Reduced early diastolic inflow velocities in the antero-posterior transverse direction in the left ventricle of patients with dilated cardiomyopathy

In patients with dilated cardiomyopathy (DCM), the left ventricular (LV) inflow jet is narrow and has a high pressure gradient. A pulsed Doppler restrictive transmitral flow pattern is a characteristic feature of severe left ventricular disease. However, Doppler flow analysis is limited by the angle between the blood flow jet and the ultrasonic beam. In this study we used gated magnetic resonance imaging (MRI) to investigate the inflow velocity in the LV transverse directions during early diastole in patients with DCM. Methods: We studied 10 patients with DCM (mean age: 47 y). Ten age-matched healthy volunteers were also examined. Gradient echo images of the LV were obtained. Left ventricular short axis phase contrast images were obtained at the level of the mitral valve tip and 1 cm inside the LV. Long axis images were also obtained. Through-plane peak velocities at peak early diastolic filling were measured along the LV long axis, antero-posterior short axis, and right-left short axis. Blood velocity was measured in 50 ms blocks. Results: Early diastolic inflow velocity along the long axis, especially at the center of the LV, was well preserved in DCM. However, the inflow velocity in the antero-posterior transverse direction of the LV (i.e., in the direction of mitral valve excursion) was significantly reduced in DCM. Conclusions: Early diastolic inflow velocity in the antero-posterior transverse direction of the LV is reduced in patients with DCM indicating that the vector component of the forces acting in the antero-posterior transverse direction of the LV may be decreased in patients with DCM during early diastolic filling.     

Echocardiographic evaluation of left ventricular function in pure mitral stenosis

Echocardiographic evaluation of left ventricular function was performed in 22 cases of pure rheumatic mitral stenosis and 22 age matched normal persons. Cases with any evidence of rheumatic activity in the preceding six months, those with gross tricuspid regurgitation and paradoxical movement of the interventricular septum and cases with atrial fibrillation were excluded. None of the patients showed systolic left ventricular dysfunction. Left ventricular end diastolic dimension was also not affected. Echocardiographic parameters did not have any relation for mitral valve area. Our observations show that mitral stenosis per se does not affect left ventricular function.     

左心室酷似肿瘤样血栓腔镜辅助下手术治疗1例报告

左心室酷似肿瘤的血栓罕见,手术治疗是积极、有效措施。不切开左心室摘除心尖部血栓常很困难。本例左室心尖部酷似肿瘤样血栓,经二尖瓣利用腔镜辅助顺利摘除瘤样血栓；手术过程操作时间短,心脏创伤轻,术后恢复快。     

Cardiac magnetic resonance determinants of functional mitral regurgitation in ischemic and non ischemic left ventricular dysfunction

Functional mitral regurgitation (FMR) is frequent in left ventricular (LV) dilatation/dysfunction. Echocardiographic predictors of FMR are known. However, cardiac magnetic resonance (CMR) predictors of FMR have not been fully addressed. The aim of the study was to evaluate CMR mitral valve (MV) parameters associated with FMR in ischemic and non ischemic LV dysfunction. 80 patients with LV ejection fraction bellow 45% and/or left ventricular dilatation of ischemic and non ischemic etiology were included. Cine-MR images (steady state free-precession) were acquired in a short-axis and 4 chambers views where MV evaluation was performed. Delayed enhancement was performed as well. Significant FMR was established as more than mild MR according to the echocardiographic report. Mean age was 59 years, males 79%. FMR was detected in 20 patients (25%) Significant differences were noted in LV functional parameters and in most MV parameters according to the presence of significant FMR. However, differences were noted between ischemic and non ischemic groups. In the first, differences in most MV parameters remained significant while in the non ischemic, only systolic and diastolic interpapillary muscle distance (1.60 vs. 2.19 cm, P = 0.001; 2. 51 vs. 3.04, P = 0.008) were predictors of FMR. FMR is associated with a more severe LV dilatation/dysfunction in the overall population. CMR MV parameters are associated with the presence of significant FMR and are different between ischemic and non ischemic patients. CMR evaluation of these patients may help in risk stratification as well as in surgical candidate selection.     

Elusive left ventricular thrombus: Diagnostic role of cardiac magnetic resonance imaging-A case report and review of the literature

Identification of left ventricular mural thrombus (LVT) may be challenging depending on the imaging modality used. We present a case of LVT which was incidentally identified on cine cardiac magnetic resonance imaging (CMR). A sixty-four years old female presented with worsening dyspnea on exertion with troponin elevation. Transthoracic echocardiography (TTE) revealed a dilated left ventricle (LV) and ejection fraction (EF 30%) with thinning and akinesis of inferior/inferolateral wall was noted with basal and mid inferior wall aneurysm, and thrombus was not identified. CMR done to ascertain viability of myocardium revealed a mural thrombus within basal inferior aneurysm. This was not visualized on transthoracic echocardiography with and without use of contrast. She underwent coronary artery bypass grafting, bioprosthetic mitral valve replacement, resection and plication of posterior left ventricular aneurysm with removal of mural thrombus, and was started on anticoagulation with warfarin post-operatively for the apical thrombi. Cardiac magnetic resonance is a well suited imaging modality in detecting LVT due to its high resolution images and is more reproducible than TTE. In our patient, conventional TTE despite administration of echo-contrast agents failed to diagnose the presence of LVT in the basal inferior aneurysm as well as the apical thrombi. Delayed-enhancement CMR provides the greatest sensitivity for detection of left ventricular thrombus, superior to standard transthoracic and contrast-enhanced transthoracic echocardiography.     

Anomalous origin of the left coronary artery from the pulmonary artery: mid-term results after surgical correction

Objectives Children with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) are at risk for myocardial infarction and death. This retrospective study shows the mid-term follow-up after the use of aortic implantation and alternative methods to achieve coronary transfer. Methods Since 1990 seven consecutive children underwent primary repair of ALCAPA. Age at operation ranged from 2 to 71 months (median 11 months). Operative techniques included ligation (n = 1), intrapulmonary tunnel (n = 1), and aortic implantation (n = 5). One patient with severe mitral valve incompetence underwent additional mitral valve replacement. A 4-month-old patient was successfully treated after the operation with a left heart assist device. Results One death in the series occurred at 2 weeks after intrapulmonary tunneling. The mid-term results were evaluated in the six survivors with a follow-up mean of 98 months (ranged 58–168). In all surviving patients with two-vessel coronary blood supply, left ventricular end-diastolic volume and left ventricular ejection fraction returned to near normal values 2–12 months postoperatively. The mitral valve incompetence decreased in all patients with a native mitral valve. One patient with coronary ligation showed severe mitral valve regurgitation and received additional mitral valve replacement concomitantly. Six years after primary valve replacement of a 21 mm SJM (Saint Jude Medical) a change of the mechanical valve to a 27 mm valve was necessary because of development of severe stenosis due to growth. Conclusions It is always preferable to establish an antegrade flow of oxygenated blood through the coronary arteries and to create a two-coronary artery system. Mitral valve annuloplasty or replacement may be necessary for patients with severe mitral valve incompetence.     

扩张型心肌病左心室血栓形成影响因素的超声心动图研究

目的 探讨扩张型心肌病时左心室血栓形成的影响因素,及二尖瓣反流对左心室血栓形成的影响。方法 65例扩张型心肌病患者根据有无左室血栓分成A组（无左室血栓组）和B组（左室血栓组）,对两组患者的临床资料及超声心动图进行比较分析。结果 A组57例,B组8例,两组患者年龄、性别、临床资料以及凝血象差异均无显著性意义。B组左房内径、左室收缩末内径均较A组明显增大,而左室射血分数较A组明显减低。存在二尖瓣反流的患者两组间无明显差别,但重度二尖瓣反流只存在于A组患者中。结论 扩张型心肌病时左室血栓的形成与多种因素有关,左室射血分数是影响左室血栓形成的最重要促进因素,严重二尖瓣反流在防止左室血栓形成中可能起保护作用。     

兔室壁瘤形成后左心室舒张及收缩功能的变化

目的 应用二尖瓣血流脉冲多普勒(PWD)频谱及二维超声斑点追踪显像(STI)技术观察兔心肌梗死室壁瘤形成后左心室舒张和收缩功能的变化特点.方法 以28只健康新西兰大白兔制作心肌梗死模型,饲养4周,23只兔成模并存活.以建模前超声检查作为对照组,术后4周复查超声并行病理学检查,根据有无室壁瘤形成分为心肌梗死组(n=11)和室壁瘤组(n=12).测量左心室二维超声指标后,应用PWD分别测量各组二尖瓣的舒张早期血流速度(E)、舒张晚期血流速度(A);应用STI技术分别测量各组左心室短轴瓣环水平、心尖水平各节段的旋转角度、短轴瓣环水平圆周应变率(SrC)和径向应变率(SrR)的收缩期峰值应变率(SrC-S,SrR-S)、舒张早期峰值应变率(SrC-E,SrR-E)、舒张晚期峰值应变率(SrC-A,SrR-A),计算左心室整体扭转角度及舒张早期与舒张晚期峰值应变率之比(SrCe/SrCa,SrRe/SrRa).结果 与对照组比较,心肌梗死组和室壁瘤组左心室整体扭转角度及SrCe/SrCa、SrRe/SrRa均减小,以室壁瘤组更显著(P均＜0.05);各组间E/A差异无统计学意义(P均＞0.05).结论 兔心肌梗死室壁瘤形成后,E/A呈假性正常化,而短轴瓣环水平圆周和径向应变率、左心室整体扭转角度显著减小,左心室局部和整体舒张功能及收缩功能进一步恶化.     

组织多普勒显像技术评价初发心肌梗死患者左室功能

目的探讨组织多普勒显像（DTI）技术在评价初发心肌梗死患者左室功能中的应用价值。方法常规超声心动图检查显示左室收缩及舒张功能正常的初发心肌梗死患者18例及与其年龄匹配的健康对照者15例入选本研究。应用DTI技术二尖瓣环平均运动速度指标评价两组对象的左室功能。同时计算二尖瓣血流舒张早期峰值速度与二尖瓣环舒张早期峰值速度的比值（E／Em）,以评估左室平均充盈压。结果心肌梗死患者组二尖瓣环收缩期峰值速度（Sm）、舒张早期速度（Em）及晚期峰值速度（Am）均明显低于正常对照组（P〈0．05）;心肌梗死组E／Em比值明显高于正常对照组（P〈0．05）。结论DTI技术可以较常规超声心动图更加敏感地检测出初发心肌梗死患者的左室功能异常。     

巨大左心室瓣膜置换术的外科治疗经验

目的总结合并巨大左心室的心脏瓣膜置换术的外科治疗经验。方法1998年7月至2007年4月51例合并巨大左心室的心脏瓣膜病人实施换瓣术。其中主动脉瓣置换术34例，双瓣置换术17例；同时行左房折叠术12例，三尖瓣成形术17例。结果术后早期死亡8例（占15．7％），晚期死亡6例（占11.8％）。影响瓣膜置换术早期疗效及导致死亡的主要因素是术前严重左室扩大，舒张末直径（LVEDD）〉8．5cm；严重左室收缩功能下降，射血分数（EF）〈0．40；术后恶性心律失常和严重低心排以及多脏器功能衰竭；术后室颤和术前严重左室扩大伴收缩功能下降也是导致晚期死亡的主要原因。结论对心脏左室功能的正确评估、手术适应证和时机的选择、围术期的正确处理是治疗关键。     

Left Ventricular Diastolic Dysfunction in Patients With Mitral Stenosis Undergoing Percutaneous Mitral Balloon Valvotomy

ObjectiveTo investigate the effect of left ventricular diastolic dysfunction on outcome in patients with mitral stenosis undergoing percutaneous mitral balloon valvotomy (PMBV).Patients and MethodsWe evaluated consecutive patients with mitral stenosis who underwent PMBV from November 1, 2002, through October 30, 2011, at our institution.ResultsOf 107 total patients, 35 (32.7%) had diastolic dysfunction, defined as a preprocedural elevation in left ventricular end-diastolic pressure (LVEDP) (>15 mm Hg). The LVEDP was normal in the remaining 72 patients (≤15 mm Hg). Clinical factors associated with diastolic dysfunction were body mass index (32±7 vs 28±5; P=.004) and diabetes mellitus (29% vs 6%; P=.002), but no differences were found in severity of pulmonary hypertension or degree of improvement in mitral valve hemodynamics after PMBV between the 2 groups. Survival free of recurrent severe symptoms, repeated PMBV, or mitral valve replacement was worse in patients with elevated LVEDP vs normal LVEDP (1-year estimate, 42% vs 81%; hazard ratio, 2.83; 95% CI, 1.62-4.96).ConclusionIn patients referred for treatment of symptomatic mitral stenosis, left ventricular diastolic dysfunction may contribute to elevated left atrial pressure, and its presence is associated with a greater risk of failure of PMBV to improve symptoms. These data have implications for counseling and patient selection for PMBV.     

Chronic mitral regurgitation and Doppler estimation of left ventricular filling pressures in patients with heart failure.

Previous studies relating Doppler parameters and pulmonary capillary wedge pressures (PCWP) typically exclude patients with severe mitral regurgitation (MR). We evaluated the effects of varying degrees of chronic MR on the Doppler estimation of PCWP. PCWP and mitral Doppler profiles were obtained in 88 patients (mean age 55 +/- 8 years) with severe left ventricular (LV) dysfunction (mean ejection fraction 23% +/- 5%). Patients were classified by severity of MR. Patients with severe MR had greater left atrial areas, LV end-diastolic volumes, and mean PCWPs and lower ejection fractions (each P <.01). In patients with mild MR, multiple echocardiographic parameters correlated with PCWP; however, with worsening MR, only deceleration time strongly related to PCWP. From stepwise multivariate analysis, deceleration time was the best independent predictor of PCWP overall, and it was the only predictor in patients with moderate or severe MR. Doppler-derived early mitral deceleration time reliably predicts PCWP in patients with severe LV dysfunction irrespective of degree of MR.     

超声心动图评价高血压病患者左心功能

目的运用超声心动图技术综合评价高血压病患者左室收缩功能和舒张功能。方法高血压病组56例和对照组36例,M-型和二维(2D)超声心动图检测:左房内径(LAd),舒张期室间隔厚度(IVST)和左室后壁厚度(PWT),左室舒张末期内径(LVDd),二尖瓣EF斜率,室间隔及左室后壁运动幅度,左室射血分数(EF),左室短轴缩短率(FS),每搏量(SV);脉冲多普勒(PW)检测二尖瓣口舒张早期充盈峰速度(VE),舒张晚期充盈峰速度(VA),E/A比值,等容舒张时间(IVRT)。结果高血压病患者左室壁与室间隔收缩期运动幅度普遍增强,与对照组比较P<0.01;左室收缩功能各项参数(EF、FS、SV)高于对照组(P<0.05),高血压病组左室舒张功能各参数异常,表现为VE减低,VA升高,E/A<1,IVRT延长,MV-EF斜率减慢,与对照组比较P<0.001;左房扩大(P<0.001)。结论超声心动图技术可反映高血压病患者左心结构和功能变化,为临床诊治提供客观依据。     

Noncompacted myocardium in Ebstein's anomaly: initial description in three patients.

Exercise intolerance in Ebstein's anomaly is usually attributed to desaturation secondary to right-to-left shunting as a result of a small or distorted left ventricle (LV), significant tricuspid valve regurgitation, right ventricular dysfunction, or a combination of these. We observed one boy (age 15 years) and two women (ages 20 and 29 years) with severe Ebstein's anomaly and strikingly abnormal LV myocardium resembling the features described for LV noncompaction. LV size and systolic function were normal in the two women; the boy had a dilated LV with severely diminished ejection fraction. The LV myocardium was found to be unusually coarse and hypertrabeculated, with small intertrabecular recesses and an irregular endocardial surface. The findings in these 3 patients represent the whole spectrum of mild to severe LV noncompaction. Diastolic dysfunction was present in 2 of the 3 patients. Exercise tolerance was diminished in all. There was no mitral or aortic valve disease. The 15-year-old boy underwent heart transplantation 6 months later for biventricular failure. Thus, Ebstein's anomaly does not seem to be a pathology confined to the right ventricle, but may rarely lead to LV noncompacted myocardium. This LV pathology may be an additional explanation for exercise intolerance or signs of left heart failure in patients with Ebstein's anomaly.     

Transmitral extraction of a huge left ventricular mural thrombus using a novel mitral leaflet retractor

A 52‐year‐old woman with a past history of anterior myocardial infarction 15 years previously was found to have a pedunculated mobile thrombus with a narrow stalk originating from the left ventricle, and a huge laminated mural thrombus. Surgical extraction of the two organized thrombi was successfully performed with transmitral approach using a novel, flexible, self‐retained, and reusable leaflet retractor, which was originally developed for exposure of the subvalvular apparatus during mitral valve repair. Excellent access, exposure, and visualization of the left ventricle were achieved by this heart valve retractor and an endoscope for removal of a huge mural thrombus.     

Use of tissue Doppler echocardiography in early detection of left ventricular systolic dysfunction in patients with mitral regurgitation

Objective: Left ventricular ejection fraction (EF) and left ventricular (LV) end-systolic diameter measurements are the most widely accepted and utilized methods to demonstrate LV dysfunction in patients with mitral regurgitation (MR). However, these parameters still have many drawbacks in predicting early LV dysfunction. This study investigates the clinical usefulness of tissue Doppler echocardiography technique in detecting early disturbance of myocardial contractility in asymptomatic patients with chronic, severe MR and normal LV ejection fraction values. Methods and Results: Regional systolic peak velocities of mitral annular motion during the ejection phase of systole (SW2) were obtained at the mitral annuli of the ventricular septal, lateral, anteroseptal, posterior, anterior and inferior wall sites in the long axis in 31 asymptomatic patients with severe MR (with a regurgitant volume of more than 50 ml) and with EFs more than 60%. The patients were grouped according to their dP/dt values (more or less than 1300 mm Hg/s) estimated non-invasively by using continuous Doppler wave of MR SW2 measurements of Group I were higher than Group II in all of the analyzed segments. The difference was statistically significant for all of the segments. SW2 values of the whole study group was moderately correlated with dP/dt measurements in all of the analyzed segments other than the interventricular septum. Conclusion: SW2 measurements in the long axis, which are considered to be relatively independent from afterload conditions may be helpful in early detection (while EF is still in normal range) of LV systolic dysfunction during the follow-up of patients with chronic MR.     

严重器质性二尖瓣反流患者肺动脉压的预测因素

目的 探讨严重器质性二尖瓣反流患者肺动脉收缩压(PASA)升高的预测因素及与左右心室收缩、舒张功能的关系.方法 二尖瓣脱垂或连枷样引起的中-重度二尖瓣反流患者694例,男361例,女333例,年龄17～57岁,均行常规超声心动图检查并行组织多普勒(TDI)分析,根据三尖瓣反流速度测算PASP;合并EF%<55%及原发性肺动脉高压患者予以排除.根据PASA数值由低至高分成四组,作相关因素分析比较.结果 PASP平均为(40±15)mmHg,与年龄(r=0.36,P<0.01)、MR(r=0.30,P<0.01)、二尖瓣瓣环E/E(侧壁,r=0.40,P<0.01;室间隔,r=0.41,P<0.01)、左心房内径指数(r=0.50,P<0.01)、右心室内经指数(r=0.30,P<0.01)、左心室及右心室舒张功能参数均有很好的相关性,这些变量随PASP的增加而增加;PASP与二尖瓣瓣环TDI收缩期速度、左心室射血分数、左心室短轴缩短率的相关性则较差.多变量分析结果提示,年龄、MR、左心房大小,以及左心室充盈压指标E/E(侧壁、室间隔)是PASP升高的独立性预测因子.结论 二尖瓣脱垂或连枷样二尖瓣引起中-重度器质性二尖瓣反流且左心室收缩功能尚正常的患者,年龄、MR、左心房内径、左心室充盈压及左、右心室舒张功能指标对PASP有预测作用.     

斑点追踪成像技术评价冠状动脉不同狭窄程度患者的左室扭转运动

目的 应用斑点追踪成像(STI)技术评价冠状动脉不同狭窄程度患者左室扭转运动的特点及规律性.方法 临床拟诊为冠心病患者117例,根据冠状动脉造影或冠状动脉CT结果分成心肌梗死组(60例)、心肌缺血组(31例)及对照组(26例),常规超声测量左室收缩及舒张末期内径(LVDs,LVDd)、容积(LVVESV,LVEDV)及射血分数(LVEF),组织多普勒测量二尖瓣后瓣环收缩期峰值运动速度(S')及Tei指数,运用STI技术分析左室二尖瓣水平与心尖水平旋转运动、整体扭转运动,测定旋转角度/率、扭转角度/率.结果 与心肌缺血组及对照组比较,心肌梗死组LVDd、LVDs、LVEDV、LVESV及Tei指数均增大,LVEF及S'减低,差异均有统计学意义(P<0.05).与对照组比较,心肌梗死组及心肌缺血组左室心尖水平旋转角度/率、二尖瓣水平旋转率、扭转角度/率均减低,差异均有统计学意义(P<0.05),以心肌梗死组减低更为显著(P<0.01).左室整体的扭转角度与LVEF呈较强的正相关(r=0.618,P<0.001).结论 冠心病患者的冠状动脉狭窄程度越严重,左室整体的扭转运动受损越明显,以心肌梗死组减低更为显著.应用STI评价左室的扭转运动与常规超声参数相比较,能更好地反映心肌缺血患者的左心室收缩运动.     

斑点追踪显像评价束支传导阻滞患者左心室短轴方向的收缩同步性

目的 探讨完全性左束支传导阻滞(CLBBB)及完全性右束支传导阻滞(CRBBB)患者左心室短轴方向的收缩同步情况.方法 选取28例CLBBB患者[包括左心室收缩功能正常(CLBBBa组,15例)及左心室收缩功能不全(CLBBBb组,13例)者]、29例CRBBB患者[包括左心室收缩功能正常(CRBBBa组,16例)及左心室收缩功能不全(CRBBBb组,13例)者]及对照组25例无心血管疾病者,应用斑点追踪显像技术分析左心室二尖瓣水平、乳头肌水平及心尖水平径向应变、周向应变以及旋转角度收缩期达峰时间,计算收缩期达峰时间标准差.结果 除CLBBBa组心尖水平周向应变收缩期达峰时间外,CLBBB患者径向应变、旋转角度及周向应变收缩期达峰时间较对照组明显增加(P均＜0.05),CRBBBb组径向应变收缩期达峰时间较对照组明显增加(P均＜0.05).CLBBB患者径向应变、周向应变及旋转角度收缩期达峰时间标准差较对照组明显增加(P均＜0.05).CRBBBb组径向应变收缩期达峰时间标准差大于CRBBBa组和对照组(P＜0.05).结论 CLBBB患者存在明显心肌收缩不同步现象,左心室收缩功能不全CRBBB患者心肌存在径向应变上收缩不同步现象.     

实时三维超声心动图容积-时间曲线评价左心室舒张功能的初步研究

目的 利用实时三维超声心动图容积-时间曲线评价左室舒张功能正常及异常患者的曲线变化情况。方法以频谱组织多普勒二尖瓣环舒张早期速度〈二尖瓣环舒张晚期速度为左室舒张功能减低的诊断标准，取24例单纯左室舒张功能减低的患者（分为松弛延迟组及假性正常化组，各12例）和24例健康志愿者，进行实时三维超声心动图全容积采集，并进行容积-时间曲线分析，比较三组实时三维超声心动图参数：左室舒张末容积（EDV）、左室收缩末容积（ESV）、左室射血分数（LVEF）、左室最大射血速率（PER）、左室最大充盈速率（PFR）之间的差异。结果与正常对照组相比，松弛功能延迟组及假性正常化组的实时三维超声心动图舒张充盈参数PRF明显降低（P〈0．05），其他指标EDV、ESV、LVEF、PER无明显差异（P〉0．05）。结论实时三维超声心动图容积-时间曲线参数PFR可以评估早期左室舒张功能减低，为临床评价左室舒张功能提供了一个无创、快速、准确的新手段。