Does left ventricular diastolic function deteriorate earlier than left ventricular systolic function in anthracycline cardiotoxicity?

Cardiotoxicity is the most important complication in patients receiving anthracycline chemotherapy. We studied the left ventricular diastolic function (LVDF) and systolic function (LVSF) in these patients and assessed whether LVDF deteriorates earlier than LVSF. We prospectively studied 58 patients (mean age 48.02 ± 13.87; 32 female, 26 male) on anthracycline treatment, before chemotherapy (S0) and after cumulative doses of 139 ± 12 mg/m(2) (S1) and 308 ± 14 mg/m(2) (S2). The LVSF was computed in terms of left ventricular ejection fraction (LVEF) from equilibrium radionuclide angiography (ERNA). The peak ejection rate (PER), peak filling rate (PFR), time to peak ejection rate (TPER), time to peak filling rate (TPFR), 1/3rd filling fraction and ratio of PFR and PER were calculated from ERNA and were also standardized using 150 baseline ERNA studies. Statistical analysis was done by repeated measures analysis of variance (ANOVA). We found significant decrease in LVEF (P<0.001) and PER (P<0.001) between the S1 and S2 studies and PFR (P<0.007) between the S0 and S1 studies. In conclusion in patients receiving anthracycline treatment, LVDF deteriorates earlier than left ventricular systolic function (LVSF).     

Quantification of left ventricular regional functions using ECG-gated myocardial perfusion SPECT —validation of left ventricular systolic functions—

OBJECTIVE: We have developed a program to quantify regional left ventricular (LV) function and wall motion synchrony using ECG-gated myocardial perfusion SPECT (MPS). This preliminary study was undertaken to validate the use of this program for estimating regional LV systolic function. METHODS: Patients were subjected to MPS by 99mTc-sestamibi at rest. The study included 20 patients who were confirmed to have a low probability of coronary artery disease (LPG; low probability group), 19 heart disease patients who were examined by MPS and equilibrium radionuclide angiography (ERNA) (ERG; ERNA group), and 24 patients who were examined by MPS and 2-dimensional echocardiography (2DE) (2DEG; 2DE group). The values of the ejection fraction (EF) and peak ejection rate (PER) were estimated. The global functions evaluated by this program were compared with those obtained by ERNA in the ERG. For regional assessment, the reference values of the functional indices were obtained for 17 LV segments in LPG. The Z score, (reference average value of the segment--patient's value of the segment)/reference standard deviation of the segment, was used for the evaluation of regional functions; a score equal to or greater than 2 was defined as abnormal. Semiquantitative visual interpretation of 2DE was used as the standard to assess wall motion. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these criteria and the relationship between 2DE grading and Z scoring were validated in 2DEG. RESULTS: The values of the global EF and PER evaluated by this program correlated with those determined by ERNA (r = 0.76 and 0.58, respectively; p < 0.005 and 0.01, respectively). The sensitivities of regional EF and PER for segmental wall motion abnormalities were 86.7% and 68.7%, respectively; their specificities were 86.7% and 95.5%, respectively; their PPVs were 64.3% and 79.2%, respectively; and their NPVs were 96.0% and 91.7%, respectively. The Z scores of these indices significantly correlated with the scores determined by 2DE (rs = 0.70 and 0.68, respectively; p < 10(-10)). CONCLUSION: The potential of this program to quantify the regional systolic function was validated.     

Incidental finding of a right ventricular mass: Fibroma or thrombosis?

Primary cardiac tumors are very rare and are often confused with other conditions due to clinical presentations or initial imaging. Here, we present a rare case of a 56-year-old male with right ventricular mass incidentally found on imaging. Appropriate testing should be conducted to rule out the possibility of a benign tumor. Asymptomatic patients with co-morbidities can be managed without surgery. More research is needed to devise guidelines for the management of these cases.     

Which factors predict the behavior of ventricular extrasystoles in athletes over time?

Spontaneous behavior of ventricular extrasystoles (VE) was analysed. From a database containing 578 athletes with VE, 84 males and 11 females (29.9 ± 18.1 years) having ≥ 100 VE or repetitive VE [ventricular couplets (VC) or ventricular tachycardias (VT)] at first 24‐hour Holter electrocardiographic monitoring (24‐h‐HM) (baseline) and at least 1‐year of follow‐up (3.1 ± 2.2 years) over the past 10 years were selected. The baseline was compared with the last 24‐h‐HM to establish DVE (VE reduction of at least 98%/24 h in the absence of VC or VT). SDVE was calculated as standard deviation of the number of VE on serial 24‐h‐HMs. DVE and SDVE were considered as dependent variables. Independent variables were: age, sex, type of sport, symptoms, baseline VE rate (BVE), baseline VC and VT, VE morphology, VE behavior during the baseline training session, disqualification from competitive sports, echocardiographic abnormalities. DVE occurred in 32 athletes (34%). SDVE varied from 0 to 12 658 VE/24 h (1916 ± 2649.9). Disappearance of VE during the baseline training session (DVET) correlated to DVE (P = 0.0319). BVE directly correlated to SDVE (P = 0.0008). Athletes' VE are highly variable over time, their variability depending on BVE, and they not infrequently tend to disappear. The only useful variable for predicting DVE is DVET.     

Left ventricular function in physiologic and pathologic hypertrophy in Sprague–Dawley rats

Objective

The aim of this study was to design a high intensity swimming training and two-kidney, one-clip (2K1C) hypertension protocol in Sprague–Dawley (SD) rats and to use current echocardiography techniques to examine the differential diagnosis between physiological and pathological left ventricular hypertrophy.

Methods

One group of SD rats performed swimming training at high intensive swimming training (HIGH) for eight weeks. In animals of the other arm of the study, a 2KIC hypertension was created and maintained for eight weeks.

Results

After eight weeks, all rats were studied by standard and tissue Doppler echocardiography. The heart weight/body weight ratio (HW/BW) of 2K1C and HIGH rats increased by 16% and 42%, respectively. Echocardiography showed increased septal and posterior wall thickness in both the 2K1C and HIGH rats. Left ventricular increased by 35 and 41% respectively. Left ventricular diameters, stroke volumes, cardiac output, and ejection fractions were unchanged in either group. Mitral inflow showed a decrease in late-wave velocity, thus increasing the E/A ratio in HIGH rats. However, mitral inflow showed an increase in late-wave velocity, thus decreasing the E/A ratio in 2K1C rats. There was a significant increase in Ea and early diastolic (Em)/late diastolic (Am) in HIGH rats in basal septum and lateral mitral valve annulus. And there was a significant increase in Am, which led to a significant decrease of Em/Am in 2K1C rats. No significant change occurred in pulmonary vein systolic velocity and diastolic velocity, in either of the three animal groups. However, there was significant increase in atrial reversal velocity in HIGH rats.

Conclusions

Doppler echocardiographic parameters of LV diastolic function can be of diagnostic importance for discrimination between pathologic and physiologic LV hypertrophy.     

Can left ventricular end-diastolic volumes be estimated with prospective ECG-gated CT coronary angiography?

Background

With the goal of minimizing patient radiation exposure, many centres have adopted prospective ECG-gated computed tomographic coronary angiography. Since image acquisition occurs only during ventricular diastasis, the ability to measure left ventricular (LV) ejection fraction (EF) and LV volumes has been lost. Given that LV volumes have prognostic value, the ability to estimate LV end diastolic volume (EDV) may be clinically desirable.

Objective

We sought to predict LV EDV using CT coronary angiography (CTA) images obtained during ventricular diastasis.

Methods

Consecutive patients who underwent retrospective ECG-gated CTA were enrolled. Images were reconstructed at the 75% phase and at end-diastole. LV and left atrial (LA) volumes were measured.

Results

A total of 153 consecutive patients were analyzed (mean age = 56.7 ± 11.2 years; men = 56.2%). The mean LV EDV and EF were 144.4 ± 40.2 mL and 63.4 ± 9.9%, respectively. There appeared to be a very strong linear relationship between the 75% phase LV volume and LV EDV with an R² of 0.993. Using LV and LA volumes at the 75% phase, a prediction model of LV EDV was developed (LV EDV = (1.021 × 75% phase LV volume) + (0.259 × 75% phase LA volume), adjusted R² = 0.995).

Conclusion

LV EDV can be estimated using CTA data obtained during ventricular diastasis. Further studies are needed to demonstrate that such estimates of LV EDV have incremental prognostic value over coronary artery disease severity assessment with prospective ECG-gated CTA.     

Effect of PTCA and stenting on left ventricular diastolic function in patients with CHD

Effect of PTCA and stenting on left ventricular diastolic function in patients with CHD!050000$河北医科大学第二医院河北医科大学心脏介入中心@傅向华     

In utero magnetic resonance of non-isolated ventriculomegaly: Does ventricular size or morphology reflect pathology?

AIM: To confirm whether ventricular size or morphology reflects the underlying pathology in foetuses referred with a diagnosis of possible ventriculomegaly (Vm) and central nervous system (CNS) pathology. METHODS: Retrospective analysis of 40 in utero magnetic resonance (MR) examinations was undertaken. Ventricular size was measured on axial sections by two observers, and morphology was agreed by consensus. Results were analysed according to gestational age at referral, degree of Vm (mild 10-15 mm, moderate/severe >15 mm) and morphology. RESULTS: Nine cases had no Vm (mean gestational age 23.6 weeks, range 19-33), 17 had mild Vm (mean age 23.9 weeks, range 20-31), and 14 had moderate/severe Vm (mean age 25.9 weeks, range 20-35). All groups had a mix of morphology and pathology. Eighteen suspected cases of spina bifida were referred and 17 confirmed (mean age 22.6 weeks, range 19-30) using MR. The morphology was mixed, five cases (27.8%) had an angular appearance (this morphology was only seen in cases with spina bifida). Fourteen cases (77.8%) had Vm (eight mild, six severe). Of the thirteen cases of agenesis of the corpus callosum (ACC) suspected on ultrasound, seven were confirmed using MR (mean age 26.5 weeks, range 20-35). Of those seven cases with ACC confirmed on MR, and three additional cases only detected by in utero MR, five had colpocephaly, seven had Vm (four mild, three severe). CONCLUSION: Severity of Vm did not reflect the type, or presence, of underlying pathology. Morphology appears an indicator of pathology. Angular ventricles should initiate a search for spinal defects. Colpocephaly may indicate ACC.     

Do electrocardiographic changes with adenosine myocardial perfusion imaging predict ischaemia in patients with left ventricular hypertrophy?

BACKGROUND: Electrocardiographic (ECG) changes during adenosine myocardial perfusion imaging (MPI) correlate with severe coronary artery disease and the presence of collaterals. However, the significance of these changes during adenosine MPI in patients with left ventricular hypertrophy (LVH) on baseline electrocardiogram is less well understood. OBJECTIVE: To evaluate whether ECG changes on adenosine MPI predict ischaemia in patients with LVH. METHODS: We reviewed retrospectively 454 consecutive patients who had undergone adenosine MPI at our institution. The baseline electrocardiogram was reviewed to determine whether or not LVH was present. All patients were administered adenosine at 140 microg x kg x min for a total of 6 min and Tc-sestamibi was injected at 3 min into the protocol. None of the patients underwent any form of exercise during the stress test. RESULTS: Of the 146 patients with LVH, 10 had stress ECG changes suggestive of ischaemia and 40 had evidence of ischaemia on MPI. Similarly, of the 308 patients without LVH, 43 had stress ECG changes suggestive of ischaemia and 68 had ischaemia on MPI. The sensitivity and specificity of stress ECG changes in predicting ischaemia on perfusion in patients with LVH were 12.5% and 95.3%, respectively, with a positive predictive value of 50% and a negative predictive value of 74.3%. CONCLUSION: ECG changes suggestive of ischaemia in patients with LVH are very specific for ischaemia on MPI, and their significance is similar to that in patients without LVH.     

Assessing ventricular size: is subjective evaluation accurate enough? New MRI-based normative standards for 19-year-olds

Introduction  To create new standards for radiological indices of dilated ventricles and to compare these with subjectively assessed ventricular size. Methods  One hundred healthy controls (54 females), birth weight above 3,000 g, were followed throughout childhood as part of a longitudinal study of ex-prematures. All had a 3 Tesla brain magnetic resonance scan at age 17–20, and the following measurements were performed: biparietal and occipitofrontal diameters, width and depth of the frontal and occipital horns, diameter of the third ventricle and the frontal sub-arachnoid space. Ventricular size was judged subjectively by two neuroradiologists as being normal, or mildly, moderately or severely dilated. Results  Head circumference was 31 mm higher for males than for females (95% confidence interval (CI) 25–28, p < 0.001). Similar, ventricular size except for the depth of the right frontal horn was larger for male; however, the observed differences were partly accounted for by the larger head circumference. Normative sex specific standards for different cerebral measurements were presented as mean and ranges and additional 2.5, 10, 50, 90, 97.5 percentiles. The mean depth of the left ventricle was larger than the right for males, with an observed difference of 0.6 mm in male (95% CI 0.2–0.9, p = 0.005). The mean width of the left ventricle was larger than the right for females, with an observed difference of 0.4 mm in male (95% CI 0.1–0.7, p = 0.018). Two subjects were judged to have moderately and 36 to have mildly dilated ventricles by observer one, while figures for observer two were one and 14. Overall, the two observers agreed on 15 having either mild or moderate dilatation (kappa 0.43). For both sexes, the mean depth of the frontal horns as well as of the larger occipital horns differed significantly between the no dilatation and the mild/moderate dilatation groups. Conclusion  In our unselected cohort of healthy 19-year-olds, a high total of 14% was diagnosed to have dilated cerebral ventricles when subjectively assessed by an experienced neuroradiologist, underscoring the need for our new normative standards.     

Is abnormal iodine-123-MIBG kinetics associated with left ventricular dysfunction in patients with diabetes mellitus?

BACKGROUND: Although autonomic neuropathy is frequently recognized in patients with diabetes mellitus, it is uncertain whether cardiac sympathetic neuropathy may play a role in the development of diabetic cardiomyopathy. METHODS AND RESULTS: In 10 control subjects and 61 patients with diabetes mellitus who did not have coronary artery disease, cardiac sympathetic function and left ventricular ejection fraction (LVEF) were evaluated by using iodine-123-metaiodobenzylguanidine (MIBG) imaging and echocardiography, respectively. Dynamic acquisitions and planar images obtained 15 and 150 minutes after injection were used as a means of measuring early and late myocardial uptake and clearance rates of MIBG from the heart. Eight patients with an LVEF less than 50% demonstrated a lower late myocardial MIBG uptake (0.0043% +/- 0.0017% vs. 0.0024% +/- 0.0009%/pixel, P = .002) and a higher clearance rate (22.9% +/- 17.7% vs. 49.3% +/- 12.2%, P<.0001) than the 53 patients with an LVEF of 50% or greater, although the age, sex, type of diabetes mellitus, and frequency of neuropathy, retinopathy, and nephropathy were not significantly different between the 2 subgroups. The LVEF correlated weakly but significantly with early and late myocardial uptake and clearance rate (r = 0.277, P = .03; r = 0.421, P = .001; r = 0.382, P = .002; respectively) in patients with diabetes mellitus. CONCLUSION: Marked MIBG abnormalities are associated with left ventricular dysfunction in patients with diabetes mellitus. However, long-term follow-up of patients with diabetes mellitus who have marked MIBG abnormalities and normal LVEF will be required to determine whether these patients would demonstrate systolic dysfunction earlier than patients without an MIBG abnormality.     

Transient increase in wall thickness of the left ventricular apex during recovery from “ampulla” cardiomyopathy

"Ampulla" cardiomyopathy is a syndrome characterized by transient abnormal left ventricular wall motion with hypokinesia around the apical area and hyperkinesia at the basal area, without any detectable coronary lesion. Two cases of transient wall thickening of the left ventricular apex during recovery from "ampulla" cardiomyopathy are described. Apical wall thickening was documented by left ventriculography, echocardiography, and thallium (201Tl) single-photon emission computed tomography (SPECT) during the recovery phase. The thickness of the apical wall subsequently returned to normal. Both patients underwent provocation tests. Coronary spasms were positive. This transient increase in left ventricular apical volume may have been caused by myocardial inflammation secondary to "ampulla" cardiomyopathy.     

Proton magnetic resonance spectroscopy of neurocytoma outside the ventricular region – case report and review of the literature

Central neurocytoma is classically considered as an intraventricular benign tumour, largely based on data from small retrospective series and single case reports. We report on a 16-year-old girl who suffered from a large parietooccipital tumour that was diagnosed histologically as central neurocytoma. The features of CT, MRI and proton MR spectroscopy studies are discussed. This is the first report on spectroscopic findings in a case of extraventricular neurocytoma. As well as elevated choline (Cho), the tumour spectrum showed strongly decreased N-acetylaspartate (NAA). NAA is assumed to be produced in mature neurons, and we therefore expected to find high amounts of NAA in this well-differentiated tumour, which was histologically composed of mature neuronal tissue. This observation leads to the conclusion that even the highly differentiated cells of neurocytomas are too immature to produce NAA.     

Post-mortem evidence of idiopathic left ventricular hypertrophy and idiopathic interstitial myocardial fibrosis: is exercise the cause?

A growing body of evidence reporting altered cardiac function and myocardial damage after arduous exercise, together with the increased prevalence of arrhythmias observed in highly trained athletes, suggests that repetitive bouts of prolonged, arduous exercise may be deleterious to long-term cardiac health. We report the case of an experienced, highly trained marathon runner who died suddenly while running. On post-mortem examination, left ventricle hypertrophy and idiopathic interstitial myocardial fibrosis was found. We believe that life-long, repetitive bouts of arduous physical activity resulted in fibrous replacement of the myocardium, causing a pathological substrate for the propagation of fatal arrhythmias.     

Comparative assessment of rest and post-stress left ventricular volumes and left ventricular ejection fraction on gated myocardial perfusion imaging (MPI) and echocardiography in patients with transient ischaemic dilation on adenosine MPI: Myocardial stunning or subendocardial hypoperfusion?

Background

Transient ischaemic dilation (TID) on myocardial perfusion imaging (MPI) is an important finding, conveying a high risk of subsequent cardiac events. However, the mechanism leading to TID on MPI is not well elucidated. This study aimed to determine if TID is due to true LV cavity dilation and ventricular stunning, or is due to relative subendocardial hypoperfusion.

Methods

31 patients undergoing single-day Tc-99m adenosine sestamibi MPI were recruited. All had routine ECG-gated single-day rest-stress adenosine MPI, with transthoracic echocardiograms (echo) acquired concurrently at rest, and both immediately, and 2?hours, post-stress. Echocardiography was performed using a Vivid-7 (GE). LV volumes and LVEF were quantified blinded to MPI results, using biplane Simpson method on echo, and quantitatively (including TID) with QGS^?, on MPI.

Results

Patients were divided into quartiles for TID, with the top quartile considered TID positive [TID+ 9/31 (TID ratio 1.3?±?0.09)], and TID negative [TID? 22/31 (TID ratio 1.01?±?0.04)]. There was good correlation between resting echo and MPI physical measurements (LVEDV r ²?=?0.79, LVESV r ²?=?0.9, and LVEF r ²?=?0.75). On MPI, a significant drop in LVEF was observed between rest and early stress in the TID+ group (56.6% vs 46.5%, P?<?.002), as well as an increase in both LVESV (62 vs 79?mls, P?<?.0001) and LVEDV (113 vs 131?mls, P?<?.0001). However, no statistically significant change in LVEF, LVESV or LVEDV was identified on concurrent echo imaging (LVEF 57% vs 56%, P?<?.66; LVESV 48 vs 54?mls, P?<?.26; LVEDV 87 vs 97?mls, P?<?.299). No significant change in LVEF or ventricular volumes was noted in the TID? group by either echo or MPI.

Conclusion

Transient dilation of the left ventricle on adenosine MPI is not related to chamber enlargement and myocardial stunning, but is more likely a function of subendocardial hypoperfusion and impaired coronary flow reserve.