Impact of Chocolate percutaneous transluminal angioplasty balloon on vessel preparation in drug-coated balloon angioplasty for femoropopliteal lesion.

PURPOSE: To compare the impact of Chocolate and conventional balloons on vessel preparation in percutaneous transluminal angioplasty. MATERIALS AND METHODS: This single-center retrospective study included 111 endovascular therapy consecutive cases of femoropopliteal lesions using drug-coated balloon strategy with a 1:1 pre-dilation balloon diameter between February 2020 and August 2021, divided into the Chocolate percutaneous transluminal angioplasty (n = 48) and conventional (n = 63) groups. Before the availability of Chocolate balloons in Japan (December 2020), a standard semi-compliant or non-compliant balloon was used for vessel preparation. The primary endpoint was rate of severe dissection after pre-dilatation. Secondary endpoints were angiographic percent diameter stenosis, bailout stent rate, primary patency rate, and freedom from target-lesion-revascularization rate at six months. RESULTS: There was no significant difference in patient and lesion characteristics. The procedural characteristics comprised balloon length 90 ± 37 and 149 ± 95 mm (P = 0.004) and inflation pressure 11 ± 3 and 16 ± 7 atm (P < 0.001) in the Chocolate and conventional groups, respectively. Regarding primary endpoint, rates of severe dissection were 4.2% and 25% (P = 0.003); regarding secondary endpoints, percent diameter stenosis was 18 ± 15% and 20 ± 17% (P = 0.409), and the rate of bailout stenting was 2.1% and 15.9% (P = 0.016) in the Chocolate and conventional groups, respectively. The primary patency rates at six months were 89.1% and 85.2% (P = 0.670), and freedom from target-lesion-revascularization rate at six months was 100% and 92.8% (P = 0.691) in the Chocolate and conventional groups, respectively. CONCLUSION: Chocolate percutaneous transluminal angioplasty balloons reduce the rate of severe dissection while maintaining a sufficient dilatation effect during drug-coated balloon vessel preparation.

Vascular Response after Directional Coronary Atherectomy for Left Main Bifurcation Lesion.

AIMS: To evaluate the vascular response after directional coronary atherectomy (DCA) for left main (LM) bifurcation lesion. METHODS: This study was a retrospective, single-center study enrolling 31 patients who underwent stentless therapy using DCA followed by drug-coated balloon (DCB) angioplasty for LM bifurcation lesion. We compared intravascular ultrasound (IVUS) findings before and after DCA. RESULTS: After DCA, the lumen and vessel areas significantly increased, whereas the plaque area (PA) and %PA were significantly reduced. When the lesions were divided into small vessel and large vessel groups using the median value of the vessel area, the maximum balloon pressure of the DCA catheter was greater in the large vessel group. Changes in the lumen and vessel areas were also significantly greater in the large vessel group. On the other hand, the changes in PA and %PA were similar between groups. CONCLUSIONS: The main vascular responses associated with lumen enlargement after DCA were plaque reduction and vessel expansion. Contribution of vessel expansion to lumen enlargement was larger than the effect of plaque reduction in large vessel lesions.

A Case of Acquired Haemophilia A in a Patient with Chronic Myelomonocytic Leukaemia.

A 67-year-old male, with a known diagnosis of myelodysplastic syndromes with multilineage dysplasia (MDS-MLD) was admitted to our hospital with a primary complaint of subcutaneous bleeding in his left thigh. Laboratory data showed anaemia and prolongation of activated partial thromboplastin time (85.8 s, normal range 24-39 s) without thrombocytopenia. Coagulation factor VIII (FVIII) activity was less than 1% (normal range 60-150%), and a FVIII inhibitor was identified and quantified at 166 BU/mL to indicate a diagnosis of acquired haemophilia A (AHA). A recent, but sustained circulating monocytosis (>1 × 109/L) was observed, which combined with elevated numbers of neutrophil and monocytic cells in the marrow, suggested evolution of MDS-MLD to chronic myelomonocytic leukaemia (CMML), coinciding with AHA. Further analysis revealed a karyotype of 46, XY, i(14) (q10), which was the same abnormality previously identified in the patient. To treat bleeding caused by AHA, steroid and activated prothrombin complex concentrate were administered. Azacitidine (AZA) was used to treat CMML. During the clinical course, bleeding partially improved; however, subsequent acute myocardial infarction occurred on day 87. Worsening bone marrow failure was observed 4 months after the original admission, despite administration of AZA therapy, and the patient died due to bleeding from AHA. This case suggests that the evolution of MDS to CMML status can be associated with AHA conferring a bleeding tendency.

Efficacy of Complex Fractionated Atrial Electrogram-Guided Extensive Encircling Pulmonary Vein Isolation for Persistent Atrial Fibrillation.

Background: In persistent AF, the effect of adjunctive ablation in addition to PV isolation (PVI) is controversial. We considered a new modified PVI including complex fractionated atrial electrogram (CFAE) area. Methods and Results: In 57 patients with persistent AF undergoing first ablation, CFAE were mapped before ablation and CFAE-guided extensive encircling PVI (CFAE-guided EEPVI) was performed. The PVI line was designed to include the CFAE area near PV or to cross the minimum cycle length points of the CFAE area near PV (CFAE-guided EEPVI group). The outcome was compared with conventional PVI in 34 patients with persistent AF (conventional PVI group). During a mean follow-up of 365±230 days after the first procedure, AF in 13 and atrial tachycardia (AT) in 9 patients recurred in the CFAE-guided EEPVI group, while only AF in 17 patients recurred in the conventional PVI group. Eight of 9 AT in the CFAE-guided EEPVI group were successfully ablated at second procedure. After first and second procedures, the recurrence of atrial tachyarrhythmia in the CFAE-guided EEPVI group was significantly reduced compared with the conventional PVI group (8 patients, 14% vs. 11 patients, 32%, respectively; P<0.01, log-rank test). Conclusions: CFAE-guided EEPVI was more effective for persistent AF compared with conventional PVI after first and second procedures, because recurring AT as well as re-conduction of PV was successfully ablated.

The optimization of iloprost inhalation under moderate flow of oxygen therapy in severe pulmonary arterial hypertension.

Inhaled iloprost efficiently improves pulmonary hemodynamics, exercise capacity, and quality of life in patients with pulmonary arterial hypertension (PAH). However, the process of inhalation is laborious for patients suffering from resting dyspnea. We describe a 75-year-old man with idiopathic PAH and a low gas transfer. Investigations excluded significant parenchymal lung disease and airflow obstruction (presuming FEV1/FVC ration > 70%). The patient struggled to complete iloprost inhalation due to severe dyspnea and hypoxemia. As such, we optimized the methods of oxygen supply from the nasal cannula to the trans-inhalator during the inhalation. We successfully shortened the inhalation duration that effectively reduced the laborious efforts required of patients. We also recorded pulmonary hemodynamics during inhalation of nebulized iloprost. This revealed significant hemodynamic improvement immediately following inhalation but hemodynamics returned to baseline within 2 hours. We hope that this optimization will enable patients with severe PAH to undergo iloprost inhalation.

Utility of Isovolumic Contraction Peak Velocity for Evaluation of Adult Patient Status after Transcatheter Closure of Atrial Septal Defect.

BACKGROUND: Transcatheter closure is a well-established treatment for patients with atrial septal defect (ASD), but long-term outcome prognostic factors for adults have not been fully identified yet. METHODS: Forty-nine consecutive patients (age 57 ± 17 years, 59% female), who underwent transcatheter closure of ASD, were the subjects of this study. Transthoracic echocardiography was performed before and midterm after the procedure (6 ± 1 months). Isovolumic contraction peak velocity (IVV) was measured at the lateral site of the tricuspid annulus using spectral tissue Doppler imaging, and ΔIVV was determined as the absolute change at midterm follow-up. Long-term unfavorable outcome events, tracked for 19 ± 9 months, were prespecified as primary end points comprising newly developed atrial fibrillation, cerebral infarction, and heart failure. RESULTS: Symptomatic improvement, defined as an improvement in New York Heart Association functional class by one grade or more at midterm after the procedure, was observed in 24 patients (49%), and the remaining 25 (51%) were classified as not symptomatically improved. ΔIVV was significantly larger for patients with symptomatic improvement than for those without (from 11.5 ± 4.3 cm/s to 14.2 ± 3.7 cm/s vs. from 11.8 ± 4.1 cm/s to 12.5 ± 2.9 cm/s; P = 0.045). An important finding of the multivariate Cox proportional-hazards analysis was that only ΔIVV was independently associated with cardiovascular events (HR: 0.701; 95% CI 0.537-0.916; P = 0.01). Kaplan-Meier analysis showed that more patients with enhanced ΔIVV presented with favorable long-term outcome than those with diminished ΔIVV (log-rank P = 0.0001). CONCLUSIONS: IVV, which is a less volume-sensitive parameter, can be useful for comprehensive evaluation of ASD patients referred for transcatheter closure.

Impact of Right Ventricular Geometry on Mitral Regurgitation After Transcatheter Closure of Atrial Septal Defect.

Worsening of mitral regurgitation (MR) is sometimes observed after closure of an atrial septal defect (ASD). However, since the mechanism of this deterioration remains unclear, the aim of our study was to investigate the effect of left (LV) and right ventricular (RV) geometry on MR after transcatheter closure of ASD.We studied 27 patients with ASD who underwent transcatheter closure. Echocardiography was performed before and 6 ± 2 months after the procedure. In addition to conventional echocardiographic parameters, full volume data of the whole LV and RV heart was obtained with 3-dimensional echocardiography. MR was quantified by measuring the width of the vena contracta, and was graded as mild (< 3.0 mm), moderate (3.0 to 6.9 mm), or severe (≥ 7.0 mm).Ten patients (37%) were classified as having worsening MR and the remaining 17 (63%) as not having worsening MR. The two groups showed similar baseline characteristics, except for patients with worsening MR being more likely to be older (P = 0.009) and having a larger left-to-right shunt of pulmonary and systemic blood flow ratio (P = 0.02). It is noteworthy that the horizontal-to-vertical ratio of basal-RV at end-systole for patients with worsening MR was significantly smaller than that for patients without worsening MR (1.0 ± 0.2 versus 1.4 ± 0.2, P < 0.0001). Furthermore, multivariate analysis showed that the horizontal-to-vertical ratio of basal-RV at end-systole was the independent predictor of worsening MR during follow-up (P < 0.001).RV geometry may affect MR after closure of ASD. The pre-operative horizontal-to-vertical ratio of basal-RV is considered useful for predicting worsening of MR after closure of ASD.

Combined baseline strain dyssynchrony index and its acute reduction predicts mid-term left ventricular reverse remodeling and long-term outcome after cardiac resynchronization therapy.

The objective of this study was to test the hypothesis that combining assessment of baseline radial strain dyssynchrony index (SDI), that expressed both left ventricular (LV) dyssynchrony and residual myocardial contractility, and of acute changes in this index can yield more accurate prediction of mid-term responders and long-term outcome after cardiac resynchronization therapy (CRT). Radial SDI for 75 CRT patients was calculated as the average difference between peak and end-systolic speckle tracking strain from 6 segments of the mid-LV short-axis view before and 8 ± 2 days after CRT. Mid-term responder was defined as ≥ 15% decrease in LV end-systolic volume 6 ± 2 months after CRT. Long-term outcome was tracked over 5 years. Baseline radial SDI ≥ 6.5% is considered predictive of responder and favorable outcome, as previously reported. Acute reduction in radial SDI ≥ 1.5% was found to be the best predictor of mid-term responders with CRT. Furthermore, patients with acute reductions in radial SDI ≥1.5% were associated with a significantly more favorable long-term outcome after CRT than those with radial SDI <1.5% (log rank P < 0.001). An important findings were that baseline radial SDI ≥6.5% and acute reductions in radial SDI ≥ 1.5% in 42 patients were associated with the highest event-free survival rate of 92%, whereas, 21 patients corresponding values of <6.5% and <1.5% were associated with low event-free survival rate of 46% (log rank P < 0.001). Combined assessment of baseline radial SDI and its acute reduction after CRT may have clinical implications for predicting responders and thus patients' care.

Dynamic left ventricular dyssynchrony assessed on 3-dimensional speckle-tracking area strain during dobutamine stress has a negative impact on cardiovascular events in patients with idiopathic dilated cardiomyopathy.

BACKGROUND: Left ventricular (LV) dyssynchrony is not a stable phenomenon, but rather, changes dynamically. Given that the prognostic impact of dynamic dyssynchrony has not yet been elucidated, the objective was to investigate the clinical impact of dynamic dyssynchrony on patients with dilated cardiomyopathy (DCM). METHODS AND RESULTS: Seventy DCM patients with ejection fraction 32±9% were retrospectively recruited, and 3-dimensional speckle-tracking area strain was used to measure both contractile reserve and changes in dyssynchrony during dobutamine stress. The standard deviation of time-to-peak area strain was adopted as the systolic dyssynchrony index. Event-free survival was then tracked over a 13-month period. A ≥7.55% increase in systolic dyssynchrony index during dobutamine stress (Δsystolic dyssynchrony index) was the best predictor of cardiovascular events with 77% sensitivity and 88% specificity. Multivariate Cox analysis indicated that not only the absence of contractile reserve (Δglobal area strain ≤21.1%: hazard ratio [HR], 15.29; P=0.01), but the presence of dynamic dyssynchrony (ΔLV dyssynchrony ≥7.55%: HR: 7.591; P=0.003) was an independent predictor of cardiovascular events. Importantly, absence of dynamic dyssynchrony and presence of contractile reserve were associated with the most favorable outcome (98%), whereas the reverse condition was associated with the worst outcome (20%, P<0.001). CONCLUSIONS: Dynamic dyssynchrony is a potential predictor of cardiovascular events in patients with DCM, while assessment of dynamic dyssynchrony in combination with contractile reserve may further improve prognostic risk stratification.

Capability of three-dimensional speckle tracking radial strain for identification of patients with cardiac sarcoidosis.

Since cardiac sarcoidosis (CS) leads to substantial morbidity and sudden death, early diagnosis and appropriate management are crucial for patients with CS. Echocardiography used to be considered a useful diagnostic tool for patients with CS, but CS may clinically present as dilated cardiomyopathy (DCM). Our objective was to investigate whether a novel three-dimensional (3-D) speckle-tracking strain can identify patients with CS more accurately. We studied 23 CS patients with an ejection fraction (EF) of 46 ± 10 %, and 16 EF-matched patients with DCM (EF 45 ± 11 %). Global radial (GRS), circumferential (GCS) and longitudinal (GLS) strain was assessed using 3-D speckle-tracking system. GRS of patients with CS was significantly lower than that of patients with DCM (18.5 ± 8.4 vs. 28.5 ± 8.3 %, p < 0.01), but GCS and GLS in patients with CS and DCM were similar. GRS ≦ 21.1 could differentiate CS from DCM with a sensitivity of 70 %, specificity of 88 % and area under the curve of 0.79. An additional noteworthy findings was that, patients with CS showed more negative radial strain curves than did those with DCM (1.7 ± 2.3 vs. 0.1 ± 0.5, p < 0.01). In conclusion, 3-D speckle-tracking radial strain shows good potential to distinguish CS from DCM. Our observations can thus be expected to have clinical implications for management of CS patients.

Utility of combined assessment of baseline dyssynchrony and its acute improvement to predict long-term outcomes after cardiac resynchronization therapy.

Although left ventricular (LV) mechanical dyssynchrony can predict the response to cardiac resynchronization therapy (CRT), the presence of baseline LV dyssynchrony might not be the only determinant of the response to CRT. The objectives of the present study were to test the hypothesis that a combined assessment of baseline LV dyssynchrony and its acute improvement can produce a more accurate prediction of the long-term outcomes after CRT. We studied 121 patients with heart failure undergoing CRT. LV dyssynchrony was determined by measuring the anteroseptal-to-posterior wall time delay using the speckle-tracking radial strain (≥130 ms was predefined as significant) and was assessed at baseline and 7 ± 3 days after CRT. Long-term unfavorable outcome events were tracked for 5 years. Acute improvement in LV dyssynchrony of ≥33% was predictive of the long-term outcome with an area under the curve of 0.67 (p = 0.0024). Using this cutoff value, the Kaplan-Meier curve showed that patients with acute improvement in LV dyssynchrony experienced fewer cardiovascular events than those without (log-rank p = 0.0002). The event-free survival of patients whose baseline LV dyssynchrony was ≥130 ms and whose acute improvement in LV dyssynchrony was ≥33% was greater than that of the patients with baseline LV dyssynchrony of ≥130 ms but with acute improvement in LV dyssynchrony of <33% (88% vs 65%, p = 0.012). In conclusion, the combined assessment of baseline LV dyssynchrony and its acute improvement after CRT produced a more accurate prediction of long-term outcomes after CRT.

Tissue Doppler imaging-derived myocardial acceleration during isovolumetric contraction predicts pulmonary capillary wedge pressure in patients with reduced ejection fraction.

BACKGROUND: Tissue Doppler imaging-obtained isovolumetric myocardial acceleration (IVA) is load independent, reportedly predicts systolic functions, and correlates with exercise capacity in patients with reduced ejection fraction (EF). We hypothesized that IVA correlates with the pulmonary capillary wedge pressure (PCWP) in patients with reduced EF. METHODS AND RESULTS: Of 113 patients, correlations between PCWP and IVA were done for all patients, 48 patients with EF ≥55%, and 65 patients with EF <55%. Results were compared to the correlation between PCWP and other echocardiographic predictors. IVA correlated moderately with PCWP in all patients (r=0.54, P<0.0001) and was comparable to the E/A and E/e' ratios. In patients with EF ≥55%, IVA lost correlation and the only predictor was the E/e' ratio (r=0.08, 0.58, P=0.58, <0.0001). In patients with EF <55%, IVA was better than E/A and E/e' (r=0.72, 0.61, 0.51, P<0.0001), especially for atrial fibrillation or when E/e' fell between 8 and 15. Furthermore, IVA >1.60 m/s(2) can predict PCWP ≥15 mmHg, with a sensitivity of 95%, specificity of 73%, and an area under the curve of 0.867 (P<0.0001). CONCLUSIONS: IVA can predict PCWP in patients with reduced EF, and can be considered an alternative to the E/e' ratio for patients with atrial fibrillation or E/e' ratio between 8 and 15.

Multidirectional left ventricular performance detected with three-dimensional speckle-tracking strain in patients with chronic right ventricular pacing and preserved ejection fraction.

AIMS: Although right ventricular (RV) pacing has a detrimental effect on global left ventricular (LV) function even in some patients with preserved ejection fraction (EF), its mechanism remains unclear. METHODS AND RESULTS: We studied 116 subjects; 56 patients with RV pacing and preserved EF (all ≥50%), 30 EF-matched controls, and 30 heart failure (HF) patients with RV pacing and reduced EF (all ≤35%). Radial, circumferential, and longitudinal dyssynchrony and function were quantified as standard deviations of the time-to-peak strain and global peak strain from all 16 LV segments using three-dimensional (3D) speckle-tracking strain. The degree of radial and circumferential dyssynchrony and function were similar for patients with RV pacing and preserved EF and controls. However, patients with RV pacing and preserved EF showed a greater longitudinal dyssynchrony of 46 ± 14 vs. 31 ± 9 ms (P < 0.01) and lower global longitudinal strain at 25 ± 4 vs. 34 ± 7% compared with controls (P < 0.001). Furthermore, longitudinal strain at the apical level was significantly lower than that at the mid- and basal level (20 ± 4 vs. 27 ± 5 and 26 ± 5%, P < 0.001), and longitudinal dyssynchrony at the apical level was significantly larger than at the mid- and basal level (44 ± 19 vs. 36 ± 20 and 32 ± 15 ms, P < 0.05) in patients with RV pacing and preserved EF. In contrast, HF patients with RV pacing and reduced EF showed greater radial, circumferential, and longitudinal dyssynchrony, and lower global radial, circumferential, and longitudinal strain than did controls (all P < 0.001). CONCLUSION: Three-dimensional speckle-tracking strain was found to be useful for evaluating early subtle changes associated with chronic RV pacing, and may thus play a clinical role in predicting future global LV dysfunction.

Left ventricular dyssynchrony using three-dimensional speckle-tracking imaging as a determinant of torsional mechanics in patients with idiopathic dilated cardiomyopathy.

The aim of this study was to use 3-dimensional (3D) speckle-tracking echocardiography to test the hypothesis that left ventricular (LV) dyssynchrony may negatively affect LV torsional mechanics in patients with idiopathic dilated cardiomyopathy (IDC) and that LV torsion may improve after cardiac resynchronization therapy. This study included 65 subjects; 20 with IDC with ejection fractions ≤35% and wide QRS complexes (≥120 ms), 20 with IDC with ejection fractions ≤35% and narrow QRS complexes (<120 ms), and 25 controls. LV dyssynchrony index was determined as the SD of time to peak 3D speckle-tracking radial strain and regional heterogeneity of LV rotation (rotational dispersion index) as the SD of 3D speckle-tracking time to peak rotation. All rotational indexes were significantly impaired in patients with IDC, while LV torsion in patients with IDC with wide QRS complexes was significantly smaller than that in patients with IDC with narrow QRS complexes and controls. Conversely, LV dyssynchrony index (127.3 ± 24.0 ms [p <0.01 vs controls and vs patients with narrow QRS complexes] vs 88.8 ± 22.5 ms [p <0.01 versus controls] vs 30.9 ± 10.0 ms) and rotational dispersion index (115.1 ± 27.5 ms [p <0.01 vs controls and vs patients with narrow QRS complexes] vs 96.0 ± 23.4 ms [p <0.01 versus controls] vs 45.0 ± 13.7 ms) were significantly higher in patients with IDC with wide QRS complexes. Multivariate analysis showed that the LV ejection fraction (ß = 0.688, p <0.001) and rotational dispersion index (ß = -0.249, p <0.01) were independent determinants of LV torsion. Moreover, LV torsion in patients with IDC with wide QRS complexes improved after cardiac resynchronization therapy (p <0.05), along with reductions in LV dyssynchrony and rotational dispersion indexes. In conclusion, these findings obtained with a novel 3D speckle-tracking system feature a novel aspect of LV torsional mechanics and demonstrate its association with LV dyssynchrony.

Impact of left ventricular afterload on longitudinal dyssynchrony in patients with severe aortic stenosis and preserved ejection fraction.

BACKGROUND: The purpose of this study was to investigate whether patients with severe aortic stenosis (AS) and preserved ejection fraction (EF) have dyssynchrony and whether it improves after aortic valve replacement (AVR). METHODS AND RESULTS: We studied 30 consecutive patients with severe AS and preserved EF undergoing AVR. For baseline comparison, we studied 17 EF-matched patients with mild-to-moderate AS, and 18 EF-matched normal volunteers. Longitudinal dyssynchrony was determined as the standard deviation for time-to-peak speckle-tracking strain in apical 4- and 2-chamber views at the basal- and mid-levels. Radial and circumferential dyssynchrony was determined as the difference for time-to-peak strain between the anteroseptum and posterior wall from the mid-left ventricular (LV) short-axis view. Each of the myocardial functions was also evaluated by averaging each peak systolic strain. Longitudinal dyssynchrony and function in patients with severe AS was significantly worse than in the patients with mild-to-moderate AS and the controls (94 ± 46 vs. 66 ± 18 ms* and 52 ± 17 ms*, and 12.5 ± 3.7% vs. 16 ± 3.5%* and 18.7 ± 3.7%*, respectively, *P<0.05, vs. severe AS). In contrast, radial and circumferential dyssynchrony were similar for the 3 groups. Importantly, the dyssynchrony of patients with severe AS significantly improved after AVR from 94 ± 46 ms to 68 ± 22 ms (P<0.005). CONCLUSIONS: Significant longitudinal dyssynchrony was present in patients with severe AS and preserved EF, and it improved after AVR.

Mechanical left ventricular dyssynchrony in heart failure patients with narrow QRS duration as assessed by three-dimensional speckle area tracking strain.

The aim of this study was to assess whether heart failure (HF) patients with narrow QRS durations have mechanical left ventricular (LV) dyssynchrony compared to those with wide QRS durations and with normal subjects. The strain dyssynchrony index with 3-dimensional area tracking (ASDI) was used, which represents mechanical LV dyssynchrony and residual endomyocardial function from circumferential as well as longitudinal directions. The study included 79 subjects: 32 HF patients with ejection fractions ≤ 35% and narrow QRS durations (<120 ms) and 22 with ejection fractions ≤ 35% and wide QRS durations (≥ 120 ms), all candidates for cardiac resynchronization therapy, and 25 normal controls. ASDI was calculated as the average difference between peak and end-systolic area strain of LV endocardium obtained using 3-dimensional speckle-tracking imaging using 16 LV segments (≥ 3.8% predefined as significant). ASDI in HF patients with narrow QRS durations was lower than in their counterparts with wide QRS durations (2.5 ± 1.3% vs 4.2 ± 1.2%, p <0.001) but higher than in normal controls (2.5 ± 1.3% vs 0.73 ± 0.53%, p <0.001). Furthermore, the prevalence of significant ASDI in HF patients with narrow QRS durations was significantly higher than in normal controls (22% vs 0%, p = 0.01) but significantly lower than in HF patients with wide QRS durations (22% vs 59%, p <0.01). In conclusion, HF patients with narrow QRS durations have LV dyssynchrony. These observations suggest that the use of 3-dimensional speckle area tracking strain might be extended to HF patients with narrow QRS durations who are being considered as potential candidates for cardiac resynchronization therapy.

Exercise-induced left bundle branch block and subsequent mechanical left ventricular dyssynchrony--resolved with pharmacological therapy.

A 53-year-old man with depressed ejection fraction (EF) of 35% and QRS width of 88 ms at rest was admitted to our institution with a complaint of exertional chest discomfort and dyspnea. During treadmill exercise, left bundle-branch block (LBBB) with a QRS width of 152 ms occurred at a heart rate of 100 bpm. During LBBB, the patient showed significant mechanical dyssynchrony as evidenced by a two-dimensional speckle tracking radial strain of 260 ms (≥ 130 ms), defined as the time difference between anterior-septum and posterior wall. Five-month after carvedilol and candesartan administration, EF had improved to 49% and LBBB did not occur until a heart rate of 126 bpm was attained during treadmill exercise. It appears that pharmacological therapy may be useful for patients with heart failure and exercise-induced LBBB.