Altered Aortic Hemodynamics and Relative Pressure in Patients with Dilated Cardiomyopathy.

Ventricular-vascular interaction is central in the adaptation to cardiovascular disease. However, cardiomyopathy patients are predominantly monitored using cardiac biomarkers. The aim of this study is therefore to explore aortic function in dilated cardiomyopathy (DCM). Fourteen idiopathic DCM patients and 16 controls underwent cardiac magnetic resonance imaging, with aortic relative pressure derived using physics-based image processing and a virtual cohort utilized to assess the impact of cardiovascular properties on aortic behaviour. Subjects with reduced left ventricular systolic function had significantly reduced aortic relative pressure, increased aortic stiffness, and significantly delayed time-to-pressure peak duration. From the virtual cohort, aortic stiffness and aortic volumetric size were identified as key determinants of aortic relative pressure. As such, this study shows how advanced flow imaging and aortic hemodynamic evaluation could provide novel insights into the manifestation of DCM, with signs of both altered aortic structure and function derived in DCM using our proposed imaging protocol.

High seroprevalence of SARS-CoV-2 in elderly care employees in Sweden.

The COVID-19 pandemic is growing and spread in the Swedish elderly care system during April 2020. The increasing number of employees on sick-leave due to COVID-19 created severe logistic problems. Some elderly care homes therefore started to screen their personnel to secure the safety of the elderly and to avoid unnecessary quarantine of potentially immune employees. Secondary data from a screening with a COVID-19 rapid test for detection of SARS-CoV-2-specific IgM and IgG of 1,005 employees in 22 elderly care homes in Stockholm, Sweden, were analyzed. Seropositive employees were found in 21 out of the 22 care homes. In total, 23% (231/1,005) of the employees tested positive for antibodies against SARS-CoV-2, and 14.3% (144/1,005) were found positive for IgM (either alone or combined with IgG), indicating recent or present infection. Of those that tested seropositive, 46.5% did not report any clinical symptoms, indicating pre- or asymptomatic infections. Reported symptoms with the highest correlation with seropositivity were fever and loss of smell and taste. These results suggest that antibody testing of employees in elderly care homes is valuable for surveillance of disease development and a crucial screening tool in the effort to decrease the death toll in this pandemic.

Author Correction: Combined spatiotemporal and frequency-dependent shear wave elastography enables detection of vulnerable carotid plaques as validated by MRI.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Combined spatiotemporal and frequency-dependent shear wave elastography enables detection of vulnerable carotid plaques as validated by MRI.

Fatal cerebrovascular events are often caused by rupture of atherosclerotic plaques. However, rupture-prone plaques are often distinguished by their internal composition rather than degree of luminal narrowing, and conventional imaging techniques might thus fail to detect such culprit lesions. In this feasibility study, we investigate the potential of ultrasound shear wave elastography (SWE) to detect vulnerable carotid plaques, evaluating group velocity and frequency-dependent phase velocities as novel biomarkers for plaque vulnerability. In total, 27 carotid plaques from 20 patients were scanned by ultrasound SWE and magnetic resonance imaging (MRI). SWE output was quantified as group velocity and frequency-dependent phase velocities, respectively, with results correlated to intraplaque constituents identified by MRI. Overall, vulnerable lesions graded as American Heart Association (AHA) type VI showed significantly higher group and phase velocity compared to any other AHA type. A selection of correlations with intraplaque components could also be identified with group and phase velocity (lipid-rich necrotic core content, fibrous cap structure, intraplaque hemorrhage), complementing the clinical lesion classification. In conclusion, we demonstrate the ability to detect vulnerable carotid plaques using combined SWE, with group velocity and frequency-dependent phase velocity providing potentially complementary information on plaque characteristics. With such, the method represents a promising non-invasive approach for refined atherosclerotic risk prediction.

Plaque characterization using shear wave elastography-evaluation of differentiability and accuracy using a combined ex vivo and in vitro setup.

Ultrasound elastography has shown potential for improved plaque risk stratification. However, no clear consensus exists on what output metric to use, or what imaging parameters would render optimal plaque differentiation. For this reason we developed a combined ex vivo and in vitro setup, in which the ability to differentiate phantom plaques of varying stiffness was evaluated as a function of plaque geometry, push location, imaging plane, and analysed wave speed metric. The results indicate that group velocity or phase velocity ⩾1 kHz showed the highest ability to significantly differentiate plaques of different stiffness, successfully classifying a majority of the 24 analysed plaque geometries, respectively. The ability to differentiate plaques was also better in the longitudinal views than in the transverse view. Group velocity as well as phase velocities <1 kHz showed a systematic underestimation of plaque stiffness, stemming from the confined plaque geometries, however, despite this group velocity analysis showed lowest deviation in estimated plaque stiffness (0.1 m s-1 compared to 0.2 m s-1 for phase velocity analysis). SWE results were also invariant to SWE push location, albeit apparent differences in signal-to-noise ratio (SNR) and generated plaque particle velocity. With that, the study has reinforced the potential of SWE for successful plaque differentiation; however the results also highlight the importance of choosing optimal imaging settings and using an appropriate wave speed metric when attempting to differentiate different plaque groups.

Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach.

Objective: Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR. Methods: A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery. Results: Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (-1.5±0.5 vs -1.5±0.4 1/s, p=0.84) but declined following AVR (-1.7±0.3 vs -1.4±0.3 1/s, p<0.01). RV longitudinal strain reduced following AVR (-27.4±2.9% vs -18.8%±4.7%, p<0.001) and MIAVR (-26.5±5.3% vs -20.7%±4.5%, p<0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p<0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p<0.01) when comparing preoperative values with postoperative values. Conclusions: RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent.

Test of simulator-based assessment of psychomotor skill in transthoracic echo.

BACKGROUND: We developed a transthoracic echo simulator that measures technical skill in image acquisition in terms of the deviation angle between an acquired image and the anatomically correct plane for that view. We studied whether this metric reflects the clinical experience of providers. METHODS: Attendees at an echo course or at the annual meeting of the Swedish Heart Association were invited to test themselves on the simulator by scanning a mannequin and acquiring four views in 15 min: parasternal long axis (pLAX) in patient 1, apical four chamber and apical long axis (aLAX) in patient 2 and pLAX in patient 3. Their experience with echo was assessed from duration in years and procedure volume in the past year. Image acquisition error was assessed from the deviation angle. RESULTS: Of 61 participants, there were 37 physicians and 24 non-physicians (22 sonographers and two nurses). Non-physicians had higher procedure volume than physicians (850 ± 599 versus 312 ± 393 tests year-1 , P<0·001); both had similar duration of experience (9 ± 8 versus 12 ± 11 years, P = NS). The deviation angle for aLAX (55 ± 37 degrees) was higher than for any other view (P<0·00001). aLAX was the only view whose deviation angle correlated significantly with experience and only with procedure volume (r = -0·357, P = 0·008). CONCLUSIONS: These results demonstrate that deviation angle, a novel metric of technical skill in image acquisition, reflects clinical experience. Simulator-based testing provides objective and quantitative assessment that may be of value in the certification of trainees and for maintenance of certification.

Method comparison for cardiac image registration of coronary computed tomography angiography and 3-D echocardiography.

Treatment decision for coronary artery disease (CAD) is based on both morphological and functional information. Image fusion of coronary computed tomography angiography (CCTA) and three-dimensional echocardiography (3DE) could combine morphology and function into a single image to facilitate diagnosis. Three semiautomatic feature-based methods for CCTA/3DE registration were implemented and applied on CAD patients. Methods were verified and compared using landmarks manually identified by a cardiologist. All methods were found feasible for CCTA/3DE fusion.

Comparison of right ventricular function after ministernotomy and full sternotomy aortic valve replacement: a randomized study.

OBJECTIVES: Right ventricular (RV) function is impaired after cardiac surgery, possibly because of the opening of the pericardium. In minimally invasive aortic valve replacement, the pericardium is only partially incised. METHODS: A randomized trial compared RV function after ministernotomy versus full sternotomy in 40 adults undergoing aortic valve replacement at the Karolinska University Hospital. Primary outcomes were tricuspid annular plane systolic excursion, RV pulsed-wave tissue Doppler velocity, RV fractional area change and basal and mid-RV transversal diameters on postoperative Days 4 and 40. RESULTS: On postoperative Day 4, the tricuspid annular plane systolic excursion had decreased in both groups [ministernotomy: median (Q1-Q3) 25 (21-28) vs 16 (11-18), P < 0.001; sternotomy: 22.5 (22-22.5) vs 8 (7-12) mm, P < 0.001] but was higher in the ministernotomy group (P < 0.001). Pulsed-wave tissue Doppler RV velocity decreased significantly in patients who underwent sternotomy [10.5 (10-12) vs 6.5 (5-8) cm/s, P < 0.001] but did not decrease significantly in patients who underwent ministernotomy [11.5 (11-12) vs 10 (9-11) cm/s, P = 0.054]. Fractional area change was equally decreased in both groups [ministernotomy: 46 (39-51) vs 38 (34-44)%, P < 0.001; sternotomy: 45 (40-49) vs 37 (25-39.5)%, P = 0.003]. RV dimensions did not change on postoperative Day 4 in both groups. The differences between the 2 groups were similar 40 days postoperatively. CONCLUSIONS: RV long-axis function was reduced after both ministernotomy and full sternotomy aortic valve replacement, but the reduction was more pronounced in the full sternotomy group. Global RV function was equally impaired in both groups postoperatively. Clinical trial registration: http://www.clinicaltrials.gov. Unique identifier: NCT01972555.

Patient-Specific Left Ventricular Flow Simulations From Transthoracic Echocardiography: Robustness Evaluation and Validation Against Ultrasound Doppler and Magnetic Resonance Imaging.

The combination of medical imaging with computational fluid dynamics (CFD) has enabled the study of 3-D blood flow on a patient-specific level. However, with models based on gated high-resolution data, the study of transient flows, and any model implementation into routine cardiac care, is challenging. This paper presents a novel pathway for patient-specific CFD modelling of the left ventricle (LV), using 4-D transthoracic echocardiography (TTE) as input modality. To evaluate the clinical usability, two sub-studies were performed. First, a robustness evaluation was performed, where repeated models with alternating input variables were generated for six subjects and changes in simulated output quantified. Second, a validation study was carried out, where the pathway accuracy was evaluated against pulsed-wave Doppler (100 subjects), and 2-D through-plane phase-contrast magnetic resonance imaging measurements over seven intraventricular planes (6 subjects). The robustness evaluation indicated a model deviation of <12%, with highest regional and temporal deviations at apical segments and at peak systole, respectively. The validation study showed an error of <11% (velocities <10 cm/s) for all subjects, with no significant regional or temporal differences observed. With the patient-specific pathway shown to provide robust output with high accuracy, and with the pathway dependent only on 4-D TTE, the method has a high potential to be used within future clinical studies on 3-D intraventricular flow patterns. To this, future model developments in the form of e.g., anatomically accurate LV valves may further enhance the clinical value of the simulations.

Heart rate and dyssynchrony in patients with cardiac resynchronization therapy: a pilot study.

OBJECTIVES: The objective of this pilot study was to describe the impact of paced heart rate on left ventricular (LV) mechanical dyssynchrony in synchronous compared to dyssynchronous pacing modes in patients with heart failure. METHODS: Echocardiography was performed in 14 cardiac resynchronization therapy (CRT) patients at paced heart rates of 70 and 90 bpm in synchronous- (CRT), and dyssynchronous (atrial pacing + wide QRS activation) pacing modes. LV dyssynchrony was quantified using the 12-segment standard deviation model (Ts-SD) derived from Tissue Doppler Imaging. In addition, cardiac cycle intervals were assessed using cardiac state diagrams and stroke volume (SV) and filling pressure were estimated. RESULTS: Ts-SD decreased significantly with CRT at 90 bpm (25 ± 12 ms) compared to 70 bpm (35 ± 15 ms, p = .01), but remained unchanged with atrial pacing at different paced heart rates (p = .96). The paced heart rate dependent reduction in Ts-SD was consistent when Ts-SD was indexed to average Ts and systolic time interval. Cardiac state diagram derived analysis of cardiac cycle intervals demonstrated a significant reduction of the pre-ejection interval and an increase in diastole with CRT compared to atrial pacing. SV was maintained at the higher paced heart rate with CRT pacing but decreased with atrial pacing. DISCUSSION: Due to the small sample size in this pilot study general and firm conclusions are difficult to render. However, the data suggest that pacing at higher heart rates acutely reduces remaining LV dyssynchrony during CRT, but not during atrial pacing with dyssynchronous ventricular activation. These results need confirmation in a larger patient cohort.

Immediate and 12-Month Outcomes of Ischemic Versus Nonischemic Functional Mitral Regurgitation in Patients Treated With MitraClip (from the 2011 to 2012 Pilot Sentinel Registry of Percutaneous Edge-To-Edge Mitral Valve Repair of the European Society of Cardiology).

In literature, there are limited data comparing ischemic mitral regurgitation (I-MR) versus nonischemic MR regarding outcomes after percutaneous "edge-to-edge" repair. We aimed to describe the early and 12-month results after MitraClip device implantation regarding the 2 etiologies. From January 2011 to December 2012, the Transcatheter Valve Treatment Sentinel Pilot Registry included 452 patients with MR who underwent MitraClip procedure in 25 centers across Europe. The prevalent etiology was I-MR (235 patients, 52.0%). I-MR group had a significantly higher proportion of men (74.9 vs 59.9%, p <0.001) and surgical risk (logistic EuroSCORE 24.8 ± 18.2 vs 18.8 ± 16.3, p <0.001). Acute procedural success was high (96%) and similar between groups (p = 0.48). Patients with I-MR required a higher, albeit not significant, number of clips to reduce MR (p = 0.08). Inhospital mortality was low (2.0%) without significant differences between etiologies. The estimated 1-year mortality and rehospitalization rates were 15.0% and 25.8%, respectively, without significant differences between groups. Paired echocardiographic data showed a persistent improvement of MR at 1 year in both etiologies. Despite a significant overall reverse atrial remodeling after clip, there were no significant changes in left ventricular volumes. In conclusion, this large independent cohort showed that percutaneous "edge-to-edge" therapy was associated with early- and long-term improvement of MR severity and functional condition both in patients with I-MR and nonischemic MR. There were no significant differences between the 2 etiologies regarding survival and freedom from rehospitalization due to heart failure at the 1-year follow-up.

Effects of neoadjuvant chemo or chemoradiotherapy for oesophageal cancer on perioperative haemodynamics: A prospective cohort study within a randomised clinical trial.

BACKGROUND: Neoadjuvant chemoradiotherapy might improve oncological outcome compared with chemotherapy after surgery for oesophagus or gastrooesophageal junction cancer. However, radiotherapy may induce cardiovascular side-effects that could increase the risk of perioperative adverse effects and postoperative morbidity. OBJECTIVES: The aim of this study was to compare the perioperative haemodynamics in patients undergoing oesophagectomy following neoadjuvant chemotherapy or chemoradiotherapy for cancer. DESIGN: A prospective single-centre cohort study within a randomised multi-centre trial. SETTING: A Swedish University Hospital from January 2009 to March 2013. PATIENTS: A total of 31 patients (chemotherapy 17, chemoradiotherapy 14) included in a multi-centre trial randomising chemotherapy vs. chemoradiotherapy and operated at Karolinska University Hospital, Huddinge. INTERVENTIONS: Cisplatin and 5-fluorouracil, either with or without concurrent radiotherapy (40 Gy), were given prior to surgery. Cardiac function was assessed with LiDCOplus (LiDCO Ltd, London, United Kingdom), echocardiography, troponin T and N-terminal pro-B-type natriuretic peptide, before, during and after surgery. MAIN OUTCOME MEASURES: The primary outcome was the interaction effect of the neoadjuvant treatment on stroke volume index during the perioperative period. Secondary outcomes were the interaction effects of oxygen delivery index, cardiac index, echocardiography and biochemical markers. RESULTS: The groups were matched regarding comorbidities, but patients in the chemoradiotherapy group were older (66 vs. 60 years P = 0.03). Haemodynamic values changed in a similar way in both groups during the study period. The chemoradiotherapy group had a lower cardiac index before surgery (2.9 vs. 3.4 l min m, P = 0.03). On the third postoperative day, both groups displayed a hyperdynamic state compared with baseline, with no increase in troponin T, and a similar increase in N-terminal pro-B-type natriuretic peptide. CONCLUSION: Neoadjuvant chemoradiotherapy for oesophageal or gastrooesophageal junction cancer seems to induce only a marginal negative effect on cardiac function compared with neoadjuvant chemotherapy. This difference did not remain when patients' haemodynamics were challenged by surgery. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01362127.

The potential clinical value of contrast-enhanced echocardiography beyond current recommendations.

BACKGROUND: Contrast agents are used in resting echocardiography to opacify the left ventricular (LV) cavity and to improve LV endocardial border delineation in patients with suboptimal image quality. If a wider use of contrast-enhanced echocardiography would be adopted instead of the current selective approach, diagnoses such as myocardial ischemia and LV structural abnormalities could potentially be detected earlier. The aim was therefore to retrospectively investigate if contrast-enhanced echocardiography beyond the current recommendations for contrast agent usage affects assessment of wall motion abnormalities, ejection fraction (EF) and detection of LV structural abnormalities. A secondary aim was to evaluate the user dependency during image analysis. METHODS: Experienced readers (n = 4) evaluated wall motion score index (WMSI) and measured EF on greyscale and contrast-enhanced images from 192 patients without indications for contrast-enhanced echocardiography. Additionally, screening for LV structural abnormalities was performed. Repeated measurements were performed in 20 patients by the experienced as well as by inexperienced (n = 2) readers. RESULTS: Contrast analysis resulted in significantly higher WMSI compared to greyscale analysis (p < 0.003). Of the 83 patients, classified as healthy by greyscale analysis, 55% were re-classified with motion abnormalities by contrast analysis. No significant difference in EF classification (≥55%, 45-54%, 30-44%, < 30%) was observed. LV structural abnormalities, such as increased trabeculation (n = 21), apical aneurysm (n = 4), hypertrophy (n = 1) and thrombus (n = 1) were detected during contrast analysis. Intra- and interobserver variability for experienced readers as well as the variability between inexperienced and experienced readers decreased for WMSI and EF after contrast analysis. CONCLUSIONS: Contrast-enhanced echocardiography beyond current recommendations for contrast agent usage increased the number of detected wall motion and LV structural abnormalities. Moreover, contrast-enhanced echocardiography increased reproducibility for assessment of WMSI and EF.

Effect of advanced chronic kidney disease in clinical and echocardiographic outcomes of patients treated with MitraClip system.

BACKGROUND: Data regarding the influence of different levels of renal dysfunction on clinical and echocardiographic results of MitraClip therapy are scarce. We aimed to evaluate the impact of baseline advance renal failure in the outcomes of a cohort of patients treated with MitraClip. METHODS AND RESULTS: We analyzed data from a multicenter registry of 173 patients treated with MitraClip between 2009 and 2012. Patients were classified as advanced chronic kidney disease (CKD, creatinine clearance [CrCl] <30 ml/min, group 1, n=20), moderate CKD (CrCl 30-60 ml/min, group 2, n=78) and normal renal function (CrCl >60 ml/min, group 3, n=75). Twenty patients (11.5%) presented advanced CKD. Procedural success was equal in the 3 groups (95.0% group 1, 100% in group 2 and 96.0% in group 3, p=0.180). Post-procedural MR and NYHA class at 1 month (MR ≥ 3+5.0% vs. 0% vs. 4.0% p=0.190 and NYHA>II 40.0% vs. 21.0% vs. 18.3%, p=0.101) and 6 months (MR ≥ 3+0% vs. 13.0% vs. 2.7%, p=0.330; and NYHA class>II 54.5% vs. 26.9% vs. 25.6%, p=0.298) did not differ between groups. However, patients in group 1 experienced higher frequency of the composite end-point of mortality or readmission at 16.2 ± 11.1 months of follow-up (HR 4.8, CI 95% 1.1-21.3). CONCLUSION: Advanced CKD is linked to an excess of cardiac adverse events. This should be judiciously taken into account when selecting patients for MitraClip.

Effect of gender on results of percutaneous edge-to-edge mitral valve repair with MitraClip system.

Knowledge regarding gender-specific results of percutaneous edge-to-edge mitral valve repair is scarce. The aim of this study was to investigate gender differences in outcomes in a cohort of patients treated with MitraClip implantation. A multicenter registry of 173 patients treated with MitraClip prostheses from 2009 to 2012 at 3 experienced centers was performed. One hundred nine patients (63%) were men. Men were younger (mean age 73 ± 10 vs 79 ± 9 years, p = 0.001) and had a higher prevalence of previous coronary bypass graft surgery (34% vs 13%, p = 0.002), previous myocardial infarction (46% vs 20%, p = 0.001), and diabetes mellitus (26% vs 11%, p = 0.020). There were no differences regarding New York Heart Association (NYHA) functional class before the intervention (NYHA class III or IV in 95% of men vs 97% of women, p = 0.472) or the cause of mitral regurgitation (MR) (functional in 58% of men vs 48% of women, p = 0.233). Men exhibited significantly larger ventricles (mean indexed left ventricular end-systolic diameter 2.4 ± 0.8 vs 2.0 ± 1.6 cm/m(2), p = 0.002, and mean indexed left ventricular end-diastolic volume 92.7 ± 46.1 vs 59.9 ± 24.6 ml/m(2), p <0.001). At 1 month, there were no differences between groups in the reduction of MR or NYHA functional class (MR grade ≤2+ in 98.2% of men vs 96.8% of women, p = 0.586, and NYHA class ≤II in 78.3% of men vs 77% of women, p = 0.851). At 6 months, results were maintained (MR grade ≤2+ in 89.5% of men vs 96.8% of women, p = 0.414, and NYHA class ≤II in 73.1% of men vs 74.2% of women, p = 0.912). After a mean follow-up period of 16.1 ± 11.1 months, no difference was found between groups in the incidence of death or admission for heart failure (log-rank p = 0.798). In conclusion, MitraClip implantation seems to be an equally safe and effective treatment of MR in men and women.

The impact of arterial load on left ventricular performance: an invasive haemodynamic study in severe mitral stenosis.

KEY POINTS: A hallmark of mitral stenosis (MS) is the markedly altered left ventricular (LV) loading. As most of the methods used to determine LV performance in MS patients are influenced by loading conditions, previous studies have shown conflicting results. The present study calculated LV elastance, which is a robust method to quantify LV function. We demonstrate that LV loading in MS patients is elevated but normalizes after valve repair and might be a result of reflex pathways. Additionally, we show that the LV in MS is less compliant than normal due to a combination of right ventricular loading and the valvular disease itself. Immediately after valve dilatation the increase in blood inflow into the LV results in even greater LV stiffness. Our findings enrich our understanding of heart function in MS patients and provide a simple reproducible way of assessing LV performance in MS. ABSTRACT: Left ventricular (LV) function in rheumatic mitral stenosis (MS) remains an issue of controversy, due to load dependency of previously employed assessment methods. We investigated LV performance in MS employing relatively load-independent indices robust to the altered loading state. We studied 106 subjects (32 ± 8 years, 72% female) with severe MS (0.8 ± 0.2 cm(2) ) and 40 age-matched controls. MS subjects underwent simultaneous bi-ventricular catheterization and transthoracic echocardiography (TTE) before and immediately after percutaneous transvenous mitral commisurotomy (PTMC). Sphygmomanometric brachial artery pressures and TTE recordings were simultaneously acquired in controls. Single-beat LV elastance (Ees ) was employed for LV contractility measurements. Effective arterial elastance (Ea ) and LV diastolic stiffness were measured. MS patients demonstrated significantly elevated afterload (Ea : 3.0 ± 1.3 vs. 1.5 ± 0.3 mmHg ml(-1) ; P < 0.001) and LV contractility (Ees : 4.1 ± 1.6 vs. 2.4 ± 0.5 mmHg ml(-1) ; P < 0.001) as compared to controls, with higher Ea in subjects with smaller mitral valve area (≤ 0.8 cm(2) ) and pronounced subvalvular fusion. Stroke volume (49 ± 16 to 57 ± 17 ml; P < 0.001) and indexed LV end-diastolic volume (LVEDVindex : 57 ± 16 to 64 ± 16 ml m(-2) ; P < 0.001) increased following PTMC while Ees and Ea returned to more normal levels. Elevated LV stiffness was demonstrated at baseline and increased further following PTMC. Our findings provide evidence of elevated LV contractility, increased arterial load and increased diastolic stiffness in severe MS. Following PTMC, both LV contractility and afterload tend to normalize.

Effects on heart function of neoadjuvant chemotherapy and chemoradiotherapy in patients with cancer in the esophagus or gastroesophageal junction - a prospective cohort pilot study within a randomized clinical trial.

BACKGROUND: Neoadjuvant therapy for cancer of the esophagus or gastroesophageal (GE)-junction is well established. The pros and cons of chemoradiotherapy and chemotherapy are debated. Chemoradiotherapy might impair cardiac function eliciting postoperative morbidity. The aim of this pilot study was to describe acute changes in left ventricular function following chemoradiotherapy or chemotherapy. METHODS: Patients with esophageal and (GE)-junction cancer enrolled at our center into a multicenter trial comparing neoadjuvant chemoradiotherapy and chemotherapy were eligible. Patients were randomized to receive cisplatin and 5-fluorouracil with or without the addition of 40 Gy radiotherapy prior to surgery. Left ventricular function was evaluated using echocardiography and plasma N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) before and after neoadjuvant treatment. The primary outcome measure was left ventricular global strain (GS). Clinical effects were assessed using repeated exercise tests. Linear mixed models were used to analyze the effects of treatment group, and the interaction between groups. RESULTS: 40 patients participated (chemoradiotherapy, n=17; chemotherapy, n=23). In the chemoradiotherapy group there was no change in left ventricular global strain but mitral annular plane systolic excursion (MAPSE) of the ventricular septum, early diastolic filling velocity (E-velocity), and the ratio of early to late ventricular filling velocities (E/A ratio) decreased significantly (p=0.02, p=0.01, and p=0.03, respectively). No changes were observed in the chemotherapy group. There was a trend towards an interaction effect for MAPSE sept and E (p=0.09 and p=0.09). NT-proBNP increased following chemoradiotherapy (p=0.05) but not after chemotherapy (p>0.99), and there was a trend towards an interaction effect (p=0.07). Working capacity decreased following neoadjuvant treatment (chemoradiotherapy p = 0.001, chemotherapy p=0.03) and was more pronounced after chemoradiotherapy with a trend towards an interaction effect (p=0.10). CONCLUSIONS: Neoadjuvant chemoradiotherapy but not chemotherapy before surgery for cancer of the esophagus or GE-junction seems to induce an acute negative effect on both systolic and diastolic left ventricular function. Future studies on neoadjuvant treatment for esophageal cancer are suggested to add measurements of cardiac function. TRIAL REGISTRATION: Clinical Trials.gov NCT01362127 .

Combination of contrast-enhanced wall motion analysis and myocardial deformation imaging during dobutamine stress echocardiography.

BACKGROUND: The combination of deformation analysis with conventional wall motion scoring (WMS) has been shown to increase the diagnostic sensitivity of dobutamine stress echocardiography (DSE). The feasibility and diagnostic power of WMS is largely improved by contrast agents; however, they are not used in combination with deformation analysis, as contrast agents are generally considered to render strain measurement unfeasible. AIMS: To assess the feasibility of tissue velocity (TVI)- and 2D speckle tracking (ST)-based strain analysis during contrast-enhanced DSE; and to show whether there is an incremental value in combining deformation analysis with contrast-enhanced WMS. METHODS: DS echocardiograms containing native, tissue Doppler, and contrast-enhanced loops of 60 patients were analysed retrospectively. The feasibility of WMS, TVI-, and ST-strain measurement was determined in 40 patients according to pre-defined criteria. The diagnostic ability of a combined protocol integrating data from contrast-WMS and TVI-strain measurement was then compared with contrast-WMS alone in all 60 patients, using coronary angiograms as a gold standard. RESULTS: Both TVI- and ST-based strain analysis were feasible during contrast-DSE (feasibility at peak stress: 87 and 75%). At the patient level, the diagnostic accuracy of the combined method did not prove superior to contrast-WMS (82 vs. 78%); a trend towards improved sensitivity and specificity for detecting coronary artery disease in the right coronary artery circulation (sensitivity: 85 vs. 77%, P = NS; specificity: 96 vs. 94%) was, however, observed. CONCLUSION: Both TVI- and ST-based myocardial deformation analysis are feasible during contrast-enhanced DSE, however, our results fail to demonstrate a clear diagnostic benefit of additional strain analysis over expert WMS alone.

The causality quandary in a patient with stroke, Takotsubo syndrome and severe coronary artery disease.

Takotsubo-like left ventricular dysfunction syndrome (TLVDS) and acute coronary syndrome have almost always the same clinical presentation and ECG findings. Both diseases may become a potential cardioembolic source to the cerebrovascular system. Stroke has been linked to TLVDS either as the trigger or as a complication. We report on a 67-year-old female patient who presented with an acute ischemic stroke confirmed by computed tomographic scan of the brain. She also had electrocardiographic features and laboratory findings suggestive of both acute myocardial infarction (AMI) and TLVDS. Coronary angiography revealed severe coronary artery stenoses but the coronary lesions did not have any of the features suggestive of an acute pathology. Echocardiography and left ventriculography showed a striking apical ballooning of the left ventricle, which resolved completely within 1 week, a clinical picture and course typical for TLVDS. There were no signs of left ventricular thrombus. A few burning questions arose from this case: what was the acute cardiac disease - TLVDS or AMI? Which disease came first - the stroke or the acute cardiac illness? An intricate cause-effect relationship is discussed; and finally, does an obstructive coronary artery disease rule out TLVDS?