ± 10 vs. 55 ± 8 %, p = 0.001), and larger LV-SD (57 ± 18 vs. 36 ± 18 ms, p < 0.001). RV-SD significantly correlated with LV-SD (r = 0.55, p < 0.001) and LVEF (r = ?0.23, p = 0.02). Multiple linear regression analysis showed an independent association between RV-SD and LV-SD (β = 0.35, 95 %CI 0.21–0.49, p < 0.001). RV dyssynchrony is significantly associated with LV dyssynchrony and reduced LVEF in patients with pulmonary hypertension.     

Improvement of left ventricular longitudinal systolic function after transcatheter aortic valve implantation: a speckle-tracking prospective study

Transcatheter aortic valve implantation (TAVI) is able to determine a significant improvement of left ventricular ejection fraction (LVEF). The variations of LV global longitudinal strain (GLS) have not been yet investigated in TAVI patients with reduced LVEF. The aim of this study was to determine the effects of TAVI on LV function by 2D speckle-tracking echocardiography (STE) in patients with reduced LVEF. Eighteen consecutive patients undergoing TAVI in our centre were prospectively enrolled. Echocardiography was performed pre-procedurally the day of TAVI and at 40-day and 3-month follow-up (FU). The mean age of TAVI patients was 79.75 ± 7.68 years. The mean EuroSCORE was 26.59 ± 14.62 %. A significant decrease of mean trans-aortic gradient was observed 40 days after TAVI (51.69 ± 18.82 vs. 9.62 ± 3.28 mmHg, p < 0.0001). LV mass index significantly decreased at 40-day FU (165.72 ± 37.75 vs. 145.52 ± 31.32 g/m², p < 0.001) with a further reduction at 3-month FU (136.91 ± 26.91 g/m², p < 0.05 in comparison with 40-day FU). The mean pre-procedural LVEF was 45.87 ± 7.95 %. LVEF significantly increased at 40-day FU (55.20 ± 5.91 %, p < 0.05) and remained stable at 3-month FU (55.58 ± 6.14 %). Interestingly, an early improvement of LV GLS was observed at 40-day FU (?11.09 ± 3.40 vs. ?14.40 ± 3.68 %, p < 0.001) with a slight further increase at 3-month FU (?14.71 ± 3.56 %). Our results indicate that significant improvements of LVEF and LV GLS can be observed in patients undergoing TAVI with impaired LVEF. Two-dimensional STE was able to detect the reverse remodeling of LV function, adding further insights into the assessment of LV mid-term recovery after TAVI.     

Assessment of microembolization associated with revascularization in acute myocardial infarction: MDCT cardiac perfusion and function study

To use multi-detector computed tomography (MDCT) for assessing the effects of coronary microemboli on pre-existing acute myocardial infarct (AMI) and to compare this pathology to LAD microembolization and occlusion/reperfusion. An angioplasty balloon catheter was placed in the LAD coronary artery of pigs under X-ray guidance. Four animals served as controls without intervention (group A) and an additional 24 animals (8/group) were subjected to microembolization (group B), occlusion/reperfusion (group C) or combination of the two insults (group D). MDCT was used to assess perfusion, LV function and viability. At postmortem, the LV sections were stained with hematoxylin/eosin and triphenyltetrazolium chloride (TTC). Dynamic perfusion and helical cine MDCT demonstrated decline in regional LV perfusion and function, respectively, after all interventions. MDCT showed significant differences in ejection fraction between groups: A = 57.5 ± 4.7 %, B = 40.3 ± 0.5 % P < 0.05, C = 34.9 ± 1.3 % P < 0.05 and D = 30.7 ± 1.2 % P < 0.05, while viability MDCT demonstrated differences in enhancement patterns and extents of damage between the groups (B = 9.1 ± 0.4 % LV mass, C = 11.9 ± 0.7 % and D = 16.2 ± 1.2 %, P < 0.05) and extent of microvascular obstruction (MVO) (group C = 3.2 ± 1.0 % LV mass versus D = 5.2 ± 0.7 %, P < 0.01). DE-MDCT overestimated all types of myocardial damage compared with TTC, but showed a close correlation (r > 0.7). Microscopic examination confirmed the presence of patchy and contiguous necrosis, MVO, edema and calcium deposits. Dynamic and helical cine MDCT imaging can grade LV dysfunction and perfusion deficit, respectively. DE-MDCT demonstrated a large and persistent MVO zone after microembolization of pre-existing AMI. Furthermore, it has the potential to visualize patchy microinfarct, detect perfusion deficits and dysfunction at the border zone after microembolization of pre-existing AMI.     

Early changes of left ventricular geometry and deformational analysis in obese subjects without cardiovascular risk factors: a three-dimensional and speckle tracking echocardiographic study

Subclinical myocardial dysfunction has been identified in obese subjects without cardiovascular risks factors and has been defined as “obesity cardiomyopathy”. We evaluated left ventricular (LV) function and geometry in obese patients by using a 3 dimensional echocardiography (3DE). We also aimed to look at the influence of ventricular geometry upon functional parameters of the LV by using 3D speckle tracking imaging (3D-STI). 30 consecutive and asymptomatic obese cases (OB group) with no comorbidities were prospectively enrolled. The control group included 30 healthy volunteers (HS group), matched for age and sex. All subjects underwent 3DE and 3D-STI. Ventricular geometry was evaluated with the LV sphericity index (LV SpI) and the LV diastolic volume to mass ratio (LV EDV/Mass ratio). LV Mass was significantly increased in OB group and the LV EDV/Mass ratio had a significantly lower mean value in this group (p < 0.001 and p = 0.002, respectively). LV SpI was significantly reduced in obese subjects (p < 0.001). A significant reduction in longitudinal (GLS), radial (GRS) and area strain (GAS) was observed in OB group (p = 0.001 for all) while circumferential mechanic (GCS) was not different between the two groups (p = 0.052). LV EDV to mass ratio was significantly related to GLS (r = ?0.298, p = 0.022) and GAS (r = ?0.289, p = 0.026). On multivariate analysis, GRS and GAS were independently related to LV SpI (β = 0.222, p = 0.031 and β = ?0.222, p = 0.034, respectively). Geometrical and structural ventricular remodeling negatively influences functional properties of the LV in obese subjects without cardiovascular risks factors. Further studies are needed to assess the prognostic value of our findings.     

Echocardiographic assessment of right ventricular functions in patients with proximal right coronary artery chronic total occlusion

To assess right ventricular functions by echocardiography in patients with proximal right coronary artery (RCA) CTO and correlating it with clinical and angiographic variables. We studied 60 consecutive patients with CTO of the proximal RCA and no other significant lesions in the left coronary system. Echocardiography was performed in order to measure left ventricular (LV) dimensions, LVEF, RV end diastolic area (RVEDA), RV end systolic area (RVESA), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), Doppler myocardial performance index (MPI), trans-tricuspid E and A waves, E/A ratio, S′, e′ and a′. Grades of coronary collaterals was assessed. Doppler MPI showed negative correlation with TAPSE (r = ?0.8997, p < 0.0001) and RVFAC (r = ?0.928, p < 0.0001). Positive correlation with trans-tricuspid E/A ratio (r = 0.893, p < 0.0001) and E/e′ ratio (r = 0.783, p < 0.0001). Patients with no evidence of MI had more well-developed (grade 3) coronary collaterals (83.8 vs. 17.4 %). Patients with evidence of MI had lower RVFAC 38.13 ± 5.39 versus 45.08 ± 4.99 % (p < 0.0001), lower TAPSE 20.17 ± 3.85 versus 25.35 ± 3.46 mm (p < 0.0001), higher MPI 0.4 ± 0.08 versus 0.31 ± 0.05 (p < 0.0001), higher trans-tricuspid E/A ratio 1.79 ± 0.38 versus 1.13 ± 0.36 (p < 0.0001) and E/e′ ratio 5.23 ± 1.02 versus 3.61 ± 0.88 (p < 0.0001). Patients with poorly developed collaterals had lower TAPSE and RVFAC and a higher MPI (p < 0.0001 for each). Patients with proximal RCA CTOs and evidence of inferior wall MI have significant impairment of RV functions in addition to poorly developed coronary collaterals. Those with proximal RCA CTOs and well-developed coronary collaterals have better RV functions.     

Assessment of pulmonary arterial stiffness in obstructive sleep apnea

Pulmonary hypertension (PH) is one of the major complications of obstructive sleep apnea syndrome (OSAS). Pulmonary arterial stiffness (PAS) can be used in determination of PH. The aim of the present study was to evaluate the PAS and cardiac function of patients with OSAS and analyses the relationship between OSAS severity and PAS. Sixty newly diagnosed patients with OSAS (mean age 49.6 ± 11.7 years) and 30 healthy controls (mean age 46.4 ± 14 years) were enrolled. Right ventricle (RV) and left ventricle (LV) echocardiographic parameters and PAS values of study groups were compared. There were no significant differences in terms of LV ejection fraction, LV Tei-index and tricuspid annular plane systolic excursion. PAS, mean pulmonary arterial pressure (PAP) and RV Tei-index were significantly higher but tricuspid annulus early diastolic myocardial velocity was lower in patients with OSAS than control subjects (respectively p < 0.001, p < 0.001, p = 0.001, p = 0.001). Moreover, we found a higher PAS in OSAS patients without PH compared to controls (p < 0.001). When we investigated the relationship between polysomnographic variables and echocardiographic parameters, we found positive correlations between apnea hypopnea index and total oxygen desaturation with PAS and mean PAP (r = 0.384, p < 0.001; r = 0.404, p < 0.001; r = 0.36, p < 0.001; r = 0.349, p = 0.001 respectively). PAS and mean PAP were increased in patients with OSAS. Pulmonary vascular bed may be affected due to the fluctuation of PAP during day and night time. Therefore, assessment of PAS can be more useful than PAP in OSAS patients.     

Semiautomatic three-dimensional CT ventricular volumetry in patients with congenital heart disease: agreement between two methods with different user interaction

To assess agreement between two semi-automatic, three-dimensional (3D) computed tomography (CT) ventricular volumetry methods with different user interactions in patients with congenital heart disease. In 30 patients with congenital heart disease (median age 8 years, range 5 days–33 years; 20 men), dual-source, multi-section, electrocardiography-synchronized cardiac CT was obtained at the end-systolic (n = 22) and/or end-diastolic (n = 28) phase. Nineteen left ventricle end-systolic (LV ESV), 28 left ventricle end-diastolic (LV EDV), 22 right ventricle end-systolic (RV ESV), and 28 right ventricle end-diastolic volumes (RV EDV) were successfully calculated using two semi-automatic, 3D segmentation methods with different user interactions (high in method 1, low in method 2). The calculated ventricular volumes of the two methods were compared and correlated. A P value <0.05 was considered statistically significant. LV ESV (35.95 ± 23.49 ml), LV EDV (88.76 ± 61.83 ml), and RV ESV (46.87 ± 47.39 ml) measured by method 2 were slightly but significantly smaller than those measured by method 1 (41.25 ± 26.94 ml, 92.20 ± 62.69 ml, 53.61 ± 50.08 ml for LV ESV, LV EDV, and RV ESV, respectively; P ≤ 0.02). In contrast, no statistically significant difference in RV EDV (122.57 ± 88.57 ml in method 1, 123.83 ± 89.89 ml in method 2; P = 0.36) was found between the two methods. All ventricular volumes showed very high correlation (R = 0.978, 0.993, 0.985, 0.997 for LV ESV, LV EDV, RV ESV, and RV EDV, respectively; P < 0.001) between the two methods. In patients with congenital heart disease, 3D CT ventricular volumetry shows good agreement and high correlation between the two methods, but method 2 tends to slightly underestimate LV ESV, LV EDV, and RV ESV.     

Reduced global longitudinal and radial strain with normal left ventricular ejection fraction late after effective repair of aortic coarctation: a CMR feature tracking study

We sought to determine whether global and regional left ventricular (LV) strain parameters were altered in repaired coarctation of the aorta (COA) with normal LV ejection fraction (EF) when compared with healthy adult controls, and whether such alterations were related to LV hypertrophy (LVH). We identified 81 patients after COA repair (31 female, age 25 ± 8.5 years) with inclusion criteria at follow-up CMR of: age ≥13 years, time post-repair ≥10 years, no aortic valve disease, LV-EF >50 %). LV deformation indices derived using CMR-feature tracking and volumetric EF were compared between COA patients and normal controls (n = 20, 10 female, age 37 ± 7 years), and between COA with versus without LVH. In repaired COA versus controls, LV-EF (%) was 62 ± 7.2 versus 58 ± 3.0 (p = 0.01), and LV mass (g/m²) 66 ± 16.8 versus 57.7 ± 6.0 (p = 0.0001). LV global longitudinal strain (GLS) was decreased to ?17.0 ± 4.7 % in COA (?20 ± 5 % in controls, p = 0.02), and global radial strain (GRS) reduced to 40 ± 15 % (50 ± 12.4 % in controls, p = 0.003). The global circumferential strain (GCS) was preserved in COA at ?23 ± 4.7 % (?24.6 ± 2.4 % in controls, p = 0.14). Regionally, LS decrease was marked in the basal segments (septal, p = 0.005, lateral, p = 0.013). In COA with LVH (n = 45, mass 76.3 ± 12.8 g/m²) versus without LVH (n = 36, mass 52.2 ± 10 g/m²), GLS was more markedly decreased (?15.7 ± 4.8 vs. ?18.5 ± 4.2 %, p = 0.016, but GRS and GCS were similar (p = 0.49 and 0.27). In post-repair COA with normal LV-EF, GLS and GRS are reduced whilst GCS is preserved. GLS reduction is more pronounced in the presence of LVH. GLS may qualify as indicator of early LV dysfunction.     

Longitudinal systolic ventricular interaction in pediatric and young adult patients with TOF: a cardiac magnetic resonance and M-mode echocardiographic study

Aim of this prospective study was to evaluate longitudinal systolic left ventricular (LV)–right ventricular (RV) interaction using M-mode compared to magnetic resonance imaging (MRI) data in 146 pediatric and adults with operated tetralogy of Fallot (TOF). We determined biventricular measures of longitudinal M-mode echocardiography [i.e. tricuspid annular plane systolic excursion (TAPSE); the mitral annular plane systolic excursion (MAPSE)] compared to longitudinal function parameters using MRI. M-mode data were compared to established normal z-score values. We found a good correlation between MAPSE and LVEF values (r = 0.788; p < 0.001). Correlations between MRI derived MAPSE and M-mode guided MAPSE (r = 0.879, p < 0.001), and between MRI derived TAPSE and M-mode guided TAPSE were significant (r = 0.780, p < 0.001). While the LVEF was normal in patients with a normal RVEF, the LVEF was decreased in patients with significantly reduced RVEF. Patients with a significantly dilated RV (RVEDVi > 150 ml/m²) showed a significantly reduced mean MAPSE of 1.30 ± 0.26 cm. LV longitudinal function decreases below ?2 SD of normal MAPSE z-score values after a mean of 22 postoperative years. Our data confirm progressive adverse RV–LV interaction in the long-term follow-up of TOF. We show that simple M-mode measurement of the longitudinal LV function (i.e. MAPSE) is a sufficient surrogate for estimation of LVEF. Therefore determination of the MAPSE is a helpful additional tool for LV systolic function assessment late after TOF repair.     

Myocardial area at risk after ST-elevation myocardial infarction measured with the late gadolinium enhancement after scar remodeling and T2-weighted cardiac magnetic resonance imaging

To evaluate the myocardial area at risk (AAR) measured by the endocardial surface area (ESA) method on late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) when applied after scar remodeling (3 months after index infarction) compared to T2-weighted CMR imaging. One hundred and sixty nine patients with ST-elevation myocardial infarction, treated with primary percutaneous coronary intervention, underwent one CMR within 1 week after index treatment to determine the AAR with T2-weighted imaging and a second scan 3 months after to measure AAR with the ESA method. There was a moderate correlation between the two methods (r = 0.86; P < 0.001). The AAR was significantly higher measured with T2-weighted imaging than with the ESA methods (32 ± 11% of left ventricle (LV) vs. 26 ± 10%LV; P < 0.001). The mean difference was 6 ± 6%LV. Furthermore, the mean difference between the two methods was statistical higher in the patients with myocardial salvage index ≥0.90 than in the remaining patients (9 ± 8%LV vs. 6 ± 5%LV; P = 0.02). The ESA method performed after scar remodeling (3 months following STEMI) yields significantly lower AAR′s and myocardial salvage indices compared to the T2-weighted method. Therefore, T2-weighted CMR plus LGE is the method of choice to assess AAR and myocardial salvage index using CMR. However, the ESA method is an easy and valid method for determining AAR, which can be used in settings where T2-weighted imaging has not been obtained in the acute phase.     

Quantitative assessment of systolic left ventricular function with speckle-tracking echocardiography in adult patients with repaired aortic coarctation

Despite successful aortic coarctation (CoA) repair, systemic hypertension often recurs which may influence left ventricular (LV) function. We aimed to detect early LV dysfunction using LV global longitudinal strain (GLS) in adults with repaired CoA, and to identify associations with patient and echocardiographic characteristics. In this cross-sectional study, patients with repaired CoA and healthy controls were recruited prospectively. All subjects underwent echocardiography, ECG and blood sampling within 1 day. With speckle-tracking echocardiography, we assessed LV GLS on the apical four-, three- and two-chamber views. We included 150 subjects: 75 patients (57 % male, age 33.4 ± 12.8 years, age at repair 2.5 [IQR: 0.1–11.1] years) and 75 healthy controls of similar sex and age. LV GLS was lower in patients than in controls (?17.1 ± 2.3 vs. ?20.2 ± 1.6 %, P < 0.001). Eighty percent of the patients had a normal LV ejection fraction, but GLS was still lower than in controls (P < 0.001). In patients, GLS correlated with systolic and diastolic blood pressure (r = 0.32, P = 0.009; r = 0.31, P = 0.009), QRS duration (r = 0.34, P = 0.005), left atrial dimension (r = 0.27, P = 0.029), LV mass (r = 0.30, P = 0.014) and LV ejection fraction (r = ?0.48, P < 0.001). Patients with either associated cardiac lesions, multiple cardiac interventions or aortic valve replacement had lower GLS than patients without. Although the majority of adults with repaired CoA seem to have a normal systolic LV function, LV GLS was decreased. Higher blood pressure, associated cardiac lesions, and larger left atrial dimension are related with lower GLS. Therefore, LV GLS may be used as objective criterion for early detection of ventricular dysfunction.     

Left ventricular synchrony,torsion, and recoil mechanics in Ebstein’s anomaly: insights from cardiovascular magnetic resonance

Background

Disease progression and heart failure development in Ebstein’s Anomaly (EA) of the tricuspid valve is characterized by both right and left ventricular (LV) deterioration. The mechanisms underlying LV dysfunction and their role in heart failure development are incompletely understood. We hypothesized that LV dyssynchrony and impaired torsion and recoil mechanics induced by paradoxical movement of the basal septum may play a role in heart failure development.

Methods

31 EA patients and 31 matched controls underwent prospective cardiovascular magnetic resonance (CMR). CMR feature tracking (CMR-FT) was performed on apical, midventricular and basal short-axis and 4D–volume analysis was performed using three long-axis views and a short axis cine stack employing dedicated software. Circumferential uniformity ratio estimates (CURE) time-to-peak-based circumferential systolic dyssynchrony index (C-SDI), 4D volume analysis derived SDI (4D–SDI), torsion (Tor) and systolic (sysTR) and diastolic torsion rate (diasTR) were calculated for the LV. QRS duration, brain natriuretic peptide, NYHA and Total R/L-Volume Index (R/L Index) were obtained.

Results

EA patients (31.5 years; controls 31.4 years) had significantly longer QRS duration (123.35 ms?±?26.36 vs. 97.33 ms ±?11.89 p <?0.01) and showed more LV dyssynchrony (4D–SDI 7.60%?±?4.58 vs. 2.54%?±?0.62, p <?0.001; CURE 0.77?±?0.05 vs. 0.86?±?0.03, p?<?0.001; C-SDI 7.70?±?3.38 vs. 3.80?±?0.91, p =?0.001). There were significant associations of LV dyssynchrony with heart failure parameters and QRS duration. Although torsion and recoil mechanics did not differ significantly (p >?0.05) there was an association of torsion and recoil mechanics with dyssynchrony parameters CURE (sysTR r =??0.426; p =?0.017, diasTR r =?0.419; p =?0.019), 4D–SDI (sysTR r =?0.383; p =?0.044) and C-SDI (diasTR r =??0.364; p?=?0.044).

Conclusions

EA is characterized by LV intra-ventricular dyssynchrony, which is associated with heart failure and disease severity parameters. Markers of dyssynchrony can easily be quantified from CMR-FT, and may have a role in the assessment of altered cardiac function, carrying potential management implications for EA patients.

     

Gender- and age-related differences in rest and post-stress left ventricular cardiac function determined by gated SPECT

Gender- and age-related changes of left ventricular (LV) function and dimensions have not been elucidated in a large population by gated SPECT. Thus, the aim of this study was to derive male and female reference limits for left ventricular functional parameters, and determine the effect of age on LV dimensions and systolic function for this imaging modality. 1,639 (53 % males) subjects without cardiovascular disease who underwent cardiac SPECT between January 2002 and June 2012 were included in this study. Mean age at presentation was 61 ± 12 years (range 18–92 years). A significant effect of age (p = 0.011) and gender (p < 0.0001) on resting LV ejection fraction (LVEF) was observed, with an increase in LVEF with age being more pronounced in women (ΔB-coefficient: ?0.088, p = 0.011). Overall, mean LVEF was higher in women compared to men (70.3 ± 8.6 % vs. 64.4 ± 7.5 %, p < 0.0001). LVEF after pharmacological stress with adenosine was significantly lower than at rest in both women and men (?LVEF = 1.1 % in males and ?LVEF = 1.6 % in females, p = 0.01), which was the result of a significant increase in end-systolic volume after stress (p = 0.0001). With advancing age an increase in LVEF was observed that was more pronounced in women than in men. These findings indicate that the evaluation of cardiac function and volumes of patients by gated SPECT should consider age- and gender-matched normative values.     

Progression of diffuse myocardial fibrosis assessed by cardiac magnetic resonance T1 mapping

To evaluate long-term changes in diffuse myocardial fibrosis using cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) and T₁ mapping. Patients with chronic stable cardiomyopathy and stable clinical status (n = 52) underwent repeat CMR at a 6 month or greater follow up interval and had LGE and left ventricular (LV) T₁ mapping CMR. Diffuse myocardial fibrosis (excluding areas of focal myocardial scar) was assessed by post gadolinium myocardial T₁ times. Mean baseline age of 52 patients (66 % male) was 35 ± 19 years with a mean interval between CMR examinations of 2.0 ± 0.8 years. CMR parameters, including LV mass and ejection fraction, showed no change at follow-up CMR (p > 0.05). LVT₁ times (excluding focal scar) decreased over the study interval (from 468 ± 106 to 434 ± 82 ms, p = 0.049). 38 Patients had no visual LGE?, while 14 were LGE+. For LGE? patients, greater change in LV mass and end systolic volume index were associated with change in T₁ time (β = ?2.03 ms/g/m², p = 0.035 and β = 2.1 ms/mL/m², p = 0.029, respectively). For LGE+ patients, scar size was stable between CMR1 and CMR2 (10.7 ± 13.8 and 11.5 ± 13.9 g, respectively, p = 0.32). These results suggest that diffuse myocardial fibrosis, as assessed by T₁ mapping, progresses over time in patients with chronic stable cardiomyopathy.     

Intra-procedural imaging of the left atrium and pulmonary veins with rotational angiography: a comparison of anatomy obtained by pre-procedural cardiac computed tomography and trans-thoracic echocardiography

This study evaluated the feasibility and accuracy of three-dimensional rotational angiography (3DRA) to determine the anatomy of the left atrium (LA) and pulmonary veins (PVs) compared with cardiac computed tomography (CCT) and trans-thoracic echocardiography (TTE). One hundred two patients (56.1 ± 9.9 years, 86 males) with an indication for atrial fibrillation ablation were prospectively enrolled. Intra-procedural 3DRA was performed with power injected contrast medium (20 cc/s for 4 s, 240°) in the LA. 3DRA images of the LA and PVs were assessed qualitatively and then compared quantitatively. LA volume measured by 3DRA, CCT and TTE were compared. The majority of 3DRA acquisitions were optimal in delineating the right-side LA–PV (95 % for right superior PV and 96 % for right inferior PV) and left inferior PV anatomy (91 %), whereas it was optimal in only 63 % of left superior PV and 73 % of the LA appendage. The circumferences of PV ostia identified by 3DRA and CCT were correlated in four PVs (r = 0.57 for right superior PV, r = 0.67 for right inferior PV, r = 0.60 for left superior PV, and r = 0.52 for left inferior PV, p < 0.001). The mean LA volume measured by 3DRA (120 ± 32 mL) was greater than that found by CCT (109 ± 35 mL) or TTE (64 ± 23 mL), but the 3DRA LA volume measurements correlated well with those of CCT (r = 0.83, p < 0.001) and TTE (r = 0.69, p < 0.001). Intra-procedural 3DRA provided anatomical accuracy of LA and PVs comparable to those of CCT. However, optimal delineation of the left superior PV and LA appendage was limited. The LA volume determined by 3DRA was well correlated with those of CCT and TTE, despite different absolute values of each.     

23Na chemical shift imaging and Gd enhancement of myocardial edema

Myocardial edema can arise in several disease states. MRI contrast agent can accumulate in edematous tissue, which complicates differential diagnosis with contrast-enhanced (CE)-MRI and might lead to overestimation of infarct size. Sodium Chemical Shift Imaging (²³Na-CSI) may provide an alternative for edema imaging. We have developed a non-infarct, isolated rat heart model with two levels of edema, which was studied with ²³Na-CSI and CE-MRI. In edematous, but viable tissue the extracellular sodium (Na _e ⁺ ) signal is hypothesized to increase, but not the intracellular sodium (Na _i ⁺ ) signal. Isolated hearts were perfused at 60 (n = 6) and 140 mmHg (n = 5). Dimethyl methylphosphonate (DMMP) and phenylphosphonate (PPA) were used to follow edema formation by ³¹P-MR Spectroscopy. In separate groups, Thulium(III)1,4,7,10 tetraazacyclododecane-N,N′,N″,N′′′-tetra(methylenephosphonate) (TmDOTP^5?) and Gadovist were used for ²³Na-CSI (n = 8) and CE-MRI (n = 6), respectively. PPA normalized signal intensity (SI) was higher at 140 versus 60 mmHg, with a ratio of 1.27 ± 0.12 (p < 0.05). The (DMMP-PPA)/dry weight ratio, as a marker of intracellular volume, remained unchanged. The mid-heart cross sectional area (CSA) of the left ventricle (LV) was significantly increased at 140 mmHg. In addition, at 140 mmHg, the LV Na _e ⁺ SI increased with a 140 mmHg/60 mmHg ratio of 1.24 ± 0.18 (p < 0.05). Na _i ⁺ SI remained essentially unchanged. With CE-MRI, a subendocardially enhanced CSA was identified, increasing from 0.20 ± 0.02 cm² at 60 mmHg to 0.31 ± 0.02 cm² at 140 mmHg (p < 0.05). Edema shows up in both CE-MRI and Na _e ⁺ . High perfusion pressure causes more edema subendocardially than subepicardially. ²³Na-CSI is an attractive alternative for imaging of edema and is a promising tool to discriminate between edema, acute and chronic MI.