Head-to-head comparison of left ventricular function assessment with 64-row computed tomography, biplane left cineventriculography, and both 2- and 3-dimensional transthoracic echocardiography: comparison with magnetic resonance imaging as the reference standard.

OBJECTIVES: This study was designed to compare the accuracy of 64-row contrast computed tomography (CT), invasive cineventriculography (CVG), 2-dimensional echocardiography (2D Echo), and 3-dimensional echocardiography (3D Echo) for left ventricular (LV) function assessment with magnetic resonance imaging (MRI). BACKGROUND: Cardiac function is an important determinant of therapy and is a major predictor for long-term survival in patients with coronary artery disease. A number of methods are available for assessment of function, but there are limited data on the comparison between these multiple methods in the same patients. METHODS: A total of 36 patients prospectively underwent 64-row CT, CVG, 2D Echo, 3D Echo, and MRI (as the reference standard). Global and regional LV wall motion and ejection fraction (EF) were measured. In addition, assessment of interobserver agreement was performed. RESULTS: For the global EF, Bland-Altman analysis showed significantly higher agreement between CT and MRI (p < 0.005, 95% confidence interval: ±14.2%) than for CVG (±20.2%) and 3D Echo (±21.2%). Only CVG (59.5 ± 13.9%, p = 0.03) significantly overestimated EF in comparison with MRI (55.6 ± 16.0%). CT showed significantly better agreement for stroke volume than 2D Echo, 3D Echo, and CVG. In comparison with MRI, CVG-but not CT-significantly overestimated the end-diastolic volume (p < 0.001), whereas 2D Echo and 3D Echo significantly underestimated the EDV (p < 0.05). There was no significant difference in diagnostic accuracy (range: 76% to 88%) for regional LV function assessment between the 4 methods when compared with MRI. Interobserver agreement for EF showed high intraclass correlation for 64-row CT, MRI, 2D Echo, and 3D Echo (intraclass correlation coefficient >0.8), whereas agreement was lower for CVG (intraclass correlation coefficient = 0.58). CONCLUSIONS: 64-row CT may be more accurate than CVG, 2D Echo, and 3D Echo in comparison with MRI as the reference standard for assessment of global LV function.

Early right ventricular systolic dysfunction in patients with systemic sclerosis without pulmonary hypertension: a Doppler Tissue and Speckle Tracking echocardiography study.

BACKGROUND: Isovolumetric acceleration (IVA) is a novel tissue Doppler parameter for the assessment of systolic function. The aim of this study was to evaluate IVA as an early parameter for the detection of right ventricular (RV) systolic dysfunction in patients with systemic sclerosis (SSc) without pulmonary hypertension. METHODS: 22 patients and 22 gender- and age-matched healthy subjects underwent standard echocardiography with tissue Doppler imaging (TDI) and speckle tracking strain to assess RV function. RESULTS: Tricuspid annular plane systolic excursion (TAPSE) (23.2 +/- 4.1 mm vs. 26.5 +/- 2.9 mm, p < 0.006), peak myocardial systolic velocity (Sm) (11.6 +/- 2.3 cm/s vs. 13.9 +/- 2.7 cm/s, p = 0.005), isovolumetric contraction velocity (IVV) (10.3 +/- 3 cm/s vs. 14.8 +/- 3 cm/s, p < 0.001) and IVA (2.3 +/- 0.4 m/s2 vs. 4.1 +/- 0.8 m/s2, p < 0.001) were significant lower in the patient group. IVA was the best parameter to predict early systolic dysfunction with an area under the curve of 0.988. CONCLUSION: IVA is a useful tool with high-predictive power to detect early right ventricular systolic impairment in patients with SSc and without pulmonary hypertension.

Is antiarrhythmia device implantation safe under dual antiplatelet therapy?

BACKGROUND: Device implantations in patients on dual antiplatelet-therapy (DA-therapy) continue to rise. The aim of our study was to compile and analyze data on complications of antiarrhythmia device implantation under DA-therapy. METHODS: We prospectively collected data on all device implantations in our department from January 2008 until February 2009. The control group was comprised of patients on acetylsalicylic acid alone or no antiplatelet medication at all (318 subjects). The DA-therapy group consisted of 109 patients of whom 71 were analyzed retrospectively (implantations from 2002 to 2007). RESULTS: Procedure times were significantly longer in DA-therapy patients receiving a pacemaker for the first time. In contrast, procedure times did not differ significantly between the two study groups for implantable cardioverter defibrillator (ICD) implantations and for pacemaker replacements. Fluid losses via drainage systems and drainage times were significantly increased in the DA-therapy group as compared with the control group after pacemaker but not after ICD implantations. Importantly, there were no significant differences in complication rates, particularly the hematoma rate, between the DA-therapy and the control group. CONCLUSIONS: When drainage systems are used, antiarrhythmia device implantation is safe and can be performed without significantly increased risk of clinically relevant hematoma in patients on continued DA-therapy. (PACE 2010; 394-399).

Implementation of seven echocardiographic parameters of myocardial asynchrony to improve the long-term response rate of cardiac resynchronization therapy (CRT).

BACKGROUND: Cardiac resynchronization Therapy (CRT) is an effective therapy for chronic heart failure with beneficial hemodynamic effects leading to a reduction of morbidity and mortality. The responder rates, however, are low. There are various and contentious echocardiographic parameters of myocardial asynchrony. Patient selection by echocardiographic assessment of asynchrony is thought to improve responder rates. METHODS: In this small single-center pilot-study, seven established parameters of myocardial asynchrony were used to select patients for CRT: (1) interventricular electromechanical delay (IMD, cut-off > or = 40 ms), (2) Septal-to-posterior wall motion delay (SPWMD, > or = 130 ms), (3) maximal difference in time-to-peak velocities between any two of twelve LV segments (Ts-12 > or = 104 ms), (4) standard deviation of time to peak myocardial velocities (Ts-12-SD, > or = 34.4 ms), (5) difference between the septal and basal time-to-peak velocity (TDId, > or = 60 ms), (6) left ventricular electromechanical delay (LVEMD, > 140 ms) and (7) delayed longitudinal contraction (DLC, > 2 segments).16 chronic heart failure patients (NYHA III-IV, LVEF < 0.35, QRS > or = 120 ms) at least two out of seven parameters of myocardial asynchrony received cardiac resynchronization therapy (CRT-ICD). Follow-up echo examination was after 6 months. The control group was a historic group of CRT patients (n = 38) who had not been screened for echocardiographic signs of myocardial asynchrony prior to device implantation. RESULTS: Based on reverse remodeling (relative reduction of LVESV > 15%, relative increase of LVEF > 25%), the responder rate to CRT was 81.2% in patients selected for CRT according to our protocol as compared to 47.4% in the control group (p = 0.04). At baseline, there were on average 4.1 +/- 1.6 positive parameters of asynchrony (follow-up: 3.7 [+/- 1.6] parameters positive, p = 0.52). Only the LVEMD decreased significantly after CRT (p = 0.027). The remaining parameters showed a non-significant trend towards reduction of myocardial asynchrony. CONCLUSION: The implementation of different markers of asynchrony in the selection process for CRT improves the hemodynamic response rate to CRT.

Circumferential 2D-strain imaging for the prediction of long term response to cardiac resynchronization therapy.

BACKGROUND: Cardiac Resynchronization Therapy (CRT) leads to hemodynamic and clinical improvement in heart failure patients. The established methods to evaluate myocardial asynchrony analyze longitudinal and radial myocardial function. This study evaluates the new method of circumferential 2D-strain imaging in the prediction of the long-term response to CRT. METHODS AND RESULTS: 38 heart failure patients (NYHA II-III, QRS > 120 ms, LVEF < 0.35) received CRT and echocardiographic evaluation with a mean follow-up of 9.4 months. 18 (47.4%) of the patients were hemodynamic responders to long-term CRT. In the responder group, the maximum delay in the circumferential 2D-strain in the basal segments decreased (246 +/- 94 to 123 +/- 92 ms, p < 0.001). In the non-responder group there was no significant change (pre CRT: 195 +/- 86, post CRT 135 +/- 136 ms, p = 0.84). This was paralleled by a reduction of the maximum delay in the radial and longitudinal 2D strain in the basal segments. In ROC analysis, the baseline delay of circumferential 2D strain (AUC 0.66 (+/- 0.14)) does not predict a long-term response to CRT (p = 0.37). CONCLUSION: There is a significant decrease in the circumferential 2D-strain derived delays after CRT, indicating that resynchronization induces improvement in all three dimensions of myocardial contraction. However, the resulting predictive values of 2D strain delays are not superior to longitudinal and radial 2D-strain or TDI delays.

Interventricular septum hematoma during cineventriculography.

BACKGROUND: Intraseptal hematoma and subsequent myocardial infarction due to accidental contrast agent deposition complicating diagnostic cineventriculography is a previously undescribed complication of angiography. CASE PRESENTATION: A 61 year old man was admitted at intensive care unit because of unstable angina pectoris 1 hour after coronary angiography. Transthoracic contrast echocardiography showed a non-perfused area in the middle of interventricular septum with an increase of thickening up to 26 mm. Review of cineventriculography revealed contrast enhancement in the interventricular septum after contrast medium injection and a dislocation of the pigtail catheter tip. Follow up by echocardiography and MRI showed, that intramural hematoma has resolved after 6 weeks. After 8 weeks successful stent implantation in LAD was performed and after 6 month the patient had a normal LV-function without ischemic signs or septal thickening demonstrated by stressechocardiography. CONCLUSION: A safe and mobile position of the pigtail catheter during ventriculography in the middle of the LV cavity should be ensured to avoid this potentially life-threatening complication. For assessment and absolute measurement of intramural hematoma contrast-enhanced echocardiography is more feasible than MRI and makes interchangeable results.

Noninvasive monitoring of myocardial function after surgical and cytostatic therapy in a peritoneal metastasis rat model: assessment with tissue Doppler and non-Doppler 2D strain echocardiography.

OBJECTIVE: We sought to evaluate the impact of different antineoplastic treatment methods on systolic and diastolic myocardial function, and the feasibility estimation of regional deformation parameters with non-Doppler 2D echocardiography in rats. BACKGROUND: The optimal method for quantitative assessment of global and regional ventricular function in rats and the impact of complex oncological multimodal therapy on left- and right-ventricular function in rats remains unclear. METHODS: 90 rats after subperitoneal implantation of syngenetic colonic carcinoma cells underwent different onclogical treatment methods and were diveded into one control group and five treatment groups (with 15 rats in each group): group 1 = control group (without operation and without medication), group 2 = operation group without additional therapy, group 3 = combination of operation and photodynamic therapy, group 4 = operation in combination with hyperthermic intraoperative peritoneal chemotherapy with mitomycine, and group 5 = operation in combination with hyperthermic intraoperative peritoneal chemotherapy with gemcitabine, group 6 = operation in combination with taurolidin i.p. instillation. Echocardiographic examination with estimation of wall thickness, diameters, left ventricular fractional shortening, ejection fraction, early and late diastolic transmitral and myocardial velocities, radial and circumferential strain were performed 3-4 days after therapy. RESULTS: There was an increase of LVEDD and LVESD in all groups after the follow-up period (P = 0.0037). Other LV dimensions, FS and EF as well as diastolic mitral filling parameters measured by echocardiography were not significantly affected by the different treatments. Values for right ventricular dimensions and function remained unchanged, whereas circumferential 2D strain of the inferior wall was slightly, but significantly reduced under the treatment (-18.1 +/- 2.5 before and -16.2 +/- 2.9 % after treatment; P = 0.001) without differences between the single treatment groups. CONCLUSION: It is feasible to assess dimensions, global function, and regional contractility with echocardiography in rats under different oncological therapy. The deformation was decreased under overall treatment without influence by one specific therapy. Therefore, deformation assessment with non-Doppler 2D strain echocardiography is more sensitive than conventional echocardiography for assessing myocardial dysfunction in rats under oncological treatment.

Haemodynamic effects of intravenous quinaprilat in comparison to sodium nitroprusside in patients with chronic heart failure.

We compared the haemodynamic effects of intravenous boluses of the ACE inhibitor quinaprilat with an intravenous infusion of sodium nitroprusside in 23 patients with chronic heart failure (NYHA Class III or IV). At the highest drug doses, sodium nitroprusside significantly increased stroke volume index (+6.63 ml/m(2), p=0.045), whereas quinaprilat induced only a minor increase (+1.79 ml/m(2), n.s.).

Hemodynamic effects of alpha1-adrenoceptor antagonist, doxazosin, in patients with chronic congestive heart failure.

PURPOSE: Non-selective alpha-adrenoceptor antagonists have not demonstrated significant beneficial effects in chronic heart failure. Previous studies with the selective alpha1-adrenoceptor antagonist, doxazosin, led to conflicting results. We assessed the hypothesis that treatment with doxazosin adjuvant to standard oral therapy results in significant increase in cardiac index in patients with chronic heart failure. METHODS: A double-blind, randomized study was conducted on 30 patients with chronic congestive heart failure (NYHA III-IV), with cardiac index<2.5 l/minxm, and/or with pulmonary capillary wedge pressure>16 mm Hg. Of the 30 patients, 15 were treated with doxazosin and 15 with placebo, both adjuvant to stable oral therapy, which included a minimum of an ACE inhibitor and a diuretic. Hemodynamic measurements were performed on days 1 and 2, and after 12 weeks on study medication. On day 1, patients were treated with 4 mg doxazosin or placebo. On day 2 and throughout the following 12 weeks, the patients were treated with 4 mg or 8 mg doxazosin/d (the latter, if 4 mg/d did not induce an increase >0.75 l/minxm in cardiac index), or with placebo. RESULTS: Six patients were treated with 4 mg doxazosin/d (group A), 9 patients with 8 mg doxazosin/d (group B), and 15 with placebo. Baseline values for the cardiac index on day 1, day 2, and after 12 weeks failed to disclose significant differences between patient groups and between the days of study. On day 1, the increase in cardiac index compared with baseline was significantly higher in group A than in the placebo group (P=0.004) and group B (P=0.001). On day 2, the increase in cardiac index compared with baseline on day 1 was significantly higher in group A than in group B (P=0.003) (with reference to alpha/3=0.0167 according to Bonferroni). This was no longer observed after 12 weeks. In the placebo group, following significant changes occurred in baseline values, heart rate was lower (P=0.023) and stroke volume index was higher after 12 weeks in comparison to day 1 (P=0.032). CONCLUSIONS: In conclusion, oral application of doxazosin supplementary to standard oral medication did not induce sustained hemodynamic benefit. Significant acute increase in cardiac index was observed in a minority (40%) of patients, whereas favorable changes in baseline hemodynamic parameters after 12 weeks occurred in the placebo group.

Long-term results after partial left ventriculectomy.

BACKGROUND: Long-term clinical, echocardiographic and hemodynamic effects after partial left ventriculectomy (PLV) and predictors of outcome have been determined. METHODS: Between January 1995 and July 1999, PLV was performed in 39 patients. In 15 patients the etiology of heart failure was idiopathic dilated cardiomyopathy (DCMP), 19 patients had ischemic cardiomyopathy (ICMP) and five patients had valvular cardiomyopathy. Concomitant procedures included coronary artery bypass grafting in 16 patients, mitral valve repair in 33 patients and aortic valve replacement in five patients. All patients belonged in New York Heart Association (NYHA) functional class III or IV. Mean follow-up was 663+/-514 days. Clinical, echocardiographic and hemodynamic assessments and metabolic stress testing were performed preoperatively, within 30 days postoperatively and 6, 12 and 24 months after the operation. RESULTS: Actuarial survival was 64% after 1 year, 55% after 2 years and 44% 3 years after the operation. In patients with ICMP as well as in patients with DCMP actuarial 1 year survival was 60%. At 2-year follow-up NYHA functional class was improved significantly (P<0.05), but LV ejection fraction, LV end-diastolic diameter, cardiac index and peak oxygen consumption did not differ significantly from preoperative values. Analysis of factors influencing postoperative outcome indicated that decreased left ventricular wall thickness and a failure to increase the stroke volume index as a response to preoperative dobutamine administration were associated with postoperative mortality. CONCLUSIONS: PLV is associated with considerable postoperative mortality and lacking long-term improvement of cardiac performance.

Apical tissue tracking echocardiography for characterization of regional left ventricular function: comparison with magnetic resonance imaging in patients after myocardial infarction.

OBJECTIVE: The purpose of this study was to characterize the normal pattern of apical tracking and to investigate whether tissue tracking imaging is more useful for evaluation of regional left-ventricular function than noncontrast harmonic echocardiography in patients after myocardial infarction. BACKGROUND: Left ventricular longitudinal shortening plays an important role in cardiac contraction, and can be evaluated online by a new Doppler tissue imaging method. METHODS: We included 40 healthy participants and 40 patients after myocardial infarction. They underwent tissue tracking imaging and noncontrast harmonic imaging by an experienced and an inexperienced observer. Diagnostic accuracy of semiquantitative evaluation of left ventricular function was compared using magnetic resonance imaging as reference method. RESULTS: Velocity-time integrals decreased from basal to apical segments in healthy participants. Tissue tracking imaging has a higher diagnostic sensitivity than noncontrast imaging for the diagnosis of regional wall-motion abnormalities (expert, 78% vs 97%, P <.01; beginner, 63% vs 91%, P <.001), whereas specificity remained unchanged (expert, 99% vs 97%, not significant; beginner, 91% vs 92%, not significant). CONCLUSIONS: Tissue tracking imaging is feasible and evaluates regional systolic myocardial function quantitatively with high diagnostic accuracy compared with magnetic resonance imaging in patients after myocardial infarction, and is more accurate than noncontrast harmonic echocardiography.

Does contrast echocardiography with Optison induce myocardial necrosis in humans?

Myocardial contrast echocardiography is a promising diagnostic tool for detecting microvascular integrity. Multiple experimental laboratories have shown that diagnostic combined microbubble contrast and ultrasound exposure can cause vessel rupture and myocardial damage in laboratory animals. This study investigated the phenomenon of contrast ultrasonically induced myocardial damage in human beings. Twenty consecutive patients (mean age of 60 +/- 12 years, 14 men) underwent contrast echocardiography with intravenous Optison using a mechanical index of at least 1.4 (Vivid Five System (GE, Vingmed Ultrasound, Horton, Norway). Creatine kinase (CK), creatine kinase-isoenzyme MB (CK-MB); CK-MB mass, myoglobin, and troponin I were measured before and 2, 4, 8, and 24 hours after contrast echocardiography. There was no significant correlation concerning the response to contrast echocardiography for any pair of parameters at any time after the intervention. Only in 2 patients were there higher values for troponin I before and after contrast echocardiography without an increase of myoglobin, CK, or CK-MB mass and activity. These values were therefore interpreted as false positive because of renal failure and severe heart failure. The use of contrast echocardiography is without demonstrated risk of myocardial damage even in patients with different cardiologic entities.

Myocardial contrast echocardiography for predicting functional recovery after acute myocardial infarction.

UNLABELLED: Myocardial contrast echocardiography (MCE) is a promising diagnostic tool for detecting microvascular integrity. The aim of the study was to investigate the comparative specificity and sensitivity of intravenous MCE, technetium-99m Sestamibi single-photon emission computed tomography (SPECT) and dipyridamole-dobutamine (DIDO) stress echocardiography for predicting functional recovery after coronary revascularization in patients with acute myocardial infarction (AMI). METHODS: In a prospective, observational study, 17 consecutive patients short after AMI who received successful treatment with primary percutaneous coronary angioplasty (PTCA) plus stent-implantation were examined with DIDO (dipyridamole with 0.28 mg/kg over 4 min plus dobutamine up to 10 mcg/kg/min), MCE (10 ml 4 g, 400 mg/ml Levovist intravenously; second harmonic power imaging) within 12-24 h and resting perfusion SPECT within 48-72 h after PTCA. Functional recovery of regional contractile function after 6-month follow-up was the gold standard to assess viability. RESULTS: The rate of agreement between SPECT and MCE was 69% and between SPECT and a positive response to stress echo was 76% for combined DIDO. MCE showed a higher sensitivity (96%) in the identification of viability than SPECT (77%) and combined DIDO alone (79%). Specificity was lower for viability recognition with MCE (58%) compared with SPECT (93%) and DIDO (87%). CONCLUSIONS: The wall motion response during DIDO echocardiography is useful in the prediction of recovery of regional and global ventricular function after revascularization in patients after AMI. Combined intravenous MCE and DIDO is more accurate in the diagnosis of stunned myocardium than Tc-99m-MIBI SPECT alone.