Changes in QRS voltage in cardiac tamponade and pericardial effusion: reversibility after pericardiocentesis and after anti-inflammatory drug treatment.

OBJECTIVES: The goal of this study was to define the association between low QRS voltage and cardiac tamponade or pericardial effusion and to assess the reversibility of low QRS voltage after therapeutic procedures. BACKGROUND: It is unclear whether low QRS voltage is a sign of cardiac tamponade or whether it is a sign of pericardial effusion per se. METHODS: In a prospective study design, we recorded consecutive 12-lead electrocardiograms and echocardiograms in 43 patients who were referred to our institution for evaluation and therapy of a significant pericardial effusion. Cardiac tamponade was present in 23 patients (53%). Low QRS voltage (defined as maximum QRS amplitude <0.5 mV in the limb leads) was found in 14 of these 23 subjects (61%). Nine of these 14 patients were treated by pericardiocentesis (group A). Five patients received anti-inflammatory medication (group B). Group C consisted of nine patients with pericarditis and significant pericardial effusion who had no clinical evidence of tamponade. RESULTS: In group A, low QRS voltage remained largely unchanged immediately after successful pericardiocentesis (0.36 +/- 0.17 mV before vs. 0.42 +/- 0.21 mV after, p = NS), but QRS amplitude recovered within a week (0.78 +/- 0.33 mV, p < 0.001). In group B, the maximum QRS amplitude increased from 0.40 +/- 0.20 mV to 0.80 +/- 0.36 mV (p < 0.001) within six days. In group C, all patients had a normal QRS amplitude initially (1.09 +/- 0.55 mV) and during a seven-day follow-up (1.10 +/- 0.56 mV, p = NS). CONCLUSIONS: Low QRS voltage is a feature of cardiac tamponade but not of pericardial effusion per se. Our findings indicate that the presence and severity of cardiac tamponade, in addition to inflammatory mechanisms, may contribute to the development of low QRS voltage in patients with large pericardial effusions.

The role of phagocytic cells in human blood leukocyte suspensions for in vitro colony-forming cells.

The iron ingestion method was used to separate colony stimulating cells from in vitro colony forming cells (CFU-C) in human white blood cell (WBC) suspensions. The depletion of phagocytic cells (granulocytes and monocytes) from WBC eliminated spontaneous colony growth, without influencing the total number of CFU-C. Thus, phagocyte-free human WBC can be used as a target for measuring human colony stimulating activity (CSA). Such leukocytes can be cryopreserved, thus making possible the use of standardized target cell preparations for longitudinal studies. Hemolysate added to phagocyte-free blood leukocytes did not induce colony formation but could enhance it in the presence of a suitable CSA. Spontaneous colony formation of unseparated WBC was significantly reduced by selective destruction of granulocytes by freezing in 10% DMSO, thus indicating that both granulocytes and monocytes are involved in the production of endogenous CSA in WBC suspensions.

Studies on the inhibitory effect of granulocytes on human granulocytopoiesis in agar cultures.

In the present study, the inhibitory effect of blood granulocytes on granulocytic colony formation from human white blood cells was tested. Attempts were made to clarify the effects of granulocytes by plating increasing numbers of polymorphonuclear cells (PMN) by using granulocytes which had been inactivated by freezing, by studying the effect of PMN removal and by observing the effect of dilution of granulocyte inhibitors to ineffective levels at different time intervals after the onset of culture. It will be shown that colony formation is inhibited by an excess of PMN and that the inhibitor is produced only by viable PMN. There is no inhibition during the early phase of the culture, thus suggesting that the CFU-C itself is not the target cell for the inhibition of colony formation in agar culture, but rather the more mature precursor cells of granulopoiesis.

Investigation of bax, bcl-2, bcl-x and p53 gene polymorphisms in multiple sclerosis.

Clinical course, outcome, radiological features, severity, and histopathology are heterogenous in multiple sclerosis (MS). Since MS is considered to be a polygenic disease, the genetic background may at least partly be responsible for this variability. Some MS cases are histopathologically characterized by a dramatic oligodendrocyte loss that is in part caused by apoptosis. A dysregulated apoptotic elimination of self-reactive T cells may also contribute to disease susceptibility. To analyze genetic differences in the apoptosis regulating factors bcl-2, bax, bcl-x and p53 we investigated polymorphisms of these genes in 105 patients with a relapsing remitting disease course and 99 controls by PCR-SSCP and direct sequencing. We identified so far unpublished sequence alterations in the promotor region of the bxl-x gene, in exon 7 of the p53 gene, and in exon 1 of the bax gene. No differences were observed between MS patients and controls. Additional known polymorphisms were found in intron 3 of the bax gene and in exon 6 of the p53 gene. No significant differences in the frequency of gene sequence variations were found between MS patients and controls. The apoptosis genes studied here therefore appear less likely to be important effector genes in MS.

M-mode analysis of mitral annulus motion for detection of pseudonormalization of the mitral inflow pattern.

Left ventricular (LV) diastolic dysfunction is a frequent cause of heart failure. Doppler echocardiography has become the method of choice for the noninvasive evaluation of LV diastolic dysfunction. However, pseudonormalization of mitral inflow often presents a diagnostic problem in clinical practice. We sought to define the role of mitral annulus motion in this setting. We performed echocardiography in 36 consecutive subjects (age 59 +/- 10 years). Eighteen had recently (within 3 months) been diagnosed with coronary artery disease, 18 had clinical suspicion of coronary artery disease, and 15 had symptoms of heart failure (New York Heart Association class 2.4 +/- 0.5). The amplitude (E(M)) and the slope (slope E) of early diastolic motion of the septal mitral annulus were derived from M-mode analysis. Left heart catheterization was performed for direct measurement of LV end-diastolic pressure. Pseudonormalization defined by an E/A ratio > 1 and a LV end-diastolic pressure > or = 16 mm Hg was found in 9 patients. All patients with pseudonormalization were symptomatic (New York Heart Association class 2.8 +/- 0.5). Patients with and without pseudonormalization did not differ with respect to the E/A ratio (1.29 +/- 0.44 vs 1.16 +/- 0.23, p = NS), deceleration time (182 +/- 38 vs 205 +/- 42 ms, p = NS), and isovolumic relaxation time (88 +/- 24 vs 92 +/- 18 ms, p = NS). In the group with pseudonormalization, a significant reduction of E(M) (3.9 +/- 1.6 vs 5.7 +/- 1.5 mm, p = 0.008) and slope E (24.5 +/- 11.8 vs 43.9 +/- 7.7 mm/s, p <0.001) was detected. Using E(M) <4.3 mm and slope E <35 mm/s as cut points, sensitivity and specificity for the detection of pseudonormalization were 66% and 82% for E(M) and 77% and 87% for slope E, respectively. There was no significant relation between LV end-diastolic pressure as a measure of preload and either E(M) (r = 0.44, p >0.5) or slope E (r = 0.30, p >0.2). Thus, E(M) and slope E may be preload-independent tools for assessing LV diastolic dysfunction in symptomatic patients with a pseudonormal mitral inflow pattern and elevated filling pressures.

Usefulness of motion patterns indentified by tissue Doppler echocardiography for diagnosing various cardiac masses, particularly valvular vegetations.

This study sought to test whether anomalous cardiac and aortic structures can be differentiated from native tissue and artifacts by physical properties of tissue motion using transesophageal tissue Doppler echocardiography (TDE). TDE was employed in 85 consecutive patients after anomalous structures had been detected by conventional transesophageal echocardiography (TEE). The control group consisted of 40 randomized patients. Certainty of diagnosis was divided into 4 categories, and TDE signals were related to particular anomalous structures by a blinded second observer. A mechanical model of a beating ventricle was constructed and suspended in a water bath. Synthetic material was utilized to simulate anomalous intracavitary structures with varying shape, consistency, and attachment. Incoherent motion was present in endocarditic vegetations, freely oscillating thrombi, fourth-degree aortic plaques, Chiari network, valvular prolapse, tumors, and in normal valve leaflets and papillary muscles. Within 15 seconds vegetations could be detected in 17 patients (68%) using TDE versus 5 patients (20%) using only conventional imaging. Coherent motion with a phase difference occurred due to damped oscillation. This phenomenon occurred in 5 patients with thrombi of the left atrial appendage (100%), in 3 ventricular clots (75%), and in 2 hypernephroma in the right atrium (100%). Rapid identification of clots could be achieved in 15 patients (71%) versus 12 patients (57%). Concordant motion was shown in third-degree aortic plaques, postrheumatic valvular lesions, and aortic intramural hematomas, but diagnostic benefit could not be demonstrated. In 41 patients (48%) histopathologic and intraoperative results confirmed echocardiographic findings. Motion patterns could be reproduced independently of the heart rate by model experiments. This study demonstrates that TDE expedites the detection of vegetations in infective endocarditis. Diagnostic certainty can be increased as well for thrombus formations.

A flexible and stable numerical method for simulating the thermal decomposition of wood particles.

The objective of this paper is to present a flexible and stable simulation method to predict the thermal conversion of wood particles. A combination of several subprocesses such as heating-up, drying, pyrolysis, gasification and combustion of fuel particles of different properties and sizes represents the global process of thermal conversion. This approach allows for simultaneous processes e.g. reactions in time and covers the entire range between transport-limited (shrinking core) and kinetically limited (reacting core) reaction regimes. Thus, the model is applicable to simulate sufficiently accurate the thermal decomposition of each particle in a packed bed, of which the entire conversion is regarded as the sum of all particle processes. Effects such as fragmentation, swelling, homogeneous reactions e.g. ignition outside a particle are excluded as a tradeoff between complexity and calculation time. However, a description of the particle processes by one-dimensional and transient differential conservation equations for mass and energy is feasible to represent the above mentioned subprocesses. The particles are coupled to the gas phase by heat and mass transfer taking into account the Stefan correction due to the gas outflow during conversion. A general formulation of the conservation equations allows the geometry of a fuel particle to be treated as a plate, cylinder or sphere. In order to achieve a high degree of flexibility, the method distinguishes between data, such as kinetics or material properties and the conversion process, for which relevant data are stored in a data base for easy access and extension. The resulting modules of this subdivision are encapsulated into separate software units cast in a hierarchy of well-defined classes in Tools of Object-oriented Software for Continuum-Mechanics Applications (TOSCA) by object-oriented techniques.

Diastolic filling pattern and left ventricular diameter predict response and prognosis after cardiac resynchronisation therapy.

OBJECTIVE: To investigate predisposing factors for cardiac resynchronisation therapy (CRT) response. DESIGN: Single-centre study. SETTING: University hospital in Germany. PATIENTS: 122 consecutive patients with heart failure (mean (SD) age 65 (11) years; ischaemic/non-ischaemic 41%/55%; New York Heart Association (NYHA) class 3.1 (0.3); left ventricular ejection fraction 24.4 (8.1)%; QRS width 170 (32) ms, quality of life (QoL) 43.5 (19.2)) with an indication for CRT and demonstrated left ventricular dyssynchrony by echocardiography including tissue Doppler imaging. INTERVENTIONS: Besides laboratory testing of clinical variables, results of ECG, echocardiography including tissue Doppler imaging, invasive haemodynamics, measures of QoL and of exercise capacity were obtained before CRT implantation and during follow-up. MAIN OUTCOME MEASURE: Responders were predefined as patients with improvement by one or more NYHA functional class or reduction of left ventricular end-systolic volume by 10% or more during follow-up. Mean (SD) follow-up was 418 (350) days. RESULTS: Overall, 70.5% of patients responded to CRT. Responders had a significantly improved survival compared with non-responders (96.2% vs 45.5%, log-rank p<0.001). On univariate analysis, left ventricular end-diastolic diameter, left ventricular end-systolic diameter (LVESD), E/A ratio, a restrictive filling pattern, mean pulmonary artery pressure, pulmonary capillary pressure, N-terminal pro-brain natriuretic peptide and Vo(2)max were significant predictors of outcome. On multivariate analyses, LVESD (p = 0.009; F = 7.83), pulmonary capillary pressure (p = 0.015, F = 6.61) and a restrictive filling pattern (p = 0.026, F = 5.707) remained significant predictors of response. CONCLUSIONS: Despite treatment according to present guidelines nearly 30% of patients had no benefit from CRT treatment in a clinical setting. On multivariate analyses, patients with an increased left ventricular end-systolic diameter and concomitant diastolic dysfunction had a significantly worse outcome.

Aminoterminal B-type pro-natriuretic peptide as a marker of recovery after high-risk coronary artery bypass grafting in patients with ischemic heart disease and severe impaired left ventricular function.

BACKGROUND: Aminoterminal B-type pro-natriuretic peptide (NT-proBNP) is a reliable indicator of heart failure severity. Levels of NT-proBNP are markedly increased in patients with coronary artery disease (CAD) and severely impaired left ventricular (LV) function. The aim of our study was to assess the impact of NT-proBNP levels after high-risk coronary artery bypass grafting (CABG) with regard to recovery potential. METHODS: Between 1998 and 2004, 121 patients with CAD and severely impaired LV function, who were undergoing CABG, were investigated. Their mean age was 64 +/- 11 years. All patients were in New York Heart Association (NYHA) Class III/IV status; LV ejection fraction (EF) was 20 +/- 6%. All survivors underwent follow-up (59 +/- 34 months) spiroergometric, electrocardiographic (ECG) and echocardiographic assessment and were tested for routine blood controls and NT-proBNP levels (Roche, Mannheim, Germany). RESULTS: The survival rate after 8 years was 70%. All survivors received follow-up assessment. Among survivors the median NT-proBNP level at follow-up was 896 (521 to 1,687) pg/ml. The maximum oxygen uptake was 14.6 +/- 4.9 ml/min/kg, and EF increased to 42% at follow-up among all survivors. On dichotomizing survivors into two groups with NT-proBNP levels above and below the median, the post-operative body mass index was significantly higher in the high NT-proBNP group (p = 0.036). EF (p = 0.028) and NYHA classification (p < 0.05) improved significantly in both groups, with a tendency toward higher EF in the low NT-proBNP group. CONCLUSIONS: Patients undergoing a high-risk CABG procedure have a survival rate comparable to heart transplantation patients and show a potential for clinical and myocardial recovery. NT-proBNP use a useful marker for recovery after a high-risk CABG procedure, with significant correlation with clinical parameters.

Primary left atrial angiosarcoma mimicking severe mitral valve stenosis.

Primary cardiac tumours are quite rare and most of these tumours are benign. In this report, a patient presented with heart failure symptoms attributable to severe mitral valve stenosis. Echocardiography showed a dense left atrial mass causing functional mitral valve obstruction. The morphological and intraoperative presentation was highly suggestive of a myxoma but histopathological examination found a primary pedunculated cardiac angiosarcoma. The role of two dimensional and transoesophageal echocardiography in the assessment of cardiac masses and tumours is discussed.

Studies on the regeneration of the CFU-C population in blood and bone marrow of lethally irradiated dogs after autologous transfusion of cryopreserved mononuclear blood cells.

In a group of 8 lethally irradiated (1200 R) dogs, that were transfused autologously with cryopreserved mononuclear cells (MNC) derived from the peripheral blood by leucapheresis the concentration of colony-forming units in agar (CFU-C) in bone marrow and peripheral blood was estimated at regular intervals after irradiation and transfusion of MNC. The numbers of MNC transfused per kg body weight ranged from 0.32 x 10(9) to 1.63 x 10(9) with an incidence of CFU-C between 0.02 x 10(5) and 1.38 x 10(5). In 6 dogs the CFU-C levels in the bone marrow reached the normal pre-irradiation values between days 15 and 20. But in 2 dogs that had received the lowest CFU-C numbers the regeneration of the bone marrow CFU-C was markedly delayed. In general the time course of the bone marrow repopulation by CFU-C for single dogs was reflected by a corresponding regeneration pattern of the blood CFU-C. The time course of the curves for the blood CFU-C levels on the other hand was of the same kind as for the granulocyte values in the peripheral blood, thuations were seen in the blood CFU-C levels of single dogs before irradiation and after mononuclear leucocyte transfusion. Despite of such limitations the blood CFU-C content appeared to be a useful indicator of haematopoietic regeneration of the bone marrow.

Colony formation by canine hemopoietic cells in vitro. Inhibition by polymorphonuclear leukocytes.

In soft agar cultures of canine blood leukocytes, an inhibition of colony formation was observed relative to the size of the inoculum. Analysis of the cellular composition of the inoculum suggested that this inhibition was associated with the number of polymorphonuclear leukocytes present. Removal of phagocytic cells by the iron ingestion method or selective destruction of granulocytes by freezing in the presence of dimethyl sulfoxide eliminated the inhibitory action on colony formation. In mixed cultures of canine bone marrow and antologous blood leukocytes, a similar inhibition of colony formation was observed. The results presented indicate that polymorphonuclear leukocytes, if present in a concentration exceeding 2.5X10(6)/ml of inoculum, inhibit in vitro granulocytic/monocytic colony formation.

[Sinus node dysfunction with intermittent sinus arrest and AV-nodal escape rhythm as initial manifestation of pheochromocytoma]. / Sinusknotendysfunktion mit intermittierendem Sinusarrest und AV-junktionaler Ersatzrhythmus als Erstmanifestation eines Phäochromozytoms.

A 25-year-old male student complained about episodic palpitations, dizziness, nausea and headache 5 years prior to presentation. No otorhinolaryngic, neurologic or gastrointestinal causes were identified. Several ECG recordings revealed sinus node dysfunction with intermittent sinus arrest and AV-nodal escape rhythm. The patient was given a permanent DDD-pacemaker. Six months later, the clinical symptoms were unchanged. During an attack, physical examination revealed paleness, diffuse sweating and an arterial blood pressure of 250/130 mmHg, which decreased to 120/80 mmHg within a few minutes. Abdominal ultrasound and abdominal computed tomographic scan demonstrated the presence of a large (6.4 x 5.5 cm) left-sided adrenal mass. Two 24-h-urinary collections demonstrated elevated noradrenaline (mean 315 micrograms/24 h, normal < 80 micrograms/24 h) and adrenaline (mean 268 micrograms/24 h, normal < 20 mg/24 h) levels. Blood samples, which were drawn during excessive blood pressure rise, revealed elevation of plasma catecholamines (6.793 pg/ml for adrenaline (normal 50-150 pg/ml) and 10.424 pg/ml for noradrenaline (normal 200-500 pg/ml), so that the diagnosis of pheochromocytoma was considered established. The tumor was successfully removed during laparascopic surgery. After surgery, the patient remained well and normotensive. Three months later, several long-term ECG recordings showed sinus arrhythmia with no evidence of sinus arrest or AV-nodal escape rhythm, so that the DDD pacemaker was turned off. This case underlines that sinus node dysfunction with intermittent sinus arrest and AV-nodal escape rhythm is a potential early manifestation of a pheochromocytoma. These changes seem to disappear after successful removal of the tumor.

Tei-Index in coronary artery disease--validation in patients with overall cardiac and isolated diastolic dysfunction.

BACKGROUND: The index "isovolumic contraction time and isovolumic relaxation time divided by ejection time" ("Tei-Index") has been demonstrated to provide useful information about disease severity and prognosis in patients with dilated cardiomyopathy and cardiac amyloidosis. In patients with coronary artery disease (CAD), the diagnostic utility of this index is unclear. We attempted to validate the Tei-Index in CAD patients with overall cardiac or isolated diastolic dysfunction. METHODS AND RESULTS: Sixty subjects were included who underwent left heart catheterization for invasive measurement of left ventricular end-diastolic pressure (LVEDP): 20 symptomatic CAD patients with overall cardiac dysfunction (defined by a LV ejection fraction (EF) < 45% (mean 27 +/- 8%) and a LVEDP > or = 16 mmHg, (mean 22 +/- 6 mmHg), NYHA class 2.7 +/- 0.4, OCD group), 29 symptomatic CAD patients with isolated diastolic dysfunction (defined by an EF > 45% (mean 55 +/- 8%), a normal end-diastolic diameter index (mean 2.8 +/- 0.4 cm/m2) and a LVEDP > or = 16 mmHg (mean 22 +/- 6 mmHg), NYHA class 2.3 +/- 0.4, IDD group) and 11 asymptomatic control subjects (EF 65 +/- 9%, LVEDP 11 +/- 4 mmHg, CON group). After conventional 2-D- and Doppler echocardiographic examination, the Tei-Index was obtained. The Tei-Index was easily and reproducibly measured in all study subjects. In the OCD group, isovolumic contraction time was prolonged and ejection time was shortened in comparison to the CON group, resulting in a significantly increased Tei-Index (0.71 +/- 0.28 vs 0.40 +/- 0.11, p < 0.01). In the IDD group, isovolumic relaxation time was prolonged and isovolumic contraction time was shortened in comparison to controls, resulting in a largely unchanged Tei-Index (0.45 +/- 0.14, p = ns). Receiver operating characteristic curve analysis for the Tei-Index yielded an area under the curve of 0.92 +/- 0.04 for separating patients with vs without OCD. Using a Tei-Index > 0.49 as a cut-off, OCD patients were identified with a sensitivity of 96% and a specificity of 86%. CONCLUSION: The Tei-Index is a valid and readily derived indicator of global cardiac dysfunction in CAD patients with impaired systolic and diastolic LV performance. The use of this index seems to be limited in CAD patients with primary diastolic dysfunction.

[Spontaneous echo contrast in the left ventricle as an indicator for an increased risk of thromboembolism]. / Spontaner Echokontrast im linken Ventrikel als Indikator für ein erhöhtes Thromboembolie-Risiko.

A 69-year-old man with coronary heart disease complained of pain in his right flank. He had dyspnoea, cough and fever up to 38.8 degrees C. In addition to various positive indicators of inflammatory disease he had a creatinine concentration of 1.8 mg/dl and an increased activity of lactate dehydrogenase (1655 U/l). The chest radiograph demonstrated pneumonia and computed tomography showed an infarct in the right kidney. The ECG indicated atrial fibrillation with an irregular ventricular rate and left bundle branch block. Echocardiography demonstrated dilatation of the left ventricle and a thrombus adherent to the wall. Transoesophageal echocardiography additionally recorded spontaneous type I echo-contrast, which disappeared after therapeutic heparinization. Cerebral infarctions were shown by computed tomography, undertaken because of neurological symptoms. There were also signs of silent myocardial ischaemia. As a coronary artery bypass operation was contraindicated, percutaneous transluminal balloon angioplasty was attempted but dissection occurred, causing irreversible cardiogenic shock of which the patient died.

Stroke volume and mitral annular velocities. Insights from tissue Doppler imaging.

The aim of this study was to assess the impact of stroke volume (SV) on mitral annular velocities derived from tissue Doppler imaging (TDI). To this end, conventional echocardiographic variables and TDI derived mitral annular velocities (S', E', A') were obtained in 14 patients (pts) with increased SV (due to primary mitral (n=12) (ISV group)), in 41 pts with reduced SV (due to ischemic (n=27) or dilated cardiomyopathy (n=9) or hypertensive heart disease (n=5) (RSV group)) and 29 asymptomatic controls with normal SV (CON group). Systolic (S') and early diastolic (E') mitral annular velocities were elevated in the ISV group in the comparison to the CON group, but were significantly reduced in the RSV group. Late diastolic annular velocities (A') did not differ between the ISV and the CON group, but were lowest in the RSV group. On simple linear regression analysis, SV was significantly related to S' (r=0.74, p<0.001), to E' (r=0.74, p<0.001) and to A' (r=0.43, p<0.01). On multiple regression analysis, SV was a stronger independent predictor of S' and E' than conventional systolic or diastolic echocardiographic variables. Thus, stroke volume has a significant impact on TDI derived systolic (S') and early diastolic (E') mitral annular velocities. This should be considered, when TDI is used in the evaluation of LV performance or in the estimation of filling pressures.

[Improved structure identification with tissue Doppler echocardiography]. / Verbesserte Strukturidentifizierung mittels Gewebe-Doppler-Echokardiographie.

Tissue Doppler echocardiography (TDE) has been shown to be of particular value in patients with impaired myocardial function. Recently, the technique was successfully employed to localize the ventricular insertion of accessory atrioventricular pathways. The identification of abnormal cardiac structures is coming up now as a new field of clinical interest. The purpose of this study was to differentiate anomalous cardiac and aortic from native structures by physical properties of tissue motion using transesophageal TDE. Characteristic motion patterns of anomalous structures have not been described in detail and tissue Doppler findings have not been associated with clinical features up to now. Forty consecutive patients were included after anomalous cardiac or vascular structures had been detected by conventional transesophageal echocardiography (TEE). A control group consisted of 20 subjects. Rapidity of diagnosis in anomalous structures was divided into 3 categories, and TDE signals were related to particular pathology by a blinded, 2nd observer. Three different motion patterns could be defined: incoherent motion due to free oscillation of an anomalous structure which is independent of the surrounding tissue (Figure 1b); coherent motion with a phase difference meaning that motion depends on the motion of the surrounding tissue but is out of phase (Figure 2); concordant motion showing no difference in direction, velocity, or phase of motion compared with the surrounding tissue. Incoherent motion was present in endocarditic vegetations, 4th degree aortic plaques, Chiari network, valvular prolapse, intracavitary tumors, and freely oscillating thrombi as well as in normal valve leaflets and papillary muscles. Especially if endocarditic vegetations are present its incoherent motion facilitates to recognize these small structures. The colorcode of this motion pattern demarcates the vegetation reliably from the surrounding tissue (Figure 1b). Within 15 seconds vegetations could be detected in 9 (82%) vs 2 (18%) patients employing only conventional imaging. Using conventional echocardiographic approaches detection of vegetations is frequently hindered by their small size and minor echo intensity (Figure 1a). In contrast, size and echo intensity do not affect the tissue Doppler signal. Normal papillary muscles and distal portions of the mitral and tricuspid valves were demonstrated to regularly meet the criterion of incoherent tissue motion in the control group. In part, this was also observed with respect to the aortic and pulmonary valves. In valvular tissue incoherent motion was caused by passive floating, whereas papillary muscles show an active inverse motion for short time intervals. Nevertheless, physiologic incoherent motion did not lead to any false differential diagnosis. The phase difference of coherent motion results from damped oscillation. This phenomenon was visualized by tissue Doppler M-mode in 5 thrombi of the left atrial appendage (LAA) (100%) and in 1 ventricular thrombus (50% of all clots). Concordant motion was shown in 3rd degree aortic plaques and postrheumatic and calcified vegetations. These structures were found to be completely embedded or closely attached, so that their passive motion corresponded to the motion of the surrounding regular tissue. Detection and assessment of anomalous structures are based on their motion patterns which can be synchronous or asynchronous in comparison with the surrounding tissue. Another goal of this investigation was to test if the sensitivity of TEE to spontaneous echo contrast can be improved using TDE. In 21 patients presenting with left atrial dilation (left atrial diameter > 44 mm) due to mitral stenosis (n = 8), mitral regurge (n = 5), arterial hypertension (n = 5) and multiple valvular disease (n = 3) fundamental multiplane TEE and transesophageal TDE were performed with standardized gain setting. The control group consisted of 20 randomized individuals with normal left

[Asynchrony of ventricular contraction and relaxation--pathophysiologically recognized phenomenon, now can be clinically assessed]. / Asynchronie der ventrikulären Kontraktion und Relaxation--pathophysiologisch erkanntes Phänomen, jetzt klinisch nachweisbar.

When regional myocardial dysfunction is present, the physiological pattern of ventricular filling and contraction is impaired. During acute coronary occlusion, characteristic changes are observed in the ischemic myocardial segment: the amplitude of the systolic wall thickening is reduced (hypokinesia), then virtually absent (akinesia) and finally replaced by a paradoxical outward motion (dyskinesia). The maximum amplitude is reached in early diastole ("post-ejection thickening"). Since hyperkinesis develops in the normal region, the ischemic and the normal region contract asynchronously. Experimentally left ventricular asynchrony can be detected by means of subendo- and subepicardially implanted ultrasonic crystals ("sonomicrometry") or by the analysis of the phase difference of the first Fourier harmonic of dysfunctional versus control myocardial wall motion. In the clinical setting, digitized cineventriculography, radionuclide angiography and digitized M-mode echocardiography were used to assess left ventricular asynchrony in patients with coronary artery disease and hypertrophic cardiomyopathy. However, these imaging modalities are time-consuming and require complicated off-line analysis. Tissue Doppler echocardiography (TDE) is a new ultrasound modality that is based on color Doppler principles and allows for quantification of myocardial wall motion velocity by detection of consecutive phase shifts of the ultrasound signal reflected from the myocardium. The Doppler signals are displayed as a color or pulsed Doppler image by rejecting low-amplitude echoes from the blood pool due to changes in thresholding and filtering algorithms. In addition, the ability to measure low velocity is improved in the TDE system so that the lowest measurable velocity is 0.2 cm/s, a velocity level associated with cardiac tissue motion (Table 1). Due to its high temporal and spatial resolution, TDE provides valuable information on regional myocardial wall motion during different intervals of the cardiac cycle. In healthy subjects, patients with coronary artery disease and patients with hypertrophic cardiomyopathy, tissue Doppler echocardiography was used to assess myocardial synchrony/asynchrony on a 2-fold temporal and spatial analysis. Peak myocardial velocities in different myocardial regions were detected during rapid ejection, isovolumic relaxation, rapid filling and atrial contraction (Figure 1). In the apical view, during the isovolumic relaxation time (IVRT) healthy subjects showed slow, synchronous outward motion of the septum and the lateral wall with homogeneous color-encoding (blue/green, Figure 2). Analysis of peak velocities revealed low, negative velocities in both the septum and the lateral wall (Figure 3). In patients with a significant luminal narrowing of the LAD myocardial asynchrony was detected during the isovolumic relaxation period: while the septum was moving inwards (red color-encoding with low, positive velocities), the lateral wall was moving outwards (blue/green encoding, low, negative velocities). A representative example of a patient with CAD is given in Figure 4. The M-mode analysis of the abnormally contracting interventricular septum reveals positive peak tissue velocities during the isovolumic relaxation period (Figure 5). In hypertrophic cardiomyopathy, TDE was able to detect an abnormal inward motion of the interventricular septum during IVRT and a delay in the onset of rapid filling (Figure 6). Thus, tissue Doppler echocardiography is a feasible method for the on-line detection of myocardial asynchrony. Sensitivity and specificity of the findings have to be explored in further, prospectively randomized trials.

[Detection of ventricular asynchrony using tissue Doppler echocardiography--a new method for assessing left ventricular wall motion]. / Aufdeckung ventrikulärer Asynchronie mittels Gewebe-Doppler-Echokardiographie (tissue Doppler echocardiography-TDE)--ein neues Verfahren zur linksventrikulären Wandbewegungsanalyse.

UNLABELLED: The asynchrony of the heart in patients with coronary artery disease can be detected by digitized cine- and radionuclidventriculography. Both methods require time-consuming offline analysis. The aim of the current study was the assessment of the clinical value of the recently developed tissue Doppler echocardiography (TDE) to detect myocardial asynchrony. In the current study, 21 healthy subjects (age 49 +/- 14 y) and 22 patients with known coronary artery disease (20 with > 70% luminal narrowing of the LAD, 4 with a history of CABG, age 58 +/- 12 y) were included. In the apical 4-chamber-view, midseptal and midlateral LV segments were analyzed by 2-D and M-Mode-TDE. Evaluation was possible in 20 healthy subjects (95%) and 20 CAD patients (91%). During isovolumic relaxation time (IVRT) healthy subjects showed slow synchronous outward motion of the septum and the free wall with homogenous color coding (blue/green) and low negative tissue velocities followed by rapid symmetrical outward motion during rapid filling (RF) and atrial contraction (AC) phase (high negative velocities). During diatasis (DI) almost no wall motion could be detected. In 17 (85%) of 20 CAD patients, myocardial asynchrony during IVRT was detected; while the septum was moving inward (red coding with low positive velocities), the free wall was moving outward (blue green coding with low negative/velocities). After opening of the mitral valve, all CAD patients showed rapid, symmetrical outward motion of both the septum and the free wall with homogenous color coding and high negative tissue velocities. CONCLUSION: Tissue Doppler echocardiography detects ventricular asynchrony online. In patients with significant LAD stenosis, a pathological septal movement is observed during isovolumic relaxation time. Determinants of the etiology could be chronic hypoperfusion or ischemia ("hibernating myocardium").