Subaortic membrane and aorto-septal angle: an echocardiographic assessment and surgical outcome.

BACKGROUND: Development of a subaortic membrane is not fully understood. Recurrence after surgical removal continues to be high. We sought to assess the differences in aorto-septal angles (AoSA) to possibly explain alterations within the left ventricular outflow tract, hence in subaortic membrane formation. METHODS: A total of 113 patients who underwent subaortic membrane resection were matched by age and sex with 113 controls. The subaortic membrane resection group included isolated subaortic membranes (n = 34, group I), associated with ventricular septal defect (n = 29, group II), or patent ductus arteriosus (n = 50, group III). RESULTS: Mean (± standard deviation) AoSA (in degrees) were not different between subaortic membrane groups I, II, and III but were steeper than their control groups (126.2 ± 9.2 vs 138.6 ± 7.0, 129.2 ± 9.9 vs 137.7 ± 10.0, and 126.2 ± 8.1 vs 135 ± 8.5, respectively; all Ps < .05). Additionally, group II had lower preoperative gradients (28.8 ± 20.7 mm Hg) compared to groups I and III (67.0 ± 32.9 and 66.2 ± 33.1 mm Hg, respectively, P < .001). Follow-up ranged from 3 to 132 months. In 22 (32%) patients, a subaortic membrane recurred. Early postoperative residual gradients and development of aortic regurgutation were associated with the need for reoperation (P < .05). CONCLUSIONS: These findings suggest a contributing role of the AoSA in the development of subaortic membrane. Further rheological experiments are warranted. Whether the steeper the angle the higher the risk of recurrence may be revealed by longer follow-up periods.

An assessment of regression of left ventricular hypertrophy following alcohol ablation of the interventricular septum in patients with hypertrophic cardiomyopathy with left ventricular outflow tract obstruction.

BACKGROUND: Hypertrophic obstructive cardiomyopathy (HOCM) is characterised by asymmetric myocardial hypertrophy, which is most pronounced in the interventricular septum (IVS) and is responsible for the dynamic obstruction of the left ventricular outflow tract (LVOT). Successful alcohol septal ablation (ASA) of the IVS allows to reduce the thickness of the parabasal part of the IVS myocardium and, in most cases, to permanently reduce the gradient in the LVOT. AIM: To assess, using cardiac magnetic resonance imaging (MRI) and transthoracic echocardiography (TTE), the impact of gradient reduction in the LVOT on the type and severity of left ventricular (LV) remodelling. METHODS: The study included 30 patients (aged 56.9 ± 11.9 years) with HOCM and the mean peak gradient (PG) in the LVOT of 123 ± 33 mm Hg who underwent ASA. MRI measurements were performed before and at 6 months after ASA and TTE measurements were performed before, at 3 months and at 6 months after ASA. RESULTS: PG in the LVOT decreased to an average of 52 ± 37 mm Hg (p 〈 0.0001) at 3 months after ASA and to 37 ± 28 mm Hg (p 〈 0.0001) at 6 months after ASA. TTE revealed a decrease in IVS thickness outside the scar following ASA from 23.6 ± 3.5 mm to 19.3 ± 4.0 mm (p 〈 0.0001) and 19.4 ± 0.4 mm (p 〈 0.0001) at 3 and 6 months, respectively. There was also a decrease in lateral wall (PW) thickness from 15.9 ± 3.2 mm to 14.9 ± 2.9 mm (p = 0.046) and 14.16 ± 2.00 (p = 0.0065) at 3 and 6 months, respectively. MRI revealed a decrease in IVS thickness from 23.7 ± 2.8 mm to 18.04 ± 4.00 mm (p = 0.0001) at 6 months following ASA. We observed a regression of the PW hypertrophy from 13.2 ± 3.35 mm to 12.18 ± 2.4 mm (p = 0.0225). There was a decrease in IVS mass from 108.9 ± 20 g to 91.5 ± 29 g (p = 0.0006). There was a trend towards a decreased LV mass and LV mass excluding IVS mass at 6 months. CONCLUSIONS: A significant decrease in PG in the LVOT is associated with a decrease in LV mass and with regression of LV hypertrophy outside the scar after ASA.

Geometric assessment of asymmetric septal hypertrophic cardiomyopathy by CMR.

OBJECTIVES: The aim of this study was to analyze the geometric pattern of hypertrophy (HT) in patients with asymmetrical septal hypertrophic cardiomyopathy (HCM) using cardiac magnetic resonance (CMR) and to test the hypothesis that at least in some patients, the HT follows a longitudinal spiral pattern. BACKGROUND: The highly heterogeneous phenotypic expression of HCM is a well-known phenomenon. CMR has emerged as a robust 3-dimensional (3D) tomographic imaging technique that is increasingly used to explore phenotypic expression. METHODS: Short-axis cine CMR was used to study the 3D extent of HT (i.e., radial, circumferential, and longitudinal extent, as well as the relation between circumferential and longitudinal extent). Inclusion criteria were septal wall thickness (WT) ≥15 mm and septal to free wall WT ratio >1.3. RESULTS: CMR was performed in 132 patients. Maximal WT was 22 ± 5 mm, with a circumferential extent of 131 ± 51°, and a longitudinal extent of 64 ± 19%, resulting in a hypertrophied left ventricular (LV) surface of 26 ± 15%. Linear regression analysis showed in 86% of patients a consistent course of HT along the longitudinal direction. The HT invariably started at the basal anteroseptum and rotated, except in 2 patients, in a counterclockwise direction (CC-spiral patients) with a mean global rotation of 116 ± 68° (range 5° to 350°). After the CC-spiral patients were divided according to magnitude of rotation quartiles (Q1: 5° to 70°, Q2: 75° to 105°, Q3: 110° to 150°, and Q4: 155° to 350°), Q4 patients were significantly older and had more LV outflow tract obstruction and hypertension than patients without the spiraling pattern. In 11 patients, continuation of HT into an apical form of HCM was found. CONCLUSIONS: Using 3D analysis, we found that the majority of patients with asymmetrical septal HCM in fact showed a spiral pattern of HT following a counterclockwise (or "left-handed") spiral trajectory. The variation in magnitude of rotation among patients, however, was highly variable. Further research is warranted to better understand the significance of the current findings, in particular to relate them to the genetic and morphological substrate, hemodynamic consequences, and patient outcome.

Dual-echo TFE MRI for the assessment of myocardial iron overload in beta-thalassemia major patients.

PURPOSE: Cardiac failure due to myocardial iron overload is the most common cause of death in beta-thalassemia patients. Multi/ two echo times-turbo field echo (TE-TFE) magnetic resonance imaging (MRI) is considered the gold standard technique in the evaluation of myocardial iron accumulation. However, multi TE-TFE technique is not available in all scanners. The aim of our study was to show the role of black blood dualecho cardiac triggered TFE in the assessment of myocardial iron overload. MATERIALS AND METHODS: Sixteen beta-thalassemia major patients (10 males) with a mean age of 19 years who were receiving parenteral deferoxamine and oral deferiprone treatment were included in this study. Baseline measurement of myocardial T2* values were < 20 ms in all patients. Cardiac MRI was performed after 6 months, 12 months, and 18 months with the same technique. RESULTS: The average baseline value of T2* was 8.2 +/- 3.6 ms. After treatment of combined deferoxamine and deferiprone, the average measurements of myocardial T2* at 6, 12, and 18 months were 11.3 +/- 6.0, 13.6 +/- 7.5, and 15.7 +/- 7.4 ms, respectively (P < 0.05). The basal ejection fraction (EF) value was 49 +/- 8.7%. The EFs were 54.4 +/- 11% at 6 months, 54.8 +/- 6.9% at 12 months, and 58.6 +/- 3.6% at 18 months of followup (P > 0.05). CONCLUSION: Cardiac MRI with dual TE-TFE technique can be used to determine myocardial iron accumulation and response to the chelation treatment.

Cardiomyopathy in Friedreich's ataxia-assessment by cardiac MRI.

Cardiomyopathy is an important and frequently life limiting manifestation of Friedreich's ataxia (FA), the most prevalent form of autosomal recessive ataxia. Left ventricular mass is used as primary outcome measure in recent intervention studies but systematic analyses of FA cardiomyopathy are sparse. To assess cardiac hypertrophy by cardiac magnetic resonance imaging (MRI) in vivo, we assessed 41 adult patients with genetically confirmed FA and 33 age- and sex-matched healthy controls by cardiac MRI and echocardiogarphy. Septal hypertrophy and left ventricular mass index were determined by two independent raters. MRI revealed hypertrophy of the interventricular septum in 40% and increased left ventricular mass index in 29% of patients. Interobserver variability was less than 5% for both measures. GAA repeat length had only minor influence on interventricular septum thickness. Left ventricular mass index decreased with age. Severity of ataxia did not correlate with cardiac disease. In echocardiography wall diameter was assessable only in 31 of 41 FA patients with 32% of patients presenting septal hypertrophy and 6% increased left ventricular mass index. We conclude that cardiac hypertrophy is present only in a minority of adult FA patients. If despite this limitation intervention studies use left ventricular mass as outcome measure, MRI is recommended as the most accurate assessment of cardiac anatomy in vivo.

Chronic thromboembolic pulmonary hypertension: pre- and postoperative assessment with breath-hold MR imaging techniques.

PURPOSE: To evaluate the potential of breath-hold magnetic resonance (MR) imaging techniques in morphologic and functional assessment of patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and after surgery. MATERIALS AND METHODS: Thirty-four patients with CTEPH were examined before and after pulmonary thromboendarterectomy (PTE). For morphologic assessment, contrast material-enhanced MR angiography was used; for assessment of hemodynamics, velocity-encoded gradient-echo sequences and cine gradient-echo sequences along the short axis of the heart were performed. Contrast-enhanced MR angiography was compared with selective digital subtraction angiography (DSA) for depiction of central thromboembolic material and visualization of the pulmonary arterial tree. Functional analysis included calculation of left and right ventricular ejection fractions and peak velocities, net forward volumes per heartbeat, and blood volume per minute in the left and right pulmonary arteries and ascending aorta. Flow measurements were compared with invasively measured mean pulmonary arterial pressure (MPAP) and pulmonary vascular resistance (PVR) measurements. Nonparametric Wilcoxon and sign tests were used for statistical analysis. RESULTS: MR angiography revealed typical findings of CTEPH (intraluminal webs and bands, vessel cutoffs, and organized central thromboemboli) in all patients. It depicted pulmonary vessels up to the segmental level in all cases. For subsegmental arteries, DSA revealed significantly more patent vessel segments than did MR angiography (733 versus 681 segments, P <.001). MR angiography revealed technical success of surgery in 33 of 34 patients. Patients had reduced right ventricular ejection fractions and pulmonary peak velocities that significantly increased after PTE (P <.001 for both). Right ventricular ejection fraction had good correlation with PVR (r = 0.6) and MPAP (r = 0.7). The postoperative decrease in MPAP correlated well with the increase in right ventricular ejection fraction (r = 0.8). Postoperatively, there was complete reduction of a preoperatively existing bronchosystemic shunt volume in 33 of 34 patients. CONCLUSION: Breath-hold MR imaging techniques enable morphologic and semiquantitative functional assessment of patients with CTEPH.

Regional heterogeneity of myocardial perfusion in healthy human myocardium: assessment with magnetic resonance perfusion imaging.

The knowledge of myocardial perfusion in healthy volunteers is fundamental for evaluation of patients with ischemic heart disease. The study was conducted to determine range, regional variability, and transmural gradient of myocardial perfusion in normal volunteers with Magnetic Resonance Perfusion Imaging (MRPI). Perfusion was assessed in 17 healthy volunteers (age: 20-47 yr, 11 males) at rest and adenosine-induced hyperemia using a 1.5 T MR scanner. Perfusion was quantified (mL/g/min) for the transmural myocardium and separately for the endo- and epimyocardium in the anterior, lateral, posterior, and septal left ventricular wall using the Fermi model for constrained deconvolution. Regional variabilities for resting, hyperemic perfusion, and perfusion reserve were 22 +/- 8%, 21 +/- 10%, and 35 +/- 18%. Mean resting, hyperemic perfusion, and perfusion reserve were 1.1 +/- 0.4 mL/g/min, 4.2 +/- 1.1 mL/g/min, and 4.1 +/- 1.4. Perfusion in the septum was higher at rest (1.3 +/- 0.3 mL/g/min vs. 1.0 +/- 0.3 mL/g/min, p < 0.05) and lower during hyperemia (3.6 +/- 0.8 mL/g/min vs. 4.5 +/- 1.1 mL/g/min, p < 0.03), resulting in a reduced perfusion reserve (PR) (3.2 +/- 0.9 vs. 4.5 +/- 1.4, p < 0.01) in the septum vs. the combined anterior, lateral, and posterior segments. Resting (0.9 +/- 0.3 mL/g/min vs. 1.4 +/- 0.5 mL/g/min, p < 0.01), but not hyperemic perfusion, was lower in the epi- vs. endomyocardium, resulting in a higher epimyocardial PR (4.8 +/- 1.8 vs. 3.5 +/- 1.4, p < 0.01) in all regions but the septum, where endo- and epimyocardial perfusion and perfusion reserve were not different. A considerable regional variability of myocardial perfusion was confirmed with MRPI. The exceptional anatomical position of the septum is reflected by the lack of a perfusion gradient, which was demonstrated in all other regions but the septum.

Echocardiographic assessment of right ventricular obstruction in hypertrophic cardiomyopathy.

Echocardiography was used to evaluate the incidence, flow dynamics and morphological characteristics of right ventricular obstruction in 91 patients with hypertrophic cardiomyopathy. Color flow mapping was used to define the sites of obstruction in the left and right ventricles. Ventricular obstruction was considered to be present if the flow velocity was less than 2.0 m/s as measured by continuous wave Doppler. The thickness of both the right ventricular free wall and anterior ventricular septum was measured to assess the magnitude and extent of hypertrophy. Right ventricular obstruction was present in 14 patients of whom 6 (43%) had left ventricular obstruction also. The right ventricular obstructions were found in the outflow tract (9 patients), mid-base septal bulge (2 patients) and apical trabecular region (3 patients). Doppler waveform was confined to systole in all patients with obstruction in the outflow tract and in one of the patients with mid-base septal bulge. Moreover, the flow wave persisted into early diastole in 4 patients, including 2 with apical trabecular obstruction. The thickness of both the right ventricular free wall and anterior ventricular septum suggested that these hypertrophied regions were the sites of right ventricular obstruction. Thus, echocardiography was useful in evaluating right ventricular obstruction in hypertrophic cardiomyopathy.

Assessment of muscular ventricular septal defect closure by transcatheter or surgical approach: a three-dimensional echocardiographic study.

AIMS: Previous classification of muscular ventricular septal defects (VSDs) visualized on two-dimensional echocardiography relied on artificial divisions of the septum. New visualization of the ventricular septum integrating the third dimension would facilitate communication between cardiologists and surgeons. The objectives of this study were (1) to assess in patients with muscular ventricular septal defects the accuracy of left ventricular three-dimensional echocardiographic reconstructions in demonstrating the position, the size and the tissue rims of the defects; (2) to compare findings by three-dimensional echocardiography with those obtained by surgical and transcatheter approaches. METHODS AND RESULTS: Twenty-six patients, aged from one month to 40 years, with muscular ventricular septal defects underwent three-dimensional echocardiographic study. From the left ventricular three-dimensional echocardiographic reconstructions, the localization, the maximal diameter and the tissue rim of the defect were analysed and compared with surgical or transcatheter findings. Optimal three-dimensional echocardiographic reconstructions were obtained in 22 patients. Nineteen had a single muscular ventricular septal defect and three had multiple muscular ventricular septal defects. The muscular ventricular septal defect localizations were the inlet septum in three, the outlet septum in three, the mid-muscular septum in 14 and the apex in eighth. In 10 patients who underwent surgical closure, the correlation between three-dimensional echocardiography and surgery for muscular ventricular septal defect maximal diameter was y=0 x 95 x +0.13 (r=0.98; P<0.001). The agreement between three-dimensional echocardiographic and intraoperative findings on muscular ventricular septal defect localization were complete. In five patients who underwent transcatheter closure, the mean difference between three-dimensional echocardiographic maximal diameter and stretched diameter was 1 x 8+/-0 x 5 mm. CONCLUSION: The three-dimensional echocardiographic left ventricular views provide a new and easily communicated visualization of various muscular ventricular septal defects. Such new imaging should contribute to the surgical and transcatheter treatments of muscular ventricular septal defects.

[Lipomatous hypertrophy of the interatrial septum: its assessment with TEE, CT and MRI]. / Ipertrofia lipomatosa del setto interatriale: valutazione con TEE, TAC e RMN.

BACKGROUND: Lipomatous atrial septal hypertrophy (LHS) is an uncommon condition characterized by the deposition of excessive adipose tissue in the atrial septum. The fossa ovalis is spared by this infiltration of fat. A variety of atrial arrhythmia has been associated with this lesion, which is more common in obese, elderly female patients. Because of the lack of specific symptoms, LHS is the outcome of casual observation during echo-Doppler or autopsy studies. METHODS: We describe the case of a 76-year-old woman who came under our observation due to stroke and atrial arrhythmia. Transesophageal echocardiography clearly revealed lipomatous atrial septal hypertrophy. RESULTS: The MRI confirmed the diagnosis, visualizing the typical "dumbbell" interatrial septum. Computed tomography made it possible to define the anatomic substance of the lesion as "fatty". CONCLUSIONS: Transesophageal echocardiography is the method of choice in the diagnosis of LHS. Other techniques such as RMI or CT-scan can be useful only in selected patients with large fatty infiltration of the atrial wall or marked hypertrophy of the interatrial septum.

[Assessment of localized hypertrophy in the basal part of the interventricular septum in the elderly].

The basal part of the interventricular septum (IVS) is known to show different hypertrophic features from those observed in the other parts of the left ventricular wall. These are considered to reflect physiological changes that occur with normal aging. However, these changes have not been carefully evaluated, and their clinical significance has not been defined. We assessed these changes echocardiographically. The subjects were patients at least 70 years of age in whom localized hypertrophy in the basal part of the IVS was seen during the whole cardiac cycle on echocardiography. The prevalence was 6.3% among 96 consecutively studied patients. All 6 patients had a history of hypertension. Echocardiographic findings were as follows: 1) the left atrium was mildly or moderately dilated, 2) there was no evidence of either dilatation or narrowing of the left ventricular cavity, 3) the left ventricular wall motion appeared normal and indices of systolic function were within normal limits in all subjects except one who had a history of myocardial infarction, 4) the angle formed by the aorta and the IVS averaged 106.7 degrees (range: 95 to 120 degrees), 5) Doppler examination showed increases in the ratio of the peak flow velocity during atrial systole to the peak flow velocity early in diastole, and 6) prolongation of the deceleration time of the flow velocity early in diastole. The last of these findings suggested left ventricular diastolic dysfunction, but peak flow velocity at the left ventricular outflow tract was normal. There was no evidence of stenosis of the left ventricular outflow tract. Localized hypertrophy in the basal part of the IVS in elderly patients could be a type of cardiac hypertrophy caused by hypertension. On echocardiography, the basal part of the IVS seemed to protrude toward the left ventricular cavity, but there was no evidence of stenosis in the left ventricular outflow tract.

Assessment of cardiac rejection by MR-imaging and MR-spectroscopy.

BACKGROUND: Detection of cardiac rejection is a major problem in cardiac transplantation. The gold standard is, and remains, endomyocardial biopsy. PURPOSE: Evaluation of MR-imaging and MR-spectroscopy for detection of cardiac rejection. METHODS: Orthotopic cardiac transplantation (HTX) was performed in 13 pigs (body weight 30 kg). All animals obtained immunosuppressive (triple) therapy for 1 week after the operation. Thereafter immunosuppression was stopped to induce cardiac rejection. MRI and MRS (1.5 Tesla General Electrics Signa) were performed pre- and post-operatively on days 10, 17, 24 and 31. The degree of rejection was determined post-operatively using endomyocardial biopsy (Texas grading score). RESULTS: (1) MR-imaging: LV function remained unchanged after HTX. LV mass increased (+42%; P < 0.05) with cardiac rejection. (2) MR-spectroscopy: a marked reduction in the ratio of phosphocreatine and adenosine triphosphate, respectively, to inorganic phosphate was observed in the rejecting hearts. (3) Histologic grading confirmed cardiac rejection after stopping immunosuppression. The Texas score was 5.7+/-0.8 at autopsy. CONCLUSIONS: MR-imaging and MR-spectroscopy allow the detection of changes associated with cardiac rejection. Both techniques are correlated with histologic rejection. However, endomyocardial biopsy remains the gold standard for reliable detection of cardiac rejection.

Assessment of atrial septal defect morphology by transthoracic three dimensional echocardiography using standard grey scale and Doppler myocardial imaging techniques: comparison with magnetic resonance imaging and intraoperative findings.

OBJECTIVE: To determine whether transthoracic three dimensional echocardiography is an accurate non-invasive technique for defining the morphology of atrial septal defects (ASD). METHODS: In 34 patients with secundum ASD, mean (SD) age 20 (17) years (14 male, 20 female), the measurements obtained from three dimensional echocardiography were compared to those obtained from magnetic resonance imaging (MRI) or surgery. Three dimensional images were constructed to simulate the ASD view as seen by a surgeon. Measured variables were: maximum and minimum vertical and horizontal ASD dimension, and distances to inferior and superior vena cava, coronary sinus, and tricuspid valve. In each patient two ultrasound techniques were used to acquire three dimensional data: standard grey scale imaging (GSI) and Doppler myocardial imaging (DMI). RESULTS: Good correlation was found in maximum ASD dimension (both horizontal and vertical) between three dimensional echocardiography and both MRI (GSI r = 0.96, SEE = 0.05 cm; DMI r = 0.97, SEE = 0.04 cm) and surgery (GSI r = 0.92, SEE = 0.06 cm; DMI r = 0.95, SEE = 0.06 cm). The systematic error was similar for both three dimensional techniques when compared to both MRI (GSI = 0.40 cm (27%); DMI = 0.38 cm (25%)) and surgery (GSI = 0.50 cm (29%); DMI = 0.37 cm (22%)). A significant difference was found in both horizontal and vertical ASD dimension changes during the cardiac cycle. This change was inversely correlated with age. These findings were consistent for both DMI and GSI technique. In children (age < or = 17 years), the feasibility of detecting structures and undertaking measurements was similar for both echo techniques. However, in adult ASD patients (age > or = 18 years) this feasibility was higher for DMI than for GSI. CONCLUSIONS: Transthoracic three dimensional imaging using both GSI and DMI accurately displayed the varying morphology, dimensions, and spatial relations of ASD. However, DMI was a more effective technique than GSI in describing ASD morphology in adults.

Noninvasive assessment of myocardial involvement in patients with systemic sclerosis: role of signal averaged electrocardiography.

OBJECTIVE: To assess the role of late ventricular potentials (LVP) in detecting early myocardial involvement in patients with systemic sclerosis (SSc). METHODS: Seventy-seven patients with SSc (68 women, 9 men, mean age 50 +/- 13 yrs) and 33 control subjects (18 women, 15 men, mean age 46 +/- 10 yrs) underwent resting electrocardiogram (ECG), 24 h Holter monitoring, complete echocardiographic and Doppler echocardiographic examination, and signal averaged ECG at high pass setting of 40 Hz, with the low pass fixed at 250 Hz. Patients with SSc underwent resting myocardial scintigraphy and radionuclide angioventriculography. RESULTS: The prevalence of LVP at 40 Hz was 20.5%. Compared to control subjects, patients with SSc showed higher prevalence of septal infarction pattern (p = 0.05), complex ventricular arrhythmias (p = 0.03), pulmonary arterial hypertension (p < 0.001), and LVP (p = 0.02). Forty-four patients with SSc (57.1%) had resting perfusion defects by myocardial scintigraphy. Fourteen of 15 patients with LVP showed perfusion defects compared to 29 of 58 without LVP (p = 0.002). Linear regression analysis showed that myocardial perfusion defect score was significantly correlated to either the filtered QRS duration, or the duration of low amplitude signals < 40 microV of the terminal QRS, or the root mean square voltage of the last 40 ms of the QRS complex. After a mean followup period of 20 months, 8 patients died. In 2 patients who died suddenly, LVP were present. CONCLUSION: Signal averaged ECG is a sensitive and inexpensive technique in the clinical assessment and followup of patients with SSc.

Dynamic magnetic resonance imaging assessment of the effect of ventricular wall curvature on regional function in hypertrophic cardiomyopathy.

We hypothesized that contraction within the ventricular septum in hypertrophic cardiomyopathy (HC) may be related to its abnormal morphology because ventricular wall stress is related to wall curvature by the Laplace equation. To test this, we studied 17 HC patients with various septal morphologies using dynamic magnetic resonance imaging techniques. Short- and long-axis curvatures of the basal septal and basal lateral walls were determined on cine images as the reciprocal of the radius of the arc best fit to the endocardial contour, which was negative if the wall was convex to the cavity of the left ventricle. Endocardial and epicardial intramyocardial circumferential shortening (% circumferential shortening) was measured in the septal and lateral walls on basal short-axis myocardial tagging images. Septal walls were flatter in the short-axis plane and more convex toward the left ventricular cavity in the long-axis plane than lateral walls, as indicated by smaller short- and long-axis curvatures. Septal percent circumferential shortening was significantly lower than the lateral percent circumferential shortening, suggesting reduced septal contraction. Endocardial and epicardial percent circumferential shortening showed significant positive correlations with wall curvatures. Multiple stepwise linear regression analysis revealed that both short- and long-axis curvatures significantly contributed to percent circumferential shortening (r=0.87 for endocardial and r=0.70 for epicardial, both p<0.0001). In conclusion, wall curvature is related to wall function in HC; the more convex toward the left ventricular cavity the wall is, the less it contracts. Reduced contraction of the septum in HC may be partly due to its abnormal curvature.

Ultrasonic myocardial tissue characterization in patients with dilated cardiomyopathy: value in noninvasive assessment of myocardial fibrosis.

Dilated cardiomyopathy (DCM) is usually diagnosed from the left ventricular functional viewpoint by the detection of dilated ventricular cavity and depressed myocardial contractility. Although histologic analysis of the myocardium no doubt provides clinically important information, it is possible only with microscopic examination of biopsy specimen of the myocardium. The objective of this particular study is to clarify the comparative values of the measures of ultrasonic tissue characterization, that is, calibrated myocardial integrated backscatter (IB) and the magnitude of cyclic variation in IB, with conventional echocardiographic parameters in assessing histologic condition of the myocardium. The magnitude of cyclic variation in IB and myocardial IB at end-diastole calibrate with the power of Doppler signals from the blood were measured in addition to conventional echocardiographic parameters in 14 patients with DCM. Calibrated myocardial IB was higher in patients with more fibrosis in the biopsy specimen of the heart tissue, whereas the magnitude of variation in IB or conventional echocardiographic parameters did not significantly correlate with a histologic estimate of myocardial fibrosis. Calibrated myocardial IB provides information about the myocardial fibrosis that cannot be assessable with conventional echocardiographic parameters. Calibrated myocardial IB and the magnitude of cyclic variation of IB are likely to reflect somewhat different acoustic properties of the myocardium.

Assessment of postinfarction ventricular septal ruptures by transesophageal Doppler echocardiography.

Transthoracic Doppler echocardiography has been shown to be a sensitive modality for the diagnosis of acute septal ruptures after myocardial infarctions. Transesophageal echocardiography has been shown to improve diagnostic accuracy and image quality in many clinical settings. We performed transesophageal Doppler echocardiography in 10 patients with acute septal ruptures. Transesophageal echocardiography provided improved visualization of the rupture morphology (6 of 10 by transthoracic versus 10 of 10 by transesophageal imaging), better detection of multiple rupture sites (2 by transthoracic, 5 by transesophageal study) and better detail of the direction of shunt flow. On the basis of the transesophageal echocardiographic appearance, we propose that septal ruptures after acute myocardial infarctions be classified as simple or complex, consistent with pathologic criteria for left ventricular septal and free wall ruptures. Transesophageal echocardiography proved a useful and safe adjunct to transthoracic imaging, overcoming the technical limitations in these critically ill patients.

[The clinico-morphological assessment of the changes in the interventricular heart septum in cardiomyopathy]. / Kliniko-morfologicheskaia otsenka izmenenii mezhzheludochkovoi peregorodki serdtsa pri kardiomiopatii.

A morphological study is presented of 120 hearts of those dying from different forms of cardiomyopathy. Postmortal coronarography, cardioventriculography, histological, histotopographic, volume-weight, and planimetric cardiometry, echocardiographic and pathomorphological methods were used. The interventricular septum showed a complicated construction pathognomonic for each form of cardiomyopathy. Echocardiographic and pathomorphological findings coincided completely in 43.3%, partially in 28.3% and were controversial in 23.3%.

[Echocardiographic assessment of mitral annular calcification in hypertrophic cardiomyopathy with asymmetric septal hypertrophy and healthy elderly cases].

The prevalence and degree of mitral annular calcification (MAC) in elderly cases of hypertrophic cardiomyopathy with asymmetric septal hypertrophy (ASHCM) were studied in comparison with healthy elderly and chronic hypertensive elderly with concentric left ventricular hypertrophy (HT + LVH) by echocardiography. In seven elderly patients with ASHCM (mean age 77.3 +/- 8.1 years) severe MAC was observed in all cases (1 male and 6 females) and systolic anterior motion of the mitral valve (SAM) was present in 3 cases, incomplete in 2 and absent in 2 cases. Of 57 healthy elderly with a mean age of 78.8 +/- 8.8 years, 8 subjects (1 male and 7 females, 14%) showed MAC. The prevalence of MAC was 0% in the sixties, 14% in the seventies, 16% in the eighties and 29% in the nineties. MAC was severe in four subjects above eighty years old. In 3 cases with HT + LVH with a mean age of 72.3 +/- 4.7 years no MAC was observed and SAM was present in one, partially observed in one and absent in one case, respectively. Serum calcium (Ca) and phosphorus (P), reported to be related with the formation of MAC, and fasting blood sugar level (FBS) were evaluated. In healthy elderly with MAC, serum Ca was 8.78 +/- 0.46 mg/dl, P 3.55 +/- 0.37 mg/dl and FBS 97.75 +/- 29.01 mg/dl, P 3.55 +/- 0.37 mg/dl and FBS 97.75 +/- 29.01 mg/dl.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic assessment of infants born to diabetic mothers.

Echocardiography was carried out in 31 neonates (group 1) born to diabetic mothers and 37 control infants (group 2) matched for weight and gestational age. The interventricular septum was significantly thicker in group 1 babies (mean (SD) 4.77 (1.4) mm) compared with those in group 2 (2.5 (0.7) mm); in eight it was more than 5 mm, but had regressed in six over a period of three months. There was no significant difference between the two groups in the left ventricular internal dimension, right ventricular outflow tract, or size of the left atrium or the aorta. The left ventricular mass was significantly greater in infants born to diabetic mothers. The left ventricular contractility (judged by the percentage of shortening of the internal dimension and the ejection fraction) was significantly greater in group 1. No evidence of left ventricular outflow obstruction was found on pulse Doppler echocardiography in group 1.