Assessment of ST‐Elevation Myocardial Infarction–Related Diastolic Dysfunction with Compensatory Rise in Left Atrial Ejection Force

Background: It is well known that patients with ST‐elevation myocardial infarction (STEMI) show both systolic and diastolic left ventricular dysfunction. The aim of this study was to assess post–myocardial infarction diastolic dysfunction using left atrial ejection force (LAEF) in patients treated with primary percutaneous coronary intervention (PCI). Methods and Results: We enrolled 58 patients presenting with STEMI who were treated with primary PCI and 23 healthy subjects as a control group. A detailed transthoracic echocardiogram, including mitral flow velocities, tissue Doppler mitral annular velocities, and left atrial (LA) phasic volumes, was performed in both groups. We also measured the level of B‐type natriuretic peptide (BNP). LAEF was calculated using the formula: 0.5 × P × Mitral orifice area × (Peak A velocity)². Correlations between variables were studied using “Pearson and Spearman's rho” test. In the test group, we found that the level of BNP in the plasma, E/E′ ratio, and the LA volume measurements were higher than that of the control group, and those differences were statistically significant. LAEF was increased in patients with myocardial infarction (MI); moderately correlated to BNP (r = 0.383 and P = 0.001) and E/E′ (r = 0.473 and P = 0.001), and strongly correlated to A‐wave velocity (r = 0.731 and P = 0.001). LAEF was also negatively correlated to E/A ratio (r = ?0.419 and P = 0.001) and LVEF (r = ?0.339 and P = 0.003). Conclusion: Impaired diastolic function in STEMI affects LA and increased LAEF is one of its manifestations. LAEF may also have diagnostic importance in diastolic dysfunction, but these findings should be confirmed by further studies.     

Combined Assessment of Myocardial Perfusion and Diastolic Function Enhances Risk Stratification in Patients with Anterior Wall Myocardial Infarction

Objective: Evaluate the utility of a combined risk stratification scheme including diastolic dysfunction and "no-reflow," to identify high-risk patients following acute myocardial infarction (AMI). Background: Recent studies have demonstrated that the "no-reflow" phenomenon (defined by myocardial contrast echocardiography) and severe diastolic dysfunction (identified by Doppler echocardiography) identify patients at high risk for mortality following AMI. Methods: We evaluated 111 patients with recent anterior acute myocardial infarction from July 2000 to June 2004. Diastolic function and myocardial perfusion was evaluated by echocardiography. Patients were placed into 1 of 3 groups based on diastolic function and myocardial perfusion: Group 1 (normal perfusion and normal diastolic function), Group 2 (abnormal perfusion or abnormal diastolic function), and Group 3 (abnormal perfusion and abnormal diastolic function). We compared the long term all-cause mortality within these groups. Results: Patients in each group were similar with respect to myocardial infarction size as defined by biomarkers, extent and severity of coronary artery disease, and medical and interventional therapy. Mortality was much higher in Group 3 (26.9%) compared to Group 1 (0%) and Group 2 (15.2%) (p = 0.048). Conclusion: Combined assessment of diastolic function and myocardial perfusion enhances risk stratification post myocardial infarction.     

Echocardiographic Assessment of Complications Related to Left Ventricular Function in Acute Myocardial Infarction

Three complications of acute myocardial infarction without myocardial rupture are directly associated to the function of the myocardium: papillary muscle dysfunction, congestive heart failure, and cardiogenic shock. In this article, the pathophysiological mechanism of each complication is discussed, and the contribution of echocardiography to diagnosis and management is reviewed.     

急性心肌梗死对左心房的影响

急性心肌梗死后心脏收缩和舒张功能受损,直接影响到患者的预后.既往对心室收缩功能研究较多,对急性心肌梗死时左心房结构及功能变化的研究相对较少,而左心房结构及功能的变化又直接影响到心室的舒张功能及患者的预后.现就急性心肌梗死时左心房结构及功能的变化及其意义做一总结.     

Transesophageal Echocardiographic Study of Right Atrial Myocardial Infarction and Myocardial Viability

In order to determine the effects of dobutamine on right atrial wall movement, two groups were studied using transesophageal echocardiography. Group A included six patients without ischemic heart disease. Group B included six patients with infarction of the inferior wall of both ventricles and abnormal wall movement of the right atrium. In group A, an increase in the amplitude of right atrial movement was observed with dobutamine at doses of 5 and 10 μ/kg per minute. In group B, infusion of dobutamine did not modify wall akinesis in three patients with right atrial infarction; in the remaining three, alterations of segmental atrial movement were evident, and their responses to dobutamine were related to the patency of right atrial coronary branches. The following conclusions were reached: (1) dobutamine has a positive inotropic effect on atrial myocardium; (2) right atrial ischemia appears in the echocardiogram as altered segmental or global wall movement; (3) dobutamine can be used in the evaluation of atrial myocardial viability.     

Association of Left Atrial Strain and Strain Rate Assessed by Speckle Tracking Echocardiography with Paroxysmal Atrial Fibrillation

Background: We hypothesized that contraction of the LA wall could be documented by speckle tracking and could be applied for assessment of LA function. This study tried to identify the association between LA longitudinal strain (LAS) and strain rate (LASR) measured by speckle tracking with paroxysmal atrial fibrillation (PAF). Methods: Fifty‐two patients (61 ± 17 years old, 23 men) with sinus rhythm at baseline referred for the evaluation of episodic palpitation were included. Standard four‐chamber and two‐chamber views were acquired and analyzed off‐line. Peak LAS and LASR were carefully identified as the peak negative inflection of speckle tracking waves after P‐wave gated by electrocardiography. Results: Ten patients (19%) had PAF. LAS, LASR, age, left ventricular end‐diastolic dimension, left ventricular mass, LA volume, and mitral early filling‐to‐annulus early velocity ratio were different between patients with and without PAF. After multivariate analysis, LASR was significantly independently associated with PAF (OR 8.56, 95% CI 1.14–64.02, P = 0.036). Conclusion: Speckle tracking echocardiography could be used in measurements of LAS and LASR. Decreased negative LASR was independently associated with PAF. (ECHOCARDIOGRAPHY, Volume 26, November 2009)     

Association of Stage of Left Ventricular Diastolic Dysfunction with P Wave Dispersion and Occurrence of Atrial Fibrillation after First Acute Anterior Myocardial Infarction

Objectives: The aim of this study was to investigate the association of stage of left ventricular diastolic dysfunction after acute myocardial infarction (AMI) with P maximum, P dispersion, and atrial fibrillation (AF) occurrence rate. Background: The occurrence of AF following AMI is frequently associated with a left ventricle restrictive filling pattern. Increased P dispersion is also associated with the occurrence of AF after AMI. But, the relation between the stage of left ventricular diastolic dysfunction and the P wave measurements after AMI has not yet been investigated. Methods: Electrocardiograms of 90 patients with first anterior AMI were recorded on admission, and P wave measurements were performed. The left ventricular diastolic functions were evaluated by transthoracic echocardiography. On the basis of mitral inflow, subjects were stratified into three left ventricular diastolic filling patterns. All patients were monitored continuously for the detection of AF in the Coronary Care Unit. Results: Thirty patients had a normal filling pattern (33.3%) (NF group), 37 had impaired relaxation (41.1%) (IR group), and 23 had pseudonormal/restrictive filling pattern (25.6%) (PN/R group). P maximum was longer in the PN/R group (103 ± 12 ms) compared with the NF group (94 ± 9 ms, P = 0.019), but no significant difference was found between PN/R and IR (96 ± 13 ms, P > 0.05) groups, and between NF and IR groups (P > 0.05). There was no significant difference for P minimum among the groups (P > 0.05). P dispersion was longer in the PN/R group (35 ± 6 ms) than in the NF (26 ± 7 ms, P < 0.001) and IR groups (26 ± 6 ms, P < 0.001), but not different between the NF and IR groups (P > 0.05). Occurrence of AF was significantly more frequent in the PN/R group (52.2%) than in the NF (16.7%, P = 0.007) and IR groups (10.8%, P = 0.001). Frequency of AF was not different between the NF and IR groups (P > 0.05). In multivariate analyses, the stage of diastolic dysfunction was independently associated with P maximum, P minimum, P dispersion, and the occurrence of AF (P < 0.001, P = 0.035, P < 0.001, and P = 0.002, respectively). Conclusions: P maximum and P dispersion are increased, and AF occurrence risk is higher in patients with pseudonormal/restrictive filling pattern after first anterior AMI. The stage of diastolic dysfunction is an independent predictor of P wave measurements and AF occurrence.     

Left Ventricular Regional Diastolic Dysfunction in Patients with First Myocardial Infarction Determined by Diastolic Motion of the Atrioventricular Plane

Motion of the left ventricular [left ventricle (LV)] atrioventricular (AV) plane has been used to assess systolic LV function. The method has not been used properly to assess diastolic function, especially after a first myocardial infarction (MI). The diastolic function was assessed in 47 previously healthy patients with a first MI assessed by echocardiographic diastolic motion of the LV AV plane. The motion of the AV plane was recorded at four different LV sites, that is, at the septal, anterior, lateral, and inferior walls. Two distinct phases of motion were noticed during diastole at all the sites: one at the early diastole caused by rapid filling of the LV and the other at late diastole during the atrial contraction. The contribution of left atrial contraction to LV filling at different LV sites was calculated by relating the magnitude of the motion caused by atrial contraction to the total diastolic AV plane motion at the respective sites. These left atrial contributions were regarded as the regional diastolic function of the respective LV sites. The global LV diastolic function was determined from the left atrial contribution to total AV plane motion from the above four sites. Patients with anterior MI had a significantly lower ejection fraction than those with inferior MI (41% and 49%, respectively; P < 0.01). Compared with age-matched healthy subjects, the regional atrial contribution to diastolic filling was significantly higher at the anterior wall in anterior MI (38% and 52%, respectively; P < 0.001) and at the inferior wall in inferior MI (43% and 53%, respectively; P < 0.01). The atrial contribution to global LV filling was increased in anterior MI (48% compared with 42% in healthy subjects; P < 0.05) but not in inferior MI. These findings suggest that the diastolic AV plane displacement (AVPD) may be used to assess both the regional and the global diastolic function in patients following an MI.     

Left Ventricular Hypertrophy Determines the Severity of Diastolic Dysfunction in Patients with Nonvalvular Atrial Fibrillation and Preserved Left Ventricular Systolic Function

Regression of left ventricular (LV) hypertrophy (LVH) is known to be related to a lower incidence of stroke in hypertensive patients with nonvalvular atrial fibrillation (NV-AF). However, its mechanism remains controversial. Recently, diastolic dysfunction (DD) was reported to be correlated with ischemic stroke in NV-AF. We hypothesized that hypertension (HTN) and resultant LVH might be associated with the severity of DD in NV-AF. Two hundred and ninety-four patients (204 males, age 66 ± 12 y) with NV-AF with preserved LV systolic function were included. Clinical and echocardiographic data were compared between patients with enlarged left atrial (LA) volume (n == 237) and patients with normal LA. Age (60 ± 12 vs. 67 ± 11 years), sex (male; 81 vs. 62%%), duration of NV-AF (4.1 ± 7.8 vs. 45.7 ± 49.0 months), brain natriuretic peptide (108.3 ± 129.3 vs. 236.1 ± 197.0 pg//mL), right ventricular systolic pressure (24.5 ± 5.5 vs. 33.1 ± 11.1 mmHg), mitral inflow velocity (E [77.4 ± 22.2 vs. 88.3 ± 22.0 cm//s]), LV mass index (LVMI [87.6 ± 22.2 vs. 105.1 ± 23.2 g//m²]), peak systolic mitral annular velocity (S' [7.2 ± 2.0 vs. 5.8 ± 1.8 cm//s]), and mitral inflow velocity to diastolic mitral annular velocity (E//E' [9.8 ± 3.4 vs. 12.1 ± 4.4]) were significantly different between the two groups, respectively (P < 0.05). In multivariate analysis, LVMI was independently correlated with increased LA volume (OR: 1.037 [95%% CI: 1.011–1.063], P < 0.05), whereas HTN was not. LA enlargement, which reflects the severity and chronicity of DD, is independently associated with LVH in patients with NV-AF. Therefore, regression of LVH with anti-hypertensive treatment may lead to improvement of diastolic function and favorable clinical outcomes in hypertensive patients with NV-AF.     

应用定量组织速度成像技术对心肌梗死患者左心功能的研究

目的用定量组织多普勒成像(QTVI)技术评价心肌梗死患者左心功能。方法利用 QTVI技术,测算30名心肌梗死患者(MI组)和30名正常人二尖瓣环各位点的收缩期峰值速度s、舒张早期速度e、舒张晚期速度a、收缩期位移D以及各位点的Tei指数,上述各指标取6个位点测值的均值作为左室整体指标测值。所有MI患者行同位素门控心血池造影检查,记录左心室射血分数 (ECT-EF)及左心室峰充盈率(PFR)。结果 (1)MI组二尖瓣环整体以及各位点的s、e、a及D均较对照组显著减低,Tei指数测值较对照组显著延长;(2)不同部位的心肌梗死患者,其各室壁D减低、Tei 值延长的程度不同,以梗死侧室壁更为显著;(3)MI患者D、Tei值与门控心血池造影所测得的ECT- EF、PFR之间呈相关性。结论利用QTVI可准确评价心脏整体和局部功能,有临床推广应用价值。     

Assessment of Right Ventricular Diastolic Function by Tissue Doppler Imaging in Patients with Acute Right Ventricular Myocardial Infarction

Background: It is known that right ventricular systolic parameters as assessed by color tissue Doppler imaging (TDI) are abnormal in patients with inferior wall ST elevation myocardial infarction (IWMI) with right ventricular myocardial infarction (RVMI). This study was undertaken to determine right ventricular diastolic function as assessed by TDI in patients with acute RVMI. Methods: Thirty‐five patients with first IWMI were studied and compared with 20 age‐matched healthy controls, and categorized into those with (14 patients) and without (21 patients) RVMI based on standard ECG criteria. Peak systolic, peak early and late diastolic velocities (Sm, Em, and Am), Em/Am ratio along with time to Sm (ECG Q‐Sm) and time to Em (ECG Q‐Em) were acquired from the apical 4‐chamber view at the lateral side of tricuspid annulus using TDI. Results: Sm, Em, and Em/Am ratio was reduced significantly in patients with RVMI as compared with those without RVMI and healthy individuals (Sm [11.1 ± 2.9] vs. [14 ± 1.9] and [14.5 ± 2.1] cm/sec, P < 0.01; Em [9.2 ± 3.5] vs. [12.9 ± 3] and [14.0 ± 2.0] cm/sec, P < 0.01; Em/Am ratio 0.53 ± 0.2 vs. 0.78 ± 0.19 and 0.8 ± 0.3 [P < 0.0001]). Among the intervals, there was significant prolongation of Q‐Em (558 ± 14.8 vs. 507 ± 16.2 and 480 ± 20 ms [P < 0.0001]) but Q‐Sm and Am were not statistically different between the groups. Conclusion: Right ventricular TDI diastolic parameters are abnormal in patients with RVMI. The method of recording the velocities and time intervals are simple and can be used to assess right ventricular diastolic function in patients with RVMI. (Echocardiography 2010;27:539‐543)     

梗死前心绞痛对合并糖尿病的急性心肌梗死患者左心室功能的影响

目的　探讨梗死前心绞痛对合并糖尿病的急性心肌梗死 (AMI)患者左心室功能的近期影响。方法　首次AMI并行急诊PCI患者 15 6例 ,在糖尿病和非糖尿病患者中分别比较有梗死前心绞痛和无梗死前心绞痛组血清肌酸激酶MB(CKMB)峰值和左心室功能的变化。结果　非糖尿病患者中有梗死前心绞痛组血清CKMB峰值低于 ,左室EF高于无梗死前心绞痛组 (CKMB :10 8± 79IU/Lvs 15 6± 10 1IU/L ;EF∶5 8± 13%vs 5 0±11% ,P <0. 0 5 ;糖尿病患者中有梗死前心绞痛组和无梗死前心绞痛组血清CKMB峰值和左心室EF无显著性差异。结论　梗死前心绞痛可在非糖尿病合并AMI患者中限制梗死面积 ,保护左心功能 ,而在糖尿病合并AMI患者中无保护作用。     

Acute Myocardial Infarction During Transesophageal Echocardiography

We describe the occurrence of acute myocardial infarction during transesophageal echocardiography (TEE) in a patient with atrial fibrillation and underestimated angina. Such a case has not been previously reported in the literature. This case illustrates one of the possible complications of TEE, leading us to suggest systematic sedation in patients with angina in whom TEE is envisaged.     

Myocardial Viability Detected by Myocardial Contrast Echocardiography—Prognostic Value in Patients after Myocardial Infarction

Objective: This study aimed to assess the role of myocardial contrast echocardiography (MCE) as a predictor of cardiac events and death in patients with acute myocardial infarction (AMI). Methods: Eighty‐six patients underwent primary percutaneous coronary angioplasty for AMI. Segmental perfusion was estimated by MCE in real time at mean 5 days after PCI using low MI (0.3) after 0.3–0.5 ml bolus injection of intravenous Optison. MCE was scored semiquantitatively as: (1) normal perfusion (homogenous contrast effect), (2) partial perfusion (patchy myocardial contrast enhancement), (3) lack of perfusion (no visible contrast effect). A contrast score index (CSI) was calculated as the sum of MCE scores in each segment divided by the total number of segments. The patients were followed up for cardiac events and death. Results: A CSI of >1.68 was taken to be a predictor of cardiac events and death. Death occurred only in patients with CSI >1.68. Patients with CSI >1.68 had a significantly (P = 0.03) higher incidence of cardiac death or cardiac events (75%) compared to those with CSI <1.68 (27%). The absence of residual perfusion within the infarct zone was an independent predictor of death and cardiac events (P = 0.02). Conclusions: The absence of residual myocardial viability in the infarct zone supplied by an infarct‐related artery is a powerful predictor of cardiac events in patients after AMI. (Echocardiography 2010;27:430‐434)     

Unusual Site of Left Ventricular Thrombus after Acute Myocardial Infarction

Left ventricular (LV) thrombus formation is a frequent complication in patients with acute anterior myocardial infarction (MI). Its incidence is lower with inferior wall MI. Risk factors for the development of LV thrombus are consistently irrespective of infarct treatment and include large infarct size, severe apical akinesia or dyskinesia LV aneurysm, and anterior MI.     

急性心肌梗塞患者的高胰岛素血症

检测１３例合并糖尿病的急性心肌梗塞（ＡＭＩ），２３例无糖尿病ＡＭＩ患者的空腹血胰岛素和Ｃ肽水平，并与２０例正常人作比较，发现两组均存在高胰岛素血症，合并糖尿病的ＡＭＩ组更为明显。１０例ＡＭＩ患者４周后复查，血胰岛素水平有显著下降。提示胰岛素在ＡＭＩ发病中有意义。     

Acute Myocardial Infarction in Diabetic Patients

ABSTRACT. All patients hospitalized during a 3-year period with an acute myocardial infarction were followed for the occurrence of reinfarction or death. The patients with diabetes mellitus (n=95) were compared with the non-diabetic population (n=545). The diabetics had a higher mortality rate (relative death rate of 1.44 vs. 0.93, p<0.01) and a higher frequency of reinfarctions (18.9 vs. 10.8%, p=0.04) than the non-diabetic population. A larger proportion of the diabetics had suffered a previous infarction, but the excess mortality was also present in those without a previous infarction. Established risk factors for death after myocardial infarction, such as age, infarct size, infarct localization and heart size, could not account for the difference in mortality. It is suggested that the increased mortality among the diabetics may be due to an increase in the rate of progression of the atherosclerotic heart disease.