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The Seventh Annual Meeting of the
European Association of Echocardiography,
a registered branch of the ESC,
formerly known as the Working Group on
Echocardiography
in cooperation with the Working Group on
Echocardiography of the Spanish Society of Cardiology
Barcelona, Spain, 3–6 December 2003
Aims and Scope
European Journal of Echocardiography — The Aim of the journal is to publish high-quality, peer-reviewed articles on the ultrasonic examination of the cardiovascular system. The journal will publish original research articles, Guest Editorials, Reviews,
Technical Evaluations, Case Reports and Letters to the Editor. Every year, the abstracts from Euroecho will be published as a
supplement. In the ﬁrst instance, the journal will be published quarterly.
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EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY
Editor-in-Chief
Jos Roelandt
Deputy Editor
Petros Nihoyannopoulos
Associate Editors
Klaas Bom
Gerald Maurer
Don Poldermans
Editorial Assistant
Willeke A. Korpershoek
Editorial Board
George Athanassopoulos (GR)
Helmut Baumgartner (AT)
Eric Boersma (NL)
Lars-Ake Brodin (SE)
Ivo Cikes (Croatia)
Werner Daniel (DE)
Pierre Decoodt (BE)
Alain Delabays (CH)
Raffaele De Simone (DE)
Johan De Sutter (BE)
Raimund Erbel (DE)
Arturo Evangelista Masip (ES)
Harvey Feigenbaum (US)
Frank Flachskampf (DE)
Tamas Forster (HU)
Miguel Garcia Fernandez (ES)
John Gibbs (GB)
Derek Gibson (GB)
Pascal Guéret (FR)
Peter Hanrath (DE)
Liv Hatle (BE)
M. Mohsen Ibrahim (EG)
Sabino Iliceto (IT )
Gabriel Kamensky (SK )
Gad Keren (IL)
Joseph Kisslo (US)
Thomas Marwick (AU)
Kunio Miyatake (JP)
Maria Grazia Modena (IT)
Mark Monaghan (GB)
Andreas Mügge (DE)
Navin Nanda (US)
Joachim Nesser (AT)
Miodrag Ostojic (YU)
Mehmet Özkan (TR)
Natesa Pandian (US)
Luc Piérard (BE)
Massimo Pozzoli (IT)
Harry Rakowski (CA)
Daniele Rovai (IT )
Alessandro Salustri (IT )
Udo Sechtem (DE)
George Sutherland (BE)
Folkert Ten Cate (NL)
Adam Torbicki (PL)
S. Richard Underwood (GB)
Jean-Louis Vanoverschelde (BE)
Cees Visser (NL)
Junichi Yoshikawa (JP)
All manuscripts, together with those that are being refereed or that have been returned to
authors for revision, should be sent to:
Professor J. R. T. C. Roelandt, Editor in Chief,
European Journal of Echocardiography,
Thoraxcenter, Room H-538,
Erasmus MC, Dr Molewaterplein 40,
3015 GD Rotterdam, The Netherlands
All proofs should be returned to:
European Journal of Echocardiography,
Login Department, Elsevier Ltd,
Stover Court, Bampfylde Street,
Exeter, Devon EX1 2AH, U.K.
European Association of Echocardiography,
a registered branch of the
European Society of Cardiology
Ofﬁce Bearers
President: Fausto J. Pinto, Lisbon (Portugal),
e-mail: [email protected]
President Elect: Alan G. Fraser, Cardiff (United Kingdom),
e-mail: [email protected]
Past-Chairman: George R. Sutherland, Leuven (Belgium),
e-mail: [email protected]
Treasurer: Ariel Cohen, Paris (France),
e-mail: [email protected]
Secretary: Genevieve A. Derumeaux, Rouen (France),
e-mail: [email protected]
Chairman Educational Committee: Frank Flachskampf, Erlangen (Germany),
e-mail: frank.ﬂ[email protected]
Nucleus Voting Members
George Athanassopoulos (Athens, Greece),
e-mail: [email protected]
Marco Campana (Italy),
e-mail: [email protected]
Mauro Pepi Milano (Italy),
e-mail: [email protected]
Helene von Bibra (Munich, Germany),
e-mail: [email protected]
Jose L. Zamorano (Madrid, Spain),
e-mail: [email protected]
Ex Ofﬁcio Non-Voting Members
Editor EJE (ex ofﬁcio): Jos R.T.C. Roelandt Rotterdam (The Netherlands),
e-mail: [email protected]
Chairman Accreditation Assessment Committee (ex ofﬁcio): Kevin Fox, London (United Kingdom),
e-mail: [email protected]
DECEMBER 2003
ABSTRACTS SUPPLEMENT
Welcome address
Statistics
VII
VIII
Poster Session 1
Moderated Posters
Diastology
Atrial function
Contrast echocardiography
The heart in systemic and metabolic diseases
S1
S1
S4
S14
S15
S20
Poster Session 2
Moderated Posters
Dilated cardiomyopathy
Left-ventricular function
Coronary ﬂow reserve
S26
S26
S29
S38
S44
Poster Session 3
Moderated Posters
Left-ventricular hypertrophy
Athlete
Hypertension
Hypertrophic CMP
Left-ventricular asynchrony and resynchronization
Congenital heart disease
Right ventricle
S51
S51
S53
S55
S56
S59
S64
S68
S71
Poster Session 4
Moderated Posters
Ischaemic heart disease
Stress echocardiography
Vascular function
S77
S77
S79
S86
S98
Poster Session 5
Moderated Posters
Transoesophageal echocardiography
Source of embolism
Valvular heart disease
Valvular
3D echocardiography
Hand-held devices
New ultrasound technology
S101
S101
S104
S107
S109
S110
S118
S120
S122
VI
Contents
Oral Presentations
Prognostic value for stress echo
The added value of coronary ﬂow reserve assessment by echocardiography
Transoesophageal echo and source of embolism
Left-ventricular and endothelial function
New insights into right-ventricular function
More insight into myocardial contrast echo
Preclinical diagnosis of myocardial disease: new indications for tissue Doppler
Valvular heart disease
Resynchronisation in heart failure
Echo quantiﬁcation of left atrial function
Young Investigator Awards
Author index
S125
S127
S129
S131
S133
S135
S137
S139
S141
S143
S145
S147
The authors, editors, owners and publishers do not accept responsibility for any loss or damage arising from actions or decisions based on
information contained in this publication; ultimate responsibility for the treatment of patients and interpretation of published material lies
with the medical practitioner. The opinions expressed are those of the authors and the inclusion in this publication of material relating to a
particular product, method or technique does not amount to an endorsement of its value or quality, or of the claims made by its manufacturer.
VII
Welcome Address
The Working Group on Echocardiography of the ESC warmly invites you to attend our Seventh Annual Meeting, which
will be held in Barcelona from 3 to 6 December 2003. This year is the ﬁftieth anniversary of the development of echocardiography by Inge Edler and Hellmuth Hertz in Lund, and it is also the 200th anniversary of the birth of Christian Doppler
(and 150 years since his death). There will be special events to commemorate these important anniversaries, and so we
hope that you will be able to join us in reviewing the past and contemplating the future of non-invasive investigations in
clinical cardiology.
EUROECHO is now ﬁrmly established as the major event in cardiac ultrasound in Europe, for clinical education through
symposia and case discussions, and for review of progress in research through invited and abstract presentations. We are
conﬁdent that you will enjoy and beneﬁt from the interesting and varied programme that has been arranged.
Our local hosts, the Spanish Working Group on Echocardiography, have organised a course on stress echocardiography
on Wednesday 3rd December (in Spanish), before the formal opening of the meeting. Three other intensive courses will
be repeated – each with revised programmes and new information, on: Perioperative Transoesophageal Echocardiography (in conjunction with the European Association of Cardiothoracic Anaesthesia), Cardiovascular Magnetic Resonance
(organised by the ESC Working Group on CMR), and Basic Research in Ultrasound.
The opening ceremony will be held at 16:30 on Wednesday 3 December, and it will include the Edler lecture by Dr
Miguel-Angel Garcia-Fernandez, from Madrid. It will be followed by the Business Meeting of the Working Group on
Echocardiography, which we strongly encourage you to attend, because major changes in the organisation and status of the
WGE within the European Society of Cardiology will be discussed. Thereafter there will be a reception during the opening
of the exhibition.
This year, there will be special sessions at EUROECHO 7 on two principal themes. In conjunction with the Working Group
on Grownup Congenital Heart Disease of the ESC, and with colleagues from the Association of European Paediatric
Cardiology, we have organized a one day course on the anatomy and diagnosis of congenital heart disease (on Wednesday)
and then special sessions on adult congenital heart disease (during Thursday). On Friday, EUROECHO 7 will host the
Third European Diastology Meeting, with sessions throughout the day which will review basic mechanisms and diagnosis
of diastolic dysfunction. In addition, we will strengthen our links with other working groups through joint sessions on
valve disease, exercise physiology, and ventricular function. We will have a joint session with the American Society of
Echocardiography on the future clinical role of hand-held machines. The EUROECHO lecturer will be Dr Arthur Weyman.
We will keep some of the previously successful initiatives, including DICE sessions presentations, where several national
or scientiﬁc societies will present challenging cases, as well as the Teaching Course, which will run parallel to the main
sessions and where a systematic approach to echocardiography will be presented by several experts.
This year a record number of more than 800 abstracts were submitted for presentation. A very high standard has been
maintained, and a larger number than ever before will be presented. We urge you to attend the Young Investigators’ Award,
the oral abstract sessions, and the moderated posters and general poster sessions, since these are our main forum for the
presentation of research. This year, for the ﬁrst time, the WG decided to grant 40 travel awards for young investigators in
order to enhance the possibilities of these younger colleagues present their work at EUROECHO.
The scientiﬁc sessions will close at 12:30 on Saturday, 6 December 2003. In the afternoon we will hold the ﬁrst ofﬁcial
Accreditation Examination, which will launch the Process of Accreditation on Echocardiography in Europe, one of the
main current tasks of our WG.
Thereafter we hope you will join us at our Farewell Dinner on Saturday evening.
We wish you a successful meeting and an enjoyable stay in Barcelona.
Professor F.J. P INTO
President of the EAE
Professor A.G. F RASER
President Elect of the EAE
Statistics
By country
Submission
Country
Albania
Argentina
Armenia
Australia
Austria
Belarus
Belgium
Brazil
Bulgaria
Canada
China, Republic of
Czech Republic
Denmark
Egypt
Finland
Former Yugoslav Republic Macedonia
France
Georgia
Germany
Greece
Hong Kong
Hungary
India
Iran (Islamic Republic of)
Ireland
Israel
Italy
Japan
Korea, Republic of
Kyrgyzstan
Lithuania
Martinique
Norway
Paraguay
Poland
Portugal
Romania
Russian Federation
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Taiwan, Province of China
The Netherlands
Turkey
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uzbekistan
Total
%
2002
2003
2002
2003
0
1
1
2
2
2
20
9
0
0
4
3
1
10
2
5
17
3
53
48
2
15
0
3
1
7
82
4
5
1
7
0
13
1
71
44
28
10
30
1
0
23
14
7
0
8
64
5
1
45
22
4
2
2
2
3
8
0
15
21
1
1
6
16
1
13
3
3
20
4
43
56
2
24
1
2
1
6
108
7
4
0
4
1
12
0
79
24
37
14
32
2
1
47
26
6
1
22
39
4
0
39
10
6
0.00%
0.14%
0.14%
0.29%
0.29%
0.29%
2.85%
1.28%
0.00%
0.00%
0.57%
0.43%
0.14%
1.43%
0.29%
0.71%
2.43%
0.43%
7.56%
6.85%
0.29%
2.14%
0.00%
0.43%
0.14%
1.00%
11.70%
0.57%
0.71%
0.14%
1.00%
0.00%
1.85%
0.14%
10.13%
6.28%
3.99%
1.43%
4.28%
0.14%
0.00%
3.28%
2.00%
1.00%
0.00%
1.14%
9.13%
0.71%
0.14%
6.42%
3.14%
0.57%
0.26%
0.26%
0.26%
0.38%
1.02%
0.00%
1.92%
2.69%
0.13%
0.13%
0.77%
2.05%
0.13%
1.66%
0.38%
0.38%
2.56%
0.51%
5.51%
7.17%
0.26%
3.07%
0.13%
0.26%
0.13%
0.77%
13.83%
0.90%
0.51%
0.00%
0.51%
0.13%
1.54%
0.00%
10.12%
3.07%
4.74%
1.79%
4.10%
0.26%
0.13%
6.02%
3.33%
0.77%
0.13%
2.82%
4.99%
0.51%
0.00%
4.99%
1.28%
0.77%
701
781
100.00%
100.00%
Statistics
IX
By submission
Submission
Country
Italy
Poland
Greece
Spain
Germany
Turkey
United Kingdom
Romania
Serbia and Montenegro
Sweden
Portugal
Hungary
Brazil
The Netherlands
France
Czech Republic
Belgium
Russian Federation
Egypt
Norway
United States of America
Austria
Japan
Israel
Switzerland
Uzbekistan
China, Republic of
Lithuania
Ukraine
Korea, Republic of
Georgia
Former Yugoslav Republic Macedonia
Australia
Finland
Iran (Islamic Republic of)
Hong Kong
Armenia
Argentina
Slovakia
Denmark
Ireland
Bulgaria
India
Martinique
Slovenia
Taiwan, Province of China
Canada
Belarus
Paraguay
Kyrgyzstan
United Arab Emirates
Albania
Total
%
2002
2003
2002
2003
82
71
48
23
53
64
45
28
30
14
44
15
9
8
17
3
20
10
10
13
22
2
4
7
7
4
4
7
5
5
3
5
2
2
3
2
1
1
1
1
1
0
0
0
0
0
0
2
1
1
1
0
108
79
56
47
43
39
39
37
32
26
24
24
21
22
20
16
15
14
13
12
10
8
7
6
6
6
6
4
4
4
4
3
3
3
2
2
2
2
2
1
1
1
1
1
1
1
1
0
0
0
0
2
11.70%
10.13%
6.85%
3.28%
7.56%
9.13%
6.42%
3.99%
4.28%
2.00%
6.28%
2.14%
1.28%
1.14%
2.43%
0.43%
2.85%
1.43%
1.43%
1.85%
3.14%
0.29%
0.57%
1.00%
1.00%
0.57%
0.57%
1.00%
0.71%
0.71%
0.43%
0.71%
0.29%
0.29%
0.43%
0.29%
0.14%
0.14%
0.14%
0.14%
0.14%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.29%
0.14%
0.14%
0.14%
0.00%
13.83%
10.12%
7.17%
6.02%
5.51%
4.99%
4.99%
4.74%
4.10%
3.33%
3.07%
3.07%
2.69%
2.82%
2.56%
2.05%
1.92%
1.79%
1.66%
1.54%
1.28%
1.02%
0.90%
0.77%
0.77%
0.77%
0.77%
0.51%
0.51%
0.51%
0.51%
0.38%
0.38%
0.38%
0.26%
0.26%
0.26%
0.26%
0.26%
0.13%
0.13%
0.13%
0.13%
0.13%
0.13%
0.13%
0.13%
0.00%
0.00%
0.00%
0.00%
0.26%
701
781
100.00%
100.00%
Eur J Echocardiography Abstracts Supplement, December 2003
Poster Session 1
4 December 2003, 8:30 to 12:30
Location: Poster Hall
MODERATED POSTERS
109
Coronary angioplasty abolishes postsystolic shortening in stable angina
pectoris.
S. Marchev, S. Denchev, S. Dimitrov, A. Majarov, T. Draganov, Z. Kuneva. Medical
University, Department of Cardiology, Soﬁa, Bulgaria
Background: Ischemic myocardium deforms predominantly during the isovolumic
phases. Postsystolic shortening (PSS) has been proposed as a marker of ischemia
and viability. Tissue Doppler imaging (TDI) can noninvasively detect PSS. The velocity obtained from the apical view represents a cumulative velocity of all segments apical to the analyzed segment.
Methods: Pulsed TDI was performed at rest in 32 patients (21 male, 58.9±11.5
years) before and after balloon angioplasty for stable angina pectoris. Mitral annular velocities were measured lateral and septal from apical 4-chamber view, anterior and inferior from 2-chamber view. PSS was deﬁned as positive velocity after
peak systolic velocity.
Results: Before balloon angioplasty PSS (mean 3.7±1.8 cm/sec) was found in 24
of patients, in 19 of them they were on sites of mitral annulus, corresponding to
affected coronary arteries. After the angioplasty PSS disappeared on the site of
mitral annulus matching the dilated artery in 14 of those 19 patients.
Conclusions: PSS might be important marker of myocardial wall ischaemia.
110
Value of low mechanical index real time myocardial contrast
echocardiography for the prediction of left ventricular wall motion
recovery after reperfused acute myocardial infarction.
I. Garrido 1 , J. Peteiro 1 , R. Soler 2 , E. Rodriguez 2 , L. Monserrat 1 , G. Aldama 1 ,
A. Castro-Beiras 1 . 1 Juan Canalejo Hospital, Cardiology, A Coruña, Spain; 2 Juan
Canalejo Hospital, Radiology, A Coruña, Spain
Real time myocardial contrast echocardiography (RT-MCE) with low mechanical
index (RT-MCE) is a recently developed method that avoids some of the limitations
of MCE with high mechanical index. We sought to determine whether: 1) perfusion by RT-MCE predicts recovery of LV function after acute myocardial infarction
(AMI), and 2) data are comparable to perfusion by Technetium-99m-sestamibi single photon emission computed tomography (SPECT) and contrast-enhanced magnetic resonance (CMR).
Methods: We studied 89 consecutive patients (pts) with AMI submitted to percutaneous transluminal coronary angioplasty. MCE was performed (up to 3 intravenous
slow injections containing 1 cc of Optison and 9 cc of saline each) 7±4 days after AMI. 2-dimensional echocardiography (2-DE) was performed at the time of the
MCE study and at follow-up (10±4 weeks) to measure wall motion score index
(WMSI). SPECT and CMR were performed after AMI in 18 and 32 pts respectively, at a mean of 30±26 days after AMI. A 12-segment LV model was used
for RT-MCE and SPECT, scoring 0=absence of perfusion; 0.5=partial perfusion;
and 1=complete perfusion, whereas a 17-segment model was used for CMR. Regional (AMI-related territory) and global WMSI were calculated using a 16-segment
model.
Results: Follow-up 2-DE was available for 86 pts that were subdivided in 2 groups:
Recovery (RG) (n=51) and no recovery group (NRG) (n=35). Peak creatine kinase
was higher in the NRG (p<0.01) and TIMI ﬂow was lower (p<0.05). No signiﬁcant
differences in other clinical, angiographic and 2-DE variables were found between
groups at baseline. Global and regional WMSI improved from 1.4±0.3 to 1.2±0.2
(p<0.001) and from 1.7±0.5 to 1.3± 0.4 (p<0.001) in the RG, and was unchanged
from 1.5±0.3 to 1.5±0.2 and from 1.9±0.4 to 2.0±0.4 in the NRG. Regional and
global MCE perfusion score were 0.9±0.3 and 0.9±0.2 in the RG, and 0.7±0.3
and 0.8±0.2 in the NRG (both p<0.05). Independent predictors of regional LV
function recovery were post-angioplasty TIMI-ﬂow (OR: 2.5; 95% CI: 1.0-6.2) and
regional RT-MCE score (OR: 10.5; 95% CI: 2.0-53.5). Signiﬁcant correlations were
found between global RT-MCE perfusion score and global SPECT perfusion score
(r=0.79, p<0.01) and between RT-MCE and CMR (r=0.54, p<0.01). A regional
perfusion score >0.70 was the more accurate RT-MCE value to predict LV regional
recovery with positive predictive value of 70% and negative predictive value of 56%
(p<0.05).
Conclusion: RT-MCE is valuable for predicting recovery of LV function after reperfused AMI.
S2
Abstracts
111
Systematic comparison of tissue Doppler imaging with coronary
angiography results.
E. Donal 1 , P. Raud-Raynier 2 , D. Coisne 2 . 1 Departement de Cardiologie, CHU La
Milétrie, Poitiers, France; 2 CHU La Miletrie, Cardiology, Poitiers, France
Multiples indices have recently been described using tissue Doppler imaging (DTI).
The relevance of these indices in the routine management of patients with an acute
myocardial infarction (AMI) remains poorly evaluated. We sought to analyze patients by transthoracic echocardiography and regional DTI analysis after coronary
angiography (CA).
Methods: 28 consecutive patients (61±14 years old) were imaged in the 24 hours
following the PTCA for AMI. 17 control subjects with normal CA (49±11 years old)
were studied as well. Global and regional left ventricular function were analyzed.
High frame rate color DTI cineloop were recorded in apical 4 and 2 chambers for
subsequent analyses of regional myocardial velocities and gradients, at 4 levels.
Results: 15 patients were
successfully treated for anterior AMI and 13 for an inferior one. Figure 1 displayed
the ROC curve in regard to the
ability of DTI parameters to
predict the territory vascularized by a pathologic coronary
artery. The combination ICT
& IVRT had 74% sensitivity
and 68% speciﬁcity determining the pathologic artery, looking only at values obtained in
the mid-segment of each LV
wall. IVRT peak velocity was
negative in control segments
(segments related to no coronary artery stenosis, -0.70±0.99 cm/s for the mean
anterior wall) and became positive and delayed in ischemic segments (0.64±0.65
cm/s for the mean anterior wall, p<0.001). Also, regional velocities and gradients
were signiﬁcantly depressed in the AMI group compared to the normal one.
Conclusion: IVR & IVC peak velocity were strikingly informative. Strain & strain
rate are, for us, less useable in clinical practice because signal/noise ratio & difﬁculties to deﬁne systolic and post-systolic events without any phonocardiogram.
112
The contribution of systolic left ventricular long-axis function for the
detection of myocardial viability.
K. Bouki 1 , A. Kranidis 2 , G. Pavlakis 3 , T. Kakavas 3 , K. Kostopoulos 3 ,
J. Karangis 3 , T. Xydas 3 , E. Papasteriadis 3 . 1 General Hospital of Nikea,
Cardiology Dept., Pireaus, Greece; 2 Evaggelismos General Hospital, Cardiology,
Athens, Greece; 3 General Hospital of Nikea, Pireaus, Cardiological, Athens,
Greece
Objectives: Previous studies showed that systolic left ventricular (LV) long-axis
function during dobutamine stress echocardiography (DSE) provides a promising,
quantitative index for the detection of coronary ischemia. In the present study we
assessed the contribution of the LV long-axis function during DSE, in predicting
recovery of LV dyssynergies, after revascularization.
Methods: Forty patients with LV dysfunction due to old myocardial infarction
scheduled for revascularization (24 PTCA and 16 CABG) underwent low-dose (510µgr/Kg/min) DSE. The echocardiographic study included the standard protocol
of LV wall motion analysis plus the measurement of LV long-axis shortening (LAS).
The amplitude of LAS was estimated at rest and at every stage of dobutamine
infusion, using 2D guided M-Mode, towards the four sites of the left atrioventricular plane (septal, lateral, inferior and anterior), from the apical 2- and 4-champers
view. Resting two-dimensional echocardiography was also performed in all patients
101±14 days after successful revascularization.
Results: (see table) LAS showed a signiﬁcant increase during dobutamine infusion
only at LV dyssynergic sites with functional improvement in post-revascularizarion
echocardiogram. In the remaining LV dyssynergic sites LAS did not change signiﬁcantly. Use of a LAS increase>2mm during DSE at any dyssynergic site of the left
ventricle, resulted in a sensitivity of 91% and a speciﬁcity of 83% for the prediction
of recovery of regional LV dyssynergies. When LV wall motion analysis was used
for the detection of reversible dysfunction, sensitivity and speciﬁcity were found
to be 81.5% and 87.5%, respectively. When the two methods were in agreement,
positive and negative predictive values were 100% and 84.2% respectively.
113
Dyskinesis index by strain analysis - a new and early reperfusion marker.
T. Helle-Valle, E. Lyseggen, H. Skulstad, T. Vartdal, S. I. Rabben, H. Ihlen,
O. Smiseth. Rikshospitalet University Hospital, Dep. of Cardiology, Oslo, Norway
Background: This study investigates if changes in the magnitude of dyskinesis
may serve as a marker of coronary artery reperfusion. As an index of dyskinesis
we calculated a ratio between systolic lengthening and combined late systolic and
post-systolic shortening (L/S-ratio). Our hypothesis was that reperfusion would reduce the L/S-ratio.
Methods: In 10 anesthetized dogs we measured LV anterior wall longitudinal strain
with sonomicrometry and Doppler echocardiography. The LAD was occluded for 15
min in group 1 (n=5) and 4 hours in group 2 (n=5). Measurements were done at 15
min and 4 hours occlusion, and after 15 min, 1 and 3 hours of reperfusion. Necrosis
was identiﬁed by TTC staining. Fig 1 shows how the L/S-ratio was measured.
Results: Before ischemia the L/S ratio was near zero, indicating no systolic lengthening. During coronary occlusion the L/S-ratio increased markedly (Fig. 2), consistent with dominantly passive behavior of the segment. After 15 min of ischemia,
reperfusion resulted in a rapid decrease in the L/S-ratio to less than 0.5. TTC
showed viable tissue. After 4 hours of ischemia, reperfusion caused no change in
the L/S-ratio and it remained > 0.5. TTC showed necrosis. Strain measured by
Doppler was consistent with the sonomicrometry data.
Conclusions: Reperfusion of viable myocardium was associated with a decrease
in the L/S-ratio, indicating that this dyskinesis index may help to identify reperfusion. Thus, quantiﬁcation of dyskinesis may provide important diagnostic information.
114
Pulsed-wave tissue Doppler imaging for the quantiﬁcation of contractile
reserve in stunned, hibernating, and scarred myocardium.
M. Bountioukos 1 , A.F.L. Schinkel 1 , J.J. Bax 2 , V. Rizzello 1 , B.J. Krenning 1 ,
J.R.T.C. Roelandt 1 , D. Poldermans 1 . 1 Thoraxcenter, Erasmus Medical Center,
Department of Cardiology, BA302, Rotterdam, Netherlands; 2 Leiden University
Medical Center, Department of Cardiology, Leiden, Netherlands
Objectives: To assess whether quantiﬁcation of myocardial systolic velocities by
pulsed-wave tissue Doppler imaging (TDI) can differentiate between stunned, hibernating, and scarred myocardium.
Methods: Seventy patients with ischemic cardiomyopathy were studied by pulsedwave TDI of the mitral annulus at rest and during low-dose dobutamine; systolic
ejection velocity (VS) and the increase in VS at low-dose dobutamine (DVS) were
assessed according to a 6-segment model. Assessment of perfusion (with Tc-99mtetrofosmin SPECT) and glucose utilization (with F18-ﬂuorodeoxyglucose SPECT)
were used to classify dysfunctional (assessed by resting 2D echocardiography)
regions as stunned, hibernating or scarred.
Results: Myocardial systolic velocities of the 420 regions are presented in Figure.
In total, 253 regions were dysfunctional; 132 (52%) were classiﬁed as stunned,
25 (10%) as hibernating, and 96 (38%) as scarred. At rest, VS in stunned, hibernating and scar tissue was respectively 6.3±1.8 cm/s, 6.6±2.2 cm/s, and 5.5±1.5
cm/s (p=0.001 by ANOVA). There was a gradual decline in VS during low-dose
dobutamine infusion between stunned, hibernating and scar tissue (8.3±2.6 cm/s
v 7.8±1.5 cm/s v 6.8±1.9 cm/s, p<0.001 by ANOVA). DVS was signiﬁcantly higher
in stunned (2.1±1.9 cm/s), than in hibernating (1.2±1.4 cm/s, p<0.05) or scarred
(1.3±1.2 cm/s, p=0.001) regions.
LAS during DSE
Baseline
After Dobutamine infusion
p value
LAS at improved
dyssynergic sites (n=49)
LAS at non-improved
dyssynergic sites (n=35)
9.9±1.6
12.6±1.5
<0.001
9.1±2
9.2±1.9
NS
Conclusions: Assessment of long–axis function during DSE provides a promising
quantitative adjunct to wall motion analysis for the prediction of recovery of regional
LV dyssynergies after revascularization.
Eur J Echocardiography Abstracts Supplement, December 2003
Conclusion: Quantitative TDI showed a gradual reduction of regional velocities
between stunned, hibernating and scarred myocardium. Dobutamine-induced contractile reserve was higher in stunned regions than in hibernating and scarred myocardium, reﬂecting different severities of myocardial damage.
Abstracts
S3
115
Resolution of post-systolic strain as a non-invasive marker of
successful revascularisation of viable myocardium in patients with
ischaemic left ventricular dysfunction.
certainly improve the diagnostic capacity of TT, possibly by itself. Image quality of
the anterior wall is still sub optimal as we reported previously.
R I. Williams 1 , N. Payne 2 , A. Tweddel 3 , J. D’Hooge 4 , A G. Fraser 1 . 1 University
Hospital of Wales, Wales Heart Research Institute, Cardiff, United Kingdom;
2
Providence Health System, Portland, Oregon, United States of America;
3
University Hospital of Wales, Cardiology Dept., Cardiff, United Kingdom;
4
University Hospital Gasthuisberg, Department of Cardiology, Leuven, Belgium
117
Tissue velocity imaging and myocardial contrast echocardiography with
power Doppler harmonic imaging during adenosine stress.
Background: LV function improves after early revascularisation in patients with
extensive myocardial ischaemia, if there are many viable segments, and surgery
also improves survival. Identifying patients who will beneﬁt is difﬁcult. In a prospective study, we investigated if pre-operative myocardial responses to dobutamine,
assessed by tissue Doppler echocardiography (TDE), could predict improved regional function after coronary artery bypass surgery (CABG).
Methods: We studied 23 patients (21 men, aged 61±10 years) with multivessel
coronary disease and poor LV function (ejection fraction EF<35% on Technetium
99 blood pool imaging). All had graded dobutamine stress echocardiography,
with storage of digital loops (GE Vingmed) for off-line TDE analysis, and nitrateenhanced rest-redistribution Thallium 201 perfusion imaging. Perfusion scans were
analysed and scored from polar plots scaled to 100% using a 16-segment model
and a colour cut-off of 50%. Both investigations were repeated 6-8 months after
elective CABG. Graft patency was conﬁrmed by CT angiography.
Results: After CABG, mean segmental perfusion scores improved (from 6.7±2.7
pre-op to 9.8±2.7; p<0.02) and anginal symptoms abated (Canadian Cardiac Society class, from 2.08±0.85 to 0.74±0.75, p<0.005). There was a smaller reduction in NYHA class (from 2.48±0.5 to 1.65±0.88; p<0.005), global EF was unchanged (32±17% pre-op v 34±13% post-op). Systolic strain rate in basal myocardial segments imaged from apical windows (thus assessing subendocardial,
longitudinal function) increased with dobutamine both before and after CABG,
but there were no signiﬁcant differences between pre-op and post-op studies.
Peak myocardial systolic velocities increased similarly during both studies, and
were also not greater after CABG. Maximal systolic strain fell during dobutamine
pre-op (from -8.4±0.9 to -6.1±0.7%, p<0.05) suggesting ischaemia, while after CABG it remained low at rest but did not deteriorate during dobutamine (8.2±0.9 to -7.1±0.7%, ns). Post-systolic strain was observed during dobutamine
before CABG (-9.6±0.8 to -7.6±0.6%, p<0.05) but not afterwards (-0.1±0.01 to
-0.1±0.01%)(p<0.05 between pre- and post-op studies).
Conclusion: The elimination of post-systolic strain observed following successful
revascularisation may be a sensitive non-invasive marker of improved myocardial
perfusion and resolution of ischaemia. This study supports further investigation of
post-systolic strain as a potential clinical marker of hibernating myocardium.
116
Functional diagnosis of coronary stenosis using tissue tracking
provides best sensitivity and speciﬁcity for circumﬂex disease:
Experience from the MYDISE study.
S.K. Saha 1 , C. Storaa 2 , J. Nowak 3 , S. Roumina 3 , B. Lind 3 , C. Mädler 4 ,
A. Fraser 4 , L.A. Brodin 3 on behalf of the MYDISE Investigators. 1 Huddinge Univ
Hospital, Clinical Physiology C1-88, Stockholm, Sweden; 2 Karolinska Institute,
Medical Engineering, Stockholm, Sweden; 3 Huddinge University Hospital, Clinical
Physiology Dept., Stockholm, Sweden; 4 University of Wales College of Medicin,
Dept of Cardiology, Cardiff, United Kingdom
Background: Tissue Doppler (TVI) quantiﬁcation of dobutamine stress echocardiography (DSE) for velocity-aided diagnosis of coronary artery disease (CAD) has
yielded excellent diagnostic capacity in the European MYDISE & in the Australian
study. In this study we have performed displacement imaging (tissue tracking,TT)
of the MYDISE database in order to assess the diagnostic power of TT, an inbuilt component of the TVI software. Methods: The principle of TT is based on
color-coding of the longitudinal atrioventricular motion (normally in decreasing order from base to apex) of the left ventricle (LV) in systole. By dividing each LV
wall from base to apex into 8 colour bands (2 mm each), it is possible not only
to have a reasonable idea on the distribution of the motion data along a given LV
wall, it also provides information on the strain (=deformation) in multiple segments.
The stronger bands (pink, light & deep blue) represent the greater displacement in
the basal segments while the weaker apical bands (yellow and red) represent the
poorer displacement in that region. By analysing the distribution pattern of color
bands in 90 individuals with low probability of CAD, we used the ratio of the basal
to apical bands expressed as a percentage of the involved myocardium (B/A ratio)
to study 120 patients with critical CAD. The diagnostic capacity of the procedure
was assessed by the use of receiver operating characteristic curves constructed
by successive consideration of several B/A cut points in all 4 myocardial walls
(septal, anterior, lateral and inferior). Results: The TT derived B/A ratio provided a
signiﬁcant discrimination of patients with CAD (p<0.05 for anterior wall, p<0.001
for all the others). The procedure appeared to be most sensitive for the detection of circumﬂex artery disease, the B/A ratio of 0.8 in the inferior wall providing
in this respect the best combination of sensitivity and speciﬁcity values (77±8%
and 77±5%, respectively). Conclusion: Since velocity imaging alone can provide
erroneous data because of "tethering" and "translational" effects, TT may provide
an additional online option, literally in seconds, to quantify DSE in order to distinguish healthy from ischemic walls. Whether TT in combination with velocity or wall
motion scoring can provide incremental information remains to be seen. The availability of newer soft wares along with image storage at higher frame rates would
A. Hagendorff 1 , M. Pearson 1 , A. Werner 1 , N. Al-Saadi 2 , D. Pfeiffer 1 ,
H. Bechjer 3 . 1 University of Leipzig, Cardiology- Angiology, Leipzig, Germany;
2
University of Berlin - Campus Buch, Cardiology, Berlin, Germany; 3 University of
Oxford, Cardiology, Oxford, United Kingdom
Tissue velocity imaging (TVI) is able to reduce the interobserver variability of regional wall motion in comparison to the analysis by eye. Myocardial contrast echocardiography (MCE) with power Doppler harmonic maging (PDHI) using a repetitive bolus of 0.3ml Optison was shown to be able to detect regional hypoperfusion
in patients with acute coronary syndrome at rest.
The aim of the present study was to evaluate prospectively the feasibility and efﬁcacy of a combined stress protocol with TVI and MCE using PDHI during adenosine stress (140 mg kg-1 min-1) echocardiography. 40 patients with unspeciﬁc
stress-induced chest pain were investigated at rest and during vasodilator stress.
Coronary angiography was performed within one week after stress testing. Maximal shortening velocities below regional cut-off-values of regional systolic longitudinal shortening reported in the literature and regional postsystolic longitudinal
shortening of the mitral valve anulus were deﬁned as pathologic. TVI dynamic was
deﬁned as signiﬁcant alterations of TVI tracings detected in the early diastole. Perfusion according to regional cut-off-values reported in the literature using a protocol
for intravenous bolus administration of ultrasound contrast agents and according to
the algorithm DIstress > DIrest was deﬁned as pathologic. TVI and PDHI analysis
at rest showed a high sensitivity and a low speciﬁty to detect left ventricular territories supplied by a narrowed artery. The sensitivities for the detection of signiﬁcant
coronary artery disease calculated for the described dynamic TVI criteria were between 75 and 100% and the speciﬁties between 67 and 95%. On the other hand
MCE with PDHI during adenosine stress was not able to increase sensitivities and
speciﬁties to detect myocardial ischemia.
Conclusions: The combination of TVI and MCE is possible using an intermittent bolus administration of microbubbles in clinical practice. However, the present
study demonstrates that TVI is superior to MCE with PDHI using i.v. bolus administration of contrast to detect regional wall motion abnormalities due to myocardial
hypoperfusion.
118
Importance of dobutamine Doppler tissue imaging on the evaluation of
revascularization in patients with hypoperfused myocardium.
H. Yalcin, A. Aktas, F. Yapar, M. Aydin, C. Tuylu, F. Yalcin, H. Müderrisoglu.
Merkezi Kirelithane, Adana Uyg. ve Arastima, Adana, Turkey
To evaluate the efﬁciency of the new technique, colour Doppler tissue imaging
(DTI), before percutaneous coronary intervention (PCI), we studied 24 coronary
artery patients using single photon emission computed tomography (SPECT) with
Tc99m-MIBI and myocardial DTI during rest and pharmacologic stress.
Method: Dobutamine stress was used in 24 patients (mean age 56 ± 8 years; 5
women) with proven coronary artery disease (>70% diameter stenosis of at least
one major coronary artery at angiogram). Myocardial tissue systolic and diastolic
velocities from septal, lateral, anterior and inferior walls at rest and peak dobutamine infusion were determined. SPECT images were performed after injection
of MIBI at rest and peak dobutamine stress. Ischemic segments on the basis of
SPECT ﬁndings were compared to nonischemic segments using DTI.
Result: A total of 96 severely ischemic segments were visualised according to
SPECT study. Mean ejection fraction was 57±1.5. Maximum mean septal, lateral,
anterior and inferior DTI systolic velocities were similar in ischemic and nonischemic segments (6.7 ± 1.1 cm/s, 6.8 ± 1.3 cm/s, respectively) at rest. At peak
stress, maximum mean DTI systolic velocities were lower in the 37 ischemic segments (10.7 ± 2.2 cm/s) than 59 nonischemic segments (13.9 ± 1.8 m/s, p <
0.001).
Conclusion: DTI may be helpful as an adjunctive to SPECT to decide PCI, when
using dobutamine stres in the coronary artery disease. Addition to SPECT, more
quantitative data by DTI may provide better aggrement for culprit lesion revascularization.
Eur J Echocardiography Abstracts Supplement, December 2003
S4
Abstracts
DIASTOLOGY
122
Effect of simvastatine on Doppler indices of left ventricular diastolic
function in hypertensive patients with hypercholesterolemia.
120
Limitations of Valsalva maneuver to detect pseudonormal transmitral
ﬁlling pattern: a study of healthy individuals.
1
W. Kosmala, M. Przewlocka-Kosmala. Medical University, Cardiology, Wroclaw,
Poland
2 1
2
S. Cosson , J.P. Kevorkian , P. Beauﬁls . Hopital Lariboisiere, Cardiology, Paris,
France; 2 Hôpital Lariboisière, Cardiology, Paris, France
Background: Pseudonormal (PN) mitral ﬁlling pattern represents a moderate diastolic dysfunction in which an abnormal relaxation is compensated by an elevated
atrial pressure. Inversion of the mitral E/A ratio during Valsalva maneuver (VM) is
a method recommended to identify a PN ﬁlling pattern. Sparse data are available
on the effects of this maneuver in healthy asymptomatic middle-aged individuals in
whom baseline E/A ratio is close to 1.
Aim: To evaluate the effects of changes in loading condition with VM on the pattern
of Doppler mitral velocity proﬁle in middle-aged healthy individuals.
Methods: We studied 30 (23 men, 50±1 years, 42-58) healthy individuals without
any overt cardiovascular disease or vascular risk factor. Peak velocity of early (E)
and late (A) mitral waves and their ratios at rest and during VM as well as left
ventricular ejection fraction (LVEF) were measured by standard techniques. Early
(Ea) and late (Aa) myocardial velocities were obtained by pulsed tissue Doppler
imaging (TDI) at the lateral and septal mitral annulus.
Results: Measurements were feasible in all subjects. All had normal LVEF
(64±5%).
Heart rate (beats/min)
E (cm/s)
A (cm/s)
E/A
Rest
VM
P
63 ± 10
68.5 ± 8.4
55.1 ± 6
1.25 ± 0.14
73 ± 10
37.6 ± 7.1
49.9 ± 6.7
0.76 ± 0.12
< 0.01
< 0.01
< 0.01
<0.01
Nine subjects had an abnormal relaxation ﬁlling pattern (E/A < 1). E, A and E/A
signiﬁcantly decreased with VM. Inversion of E/A was observed in 20 of 21 (95%)
subjects with a baseline E/A > 1, leading to a pseudonormal classiﬁcation according to VM pattern(table). However, all had Ea > 8 cm/s (E sept 10.5±1.1 cm/s, E
lat 15.2±1.9 cm/s) and E/Ea < 10 (E/Ea lat 4.6 ±0.9, E/Ea sept 6.6±1.4).
Conclusion: Our data suggest that inversion of E/A ratio during VM does not differentiate between normal and pseudonormal LV ﬁlling patterns in normal subjects.
The use of this single method could lead to misleading results when applied to
detect early manifestation of several cardiomyopathies.
121
Left ventricular diastolic function as routinely reported in a tertiary
referral center: analysis of 3227 exams.
P. Barbier, M. Alimento, M.D. Guazzi. Centro Cardiologico Fondazione Monzino,
IRCCS, Milan, Italy
Abstracts related to left ventricular (LV) "diastology" (analysis of ﬁlling pressures
and chamber compliance) presented at scientiﬁc meetings have parallelled increased use of the Doppler techniques, but feedback of proposed algorythms to
estimate (LV) diastolic function on the "real world" of clinical diagnosis is unknown.
Aim: to analyse effective use of LV diastolic function analysis during routine
echocardiographic outpatient studies in a tertiary referral center.
Methods: we selected 3227 consecutive reports (outpatient studies) generated
between October 1999 and 2000 by 6 ASE level III, 5 level II and 3 level I (respectively 2503, 677, and 47 studies) cardiologists. Each exam included complete
M-Mode, LV biplane volumes and ejection fraction, and pulsed Doppler mitral and
pulmonary venous ﬂow parameters. We searched the database for frequencies of
numerical (mitral E/A peak velocity ratio and E deceleration time, pulmonary venous systo-diastolic velocity-time integral ratio), and text (strings in comments: "diastolic function", "ﬁlling pressure", "compliance", "restrictive") descriptions related
to LV diastolic assessment.
Results: text descriptions of LV diastolic function were found in 51%, 19% and
43% of reports of level I, II and III operators. In patients with "cardiomyopathy", text
descriptions were found in 29%, 64% and 60% of reports of level I, II III operators.
In this same subset, LV biplane end-diastolic volume, mitral E/A ratio and E deceleration time were reported by respectively 86%, 14%, and 14% of level I; 47%,
35% and 40% of level II; and 51%, 32%, and 37% of level III operators. Finally,
in patients with reduced ejection fraction (<45%), text descriptions of LV diastolic
function were found in 47% of all reports, whereas measurements of LV biplane
end-diastolic volume, mitral E/A and E deceleration time were found respectively
in 62%, 25% and 30% of all reports.
Conclusion: in the "real world" of diagnostic echocardiography, even expert cardiologists assess simple indexes of LV diastolic function in less than half of the
patients in whom they are recommended as mandatory (cardiomyopathy or LV
systolic dysfunction). These results suggest that in echocardiographic diastology
there exists a feedback gap between research ﬁndings and clinical applications of
these ﬁndings.
Eur J Echocardiography Abstracts Supplement, December 2003
No precise data are available whether treatment with statins exerts beneﬁcial effect
on left ventricular diastolic function (LVDF) in hypertensive patients.
Aim: To investigate the effect of treatment with simvastatine 20 mg daily on
Doppler indices of LVDF in pts with mild essential hypertension.
Material and methods: The population of the study consisted of 26 pts aged
62.6±11.2 years with preoviusly not-treated mild essential hypertension without other cardiovascular disorders and elevated plasma level of LDL-cholesterol
(>160 mg/dL). In all subjects hypotensive therapy with hydrochlorothiazide 12.5
mg daily was introduced. 12 pts remained only on low-cholesterol diet (control
group) whereas 14 were additionally treated with simvastatine 20 mg daily. Echo
study was performed et baseline and after 3 month of the treatment and included
estimation of peak velocity of early (E) and late (A) transmitral ﬂow, deceleration
time of E wave (DT), isovolumic relaxation time (IVRT), total ejection isovolume
index (TEI), E (ETT) and A (ATT) wave transit time to the LV outﬂow tract, ﬂow
propagation velocity of E wave (Ep).
Results: LDL-cholesterol level decreased in the simvastatine group from
186.4±19.2 to 154.7±20.6 and in the control group from 185.5±17.6 to
176.7±16.4 mg/dL being signiﬁcantly lower after treatment in the simvastatine
group. Systolic and diastolic blood pressure decreased from 153.7±9.3/94.2±4.8
mmHg to 138.6±5.2/87.5±5.4 mmHg in the simvastatine group and from
154.5±7.8/93.9±3.7 mmHg to 136.9±4.8/86.8±4.7 mmHg in the control group
and did not differ between both groups. In the simvastatine group signiﬁcant increase in Ep from 48.2±15.9 to 55.7±16.7 cm/s (p<0.05) and decrease in ETT
from 129±26 to 118±25 ms (p<0.05) was demonstrated. None of evaluated
Doppler parameters changed signﬁcantly in the control group.
In conclusion: In pts with mild hypertension and hypercholesterolemia simvastatine
improves left ventricular diastolic function which is indicated by increase in Ep and
decrease in ETT.
123
Correlation of echocardiographic diastolic parameters and exercise
tolerance in patients after myocardial infarction.
K. Wierzbowska, J. Drozdz, M. Krzeminska-Pakula, J.D. Kasprzak. Medical
University of Lodz, Cardiology Dept., Lodz, Poland
Background: Despite the knowledge of connection between left ventricular diastolic dysfunction and signs and symptoms of congestive heart failure, the relationship of wide spectrum of echocardiographic parameters with exercise tolerance
are not thoroughly examined.
Purpose: Our aim was to examine the correlation between the classic and novel
markers of diastolic function (including mitral ﬁlling propagation velocities and tissue Doppler diastolic parameters) and exercise tolerance measured as the duration of symptom-limited treadmill exercise test in patients after myocardial infarction.
Methods: In 60 patients after myocardial infarction (MI) transthoracic echocardiography and treadmill exercise test according to Bruce protocol was performed. In
46 persons the exercise test was stopped because of signs of congestive heart
failure: fatigue and dyspnoe (mean age: 60±11, 36 male, mean EF 30±10%).
Results: The strongest relationships with exercise tolerance were detected for the
difference between atrial reversal time of pulmonary vein ﬂow and duration of atrial
phase of mitral inﬂow (delta At, correlation coefﬁcient r=-0,53, p<0,001), duration and deceleration time of mitral atrial wave (At, r=0,47, Adt, r=0,45, p<0,01),
ejection fraction (EF, r=0,43) and duration of atrial reversal time (Art, r=-0,38).
Among the novel parameters a signiﬁcant correlation was found for the ratio of
peak early mitral inﬂow velocity to peak early mitral annulus (m.a.) velocity measured by pulsed tissue Doppler in lateral segment of m.a., (E/E’, r=-0,48), velocity
time integral of atrial phase of m. a. motion (A’vti, r=0,45) and early m. a. velocity
(E’, r=0,44).
Conclusions: In our study the strongest correlation with exercise tolerance was
detected mainly for parameters related to elevated left end-diastolic pressure in
the left ventricle such as atrial reversal parameters from pulmonary vein ﬂow or
E/E’ ratio. In this post-MI group also the left ventricular ejection fraction (but not
E/A ratio) showed close relationship with exercise tolerance.
Abstracts
124
Utility of new Doppler parameters connected with elevated left ventricle
end-diastolic pressure for identiﬁcation of mitral inﬂow
pseudonormalization.
K. Wierzbowska, J. Drozdz, J.D. Kasprzak, M. Krzeminska-Pakula. Medical
University of Lodz, Cardiology Dept., Lodz, Poland
The occurrence of mitral inﬂow pseudonormalization imposes some difﬁculties on
classiﬁcation of diastolic function (DF).
Our aim was to assess if a new parameters proposed as a noninvasive measurement of ﬁlling pressure, ratios of peak early wave velocity to early propagation
velocity (E/Ep) and peak early wave velocity to early diastolic motion of mitral annulus (E/E’), can help in differentiation of normal (N) and pseudonormal (PN) mitral
inﬂow.
Purpose: We compared E/Ep and E/E’ ratios and other echocardiographic parameters between patients (pts) with normal (N) and pseudonormal (PN) mitral inﬂow,
performed ROC analysis for detection of optimal cut-off values and assessed diagnostic value of this parameters for detection of pseudonormalization.
Methods: Among 120 pts with coronary artery disease and 60 healthy persons
examined by transthoracic echocardiography with assessment of diastolic function
we selected the subgroup with E/A ratio between 1 and 2, and divided them into
N and PN mitral inﬂow group according to E wave deceleration time. Propagation
velocity was measured by color M-mode and tissue Doppler parameters were assessed in lateral segment of mitral annulus. Than we compared 15 pts with PN
(mean age 57±11, male) and 54 persons with N pattern (mean age 55±9, male).
Results: In N group E/Ep and E/E’ ratios were lower than in PN group (1,7+0,4 vs
3,5±1,3 for E/Ep and 6,3±2,1 vs 9±3,7 for E/E’; p<0,001).
For cut-off values of Ev/Ep above 2,3 and of E/E’ above 8,2, sensitivity, speciﬁcity,
positive predictive value, negative predictive value and accuracy for detection of
PN were respectively: 87, 91, 72, 96, 90% and 60, 81, 47, 88, 77%.
Area under ROC curve (AUC) for Ev/Ep= 0,921 was comparable with this for left
atrium (LA) diameter (0,963) and was higher than AUC for parameters of pulmonary vein ﬂow (0,814 for atrial reversal time and 0,779 for the difference of atrial
reversal time and atrial wave duration of mitral inﬂow).
Conclusions: Both Ev/Ep and E/E’ ratios are useful for differentiation of PN and
N pattern. In our group of pts diagnostic value of E/Ep ratio was highly signiﬁcant,
greater than E/E’ ratio, comparable with enlarged LA diameter and slightly better
than value of pulmonary ﬂow parameters.
125
Correlation of left ventricular ejection fraction and systolic tissue
Doppler velocities with parameters of diastolic function.
K. Wierzbowska, J. Drozdz, J. Kasprzak, M. Krzeminska-Pakula. Medical
University of Lodz, Cardiology Dept., Lodz, Poland
Background: Tightly connected with systolic performance elastic recoil is postulated as important determinant of early ﬁlling. In spite of wide coexistence of diastolic dysfunction in patients (pts) with systolic impairment, correlations between
systolic and diastolic parameters are not sufﬁciently examined.
Purpose: Our aim was to calculate correlations between systolic variables: ejection fraction (EF) and systolic velocity of mitral annulus (m. a.) motion and comprehensive spectrum of diastolic parameters of left ventricle.
Methods: We performed transthoracic echocardiography with assessment of mitral inﬂow, pulmonary vein ﬂow, propagation of mitral early and atrial wave in color
Doppler M-mode and pulsed TDE spectrum of m. a. motion in 200 persons (80
healthy, 60 with CAD and preserved EF and 60 after myocardial infarction) and
assessed correlations between systolic and diastolic parameters.
Results: We found signiﬁcant positive correlation between EF and early propagation velocity (Ep; r=0,68) and systolic velocity of pulmonary vein ﬂow (S; r=0,46).
Negative correlation was observed for early mitral inﬂow velocity to early propagation ratio (Ev/Ep; r=-0,68) and duration of atrial reversal in pulmonary vein (Ar
t; r=-0,55). Also average systolic velocity of m. a. correlated signiﬁcantly with Ep
(r=0,42), S (r=0,31) and Ev/Ep (r=-0,34).
Conclusions: Contrary to classic mitral inﬂow parameters velocity of mitral E wave
propagation correlated signiﬁcantly with systolic function. It seems that impairment
of elastic recoil or asynchrony of diastolic motion in pts with contractility impairment
may inﬂuence early ﬁlling decreasing especially early propagation velocity.
S5
126
Gender-related differences of diastolic function in normal subjects and
patients with coronary artery disease.
K. Wierzbowska, J. Drozdz, J.D. Kasprzak, M. Krzeminska-Pakula. Medical
University of Lodz, Cardiology Dept., Lodz, Poland
Background: Recent studies indicated on some gender-related differences in diastolic ﬁlling in hypertension. Wide spectrum of new Doppler methods and parameters encourage the reexamination of impact of gender on left ventricle diastolic
performance in other group of patients (pts).
Purpose: Our aim was to study if comprehensive assessment of diastolic function
detects any difference between normal male and female subjects and pts with
angiographically proved CAD with normal ejection fraction.
Methods: We examined 127 subjects: 70 male (34 healthy and 36 with CAD)
and 57 female (33 healthy) by transthoracic echocardiography with assessment
of classic mitral and pulmonary veins ﬂow, propagation of mitral waves and tissue
Doppler variables of mitral annulus motion (TDE). Male (M) and female (F) group
were paired with regard to age, heart rate and medical treatment. We compared
separately healthy (34 M: mean age 51±13, and 33 F: mean age 53±11) and CAD
group (36 M: mean age 56±10 and 24 F: mean age 60±10).
Results: Among classic diastolic parameters in healthy subjects velocity of early
wave of mitral inﬂow (Ev) and systolic wave of pulmonary vein ﬂow (S) were signiﬁcantly higher in F: (respectively 77±18 vs 65±19 cm/s and 64±14 vs 57±11 cm/s;
p<0,05). Among propagation parameters atrial wave propagation velocity (Ap) was
lower in F: (43±12 vs 50±12 cm/s; p<0,05), early propagation to atrial propagation ratio (Ep/Ap) was higher in F: (1,1±0,5 vs0,8±0,3; p<0,05) and atrial mitral
inﬂow velocity to atrial propagation ratio (Av/Ap) was also higher in F: (1,6±0,5 vs
1,3±0,5; p<0,05). Analysis of TDE showed higher values of atrial (A’v) and systolic
(S’v) velocities of mitral annulus (m. a.) in M: (13±2 vs 12±2 cm/s and 11±2 vs
10±2 cm/s; p<0,05)and higher early inﬂow velocity to early annulus velocity ratio
(E/E’v) in F: (7,1±2 vs 5,9±1,5; p<0,01) for parameters calculated from six points
of m. a. For lateral segment of m. a. only E/E’v ratio was higher in F: (6,7±2,6 vs
5,1±1,4; p<0,01).
In CAD pts we observed higher E/A ratio in M: (1,1±0,5 vs 0,8±0,2; p<0,05),
atrial inﬂow velocity (Av) and atrial velocity to atrial propagation ratio (Av/Ap) in F:
(78±24 vs 64±17 cm/s; p<0,007 and 1,6±0,5 and 1,3±0,5; p<0,05, respectively).
Conclusions: Our data sugest tendency to slower early diastolic ﬁlling in healthy
men in comparison to aged-matched women and opposite relationship in CAD
patients. Contrary TDE velocities showed trend to lower values in healthy women
and the strongest statistical signiﬁcance was shown for higher E/E’v ratio in F.
127
Isovolumic index and left atrial and ventricular ﬁlling in patients right
and left ventricular total ejection with chronic obstructive lung disease.
G.M.A. Nasr, Mahmoud El Prince, Khalil A. Khlalil. Suez Canal Hospital,
Cardiology, Ismallia, Egypt
Abnormal left ventricular (LV) diastolic function has frequently been reported in
patients with chronic obstructive pulmonary disease (COPD).
Methods: In the present work we studied 40 patients with COPD clinically stable
and without history of heart disease and 40 control subjects. Right left ventricular
diastolic & systolic diameters, pulmonary artery pressure, left atrium diameter, left
ventricular diastolic & systolic diameters, Left ventricular mass index, Ejection fraction, E velocity, A velocity, E/A ratio were determined. Diastolic function was also
studied by a combined analysis of pulmonary venous and mitral blood ﬂow velocities. Estimations of LA pressure were obtained from the comparison of mitral and
pulmonary venous ﬂow velocities Isovolumetric relaxation time (IRT), isovolumetric contraction time (ICT), ejection time (ET) and the combined index of myocardial
performance (Total isovolumic ejection time index = IRT + ICT/ET), were calculated by echocardiography Doppler for both the right and left ventricle. Contribution
of the atrial contraction to the LV ﬁlling in COPD patients in comparison with control
subjects was also assessed.
Results: The increased contribution of the atrial contraction to the LV ﬁlling in
COPD patients in comparison with control subjects was conﬁrmed; furthermore,
a decreased left atrial (LA) ﬁlling during the ventricular systole was observed.
Changes in LV ﬁlling were not the consequence of a systolic dysfunction based
on the ejection fraction because as it was normal. However the combined myocardial performance unmasked presence of both left and right ventricular dysfunction.
Doppler indices indicated that LA pressure was below 15 cm H20 in all the patients
with COPD and control subjects.
Conclusion: Analysis of Doppler transmitral and pulmonary venous ﬂows demonstrated the role of the ventricular interdependence because a correlation existed
between LA and LV ﬁlling pattern and right ventricle pressure and diameter. Total isovolumic ejection time index could be a sensitive index for detecting early
changes in both right and left ventriclular combined performance in COPD patients. Also we strongly advocate the use of noninvasive indicators of right ventricular performance in patients with pulmonary disease as a means of identifying
those at high risk This new echocardiographic technique can be incorporated into
a conventional transthoracic study.
Eur J Echocardiography Abstracts Supplement, December 2003
S6
Abstracts
128
Incremental value of E/Vp in characterization of systolo-diastolic
dysfunctions in heart failure: a BNP study.
130
Diastolic ﬁlling vortex in the normal left ventricle.
M.V. Luong 1 , M.O. Benoit 2 , J.L. Paul 2 , E. Abergel 3 , H. Raffoul 3 , R. Khedim 3 ,
L. Auziere 3 , H. Diebold 3 , B. Diebold 3 . 1 Georges Pompidou European Hospital,
Cardiology department, Paris, France; 2 Hopital Europeen Georges Pompidou,
Biochemical department, Paris, France; 3 Hopital Europeen Georges Pompidou,
Cardiology department, Paris, France
Aim: To evaluate the incremental value of sophisticated evaluation of leftventricular ﬁlling pressure for determining systolo-diastolic interactions.
Methods: 51 patients underwent echography to evaluate systolic (ejection fraction
(EF)), and diastolic functions (mitral Doppler for E/A, deceleration time(DT), E wave
ﬂow propagation velocity (Vp), early diastolic velocity of lateral mitral annulus (Ea))
and BNP.
Results: Signiﬁcant increases of BNP between the 3 tertiles for E/Vp(p<0.01),
E/Ea,E/A(p<0.05), DT, EF, PAP(p<0.001)were obtained. Combination of EF with
diastolic indexes provided "echographic severity" proﬁles associated with elevated
BNP(Table) and led to striking differences for EF and E/Vp (p<0.00001)(Picture).
Systolo-diastolic interactions and BNP
Systolo-diastolic model
Best tertile
Intermediate
Worse tertile
p
EF-E/Vp
EF-E/Ea
EF-DT
EF-Restrictive pattern
EF/E/A
227±80
244±91
255±85
327±76
296±107
490±80
536±86
522±100
547±94
469±91
890±81
811±89
797±81
893±101
783±111
<0.00001
<0.001
<0.001
<0.001
<0.05
For each X parameter:Best tertile: EF>50th percentile+ X best 50th percentile or non restrictive pattern.Worse tertile: EF<50th percentile+ X worse 50th percentile or restrictive pattern.
Restrictive pattern: E/A>2 and DT<150.BNP values are in pg/ml.
T. Ishizu 1 , T. Ishimitsu 2 , Y. Seo 2 , K. Obara 2 , N. Moriyama 2 , I. Yamaguchi 2 .
1
University of Tsukuba, Cardiovasuclar division, Tsukuba, Japan; 2 Tsukuba,
Japan
Objectives: The aim of this study was to clarify the diastolic ﬁlling ﬂow characteristics in the normal left ventricle.
Background: During left ventricular ﬁlling, basally oriented velocities are seen in
the outﬂow compartment. These velocities may represent vortex formation at basal
level or blood returned from the apical region.
Methods: Left ventricular ﬂow patterns were visualized in 13 healthy individuals
(age 33 ± 8 years) with the use of contrast enhanced two-dimensional echocardiography techniques. Intraventricular microbubble traces were identiﬁed by frameby-frame analyses of the apical long axis view (frame rate 86 or 121 Hz).
Results: During early transmitral ﬂow acceleration, two or three mushroomshaped-ﬂuid components were created in sequence. Around the mitral valve maximum opening and semi-closure, the anterior part of the mushroom-shaped-ﬂuid
component, which was at the level of the mid-ventricle, moved toward basally and
create the clockwise swirling vortex occupying the outﬂow compartment behind the
anterior mitral leaﬂet. Other mushroom-shaped ﬂuid components transformed into
the several vortices and traveled to the apical region, which represent the apical
branches of the E wave on the M-mode color Doppler. During diastasis, vortices
breakdown occurred in basal left ventricle.
Conclusion: A common diastolic ﬂow characteristic was identiﬁed in the normal
left ventricle. The results revealed that the retrograde velocities in the outﬂow compartment were the part of the ﬁlling ﬂow vortex at the basal left ventricle behind the
anterior mitral leaﬂet. The returned ﬂow from the apical region into the outﬂow was
not observed during early diastole in normal human heart.
131
Mitral E- wave velocity to inﬂow propagation velocity ratio in assessment
of left ventricular diastolic function in patients with low ejection fraction.
A. Wojtarowicz, M. Peregud-Pogorzelska, E. Ploñska. Department of Cardiology,
Szczecin, Poland
E/Vp-EF interaction and BNP
Conclusion: In patients suspected of heart failure, BNP levels are related to systolic dysfunction but also by the severity of associated diastolic dysfunction.
129
Serun n-terminal pro-brain natriuretic peptide is a sensitive marker of
diastolic dysfunction in non-obstructive hypertrophic cardiomyopathy.
A. araujo, E. Arteaga, R. Rabelo, P. Buck, B. Ianni, C. Mady. Heart Institute - Sao
Paulo University, Cardiopatias Gerais, Sao Paulo, Brazil
Background: Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is a
marker of ventricular function ih heart failure.
Objective: we sought to investigate the diagnostic value of NT-proBNP in patients
(pts) with non-obstructive hypertrophic cardiomyopathy (NOHCM) and its utility in
determining the degree of LV diastolic dysfunction.
Methods and Results: NT-proBNP was quantiﬁed in 40 pts with NOHCM and in
20 normal volunteers (control group). The concentrations differed between pts and
normals (mean 1095 pg/ml versus 41 pg/ml, p<0.0001). The maximal serum value
in the control group was 115 pg/ml. Assuming this cutoff the test had sensitivity
78%, especiﬁcity 100% and accuracy 85%. Among the pts the best overall correlation of NT-proBNP and echodopplercardiographic indexes was with left atrium
(LA) diameter (r=0.52). There were no consistent correlations with indexes derived
from mitral ﬂow, pulmonary venous ﬂow, tissue doppler imaging and myocardial
thickeness. Pts with LA >50mm had a mean value of 2482 pg/ml and those with
LA betweeen 41-50mm 732 pg/ml; p<0.0005. Pts with a difference > 30 ms between the durations of pulmonary venous A reverse wave and mitral ﬂow A wave
had a mean value of 1773 pg/ml as compared with 567 pg/ml of those pts with a
difference < 30ms; p<0.0002. Pts with E/Ea ratio >10.0 (mitral E wave velocity/Ea
mitral annular longitudinal velocity) had a mean NT-proBNP 2420 pg/ml and those
with E/Ea <10.0, 954 pg/ml; p=0.004.
Conclusion: we concluded that serum NT-proBNP is a sensitive diagnostic test
for NOHCM and a strong predictor of LV diastolic dysfunction in such patients, with
potential usefulness for monitoring therapeuthic responses.
Eur J Echocardiography Abstracts Supplement, December 2003
Left ventricular (LV) diastolic function is an important diagnostic and prognostic factor in many clinical states. Inﬂow propagation velocity (Prop) is known as preload
independent method in LV diastolic function estimation, however in patients with
low LV ejection fraction (EF) with unfavorable restrictive ﬁlling pattern (RES) further Prop decrease is not found. The aim of our work was to evaluate of mitral E
wave velocity to Prop ratio (E/Prop) as a potentially more sensitive than Prop index
in LV diastolic dysfunction estimation in pts with low EF.
The studied groups enrolled 134 individuals with EF < 35%, on sinus rhythm and
without signiﬁcant valvular diseases. The patients were divided into three groups:
1) with impaired relaxation (REL) - 39 pts; 2) with pseudonormal pattern (PN) –
53 pts; and 3) with restrictive ﬂow pattern (RES) – 42 pts. The studied groups did
not differ signiﬁcantly regarding age, heart rate and EF values. In control group
was 25 healthy persons. Inﬂow pattern was measured on mitral oriﬁce level by
PW-Doppler, and Prop in 4 chamber apical view using M-mode color Doppler.
Results: In control group the values of the studied parameters were as follows:
Prop 69±10,9 m/s, and E/Prop 0,93±0,23. Maximal value of E/Prop was 1,3. In
the studied groups the Prop values were as follows: in RES 39,1±9,0 m/s, in
PN 37,7±7,3 m/s, and in REL 33,2±8,8 m/s. The differences between REL and
other groups were signiﬁcant (P<0,01). The E/Prop values were as follows: in the
RES group- 2,5 ± 0,6; PN- 2,12 ± 0,7, and REL- 1,45 ± 0,6. The differences between all studied groups was statistically signiﬁcant (REL vs the remaining groups:
P<0,0001, RES vs PN: P<0,01). In all patients in assessed groups Prop was
lower, and E/Prop higher, than in healthy individuals.
Conclusions:
1. LV function impairment cause decrease of Prop and increase of E/Prop ratio.
2. In similar LV systolic function impairment, E/Prop ratio is higher in more pronounced diastolic dysfunction.
Abstracts
132
Increased arterial stiffness is associated with left ventricular diastolic
dysfunction in patients with Adamantiades-Behcet’s disease.
I. Ikonomidis 1 , A. Protogerou 2 , J. Lekakis 2 , K. Stamatelopoulos 2 ,
K. Aznaouridis 2 , E. Karatzis 2 , N. Markomihelakis 3 , P.H. Kaklamanis 3 ,
M. Mavrikakis 2 . 1 Alexandra Hospital, Univ. of Athens, Dep. of Clinical
Therapeutics, Athens, Greece; 2 Alexandra General Hospital, Clinical
Therapeutics Dept., Athens, Greece; 3 Athens Medical Center, Rheumatology,
Athens, Greece
Adamantiades-Behcet’s disease (ABD) is multisystem disorder characterized by
vasculitis leading to arterial aneurysm formation, stroke and arterial or venous occlusive disease. We investigated whether arterial stiffness is related with left ventricular (LV) dysfunction in patients with ABD.
Methods: We studied 73 patients with ABD (age 3911 years) by 2D and Doppler
echocardiography for assessment of thoracic and abdominal Ao (ABAO) diameters
(mm/BSA), LV diastolic function [E/A ratio, deceleration (DT-ms) and isovolumic
relaxation time (IVRT-ms)] and radial artery tonometry with pulse wave analysis
(Sphygmocor) for estimation of arterial stiffness [central augmentation index (CAI%), reﬂection time index,(RTI-%))]
Results: All patients had normal systolic LV function. Abnormal CAI and RTI were
related to increased ABAO diameters (r=0.36 and r=-0.28, P<0.01), prolonged DT
(r=0.37 and r=-0.32, P<0.01 respectively) and IVRT (r=-0.33 and r= -0.24, P<0.01
respectively). Patients with CAI>125 ms (n=36) or RTI<14 (n=39) had increased
ABAO diameter, DT and IVRT than those with CAI<125 or RTI>14 (table). CAI
>125 would predict an IVRT >95 with 72% sensitivity and 61% speciﬁcity (ROC
curve area:71% (CI:57-83)).
CAI
>125 (n=36)
<125(n=37)
p
DT
IVRT
ABAO
RTI
DT
IVRT
ABAO
210±40
189±37
<0.01
92±16
83±15
<0.01
11±1.8
9.7±1.3
<0.01
<14(n=39)
>14(n=34)
p
208±41
189±36
<0.01
92±16
83±15
<0.01
10.5±1.5
9.9±1.7
<0.01
Conclusion: Patients with ABD present increased aortic diameters, associated
with signiﬁcant arterial stiffness possibly due to vasa vasorum vasculitis. Increased
arterial stiffness may reduce coronary blood ﬂow or increase LV afterload and thus,
cause signiﬁcant LV diastolic dysfunction in these patients.
133
Pulmonary venous ﬂow pattern indicates diastolic dysfunction in atrial
ﬁbrillation.
M. Lengyel 1 , C.S. Farsang 2 , A. Zorándi 1 . 1 Gottsegen G. Hung.Inst.of Cardiology,
Budapest, Hungary; 2 St. Imre Hospital, Budapest, Hungary
The value of pulmonary venous ﬂow (PVF) pattern in the assessment of diastolic
function in atrial ﬁbrillation (AF) is unclear. The objective of this study was to assess
the effect of AF with and without heart failure (HF) on PVF. 52 pts (25 males) with
hypertension (HT) and no valvular heart disease were prospectively studied. 2
groups had AF: GI without HF (13 pts, age 74±8.4 yrs), GII with HF (15 pts, age
80.6±7.8 yrs). 24 pts had sinus rhythm (SR): GIII with HF (12 pts, age 73.3±9.6
yrs), GIV without HF (12 pts, age 75.3±7.1 yrs). NYHA class, heart rate (HR)
and transthoracic echo variables were measured or calculated: ejection fraction
(EF), E/A, pulmonary artery systolic pressure (PASP), left atrial dimension (LA)
and pulmonary venous systolic/diastolic ﬂow velocity ratio (S/D).
Results: There was no difference in age between the groups. HR and PASP
were signiﬁcantly higher in GII than GI (93.7±28.8 vs 73.5±13.8/min, p=0.029;
50.1±14.4 vs 31.8±6.2 mmHg, p=0.0017 resp), but there was no difference in EF,
LA and S/D (0.4±0.15 vs 0.58±0.29). NYHA, HR were higher and S/D lower in GII
than in GIII (3.4±0.6 vs 2.8±0.7, p=0.03; 93.7±28.8 vs 72.2±9.7/min, p=0.02 and
0.4±0.15 vs 0.63±0.38, p=0.05 resp), but there was no difference in EF, PASP and
LA. In control GIV EF (65.7±8.1%) and S/D (1.49±0.38) was signiﬁcantly higher
than in all other groups. In SR there was no difference in HR, PASP and LA between GIII and IV, but E/A was signiﬁcantly lower (1.2±0.5 vs 2.2±0.5, p<0.0001)
in GIV than in GIII. Signiﬁcant negative correlations were found in the whole patient
population between S/D and NYHA (r=-0.52, p<0.001) and in SR between S/D and
E/A (r=-0.86, p<0.001) but there was no correlation between S/D and age.
Conclusion: decreased S/D in AF is independent of age, HT and HF; it probably
indicates impaired diastolic function in AF.
134
Assessment of left ventricular diastolic pressures in patients with
coronary artery disease: usefulness of the Tei index.
C. David 1 , A G. Almeida 2 , E I. Oliveira 2 , P. Marques 2 , J C. Cunha 2 , M
C. Vagueiro 2 . 1 Hospital de Santa Maria, Cardiology Dept, Lisbon, Portugal;
2
Hospital de Santa Maria, Cardiology, Lisbon, Portugal
Left ventricular (LV) diastolic pressures are affected by LV contraction, relaxation
and compliance, among other factors. Tei index, being inﬂuenced by LV diastolic
and systolic functions, may be useful in the estimation of LV ﬁlling pressures. However, there are contradictory data about the utility of this index in patients with
coronary artery disease.
Purpose: To evaluate the usefulness of Tei Index, assessed by transthoracic
Doppler echocardiography, in the estimation of LV diastolic pressures, in patients
with ischemic heart disease.
S7
Methods: Thirty-nine patients with coronary artery disease and referred for coronary angiography; all were in sinus rhythm and had no known valvular heart disease or chronic pulmonary disease. After conventional 2-D and Doppler examination, Tei index was calculated as the sum of the isovolumic contraction and relaxation times divided by ejection time. These data were correlated with the values of
LV ﬁlling pressures obtained during left heart catheterisation.
Results: Tei index was reproducibly measured in all the patients. We found signiﬁcant correlations of Tei index with LV end-diastolic pressure (r=0.74; p<0.01, chart)
and with pre-"a" wave LV diastolic pressure (r=0.66; p<0.01).
In this study, there were 28 patients with mitral ﬂow E/A > or = 1. Values of Tei index
> or = 0.55 differentiate pseudonormal mitral inﬂow (deﬁned as E/A > or = 1 and
LV diastolic pressure > 15 mmHg) from normal mitral inﬂow with high sensitivity
(89%), speciﬁcity (92%) and accuracy (90%).
Conclusions: In patients with coronary heart disease, Tei index is easily obtained
and useful in the assessment of LV ﬁlling pressures and may be used to identify
patients with pseudonormal mitral inﬂow.
135
Left ventricular diastolic dysfunction in unstable angina.
I. Vlasseros 1 , P. Stougiannos 1 , A. Kartalis 1 , D. Syrogiannidis 1 , I. Pylarinos 1 ,
A. Katsimichas 1 , G. Triantafyllou 2 , I. Kallikazaros 1 . 1 Hippokration Hospital, State
Cardiology Clinic, Athens, Greece; 2 Galatsi-Athens, Greece
Introduction: Coronary artery disease (CAD), in its various clinical presentations,
is often associated with systolic as well as diastolic left ventricular dysfunction
(LVDD). The purpose of this study is to evaluate the presence of LVDD in patients
with unstable angina (UA) using various echocardiographic techniques.
Methods: We studied 52 patients (pts) (39 male, 13 female, 65+12 years old) who
were treated in our department suffering from UA. They were evaluated for the
presence of LVDD, within 3 days from the onset of symptoms, by estimating: i)
the E and A waves, as well as the E/A ratio from the transmitral diastolic ﬂow, ii)
the e and a waves, as well as the e/a ratio, from the pulsed-wave Tissue Doppler
Imaging of the mitral annulus and iii) the ﬂow propagation velocity (VP) (cm/sec)
from the color M-mode of the diastolic mitral inﬂow.
Results: The E/A was <1 in 35/52 (69%) pts, the e/a was <1 in 48/52 (92%) pts
and the VP was less than 40 in 31/52 (60%) pts. 100% of pts with E/A <1 had also
e/a <1, while 23/36 (64%) pts had a VP less than 40. Among the pts with e/a <1,
34/48 (71%) had E/A <1, while 19/48 (40%) pts had a VP less than 40.
Conclusions: It seems the LVDD is quite frequent in pts with CAD presenting with
symptoms and signs of UA. It is easily detected with various echocardiographic
techniques, while the most modern of them seems to be far more sensitive for
its detection. Its presence may also be a signiﬁcant prognostic factor that needs
further investigation.
136
Systolic and diastolic left ventricular function in adolescents and young
adults with end-stage renal disease. Comparative study before and after
hemodialysis.
A. Siwinska 1 , W. Bobkowski 1 , J. Zachwieja 2 , H. Gorzna-Kaminska 1 ,
B. Mrozinski 1 , E. Stefaniak 2 , A. Warzywoda 2 . 1 University of Medical Sciences,
Department of Pediatric Cardiology, Poznan, Poland; 2 University of Medical
Sciences, Department of Pediatric Nephrology, Poznan, Poland
Background: Cardiovascular disease is the leading cause of mortality in patients
(pts) with end stage renal disease (ESRD) on maintenance hemodialysis (HD).
Congestive heart failure is the most frequent fatal complication. Therefore the diagnosis and treatment of such cardiovascular lesions is very important for improving
long-term survival.
Methods: The aims of this study were Doppler echocardiographic quantify LV enddiastolic and end-systolic volume indexes (LVEDVI, LVESVI), LV cardiac index (CI),
systemic vascular resistance index (SVRI) and LV diastolic and systolic function
in 30 pts with ESRD aged between 14 and 23 (17.3±3.6yrs), before and after HD
(bHD; aHD). ECHO parameters were compared with similar variables in 50 healthy
adolescents and adults (N). These measurements were performed according to
the guidelines of the American Society of Echocardiography.
Results: We found a signiﬁcant decrease of LVEDVI (cm3 /m2 : bHD = 138.7±10.4,
aHD = 110.8±10.4, N = 67.6±5.39), LVESVI (cm3 /m2 : bHD = 70.3±8.2, aHD =
58.7±6.8, N = 67.6±5.39) and CI (l/min/m2 : bHD = 7.9±0.9, aHD = 5.0±0.9, N =
3,9±1.1), correlated with weight loss and reduction in preload after HD (r = 0.1285,
r = 0.1246, r = 0.1342 respectively; p < 0.05). LVEF, LV% SF and SVRI. were normal and did not change after HD [(LVEF %: bHD = 64.8±3.8; aHD = 65.3±5.6;
N = 61.21±2.9), (LVSF %: bHD = 37.3±7.5; aHD = 36.6.5±6.7; N = 34.4±2.9),
(SVRI kPA.s/1: bHD = 196.4±13.6; aHD = 187.6±10.2; N = 188±10.3)]. HD patients had some impairment in LV diastolic function. MV E/A ratio was signiﬁcantly
decreased before and increased after HD, DCT and IVRT prolonged before and
signiﬁcantly decreased after HD (bHD MV E/A = 1.11±0.17, DCT = 198.5±23ms,
IVRT = 91.8±6.8ms; aHD MV E/A = 1.47±0.11, DCT = 170.8±25ms, IVRT =
65.9±6.3ms; N: MV E/A = 1.94±0.14, DCT = 150.3±22ms, IVRT = 71.4±6.3ms).
Conclusions: 1. In adolescents and young adults with ESRD HD trough the reduction in preload change LV function decreases CI, and do not change LV contractility
and SVR. 2. Impaired LV diastolic function is reversible after HD in some patients
with ESRD.
Eur J Echocardiography Abstracts Supplement, December 2003
S8
Abstracts
137
Lack of association between ACE gene polymorphism and left
ventricular systolic function and diastolic ﬁlling pattern in patients with
systolic heart failure.
E. Straburzynska-Migaj 1 , E. Chmara 2 , A. Szyszka 1 , O. Trojnarska 1 ,
L. Lastowska 2 , A. Jablecka 2 , A. Cieslinski 2 . 1 1st Dept. of Cardiology, Poznan;
2
Univ. School of Med. Sciences, Dept. of Clinical Pharmacology, Poznan, Poland
Relationship have been frequently found between angiotensin-converting enzyme
(ACE) genotype and various pathological and physiological cardiovascular outcomes and functions. It is not clear if there is an association between left ventricular systolic function and ACE genotype in patients with idiopathic dilated cardiomyopathy. We did not ﬁnd any information about relationship between diastolic
pattern and ACE genotype. We evaluated the relationship between left ventricular systolic function and diastolic ﬁlling pattern and ACE genotype in patients with
systolic heart failure due to ischemic heart disease (ICM - 22 pts) and dilated cardiomyopathy (DCM - 39 pts). They were 61 pts with LVEF less or equal to 40%,
NYHA class I - IV. The DD, ID and II genotypes were present in 23 pts (38%), 24
pts (39%) and 14 (23%) respectively. The genotype distribution was similar to that
of European control sample from Cambien et al. Echocardiography was performed
in all patients. Evaluating diastolic ﬁlling pattern we separated patients with restrictive and nonrestrictive pattern (restrictive - E/A ratio > 2 or between 1 and 2 with
E wave deceleration time less or equal to 130 ms). Considering age, duration of
symptoms, NYHA class, LVEDD, LVEF we have not found signiﬁcant differences
between groups (duration of symptoms in DD, ID, II groups: 45 months, 38 months,
and 34 months; p = n.s.,LVEDD in DD, ID, II groups: 70,3mm, 74,2 mm, 71,7 mm
respectively; p = n.s.; LVEF in DD, ID, II groups: 27,6%, 24,8%, and 25,8% respectively; p = n.s.). There was also no signiﬁcant difference in the distribution of
restrictive pattern between groups (DD, ID, II groups: 70%, 60% and 40% respectively; p = n.s.).
Conclusion: We ﬁnd no evidence to support an association between ACE genotype and left ventricular systolic function and ﬁlling pattern.
138
Does "pure" diastolic dysfunction exist in systemic sclerosis?
C. Stanescu 1 , D. Sipciu 2 , G.H.A. Dan 2 , B. Militescu 3 , S. Tanaseanu 4 ,
C. Tanasescu 4 . 1 Bucharest, Romania; 2 Colentina University Hospital, Cardiology,
Bucharest, Romania; 3 Medicover Rombel, Grozovici, Bucharest, Romania;
4
Colentina University Hospital, Internal Medicine, Bucharest, Romania
Systemic sclerosis (SS) is an autoimune disease frequently associated with cardiac involvement, mainly pulmonary hypertension and alteration of myocardial
function. SS related mortality is in particular attributable to heart failure. The prevalence of systolic and diastolic functional abnormalities, mainly in the asymptomatic
patient with SS is not well deﬁned. Patients (pts) with SS usually have diastolic dysfunction, as assessed by Doppler transmitral ﬂow, with preserved systolic function,
as assessed by ejection fraction. The velocities measured at the mitral annulus by
pulsed tissue Doppler imaging (pTDI) are likely to be indexes of global longitudinal
function of the left ventricle.
The aim of the study was to evaluate in such pts, by means of pTDI, the longitudinal
subendocardial systolic function, which could be altered even in the presence of a
normal radial systolic function, expressed by a normal ejection fraction.
Methods: We studied 34 pts with SS, 42.6 ± 7.4 years old, 91.1% women, who
had normal ejection fraction, calculated from B-mode images according to Simpson’s rule and an E/A ratio < 1, calculated from transmitral ﬂow. Systolic (Sa) and
diastolic velocities (Ea, Aa) were measured by pTDI at the mitral annulus at six
sites (lateral, septal, anterior, inferior, posterior and antero-septal), from three apical views (4-chamber, 2-chamber, and long-axis view), and were averaged. Ea/Aa
ratio was calculated for each site and averaged.
Results: The average Sa was 6.88 ± 1.78 cm/s. The average Ea/Aa ratio was
0.82 ± 0.1.4. Sa demonstrated a good correlation with Ea/Aa (r = 0.69).
Conclusions: Patients with systemic sclerosis who seem to have pure diastolic
dysfunction, might have also systolic sudendocardial dysfunction, as assessed in
longitudinal axis, by measuring mitral annulus velocities with pulsed TDI.
139
Detection of pseudonormalization of left ventricular diastolic
dysfunction by color m-mode echocardiography in asymptomatic
non-insulin-dependent diabetes mellitus patients.
G. Bajraktari 1 , S. Qirko 2 , A. Bakalli 1 , N. Zeqiri 1 , N. Rexhepaj 1 , M. Ajeti 1 ,
F. Hima 1 . 1 University Hospital Center, Service of Cardiology, Prishtina, Albania;
2
UHC "Mother Teresa", Second Clinic of Cardiology, Tirana, Albania
Objective: The aim of this study was to detect the pseudonormalization of left
ventricular diastolic dysfunction in patients with non-insulin-dependent diabetes
mellitus (NIDDM).
Methods: We studied 103 patients with NIDDM (with age 57±8.2 years, 34 men)
and no clinical evidence for ischemic heart disease (Group 1) and 103 subjects
without diabetes as a control group (Group 2) matched by age and sex. Twodimensional, M-mode and pulsed-Doppler echocardiography were performed to
assess LV systolic and diastolic function. Color M-mode echocardiography was
performed in patients with normal pulsed-Doppler ﬁndings. To exclude the presence of coronary artery disease, exercise test with treadmill was performed.
Results: The E/A ratio of mitral inﬂow registered by pulsed-Doppler indices
Eur J Echocardiography Abstracts Supplement, December 2003
had signiﬁcant differences between Group 1 and Group 2 patients (0.83±0.3 vs
1.16±0.38, p<0.01) and it was found in 71 (68.9%) patients of Gruop 1 and in
36 (34.9%) subjects of Group 2 (p<0.01). There was also signiﬁcant difference
of deceleration time of E wave (173±20.7ms vs 163.5±31.4ms, p<0.01) between
groups. Seven patients from group 1 and 3 subjects from group 2 with E/A >1
resulted with velocity propagation (Vp) <55cm/s. This was a signiﬁcant difference
between groups (p<0.01).
Conclusions: Left ventricular diastolic function is reduced in NIDDM patients with
no symptoms of cardiovascular disease and with negative exercise test. The prevalence of pseudonormalization was signiﬁcantly higher in NIDDM patients than in
control subjects.
140
Inﬂuence of coronary angioplasty and subsequent restenosis on
Doppler indices of left ventricular diastolic function in patients with
preserved left ventricular systolic performance.
W. Kosmala, M. Przewlocka-Kosmala. Medical University, Cardiology, Wroclaw,
Poland
There are conﬂicting data on the timing of improvement of left ventricular diastolic function (LVDF) after PTCA, as well as which Doppler indices of LVDF are
predominantly inﬂuenced by restenosis.
Aim: To investigate the effect of PTCA and restenosis on Doppler indices of LVDF
in pts with preserved left ventricular systolic performance.
Material and methods: Studied group consisted of 81 pts aged 63.2±10.4 years
with stable effort angina, LVEF>50% and single vessel disease reffered for elective
PTCA. Echo study was performed before and 3 days, 1, 3 and 6 months after PTCA
and included estimation of: peak velocity of early (E) and late (A) transmitral ﬂow,
deceleration time of E wave (DT), isovolumic relaxation time (IVRT), duration of
A wave (Adur), total ejection isovolume index (TEI), E (ETT) and A (ATT) wave
transit time to the LV outﬂow tract, ﬂow propagation velocity of E wave (Ep), peak
velocity of systolic (S), diastolic (D) and atrial reversal (AR) pulmonary venous ﬂow,
duration of AR wave (ARdur).
Results: None of evaluated parameters changed signﬁcantly 3 days after PTCA.
After 1 month ETT decreased signiﬁcantly from 134±28 at baseline to 120±27
ms (p<0.01). After 3 months signiﬁcant increase in Ep (46.8±19.3 vs 52.7±19.9
cm/s, p<0.02) and decrease in E/Ep (1.46±0.43 vs 1.26±0.36, p<0.03) and ARdur/Adur (1.22±0.22 vs 1.09±0.16, p<0.01) was found out. After 6 months signiﬁcant decrease in IVRT from 106±22 to 97±21 ms (p<0.03) was noted. Other
Doppler parameters did not alter during observation. Restenosis was conﬁrmed
angiographically in 16 pts and was followed by signiﬁcant increase in ETT and
E/Ep and decrease in Ep compared to the last preceding examination (136±-24 vs
109±24 ms, p<0.001; 1.46±0.49 vs 1.27±0.51, p<0.03; 46.1±19.8 vs 54.2±20.9
cm/s, p<0.01, respectively).
Conclusion: In conclusion: (1) Signiﬁcant improvement in LVDF after succesfull
PTCA in patients with preserved left ventricular systolic performance is evidenced
the most early by decrease in ETT and later by increase in Ep, decrease in E/Ep,
ARdur/Adur and IVRT. (2) ETT, Ep and E/Ep are the best indicators of worsening
of LVDF as a consequence of restenosis of coronary artery.
141
Pulmonary venous inﬂow shows impairment of left ventricle relaxation
in young healthy smokers
B. Lichodziejewska, K. Kurnicka, M. Ciurzyñski, J. Malysz, A. Lipiñska,
D. Liszewska-Pfejfer. Medical University, Internal Medicine and Cardiology,
Warsaw; Poland
The impairment of left ventricular diastolic function (LV-DF) causing changes of
mitral ﬂow (MVF) was shown in smoking healthy persons and with IHD or arterial
hypertension. The aim of our study was to examine the pulmonary venous ﬂow
(PVF) in young healthy smokers.
Material and Methods: The study group (HS) consisted of 30 healthy smokers
(16 women, 14 men; age 22 - 40, mean 32) used to smoke about from 10 to
25 (mean18) cigarettes/day from 6 to 20 (mean 13) years. The control group (C)
completed 30 healthy non-smokers (16 women,14 men; age 20 - 40, mean 30).
BMI in both groups was < 25. In ECHO the parameters of LV-DF was measured.
Results: MVF assessment: maximal velocity (Vel max; cm/sec) of early phase
(E) was lower in HS group than in C group(without statistic signiﬁcance - NS);
Vel max of late phase (A), was higher in HS than C group (NS) so the MV E/A
ratio was signiﬁcantly lower in smokers than in control group (1.3 SD 0.2 vs 1.5
SD 0.3; p< 0.02); deceleration time of MVF-E and isovolumetric relaxation time
did not change signiﬁcantly. PVF assessment: Vel max of systolic ﬂow (S) was
higher in HS group than C (NS), Vel max (cm/sec) of diastolic ﬂow (D) was lower
in HS than C group (50 SD 9 vs 55 SD 8, p<0.05); so the PVF S/D ratio was
signiﬁcantly higher in smokers than in control group (1.1 SD 0.2 vs 0.9 SD 0.3;
p< 0.02). The changes of MVF E/A ratio between group C and HS suggest the
impairment of LV- DF in smokers, but E/A still remain normal for this age group.
The PVF S/D was signiﬁcantly higher in smokers with a proﬁle (S/D >1) typical
for impaired LV relaxation in this age group. Heart rate and blood pressure did not
differ signiﬁcantly between both groups.
Conclusions: 1. The assessment of pulmonary venous ﬂow is a good method to
reﬂect LV diastolic function, even when mitral valve ﬂow remains normal. 2. The
S/D ratio of pulmonary venous ﬂow in young healthy smokers shows impairment
of LV relaxation, when mitral valve ﬂow E/A is normal.
Abstracts
S9
142
Can BNP be a useful tool for predicting severe diastolic dysfunction in
patients with chronic heart failure?
144
Association of wall motion score index with left ventricular diastolic
function and ﬁlling pressures.
Ab. Scardovi, C. Coletta, N. Aspromonte, A. Sestili, T. Di Giacomo, M. Romano,
M. Renzi, M. Greggi, V. Ceci. S.Spirito Hospital, Cardiology, Rome, Italy
A.C. Popescu 1 , B.A. Popescu 2 , M.S. Feinberg 3 , V. Guetta 3 , S. Rath 3 , M. Eldar 3 ,
E. Schwammenthal 3 . 1 University Hospital, Cardiology Department, Bucharest,
Romania; 2 Institute of Cardiology, Bucharest, Romania; 3 Heart Institute, Sheba
Medical Center, Tel Hashomer, Israel
The assessment of severe diastolic disfunction (SDD) plays a major role for the
prediction of outcome in patients (pts) with chronic heart failure (CHF). In these
pts, Doppler echocardiography (DE) remains the ﬁrst choice non- invasive technique, but other parameters could be alternatively utilized for a wider and cheaper
screening of SDD in mildly symptomatic populations. Indeed, we sought to determine the accuracy of BNP, a cardiac neurohormone directly correlated to both left
ventricular ﬁlling and pulmonary capillary wedge pressure, for predicting SDD.
Methods: One-hundred sixty four consecutive pts (age: 70 ± 11; F 34%; betablocker therapy: 53%; ischemic 52%; NYHA functional class: I: 8%; II: 68%; III:
24%; mean ejection fraction: 41 + 12%) were considered. BNP plasma level was
measured by means of the "Triage System" (Biosite Diagnostic, Triage BNP Test).
SDD was deﬁned by peak mitral early diastolic velocity/peak late diastolic velocity
ratio (E/A ratio > 1) and E deceleration time < 140 msec.
Results: 54/164 PTS had DE criteria of SDD (33%); mean BNP was 502.30±
340.9 pg/ml in pts with SDD and 75.44 ± 122.8 in pts without SDD (p< 0.001). The
receiving-operator (ROC) curves demonstrated BNP 3 138,5 pg/ml to be the best
cut-off for determining SDD, with 70% overall accuracy (Sensitivity: 72%, Speciﬁcity: 70%), area under the curve: 0,764. A value of BNP < 46 pg/ml reliably discriminated PTS without SDD (Negative predictive value: 93%).
Conclusions: BNP plasma levels could be helpful for the ﬁrst - step assessment
of SDD population referred with symptoms of CHF, improving the efﬁcacy of diagnostic ﬂow-chart in the individual patient.
143
Correlations between left-ventricular ﬁlling pressure echographic
parameters and BNP levels in patients suspected of heart failure.
M.V. Luong 1 , M.O. Benoit 2 , J.L. Paul 2 , H. Raffoul 1 , E. Abergel 1 , R. Khedim 1 ,
O. Nardi 1 , H. Diebold 1 , B. Diebold 1 . 1 Cardiology Department, 2 Biochemical
Department, Georges Pompidou European Hospital, Paris, France
Aim: High levels of B-natriuretic peptide (BNP) were related to systolic and diastolic dysfunctions or elevated systolic pulmonary artery pressure (PAP). We attempt to assess the correlations between BNP levels and combination of systolic
and diastolic parameters and PAP in patients suspected of heart failure.
Methods: We studied 51 patients who underwent echocardiography to evaluate
ventricular systolic function (ejection fraction (EF), PAP)), diastolic function (velocities of E and A mitral waves for E/A ratio, E wave deceleration time (DT), E wave
color M-mode Doppler ﬂow propagation velocity (Vp), peak E wave of the lateral
annulus velocity by Doppler tissue recordings (Ea)) for E/Vp and E/Ea ratio and
BNP blood test 48 hours within echography. Simple linear regression analysis was
used to evaluate the correlations between BNP and each parameter. Stepwise regression model was used to determine the best combined systolo-diastolic model.
Results: EF(45%±2.4; r=0.56/p<0.0001), E/Vp(2.1±0.1; r=0.52/p<0.001),
PAP(40mmHg±2; r=0.50/p<0.001), DT(181ms±11; r=0.42/p<0.01), E/A(1.4±0.2;
r=0.30/p=0.051) and E/Ea(11.4±0.7; r=0.27/p=0.053) signiﬁcantly correlated with
BNP(536pg/ml±60)levels. Stepwise regression model demonstrated that the combined "systolo-diastolic models" (EF-PAP with 1 to 4 diastolic parameters) determined BNP levels with correlation coefﬁcients above 0.64 (see Table). The best
model was the combined "E/Vp - EF - PAP" model with a correlation coefﬁcient of
0.75. Models with more variables didn’t provide signiﬁcant correlations.
Correlations: Stepwise regression model
Model size (parameters)
r
E/A
DT
E/Ea
E/Vp
EF
PAP
<0.0001
<0.001
<0.001
–
<0.0001
<0.01
–
<0.001
–
<0.001
<0.001
Table gives p value for each parameter when included in the combined model. r = R2
2 (EF-PAP)
2 (EF-E/Vp)
2 (EF-E/Ea)
2 (EF-DT)
2 (EF-E/A)
3 (E/Vp-EF-PAP)
0.701
0.646
0.579
0.577
0.594
0.749
–
–
–
–
0.171
–
–
–
0.31
–
–
–
0.17
–
–
–
<0.01
–
–
–
<0.01
Conclusion: In patients with heart failure, high levels of BNP mainly reﬂected systolic dysfunction and high PAP but were also signiﬁcantly modulated by associated
diastolic dysfunction.
Background: Coronary artery disease is characterized by regional myocardial
dysfunction affecting both contraction and relaxation. Because relaxation is impaired in any myocardial segment with wall motion abnormality, the wall motion
score index (WMSI) should not only reﬂect extent of systolic dysfunction, but also
extent of diastolic dysfunction.
Objectives: We therefore hypothesized that WMSI is able to separate patients
(pts) with clinical events of pulmonary congestion (elevated ﬁlling pressures) from
pts without pulmonary congestion and that WMSI correlates with left ventricular
end-diastolic pressure (LVEDP).
Methods: The study group consisted of 54 consecutively studied pts, divided into
two groups: group A included pts with clinical events of pulmonary congestion (24
pts, 22 men, mean age 64.2 ± 12.3 years) and group B consisted of pts without
pulmonary congestion (30 pts, 21 men, mean age 66 ± 10.7 years). In addition,
WMSI was assessed in a group of 18 consecutive pts (16 men, mean age 65.4
± 10 years) who underwent diagnostic cardiac catheterization including measurement of LVEDP.
Results: WMSI was signiﬁcantly higher in group A than in group B (2.12 ± 0.48 vs
1.25 ± 0.38, p <0.0001). Analysis of the receiver operating characteristic (ROC)
curve showed the best separation between the two groups for a cut-off value of
WMSI of 1.75 (sensitivity - 83.3%, speciﬁcity - 90% and accuracy - 87%). In pts
undergoing catheterization WMSI correlated well with LVEDP (r = 0.75, p <0.001).
Conclusions: WMSI has a high diagnostic accuracy in separating pts with a clinical event of pulmonary congestion from pts without such an event and correlates
well with directly measured LVEDP, which may indicate its association with diastolic dysfunction. WMSI should therefore not simply be regarded as a parameter of
systolic ventricular function but rather as an index of extent and severity of overall
myocardial segmental dysfunction.
145
Signiﬁcance of diastolic dysfunction in consecutive elderly patients
referred for surgical intervention.
M. Michalski 1 , R. Dankowski 1 , M. Kandziora 1 , W. Biegalski 1 , B. Ciesielczyk 2 ,
K. Poprawski 1 , M. Wierzchowiecki 1 . 1 University of Medical Sciences, 2nd
Department of Cardiology, Poznan, Poland; 2 Raszeja Hospital, Dept. of Surgery,
Poznan, Poland
Background: Left ventricular systolic function is well established predictor of mortality before surgical intervention in patients (pts) with cardiovascular diseases
(CVD). One year mortality of pts over 80 after surgical procedures is considered to
be in the range of 10-40%.
There are no data about clinical signiﬁcance of left ventricular diastolic function
(LVDF) before surgical intervention, especially in elderly pts.
Aim of the study was to evaluate the prognostic value of LVDF using Doppler echocardiography (DE) as a method for risk stratiﬁcation in pts over 80 with preserved
left ventricular systolic function referred for surgical intervention due to hip fracture.
Patients and methods: 35 consecutive pts before hip surgery (age 86,3 ± 6,1)
underwent echocardiographic examination, including 2D and DE. Left ventricular
ejection fraction (LVEF), mitral E-wave velocity (E), A-wave velocity (A), deceleration time of the E-wave (DT) and isovolumic relaxation time (IRT) were measured.
The E/A ratio was calculated. Pts with normal LVDF was included into the group 1
(6 pts) and with impaired LVDF into group 2 (29 pts). Duration of follow-up period
was one year.
Results: There were no deaths in perioperative period. One year mortality in both
groups was not signiﬁcantly different.
Selected patients’ characteristics are presented in a table.
Number of pts
LVEF > 45%
Impaired relaxation
Pseudonormal pattern
Restrictive pattern
Normal inﬂow pattern
Number of deaths during 1 year follow-up
Mortality (%)
Group 1
(normal LVDF)
Group 2
(impaired LVDF)
6
6
0
0
0
6
1
16
29
29
26
0
3
0
4
17,3
Conclusion: Abnormal left ventricular diastolic function with preserved normal left
ventricular systolic function does not increase risk of surgical intervention in patients over 80 with hip fracture.
Eur J Echocardiography Abstracts Supplement, December 2003
S10
Abstracts
146
Left ventricular stroke volume displaces anteriorly the aortic root
through left atrial reservoir expansion.
G. Berna, P. Barbier, M.D. Guazzi. Centro Cardiologico Fondazione Monzino,
IRCCS, Milan, Italy
Extent of aortic root (AR) systolic anterior movement has been explained as determined by left ventricular (LV) ejection and correlated to stroke volume. Further, the
AR "sits" on the anterior left atrial (LA) wall and diastolic posterior displacement of
AR has been related to LV diastolic ﬁlling and LA emptying.
Aim: Because past and recent evidence suggests a reciprocal interaction between
LA reservoir function and LV stroke volume, aim of this study was that to demonstrate that the AR is directly displaced by extent of LA expansion during reservoir,
as a function of LV stroke volume.
Methods: in 20 normal subjects and 80 consecutive patients undergoing diagnostic echocardiography (age 59±15) we analyzed the ability to predict anterior movement of AR, measured in parasternal view with respect to transducer position, of
different LA dimensions non contiguous to the AR in the apical 4-chamber (superoinferior, medio-lateral diameters and area) and 2-chamber (supero-inferior, anteroposterior diameters and area) views. For all dimensions, LA reservoir indexes were
calculated as maximum – minimum dimension.
Results: at multiple regression analysis, reservoir expansion of 2-chamber superoinferior and 4-chamber medio-lateral diameters, and LV biplane stroke volume predicted (<. 002) with decreasing importance anterior movement of AR, independently from BSA, age, heart rate, LA and AR dimensions, LV preload and ejection
fraction, and heart disease. When LA reservoir function indexes were excluded
from analysis, only LV stroke volume predicted (p<.001) AR movement.
Conclusion: our analysis suggests that LV stroke volume inﬂuences indirectly the
systolic anterior displacement of the AR through the direct inﬂuence of LA reservoir
expansion.
147
Is the diastolic velocity decay from the left ventricular inﬂow tract to the
left ventricular outﬂow tract affected by the systolic function?
C. Tiano 1 , J. Roisinblit 2 , V. Volberg 2 , R. Brunoldi 2 , R. Montecchiesi 2 ,
J. Lerman 2 , D. Piñeiro 2 . 1 ING Maschwitz, Argentina; 2 Hospital de Clinicas,
Cardiology, Buenos Aires, Argentina
149
Is the slowed left ventricular relaxation or augmented atrial transport
function the primary abnormality of ﬁlling in mild hypertension?
S. Qirko 1 , T. Goda 2 . 1 University Hospital Center, Department of cardiology,
Albania, Albania; 2 University Hospital Center, Department of Cardiology, Tirana,
Albania
Background: The diastolic dysfunction in the early phases of hypertension has
been attributed to a primary slowing of LV relaxation, expressed by reduced
Doppler E wave. The augmentation of atrial ﬁlling, manifested by an increased
Doppler A wave, is considered compensatory and secondary. The aim of this study
was to evaluate whether the primary abnormality of the LV ﬁlling in mild hypertension is the augmented atrial transport or the reduced of LV relaxation.
Methods: 35 normotensive (NT) and 45 untreated subjects (HT) were included in
the study. They were matched for age. All of them were free of any other type of cardiopathy. LV relaxation was assessed by measuring of doppler E wave velocity and
by evaluation of the mitral propagation velocity (Vp) (a load-insensitive method)
measured by color M-mode echo. Atrial transport was assessed by Doppler A
wave velocity. LV mass index (LVMI, g/m2 ) and LV shortening fraction (LVSHF)
were measured and calculated by echo.
Results: E wave velocity, Vp, LVMI and FSh were similar for both groups. Signiﬁcant difference was observed only in A wave velocity, as shown on the table.
Relaxation
Background: E rebound (Er) and A rebound (Ar) diastolic velocities in the left
ventricular outﬂow tract (LVOT) are easily recorded, the process of the diastolic
velocity decay from the inﬂow tract to the LVOT is not established. The effect of
some diastolic and systolic parameters over this velocity loss was investigated.
Methods: 59 unselected patients, 27 female, mean age 63 ± 17 years (19-91).
The left ventricular ejection fraction (LVEF) (Simpson’s) was 51 ± 17% (19-76).
In 22 p. the LVEF was < 45%. We also measured the isovolumic relaxation time
(IVRT), the E and A wave diastolic velocities at the tip of the mitral valve and at
the LVOT (Er and Ar), the E deceleration time (DT), the E propagation velocity with
color M mode (EPV), the left ventricular (LV) Dp/Dt from the mitral regurgitation
spectral waveform in 23 p, as well as the Er/E and Ar/A ratios. The IVRT, DT, EPV
color M mode, were considered as diastolic function indices and LVEF, LV Dp/Dt
as systolic function indices.
Results: see table below ((1)p<0,05; (2)p<0,01; (3)p<0,001).
Univariate correlation coefﬁcients
AGE
IVRT
DT
EPV
LVEF
LV Dp/Dt
Results: In patients with inferior MI the delayed onset of the posterior long axis
lengthening, with respect to end ejection, was not different from normal 69+28
vs 65+10 ms (NS), at admission. This delay correlated closely with ST segment
(r=-0.8, p<0.001) and T wave (r=0.9, p<0.001) duration. In contrast, with anterior
infarction the onset of anterior long axis lengthening was delayed by 20ms, 80+24
vs 60+9 ms, p<0.001 compared to normal. This delay became only related to ST
duration 30 days after MI infarction (r=0.8, p<0.001) but not with the T wave.
Conclusion: Patients with inferior MI recover their diastolic electromechanical relationship within days after thrombolysis, however with anterior infarction this relationship becomes apparent 30 days after thrombolysis. These ﬁndings suggest a
signiﬁcant ventricular remodelling process after thrombolysis for anterior infarction.
E
A
Er
Ar
Er/E
Ar/A
-0,14
-0,56 (3)
0,31 (1)
0,31 (1)
0,07
0,19
0,44 (3)
0,41 (2)
0,29 (1)
-0,29 (1)
0,09
0,26
-0,14
-0,44 (2)
0,05
0,48 (3)
0,62 (3)
0,65 (2)
0,43 (2)
0,16
0,49 (3)
0,01
0,53 (3)
0,66 (2)
-0,02
-0,13
0,23
0,28 (1)
0,63 (3)
0,57 (2)
-0,02
-0,23
0,11
0,35 (1)
0,56 (3)
0,58 (2)
Forward stepwise multivariate regression analysis identiﬁes the LVEF and Dp/Dt
as the only factors with signiﬁcant inﬂuence over Er/E and Ar/A.
Conclusion: These data suggest that the diastolic velocity decay from the inﬂow
tract to the LVOT is mainly determined by the LV systolic performance.
LV elastic recoil reduction could be a possible explanation.
148
Diastolic ventricular electromechanical response to thrombolysis for
acute myocardial infarction.
I.S. Ramzy 1 , M. Dancy 1 , D. Gibson 2 , A. Coats 2 , M. Henein 2 . 1 Central Middlesex
Hospital, Cardiology Dept., London, United Kingdom; 2 Royal Brompton Hospital,
Cardiology, Echo Dept., London, United Kingdom
Background: The effect of acute myocardial infarction (MI) on left ventricular (LV)
function differs according to its location, anterior and inferior.
Aim: To study diastolic ventricular electromechanical behaviour after thrombolysis
for acute MI in patients with anterior and inferior MI.
Methods: We studied 21 patients with acute MI; 11 anterior (age 52+8 years) and
10 inferior (age 59+16 years) at admission during thrombolysis and 30 days after
recovery using ECG and echocardiography. Electromechanical segmental delay
was taken from the end of the T wave to the onset of long axis lengthening in early
diastole at different sites; anterior, posterior, lateral and septal. ST and T wave
durations were compared with corresponding segmental mechanical delay.
Eur J Echocardiography Abstracts Supplement, December 2003
NT
HT
Atrial Function
LVMI
FSH(%)
E (cm/s)
VP (cm/s)
A (cm/s)
94 ± 24
99 ± 16
40 ± 6
39 ± 7
78 ± 10
76 ± 8
70 ± 8
66 ± 4
55 ± 10
81 ± 12*
*p<0.05 HT vs NT
Conclusion: The augmentation of the atrial transport is rather than the impaired
relaxation the earlest alteration of the LV ﬁlling in arterial hypertension.
150
Losartan improves left ventricle diastolic dysfunction in patients with
hypertrophic cardiomyopathy.
A. araujo, E. Arteaga, P. Buck, B. Ianni, C. Mady. Heart Institute - Sao Paulo
University, Cardiopatias Gerais, Sao Paulo, Brazil
Objective: to determine the effects of angiotensin II (Ang II) blockade on left ventricle (LV) diastolic function of patients with hypertrophic cardiomyopathy (HCM).
Background: interstitial ﬁbrosis impairs LV compliance in HCM. Ang II has proﬁbrotic effects on myocardium that can be inﬂuenced by an Ang II receptor antagonist. Losartan reversed myocardial ﬁbrosis in mice with a transgenic model of
human HCM but the effects of Ang II blockade in human HCM is unknown.
Methods: in 12 non-obstructive HCM patients with a septal thickness > 15mm
we performed Doppler echocardiographic evaluation of LV diastolic function. The
measurements consisted of M-mode left atrium diameter (LAD), mitral peak early
(E) and atrial (A) ﬁlling velocities, E/A ratio, Edt, IRVT, pulmonary venous peak systolic (S), diastolic (D) and atrial (PVA) velocities, tissue Doppler early longitudinal
diastolic velocity of mitral annulus (Ea) and the E/Ea ratio. The patients received
100mg/day of losartan during a mean period of 177 days. At the end of the treatment the studies were repeated. A paired t-test p<0.05 was considered signiﬁcant.
Results: all 8 previously symptomatic patients related exercise tolerance improvement. The following parameters signiﬁcantly improved: LAD diminution, S and PVA
lowering, Ea increase and E/Ea reduction (table). The mean E/A ratio was not signiﬁcantly altered but patients with E/A<1.0 had an inversion to >1.0 and restrictive
patterns of E/A changed to normal ratios.
Parameter
Baseline
6 months
paired t-test
LAD (mm)
S (cm/s)
PVA (cm/s)
Ea (cm/s)
E/Ea
42.7
65.1
37.7
11.7
6.6
39.1
56.8
30.9
13.2
5.1
p=0.003
p=0.04
p=0.01
p=0.02
p=0.005
Data expressed as mean values of 5 averaged measurements obtained by 2 observers
Conclusions: in patients with non-obstructive HCM, long term Ang II blockade with
losartan caused an improvement in Doppler indexes of LV diastolic dysfunction and
an increase in exercise tolerance. These ﬁndings support the view that pharmacological interventions targeting myocardial interstitial ﬁbrosis can have salutary
effects in human HCM.
Abstracts
S11
151
Improvement of left ventricular diastolic function after successful
catheter ablation for lone paroxysmal atrial ﬁbrillation.
153
Tissue Doppler imaging (TDI) for estimation of ﬁlling pressures
validation in patients with primary or secondary mitral regurgitation.
P. Reant, S. Laﬁtte, P. Jais, V. Le Bouffos, R. Weerasooriya, R. Roudaut,
M. Haissaguerre. Hopital Cardiologique Haut Leveque, 33, PESSAC, France
C. Bruch, J. Stypmann, M. Grude, T.H. Wichter, G. Breithardt. WWU Münster,
Innere Medizin C, Münster, Germany
Background: We investigated whether lone atrial ﬁbrillation (LAF) was the cause
or/and consequence of left heart remodeling using serial transthoracic echocardiographic (TTE) studies.
Methods: 28 pts (mean age 52±9 yrs, 5F) underwent successful ablation of LAF
by pulmonary vein isolation in combination with mitral isthmus linear ablation. TTE
measurements including parameters from pulsed Doppler, Doppler tissue imaging,
acoustic quantiﬁcation and transmitral ﬂow velocity propagation were prospectively
acquired before and 1, 3 and 6 months after the ablation procedure.
Results: In all 28 pts, stable sinus rhythm was maintained during follow-up. Mmode left ventricular (LV) velocity propagation (Vp) as well as pulmonary A wave
velocity and TEI index were signiﬁcantly improved in the entire group at 3 and 6
months. In 7 pts who had baseline E/A ratio<1, a normal proﬁle was additionally observed after ablation. Progressive signiﬁcant reductions of left atrial dimensions from both parasternal and apical views were documented during follow-up.
No signiﬁcant difference was observed before and after treatment for LV dimension (28pts), systolic (28pts) and conventional diastolic parameters (E and A mitral
waves)(21pts).
Background: Mitral annular velocities derived from by tissue Doppler imaging
(TDI) complement traditional variables in the evaluation of left ventricular (LV) performance. The mitral E/E’-ratio has been suggested as an estimate of LV ﬁlling
pressures in selected subsets of patients. However, E/E’ has not been validated in
patients with primary or secondary mitral regurgitation (MR).
Methods & Results: 14 patients (pts.) with primary MR (prolapse (n=6), ﬂail leaﬂet
(n=3), rheumatic degeneration (n=3); mean grade 3.2±0.3, age 49±11 y., PMR
group), 26 pts. with MR secondary due to ischemic (n=19) or dilated cardiomyopathy (n=7) (mean grade 2.7±0.3, age 60±12 y., SMR group) and 29 asymptomatic
controls (age 56±11 y., CON group) underwent echocardiographic measurements
of ejection fraction (EF) and mitral inﬂow velocities (E, A, E/A-ratio). Mitral annular
velocities (S’, E’, A’) derived from pulsed TDI were obtained at the septal mitral
annulus. In pts., LV end-diastolic pressure (LVEDP) was derived from left heart
catheterization.
Echocardiographic results
CON (n=29) 67±8
PMR (n=14) 70±10
SMR (n=26) 30±1112
LA long. parasternal diameter
LA longitudinal 4C diameter
LA longitudinal 2C diameter
pulmonary vein A wave velocity
E/Vp
TEI modiﬁed septal
%EF
ESA ABD
D-1
M+1
M+3
M+6
54,3±7,2
52,1±6,1
50,3±6,8
29,5±5,5
1,64±0,39
0,57±0,17
62±5
20,2±8,2
46±6,7***
48±6,9**
46,3±6,7
25,9±2,1**
1,40±0,54**
0,54±0,22
61,9±5,7
16,1±3,1
44,8±6,2***
47,5±7,1**
46,2±6**
25,2±3,7**
1,30±0,3**
0,48±0,1(*)
60,6±6,8
16,08±4,1*
43,9±5*******
46,6±5,9***
45,7±7,4**
23,8±2,7***
1,30±0,34**
0,50±0,12*
61,5±5,2
15,9±3,7**
Conclusion: Elimination of LAF is associated with improvement of LV diastolic
function and signiﬁcant reduction of LA dimensions suggesting that the arrhythmia
is linked to these abnormalities.
152
A prevalence and determinants of diastolic dysfunction in a general
population.
A. Ryabikov, T. Kuznetsova, S. Malyutina. Institute of Internal Medicine, Lab. of
Cardiology, Novosibirsk, Russian Federation
The incidence of primary diastolic heart failure (DHF) in ageing European populations is remarkably rising. But DHF’ prognosis and its prevalence in general
population is still unclear.
Impaired left ventricular (LV) diastolic function plays an important role in such common cardiovascular disorders as hypertension, ischemic heart disease, and congestive heart failure.
The purpose of this investigation was to assess the prevalence of LV diastolic dysfunction according to Doppler criteria, and to analyze its determinants in general
population.
Methods: The cross-sectional study was carried out in Novosibirsk, Russia in the
frame of WHO MONICA Project. Doppler analysis of LV inﬂow was performed in
general population sample of 346 men aged 35-54 (technically inadequate patients
and those with the presence of systolic cardiac failure and aortic regurgitation were
excluded). Peak ﬂow velocity in early diastole (peak E), in late diastole (peak A),
and the E/A ratio were measured. All measures were compared with healthy reference group (n=68) selected from the same population.
Results: Prevalence of LV diastolic dysfunction was of 24.7% in men under 50
(E/A<1.0) and was of 33.7% in those above 50 (E/A<0.5). In the entire sample
peak E, peak A and E/A ratio were, respectively: 49.0 ± 10.4 cm/s, 45.0 ± 8.6 cm/s
and 1.13 ± 0.34 cm/s. In the entire sample and healthy group the age, heart rate,
systolic blood pressure (SBP) and LV percent fractional shortening by multivariate
models were strongly related to early and late diastolic transmitral peak velocities
and E/A ratio. Age was negatively associated with E peak (b= -0.58, p <0.001) and
E/A ratio (b= -0.02, p < 0.001) and positively associated with A peak (b= 0.23, p <
0.001) in both groups, and univariate correlation was not markedly attenuated by
adjusting for other factors tested in multivariate model. SBP within normal range
in reference group negatively correlated with E/A ratio (b= -0.009, p = 0.01), but
did not reach signiﬁcant values for absolute parameters as peak E and A. In the
population, mean wall thickness at end-diastole was an independent predictor of E
peak (b= -0.68, p < 0.05), A peak (b= 1.60, p < 0.001) and E/A ratio (b= -0.04, p
< 0.001).
Conclusion: The prevalence of LV diastolic dysfunction in middle-age male population is relatively high: about 29%. In general population Doppler parameters of
LV diastolic ﬁlling are associated with age, blood pressure, heart rate, LV systolic
function and wall thickness.
Group
1
EF
(%)
Mitral E/A-ratio
1.20±0.35
1.74±0.64
2.12±1.321
S’
cm/s)
E’
cm/s)
A’
cm/s)
E/E’
(mmHg)
LVEDP
8.8±1.3 11.6±2.5 11.3±2.0 6.5±1.5
13±6
10.2±2.51 12.3±3.2 11.2±2.1 8.5±3.4
4.7±1.112 5.7±1.312 6.9±2.512 16.2±4.51 2 20±62
p<0.05 vs. CON group, 2 p<0.01 PMR vs. SMR group
E/E’ was signiﬁcantly related to LVEDP in the SMR group (r=0.61, p<0.001), but
not in the PMR group (r=0.17, p=ns). Derived from receiver operating characteristic
curve analysis, in the SMR group an E/E’> 13.5 identiﬁed pts. with LVEDP > 15
mmHg with a sensitivity 80% of and a speciﬁty of 83% (area under the curve:
0.88±0.05).
Conclusion: In subjects with secondary MR and reduced LV performance, E/E’ is
a reliable estimate of ﬁlling pressures. In subjects with primary SV and preserved
LV performance, ﬁlling pressures are underestimated by E/E’, mainly due to increased E’.
154
Tissue Doppler predicts left ventricular ﬁlling pressure better than
standard Doppler in patients with mitral valve regurgitation.
E. Agricola 1 , M. Galderisi 2 , M. Oppizzi 1 , G. Melisurgo 1 , F. Airoldi 3 ,
A. Margonato 1 . 1 Ospedale San Raffele, Division of Non-Invasive Cardiology,
Milan, Italy; 2 Federico II University, Clinical and Experimental Medicine, Naples,
Italy; 3 Ospedale San Raffaele, Interventional Cardiology, Milan, Italy
Background: Doppler mitral and pulmonary vein ﬂow measurements are widely
used to estimate changes of left ventricular (LV) ﬁlling pressure. Mitral regurgitation
(MR) induces modiﬁcation of both mitral and pulmonary vein ﬂow making these
parameters unreliable to assess LV diastolic function.
Objective: To evaluate whether tissue Doppler (TD) diastolic indices measured at
the level of LV mitral annulus can predict LV ﬁlling pressure in patients with MR.
Methods: Forty patients (age: 55+11 years) with severe MR (ejection fraction 40%
- 75%), underwent a complete Doppler echocardiographic examination including
TD. Transmitral E and A wave velocities, E wave deceleration time, A wave duration, pulmonary systolic and diastolic velocity, reversal ﬂow duration, the difference
between pulmonary and mitral A wave (A’-A), TD-derived Em and Am of LV lateral
mitral annulus were measured. LV end-diastolic pressure (LVEDP) was measured
invasively.
Results: E peak velocity (r= 0.56, p<0.001), E deceleration time (r=0.70,
p<0.0001), Em velocity (r= -0.78, p<0.0001), Em/Am ratio (r=-0.71, p<0.0001),
E/Em ratio (r=0.88, p<0.0001), pulmonary vein systolic velocity and systolic/diastolic ratio (r=-0.70, p<0.005 and r=-0.57, p<0.01, respectively) and A’-A (r=0.55,
p<0.001) had univariate relations to LVEDP in the overall population. By a multiple linear regression analysis, E/Em ratio (â=0.87, p=0.0001) was an independent
predictor of LVEDP while standard Doppler tramsmitral and pulmonary vein ﬂow
indexes did no enter the model (R2= 0.74, S.E.=4, p<0.0001). An E/Em ratio >10
detected a mean LVEDP >15 mmHg with a sensitivity of 90% and a speciﬁcity of
83%.
Conclusion: Mitral regurgitation inﬂuences the majority of standard Doppler measurements used in the clinical setting to predict LVEDP but not E/Em ratio. Mitral E
velocity adjusted for the inﬂuence of relaxation (i.e. the E/Em ratio) may be considered a reliable measurement to estimate accurately LVEDP in patients with MR.
Eur J Echocardiography Abstracts Supplement, December 2003
S12
Abstracts
155
Assessment of Valsalva maneuver as a method for evaluation of patients
with pseudonormalized left ventricular ﬁlling pattern.
Said Shalaby, Walaa Farid, Ahmed Ashraf Reda, Ahmed El Kersh. Menouﬁa Univ.
Faculty of Medicine, Cardiology Dept., Shebin el kom menouﬁa, Egypt
Background: . Valsalva maneuver was used to differentiate normal from
pseudonormal mitral ﬂow pattern. Doppler tissue imaging (DTI), differentiates normal from abnormal diastolic function.
Aim of the Work: Assessment of Valsalva maneuver as a mean to differentiate
pseudonormal from normal mitral ﬂow pattern (MFP), using pulsed- wave DTI
Patients and Methods: sixty patients with dilated cardiomyopathy (EF<40%), sinus rhythm and pseudonormalized MFP were selected. Transmitral ﬂow velocity
curve (MFVC), before and during Valsalva maneuver was recorded. Peak early
mitral ﬁlling (Em), peak atrial ﬁlling (Am) and Em/Am were measured before and
during Valsalva. After Valsalva patients were classiﬁed into two groups. Group I
included 24 patients with Em/Am <1 and group II, 36 patients with Em/Am >1.
Pulsed-wave DTI was recorded at septal, lateral, inferior and anterior aspect of the
mitral annulus from apical 4 and 2 chamber views. The mean peak early velocity
(Ea), Peak atrial (Aa), and Ea/Aa of the 4 sites were measured from DTI derived
velocity curve for each patient. The results were compared with the MFP.
Results: Valsalva maneuver was able to detect a hidden relaxation abnormality in
40% of patients where Em/Am became <1 with signiﬁcantly prolonged deceleration time (DT), and isovolumetric relaxation time (IVRT). However, 60% of patients
the Em/Am remained >1 with slightly prolonged DT and IVRT. Pulsed-wave
DTI detected relaxation abnormality in all patients. They had Ea/Aa 0.79±0.11,
prolonged DT and IVRT. Group 1 had higher EF (36.71% vs. 32.87%), higher Ea
(6.1±0.68 vs 5.3±0.1cm/s), lower Aa (7.9±2.012 vs 8.1±1.91 cm/s) and higher
Ea/Aa ratio (0.77 vs 0.65) than group II patients. These data may denote that it was
a progression of diastolic dysfunction with or without a hemodynamic factor that
was responsible for the persistence of pseudonormalized pattern during Valsalva.
Conclusion: Patient uncoperation, less sensitivity, and speciﬁcity are the major
limitations Valsalva maneuver in assessment of patients with pseudonormalized
MFP.Doppler tissue imaging is a simple noninvasive bedside technique with less
load dependence. it can be used in combination with MFP for better understanding
and assessment of diastolic dysfunctionin those patients.
156
Echocardiographic diastolic dysfunction parameters and mitral
regurgitation are predictors of pulmonary hypertension in left ventricular
dysfunction.
J. Saavedra, P. Talavera, E. García, P. Awamleh, M.T. Alberca, A. Karoni,
F.G. Cosio. 1 Hospital Universitario de Getafe, Cardiology, Getafe, Spain
Introduction: Pulmonary hypertension (PHT) in patients with left ventricular systolic dysfunction (LVSD) is associated to a worse prognosis.
Objectives: We sought to study the prevalence of PHT in a group of patients with
LVSD and its relation to echocardiographic parameters of diastolic function (DF).
Methods: We have studied a series of 71 patients, 58 men, medium age 53±14
years with LVSD, mean ejection fraction (EF) 25±7%. 34 of them had coronary
disease and 37 had dilated cardiomyopathy. A transthoracic echocardiography was
performed measuring: the systolic pulmonary arterial pressure (SPAP), DF parameters in the mitral ﬂow, E and A velocity, E/A ratio, E deceleration time(EDT) and
isovolumetric relaxation time (IVRT), and in the right superior pulmonary vein: systolic wave velocity (S), diastolic (D) their areas (ARS and ARD) and their ratio (S/D)
and the velocity of the atrial retrograde wave (A). Mitral regurgitation and its severity was also assessed. SPAP could be measured in 55 patients (77%). The mean
SPAP was 43±18 mmHg. Mean SPAP was 36 mmHg in patients with grade I mitral
regurgitation, 45 mmHg in grade II, 55 mmHg in grade III and 63 mmHg in grade
IV, p= 0,01.SPAP was higher in patients with a more severe diastolic dysfunction
as shown in the table (p<0,01),
Mean PSAP in diastolic ﬁlling patterns
LV ﬁlling pattern
Impaired relaxation
Pseudonormal
Restrictive
Number of patients
PSAP
21
6
28
31 mmHg
41 mmHg
53 mmHg
Conclusions: 1) The severity of PHT is correlated with DF parameters and mitral
regurgitation in patients with cardiac failure due to LVSD. 2) Those patients with a
more restrictive inﬂow pattern and more severe mitral regurgitation have a higher
SPAP.
157
Prognosis of systolic and diastolic heart failure in the elderly.
M. Lengyel 1 , C.S. Farsang 2 , A. Zorándi 1 . 1 Gottsegen G. Hung.Inst.of Cardiology,
Budapest, Hungary; 2 St. Imre Hospital, Budapest, Hungary
The results of comparison of prognosis of systolic (S) and diastolic (D) heart failure
(HF) has been controversial. The objective of this study was to compare outcomes
of SHF and DHF in elderly hospitalized patients.
Left ventricular ejection fraction (EF), mitral E/A velocity ratio and deceleration
time (DT) were measured and calculated by echocardiography. In NYHA class
II-IV pts SHF was deﬁned as EF</=40% and DHF as EF>/=50% plus either im-
Eur J Echocardiography Abstracts Supplement, December 2003
paired relaxation (E/A</=1.0 and DT >/=200 ms) or restrictive function (E/A>/=2.0
or DT</=140 ms) or atrial ﬁbrillation. Actuarial survival was assessed by KaplanMeier analysis. 77 patients >/=65 years (28 males and 49 females) were followed
for mean 11.4±6.4 months. 34 pts (GI) had DHF and 41 pts (GII) had SHF. 37
pts died (48%):15 in GI and 22 in GII (NS), HF mortality was 3 in GI and 11 in
GII (p=0.033). 2 years actuarial survival in the whole group was 30%. There was
no difference between survivors and nonsurvivors in age (77.1±6.4 vs 79.3±7.7),
EF (46.2±18.2 vs 42.5±21.8%), pulmonary artery systolic pressure (43.1±12.9 vs
47.6±15.0 mmHg), but NYHA class was signiﬁcantly lower (2.9±0.7 vs 3.4±0.85,
p<0.05) and pleural effusion by echo was signiﬁcantly less frequent (27.5 vs
57.1%, p<0.05) in survivors than in nonsurvivors. Actuarial 2 year survival of pts
in class IV was signiﬁcantly worse (10%) compared to NYHA II-III (41%), p=0.003.
There was no difference in the 2 year survival between GI (32%) and GII (27%).
Conclusions: Overall survival in SHF and DHF in the elderly is similar; survivorship was independent of age and EF but it was inversely related to functional class.
158
Suspected isolated diastolic dysfunction occurs in 36% of patients with
the clinical diagnosis of congestive heart failure.
M.R. Movahed, M. Ahmadi-Kashani, R. Gim, B. Kasravi, M. Hashemzadeh. UCI
Medical Center, Dept. of Medicine/Cardiology, Orange, United States of America
Introduction: The prevalence of diastolic left ventricular (LV) dysfunction in a population presenting with the diagnosis of congestive heart failure (CHF) is controversial. The prevalence of systolic and diastolic LV dysfunction in patients with CHF
varies considerably in current literature. We evaluated the prevalence of systolic
and suspected diastolic LV dysfunction in a large population presenting with a clinical diagnosis of CHF using echocardiography.
Methods: We retrospectively reviewed 24,380 echocardiograms performed at our
institution from 1984 to 1998. We evaluated the prevalence of abnormal LV systolic
and diastolic dysfunction in patients with the clinical diagnosis of CHF. Suspected
diastolic dysfunction was deﬁned as presence of left atrial enlargement, left ventricular hypertrophy or reverse diastolic mitral ﬂow ratio (A over E reversal).
Results: In this cohort, 636 echocardiograms with CHF as the primary diagnosis
were reviewed. LV function data were available in 461 patients. Normal LV size and
function was found in 238 patients (48%). Isolated suspected diastolic LV dysfunction was found in 166 patients (36%). Normal systolic and diastolic function was
observed in 12% of patients.
Conclusion: Nearly one-half of the echocardiograms with the primary diagnosis
of CHF exhibited normal LV size and systolic function. In this cohort, 36% of the
patients had suspected echocardiaographic evidence of abnormal diastolic dysfunction along with the clinical diagnosis of CHF.
159
Left ventricular longitudinal relaxation velocity; a sensitive index of
diastolic function.
B. Nilsson 1 , Y. Fornander 2 , R. Egerlid 3 , B. Wandt 4 . 1 Anaesthesiology, Karlstad;
2
Internal medicine and Clinical Physiol, Borås and Örebro; 3 Örebro University
Hospital, Clinical Physiology, Örebro; 4 Sahlgrenska and Örebro University Hosp,
Clinical Physiology, Gothenburg and Örebro, Sweden
Objective: The aim of the present study was to evaluate maximal longitudinal
relaxation velocity of the left ventricle as an index of diastolic function.
Methods: Sixty-four consecutive patients with known or suspected heart failure,
referred to echocardiography were investigated. The patients were aged 29-74,
with mean age of 59. Twenty-ﬁve had a history of hypertension, 13 a history of
angina pectoris and 11 a history of myocardial infarction. The long axis movements
of the mitral annulus were obtained at four sites, and M-mode and pulsed tissue
Doppler recordings of the maximal early diastolic velocity were analysed by using
the mean value from four sites. The maximal relaxation velocity by M-mode (MRVm) was measured as the steepest part of the curve in early diastole and the
velocities recorded by pulsed tissue Doppler (TD-RVm) were measured from the
outer border of the dense part of the spectral curve. The diastolic mitral inﬂow
velocity and pulmonary vein ﬂow were recorded by pulsed Doppler from the apical
four-chamber view.
Every case was classiﬁed as belonging to the group with normal or to the group
with impaired diastolic function with all three methods, M-RVm, TD-RVm and the
combination E/A ratio of the mitral inﬂow and recording of the pulmonary vein ﬂow.
Cases with diastolic dysfunction according to the latter method were regarded as
true cases when the sensitivity and speciﬁcity for M-RVm and TD-RVm were calculated. Previously reported reference values were used for M-RVm and TD-RVm.
Results: According to age-related reference values for the E/A ratio of the mitral
inﬂow, and for pulmonary vein ﬂow, 27 of the 64 patients had diastolic dysfunction,
of whom 12 had also systolic dysfunction (EF<50% by Simpson’s rule).
When diastolic dysfunction was identiﬁed by measures of the E/A ratio and pulmonary vein ﬂow, M-RVm had a sensitivity of 89% and a speciﬁcity of 81%. TDRVm had a sensitivity of 81% and a speciﬁcity of 78%. Fisher’s exact text showed
that RVm recorded by either modality can be used to identify diastolic dysfunction
(p<0.0001). TD-RVm (mean 86.8 mm/sec) was 29.7% (p<0.0001) higher than MRVm (mean 66.9 mm/sec).
Conclusions: Maximal relaxation velocity in the long axis of the left ventricle,
recorded by either M-mode or tissue Doppler can be used for assessment of diastolic function. Considerably higher velocities are recorded by tissue Doppler than
by M-mode. Different age-related reference values must therefore be used.
Abstracts
S13
160
Plasma level of nitric oxide in hypertensive patients with mild heart
failure secondary to left ventricular diastolic dysfunction.
162
Is color m-mode of mitral inﬂow a load independent parameter in a
clinical setting?
W. Kosmala, M. Przewlocka-Kosmala. Medical University, Cardiology, Wroclaw,
Poland
J. Nuñez-Morcillo 1 , C. Fernandez Palomeque 2 , J.F. Forteza 2 , A. Rodriguez 1 ,
H. Conde 1 , A. Bethencourt 2 . 1 Hospital Universitario Son Dureta., Cardiology
Department., Palma de Mallorca, Spain; 2 Hospital Son Dureta - IUNICS,
Cardiology Department, Palma de Mallorca, Spain
Elevated plasma level of nitric oxide (NO) is common ﬁnding in patients (pts) with
systolic heart failure. However, the relation of NO to diastolic dysfunction is not well
deﬁned.
Aim: The aim of the study was to investigate plasma level of NO in hypertensive
pts with pure diastolic heart failure.
Material and Methods: Studied group consisted of 57 pts (26 males, 31 females)
mean age 53.5±11.7 with essential hypertension. 26 pts presented symptoms of
NYHA class I and 31 NYHA class II. 18 healthy persons mean age 52.2±12.1
served as control group. Only pts with normal global and regional left ventricular
systolic function were enrolled into the study. Systolic and diastolic function of left
ventricle was assessed echocardiographicaly by measurements of left ventricular
ejection fraction and velocity of early (E) and late (A) transmitral ﬂow, deceleration
time of E wave (DT), isovolumic relaxation time (IVRT) and ﬂow propagation velocity of E wave (Vp). Plasma NO level was indirectly measured by determining both
nitrate and nitrite levels using spectrophotometry.
Results: In all hypertensive pts impaired relaxation of left ventricle was found out.
Pts with NYHA II showed signiﬁcantly lower values of E/A and higher values of
A compared to pts with NYHA I, whereas both groups did not differ with respect
to E and IVRT. Plasma levels of NO signiﬁcantly differed among groups NYHA I,
NYHA II and controls as shown in the table. Plasma NO level did not correlate with
individual diastolic parameters.
A [cm/s]
E/A
NO [mcmol/L]
NYHA I
NYHA II
Control group
65.5 ± 8.0
1.02 ± 0.26 *
28.1 ± 6.5 *
74.8 ± 11.7 ** #
0.90 ± 0.18 ** #
41.9 ± 9.3 ** #
65.1 ± 16.1
1.12 ± 0.24
17.5 ± 5.4
* - p<0.05 vs control group; ** - p<0.01 vs control group; # - p<0.04 vs NYHA I
Conclusion: In conclusion, plasma NO level is elevated in hypertensive pts with
mild isolated diastolic heart failure and it depends on the severity of heart failure
being signiﬁcantly higher in NYHA class II than in NYHA class I.
161
Evaluation of preload dependency of mitral inﬂow, tissue Doppler and
color M-mode velocities and time intervals.
M. Kilickap 1 , S. Turhan 1 , G. Nergizoglu 2 , K. Keven 2 , U. Rahimov 1 , N. Duman 2 ,
G. Akgun 1 . 1 Ankara University School of Medicine, Cardiology, Ankara, Turkey;
2
Ankara University School of Medicine, Nephrology, Ankara, Turkey
Purpose: Some of the echocardiographic parameters that used in evaluation of
left ventricular diastolic function are preload-dependent. In this study we evaluated
preload dependency of these criteria.
Method: Forty-one patients undergoing hemodialysis due to chronic renal failure
were enrolled to the study. In order to demonstrate preload dependency of the
echocardiographic parameters of diastolic function, velocities and time intervals of
mitral inﬂow (E and A wave velocities, E-wave deceleration time, and isovolemic
relaxation time), tissue Doppler velocities of mitral lateral annulus (Em and Am),
color M-mode ﬂow propagation velocity (Vp), and time difference in mitral inﬂow
between mitral tip and left ventricular apex (Td) were evaluated before and after
dialysis, and then compared.
Results: Stroke volume and cardiac output were signiﬁcantly decreased after
dialysis. Velocities and time intervals of mitral inﬂow were found to be preloaddependent. Although tissue Doppler velocities were inﬂuenced partially by the
change in preload, color M-mode parameters were found preload-independent (Table 1).
Table 1. Echocardiographic Parameters
Stroke Volume (mL/beat)
Cardiac Output (L/min)
E (cm/sec)
A (cm/sec)
E/A
Deceleration time (msec)
Isovolemic relaxation time (msec)
Em (cm/sec)
Am (cm/sec)
Em/Am
E/Em
Vp (cm/sec)
Td (msec)
Before Dialysis
After Dialysis
p
97.7 ± 28.4
6.9 ± 2.1
87.2 ± 18.8
80.5 ± 18.6
1.13 ± 0.39
213.2 ± 39.0
93.6 ± 18.9
12.0 ± 3.6
11.6 ± 2.3
1.1 ± 0.4
7.7 ± 2.8
51.3 ± 15.3
85.5 ± 29.1
73.3 ± 20.5
5.9 ± 2.0
64.0 ± 21.9
73.1 ± 18.8
0.88 ± 0.38
234.4 ± 46.6
101.4 ± 20.7
11.6 ± 3.3
10.0 ± 2.3
1.2 ± 0.4
5.7 ± 1.9
49.4 ± 28.4
98.7 ± 40.5
<0.001
<0.001
<0.001
0.005
<0.001
0.005
0.006
0.384
<0.001
0.055
<0.001
0.738
0.137
Conclusion: Color M-Mode parameters of diastolic function were superior to the
other echocardiographic parameters of diastolic function in terms of preload dependency.
Echo-Doppler is an excellent non-invasive tool for in vivo diastolic asessment.
Color M-mode of mitral inﬂow can determine the rate of ﬂow propagation in the
left ventricle (LV). When diastolic function is impaired, e wave propagation velocity
(Vpe) is slow, even when left atrial (LA) pressure is increased. This "relative" load
independence has been previously reported under several conditions.
We analysed Vpe behavior in the strain phase of the Valsalva maneouver (VM). 23
subjects (10 men, 13 women, aged 56.5 ±14.5 years) comprised the study group.
16 were normal and 7 had ischemic heart disease. All patients were in sinus rhythm
and exclusion criteria were severe LV systolic disfunction or valvular disorders.
Mean LV ejection fraction (EF) was 63.9 ± 10% and mean LA diameter 3.7 ± 0.5
cm. Diastolic E and A waves, deceleration time (DT) and Vpe of mitral inﬂow were
measured. Systolic and diastolic time velocity integrals of pulmonary venous ﬂow
(PVF) were obtained and their ratio (S/DPV) was calculated. Peak systolic (San)
and early diastolic (Ean) Doppler myocardial velocities at both corners of mitral
annulus were also analyzed. Assessment was performed in basal situation and 10
seconds after the VM.
11 PVF registers in postVM were inadecuate.
There were no differences in heart rate (63.2±11 vs 66.6 ± 16 NS).
Vpe showed an unexpected and signiﬁcant reduction after VM (61,56 ± 3,1,1 vs
38,4 ± 14,9 cm/sec p=0,003) (table)
E wave
A wave
E/A
TD
Vpe
Basal
74.5±16.3 54.4±17.2 1.8±1.13 233.1±69.7 61.56±31.1
Valsalva 54.5±17.4 53.7±25.2 1.3±0.8 309.7±11.7 38.4±14.9
p<0.0001
NS
p=0.025 p<0.0001
p<0.0001
San lateral
Ean
8.29±3.2
8.56±3.2
NS
9.7±4.3
8.05±3.5
NS
Conclusions: 1.-Valsalva maneouver decreases LV inﬂow velocity propagation in
normal subjects and also in those with impaired relaxation. 2.-Acute preload reduction could be the cause of these results. 3.-Load modifying maneouvers proposed
for diastolic assessment need to be re-evaluated and standardized.
163
Early to late left ventricular color m-mode ﬂow propagation is related
with natriuretic peptides levels in dilated cardiomyopathy.
A.P. Patrianakos 1 , F.I. Parthenakis 1 , P.G. Tzerakis 1 , E.A. Papadimitriou 1 ,
G.F. Diakakis 1 , D.C. Kambouraki 1 , P.E. Vardas 2 . 1 Heraklion University Hospital,
Cardiology Dept., Heraklion, Crete, Greece; 2 Heraklion University Hospital,
Cardiology, Heraklion, Greece
Background: In heart failure, the early ﬂow propagation (Ep) has been used as
a valuable index of diastolic dysfunction while Atrial (ANP) and Brain (BNP) natriuretic peptides are secreted from atrial and ventricles in response to volume or
pressure overload. However data about late ﬂow propagation (Ap) velocity be lacking.
We assess the relationship of Ap with natriuretic peptides levels in patients with
non-ischemic dilated cardiomyopathy (NIDC).
Methods: We study 43 pts with angiographically proven NIDC, aged 58.1±11.3y,
NYHA functional class II-III and LV ejection fraction (EF) 31.2±10.4%.
A complete echocardiography study and color M-Mode Doppler was performed
and Ep and Ap were calculated. N-Terminal-Pro ANP and BNP levels were measured to all patients.
Results: Patients were divided into group I (24 pts) with delayed relaxation pattern
if Early (E) to late (A) transmitral PW-Doppler wave was<1, isovolumetric relaxation time (IVRT) >100msec, DTE was >220 msec and atrial component (AR)
of the Pulmonary Vein ﬂow <35 cm/sec and group II with pseudonormal pattern
if E/A=1-2, IVRT=60-100 msec, DTE=150-200msec and AR>35 cm/sec. Six pts
with restrictive ﬁlling pattern were excluded because of no measurable Ap.
There were no signiﬁcant differences in age, NYHA class, LVEF, Left atrial size and
Ap (0.69±0.29 vs 0.54±0.3,p=NS) between the two groups.
Group II patients showed decreased peak systolic PV wave velocity (Spv)
(0.44±0.31 vs 0.52±0.05 m/sec,p=0.02), and increased Ep (0.44±0.21 vs
0.31±0.14 m/sec, p=0.01), and Ep/Ap ratio(1.19±1 vs 0.56±0.41,p=0.01) compared to group I pts.
Group II pts had also increased ANP (4.2±3.2 vs2.9±1.4pmol/ml, p=0.03) and
BNP (1.2±0.61 vs 0.77±0.33, p=0.03) levels compared to group I.
A signiﬁcant correlation was found between Ep/Ap ratio and AR(r=0.44, p=0.04),
ANP (r=0.49,p=0.04) and BNP (r=0.82, p<0.001) levels.
Multivariate linear regression analysis showed that the Ep/Ap ratio was the most
powerful predictor of BNP levels (p<0.001).
Conclusions: Ep/Ap ratio is associated with BNP levels in pts with NIDC suggesting that this may represent the LV end-diastolic ﬁlling pressures.
The Ep/Ap ratio may be a useful index in the clinical practice in assessing diastolic
dysfunction especially in the ﬁeld of pseudonormal ﬁlling pattern, in NIDC pts.
Eur J Echocardiography Abstracts Supplement, December 2003
S14
Abstracts
ATRIAL FUNCTION
165
The left atrial active contractile performance in patients with systemic
hypertension.
I. Stoian, C. Ginghina, I. Arsenescu. Institute of Cardiology, Bucharest, Romania
Aim: The echocardiographic evaluation of the left atrial empting volume index and
left atrial kinetic energy in patients with systemic hypertension (SI).
Method: Gr I normal (control 42 p; 29F; 13M; aged 32 – 74 y); GrII -14 p. S I mild
(interventricular septum thickness IST < 14mm;7F, 7M; aged 35- 70); GrIII –28
p. S I moderate/severe (IST > 14mm; 15F; 13M; aged 38-68). Echocardiographic
evaluation: left atrial active emptying volume(LAAEV) index (P volume – minimal
volume); P volume: left atrial volume at onset of atrial systole; minimal volume: left
atrial volume at mitral valve closure. Left atrial kinetic energy: 0.5 x p x LAAEV x
v2 (p=1.06 g x cm-3; v=Vmax A; Stefanadis C).
Results (see table).
Nr pts
LA diameter, cm
LA Vmin index, ml.m2
LA Vp index, ml/m2
LA Vae index, ml/m2
LA AEF, %
LA kinetic eng
Gr I (control)
Gr II (IST < 14mm)
Gr III (IST > 14mm)
42
3.32 ± 0.67
8.42± 3
14.1± 2.8
6.32± 2.3
40.5± 4.3
0.77
14
3.41 ± 0.4*
9.21± 2.05*
15.8± 3.2*
6.57± 1.2*
42.7± 4.3*
2.93
28
4.05± 0.5*
11.92± 2.3*
22.52± 4.98*
10.28± 2.8*
43.3± 4.8*
3.9
167
Is it possible to use the acceleration slope of mitral a wave in assessing
left atrial appendage function?
M. Eren, N. Uslu, S. Gorgulu, A. Yildirim, S. Celik, B. Dagdeviren, T. Tezel. Siyami
Ersek Heart Center, Cardiology, Istanbul, Turkey
Aim: We suggested in a previous study that the acceleration slope (Acc-S) of mitral
A wave may be used as a new parameter to evaluate global left atrial function. The
objective of this study was to assess the relationship between the Acc-S and the
left atrial appendage (LAA) emptying velocity.
Methods: Twenty-seven patients (age, 57±14 years; 67% men; all subjects in
sinus rhythm) without valvular heart disease were enrolled in this study. Acc-S
was measured by placing the PW Doppler sample volume at the tips of the mitral
leaﬂets during transthoracic echocardiography. LAA contraction velocity was measured during TEE with pulsed wave Doppler, with a 2-mm sample volumeplaced in
proximity to the LAA oriﬁce. Peak late diastolic emptying velocity (LAA contractionrelated) was analyzed in the current study.
Results: There was a signiﬁcat correlation between Acc-S and LAA emptying velocity (r=0.60, p<0.001) (ﬁgure). The accuracy, sensitivity and speciﬁcity of the
Acc-S<800 cm/sec2 for demonstrating low LAA emptying velocity (<45 cm/sec)
were 96%, 100 and 67%, respectively.
LA - left atrialV min - minimal volumeVp - volume at onset of atrial systole (P wave of ECG)
Vae - active emptying volumeAEF - active emptying fractionkinetic eng - kinetic energyIST interventricular septum thickness* - p < 0.05
Conclusions: The left atrial active contractile performance increased in patients
with severe S I (Gr III; IST > 14mm). Left atrial kinetic energy increased in patients
with severe systemic hypertension and interventricular septum hypertrophy (Gr III;
IST > 14mm).
166
The effect of pulmonary hypertension on left atrial mechanical functions
in chronic obstructive lung disease.
Regression curve
M. Acikel 1 , M. Yilmaz 1 , Y. Gurlertop 1 , H. Kaynar 2 , E. Bozkurt 1 , M.K. Erol 1 ,
N. Kose 1 , M. Meral 2 , H. Senocak 1 . 1 Department of Cardiology, 2 Department of
Chest Disease, Ataturk University School of Medicine, Erzurum, Turkey
Discussion: The acceleration slope of mitral A wave may be used to evaluate the
left atrial appendage emptying velocity.
Background: Left atrial (LA) function is an important determinant of left venricular
(LV) ﬁlling. However, the effect of pulmonary hypertension (PH) on LA mechanical
function in chronic obstructive lung disease (COLD) has not been studied yet.
Methods: Forty-nine patients (31 men, 18 women; mean age, 58.8 ± 10.0 years)
with COLD and good echocardiographic image quality were examined. As a control group, 25 age-matched healthy volunteers were studied. All patients and control subjects were in sinus rhythm. Patients were excluded for atrial ﬁbrillation,
bundle branch blocks, cardiomyopathy, LV failure, angina, myocardial infarction,
systemic hypertension, valvular left heart disease. The systolic pressure gradient between the right ventricle and right atrium was measured by calculating the
maximum peak velocity by means of the Bernoulli equation. Systolic pulmonary
artery pressure was calculated by adding to this gradient the estimated right atrial
pressure. PH was deﬁned as peak systolic pressure greater than 30 mm Hg. Patients were divided into 2 subgroups: patients without PH (group 1, n=21) and
with PH (group 2, n=28). LA volumes were determined at mitral valve opening
(Vmax), at onset of atrial systole (Vp) and at mitral valve closure (Vmin) according to biplane area-length method and the following LA parameters were calculated: Passive emptying volume (PEV=Vmax-Vp), conduit volume [CV= LV stroke
volume-(Vmax-Vmin)], passive emptying fraction (PEF=PEV/Vmax), active emptying volume (AEV=Vp-Vmin), active emptying fraction (AEF=AEV/Vp), total emptying volume (TEV=Vmax-Vmin), percent contribution of PEV, CV and AEV to LV
stroke volume.
Results: Age, gender, systemic arterial blood pressure and heart rate did not differ between three groups. LA maximal volume (p<0.01), PEV (p<0.001) and TEV
(p<0.05) were lower in group 2 than in the controls. When compared to the controls, percent contribution to LV ﬁlling of the PEV is decreased (p<0.01) and percent contribution of the AEV is increased in group 2 (p<0.05). There was no signiﬁcant difference between three groups in terms of the CV. There were inverse
correlations between pulmonary artery pressure and the following parameters: LV
stroke volume (r=-0.43, p<0.01), mitral E/A (r=-54, p<0.001), LA maximal volume
(r=-0.35, p<0.05), PEV (r=-40, p<0.01) and PEF (r=-0.43, p<0.01).
Conclusion: This study shows that the alterations of LA mechanical functions in
patients with COLD are closely correlated to PH levels. Furthermore, these results
underline the importance of maintaining a sinus rhythm in these patients.
168
Echocardiographic evidences of increased left ventricular pressure and
atrial dilatation in patients with drug-resistant paroxystic atrial
ﬁbrillation and structurally normal heart.
Eur J Echocardiography Abstracts Supplement, December 2003
D. Cozma 1 , J. Kalifa 2 , S. Pescariu 3 , D. Lighezan 3 , A. Ionac 3 , D. Dragulescu 3 ,
C. Mornos 3 , P. Djiane 2 , J.C. Deharo 2 , S.T.I. Dragulescu 3 . 1 Institute of
Cardiovascular Medicine, Timisoara, Romania; 2 Hopital Sainte Marguerite,
Cardiologie, Marseille, France; 3 Institute of Cardiology, Cardiology, Timisoara,
Romania
Background: Hemodynamic parameters in patients (pts) with drug-resistant
paroxystic atrial ﬁbrillation (pAF) have not been completely investigated. Global
myocardial index (GMI) is a simple and sensitive echocardiographic indicator of
overall cardiac function and has been signiﬁcantly related to left ventricular ﬁlling
pressure. We hypothesized that GMI and echographic indicators of atrial dilatation
were signiﬁcantly different in patients with pAF compared to normal patients.
Methods: 39 consecutive pts without structural heart disease, aged 52±10 years
with pAF, referred to electrophysiological study were compared with 36 controlmatched pts aged 48±18 years. The following parameters were assessed in all pts:
P-wave duration (Pd), GMI, left atrial dimensions (LAd=M-mode, parasternal LAt
and LAl are the measurements of short- and long-axis in apical four chamber view),
surface (LAs), volume (LAv) and ejection fraction (LA EF), right atrial dimensions
(RAd) and surface (RAs), total atrial surface (TAs), as the sum LAs and RAs. LAv
was calculated using the ellipse formula 0.52(LAdxLAlxLAt).
Results: there was no difference between the 2 groups concerning Pd (p=0.1),
LA EF (p=0.23), LAd (p=0.08) and LAt (p=0.06) while the rest of the parameters
were signiﬁcantly higher in pAF pts: LAl: 5.4±0.5 vs 4.5±0.3cm2 , p= 0.001; LAs
was founded increased in pAF pts (20.6±5.7 vs 16.3±2.1cm2 , p=0.001); GMI was
signiﬁcantly higher in pAF pts (0.5±0.17 vs 0.36±0.06, p=0.001); LAv: 51.6±10.4
vs 37.2±9.3 ml, p= 0.0001; TAs: 40.6±6.9 vs 30.6±5.1 cm2 , p=0.0001.
Conclusions: Although without structural heart disease, pts with pAF present
echographic evidences of increased left ventricle ﬁlling pressure and of left atrial dilation. These echographic parameters emphasize the role of increased intra-atrial
pressure in patients with drug-resistant paroxystic AF. Their predictive value in this
population of patients susceptible to undergo invasive procedures need to be evaluated in a larger number of patients.
Abstracts
CONTRAST ECHOCARDIOGRAPHY
170
Quantiﬁcation of regional perfusion during dipyridamole stress before
and after revascularization of left anterior descending coronary artery by
real-time myocardial contrast echocardiography.
M. Previtali 1 , L. Scuteri 1 , P. De Filippo 1 , M. Ferlini 1 , M. Revera 1 , L. Lanzarini 1 ,
U. Canosi 1 , C. Klersy 2 , L. Tavazzi 1 . 1 IRCCS Policlinico San Matteo, Cardiology
Dept., Pavia, Italy; 2 IRCCS Policlinico S.Matteo, Biometry Unit, Pavia, Italy
Aim of the study: To evaluate the ability of real-time myocardial contrast echo
(MCE) to detect changes in regional perfusion before and after revascularization of
left anterior descending coronary artery (LAD) and to correlate perfusion parameters with regional wall motion abnormalities (RWMA) and quantitative coronary
angiography (QCA).
Method: 18 pts, 11 men, aged 59±8 yrs, with >50% stenosis of LAD underwent
real-time MCE with Sonovue (Bracco) using Power Doppler Harmonic Imaging
(Vivid 7 GE) at baseline and during dipyridamole stress (0.84 mg/kg in 4’) and
QCA before and 1-4 weeks after successful coronary revascularization of LAD by
angioplasty or bypass surgery. MCE time-intensity data in 2 regions of interest
[proximal (PSE) and distal septum (DSE)] were ﬁtted to the exponential function
y= A(1-e -bt)+c, where A is the peak plateau signal intensity, b the rate of signal
increase and the product Axb is proportional to regional myocardial blood ﬂow.
Results: see table.
Before
A distal septum
b distal septum
Axb distal septum
b reserve&
Transient RWMA
MLD LAD (mm)
%DS LAD
After
Baseline
Peak
Baseline
Peak
28.14±13.3
0.31±0.18
1.5±0.92
33.08±32.7
0.37± 0.28
2.3±1.92
2.01±1.8
14/18 pts
28.18±8.7
0.39±0.26
2.22±0.33
27.45±10.8
0.82±0.47 ¶, *
4.7±2.8 ¶, *
3.18±2.8
0/18
0.58±0.46
79±15
2.48±0.22 **
10±4 **
¶ = p<0.01 vs baseline after revascularization; * = p<0.01 vs peak before revascularization, **
= p<0.001; & = b reserve: peak b/baseline b; MLD = Minimal lumen diameter; DS = Diameter
stenosis.
Conclusions: 1) In pts with LAD disease real-time MCE detects an abnormal response of regional perfusion parameters to vasodilation associated with transient
RWMA in most of them; 2)after revascularization of LAD a signiﬁcant improvement
of these parameters associated with normal wall motion response is demonstrated.
Thus, real-time MCE can be a useful tool to quantify regional perfusion in pts with
LAD disease undergoing revascularization.
171
Myocardial contrast echocardiography adds diagnostic value to stress
echocardiography in ischemia detection. A comparison study with
coronary angiography.
A G. Almeida 1 , C.N. David 2 , P.C. Silva 2 , H.M. Gabriel 2 , H.C. Costa 2 ,
C.A. Coutinho 2 , M.M. Pedro 2 , M.A. Veiga 2 , J.C. Cunha 2 , M.C. Vagueiro 2 .
1
Lisbon, Portugal; 2 Hospital Santa Maria, Cardiology Piso 8, Lisbon, Portugal
Myocardial contrast echocardiography (MCE) is a new technique for perfusion evaluation. The aim of this study was to assess of the value of MCE by real time
perfusion imaging in comparison with stress echocardiography, using coronary angiography as gold standard.
Methods: We studied 38 patients (pts), 26 males, 56±8 years old, with suspected
coronary disease and referred to coronary angiography. Pts with rest dysfunctional
segments were excluded. All were submitted to stress echocardiography (DSE)
with harmonic imaging and MCE, followed by coronary angiography. MCE was obtained in three apical views, at rest and after 0.56 mg/Kg of dipyridamole, using
Sonovue (IV infusion) as contrast agent. Real time perfusion modality was ﬂash
power pulse inversion imaging with triggering replenishment. DSE protocol was
completed until a dipyridamole dose of 0.84 mg/Kg and atropine administration
when the study was negative by the low dose. Perfusion by MCE was analysed visually, using a 16 segments model of the left ventricle; ischemia was deﬁned when
heterogeneous or absent perfusion occurred in 2 or more contiguous segments.
Quantitative analysis was performed (Qlab software) and the ratio of maximal intensity (Int-C) to left ventricle cavity was obtained to all segments. Ischemia was
considered according to contractility, when a new abnormality (hypokinesis, akynesis or dyskinesis) occurred in 2 or more contiguous segments.
Results: Coronary angiography yielded 29 patients with signiﬁcant disease (3 70%
stenosis), involving 36 territories (LAD in 20, the RCA in 8 and the CX in 8). Perfusion was adequately visualized in 98% segments. Rest studies by MCE showed
normal perfusion in all visualized segments; after stress, 31 from 36 ischemic territories were identiﬁed by visual assessment and two false negatives occurred. In
comparison with angiography, MCE yielded positive and negative predictive values
for ischemic territories detection of 88% and 97%, while DSE had 84% and 97%,
respectively. MCE and DSE together had positive and negative predictive values
of 90% and 97%. Visually detected ischemic segments had lower Int than normally
perfused ones (0.11±0.08 vs 0.65±0.21, p<0.005).
Conclusion: MCE by real time perfusion imaging yielded high predictive value in
chronic ischemia diagnosis, which was enhanced when combined to DSE. This
modality is a simple and promising method for bedside diagnosis of ischemia.
S15
172
Prediction of functional improvement of left ventricle after myocardial
infarction treated with primary coronary angioplasty: myocardial
contrast echocardiography and low-dose dobutamine study.
A. Klisiewicz 1 , P. Michalek 1 , M. Karcz 2 , M. Banaszewski 3 , W. Ruzyllo 2 ,
J. Stepinska 3 , P. Hoffman 1 . 1 Institute of Cardiology, Congenital Heart Disease
Department, Warsaw, Poland; 2 Institute of Cardiology, Coronary Artery Disease
Department, Warsaw, Poland; 3 Institute of Cardiology, Intensive Care Unit,
Warsaw, Poland
Objective: The relation between myocardial perfusion and contractile reserve
of left ventricle of patients (pts) suffered from acute myocardial infarction (AMI)
treated by means of primary coronary angioplasty (PCI) is still uncertain.
The aim of the study was to establish to what extent myocardial contrast echocardiography (MCE) and low-dose dobutamine echocardiography (LDDE) might
predict recovery of left ventricular function in these pts.
Methods: 32 consecutive pts (24 male, 8 female, mean age 56.8±10.1 yrs) with
LAD occlusion (single vessel disease) and subsequent AMI treated successfully
with PCI (TIMI 3 ﬂow) were enrolled. They underwent harmonic MCE (H-MCE) with
Levovist 1–2 days after AMI (exam I). Images were taken from apical four and two
chamber views of pulsing intervals of ﬁve to seven cardiac cycles. MCE was scored
semiquantitatively as: 2–homogenous contrast density, 1 – heterogenous, 0 – no
contrast. LDDE (up to 20 ug/kg/min) was performed 4–5 days after AMI (exam II).
One month later 2D echo was repeated (exam III). In each examination wall motion
score index (WMSI) and ejection fraction (EF) (bi-plane Simpson,s method) were
calculated. Improvement of the LV function was deﬁned as decrease of WMSI and
increase of EF between exam I and III.
Results: Functional improvement was observed in 22 pts (68%) at follow-up
(recovery group) in whom WMSI and EF changed signiﬁcantly (1.50±0.25 vs
1.26±0.20, p<0.0001 respectively, 51.2%±7.9 vs 57.3%±7.1, p<0.001, respectively). In non-recovery group corresponding values were 1.72±0.13 vs 1.74±0.15,
and 46.3%±4.6 vs 45.0%±4.6, respectively. The sensitivity of H-MCE for score 2
and 1 and LDDE for predicting functional improvement was 96% and 57% respectively with speciﬁcity 54% and 95% respectively. If homogenous perfusion (score 2)
was assessed solely sensitivity of H-MCE decreased to 85% whereas its speciﬁcity
increased up to 92%. Complementary evaluation of H-MCE and LDDE discovered
improvement of LV function in 11 pts with sensitivity 79% and speciﬁcity 100%.
Conclusions: After successful PCI for AMI signiﬁcant improvement for LV function
was observed in 68%. Evident perfusion in H-MCE seems to be a good predictor
of functional recovery of the LV after AMI. For optimal evaluation combination of
H-MCE and LDDE has to be applied.
173
Usefulness of a quantitative analysis of intravenous myocardial contrast
echocardiography to analyse coronary perfusion after myocardial
infarction in patients with an open artery.
M. Pellicer 1 , V. Bodí 1 , A. Losada 1 , J. Sanchis 1 , A. Llácer 1 , V. Bertomeu 1 ,
D. García 2 , F.J. Chorro 1 . 1 Hospital Clínic i Universitari, Servei de Cardiología,
Valencia, Spain; 2 Universitat Politècnica, Ingenieria Electrónica, Valencia, Spain
Objectives: We aimed to analyse the usefulness of myocardial contrast echocardiography with intravenous injection of contrast (MCE-iv) to study coronary perfusion after myocardial infarction (MI) in cases with an open infarct related artery
(IRA). MCE with intracoronary injection of contrast (MCE-ic) was the "gold standard" of perfusion.
Method: Twelve patients with a ﬁrst ST-elevation MI were analysed. At the end
of cardiac catheterization (median 5 days post-MI, stent in 9 cases) all patients
showed an open (TIMI 3) IRA. MCE-ic in the 3 territories (anterior descendent,
circumﬂex and right coronary arteries) was evaluated by means of intracoronary
boluses of sonicated galactose. Mean score perfusion of each territory (0="no reﬂow", .5= patchy and 1=normal. "Gold standard" of normal perfusion: MCE-ic=1)
was determined. MCE-iv ("real time" and "trigger 1:4"; bolus and intravenous infusion of "Sonoview") was performed at least 24 hours after cardiac catheterization
(median 8 days post-MI); coronary perfusion was quantiﬁed using the software
"P-Echum" ("no reﬂow"= lack of perfusion in >25% of a territory).
Results: In the 36 territories analysed (3 per patient) MCE-iv correlated with MCEic (r=-.67 p <.0001). A normal perfusion with MCE-iv ("no reﬂow" <25% of the
territory) showed a positive predictive value of 94% and a negative predictive value
of 75% in detecting a MCE-ic=1 (p=.004 Kappa=.62). In the 12 infarcted territories,
MCE-iv correctly identiﬁed 8 of 9 territories with normal perfusion (MCE-ic=1) and
2 of 3 with decreased perfusion (MCE-ic <1).
Conclusions: Our results indicate that a quantitative analysis of MCE-iv could
be useful for the non-invasive assessment of coronary microcirculation in post-MI
patients with an open IRA artery. A normal result with MCE-iv is highly suggestive
of a preserved perfusion.
Eur J Echocardiography Abstracts Supplement, December 2003
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Abstracts
174
Persistent and reversible no reﬂow: predictors and functional evolution.
L. Galiuto, A. Lombardo, D. Lomaglio, F. Belloni, F. Pennestrì, A.G. Rebuzzi,
F. Crea. Policlinico A. Gemelli Univ. Cattolica, Cardiology, Rome, Italy
Background: No reﬂow as identiﬁed 24 hours after recanalization of the infarct
related artery (IRA) can be persistent or reversible within the ﬁrst 30 days. Clinical
predictors and functional evolution of both forms of no-reﬂow are still unknown.
Methods: 32 patients with ﬁrst acute myocardial infarction (AMI) and successfully
recanalized IRA by rt-PA (n=18) or primary angioplasty (n=14) underwent myocardial contrast echocardiography (MCE) 24 hours and 30 days after symptom onset.
MCE was performed by intermittent Harmonic Power Doppler and i.v. PESDA; a
semi-quantitative contrast score index (CSI) was assessed within the dysfunctioning myocardium (myocardial opaciﬁcation in each segment: 3=absent, 2=reduced,
1=present). No-reﬂow was deﬁned as the absence of contrast in > 25% of dysfunctioning segments and was considered reversible if a reduction of at least 1
CSI was observed after 30 days. WMSI according to ASE and LV volumes were
also calculated.
Results: At 24 hours MCE, 11 patients showed reﬂow (group A) (CSI=1.1±0.05)
and 21 patients showed no reﬂow (CSI= 2.5±0.2) that was persistent after 30 days
in 11 patients (group B) (CSI=2.6±0.2) and reversible in 10 patients (group C)
(CSI=1.3±0.1; p<0,05 vs MCE at 24 hours). Persistent no-reﬂow was associated
with Q-waves on presenting ECG in 91% of patients, CK peak 4446 ± 696.9 mg/dl,
risk area myocardial thickness 0.69±0.04 cm (p<0.05 vs groups A and C). Other
clinical parameters, including time to recanalization and TIMI grade were not able
to predict persistent no-reﬂow. WMSI signiﬁcantly improved at 30 days in group A
(1.4 ± 0.3 vs 2.8 ± 0.2, p<0.0001) and C (2.9 ± 0.1 vs 2.5 ± 0.1, p<0.005), no
changes were observed in group B (2.8 ± 0.1 vs 2.8 ± 0.1, p=ns). End-systolic and
end-diastolic LV volumes dilated in group B (136.9 ± 11.6 vs 89.4 ± 5.8, p<0.0005
and 91.4 ± 10.6 vs 56.9 ± 6.1, p=0.001), but not in groups A and C.
Conclusions: Serial MCE evaluation of post AMI patients identiﬁes two groups
of no-reﬂow patients. Only sustained microvascular damage can be predicted by
clinical signs of myocardial necrosis and evolve in LV dilatation. Sustained and
reversible no-reﬂow recognize different pathogenetic mechanisms that need to be
further explored.
175
Evaluation of prognostic important segments by real-time contrast
echocardiography in successfully treated patients with the ﬁrst
myocardial infarction.
J. Krupicka 1 , P. Tousek 1 , M. Orban 2 , P. Gregor 1 , C.H. Firschke 3 . 1 FN Kralovske
Vinohrady, III. Internal-Cardiology clinic, Prague 10, Czech Republic; 2 St Anna’s
University Hospital, 1st Internal Department, Brno, Czech Republic; 3 Technische
Universitat, Deutsches Herzzentrum, Munich, Germany
Left ventricular segments with abnormal wall motion have good prognostic value
(function recovery, no remodelling) if preserved perfusion is detected by myocardial
contrast echocardiography (MCE).
The aim of the study was to evaluate left ventricular (LV) perfusion by real-time
MCE and recognise perfusion differences in segments with different kinetics.
Methods: 47 patients (36 males, average (SD) age 59 (13) of years, range 22-84)
presented with the ﬁrst myocardial infarction (MI) and treated by direct PTCA or
thrombolysis were enrolled. MCE was performed between 24 and 72 hours after
MI. Perfusion was assessed semi-quantitatively and scored as 1=normal, 2=patchy
and 3=no perfusion. 533 segments were estimated. The differences in perfusion
between akinetic and hypokinetic segments were studied. TIMI 3 ﬂow was detected
in all observed segments.
Results: From the 533 segments, 102 (19%) were hypokinetic and 99 (18%) were
akinetic. 31 (6%) segments were excluded (artefacts), no dyskinetic segments
were evaluated. Average (SD) EF was 50% (10). Most of the hypokinetic segments (95, 93%) were normally or patchily perfused, while only 35 (35%) akinetic
segments had preserved perfusion (p<0.01). Normal or patchy perfusion was detected in 130 of the 201 segments (64%) with wall motion abnormality.
Conclusion: Successful treatment of myocardial infarction preserves LV function.
Immediately (within 3 days) evaluated segments have wall motion abnormality, but
many of them are perfused. We can expect preservation of left ventricular geometry and improvement in wall motion abnormality, especially in hypokinetic segments.
Eur J Echocardiography Abstracts Supplement, December 2003
176
Improvement of left ventricular systolic performance after acute anterior
myocardial infarction treated with primary coronary angioplasty:
myocardial contrast echocardiography study.
A. Klisiewicz 1 , P. Michalek 1 , M. Karcz 2 , M. Banaszewski 3 , W. Ruzyllo 2 ,
J. Stepinska 3 , P. Hoffman 1 . 1 Institute of Cardiology, Congenital Heart Disease
Department, Warsaw, Poland; 2 Institute of Cardiology, Coronary Artery Disease
Department, Warsaw, Poland; 3 Institute of Cardiology, Intensive Care Unit,
Warsaw, Poland
Objective: The early restoration of ﬂow in patients (pts) with acute myocardial
infarction (AMI) treated with primary coronary angioplasty (PCI) is supposed to
enhance the functional recovery of left ventricular (LV) function. However, the microvascular integrity is a prerequisite for preserved myocardial viability after AMI.
The following study was performed to assess the potential of myocardial contrast
echocardiography (MCE) to predict improvement of LV function after AMI.
Methods: 32 consecutive pts (24 male, 8 female, mean age 56.8±10.1 yrs) with
LAD occlusion (single vessel disease) and subsequent AMI treated successfully
with PCI (TIMI 3 ﬂow) were enrolled. The study protocol included harmonic MCE
(H-MCE) with Levovist 1–2 days after AMI (exam I). Images were taken from apical four and two chamber views of pulsing intervals of ﬁve to seven cardiac cycles. MCE was scored semiquantitatively as: 2–homogenous contrast density, 1
–heterogenous, 0 – no contrast. One month later 2D echo was repeated (exam II).
In each study wall motion score index (WMSI) and ejection fraction (EF) (bi-plane
Simpson, s method) were calculated.Improvement of the LV function was deﬁned
as decrease of WMSI and increase of EF between exam I and II.
Results: 18 pts (group 1) revealed inevitable myocardial perfusion (score 2) within
the infarcted area whereas 14 did not (score 1 and 0) (group 2). WMSI and EF improved signiﬁcantly between exam I and II in the group 1 (1.49±0.25 vs 1.29±0.24,
p<0.001 respectively, 51.6%±7.6% vs 56.2%±7.8%, p<0.001 respectively). On
the contrary, group 2 did not exhibit such a changes (1.70±0.16 vs 1.63±0.28, NS
respectively, 46.4%±5.5% vs 48.1%±8.3%, NS, respectively). Group 1 showed
signiﬁcant changes in the WMSI and EF compared with group 2 at one-month
follow-up (p<0.001 and p<0.01 respectively). H-MCE had sensitivity 85% and
speciﬁcity 92% for predicting late functional improvement.
Conclusions: Patients with AMI treated with PCI with subsequent preserved microvascular integrity as assessed by H-MCE showed signiﬁcant improvement of
LV function at one-month follow-up. Thus, H-MCE seems to be a good tool for
predicting functional recovery of LV function after AMI.
177
The assessment of left ventricular volumes and ejection fraction by
experienced and low-experienced observers is improved by the use of a
contrast agent.
V. Rizzello 1 , E. Biagini 2 , T.W. Galema 2 , M. Bountioukos 2 , C. Colizzi 1 ,
F.B. Sozzi 2 , E.C. Vourvouri 2 , F.J. Ten Cate 2 . 1 The Catholic University, Cardiology
Department, Rome, Italy; 2 Thoraxcenter Erasmus MC, Cardiology Department,
Rotterdam, Netherlands
Background: Measurement of left ventricular (LV) volumes and ejection fraction
(EF) after acute myocardial infarction provides valuable diagnostic and prognostic informations. Moreover, these parameters are important to estimate the occurrence of LV remodeling and further changes in LV function at follow-up.
Aim: To determine whether contrast-enhanced echocardiography allows a more
reliable assessment of LV volumes and EF as compared to standard second harmonic imaging.
Methods: In 70 patients with recent acute myocardial infarction, treated by primary
percutaneous transluminal coronary angioplasty, 2-Dimensional echocardiography
was performed, before and after the opaciﬁcation of LV cavity by an intravenous
contrast agent (Sonovue, 1 ml for each view). In both native and contrast-enhanced
images second harmonic capabilities were available. LV volumes and EF were
measured by the modiﬁed Simpson’ s rule from apical 4- and 2-chamber views,
in both native and contrast-enhanced images. An experienced (training level 3)
observer performed all the measurements, which were repeated a second time
by the same observer in a different random order, to assess the intraobserver
variability. A low-experienced (training level 1) observer independently performed
all the measurements to estimate the inter-observer variability.
Results: For the measurement of the LVEF, the intra-observer difference was
4% ± 4% in the native images and 1%± 2% in the contrast-enhanced images
(p<0.00001). The inter-observer difference was 6% ± 6% in the native images
and 1% ± 3% in the contrast-enhanced images (p<0.0001). For the measurement
of the EDV and ESV, the intra-observer differences were 4 ± 15 ml and 7 ± 10
ml, respectively, in the native images and 2 ± 7 ml and 1 ± 5 ml in the contrastenhanced images (p= 0.003 for EDV and p<0.00001 for ESV). The inter-observer
differences were 8 ± 17 ml for EDV and 10 ± 12 ml for ESV in the native images
and 1 ± 8 ml for EDV and 1 ± 6 ml for ESV in the contrast-enhanced images (p=
0.0003 for EDV and p<0.00001 for ESV).
Conclusions: The administration of Sonovue improves the reproducibility of LV
volumes and EF measurement as compared to native second harmonic imaging,
both in experienced and low-experienced observers. This advantage may be clinically relevant. It may allows more reliable monitoring of LV remodeling and a proper
prognostic stratiﬁcation after acute myocardial infarction.
Abstracts
178
Quantitative evaluation of regional myocardial perfusion during
dipyridamole stress by real-time myocardial contrast echocardiography
in patients with and without coronary artery disease.
L. Scuteri 1 , M. Revera 1 , P. De Filippo 1 , M. Ferlini 1 , L. Lanzarini 1 , U. Canosi 1 ,
C. Klersy 2 , L. Tavazzi 1 , M. Previtali 1 . 1 IRCCS Policlinico S. Matteo, Cardiology,
Pavia, Italy; 2 Cardiology, Biometry Unit, Pavia, Italy
Background: In experimental studies myocardial contrast echo (MCE) parameters of regional mycardial perfusion show a good correlation with the severity of
coronary lesions, but clinical data on coronary pts are still scarce.
Purpose: 1)To assess the correlation between parameters of regional myocardial
perfusion derived from real-time MCE and severity of coronary lesions by quantitative coronary angiography (QCA) in pts with or without left anterior descending
(LAD) disease. 2)To determine the sensitivity and speciﬁcity of MCE parameters in
detecting critical LAD stenosis.
Methods: 38 pts, 21 males, aged 60±7 years, 24 with ≥50% LAD stenosis, and
14 with normal or ≤50% stenosis of LAD underwent real-time MCE with Sonovue
using Power Doppler Harmonic Imaging (Vivid 7 GE) at baseline and during dipyridamole(D) stress (0.84 mg/Kg in 4’). MCE time-intensity data in 2 regions of interest [proximal (SP) and distal septum (SD)] were ﬁtted to the exponential function
y= A (1-e-bt)+c, where A is the peak plateau signal intensity, b the rate of signal
increase and the product A x b is proportional to myocardial blood ﬂow. Baseline
and peak stress MCE parameters were correlated with minimal luminal diameter
(MLD) and % diameter stenosis (DS) of LAD by QCA.
Results: See table. The product A x b in DS at peak stress was signiﬁcantly related
with MLD (r=.52, p=.0025) and %DS of LAD (r=.58, p=.0001)and b in DS at peak
was related with %DS(r=.53, p=.0007). By ROC analysis a value of A x b < 2.45
for a >50% LAD stenosis had a 86% sensitivity and 74% speciﬁcity; for a > 70%
LAD stenosis a cut-off of Axb <1,99 had a 89% sensitivity and a 68% speciﬁcity,
with an area under the ROC curve >.80 for both values.
basal Axb distal septum
peak Axb prox septum
peak b distal septum
peak Axb distal septum
Normal/<50%LAD disease
>50%LAD disease
p value
2.14 ± 1.04
5.5 ± 2.03
.67 ± .25
4.4 ± 2.01
1.5 ± .86
3.2±2.19
.37 ± .28
2.1 ± 1.8
.06
.002
.003
.0005
Conclusions: In pts with LAD disease MCE parameters of regional perfusion during D-induced hyperemia are signiﬁcantly correlated with QCA parameters and
show a good sensitivity and speciﬁcity for detecting critical LAD stenosis.
179
Five years of adenosine contrast echocardiography: lessons from 1750
consecutive studies in a single center.
F. Morcerf 1 , A. Moraes 2 , M. Carrinho 1 , F.C. Palheiro 1 , A.C. Nogueira 1 ,
R. Morcerf 1 , C. Medeiros 1 , M. Castier 1 . 1 ECOR - Diagnóstico Cardiovascular,
Rio de Janeiro, Brazil; 2 ECOR - Diagnóstico Cardiovascular, Rio de Janeiro, Brazil
Background: Detection of myocardial perfusion by echocardiography with intravenous injection of contrast agents is an emergent technique. Five years ago we
started our experience in humans testing different protocols (varying the stressor
agents, the ultrasound technologies and PESDA administration) in 160 pts with
conﬁrmed coronary artery disease (CAD). Due to our initial results we decided by
the Adenosine Contrast Echocardiography (ACE) protocol. It is performed with continuous infusion (1-2 ml/m) of PESDA associated with triggered (ﬁxed 1:1) 2nd harmonic imaging technology, at rest and after a bolus injection of adenosine (ADN).
The aim was to report the safety, tolerance and results of this protocol in the clinical
scenario of CAD.
Methods: 1750 consecutive pts (1085 male, 12 to 91 years), were submitted to the
ACE protocol to investigate myocardial perfusion. At least 1 ampoule of 2ml/6mg
of ADN was used for each echocardiographic view. Images were obtained at the
standard apical 4-chamber and 2-chamber views. Myocardial perfusion was visually analyzed (2 independent investigators) in 3 perfusion beds (LAD, RCA and Cx
arteries).
Results: The ACE studies were interpretable for all perfusion beds in 1735 pts
(99%). PESDA infusion produced myocardial contrast and ADN bolus injection enhanced it further in at least 1 LV segment wall in all pts. 980 pts (56%) required
1 amp of ADN per view to achieve further increment of the wall contrast. 525 pts
(30%) and 245 pts (14%) required 2 and 3 amp respectively to obtain the same
result. A transient, asymptomatic 3rd degree AV block lasting less than 10s was
noted in 31, 49 and 130 pts who had 1, 2 or 3 amp of ADN respectively (total
of 210 pts-12%). 262 pts (15%) complained of lightheadedness, 140 pts (8%) of
headache, and, 105 pts (6%) of non-angina chest discomfort. All patients developed tachypnea. Symptoms lasted less than 30 s and did not required therapy or
precluded further ADN injection if needed. All our previous papers, using coronary
angiography as gold-standard in pts with high incidence of CAD, reported global
accuracy superior to 90%.
Conclusion: ACE protocol with PESDA infusion is safe and very well tolerated by
pts with suspected CAD.
S17
180
Contrast or transoesophageal dobutamine echo for the detection of
ischaemia in poorly echogenic patients?
B. Cosyns 1 , J. Van der Auwera 1 , M. Menassel 1 , M. Mantia 1 , M. Van der
Hoogstraete 2 , D. Schoors 2 , G. Van Camp 2 . 1 Hop. Braine l’Alleud Waterloo,
Cardiology, Braine- Waterloo, Belgium; 2 AZ VUB, Cardiology, Brussels, Belgium
Introduction: Dobutamine echocardiography (DASE) has been shown to be a very
useful non-invasive technique for the detection of myocardial ischemia. However,
inadequate transthoracic images preclude the use of DASE in a signiﬁcant group of
patients. Transoesophageal approach (TOE) can overcome this limitation and improves endocardial border delineation. Transthoracic contrast echo (CE) has also
been shown to improve left ventricular opaciﬁcation at rest and during stress echo.
The aim of our study: was to compare prospectively the feasibility, safety, sensitivity
and speciﬁcity of dobutamine CE and TOE for the detection of coronary artery
disease (CAD).
Methods: 42 poorly echogenic patients scheduled for cardiac catheterisation underwent prospectively both CE and TOE dobutamine tests. All underwent coronary
angiography within the 48 h. A lesion > 50% by quantitative analysis was considered signiﬁcant.
Results: One patient did not tolerate intubation with TOE probe but had developed wall motion abnormalities before the test was stopped. Mean duration of
dobutamine TOE and CE was respectively 21.7 ± 8.0 min and 14.5 ± 1.8 min
(p<0.05). There were no major complications with both techniques. Twenty-six patients of 30 patients with signiﬁcant CAD using TOE and 27 using CE had a positive
DASE (sensitivity: 86% vs 90%, NS). One of 12 patients without signiﬁcant CAD
had false positive ﬁndings using TOE, 0 using CE (speciﬁcity 92% vs 100%,NS).
Conclusions: In poorly echogenic patients, dobutamine CE is a safe, feasible and
accurate technique for the detection of myocardial ischemia in comparison with
dobutamine TOE.
Because dobutamine CE is less invasive, of shorter duration and more comfortable
than TOE, it should be used in patients with suboptimal transthoracic echocardiograms for the evaluation of CAD during dobutamine stress testing.
181
Increased feasibility of myocardial contrast echo perfusion studies in
poor acoustic windows with contrast pulse sequencing compared to a
standard pulse cancellation method.
E. Perez 1 , M.A. García Fernández 2 , T. López Fernández 2 , M.J. Ledesma 3 ,
A. Santos 3 , N. Malpica 3 , M. Moreno 2 , J. Bermejo 2 , A. Contreras 2 , M. Desco 4 .
1
Majadahonda-Madrid, Spain; 2 Hospital General Gregorio Maranon, Cardiology
Dept., Madrid, Spain; 3 Polytechnic University, Madrid, Spain; 4 HGU Gregorio
Maranon, Cardiology Dept., Madrid, Spain
Background: Poor acoustic windows are still a drawback for the evaluation of
myocardial perfusion with myocardial contrast echo (MCE).
The aim of this study is to compare feasibility of MCE performed with a new imaging
technology based on detection of non-linear fundamental and harmonic energy
with a standard cancellation pulse method(p).
Methods: 237 segments (S) from 21 non-selected consecutive p referred for
transthoracic echo were evaluated. Sonovue was administered in continuous infusion. Sequences of 200 frames with temporal resolution of 75 ms were acquired
in apical views with CPS, a new non-destructive MCE method and with CCI, a
cancellation pulse method. Both technologies were implemented in an AcusonSiemens Sequoia equipment. To analyse feasibility of both technologies and according to the quality of the perfusion image, each S was evaluated with a score
ranging from 0 to 3 (0: very poor; 1: suboptimal; 2: acceptable; 3: optimal).
Results: Mean global score from all S was higher with CPS than with CCI
(1.96±0.07 and 1.42±0.07, p=0.0005). When 128 S corresponding to p with
intermediate-poor acoustic window were selected, the advantage of CPS over CCI
was largest (difference in quality score: 0.82±0.10, p=0.0005). In 58% of 55 S not
visualized at all with CCI (Score=0), image quality improved with CPS. However,
regional differences in CPS feasibility were observed (see ﬁgure), and quality score
remained low with both techniques in basal anterior and basal lateral segments.
Image quality score with CPS
Conclusions: Beneﬁt of CPS over standard pulse cancellation studies is notorious, especially in p with poor acoustic windows. However, in some cases good
image acquisition is still difﬁcult in anterobasal and laterobasal S.
Eur J Echocardiography Abstracts Supplement, December 2003
S18
Abstracts
182
Left ventricular opaciﬁcation improves the diagnostic value of
dipyridamole-atropine stress echocardiography.
184
Contrast enhanced endocardial border delineation in real-time 3d
echocardiography.
R. Amyot, M. Di Lorenzo, R. Lebeau, D. Palisaitis, E. Schampaert, J.G. Diodati,
C. Sauvé. Sacré-Coeur Hospital, Cardiology, Montreal, Canada
S. Kapetanakis, K. Rance, O. Murray, A. Proschel, M.J. Monaghan. Kings College
Hospital, Cardiology, London, United Kingdom
High dose dipyridamole-atropine stress echocardiography (DASE) with left ventricular (LV) opaciﬁcation using ultrasound contrast agents has not been systematically validated against an angiographic gold standard. Hypothesis: LV opaciﬁcation improves the diagnostic value and interobserver agreement of DASE. Methods: Forty-one patients (age 60.8 ± 9.1 years; 34 men (82.9%)) referred for coronary artery disease (CAD) evaluation underwent DASE and coronary angiography.
Noncontrast and contrast loops were digitized in sequence using second harmonic
imaging in standard views at baseline and peak stress during DASE (up to 0.84
mg/kg of dipyridamole and 2.0 mg of atropine). LV opaciﬁcation was obtained using successive IV bolus injections (0.1 to 0.3 cc) of perﬂutren. The contrast and
noncontrast DASE images were independently reviewed in random order on different days by 2 experienced echocardiographers blinded to the clinical and angiographic data. The LV was divided into 16 segments as suggested by the American Society of Echocardiography. An endocardial delineation score (EDS) was
attributed to each LV segment: 0 = not visible; 1 = poorly visible; and 2 = clearly
visible. Coronary angiograms were performed by experienced interventional cardiologists blinded to the results of DASE. CAD diameter stenosis ≥ 70% was considered signiﬁcant. Results: Mean time between DASE and angiography was 8.9
± 8.3 days. Signiﬁcant CAD was present in 21 patients (51.2%). The proportion
of LV segments with an EDS of 2 was higher in contrast images at baseline (contrast: 69.6% (1256/1804) vs noncontrast: 62.7% (1128/1798); p < 0.0001) and
at peak stress (contrast: 73.7% (1331/1804) vs noncontrast: 62.4% (1126/1804);
p < 0.0001). Sensitivity for signiﬁcant CAD detection rose from 66.7% for noncontrast to 85.7% for contrast DASE (p = 0.040). Speciﬁcity was not signiﬁcantly
inﬂuenced by contrast use (55.0% for noncontrast vs 57.5% for contrast DASE). Interobserver agreement for DASE results increased from 70.7% (kappa = 0.41) for
noncontrast to 82.9% (kappa = 0.63) for contrast imaging. Conclusion: LV opaciﬁcation during DASE improves endocardial delineation at baseline and peak stress,
increases sensitivity for detection of signiﬁcant CAD and results in higher interobserver agreement.
Transthoracic real-time three-dimensional echocardiography (RT3DE) is a new
modality, which offers a novel approach to assessing regional and global left ventricular function. As with 2D echocardiography, endocardial delineation is limited in
a substantial proportion of patients. The use of intravenous echocardiography contrast has not been previously evaluated in RT3DE and may enhance endocardial
border detection.
During this study, 40 consecutive patients attending for dobutamine stress echocardiography (DSE) were investigated. RT3DE datasets of the left ventricle were
obtained prior to contrast infusion using the Philips Sonos 7500 and the X4 matrix
array transducer. Baseline images were then obtained with a continuous infusion
with Sonovue (1.1 ml/min) with harmonic imaging and low MI (0.3). All 3D datasets
were obtained using Full Volume Acquisition (FVA) from the apical position. Average acquisition time was 5 seconds. Using proprietary software (CardioView RT,
TomTec), the apical FVA’s were cropped to produce standard 4, 2 and 3 chamber views and a short axis view of the left ventricle. The baseline 2D and RT3DE
images with and without contrast were reviewed by two experienced interpreters
blinded to the results of the 2D stress echocardiogram and to each other’s ﬁndings.
All patients demonstrated excellent endocardial deﬁnition with good contrast deﬁnition and a frame rate of approximately 20 Hz. Contrast infusion signiﬁcantly improved endocardial border delineation compared to native imaging. Left ventricular
opaciﬁcation during RT3DE is feasible in patients referred for evaluation of LV function. It provides rapid, high quality acquisition of 3D images allowing creation of any
2D plane during off-line analysis. This technology will be especially valuable during
Stress Echo.
183
Contrast echocardiography increases accuracy and reproducibility in
measurements of left ventricular ejection fraction.
S. Malm 1 , S. Frigstad 2 , E. Sagberg 1 , H. Larsson 1 , T. Skjaerpe 1 . 1 Faculty of
Medicine, Dep.of circulation and medical imaging, Trondheim, Norway; 2 GE
Vingmed Ultrasound, R & D Department, Trondheim, Norway
Background: Improved endocardial deﬁnition by iv. contrast agents has been
demonstrated to beneﬁt echo assessment of LVEF, however, limited data exist
comparing contrast with tissue harmonic imaging vs. MRI.
Hypothesis: Contrast increases accuracy and reproducibility of echo-derived LV
volumes and EF in non-selected cardiac patients.
Methods: In 100 consecutive cardiac patients (age 59 ± 11) standard apical views
were acquired digitally with Vivid 7(GE Vingmed) in "double focus" tissue harmonic
imaging, and repeated after iv. SonoVue or Deﬁnity, using low acoustic power. MRI
was performed with TruFISP in a 1.5 T Symphony scanner. LV volumes and EF
from echo were calculated by modiﬁed biplane Simpsons rule in EchoPacPC, from
MR images in a dedicated software in MatLab. Thirty randomly selected patients
were evaluated for interobserver variability.
Results: Study patients included a wide range of LV sizes, shapes and function.
Twelve subjects with baseline image quality inadequate for endocardial delineation,
all became "traceable" after contrast. Agreement analysis demonstrated underestimation of LV volumes by echo compared to MRI, but this was signiﬁcantly less
pronounced with contrast. Limits of agreement between MRI and echo for EF narrowed signiﬁcantly after contrast addition (Figure). EF from precontrast echo and
MRI differed in absolute value by >10% in 24 patients, in none after contrast. Interobserver agreement was signiﬁcantly better for contrast images; limits of agreement for EF -6 to +7% vs. precontrast -17 to +14%.
Conclusion: Iv. contrast signiﬁcantly improved accuracy and reproducibility of
echo-derived LV volumes and EF, and in one third (36%) of consecutive cardiac
patients the differences were of possible clinical relevance.
Eur J Echocardiography Abstracts Supplement, December 2003
185
Diluted bolus contrast echo with deﬁnity signiﬁcantly improves left
ventricular endocardial border delineation.
J.E. Macioch 1 , H. Hong 2 , J.C. Provost 2 , T. Dobeck 2 , B. Williams 2 , M. Daniels 2 ,
M. Johnson 2 , J. Garze 3 , K. Bairstow 3 , S.B. Feinstein 2 on behalf of
Rush-Presbyterian-St. Luke’s Medical Center/Chicago IL USA.
1
Rush-Presbyterian-St. Luke’s Medical, Cardiology/Echocardiography, Chicago,
United States of America; 2 Rush Presbyterian St. Luke’s Hospital, Cardiology,
Chicago, Illinois, United States of America; 3 Bristol Myers Squibb, North Billerica,
United States of America
Background: Ultrasound contrast agents have been available for clinical use during the past several years. Early agents had the limitation of low reﬂectivity and
short persistence. Deﬁnity , an advanced generation agent of lipid microbubbles,
was developed for applications requiring improved left ventricular imaging capabilities, especially in the technically difﬁcult patient.
Purpose: To study the ability of Deﬁnity to improve endocaridal border delineation (EBD) in a group of technically difﬁcult patients.
Methods: Fifty (50)unselected patients referred to Echo Lab for stress testing in
which baseline apical images showed greater than or equal to 2 contiguous suboptimally visualized segments were included in the study. Non-contrast standard
views were obtained, including parasternal long axis, parasternal short axis, apical 4 chamber and apical 2 chamber images in digital format. Deﬁnity was then
administered by IV injection using a mixture of 1cc of prepared Deﬁnity and 9cc
of saline. A 2cc aliquot of this mixture was injected as a bolus with repeat imaging.
Analysis was performed by comparing non-enhanced versus contrast enhanced
images. A scoring scale was used as follows: 0 =segment not seen, 1 = adequate
but not complete visualization, 2 = full and complete visualization. Sixteen segment
standard ASE model is used.
Results: A total of 1100 segments were analyzed from the 50 patient study. Paired
study t test showing mean average score of 0.6464 ± 0.078 for
non-enhanced versus 1.7327 ± 0.044+ for the contrast enhanced segments
(p<0.0001). The most marked improvement was in the apical anterolateral and
apical septal segments, which showed a ﬁve factor improvement in visualized segments (mean wall motion score of 0.25 improving to 1.75).
Conclusion: The advanced generation contrast agent Deﬁnity signiﬁcantly improves visualization of endocardial border delineation in a cohort of technically
difﬁcult patients, with the most dramatic improvement in the apical anterolateral
and apical septal segments.
Abstracts
186
Ultrasonic characterisation of a newly developed targeted ultrasonic
contrast agent.
C. Moran 1 , J. Ross 2 , C. Oliver 2 , M. Butler 1 , W.N. McDicken 1 , K.A.A. Fox 3 .
1
Medical Physics, University of Edinburgh, Edinburgh, United Kingdom;
2
University of Edinburgh, Clinical and Surgical Sciences, Edinburgh, United
Kingdom; 3 University of Edinburgh, Cardiovascular Research, Edinburgh, United
Kingdom
Background: The size and composition of commercially available ultrasonic contrast microbubbles are such that when insonated at routinely used diagnostic frequencies (2-7MHz), the bubbles resonate and strongly scatter ultrasound. Recently there has been increasing interest in imaging and manipulating these microbubbles at higher frequencies (30-40MHz) for possible applications in targeting
microbubble-encapsulated drugs to speciﬁc plaque sites in arteries and to image
such sites using intravascular ultrasound. Due to commercial sensitivity re shell
constitutents and manufacture, targeting of speciﬁc commercial agents was not
possible.
Aim: To produce an ultrasonic contrast microbubble capable of resonating at 3040MHz and to investigate the possibility of using such an agent for targeting speciﬁc cell-lines found in the arterial wall.
Method: A lipid-encapsulated nitrogen-ﬁlled microbubble was developed in-house.
The agent was diluted to various concentrations using saline and blood-mimicking
ﬂuid (BMF). Using a ClearView Ultra system, an Atlantis SR intravascular probe
was inserted into each solution and one frame of unprocessed ultrasonic data
was acquired. The data was downloaded onto a PC. A region-of-interest (ROI)
of 128 data points and 9 ultrasonic lines was chosen. Over these ROIs, mean
backscatter power was calculated and referenced to data collected from a waterair interface. The ability of the agent to be targeted to speciﬁc cells was assessed
microscopically by labelling the microbubbles with an antibody (CD54) and then
passing these microbubbles over endothelial cells grown on an agar interface. A
ﬂow chamber was developed to enable both acoustical and optical images to be
obtained of the cells under physiological ﬂow conditions.
Results: At concentrations of 25mg/ml, mean backscatter power was approximately 9dB less than a commercially available agent (Deﬁnity). This level of
backscatter is adequate for arterial plaque studies. Further development is underway to increase the scattering cross-section of the bubbles. When observed
using a microscope and in the ﬂow chamber, antibody-loaded microbubbles were
observed ﬁrmly attached to cells.
Conclusions: This technique has the potential to identify those plaques which are
disrupted or recently eroded and for which diagnostic techniques have limitations.
187
Parameters inﬂuencing the myocardial delivery of nanoparticles using
ultrasound-targeted microbubble destruction.
D. Vancraeynest, X. Havaux, A. Pasquet, C. Beauloye, L. Bertrand, B. Gerber,
J-L. Vanoverschelde. Cliniques Universitaires St-Luc, Cardiology, Brussels,
Belgium
Background: Ultrasound (US) -targeted microbubble destruction (UTMD) is a
promising new method for delivering viral vectors to the heart. Little is known, however, regarding the efﬁciency of particulate delivery using this approach. Accordingly, the aim of the present work was to investigate the inﬂuence of US energy
and duration of US exposure on the efﬁciency of nanoparticulate delivery to the rat
myocardium.
Methods: The ability of UTMD to direct the delivery of ﬂuorescent nanoparticles
to the heart was evaluated in anesthetized rats exposed to both PESDA and
transthoracic triggered (1Hz) second harmonic (1.3-2.6 MHz) US at mechanical
indexes (MI) of 0.5, 1.0 or 1.6 for 1, 3 or 9 minutes. Pairs of 30 nm green and
100 nm blue ﬂuorescent nanospheres, carefully chosen to approximate the size of
adeno-associated viruses, adenoviruses and lentiviruses, were intravenously infused throughout the experiments. At the end of US exposure, the hearts were
harvested, washed and analyzed under the ﬂuorescent microscope to quantify the
area occupied by the nanospheres in the anterior wall.
Results: Exposure to US alone, PESDA alone or both PESDA and US at a MI of
0.5 did not result in any signiﬁcant deposition of ﬂuorescent nanoparticles in the exposed myocardium. By contrast, green and blue nanospheres could be evidenced
in the anterior wall of all the animals exposed to PESDA and US at a MI > 0.5. The
extent of nanoparticulate deposition (measured as the area occupied by the green
and the blue ﬂuorescence) increased with both the duration of US exposure (0.5 ±
0.3%, 1.4 ± 0.6%, 6.2 ± 4.1%, respectively in hearts exposed to a MI of 1.6 for 1,
3 and 9 min, P<0.05 vs Controls) and the US energy applied (0.32 ± 0.34%, 3.2
± 3.4% and 6.2 ± 4.1%, respectively in hearts exposed to an MI of 0.5, 1.0 and
1.6 for 9 min, P<0.05 for the 1.0 and 1.6 MI groups vs controls). No difference was
noted in the area occupied by the green and the blue nanospheres.
Conclusions: Delivery of ﬂuorescent nanoparticles by UTDM is time- and energydependent but is not inﬂuenced by the size of the nanoparticles. These data have
important implications for optimizing the delivery of viral vectors to the heart using
this approach.
S19
188
Early results of a novel ultrasound technology, contrast pulse
sequencing, in the evaluation of no-reﬂow by myocardial contrast
echocardiography.
L. Galiuto, A. Lombardo, D. Lomaglio, F. Belloni, F. Pennestrì, A.G. Rebuzzi,
F. Crea. Policlinico A. Gemelli Univ. Cattolica, Cardiology, Rome, Italy
Background: We report early results on the evaluation of microvascular integrity
after acute myocardial infarction (AMI) by myocardial contrast echocardiography
(MCE) using a novel ultrasound technology, named Contrast Pulse Sequencing
(CPS) (Siemens).
Materials: 17 patients with ﬁrst AMI (14 anterior) underwent MCE within 24 hours
from successful PCI. MCE was performed by real time CPS and i.v. Sonovue
(Bracco) (5 ml at 2 ml/min). Length of perfusion defect (PD) at MCE was calculated
in each apical view, averaged and expressed as % of WMA and of LV length.
Transmural extent of PD was also calculated (25-50-75-100%). Patients with PD >
25% of LV were considered as no-reﬂow (igure).
Results: A PD involving 75-100% of
myocardial thickness was present in
14 patients, ranging between 10 to
60% of LV length (24±15%). In 1 patients PD involved 25% of the wall
and in 2 patients no PD was present.
Seven patients showed no-reﬂow (PD
37.8±12.1% of LV and 82.9±16.9% of
WMA length) and 11 showed reﬂow
(PD 14.7±8.9% of LV and 47.7±31%
of WMA length, p<0.0005 and p=0.01
vs no-reﬂow).
Conclusions: MCE performed by
CPS allows an accurate assessment of
regional myocardial perfusion following
successfull primary PCI. Furthermore,
it allows the assessment of transmuSAX MCE at the papillary level
ral distribution of myocardial perfusion.
Thus, MCE by CPS might become the technique of choice for the identiﬁcation of
no-reﬂow.
189
High-resolution power modulation increases the level of agreement in
reading adenosine perfusion studies compared to angio mode: a
substudy comparison between two modalities of real-time perfusion.
M. Dencker 1 , R. Winter 2 , P. Gudmundsson 2 , O. Thorsson 1 , R. Willenheimer 2 .
1
Malmoe University Hospital, Dep of Clinical Physiology, Malmoe, Sweden;
2
Malmö University Hospital, Cardiology Dept., Malmö, Sweden
Background: The new low mechanical index contrast echocardiographic modality
of power modulation has allowed for assessment of myocardial perfusion in realtime (RTP), and thus made it possible for simultaneous analysis of perfusion and
wall motion. The high-resolution grey scale modality of power modulation (Philips
SONOS 5500 and 7500) offers a better spatial resolution compared to the earlier
angio mode of power modulation. It not clear whether this technical improvement
can be transferred into a better clinical result.
Objectives: The aim was to determine whether there is an an additive value in the
new high-resolution power modulation modality compared to the angio mode.
Methods: This study was a substudy from an ongoing prospective study were patients with known or suspected CAD, were we compare RTP to SPECT. All patients
underwent RTP imaging (SONOS 5500) using infusion of Sonovue before and during adenosine stress. In this substudy, power modulation in both angio mode and
high-resolution grey scale mode was performed. Analysis of myocardial perfusion
and wall motion using power modulation in both angio mode and high-resolution
grey scale mode was performed off-line later on two separate occasions. Two readers performed separate analysis in both cases, blinded for each other and the
earlier analysis. The two readings were performed with a minimum time-span of
two weeks. Myocardial ischemia was visually evaluated comparing rest and hyperaemia images. A myocardial segment was considered ischemic if both perfusion
and contractility were impaired in the hyperaemic images, compared to the rest
images. We deﬁned three areas of interest from the normal distribution area of
the three main coronary vessels; the left anterior descending (LAD); the circumﬂex
(Cx); and the right posterior descending (RPD). All coronary territorial segments
were interpreted regardless of the image quality.
Results: A total of 48 coronary territories were analysed both using highresolution, and angio mode of power modulation. The level of agreement between
the two readers was higher using the high-resolution mode compared to the angio
mode (overall 83% vs. 75%). The difference was consistent in all three territorries.
The level of agreement increased 6%,13% and 6% in respectively LAD, Cx and
RPD areas.
Conclusion: The new high-resolution grey scale modality of power modulation
seem to increase the level of agreement in reading adenosine RTP stress echocardiography, and may therefore simplify the reading process and improve the learning
curve in reading adenosine RTP studies.
Eur J Echocardiography Abstracts Supplement, December 2003
S20
Abstracts
190
Assessment of myocardial perfusion in patients with coronary heart
disease using real-time contrast echocardiography and global acoustic
density technique.
L.L. Cheng, X.H. Shu, C.Z. Pan, H.Z. Chen. Zhongshan Hospital, Fudan
University, Department of Cardiology, Shanghai, China
Objective: To investigate the clinical value of quantitative assessment of myocardial perfusion(MP) for patients with coronary heart disease using global acoustic
density technique(GAD) and real-time contrast echocardiography.
Methods: Nineteen patients with coronary heart disease were performed contrast
echocardiography using SonoVue (Bracco) intravenously. Four-chamber and twochamber view of left ventricular at apical were obtained. The MP were assessed
quantitatively by GAD.
Results: Quantitative methods using GAD: the MP were signiﬁcantly higher in
segments supplied by normal coronary arteries than those supplied by narrowed
ones(22.09±18.12dB2/s vs 61.94±31.01 dB2/s, p<0.01). The MP were still lower
in segments supplied by coronary arteries after PTCA and stenting than that by
normal supply(28.84±23.94 dB2/s vs 66.12±33.46 dB2/s,p<0.01). However, the
MP in segments supplied by coronary arteries after CABG were similar to that by
normal supply (64.11±23.61dB2/s vs 61.94±31.01 dB2/s,p>0.05).
Conclusions: Real-time contrast echocardiography and GAD can quantitatively
evaluate the MP in patients with coronary heart disease.
191
Clinical evaluation of SonoVue for improvement of endocardial border
delineation and assessment of myocardial perfusion.
X.H. Shu, L.L. Cheng, C.Z. Pan, H.Z. Chen. Zhongshan Hospital, Fudan
University, Department of Cardiology, Shanghai, China
Objective: SonoVue (Bracco) is a new microbubble agent containing sulfur hexaﬂuoride.
This study was aimed at evaluating the safety and efﬁcacy of SonoVue when used
to enhance left ventricular endocardial border delineation (LVEBD) and assess
myocardial perfusion (MP).
Methods: Thirty patients with suboptimal echocardiography were studied. Philips
Sonos 5500 and an S3 probe were used. Low mechanical index (MI) imaging was
used for MP, with one high MI pulse during contrast imaging to clear the myocardium and assess the contrast-reﬁll rate (reperfusion time). Each patient received two injections of SonoVue (2ml) 15 minutes apart, one for LVEBD and one
for MP. Twelve segments in apical four- and two-chamber views were scored for
LVEBD (endocardial border: 0= not visible, 1= barely visible, 2= clearly visible) and
MP (1=homogeneous, 0.5=heterogeneous, 0=absent).
Results: 1.) Three patients experienced mild and rapidly self-resolving adverse
events, no signiﬁcant post-dose effects on vital signs or ECG were observed. 2.)
LVEBD was signiﬁcantly improved in 300 of 306 (98%) segments. 3.) The MP
scores were signiﬁcantly higher in segments supplied by normal coronary arteries.
4.) The MP scores were normal in some segments supplied by narrowed coronary arteries, but those segments showed longer reperfusion time than those with
normal blood supply.
Conclusions: SonoVue is a safe, and valuable tool for LVEBD and MP assessment.
192
Predictive value of surface ECG on amount of myocardium with
preserved perfusion in patients after Q-wave myocardial infarction:
echo-contrast study.
P. Tousek 1 , J. Krupicka 1 , M. Orban 2 , P. Gregor 1 , C.H. Firschke 3 . 1 FN Kralovske
Vinohrady, III. Internal-Cardiology clinic, Prague 10, Czech Republic; 2 St Anna’s
University Hospital, 1st Internal Department, Brno, Czech Republic; 3 Technische
Universitat, Deutsches Herzzentrum, Munich, Germany
Myocardial contrast echocardiography (MCE) has recently been used for estimation of microvascular status in patients after myocardial infarction (MI). Preserved
myocardial perfusion prevents left ventricular (LV) remodelling and is a good predictive factor for regional recovery in segments with severe wall motion abnormalities. The main aim of the study was to evaluate the predictive value of surface 12
lead ECG on the amount of preserved myocardial perfusion detected by MCE in
akinetic segments.
Methods: 33 patients (26 males, average (SD) age of 57 (14) years, range 22-84
years) presented with the ﬁrst Q wave myocardial infarction (MI) and treated by
direct PTCA or thrombolysis were enrolled. MCE was performed between 24-72
hours. Segmental MCE perfusion was assessed semi-quantitatively and scored
as 1=normal, 2=patchy and 3=no perfusion. Patients were divided into 2 groups
according the number of abnormal Q waves (group A – 1 or 2 abnormal Q wave;
group B – 3 and more abnormal Q wave). Differences in kinetics and perfusion
between the two groups were studied.
Results: In group A (13 patients) 149 segments were evaluated, in group B (20
patients) 211 segments were evaluated. Akinesis was detected in 32 (22%) of
all evaluated segments in group A and in 52 (23,5%) segments in group B (NS,
p=0,64). Preserved perfusion of akinetic segments was observed in 17 (47%) segments in group A and in 13 (25%) segments in group B (p<0,01).
Conclusion: Patients with 1 or 2 abnormal Q waves have a greater amount of
preserved myocardial perfusion in segments with severe wall motion abnormality.
Eur J Echocardiography Abstracts Supplement, December 2003
THE HEART IN SYSTEMIC AND METABOLIC DISEASES
194
Echocardiographic investigation in patients with cardiac Fabry disease
(FD): deﬁnition of the cardiac phenotype.
G. Beer, H. Kuhn. Städtische Kliniken Bielefeld - Mitte, Klinik für Kardiologie,
Bielefeld, Germany
Introduction: FD is a lysosomal X-linked recessive storage disorder which is characterized by the progressive intracellular accumulation of glycosphingolipids in various tissues, especially in the cardiovascular system. Preliminary data indicate that
in a substantial part of pts with FD cardiac involvement can be the sole manifestation of the disease mimicking the clinical features of hypertrophic cardiomyopathy
(HCM). Based on recent reported progress in enzyme replacement therapy (ERT)
of FD major attention has been focused on cardiac FD. However, systematic clinical and echocardiographic studies in pts with unequivocal cardiac FD based on
morphological evaluation of cardiac biopsy tissue are lacking and the cardiac phenotype has still to be deﬁned precisely.
Methods: Therefore, for the ﬁrst time we investigated in a systematic study 18 non
related symptomatic pts (mean age 53 years; 13 male and 5 female pts) which
were referred to our institution for cardiac diagnostic evaluation. In all pts evaluation of cardiac biopsy tissue revealed cardiac FD. In all pts transthoracic echocardiography (TTE) was performed and correlated to morphological and clinical
data.
Results: Echocardiography in cardiac FD revealed in all 18 pts left ventricular
hypertrophy (LVH)(interventricular septal thickness 19 mm, range 13 to 35 mm)
mimicking the clinical features of HCM. In 44% (8 of 18 pts) symmetric LVH and
in 56% (10 of 18 pts) asymmetric septal hypertrophy was present. Only in 2 of 18
pts (11%) systolic dysfunction was diagnosed. In 16 of 18 pts (89%) left ventricular
systolic function and in 12 of 18 pts (67%) left ventricular diastolic function were
well preserved. Regional contraction disorders were detected in 11% of pts. Mild
mitral incompetence was present in 44% of pts. No signiﬁcant differences were observed between male and female pts regarding the clinical manifestation of cardiac
FD.
Conclusion: In our study, in all pts. with cardiac FD TTE revealed signiﬁcant LVH.
In the majority of pts with cardiac FD the disease completely mimicks the clinical
and echocardiographic features of HCM. A clear characterization of the phenotype
of cardiac FD regarding cardiac mass, pattern and extent of LVH is needed for the
distinction between pts with HCM and cardiac FD. Especially echocardiographic
non invasive diagnostic markers of disease manifestation and prognosis employing
Tissue Doppler Echocardiography seem to be necessary because of the progress
in ERT. For the ﬁrst time it offers a speciﬁc therapeutic option in a subgroup of pts
with the clinical features of HCM.
195
Improvement of cardiac function during enzyme replacement therapy in
patients with fabry disease. A prospective strain rate imaging studie.
F. Weidemann 1 , F. Breunig 2 , M. Beer 3 , A. Knoll 2 , O. Turschner 1 , C. Wanner 2 ,
J. Sandstede 3 , W. Voelker 1 , G. Ertl 1 , J. Strotmann 1 . 1 University Hospital
Würzburg, Cardiology, Würzburg, Germany; 2 Medizinische Universitätsklinik,
Nephrology, Würzburg, Germany; 3 Universitätsklinik, Radiology, Würzburg,
Germany
Background: Enzyme replacement therapy (ERT) has been shown to enhance
microvascular endothelial globotriaosylceramide clearance in the heart of patients
with Fabry Disease. Whether these results can be translated into an improvement
of myocardial function has yet to be demonstrated.
Methods: 16 Fabry patients who were treated with 1.0 mg/kg body weight of recombinant á-Gal A (agalsidase â, Fabrazyme ) were followed for 12 months. Myocardial mass at baseline and after 12 months of ERT was measured by Magnetic
Resonance Imaging. In addition, myocardial radial function of the posterior wall
was quantiﬁed by ultrasonic Strain Rate Imaging. Data were compared to 16 age
matched healthy controls.
Results: Myocardial mass decreased signiﬁcantly after 12 months of treatment
(baseline=200±19 g; 12 months=180±16 g, p<0.05). Both peak systolic strain rate
(parameter for the velocity of systolic deformation) and systolic strain (parameter
for the total amount of systolic deformation) were signiﬁcantly reduced in patients
with Fabry disease. Peak systolic strain rate and end-systolic strain increased signiﬁcantly in the posterior wall after one year of treatment (Figure).
Myocardial function durung ERT
Conclusions: Enzyme-replacement therapy in Fabry patients resulted in a decrease of left ventricular hypertrophy and an improvement in regional myocardial
function.
Abstracts
S21
196
Diastolic dysfunction in asymptomatic normotensive type 2 diabetic
patients: improved diagnosis of diabetic cardiomyopathy by tissue
Doppler imaging.
198
Doppler echocardiography and tissue Doppler echocardiography in the
assessment of left ventricular function in young asymptomatic patients
with well-controlled type 1 Diabetes Mellitus.
S. Cosson 1 , J.P. Kevorkian 2 , P. Henry 2 , P. Beauﬁls 2 . 1 Hopital Lariboisiere,
Cardiology, Paris, France; 2 Hôpital Lariboisière, Cardiology, Paris, France
R. Dankowski 1 , M. Michalski 1 , A. Nowicka 1 , D. Naskrêt 2 , M. Kandziora 1 ,
W. Biegalski 1 , K. Poprawski 1 , M. Wierzchowiecki 1 . 1 University of Medical
Sciences, 2nd Department of Cardiology, Poznan, Poland; 2 Raszeja Hospital,
Department of Internal Medicine, Poznan, Poland
Background: Diastolic dysfunction has been described as an early preclinical
manifestation of a speciﬁc diabetic cardiomyopathy. It mainly relied on echoDoppler methods with known limitations. Tissue Doppler imaging (TDI) has
emerged as a new accurate technique for the evaluation of diastolic function.
Objective: to assess left ventricular (LV) function in asymptomatic normotensive
type 2 diabetic patients using conventional echo-Doppler and TDI parameters.
Methods: Forty-eight consecutive patients (34 men, 50.4 ± 5.8 years) without
hypertension and coronary artery disease were matched to 30 control subjects.
Diabetics with retinopathy and/or nephropathy were classiﬁed as having microangiopathic complications (n=12). LV diastolic function was assessed by conventional
methods and pulsed TDI. Valsalva maneuver and a combined index of LV ﬁlling
pressure (E/Ea) were performed to unmask pseudonormal ﬁlling pattern.
Results: Systolic function was normal in all diabetics. Only diabetic patients with
microangiopathic complications demonstrated LV diastolic dysfunction compared
to control subjects (E/A ratio 0.95±0.21 vs. 1.13±0.23, p<0.05). Early diastolic
velocities (Ea) obtained by DTI were reduced (septal annulus 8.6±1.1 vs. 9.9±1.4
cm/s, p < 0.01; lateral annulus 12.0±2.2 vs. 13.9±2.9 cm/s respectively, p<0.05).
In subjects with a baseline E/A ratio >1, inversion during Valsalva maneuver was
observed in 71% diabetics and 95% controls. In contrast, none of these subjects
had a E/Ea ratio suggestive of a pseudonormal diastolic function.
Conclusions: In our population, moderate diastolic dysfunction was present only
in diabetics with microangiopathic complications. TDI appeared as a reliable noninvasive method to assess diastolic function in this population.
Background: In diabetic patients (pts) an early detection of impaired left ventricular function (LVF) could be very important for the prognosis. Diastolic dysfunction
may probably represent an early stage of diabetic cardiomyopathy. Tei index, which
represents global LVF was not measured in this group of pts.
Aim of the study was to assess LVF in adult pts with long term type 1 diabetes
mellitus (DM1) without any signs and symptoms of cardiovascular diseases using
newly developed echocardiographic parameters.
Patients and methods: The study group consisted of 21 pts with DM1 (11 men,
mean age 30,2±1,2 years). Mean duration time of diabetes was 15,7±5,5 years.
9 healthy volunteers (mean age 25,3±0,9) served as a control group.
In each subject two-dimensional echocardiography, Doppler echocardiography and
tissue Doppler echocardiography (TDE) were performed. Mitral E-wave velocity
(E), A-wave velocity (A), deceleration time of the E-wave (DT), isovolumic relaxation time (IRT), isovolumic contraction time (ICT) and ejection time (ET) were
measured at end-expiration. E/A ratio was calculated. Early (E-tde) and atrial (Atde) tissue Doppler velocities of the mitral annulus were recorded. The ratio of E to
E-tde was calculated.
For the assessment of a combined myocardial performance Tei index was calculated. (Tei index = (ICT+IRT)/ET)). p<0,05 was considered statistically signiﬁcant.
Results: There were no signiﬁcant differences in E, E/A and IRT measurements
between studied groups. Signiﬁcant differences are listed in the table.
Parameter
197
Echocardiographic assessment of cardiac disorders in patients with
uraemic cardiomyopathy.
M. Dorobantu, M. Marinescu, D. Constantinescu, L. Ardelean, A. Vasile,
V. Bumbea, O. Stan, A. Scafa. Emergency Hospital, Cardiology, Bucharest,
Romania
Background: The cardiovascular expression in uraemic cardiomyopathy (UCMP)
is heteregenous with various clinical and echocardiographic presentation.
Aim: The purpose of this study was to assess echograﬁc (ECHO) cardiac lesions
in patients with UCMP
Method: We have studied Echo data (2D, M-mode, Doppler, TTE and TEE) in 38
pts with cronic renal failure (mean age 38,6±11yrs, 24 males, 22female) dialysed
for 5,2±3yrs in Haemodialysis Department of our Hospital. All pts were clinical and
paraclinical evaluated (chest X-ray, ECG, blood tests). We measured EFLV, telesistolic and telediastolic LV diameters, LV diastolic parameters (E, A waves, E/A ratio)
and calculated LVMI(normal<0,135 g/m 2 in men, <115 g/m 2 in women),relative
wall thickness-h/r(N<0,39).
Results: Echo data showed LVH in 34pts-84,21% (mean LVMI 223±15g/m 2 in
men and 194±15 g/m 2 in women), signiﬁcantly correlated with less controlled
HTN(p<0,005), time from onset of UCMP(p<0,05), hipercalceamia(p<0,001) and
presence of multiple calciﬁcation. Three types of LVH were identiﬁed:type Aconcentric LVH, signiﬁcantly correlated with less controlled HTN (p<0,0005), LV
sistolic preserved and delayed relaxation as the most frequent diastolic pattern;
this patients had sensitivity for hypotension during dialysis (p<0,005); type Beccentric LVH, with LVEF<55% in 80% cases and all types of diastolic disfunction,
signiﬁcant correlated with more than 5 yrs of dialysis (p<0,005); type C-pseudoLVH (3pts) deﬁned as incresed LVMI and low voltaj of QRS complex on ECG,
with LVEF preserved in all cases and restrictive diastolic pattern. Another ﬁnding was the presence of multiple calciﬁcation (in 29pts) involving valves, cordae,
endocardium and intramyocardium, correlated with hipercalceamia (p<0,005) and
valvular dysfunction(p<0,005), myocardial stiffness (restrictive pattern- 6pts) and
LVBB. Associated signiﬁcant regurgitations, more than moderate, were noted in
22pts, correlated with valvular calciﬁcation and eccentric LVH. Pericardial involvement was noted as percardial effusion in 18 pts.(2 prs with cardiac tamponade)
and 1 pts with calciﬁcation of pericardum and restrictive phisiology. It seems that
the most appropiate explanation for the high frequence of the associated lesions
is related to the advance level of the illness.
Conclusion: This study sugests that the spectrum of morphological and functional cardiac involvement in uraemic cardiomyopathy is complex. The most speciﬁc echocardiographic features were LVH, presence of multiple carciﬁcations and
associated valvular regurgitations.
A (cm/s)
E/E-tde
ICT (ms)
Tei index
DM1
Control
p value
69,7±2,1
7,6±0,9
109,7±5,3
0,45±0,02
53,2±2,2
6,2±0,8
155,3±6,4
0,57±0,03
0,02
0,04
0,01
0,03
Conclusion: In diabetic patients, despite the lack of any signs and symptoms of
cardiovascular diseases left ventricular function could be impaired. Tei index, some
Doppler- and tissue Doppler-derived parameters seem to be of value in the detection of early stage of diabetic cardiomyopathy.
199
Combined systolic and diastolic performance, aortic root, left atrial
dimensions and carotid intima-media thickness in pregnancy-induced
hypertension: relation to parity and lipids.
G.M.A. Nasr, A.M.A. Nasr, G. Nasr. Suez Canal Hospital, Cardiology, Ismallia,
Egypt
Background and aim: Pregnancy-induced hypertension offers a natural model
of transient hypertension. This study aimed to assess the ability of echocardiographic Doppler to unmask left ventricular function impairment as well as both left
atrium and aortic root dimensions and carotid intma-media thickness as echocardiographic markers.
Patients & Methods: Forty-eight women aged 29.6±4.42 years with pregnancyinduced hypertension deﬁned as blood pressure higher than 140/90 mm Hg after
20 weeks gestation without a history of hypertension. Forty-eight normal pregnant women, aged 26.37±4.94 years, were the controls. Left ventricular diastolic
& systolic diameters, Ejection fraction, Interventricular septum, Posterior wall, Relative wall thickness, Left ventricular mass index, E velocity, A velocity, E/A ratio,
isovolumetric relaxation time (IRT), isovolumetric contraction time (ICT), ejection
time (ET), and the combined index of myocardial performance (Tei index = IRT +
ICT/ET), were calculated by echocardiography Doppler 2 to 4 days postpartum.
Left atrium & aortic root dimensions and carotid intima-media thickness were also
assessed. Lipid proﬁle was compared and the relation to parity and pregravid bodymass index were also assessed.
Results: There were statistically signiﬁcant differences between groups in the all
prameters apart from both diastolic and systolic diameters, ejection fraction, left
atrium and aortic root dimensions. Highly signiﬁcant differences existed in the
Tei Index &IRT and less signiﬁcant relation regarding carotid intima-media thickness and E/A ratio. A highly positive association with pregravid body mass index,
cholesterol, LDL, triglycerides and not HDL was found. A less positive relationship
between parity was noticed.
Conclusion: Pregnancy-induced hypertension evaluated 2 to 4 days after delivery
showed left ventricular dysfunction, mainly diastolic. The Tei index is a useful parameter to unmask left ventricular dysfunction. Carotid intima-media thickness as
well as E/A ratio are also of value. Obesity and to a lesser extent parity are also
predictors.
Eur J Echocardiography Abstracts Supplement, December 2003
S22
Abstracts
200
NT-proBNP levels among patients with b-thalassaemia major correlate
with echocardiographic markers of heart failure.
202
Antracycline chemotherapy changes tissue Doppler parameters and
strain rate velocities.
G. Pavlakis 1 , K. Bouki 2 , D. Vini 3 , M. Drosou 3 , E. Konstantellou 4 ,
E. Papasteriadis 2 . 1 General Hospital of Nikea, Greece; 2 General Hospital of
Nikea, First Cardiology Dept, Piraeus, Greece; 3 General Hospital of Nikea,
Thalassaemia Unit, Piraeus, Greece; 4 General Hospital of Nikea, Hormones
Dept, Piraeus, Greece
G. Abali 1 , L. Tokgozoglu 1 , H. Abali 2 , N. Güler 2 , K. Aytemir 1 , E. Akgül 1 ,
N. Nazlý 1 , S. kes 1 . 1 Hacettepe university, Cardiology, Ankara, Turkey;
2
Hacettepe university, Medical oncology, Ankara, Turkey
Life expectancy in patients (pts) with b-thalassaemia major is limited by development of congestive heart failure (HF) due to cardiomyopathy associated with
iron overload. The goal is to diagnose HF early and begin treatment.B-Natriuretic
peptide is a very sensitive and speciﬁc tool in order to diagnose HF, with a strong
negative predictive value.Purpose: To assess the incidence of elevated NT-proBNP
levels in pts with b-thalassaemia major who do not have symptoms or signs of HF
and correlate them with echocardiographic markers of HF. Methods: Blood samples were taken from 60 pts with b-thalassaemia major who are being transfused
periodically,and 50 normal (control) subjects in order to measure NT-proBNP levels by "Elisa" method (by Biomedica).The pts with b-thalassaemia major had no
past history of HF, were asymptomatic, they were examined by cardiologists of
our department and were found without clinical and ECG signs of HF.They were
divided in two groups using the cutoff BNP point of 500 fmol/ml and all these patients underwent cardiac echo. Results: The group A included pts whose levels
of BNP were >500fmol/lt (mean BNP levels 837 ±95 fmol/lt) (N =35 pts) and the
group B included pts whose levels of BNP were <500fmol/lt (mean BNP levels
350±60 fmol/lt)(N=25 pts).There was a difference statistically signiﬁcant among
the two groups regarding the End Systolic Diameter and posterior Wall thickness
of the left ventricle,the right ventricle dimensions and the pattern of E and A waves
of tricuspid regurgitation (Table). The value of NT-proBNP among normal (control)
subjects was 380 ±50 fmol/ml
Subjects
Group A (BNP >500fmol/lt)
group B (BNP<500fmol/lt)
P
PW (mm)
ESD (mm)
RVD (mm)
E/A
8,4
7,7
0,02
34,4
30,1
0,003
33,4
30,3
0,009
1,71
1,6
0,01
PW: Left ventricular posterior wall, ESD: LV End Systolic Diameter, RVD: Long axis diameter of
Right Ventricle, E/A: E/A of tricuspid regurgitation.
Conclusions: Elevated NT-proBNP levels correlate positively with markers of LV
and RV dysfunction as they are measured by echocardiography,in patients with
b-thalassaemia major and no signs or symptoms of HF. NT-proBNP is a simple to
measure, and it is also an accurate marker that helps in the early detection of HF
in asymptomatic pts with b-thalassaemia major.
201
Characteristics of echocardiography in familial meditterranean fever.
H.S. Sisakyan 1 , Z.A. Petrosyan 2 , T.S. M. Sargsyan 2 . 1 Yerevan State Medical
University, Internal Deseases N1, Yerevan, Armenia; 2 Yerevan State Medical
University, Internal Deseases N1, Yerevan, Armenia
Familial Mediterranean Fever (FMF) is a rheumatic autosomal recessive disease
mainly observed in Armenia, Israel, Arab countries and in countries surrounding
Mediterranean basin. It is clinically characterised by recurrent self-limited attacks
of fever, poliserositis and pain and leads to AA histochemical type of amyloidosis
predominantly affecting kidneys, adrenals, liver and spleen. Mutation genotypes,
especially homozygous state of Met694Val mutation of FMF gene causes complicated and severe course of the disease.
Methods: 12 patients with FMF aged 17 to 59 and conﬁrmed mutation were evaluated. All patients had chronic renal failure due to renal amyloidosis conﬁrmed
by renal byopsy. 6 patients had dyspnea class III-IV, 4 an edematous ascitis syndrome.
Results: In all cases echocardiography showed end-diastolic dimension of the
left ventricle within normal range. All patients had concentric hypertrophy of the
left ventricle.In all patients we observed left atrial dilation and 3 patients had dilation of both atria.In all patients there were different grades of pericardial effusion.
We did not found echo pattern of granular sparkling of myocardium suggestive
for cardiac amyloidosis, which is unusual for secondary amyloidosis. In all cases
the mutational analysis revealed Met694Val mutation in homozygous state. Two
dimensional echocardiography revealed calciﬁcation of mitral and/or valve leaﬂets
with restriction of movement and calciﬁed mitral and/or aortic oriﬁce causing mitral and aortic regurgitation that was always mild or moderate.These expressed
valvular changes may be explained by pathogenetic role of degradation of connective tissue and also by severe impairment of intracardial hemodynamics in FMF.
Doppler echo showed a restrictive pattern with short deceleration atrioventntricular time. Pulmonary veins showed marked diastolic D wave and a broad reversal A
wave.
Conclusions: We found that echocardiography showed characteristic signs for
FMF with concentric left ventricular hypertrophy, left atrial dilation, calciﬁcations of
valvular endocardium and restrictive ﬁlling Doppler pattern.
Eur J Echocardiography Abstracts Supplement, December 2003
Background: There is no reliable method for the early diagnose antracycline induced cardiotoxicity.
The aim of this study was to evaluate the effects of antracycline on left ventricular
diastolic functions by using tissue Doppler parameters and the strain rate velocities.
Methods: Thirtyseven female patients with breast cancer, mean age 43+ 7 years
old, were enrolled in this study. None of patients were diabetic, hypertensive,
smoker or had known heart disease. All patients were treated with six doses of
adriamycine 50mg/m2 containing regimens, given every four weeks. Left ventricular systolic and diastolic diameters, transmitral ﬂow velocities, septal tissue Doppler
velocities and septal strain rate velocities were recorded before and after 6 doses
of chemotherapy.
Results: None of patients developed congestive heart failure or echocardiographic left ventricular systolic dysfunction. Diastolic parameters were signiﬁcantly
changed as seen in the table.
Before Treatment.
After Treatment.
Mean Early Diastolic Mitral ﬂow velocity (E vawe) (cm/sec)
0.79+0.15/0.67+0.13/P=0.001 Mean decelaration time of E vawe (msec)
152.9+42/140.21+34/P=0.003 Mean late diastolic mitral ﬂow velocity (A vawe)
(cm/sec)
0.69+0.16/0.78+0.12/P=0.001 Septal Tissue Doppler mean peak A vawe velocity
(cm/sec)
9.9+3.4/12+3.8/P=0.001 Mitral color propagation (m/sec)
0.85+0.05/0.70+0.02/P=0.001 Basal septal
Midseptal Mean Longitudinal systolic strain rate velocities (cm/sn)
8.39+0.53/8.09+0.6/8.05+0.53/7.74+0.63/P=0.001/P=0.001 Left ventricular isovolemic relaxation time (msec)
84.10+9.4/91.9+10.1/P<0.001
Conclusion: This is the ﬁrst study to demonstrate that antracycline chemotherapy changes tissue Doppler parameters and strain rate velocities in all patients
receiving this drug. Therefore, tissue Doppler parameters may be used as an early
marker of antracycline toxicity.
203
Effects of subclinical hyperthyroidism on the heart: an ultrasonic tissue
characterization study (backscatter).
V. Di Bello 1 , F. Aghini Lombardi 2 , D. Giorgi 1 , F. Monzani 3 , E. Talini 1 , C. Palagi 1 ,
L. Antonangeli 2 , N. Caraccio 3 , M. Marianni 1 . 1 Dipartimento Cardio Toracico,
Pisa, Italy; 2 Endocrinologic Metabolic Department, Pisa, Italy; 3 Università di Pisa,
Dipartimento di Medicina Interna, Pisa, Italy
Subclinical hyperthyroidism (SH) is characterized by the presence of low or undetectable plasma TSH concentrations and normal circulating free thyroid hormones;
such as it’s realised in autonomously functioning thyroid nodule.
The aim of the present study was to analyze the effects on the heart induced
by this physiopathological condition; in particular the eventual myocardial intrinsic
alterations explored through a relatively new ultrasonic technique: the integrated
backscatter analysis. The SH patients were carefully selected in the Endocrinologic Department; 15 subjects (SH) (9 female), mean age 32.5±5.3 and 15 healthy
subjects (C) of comparable age, sex and body mass index. All study subjects
performed: conventional 2D-Doppler echocardiography and ultrasonic myocardial
integrated backscatter analysis (IBS) trough Acoustic Densitometry package implemented on Philips Sonos 5500 echograph. All subjects are normotensives, no
diabetic and have a negative maximal exercise stress test, to avoid confounding effects of coronary artery disease. Left ventricular mass in SH group was comparable
with controls, while left ventricular systolic function showed in SH a supernormal
Ejection Fraction (EF: 72 ±5% in SH vs. 63±7% in C; p<0.001), being the afterload values comparable in both groups. Left ventricular diastolic function showed
a slightly but signiﬁcant impairment in SH (E/A ratio of mitral ﬂow pattern: 1.2±0.3
vs. Controls: 1.6 ±0.3, p<.009). The isovolumic relaxation period was signiﬁcantly
lower in SH (69±10 msec) in comparison with controls (80±10; p<0.04). The IBS
parameters indexed by pericardium interface are homogeneous in both groups;
but some IBS alterations are present in SH heart if we considered the dynamic
variations both at septum (CVIibs: SH: 22±7% vs. 30±7%, p<0.02) and at posterior wall level (CVIibs: SH: 23±9% vs. 40±7%, p<0.002). The real signiﬁcance of
these myocardial alterations in SH patients is unclear. Further investigations need
to clarify the potential evolution of these ﬁndings toward an overt cardiopathy and
the opportunity to treat these patients with radio iodine therapy in order to normalize both thyroid function and cardiac performance alterations.
Abstracts
204
Doppler myocardial imaging in assessing impact of vasodilator therapy
on regional myocardial function in patients with systemic sclerosis.
M. Deljanin Ilic 1 , S. Ilic 2 , A. Stankovic 2 , B. Stamenkovic 2 , D. Djordjevic 1 .
1
Institute of Cardiology, Echo Lab, Niska Banja, Yugoslavia; 2 Institute of
Cardiology, Clinical Cardiology, Niska Banja, Yugoslavia
Objective: The aim of the study was a quantitative assessment of the effects of
calcium antagonist on regional systolic and diastolic myocardial function in patients
(pts) with systemic sclerosis (SSC), using pulsed wave Doppler myocardial imaging
(PW-DMI).
Method: Thirty-two female subjects: 17 pts with SSC (mean age 52.5 ± 8.7 years,
with an onset of SSC > 5 years; SSC group) and 15 healthy subjects (mean age
51.2 ± 7.7 years; C group) were studied. In all subjects baseline echocardiography study was performed. Regional myocardial function, was obtained from apical
approach, with PW-DMI sample volume within any left ventricular (LV) segment
at basal and medium level. In each adequately visualized segment we calculated
myocardial velocities (m.v.) of systolic (S), early (E) and late (A) diastolic waves
and their ratio E/A - index of regional diastolic function. After the initial study, pts in
the SSC group were treated with calcium antagonist for a period of six months and
after treatment period regional myocardial function was evaluated again.
Results: Baseline value of regional diastolic function of basal and medium LV segments was signiﬁcantly lower in SSC than in C group (E/A: 0.93 ± 0.33 vs 1.52
± 0.31. P<0.001 and 0.87 ± 0.32 vs 1.47 ± 0.30, P<0.001), as well as regional
systolic function (P<0.001 both). After six months treatment period with calcium
antagonist in the SSC group regional diastolic function of basal LV segments improved (E/A from 0.93 ± 0.33 to 1.08 ± 0.35, P<0.01) as well as of medium LV
segments (E/A from 0.87 ± 0.32 to 0.98 ± 0.28, P<0.05); regional systolic function
of basal LV segments increased from 8.5 ± 3.5 to 9.5 ± 3.0 cm/s, P<0.05, and of
medium LV segments from 7.8 ± 3.2 to 8.5 ± 2.9 cm/s, NS.
Conclusion: Quantitative analysis by PW DMI showed that pts with SSC have
impaired regional systolic and diastolic myocardial function. Six months treatment
with calcium antagonist in pts with SSC induced favorable modiﬁcation of regional
myocardial function, expressed through signiﬁcant increased of basal S m.v. and
ratio E/A of basal and medium left ventricular segments.
205
Myocardial remodeling in patients with chronic renal failure treated by
hemodialysis.
H.S. Sisakyan, T.S. M. Sargsyan, Z.A. Petrosyan. Yerevan State Medical
University, Internal Deseases N1, Yerevan, Armenia
Myocardial remodeling is an important predictor of risk of death in end stage
chronic renal failure. The aim of study was to investigate cardiac remodeling peculiarities in patients with chronic renal failure(CRF) treated with dialysis.
Methods: 32 patients with end stage of CRF at early treatment with hemodialysis were enrolled. The underlying diseases were glomerulonephritis (n=22), diabetes mellitus (n=7), amyloidosis(n=3). The duration of symptoms associated with
CRF end stage was 2.5±1.9 years. Echocardiography, serum creatinine, albumine,
hemoglobine, hematocrit, parathyroid hormone (PTH) concentrations were evaluated in all patients at the next hours after hemodialysis. Concentric left ventricular
hypertrophy was detected by echo in 27 patients (84%) and in 2 patients (6.2%)
eccentric hypertrophy was observed. Mean serum values of creatinine, parathyroid hormone (PTH) were differed from normal values. Left ventricular mass index (LVMI) was increased in 25 patients and was independently related to systolic
blood pressure (p=0.01). In all patient both concentric and eccentric hypertrophy
left atriun was dilated. Positive correlation was found between PTH serum activity
and LVMI, r=0.69 (p<0.01) and pth and interventricular septum thickness, r= 0.35
(p<0.01). The ejection fraction was lower than 55% in 7 patients (21.9%).
Conclusions: Myocardial remodeling in patients with end stage CRF treated by
hemodialysis is predominantly characterised by left ventricular concentric hypertrophy, left atrial dilation and relatively preserved systolic fuction.The relationship
between PTH activity and Left ventricular hypertrophy may indicate that hyperparathyroid state contributes to left ventricular hypertrophy in CRF.
206
The value of echocardiography for diagnosis of cardiac manifestations
in malignant lymphoma in child.
A. Dimitriu, I. Miron, T. Condurache, C. Jitareanu. University of Medicine and
Pharmacy, Pediatrics, Iasi, Romania
The aim of the study: to present the most important echocardiographic aspects
and value of echocardiography for evidence the cardiac manifestations, other than
those caused by the side effects of the speciﬁc therapy, in children with a malignant
lymphoma (ML)
Methods: Patients:16 children aged between 2 and 16 years diagnosed with a ML
with cardiac involvement: 14 of them with a nonHodgkin lymphoma and 2 cases
with Hodgkin disease. All patients underwent physical examination, electrocardiogram, chest x-Ray and echocardiography (echo).
Results: Cardiac involvement was observed in 5,9%of ML regardless of the inital
localisation of the tumor and the stage of the disease.The clinical signs were often
nonspeciﬁc and usually attributed to the malignant disease: chest pain, dyspneea,
superior vena cava syndrome; signs of cardiac suffering was rare: cardiac tamponade (3) and heart failure(2) The main cardiac manifestations proved by echocardio-
S23
graphy were: pericardial effusion (14 cases): serous-ﬁbrinous (4) or haemorrhagic
ﬂuid (10) up to cardiac tamponade (3), with the presence of malignant lymphomatous cells in the pericardial ﬂuid; pericardial tumour (3); cardiac masses in the right
atrium and the other one in the right ventricle, around the tricuspid valve annulus(2 cases);myocardial diffuse inﬁltration(1 case), but without clinical signs. The
speciﬁc therapy leaded, in general, to the improvement of the cardiac disorders,
without changing the prognosis of the main disease.
Conclusions: Cardiac involvement is frequently present in children with malignant
lymphoma, before administration of speciﬁc therapy. Cinical signs are often non
speciﬁc and cardiac manifestations may be severe and may worsen the prognosis.
This impose a systematic cardiological investigation, especially by echocardiography in all the stages of the disease and during the evolution.
207
Ankylosing spondylitis- echocardiography of cardiac lesions.
M. Peregud - Pogorzelska 1 , A. Wojtarowicz 1 , H. Przepiera 2 , M. Brzosko 2 ,
E. Ploñska 1 . 1 Department of Cardiology, Szczecin, Poland; 2 Depatment of
Reumathology, Szczecin, Poland
Ankylosing spondylitis (AS) is a generalized disease of the connective tissue of inﬂammatory origin. It is believed that aortic insufﬁciency (AI) is a typical cardiologic
pathology in AS. The aim of the work was to evaluate the incidence of AI and other
cardiac abnormalities in patients with AS. The study group enrolled 31 individuals
aged 26-60 years, mean age 51 ± 12, treated due to ankylosis spondylitis. The duration of the disease was 2-30 years (mean 16). Arterial hypertension was present
in 6 patients.
Echocardiography included evaluation of AI presence and degree scored from 1+
to 4+, width of aorta, aortic valve lesions, left ventricle contractility and its EF, presence of mitral valve prolapse (MVP) or mitral valve regurgitation, excessive interatrial septum (IAS) mobility and pericardiac lesions.
Results: Excessive IAS mobility and aneurysm turned out to be the prevalent abnormality found in the studied group (17 individuals, 55%); none of these patients
revealed changes more pronounced than a residual shunt. The pericardiac lesions
were found in 13 patients (42%) including 2 patients with thickened pericardium;
none of the patients showed the presence of signiﬁcant ﬂuid volumes. Mitral valve
prolapse without signiﬁcant regurgitation was found in 12 persons (39%); AI- in 9
persons (29%) including 2 patients with 2+ degree; the remaining patients revealed
1+ degree. Widening of the ascending aorta was found in 6 patients (19%), none
of them showed widening greater than 5 cm. Mean EF was 57 ± 4,9%, signiﬁcant
abnormalities of left ventricular contractility was found in one patient. No correlation was found between AI and age, arterial hypertension or other intracardiac
abnormalities. IAS mobility coexisted in 9 patients with MVP and in 4 patients with
aortic widening.
Conclusions: 1. The prevalent cardiac lesions found in the course of AS include
pericardiac lesions, excessive IAS mobility and mitral valve prolapse.
2. The correlation between AS and aortic insufﬁciency requires re-evaluation.
208
Chronic doxorubicin-induced cardiotoxicity in adults with lymphomas
and Hodgkin’s disease.
L. Elbl 1 , V. Chaloupka 2 , I. Tomaskova 2 , M. Navratil 3 , I. Vasova 3 , J. Vorlicek 3 .
1
Brno, Czech Republic; 2 University Hospital, Cardiopulmonary Testing, Brno,
Czech Republic; 3 Faculty Hospital, Internal medicine hematooncology, Brno,
Czech Republic
Introduction: Doxorubicin has been clearly established as one of the most useful antitumor drugs in current oncologic practice. Chronic anthracycline-induced
cardiotoxicity has been deﬁned as myocardial impairment diagnosed one year
after chemotherapy. We have assessed myocardial impairment during one-year
prospective follow-up after the oncological treatment.
Patients and Methods: We have investigated 90 patients (55male/35female of
age 45+17yrs) with lymphomas or Hodgkin’s disease clinically and echocardiographically before and after the chemotherapy containing doxorubicin (CHT) and 6
and 12 months thereafter. Parameters of both systolic (EF) and diastolic function
(IRT, DT, E/A index) have been calculated.
Results: The signiﬁcant deterioration of EF(drop >10% or below 50%) during the
CHT was present in 18 pts (18%) In the period after CHT we have diagnosed in 4
pts (5%) new myocardial impairment and in two pts (2%) silent myocardial infarction. Diastolic function was impaired in 25% of patients before treatment, in 44%
after CHT and in 50% of patients after one year of follow-up. The control examination after 12 month has not revealed any signiﬁcant restoration in LV systolic and
diastolic function.
14 patients (16%) died during the follow-up period due the progression of malignancy. The chemotherapy was successful in 80% of patients. 66% have reached
complete remission of the disease and 14% partial remission; 20% relapsed. The
main clinical complications (death, cardiotoxicity, relapse of malignancy and cardiovascular event) occurred in 32% of patients.
Conclusions: The changes of both systolic and diastolic LV function, which have
been induced during the administration of doxorubicin, persisted one year after
the completion of chemotherapy and revealed no tendency to the improvement.
Moreover, the number of pathological ﬁndings has been increased. For the present,
the presence of LV dysfunction has not inﬂuenced the oncological treatment.
Eur J Echocardiography Abstracts Supplement, December 2003
S24
Abstracts
209
Low myocardial strain is linked to poor baroreﬂex sensitivity in Type 2
diabetes.
A. Loimaala 1 , K. Groundstroem 2 , M. Rinne 3 , I. Vuori 3 . 1 South Karelian Central
Hospital, Clinical Physiology and Nuclear Medici, Lappeenranta, Finland;
2
Kymenlaakso Central Hospital, Medicine, Kotka, Finland; 3 UKK Institute,
Exercise Physiology Dept., Tampere, Finland
Purpose: Myocardial diastolic relaxation is impaired in Type 2 diabetes (DM2) and
low baroreﬂex sensitivity (BRS) predisposes to ventricular ﬁbrillation. The interaction of these factors are, however, not fully understood. We measured myocardial
deformation patterns, BRS, clinical and heart rate variability (HRV) in men with
diabetes.
Methods: 43 men (52.4 (5.8) yrs, BMI 29.6 (3.6) kg/m2 ) with DM2 diagnosed
<3 years earlier were investigated. Systolic (SBP) and diastolic (DBP) blood
pressure, resting HRV indexes (SDNN, pNN50, HF, LF and VLH power, 24-hour
holter), blood glucose (fb-gluc), glycated hemoglobin (GHbA1c), oxygen consumption (VO2max), and muscle strength (MS) were measured. BRS was determined
by the phenylephrine method (2 mcg/kg). Myocardial systolic (Ss) and early diastolic (Es) strain were measured from the middle segment of the inferior septum
(VingMed System V).
Results: LV ejection fraction correlated only with Ss (r = 0.44, p = 0.006). Clinical
variables did not correlate with Es, the strongest association was observed between BRS (r = 0.513, p = 0.001) and with LF power (r = 0.35, p = 0.025). BRS
correlated with VO2max (r = 0.36, p = 0.015), age (r = -0.31, p = 0.037), pNN50 (r =
0.34, p = 0.025), HF (r = 0.35, p = 0.019) and SBP (r = -0.34, p = 0.02). According
to multivariate analysis BRS was the only signiﬁcant determinant of Es. The BRS
was depressed in the lower tertiles of Es (ANOVA, BRS adjusted for age, BMI, VO2
and SBP, see Table).
Age, years
gHBA1c, %
VO2, ml/kg/min
lnLF, ms2
BRS, ms/mmHg
Tertile 1
Tertile 2
Tertile 3
p value
53.5 (1.6)
8.0 (0.4)
32.9 (1.7)
2.74 (0.1)
5.9 (0.97)
51.7 (1.5)
8.0 (0.4)
31.8 (1.7)
2.87 (0.09)
7.0 (0.95)
52.1 (1.6)
8.2 (0.4)
34.0 (1.7)
3.14 (0.09)
10.1 (0.94)
0.55 to 0.83
0.72 to 0.77
0.65 to 0.37
0.009 to 0.054*
0.004 to 0.03*
Clinical variables and BRS according to myocardial Es tertiles in DM2 patients (N=43), values
are mean (SEE). p = T3 vs. T1 and T2.
Conclusions: Diabetic patients with reduced BRS have impaired myocardial diastolic strain, whereas vagal responsives is normal in patients with the best myocardial relaxation capacity. This may be due to concomitant myocardial disease and
dysfunction of the baroreﬂex arch, and suggests a higher risk for fatal arrhythmias.
Strain patterns seem to be independent of age, glycemic balance and exercise
capacity.
210
Analysis of causes of heart failure in patients with type 2 diabetes
mellitus - a 5-year follow-up.
A. Mamcarz, W. Braksator, M. Janiszewski, A. Swiatowiec, J. Syska-Suminska,
M. Kuch, K. Sadkowska, K. Wrzosek, J. Kuch, M. Dluzniewski. Medical Academy
of Warsaw, Cardiology, Warsaw, Poland
Patients with type 2 DM are particularly susceptible to development of cardiovascular diseases, including heart failure.
Aim: The aim of the study was to investigate factors predictive of heart failure in
patients with type 2 diabetes mellitus.
Material and Methods: 67 male patients with DM t.2 (mean age 53,7 years) were
enrolled into the study. Exclusion criteria for the study included clinical symptoms of
ischemic heart diseases or electrocardiographic ischemic changes or heart failure
symptoms. Late diabetes complications were assessed in all the patients. Treadmill exercise test, echocardiography and 24-hour ambulatory ECG monitoring were
performed in all the patients. After 5 years of follow-up the patients were assessed
in terms of development of overt heart failure (II-IV NYHA class).In univariate logistic analysis parameters determining heart failure onset were evaluated and odds
ratio (OR) was calculated.
Results: The factors that signiﬁcantly increased the risk of heart failure are shown
in the table.
Parameter
Age (years)
Duration of diabetes mellitus (years)
HbA1 (%)
Fasting glycemia (mg%)
Nephropathy
Neuropathy
Retinopathy
Silent myocardial ischaemia in exercise test
Silent myocardial ischaemia in 24 hour ECG monitoring
E/A
IVRT
OR
p
1,24
1,19
2,32
1,014
5,8
5,96
4,24
4,88
5,11
0,011
1,06
<0.05
<0.01
<0.05
<0.01
<0.01
<0.01
<0.05
<0.02
<0.01
<0.01
<0.01
Conclusions: 1. The most important prognostic factors of heart failure development in patients with DM are the degree of diabetes control and presence of late
diabetes complications. 2. Episodes of silent myocardial ischemia, common in pa-
Eur J Echocardiography Abstracts Supplement, December 2003
tients with diabetes mellitus, signiﬁcantly increase the risk of heart failure. 3. Diastolic dysfunction, often asymptomatic, is the prognostic factor of heart failure
development.
211
Estimation of diastolic dysfunction using the time to onset of relaxation
by strain rate in patients with Duchenne muscular dystrophy.
N. Giatrakos 1 , M. Kinali 2 , F. Muntoni 2 , P. Nihoyannopoulos 3 . 1 London, United
Kingdom; 2 ICSM, Peadiatrics and Neonatal Medicine dept, London, United
Kingdom; 3 Hammersmith Hospital, Cardiology dept, NHLI, ICSM, London, United
Kingdom
Dilated cardiomyopathy is a primary cause of death at the late stages of patients
with Duchenne muscular dystrophy (DMD). Time to onset of regional relaxation
(TR) estimated by strain rate (SR) imaging has been used to quantify regional
myocardial function.
The objective of our study was to identify early impairment of the left ventricular
function in male patients with DMD using TR derived from estimation of SR.
Methods: Fifty-three patients with genetically conﬁrmed DMD, all asymptomatic
with normal conventional echocardiographic studies (mean age 8.7±2.8 years)
were compared with 22 normal controls matched for age (mean age 8.5±2.5
years). We used the HDI 5000 (Philips Medical Systems) to acquire the colour
M-mode tissue Doppler (TDI) of the posterior wall of the left ventricle from the
parasternal long axis. All images were stored digitally for ofﬂine analysis with dedicated software HDI-lab (Philips Medical Systems). We calculated the SR using
the formula SR=(Ua-Ub)/d where U the velocities of the endocardium a and epicardium b and d the distance of a and b at each time point. We deﬁned TR as the
time from the R-wave of the ECG trace to the transition point of SR from positive to
negative values. The TR values were corrected for the heart rate using the Bazett’s
formula and TRc (TR corrected) was expressed in msec.
Results: We did not ﬁnd any signiﬁcant difference between the parameters from
the conventional echocardiographic studies: Doppler velocities of E and A waves,
E/A ratio, IVRT and DT in the two groups. TRc was found to be signiﬁcantly higher
in patients with DMD (384,47±40,12msec vs. 364,54±23,43msec, P<0.003).
Conclusions: TRc could be a useful index for the early detection of regional myocardial diastolic dysfunction in patients with DMD when the conventional echocardiographic parameters remain within normal limits.
212
Early detection of cardiac involvement in patients with systemic
sclerosis by the use of tissue Doppler image.
E.J. Gialafos 1 , K. Aggeli 1 , P. Daskalakis 1 , J. Vlasseros 1 , T. Papaioannou 1 ,
N. Kokolakis 2 , P.P. Sﬁkakis 2 , C. Kostopoulos 2 , C. Stefanadis 1 , M. Mavrikakis 2 .
1
University of Athens., Cardiology, Athens, Greece; 2 Alexandras Hospital, Clinical
Therapeutics, Athens, Greece
Systemic Sclerosis(SSc) is a collagen disease of unknown aetiology that affects
many organs among them the heart. Although cardiac involvement can lead to
heart failure or sudden cardiac death, it may also remain clinical silent despite
extensive involvement. Tissue Doppler Imaging (TDI) is a new ultrasound modality
that records systolic and diastolic velocity and can detect with good sensitivity left
and right ventricular(LV and RV) abnormalities. Aim of our study was the early
detection of cardiac involvement in asymptomatic patients with SSc by the use of
TDI.
Methods: 30 patients with established SSc without clinical cardiac involvement
(group 1, 26 female/4 males, 51±12 years old) were compared to 25 age-matched
controls (group 2, 19 female/6 males, 48±8 yo). All the people underwent physical
examination, electrocardiogram and transthoracic echocardiographic study including TDI velocities in order to exclude patients with cardiac involvement. Early and
late transmitral (Em and Am) and transtricuspidal (Et and At) velocities, the ratio of them(Em/Am and Et/At), deceleration times of transmitral and transtricuspid
velocities (DTm and DTt), isovolumic relaxation time (IVRT) and ﬂow propagation
(Fp) of left ventricle were measured. Additionaly, the TDI derived E,A and systolic
velocities were recorded at the mitral (TDIEm, TDIAm, TDISm) and the tricuspid
valve (TDIEt, TDIAt, TDISt) annulus and the ratio of them (TDIEm/TDIAm and the
TDIEt/TDIAt).
Results: Dimensions of left and right ventricle and left atrium were similar between
the two groups. No signiﬁcant differences were detected between the two groups
for the following parameters: Em, Am, Et, DTm, DTt, IVRT, Fp. We observed signiﬁcant differences among the two groups in the At(0,45 vs 0,36, p<0.005) TDIAm
(15,3vs 18,p< 0.05), TDIAt(14,3vs18,5,p<0.005), TDI E/Am(1,49 vs 1,19, p<0.05)
and TDI E/At(1,4 vs0,9, p< 0.001). Disease duration is not correlated with cardiac
indices.
Conclusion: Tissue Doppler Image can detect early possible cardiac involvement
in patients with Systemic Sclerosis.
Abstracts
213
Tissue Doppler abnormalities in adult stable patients with sickle cell
anemia.
A. araujo, E. Arteaga, J. Leao, B. Ianni, C. Mady. Heart Institute - Sao Paulo
University, Cardiopatias Gerais, Sao Paulo, Brazil
Sickle cell anemia (SCA) induces a chronic overload to the heart but the existence
of a speciﬁc cardiac disease in SCA is not consensual.
The aim was to obtain a detailed evaluation of the left ventricle (LV) using Doppler
echo including tissue Doppler imaging.
Methods: 20 consecutive stable adult outpatients with SCA (SS hemoglobin) and
20 normal volunteers were selected. Measurements left atrium (LA) and LV diastolic diameter (DD), LV mass, systolic shortening, mitral ﬂow velocities, E/A, pulmonary venous systolic (S), diastolic (D) and atrial (PVA), early (Ea) and late (Aa)
diastolic velocities of mitral annulus (lateral and septal borders), systolic (Sa) velocities, and E/Ea ratio. ANOVA p<0.05 was considered signiﬁcant. The table contains
the main results.Only one patient had a E/A ratio<1.0. Ea/Aa ratios were >1.0 in
all patients.
age (y)
AE (mm)
DDVE (mm)
% shortening
septum (mm)
post.wall (mm)
LV mass (g)
LV mass index (g/m)
E (cm/s)
S (cm/s)
Sa lat (cm/s)
Ea lat (cm/s)
Sa sep (cm/s)
Ea sep (cm/s)
E/Ea lat
SCA
Control
p
37.6
41.91
50.74
37.65
11.47
10.69
269.6
168.4
90.62
64.35
11.68
15.94
9.44
11.85
5.6
38.9
33.92
46.16
40.36
9.64
9.28
184.7
112.5
78.56
54.98
13.62
19.57
10.96
14.79
4.15
0.24
<0.001
0.001
0.015
<0.001
<0.001
<0.001
<0.001
0.04
0.003
0.02
0.01
0.004
<0.001
<0.001
Adults (4th decade) with SCA have LA and LV cavity and myocardial thickness
increased,mild systolic and diastolic dysfunctions, when compared to normal subjects.These ﬁndings support the view that cardiac abnormalities in SCA are mainly
due to the chronic overload than to a cardiomyopathic process, allowing a good life
expectancy.
214
Left ventricular long axis systolic function is decreased in scleroderma.
I. Can 1 , K. Aytemir 1 , A.M. Onat 2 , K. Ureten 2 , S. Kiraz 2 , I. Ertenli 2 ,
L. TokgözoÕlu 1 , G. Kabakçý 1 , N. Ozer 1 , A. Oto 1 . 1 Hacettepe University,
Department of Cardiology, Ankara, Turkey; 2 Hacettepe University, Rheumatology,
Ankara, Turkey
Background: Myocardial ﬁbrosis is found in most patients with scleroderma at
autopsy ﬁndings. Long axis systolic function has not been studied yet. In this study,
systolic myocardial velocities are assessed in patients with scleroderma by tissue
Doppler echocardiography.
Methods: The study population consisted of 14 patients (mean age; 48±10 years,
9 female) with scleroderma and 11 controls (mean age 40 ±7 years, 7 female). Patients with any other underlying disease known to affect left ventricular function is
excluded from the study. Left ventricular dimension and fractional shortening were
measured by M-Mode echocardiography. Tissue Doppler imaging was performed
for the assessment of peak biventricular long axis systolic velocities.
Results: Left ventricular end-diastolic dimension and fractional shortening was
not different in the patients with scleroderma compared to controls.Tissue Doppler
systolic velocities measured from lateral and septal mitral annular regions were
signiﬁcantly lower than the controls (Table).
Table
Lateral-S
Septal S
Anterior-S
Inferior-S
RV-S
Posterior-S
Scleroderma
Control
p
8,9±1,5
7,5±1,8
8,8±2,6
8,1±1,5
13,3±1,7
9,0±1,9
12,6±1,3
8,8±0,7
10,4±1,0
10±1,3
14,6±1,1
14,6±1,1
0,01
0,04
ns
ns
ns
ns
S25
215
Doppler myocardial imaging: a more sensitive method for cardiac
involvement in familial amiloydotic polyneuropathy in comparison with
conventional echo-Doppler.
A G. Almeida 1 , M.C. Coutinho 2 , C.N. David 2 , I. Conceiçao 3 , M.C. Vagueiro 2 .
1
Lisbon, Portugal; 2 Hospital Santa Maria, Cardiology Piso 8, Lisbon, Portugal;
3
Hospital Santa Maria, Neurology, Lisbon, Portugal
Cardiac involvement in familial amiloydotic polyneuropathy (FAP) has prognostic
inﬂuence. The aim of this study is the evaluation of patients (pts) with FAP by
conventional echo-Doppler and pulsed Doppler myocardial imaging (DMI), in order
to detect early patterns of involvement.
Methods: Thirty-three consecutive pts with FAP, 21 women, 44±11 years-old were
studied. Exclusion criteria: non-sinusal rhythm, hypertension, ischemic or valvular
cardiopathy. All were submitted to conventional echo-Doppler and DMI and the
following data were obtained: 1. Left ventricle (LV): dimensions, wall thickness,
fractional shortening, segmental contractility; 2. Mitral ﬂow: E wave (cm/s), A wave
(cm/s), desaceleration time (Des; ms); 3. DMI: in three apical views, basal and mid
segments of six walls (ASE segmental model) - velocities (cm/s) of Em (early diastolic), Am (atrial systole), Sm (systolic wave). The following mitral Doppler patterns
were considered: 1- normal (normal respiration and Valsalva): E/A 1-1.9 and Des
140-239 ms; 2 - relaxation abnormality: E/A<1 and Des ≥ 240 ms; 3- restrictive
abnormality: E/A ≥ 2 and Des > 140 mseg. DMI patterns considered: 1 - Normal: Em > 8 cm/s; 2 - Relaxation abnormality: Em ≤ 8 cm/s and Em/Am<1; 3 Restrictive abnormality: Em, Am, Sm < 4 cm/s.
Results: All pts were asymptomatic and had normal LV dimensions, segmental
contractility and fractional shortening. There was septum hypertrophy and/or hyperechogenicity in 16 pts (48%). Two Groups were considered: Group A, with signs
of involvement by conventional echo-Doppler - pts with hyperechogenicity and/or
hypertrophy and/or with abnormal mitral ﬂow pattern (type 2 or 3) (17 pts, 52%);
Group B - pts without any of these abnormalities (16 pts, 48%). DMI analysed 396
LV segments and a type 2 or 3 pattern was found in 92 (25%), from 22 pts. In ﬁve
pts, there was heterogeneous patterns in different segments and in eleven a type 1
pattern was found in all segments, which was concordant with mitral Doppler pattern. Group A pts had an abnormal pattern in all pts but one (94%), while in Group
B, 10 (64%) showed abnormal DMI pattern. There was a signiﬁcant difference between Em and Sm of Groups A and B (p=0.004 e p=0.004).
Conclusion: In our study, in pts with FAP and no cardiac involvement, as assessed
by conventional echo-Doppler, DMI showed abnormalities of longitudinal diastolic
and systolic LV function. DMI seems to be a more sensitive modality for early detection of heart involvement.
216
Strain and strain rate can detect myocardial involvement earlier than
standard echocardiography in patients with Duchenne disease.
J. Ganame 1 , D. Van Laere 1 , N. Goemans 2 , L. Herbots 3 , M. Gewillig 1 ,
B. Bijnens 3 , G.R. Sutherland 3 , L. Mertens 1 . 1 University Hospital Gasthuisberg,
Pediatric Cardiology, Leuven, Belgium; 2 University Hospital Gasthuisberg,
Pediatric Neurology, Leven, Belgium; 3 University Hospital Gasthuisberg,
Cardiology Department, Leuven, Belgium
Introduction: Duchenne muscular dystrophy is a lethal inherited myopathy. All
affected patients will eventually develop cardiac involvement leading to dilated cardiomyopathy. Early detection of cardiac dysfunction could lead to better treatment.
Hypothesis: Myocardial involvement could be detected earlier with the new
echocardiographic techniques Strain(S) and Strain Rate (SR) Imaging.
Methods: We assessed 21 Duchenne patients, mean age: 11.4±8.1 years, with
gray scale M mode, 2D, blood pool and Doppler myocardial imaging. They were
divided in two groups according to whether their fractional shortening was above
(group I, N= 11) or below (group II, N=10) than 30%. We evaluated radial S and
SR in the mid infero-lateral wall from short axis in all patients and compared their
values with 33 age-matched normals (NL).
Results: The maximal systolic S and SR were signiﬁcantly reduced in both groups
compared to NL. S NL: 58%±12 vs. group I: 36%±10, p< 0.001; S NL vs. group
II: 28%±15, p< 0.001. SR NL: 3.7/s-1 ±1.1 vs. group I: 3.0/s-1 ±0.9, p< 0.01; SR
NL vs. group II: 2.7/s-1 ±1, p< 0.01. Although S and SR were lower in group II
compared to group I; interestingly, no statistically signiﬁcant difference was found
between the two Duchenne groups, while group I was considered to be NL by
conventional ultrasound analysis.
Conclusions: In patients with Duchenne disease S and SR can be more sensitive to detect left ventricular dysfunction in patients who would otherwise, be overlooked using standard echocardiography techniques.
Tissue Doppler echocardiographic variables
Conclusion: Long axis systolic velocities of left ventricle is affected in scleroderma
which may be due to myocardial ﬁbrosis.
Eur J Echocardiography Abstracts Supplement, December 2003
Eur J Echocardiography Abstracts Supplement, December 2003
Poster Session 2
4 December 2003, 14:00 to 18:00
Location: Poster Hall
MODERATED POSTERS
302
White blood cell count as a marker of acute inﬂammation in patients with
positive stress echocardiography.
1
2
1
1
303
Relation of plasma levels of proinﬂammatory cytokines and presence of
myocardial viability in early phase after acute myocardial infarction.
M. Przewlocka-Kosmala, W. Kosmala, A. Spring. Medical University, Cardiology,
Wroclaw, Poland
1 1
S. Ilic , M. Deljanin Ilic , P. Milosavljevic , B. Ilic , D. Petrovic . Institute of
Cardiology, Clinical Cardiology, Niska Banja, Yugoslavia; 2 Institute of Cardiology,
Echo lab, Niska Banja, Yugoslavia
The aim of this study was to assess whether positive exercise stress echocardiography (ESE) uncovered presence of acute inﬂammation and whether extent of
stress induced myocardial ischemia (m.i.) have impact on total white blood cell count
(WBCC).
Methods: In the study group of 69 patients (46 male and 23 female; mean age
59.7 ± 6.5 years) with known or suspected coronary artery disease sub-maximal
or symptom limited bicycle ESE was performed. ESE identiﬁed ischemia by the occurrence of wall motion abnormality (WMA) with stress-positive ESE. In all patients
before and after ESE wall motion score (WMS) was calculated. At baseline and after
ESE, in all pts total and differential white blood cell count were measured.
Results: During ESE 40 (58%) patients had new, transient WMA, while 29 (42%)
pts were without ischemia. Baseline value of total WBCC was signiﬁcantly higher
in patients with positive compared to those with negative ESE (7.7 ± 2.5 vs 6.1 ±
2.1 x 109/L, P<0.01), as well as the value of neutrophil count (P<0.05). In pts (n =
24) with positive ESE and increased WMS less or equal 3, baseline value of total
WBCC was signiﬁcantly lower than in pts (n = 16) with increased WMS > 3 (6.9
± 2.3 vs 8.5 ± 2.1 x 109/L, P<0.05). After ESE, in pts with stress induced WMA,
WBCC increased by 18.2%. Increase in total WBCC was more pronounced in pts
with increased WMS > 3 than in pts with increased WMS less or equal 3 (25.8% vs
14.5%). In pts without stress induced WMA, total WBCC slightly changed after ESE
(by - 3.3%) compared to baseline value.
Conclusion: Our results suggest that an acute inﬂammatory process may be
present in patients with positive ESE and that more severe myocardial ischemia
is associated with signiﬁcantly higher baseline WBCC and greater increase in total
WBCC after ESE.
Proinﬂammatory cytokines such as tumor necrosis factor alpha (TNF-alpha) and
interleukin-6 (IL-6) can potentiate heart muscle damage during acute myocardial
infarction (AMI). Whether changes in their plasma levels after AMI are dependent
on the presence of myocardial viability is unclear.
The aim of the study was to estimate the relation between plasma levels of TNFalpha and IL-6 and the presence of reversible and irreversible myocardial dysfunction in pts early after AMI treated thrombolytically.
Material and methods: In 32 pts (mean age 59.8±12.4) with AMI plasma levels
of TNF-alpha and IL-6 were evaluated on the 2nd and 10th day after thrombolysis.
Based on the response of dysfunctional segments of myocardium to dobutamine
infusion pts were divided into four groups: A – sustained improvement of contractility,
B – biphasic (improvement followed by worsening), C – only worsening, D – no
change. Myocardial viability was evidenced by improvement of systolic function in
at least 2 contiguous segments.
Results: No signiﬁcant differences among all four groups in plasma levels of TNFalpha and IL-6 were found out on the 2nd day after thrombolytic treatment. On the
10th day plasma levels of both TNF-alpha and IL-6 decreased in all four groups and
were the lowest in group A, intermediate in group B and the highest in the group C
and D.
TNF [pg/mL]
IL-6 [pg/mL]
2nd day
10th day
2nd day
10th day
A
B
C
D
33.2±8.6
14.6±6.3** #
106.2±22.8
43.3±18.2** #
34.1±9.1
21.2±6.9** &
110.9±24.1
66.1±19.7** &
36.5±9.2
29.9±8.9 *
116.6±23.5
92.3±18.8 *
35.9±8.8
28.2±8.4 *
102.9±25.3
90.6±22.4 *
*p<0.05 vs 2nd day; **p<0.01 vs 2nd day; #p<0.05 vs B, vs C, vs D; &p<0.05 vs C, vs D
Conclusion: Decrease in plasma levels of TNF-alpha and IL-6 in early phase after
AMI is more pronounced in patients with myocardial viability in infarct zone (group
A and B). This decline in plasma cytokines levels is attenuated by the presence of
residual ischemia in these patients (group B).
Abstracts
304
Quantitative myocardial contrast echo parameters are better predictors of
ventricular recovery after acute myocardial infarction treated with primary
angioplasty than ﬁnal angiographic data.
E. Perez 1 , M.A. García Fernández 2 , T. López Fernández 2 , J. Quiles 2 , J.L. López
Sendón 2 , E. López de Sa 2 , M.J. Ledesma 3 , M. Moreno 2 , M. Desco 4 , E. García 2 .
1
Majadahonda-Madrid, Spain; 2 Hospital General Gregorio Maranon, Cardiology
Dept., Madrid, Spain; 3 Polytechnic University, Madrid, Spain; 4 HGU Gregorio
Maranon, Cardiology Dept., Madrid, Spain
TIMI myocardial perfusion grade (TIMI MPG) and quantitative myocardial contrast
echo (MCE) can assess microcirculation integrity after primary PTCA (PPTCA) and
could be useful to evaluate prognosis after acute MI.
The aim of our study is to compare accuracy of both methods to predict myocardial
function recovery during follow-up in acute MI.
Methods: MCE studies were performed after PPTCA in 27 p with acute MI
with Contrast Pulse Sequencing (CPS, a new real-time technique from AcusonSiemens Sequoia) and Sonovue in continuous infusion. Sequences of 300 frames
with a temporal resolution of 50 ms were acquired in apical views, digitally stored
and processed with propietery software. Final angiographic result was assessed
with TIMI blood ﬂow classiﬁcation and TIMI MPG. 68 akynetic segments (S) were
selected for MCE analysis. A qualitative score from 0 to 2 (0=no contrast; 1=patchy
contrast; 2=homogeneous contrast) was assigned to each S. A mean MCE score
was obtained for each p. Quantitative analysis was done as follows: time-myocardial
contrast intensity (MCI) curves were obtained and after ﬁtting to an exponential
curve, MCE derived A (plateau MCI), B (rate of MCI rise) and their product AxB
(myocardial blood ﬂow index) were calculated. Mean MCE parameters were also
calculated for each p. A 2D echocardiography was performed 3 months later to assess improvement in wall motion systolic index (WMSI).
Results: No signiﬁcant differences in MCE score were observed between p with
normal and depressed TIMI MPG (1.4±0.3 and 1.1±0.5, p=0.1). No signiﬁcant
correlation was observed between MCE score and TIMI blood ﬂow classiﬁcation
(R=0.21, p=0.4) nor TIMI MPG (R=0.28, p=0.3). When angiographic data were
compared to quantitative MCE parameters, no signiﬁcant correlation with any of
them was observed (the highest correlation was found between TIMI MPG and myocardial blood ﬂow index: R=0.39, p=0.1). Perfusion MCE parameters correlated
well with WMSI improvement, especially B (R=0.58, p=0.01) and AXB (R=0.61,
p=0.009), whereas no signiﬁcant correlation was seen between TIMI MPG and
WMSI improvement (R=0.1, p=0.8).
Conclusions: No correlation is observed between TIMI MPG and MCE parameters after PPTCA. Quantitative MCE analysis provides better information concerning ventricular function recovery during follow-up than ﬁnal angiographic data after
primary PTCA.
305
Strain rate imaging in patients with coronary artery disease after 10
weeks training at different intensities.
B. Amundsen 1 , G. Hatlen 2 , O. Rognmo 1 , A. Støylen 2 , S.A. Slordahl 1 . 1 Faculty of
medicine, NTNU, Dep of Circulation and Medical Imaging, Trondheim, Norway; 2 St
Olavs Hospital, Dep of cardiology, Trondheim, Norway
Purpose: Physical exercise is strongly recommended in both primary and secondary prevention of coronary artery disease (CAD), but data on effects of exercise intensity are sparse. Thus, the aim of the study was to evaluate the effects of
two different aerobic exercise-training programs of uphill treadmill walking on maximum oxygen uptake (VO2peak) and myocardial contraction evaluated by ultrasound
Strain Rate Imaging (SRI).
Methods: 17 subjects with angiographically documented CAD were enrolled in the
study. They were randomly assigned to either moderate (M) (40 min continuos
walking at 50-60% of VO2 peak) or high (H) intensity exercise (4 x 4 min interval walking at 80-90% of VO2peak). Training was carried out under supervision 3
times per week for 10 weeks. Peak systolic strain rate (SR) was calculated in a
16-segment model of the left ventricle (LV), and the mean value for each subject
was used in analysis. Because of the between-group difference at pretest and to
avoid regression-towards-the-mean, changes in SR were computed by analysis of
covariance (ANCOVA) (postSR = c + preSR*b + group*b).
Results: VO2peak increased more after high than moderate intensity training (32
to 38 vs. 32 to 34, p<0,05). 227 of 272 segments were analysable with SRI at both
tests. For both groups together, mean SR was unchanged from pre- to posttest (1,12
vs. 1,14 p=0,44). SR was lower in the H compared to the M group at pretest (1,01
vs. 1,21 p=0,02), but not at posttest (1,09 vs. 1,18 p=0,44). In ANCOVA, there was
no difference in SR change between the H and M groups (95% CI for b: -0,20 - 0,06
p=0,3. R2= 0,61). When both groups were analysed together in ANCOVA, with AMI
(n=8) or non-AMI (n=9) as grouping variable, the change in SR was higher in nonAMI subjects than in AMI subjects (95% CI for b: 0,038 - 0,26 p=0,01. R2=0,74).
Among AMI subjects, there was no difference between the high or moderate intensity group.
Conclusion: High intensity endurance training improved VO2peak, but not SR,
more than training at moderate intensity. No obvious cause of the pretest difference between groups could be identiﬁed. The larger increase in SR among nonAMI subjects could be explained by more segments susceptible to training-induced
improvements.
S27
306
Evaluation of left ventricular diastolic performance following acute
myocardial infarction and thrombolysis.
D.N. Chrissos 1 , E.N. Tapanlis 1 , C.J. Aggeli 2 , A.A. Katsaros 1 , A.N. Kartalis 1 ,
I.E. Kallikazaros 1 , P.K. Toutouzas 2 . 1 Hippokration Hospital, State Cardiac
Department, Athens, Greece; 2 Athens University, Hippokration Hosp, Department
of Cardiology, Athens, Greece
Introduction: Acute myocardial infarction (AMI) is known to be a major cause of left
ventricular (LV) diastolic dysfunction. There is also no doubt about the great beneﬁts
of early thrombolytic therapy on patients (P) with AMI. The purpose of the study is
to evaluate LV diastolic performance following AMI treated or not with thrombolytic
agents by using a novel noninvasive echocardiographic index, which is independent
of preload.
Methods: We studied 77 consecutive hospitalized P with AMI (61 males and 16
females of mean age 59.79±12.23 years). 57 P received thrombolysis whereas
20 P did not. All P underwent 2-D, Doppler and color M-mode echocardiographic
study during the ﬁrst 48 hours following AMI. LV diastolic function was evaluated by
E/VFP ratio: E is the early diastolic velocity in the pulsed-wave Doppler transmitral
ﬂow (cm/sec) and VFP is the color M-mode Doppler velocity of ﬂow propagation
(cm/sec). Increased values of E/VFP ratio are identiﬁed as a prognostic factor for
high LV ﬁlling pressures and for cardiovascular events. Data were expressed as
"mean value ± standard deviation", statistical analysis was performed by the student’s t-test method and p<0.05 was considered statistically signiﬁcant.
Results: P who received thrombolysis showed signiﬁcantly lower values of E/VFP
ratio compared to P who were not treated with thrombolysis [2.23±0.83 versus
(vs) 2.68±0.95, p<0.05]. This statistical difference is more obvious concerning the
following groups: a) P with LV ejection fraction greater than 40% (2.11±0.58 vs
2.57±0.64, p<0.05). b) P without LV anterior wall involvement in the AMI (2.03±0.65
vs 2.68±0.72, p<0.05). c) P having less than three risk factors for AMI (2.08±0.64
vs 2.70±1.07, p<0.05).
Conclusions: Thrombolytic therapy of acute myocardial infarction seems to attenuate left ventricular diastolic dysfunction, as expressed by the changes of E/VFP
ratio values, already by the early post-infarction period. Consequently, E/VFP ratio
is a new echocardiographic index, which could contribute to the evaluation of the
effectiveness of treatment following myocardial infarction.
307
The impact of early infarct expansion on late ventricular remodelling - an
echocardiographic ﬁve-year follow-up.
C. Ginghina, B.A. Popescu, I. Stoian, M. Serban, M. Marinescu, R. Ionascu,
A. Apreotesei, D. Dragomir, E. Apetrei. Bucharest, Romania
Left ventricular remodelling after anterior myocardial infarction (AMI) has been related to location and size of AMI, and patency of the infarct related artery. The role
of infarct expansion on late ventricular remodeling has not been well deﬁned.
Aim: To assess the impact of early infarct expansion (IE) on late ventricular remodelling during a ﬁve-year echocardiographic (echo) follow-up period after AMI.
Additional, we have studied whether IE differs between patients (pts) with or without
thrombolysis.
Methods: We have studied 58 pts with AMI admitted in our Institute, (mean age
56±5 years; 38 male; 32 given thrombolythic therapy) by 2D-echo, on days: 1, 7,30
and on months 3 and 6 and also 1,2,3,4,5 years after AMI. We have determined LV
end-diastolic (EDI) and end-systolic (ESI) volume indexes; ejection fraction (EF)calculated by Simpson’s rule; infarct expansion index (IEI) -deﬁned as endocardial
length of asynergic/non-asynergic segment; thinning ratio (TR) -deﬁned by average
thickness of asynergic segment/average thickness of non-asynergic segment. We
deﬁned infarct expansion as: IEI>1 and/or TR<0,75 and/or increase in total endocardial length with 5% on day 7 in the same views.
Results: In pts who had IE on day 7 after AMI, we observed a progressively increase of EDI and ESI and decrease of EF from 1 month exam (p<0,01), to 6
month (p<0,001), to 12 month (p<0,001) and to 59 month (p<0,00001). In pts with
IEI <1 and/or TR>0,75 on repeated exams we haven’t found signiﬁcant differences
of EDI, ESI and EF (see table below)
Time-dependent ventricular remodelation
Thrombolysis
No thrombolysis
TIME
7 day
5 years
7 day
5 years
EDI(mm)
ESI(mm)
EF(%)
78±16
41±16
46±4
94±21
68±19
36±5
83±18
44±16
43±5
97±22
58±21
32±4
p
NS
NS
<0,01
Conclusions: Our study showed that the pts with early IE after AMI (appreciated
by IEI and TR) evolved with increasing left ventricular volumes (EDI and ESI) and
progressively decreased systolic function that have continued for 5 years after AMI.
We found no signiﬁcant differences between patients with or without thrombolysis.
Eur J Echocardiography Abstracts Supplement, December 2003
S28
Abstracts
308
Corrected TIMI frame count correlates with stenosis severity and predicts
functional improvement after percutaneous coronary intervention.
310
Echocardiographic predictors of short term evolution of patients with
cardiogenic shock.
B. Shivalkar, D. Dhondt, R. Vanbulck, F. Cools, M. Claeys, J. Bosmans, C. Vrints.
University Hospital Antwerp, Department of Cardiology, Edegem, Belgium
M. Rugina, A. Mereuta, R.O. Jurcut, I. Bostan, C. Matei, R. Cioranu, E. Apetrei.
Institute of Cardiology, Cardiology Dept., Bucharest, Romania
Introduction: The corrected TIMI frame count (cTFC) has been shown to be an
index of coronary ﬂow. Tissue Doppler imaging (TDI) can detect early ventricular
dysfunction not detected by conventional methods. We hypothesize that: 1. TDI
can detect abnormal regional function in non infarcted but chronically hypoperfused
myocardium, 2. Improved cTFC post percutaneous coronary intervention (PCI) is
associated with early functional improvement.
Methods:
Twenty nine patients (M/F: 19/10, age 67±9 years) with stable angina, and without prior myocardial infarction underwent cardiac catheterization, during which wall
motion analysis (centerline method), quantitative coronary angiography (QCA) and
CTFC (using a frame counter on a cine viewer) were measured. All patients had a
standard 2-D and Doppler echocardiography and Pulsed wave TDI of systolic (Sm)
and diastolic velocities (early: Em, late: Am) from the perfusion territories of the
left anterior descendens (LAD), the circumﬂex (CX) and the right coronary artery
(RCA), using the apical views, before and 24 hours after PCI.
Results:
All patients underwent elective PCI (19 LAD, 4 CX and 6 RCA stenoses, range 61
- 94%). There was TIMI grade 3 ﬂow before and after PCI. Regional wall motion
(centerline method and wall motion score with echocardiography) was normal in all
patients before and after PCI. Signiﬁcant improvement in the following parameters
was observed post PCI (mean ± SD): QCA, 72±12% to 8±6%; cTFC, 35±19 to
22±8; Sm, 5.4±1.1 to 8±1.4; p < 0.005 for all. An improvement was also seen
in diastolic function E/A ratio from 0.87±0.23 to 0.97±0.2. A signiﬁcant correlation
was found between cTFC and stenosis severity pre PCI (r=0.58, p=0.0028), and the
improvement in cTFC and the regional Sm values post PCI (r = 0.79, p<0.0001).
Multiple regression analysis showed that only improvement in the cTFC was important in predicting regional functional recovery within 24-hours post PCI (p=0.0005).
In conclusion, TDI could detect regional abnormal function in non infarcted but
hypoperfused myocardium, which was undetected by conventional methods. The
cTFC correlates with stenosis severity, and that improvement in cTFC (coronary
ﬂow) predicts early functional recovery after PCI.
Aim of the study: Echocardiography is one of the main methods of evaluation and
follow-up of patients with acute myocardial infarction, but little data exists yet on
the echocardiographic parameters that could be used in assessing the prognosis of
patients with cardiogenic shock. We aimed to evaluate the role of early echocardiography in determining the short-term (in hospital) prognosis of these patients.
Material and Methods: 626 patients (pts), mean age 65±12 years old, hospitalized
between june 1999 - oct 2002 in our Department with a diagnosis of acute myocardial infarction (AMI). Fourty-seven pts (7.5%) developed cardiogenic shock. Clinical
criteria for CS were hypotension (SBP<90 mmHg) for at least 30 min, clinical signs
of organ hypoperfusion, conﬁrming hemodynamic or radiographic features. Cardiovascular death during hospitalization was considered as the main end-point.
Results: All pts underwent echocardiographical study within 24 hours from hospitalization. Cardiovascular death during the hospitalization period occurred in 23 pts
with CS (48.9%). Short-term mortality was associated with a left ventricular (LV) systolic function signiﬁcantly more compromised (ejection fraction of 28.3% vs 32.8%,
p=0.02), more signiﬁcant parietal kinetic dysfunction (index of standard kinetics of
1.83 vs 1.59, p=0.03), more frequent LV diastolic dysfunction with both an impaired
relaxation pattern (26.1% vs 12.5%, p=0.006) and a restrictive pattern (17.4% vs
12.5%, p=0.03). The incidence of ischaemic mitral regurgitation (MR) was not signiﬁcantly more frequent (21.8% vs 20.8%, ns) in pts with altered prognosis.
Conclusions: Short-term (in-hospital) mortality in patients with cardiogenic shock
appears to be associated with early LV systolic (ejection fraction and abnormal parietal kinetics) and diastolic dysfunction (of both impaired relaxation and restrictive
type) as assessed by echocardiography. The incidence of ischemic MR did not appear to be signiﬁcantly different in these pts.
309
How many patients with ischemic left ventricular dysfunction do recover
in contractile function following revascularization?
Background: Left ventricular remodeling (LVR) after acute myocardial infarction
(AMI) has been extensively studied. Left atrial (LA) volume index has been very
recently described as a powerful predictor of survival after AMI. However, left atrial
remodeling (LAR) after AMI by serial echocardiographic studies in a low risk population has not been studied yet.
Aim: To assess the pattern of change in LA size and its determinants in patients
(pts) with low risk AMI by a serial 6 months echocardiographic follow-up.
Methods: We studied 597 pts (496 men, 60.8±11.9 years) from the GISSI-3 Echo
Substudy, who survived 6 months after AMI, in whom complete and accurate clinical
and echocardiographic follow-up data were available. Each patient had 4 echo studies performed: at 24-48 hours from admission (S1), at discharge (S2), at 6 weeks
(S3), and at 6 months (S4), which were analyzed in the Core Laboratory by experts
blinded to all clinical data. The following echocardiographic parameters were determined at each visit: LV ejection fraction (LVEF), indexed LV volumes (EDVi, ESVi),
LA maximal end-systolic area (4-C apical view) indexed for body surface area: LAAi
(cm2 /m2 ), mitral inﬂow E wave, E deceleration time (Edt), and mitral regurgitation
(MR) severity (0-3/3). LAAi changes and its determinants were calculated. Analysis
of variance for repeated measures was used for time-changes of echocardiographic
parameters.
Results: LAAi at S1 was higher in pts with signiﬁcant MR (2-3/3) than in pts with
mild or no MR (0-1/3)(10.4±2.2 vs 9.4±2.1, p=0.01), but LAAi change (S4-S1)
did not correlate with MR severity at S1 or with changes in MR severity (S4-S1).
LAAi signiﬁcantly increased throughout follow-up (from 9.48±2 at S1 to 9.8±2 at
S4, p<0.001), and this was already signiﬁcant at S2 (9.65±2.1, p=0.02), reﬂecting
both early and late LAR. Overall LAAi change (S4-S1) correlated with LV volumes
changes, particularly EDVi (p<0.001), with LVEF at S1 (p=0.02), and not with age.
Early LAAi changes (S2-S1) correlated with early changes in EDVi (p=0.008). Late
LAAi changes (S4-S2) correlated with early LAAi changes (p<0.001), with E at S2
(p=0.004), and with late changes in LV volumes (p=0.02 for EDVi), but not with LVEF.
Conclusions: This study demonstrates the existence of both early and late LAR
after AMI. LAR is related to LVR (it correlates better with diastolic than systolic LV
volume changes), and to EF at S1. Early LAR correlates best with early LVR, while
late LAR correlates best with early LAR ("remodeling begets remodeling").
A.F.L. Schinkel 1 , J.J. Bax 2 , A. Elhendy 1 , M. Bountioukos 1 , E. Biagini 1 ,
E.C. Vourvouri 1 , V. Rizzello 1 , F. Sozzi 1 , J.R.T.C. Roelandt 1 , D. Poldermans 1 .
1
Erasmus Medical Center Rotterdam, Cardiology Dept., Rotterdam, Netherlands;
2
Leiden University Medical Center, Cardiology, Leiden, Netherlands
Background: Contractile function in patients with ischemic left ventricular (LV) dysfunction may improve after myocardial revascularization. Currently, the incidence of
recovery of contractile function following revascularization in these patients is unclear.
Methods and Results: To assess the incidence of improvement of function after
revascularization, 258 consecutive patients (age, 59 ± 12 years) with a severely
depressed left ventricular ejection fraction (LVEF) due to chronic coronary artery
disease, and heart failure symptoms were studied. All patients underwent radionuclide ventriculography and resting 2D echocardiography before and 3 to 6 months
after revascularization. At baseline, 1330 (32%) segments were normal and 2775
(68%) were dysfunctional. Improvement following revascularization was present in
736 (27%) of the 2775 dysfunctional segments. Overall, LVEF improved from 29 ± 7
to 32 ± 9 (p<0.0001). A clinically signiﬁcant improvement of LVEF (>5% postrevascularization) was present in 101 (39%) patients. Improvement of LVEF following
revascularization was frequently observed in patients with a more severely impaired
baseline LVEF. At least 3 segments with improvement of function were needed for
an improvement of LVEF 3 5%.
Conclusions: Myocardial revascularization resulted in a clinically signiﬁcant improvement of LVEF in 39% of patients with ischemic LV dysfunction. Improvement
of LVEF following revascularization was frequently observed in patients with a more
severely depressed LV function.
Eur J Echocardiography Abstracts Supplement, December 2003
311
Left atrial remodeling after acute myocardial infarction in a low risk
population. The GISSI-3 Echo Substudy.
B.A. Popescu, F. Macor, F. Antonini-Canterin, P. Giannuzzi, P.L. Temporelli,
R. Piazza, E. Cervesato, G.L. Nicolosi. Centro Studi ANMCO, Florence, Italy
Abstracts
DILATED CARDIOMYOPATHY
313
Left ventricular ejection fraction and b2-adrenergic receptor
polymorphism in dilated cardiomyopathy.
M.V. Pitzalis, C. Forleo, S. Sorrentino, R. Romito, M. Iacoviello, F. Troisi, P. Guida,
E. De Tommasi, B. Rizzon, P. Rizzon. Institute of Cardiology, Bari, Italy
Background: Left ventricular ejection fraction (LVEF) is the parameter commonly
used to evaluate systolic function and stratify prognosis in patients with idiopathic
dilated cardiomyopathy (DCM). There are few data concerning the genetic determinants of systolic function in these patients.
The aim of this study was to evaluate the association between b2-adrenergic receptor (b2-AR) polymorphisms and LVEF in DCM patients before and after optimal
medical treatment.
Patients and Methods: We enrolled 22 consecutive unrelated patients (age 45±14
years, 17 males, NYHA functional class 1.6 ± 0.6) with DCM (WHO Criteria) in wash
out from beta-blockers (BB), ACE-inhibitors (ACE-i) and Angiotensin II receptor inhibitors (ARB). LVEF was evaluated by echocardiography at the time of the enrolment and after one year, when all patients were receiving optimal treatment with
BB and ACE-i or ARB. The genotyping for the 5’ leader cistron (5’LC) Arg19Cys,
Arg16Gly, Gln27Glu and Thr164Ile polymorphism of the b2-AR was performed on
the basis of PCR ampliﬁed DNA using RFLP.
Results: LVEF signiﬁcantly improved after optimization of therapy (from 37 ± 10 to
41 ± 10). We found a signiﬁcant association between the Arg16Gly polymorphism
and LVEF (Figure) before and after one year follow-up. In particular, homozygosity
for the Gly16 allele identiﬁed a subgroup of patients showing lower LVEF values than
the other patients. No association was found with the other studied polymorphisms.
S29
Conclusion: Patients who have MD but no clinically apparent heart disease,
nonetheless have impaired longitudinal and radial function of the left ventricle compared with age-matched controls, both in systole and in diastole. Longitudinal function is inversely related to the duration of the QRS complex.
315
Assessment of diastolic function in endomyocardial ﬁbrosis: value of
ﬂow propagation velocity.
V.M.C. Salemi 1 , M.H. Picard 2 , C. Mady 1 . 1 University of São Paulo Medical
School, Heart Institute (InCor), São Paulo, Brazil; 2 Massachussets General
Hospital, Boston, MA, United States of America
Objectives: The aim of this study was to characterize left ventricular (LV) diastolic
function in endomyocardial ﬁbrosis (EMF) by echocardiography.
Background: Endomyocardial ﬁbrosis is manifested mainly by diastolic heart failure. However, diastolic function has not been well characterized in this disease.
Methods: Eighteen patients with LV EMF and eighteen healthy subjects were studied. Cardiac volumes and ejection fraction were assessed by Simpson’s method.
Pulsed-wave Doppler was used to obtain mitral and pulmonary venous ﬂows velocities and grade diastolic function. Pulsed-wave tissue Doppler imaging velocities
along the septal side of mitral annulus, ﬂow propagation velocity (vp) of the early
diastolic mitral inﬂow, and myocardial performance index were obtained.
Results: According to this grading method, we found 4 patients with normal diastolic function, 5 with impaired relaxation, 5 with pseudonormal and 4 presented a restrictive pattern. A positive correlation of these diastolic function grades and NYHA
functional class was found (r=0.66, p=0.003). By "stepwise" logistic regression the
best index that discriminated EMF patients from controls was vp. The probability of
occurrence of EMF = exp(7.9288 - 0.1366vp)/1+exp(7.9288 - 0.1366vp).
Conclusions: A wide range of diastolic function grades is found in patients with
EMF and these correlated with functional class. Delayed myocardium relaxation, as
reﬂected by altered vp, was a frequent ﬁnding, making vp the most useful index to
discriminate EMF patients.
316
Echocardiographic assessment of left ventricular function following
surgical treatment of endomyocardial ﬁbrosis.
V.M.C. Salemi, S.A. Oliveira, R.D. Santos, C. Mady. University of São Paulo
Medical School, Heart Institute (InCor), São Paulo, Brazil
Conclusion: DCM patients homozygous for the b2-AR Gly16 allele show lower
LVEF values before and after BB, ACE-i and ARB treatment. This leads to hypothesise an inﬂuence of this allelic variant on systolic function in DCM.
314
Correlation of decreased myocardial Doppler longitudinal velocities and
intraventricular conduction abnormalities in patients with myotonic
dystrophy.
D. Vinereanu, B. Bajaj, J. Fenton-May, M. Rogers, C. Madler, A.G. Fraser. Wales
Heart Research Institute, Cardiff, United Kingdom
Cardiac involvement in myotonic dystrophy (MD) is characterised by conduction system abnormalities. Myocardial involvement, usually subclinical, can be diagnosed by
tissue Doppler, because it allows quantitative non-invasive assessment of regional
myocardial function.
Aims: We investigated long-axis and short-axis LV function in patients with MD, with
no symptoms or clinical signs of heart disease, in order to determine if they have
subclinical cardiac involvement, by comparison with age-matched normal subjects,
and to correlate myocardial function with conduction abnormalities.
Methods: 28 subjects (14 with MD, and 14 age- and sex- matched normals) had
conventional and tissue Doppler echocardiography. Myocardial velocities and timings to peak systolic contraction were measured. Genomic DNA was extracted from
peripheral blood leucocytes, and CTG repeat expansions in the DM-PK gene were
analysed using Southern blots.
Results: LV wall thickness, diameters, and EF were not different between the
groups. 29% of the MD patients had global diastolic dysfunction. Both long-axis
and short-axis systolic and early diastolic velocities were lower in patients with MD,
whereas time-to-peak myocardial contraction was longer; longitudinal systolic velocity was 5.5±1.7 cm/s in patients with MD, compared with 7.8±1.3 cm/s in normal
subjects (p<0.001). 71% of the patients had impaired longitudinal systolic function.
In patients with MD, the mean duration of the PR interval was 186±29 ms, and it was
>200 ms in 5 (36%) patients. Mean duration of the QRS complex was 111±16 ms,
and it was >120 ms in 5 (36%) patients; 1 patient had RBBB and 4 patients had
LBBB. Longitudinal systolic and diastolic velocities correlated with the duration of
the QRS complex (r=0.86 and r=0.63 respectively, both p<0.01). There was a trend
for the time-to-peak systolic velocity to increase as the QRS duration prolonged
(r=0.52, p=0.06). There were no signiﬁcant correlations between longitudinal function and the duration of the PR interval. Mean number of CTG-repeats was 492±301
(66-1000). There were no signiﬁcant correlations between the CTG-repeat size and
duration of MD since diagnosis, severity of muscle involvement, duration of the PR
interval, duration of the QRS complex, or any of the echocardiographic parameters.
Endomyocardial ﬁbrosis (EMF) is a rare restrictive cardiomyopathy, characterized by
ﬁbrous tissue deposition within the endocardium and the myocardium of the inﬂow
tract and apex of one or both ventricles. Surgical treatment consists in endomyocardial decortication and atrioventricular valve repair. It is recommended for patients in
NYHA functional class (FC) III and IV and it improves the quality of life and survival.
The aim of this study was to compare the effects of surgical treatment of EMF in left
ventricular (LV) function.
Methods: Thirteen patients (11 women, 55±10 years) with surgically proven LV
EMF with/without right ventricular involvement were studied prospectively by echocardiography. Seven patients were in atrial ﬁbrillation. The interval between preand post-operative echo was 4.5 months. Stroke volume, cardiac output and cardiac index were evaluated by LV outﬂow pulsed-wave Doppler. Left ventricular enddiastolic and end-systolic volumes/BSA were analyzed by Simpson’s modiﬁed biplane method. Propagation velocity (Vp) of early mitral ﬂow was assessed by color
M-mode Doppler.
Results: Data are shown in the table 1. Cardiac output increased mainly secondary
to the increase of stroke volume, as heart rate did not show any change. The diastolic function showed improvement as Vp increased after surgery.
Table 1
NYHA FC
Heart Rate (bpm)
Systolic BP (mmHg)
Diastolic BP (mmHg)
LV End-Diastolic Volume/BSA (ml/m2 )
LV End-Systolic Volume/BSA (ml/m2 )
LV Mass Index (g/m2 )
Stroke Volume (ml)
Cardiac Index (l/min/m2 )
Vp (cm/s)
Pre-Operative
Post-Operative
p value
2.9±0.3
78±18
119±13
77±7
53±13
25±10
126±28
31±12
1.3±0.4
37±15
1.3±0.5
80±11
115±11
72±13
74±19
41±19
98±31
46±21
2.1±0.8
58±15
0.0001
0.66
0.51
0.31
0.002
0.003
0.04
0.02
0.002
0.007
Conclusions: EchoDoppler is well suited to assess signiﬁcant improvements in LV
systolic as diastolic function after surgical treatment of EMF, which is associated
with decrease in NYHA FC.
Eur J Echocardiography Abstracts Supplement, December 2003
S30
Abstracts
317
The proﬁle of cardiac failure in restrictive cardiomyopathy: an
interpretation based on the site of restriction.
319
Left ventricular restrictive ﬁlling pattern is associated with reduced
cardiac sympathetic innervation in dilated cardiomyopathy.
C. Ginghina, B. A. Popescu, I. Stoian, I. Ghiorghiu, M. Serban, R. Ionascu,
I. Arsenescu, A. Popa, E. Apetrei. Bucharest, Romania
F.I. Parthenakis 1 , A.P. Patrianakos 1 , V. Prassopoulos 2 , P.G. Tzerakis 1 ,
E.A. Papadimitriou 1 , D.C. Kambouraki 1 , N.S. Karkavitsas 2 , P.E. Vardas 3 .
1
Heraklion University Hospital, Cardiology Dept., Heraklion, Crete, Greece;
2
Heraklion University Hospital, Dept. of Nuclear Medicine, Heraklion, Greece;
3
Heraklion University Hospital, Cardiology, Heraklion, Greece
Restrictive cardiomyopathy (RC) is deﬁned by abnormal myocadial stiffness. Under
this single haemodynamic restrictive proﬁle, were included different diseases with
polymorphous clinical and echocardiographic (echo) signs. The importance of an
accurate diagnosis lies in distinguishing RC from constrictive pericarditis, which can
also present with "restrictive physiology" but which is offer cured surgically.
Aim: The assessment of new working classiﬁcation based on clinical-echo data according to the site of the restriction to patients (pts) with RC conﬁrmed by cardiac
catheterisation (cath); the correlation with other noninvasive methods: radionuclide
angiography (RA), computerized tomography (CT) and magnetic resonance imaging (MRI).
Methods: We studied 19 pts wits RC, all conﬁrmed by cath. A complete medical
history and examination, electrocardiography, chest radiography and echo data (TM,
2D, Doppler) were performed in all pts. Echo data were compared with RA (11
pts), CT (8 pts), MRI (5 pts). Histopathological studies were performed with right
ventricular endomyocardial biopsy samples in 7 pts; 5 pts underwent autopsy.
Results: Three type of RC were identiﬁed based on noninvasive methods data according to the site of restriction: type A- symmetric RC (10pts), with biventricular
restrictive Doppler pattern of ﬂow, biventricular restrictive RA pattern (decreased
ﬁlling fraction, increased time to peak ﬁlling rate >200ms, decreased peak ﬁlling
rate, decreased ﬁrst 1/3 diastolic ﬁlling fraction, atrial contribution to ventricular ﬁlling >30%) and biventricular restrictive morphology (normal dimensions of both ventricles, biatrial enlargement) on echo, CT, MRI data; type B- left asymmetric RC (5
pts) involves selectively the left ventricle and type C- right asymmetric (4 pts) affects
only the right ventricle.
Conclusions: The application of new working classiﬁcation based on clinical-echo
data according to the site of myocardial restriction may offer a coherent pathophysiological interpretation of various entities included in RC. Associated noninvasive
methods can increase the accuracy of diagnosis by "anatomic" (CT, MRI) or functional (RA) data.
318
Assessment of diastolic function in isolated noncompaction of
ventricular myocardium.
V.M.C. Salemi, M. Regazini, C. Mady. University of São Paulo Medical School,
Heart Institute (InCor), São Paulo, Brazil
Introduction: Isolated noncompaction of ventricular myocardium is a rare congenital cardiomyopathy characterized by an arrest in endomyocardial morphogenesis in
the absence of other structural heart disease. The disease affects systolic and diastolic function, however, left ventricular (LV) and right ventricular diastolic function
has not been well characterized in this disease.
Methods: Five patients with noncompacted isolated myocardium, three of them
from the same family were prospectively studied by echocardiography. Ages ranges
from 8 to 52 years, 3 females, all in sinus rhythm with follow-up of 1.9 years. Ejection fraction was assessed by M-mode echocardiography. Pulsed-wave Doppler was
used to obtain mitral, tricuspid and pulmonary venous ﬂows velocities and grade diastolic function. Pulsed-wave tissue Doppler imaging velocities along the septal side
of mitral annulus, ﬂow propagation velocity (vp) of the early diastolic mitral inﬂow,
and myocardial performance index were obtained.
Results: According to this grading method, we found 2 patients with normal diastolic function, 2 with pseudonormal and 1 presented a restrictive pattern. A positive
correlation of these diastolic function grades and New York Heart Association functional class was found (r=0.92, p=0.017). One patient presented impared relaxation
of right ventricle. Mean peak of early diastolic myocardial velocity (E’), vp, E/vp,
and MPI were 11.5cm/s, 71cm/s, 1.4 and 0.48, respectively. Two patients presented
mild left ventricular systolic dysfunction without segmental dysfunctions. All patients
were alive in the follow-up.
Conclusions: A wide range of diastolic function grades is found in patients with isolated noncompaction of ventricular myocardium and these correlated with functional
class.
Eur J Echocardiography Abstracts Supplement, December 2003
Background: The hallmarks of Left Ventricular (LV) diastolic dysfunction are delayed relaxation and reduction of chamber compliance and are common ﬁndings in
pts with systolic dysfunction.
The adrenergic nerve system has a major role in regulating cardiac function while
cardiac ﬁxation of 123-I-Metaiodobenzylguanidine (MIBG) has been used to assess
myocardial adrenergic innervation. We assessed the relationship of LV sympathetic
innervation with the LV diastolic ﬁlling pattern in pts with non-ischemic dilated cardiomyopathy (NIDC).
Methods: Thirty -seven patients, 13 women, mean age 56.7+11,3 y, in sinus rhythm
and angiographically proven NICD, NYHA functional class II-III, LV ejection fraction
(EF) 30.8+ 9.5%, who were clinically stable during the last month, were studied with
planar MIBG and early (10 min), and late (4 hours) heart to mediastinum uptake ratio
and washout was calculated. A complete echocardiographic study was performed
to all patients.
Results: According to Doppler transmitral early (E) to late (A) ﬁlling Velocity and
E deceleration time (DTE) pts was divided into restrictive (E/A>2 or E/A=1-2 and
DTE<140msec, Group I, 15 pts) or non-restrictive (22 pts, group II) groups.
There were no differences in age (57.1±10.6 vs 53.2±13.6yrs), NYHA class
(2.2 ±0.36vs 2.4±0.44) or LV EF (33± 9.4 vs 28.1±9.2%) between two groups.
Group I pts showed increased left atrial diameter (45.8±4.1 vs 42.5±4.9,
p=0.04), and decreased early (1.48±0.12 vs1.63±0.21, p=0.01)and late(1.38±0.14
vs1.53±0.23, p=0.01) MIBG uptake compared to group II.
Late MIBG uptake was found to correlated with NYHA class(r=0.44,p=0.006), A
wave (r=0.37,p=0.02) and DTE (r=0.34,p=0.04)
Binary logistic regression analysis revealed that late MIBG uptake was independently associated with LV restrictive ﬁlling pattern (p=0.009).
Conclusion: In NIDC the transition of diastolic dysfunction from impaired relaxation
to restrictive ﬁlling pattern is independent to LV systolic function and it is strongly
correlated with the LV sympathetic innervation.
A greater percentage of beta-receptors down- regulation or destruction may contribute to the aggravation of LV diastolic dysfunction in these pts.
320
Time-movement and tissue Doppler imaging timing parameters of
ventricular desynchronization in patients with dilated cardiomyopathy.
D. Cozma, S. Pescariu, A. Ionac, D. Lighezan, D. Dragulescu, C. Mornos,
G. Cioraca, M. Dumitrasciuc, S.T.I. Dragulescu. Institute of Cardiovascular
Medicine, Timisoara, Romania
Background: The aim of this study was to compare similar Time-Movement (TM)
and Tissue Doppler Imaging (TDI) timing parameters in order to predict their value
in the assessment of the severity of systolic asynchrony for biventricular pacing
indication.
Methods: 31 patients (pts) aged 56.4±11.2 years with dilated cardiomyopathy were
included. The following parameters were measured: QRS duration (QRSd); septal
(S), posterior (P), lateral (L) and posterolateral (PL) wall delays, as the time from
QRS onset to maximal wall contraction, and the derived parameters: left ventricular mechanical delays (LVD) as the time interval from maximal contraction between
interventricular septum and posterior (LVDp), lateral (LVDl) and posterolateral wall
(LVDpl), using parasternal, 4 chamber view and subcostal incidence both in TM and
TDI; izovolumic relaxation time (IRT) in each wall using TDI; TDI measurements
were performed using both color and pulsed TDI (from QRS onset to the end of
S wave for each wall). Another derived parameter was calculated as the difference
between similar TM and TDI parameters: error parameter (Er: LVDpEr, LVDlEr, LVDplEr).
Results: TM: LVDp=116±59ms, LVDl=161±92ms, LVDpl=196±67ms; 21 pts presented QRSd>120ms (LBBB), 11 pts had QRSd<120 ms. At least one of LVD
>100ms was founded in 25 pts (19 pts LBBB and 6 pts QRSd<120ms); LVD was
signiﬁcantly higher in QRSd>120ms pts (p>0.0001 in each LVDp,l,pl). There was
no correlation between QRSd and echocardiographic parameters (r<0.3 each). TM
and TDI measuremets matched in pts with good echogenicity; differences in similar parameters as LVD ranged from 0-70ms. Er >30ms were noticed in pts with
fragmentated wall motion and IRT>30ms.
Conclusion: intraventricular asynchronized contraction occurs even in pts with normal QRS duration; these changes can be easily and accurately detected using simple TM timing parameters. The most delayed site to be stimulated can be found
either using TDI or TM.
Abstracts
S31
321
Correlation between architectonic perturbations of left ventricular
geometry, evaluated with 3D-echo, and perturbations of apical
hemodynamics, leading to apical thrombosis in dilated cardiomyopathy.
323
Assessment of mitral annulus dilatation in patients with primary dilated
cardiomyopathy before and after posterior semicircular reductive
annuloplasty.
I. Benedek, T. Hintea. University Hospital Mures, Cardiology Clinic, Targu-Mures,
Romania
V. Torbica 1 , M. Kovac 2 , D. Zecevic 1 , B. Mihajlovic 1 , Z. Potic 1 , N. Radovanovic 1 .
1
Institute of CVD, Clinic For Cardiovascular Surgery, Sremska Kamenica,
Yugoslavia; 2 Institute for CVD, Clinic of cardiology, Sremska Kamenica, Yugoslavia
In dilated cardiomyopathy (DCM), preferential localisation of intracavitary thrombosis in the Left Ventricular (LV) apex could be explained by architectonic and hemodynamic perturbation of the LV shape, which create an apical thrombogenic area.
Decrease of ﬂow velocities and persistence of ﬂow are more pronounced in areas
where architectonic modiﬁcations occur (LV apex), favoring thrombus development
at these sites.
Methods: Thirty-six patients with DCM - group A, and a control lot of 25 healthy subjects - group B. Ventricular shape and geometry were evaluated using B-mode echo.
Doppler mapping of blood ﬂow velocity in the LV was performed at different sites,
along 3 longitudinal axes at 3 levels: basal, medioventricular and apical. Threedimensional echocardiography (Sonos 5.500 - Agilent Technologies) was performed
in 12 cases, transthoracic and transesophageal, for analysis of LV architectonics.
Results: LV thrombosis was present in 56,7% of DCM cases, all of them in the
apex. Study of LV architectonics showed dilatation of LV in DCM group, 25% more
pronounced in the apex than in the medioventricular area, (p<0.001). Doppler mapping of ﬂow velocities showed a decrease of diastolic velocity from basis to apex with
0.48 m/sec (avg) in pts. with DCM and 0.25 m/sec (avg) in control group (p=0,001).
In DCM group, this velocity decrease was 2.2 times more pronounced in the apical
half of the LV (0.33 m/sec) than in the basal half (0.15 m/sec), while in control group
this decrease was uniformly distributed (0.13 m/sec vs 0.12 m/sec). Time duration
of ﬂow (on Doppler wave) increased from basis to apex (with +0.25 msec avg) in
group A (p=0.007) while in group B it decreased from basis to apex (with -0.25 msec
avg) (p=0,007). 3D echocardiography showed in all the 12 cases modiﬁcations of LV
architectonics, with a relative "narrowing" in the medioventricular area, 31% more
pronounced than in the control lot. Contrast echo showed a longer persistence of
ﬂow and turbulent ﬂow in the apex in all DCM cases.
Conclusions: In DCM, LV‘s shape and architecture presents signiﬁcant perturbations, demonstrated with 3D echo, which favor a turbulent ﬂow in the dilated apex,
leading to development of thrombi especially in this area. Doppler mapping of ﬂow
velocities in pts with DCM shows progressive decrease of ﬂow velocity from basis
to apex, more pronounced in the apical part of the LV, creating proper conditions for
apical thrombosis in DCM.
322
Inﬂuence of aetiology on long-term survival in patients with chronic heart
failure.
R.S. Sharma, R.T. Murphy, J. Gimeno Banes, P.M. Elliott, W.J. McKenna,
D. Pellerin. The Heart Hospital, London, United Kingdom
Aetiology of ischemic heart disease has been shown to be associated with worse
prognosis than idiopathic aetiology in patients with chronic heart failure. Other reports showed that survival was worse for idiopathic dilated cardiomyopathy or was
unrelated to aetiology. Due to these conﬂicting results, large therapeutic multicentre
heart failure trials included patients regardless of aetiology. We hypothesized that
patient group selection bias, for example the study of heart transplant candidates,
may explain these conﬂicting results. To determine whether ischemic or idiopathic
causes of cardiomyopathy were associated with prognosis, 287 patients with LV
ejection fraction (EF)<40% and LV end diastolic diameter > 6.0cm were followed
prospectively. LVEF was assessed by visual estimation, M-mode echo (when there
were no regional wall motion abnormalities or left bundle branch block), Simpson’s
rule and systolic mitral annular velocity. Patients had invasively proven ischemic or
idiopathic dilated cardiomyopathy. Advances in medical therapy were systematically
implemented over a mean follow-up period of 3.7±3.3 years. The cause was idiopathic in 52% of patients and ischemic in 48%. There was no signiﬁcant difference
in age (45±13 versus 48±18years), sex (male 68 versus 71%), LVEF (24±8 versus
25±7%) and LV end diastolic diameter (7.0±1.0 versus 6.8±0.8cm) between idiopathic and ischemic cardiomyopathy patients. When patients with heart transplantation were considered as deaths (n=43), there was no signiﬁcant difference in total
mortality between the 2 groups (p= 0.65 logrank test). With multiple logistic regression analysis, NYHA functional class and LVEF were identiﬁed as the variables most
closely associated with mortality (p=0.007 and 0.03 respectively) among patients
with idiopathic cardiomyopathy. In ischemic patients, only peak oxygen consumption was related to mortality (p=0.01). Left bundle branch block or QRS duration
>120ms failed to predict outcome.
Conclusion: Aetiology of ischemic heart disease was not an independent predictor
of mortality in patients with severe chronic heart failure in this prospective study.
Mitral regurgitation (MR) is one of the most common independent factors causing
heart failure in patients with primary dilated cardiomyopathy (PDCM). The main
cause of MR in PDCM is mitral annulus dilatation.
Purpose: The aim of the study is to compare changes in mitral annulus area (MAA),
changes in index of annular dilatation (IAD), changes in degree of MR before and
after posterior semicircular mitral annuloplasty.
Material and Methods: Twenty patients (9 male and 11 female, mean age 31) with
PDCM were including in the study. The following parameters were analyzed using
TEE: mitral annulus diameter in systole (MADs), mitral annulus diameter in diastole
(MADd), mitral annulus area in diastole (MAA), lengths of anterior mitral leaﬂet in
diastole (LAMLd).
MAA was calculated using Goldberg’s formula and IAD was obtained using formula
IAD=MADs/LAMLd.
Results: Results are presented in the table.
MADs (cm) MADd (cm) MAA (cm2 ) LAMLd (cm)
Before annuloplasty 4.06±0.41
After annuloplasty
1.8±0.1
p
<0.001
4.36±0.36
2.4±0.2
<0.001
14.81±2.4
5.0±1.1
<0.001
2.1±0.2
2.1±0.2
<0.001
IAD
MR Io-IVo
1.6±0.3
1.05±0.4
<0.001
3.7±0.1
0
<0.001
Conclusion: Posterior semicircular reductive mitral annuloplasty reduces signiﬁcantly MAA, IAD and eliminates MR. This procedure corrects remodeling of the
left ventricle and we recommended it in patients with PDCM immediately after ﬁrst
decompensation.
324
Thoracic ultrasonography in differentiating dyspnoea in patients with
heart failure.
M. Tsverava, D. Tsverava. Tbilisi Medical Academy, Tbilisi, Georgia
Background: Optimal management of CHF requires monitoring of the symptoms
of congestion. Pulmonary congestion (PC) is a useful marker of CHF. The diagnosis
of PC is conﬁrmed by clinical and X-ray examination. The mean sign of PC – dyspnoea, is not speciﬁc and can be caused by pulmonary diseases. Thoracic US is very
sensitive and speciﬁc in detection of pleural ﬂuid. However, US is not recognized as
the leading method of examination of respiratory system. The ﬂuid amount in lung
is increased by PC and it changes the sonographic characteristics of lung.
Objective: The aim of this study was to ﬁnd the US signs of PC.
Methods: We studied 169 patients with different grade CHF and X-ray signs of
PC(I group), 30 patients with dyspnea caused by exacerbation of chronic obstructive bronchitis, bronchial asthma or emphysema (II group) and 80 normal persons
and patients with heart diseases who had no CHF (III group). Left ventricular cavity size and EF% was determined by 2D-EchoCG, pulmonary artery pressure –
by Dopplerographic evaluation of tricuspid or pulmonary regurgitation ﬂow. Sonographic evaluation of a lung was done in horizontal and vertical positions of patient,
from 12 points on thoracic wall, which corresponded to the projection of lower, middle and upper lobes of a right lung and upper and lower lobes of left lung.
Results: In patients with CHF signiﬁcantly often was found the one of the sorts of reverberation - "Comet Tail Phenomenon" (CTPh) (100% versus 46%, p<0,005). The
count of positions on thoracic wall from where the CTPh was registered in I group
was 9.21±3.14, in II group – 1,19±1,11 (p<0,001) and in III group - 1.36±1.30
(p<0.001). There was good correlation between the count of CTPh registration
points from the thoracic wall and the heart failure NYHA class (r=0.56), left ventricular systolic (r=0.40) and diastolic (r=0.32) diameters and negative correlation
with EF% (r=-0,42). If we take 5 positions as a reference value the sensitivity of
sign in diagnosis of PC was 84.6% an speciﬁty – 98.8%. In CHF group CTPh was
prominent, protracted and multiple, while in the II and III group it was single and
short lasting.
Conclusion: (1) Thoracic US is sensitive and accurate method for evaluation of PC
in patients with CHF and in differentiating dyspnoea induced by CHF from dyspnea
induced by respiratory diseases. (2) The US sign of PC in HF is a "Comet tail Phenomenon", which is protracted, prominent, multiple and registered from larger area
of thoracic wall (5 positions or more).
Eur J Echocardiography Abstracts Supplement, December 2003
S32
Abstracts
325
Strain as an early marker of contractile improvement following beta
blockade therapy in patients with heart failure.
327
The evaluation of the effects of metoprolol theraphy on left ventricular
myocardial performance index in patients with dilated cardiomyopathy.
M. Stugaard, S. Nakatani, H. Yasuda, K. Katsuki, T. Maruo, Y. Yasumura. National
Cardiovascular Center, Osaka, Japan
A. onbasili, T. Tekten, C. Ceyhan, S. Unal. Adnan Menderes University, Cardiology,
AYDIN, Turkey
Introduction: The aim of the present study was to investigate if strain Doppler echocardiography is useful for evaluation of contractile function in patients with heart
failure treated with betablockade.
Methods: Fourteen patients with dilated cardiomyopathy (mean age 51±11 years)
were included. Standard echocardiography and tissue Doppler imaging (TDI) from
apical 4-chamber view were performed at baseline, after 3 weeks, and after 1 year
(n=6) on betablockade therapy. The basal segment of the septal wall was assessed.
Strain rate (SR) was generated from TDI by calculating velocity differences at positions 10 mm apart; then segmental strain (e=(L-L0)/L0) was estimated off-line.
Results: Data are given in table 1 (mean±1 SEM, **; p<0.05 vs baseline, *; p=0.06
vs baseline). Heart rate (HR) and systolic blood pressure (SBP) decreased signiﬁcantly at 3 weeks. Ejection fraction (EF) tended to increase and left ventricular (LV)
mass tended to decrease after 1 year. LV systolic dimension (LVS) was unchanged
at 3 weeks, but decreased signiﬁcantly at 1 year. TDI and SR during systole did
not show any signiﬁcant changes. However, peak systolic strain (SS) increased signiﬁcantly from 11±1 at baseline to 20±2% at 3 weeks and remained unchanged
after 1 year (18±3%), suggesting enhancement of myocardial contraction. TDI diastolic parameters did not show any signiﬁcant changes, neither did SR of the E
wave, however, SR of the A wave increased after 1 year, suggesting change in LV
stiffness.
Dilated cardiomyopathy is related to contraction and relaxation abnormalities of ventricle. Isolated analysis of either mechanism may not be reﬂective of overall cardiac
dysfunction. A combined myocardial performance index (MPI) has been described
which may be more effective for analysis of global cardiac dysfunction than systolic
and diastolic measures alone. It has been known that long-term beta-blocker therapy improves cardiac functions in dilated cardiomyopathy. The aim of the present
study was to investigate the effects of metoprolol on left ventricular myocardial performance index in patients with dilated cardiomyopathy.
Method: Eighteen patients (14 men, 4 women, mean age 59±10 years) who had
dilated cardiomyopathy diagnosed by echocardiographic were studied. Following
basal echocardiographic recordings, each patient was given metoprolol in an initial
dose of 12.5 mg once daily. The dose of metoprolol was aimed to be doubled in every two weeks up to 200 mg/day or up to maximum tolerated dose in 6-8 weeks. All
patients continued to receive ACE inhibitor, digitalis and diuretic treatment besides
metoprolol. Conventional echocardiographic examinations and MPI measurements
were made before the metoprolol treatment was started, at the end of ﬁrst and third
months following the maximum tolerated dose of metoprolol was achieved. MPI was
calculated according to following formula = izovolumetric contraction time (IVCT) +
izovolumetric relaxation time (IVRT)/ejection time (ET).
Results: Baseline, at the end of ﬁrst and third months following the maximum tolerated dose of theraphy, MPI were 70±15, 51±7 and 43±8, respectively (p< 0.001).
At ﬁrst month, IVCT (58.8±24 vs 48.8±13) and IVRT (121±19 vs 97±18) were
signiﬁcantly decreased, ET (256±25 vs 280±23) was signiﬁcantly increased. However, ejection fraction (EF), left ventricular dimentions, E/A ratio and E wave deceleration time (EDT) changes were not signiﬁcant. At third months, IVCT, IVRT and
ET changes were more prominent than ﬁrst month. However, the increase in EF
(30.2±6.5 vs 35.8±4.4) and the decrease in EDT (240±29 vs 231±28 ms) were
signiﬁcant, but left ventricular dimentions and E/A ratio changes were not signiﬁcant.
Conclusion: This study showed that metoprolol treatment improved the left ventricular functions in dilated cardiomyopathy by improving both systolic and diastolic
functions. Improvement in left ventricular functions may be shown by MPI at ﬁrst
month although conventional measurements may show improvement in left ventricular functions at third month.
Table 1
HR (beats/min)
SBP (mmHg)
EF (%)
LV mass (g)
LVS (cm)
SR sys (s-1)
SR A (s-1)
Peak SS (%)
Baseline
3 weeks follow-up
1 year follow-up
74±4
118±4
33±4
363±35
5.9±0.2
-1.2±0.2
1.6±0.3
11±1
62±3**
105±3**
37±2
326±28
5.9±0.3
-1.5±0.1
1.9±0.4
20±2**
67±4
110±7
44±5
260±60
4.8±0.3**
-1.3±0.3
3.4±1.2*
18±3**
Conclusion: Noninvasive strain measurement in clinical heart failure shows an
early improvement of contractile function after betablocade therapy, and thus seems
to be more sensitive than standard echocardiography.
326
Management of end-stage heart failure: non-invasive or invasive
monitoring?
N. Mansencal 1 , F. Digne 1 , T. Joseph 1 , R. Pillière 1 , J.F. Morisson-Castagnet 1 ,
P. Lacombe 2 , G. Jondeau 1 , O. Dubourg 1 . 1 Hôpital Ambroise Paré, Service de
Cardiologie, Boulogne Cedex, France; 2 Hôpital Ambroise Paré, Service de
radiologie, Boulogne, France
Swan-Ganz catheter is still used for the management of refractory heart failure.
Echocardiography with recent published criteria has been proposed for estimating
right and left ventricular ﬁlling pressure.
The aim of this prospective study was to compare echocardiography with SwanGanz data in patients with end-stage heart failure.
Methods: We prospectively studied 13 consecutive patients (11 men, mean age
47 ± 12 yrs) presenting with dilated cardiomyopathy in end-stage heart failure. All
patients underwent in the same hour a complete echocardiography and a SwanGanz catheter. Following echocardiographic parameters were assessed: 1) mean
right atrial pressure using 2D percent collapse of inferior vena cava; 2) systolic
pulmonary arterial pressure (SPAP) using CW Doppler of tricuspid regurgitation;
3) mean pulmonary arterial pressure (MPAP) using pulmonary regurgitation (CW
Doppler); 4) aortic output using PW Doppler and 2D echo; 5) pulmonary capillary
wedge pressure (PCWP) using tissue Doppler imaging according to mitral inﬂow to
annulus ratio (E/E’) (PCWP = 1.24 [E/E’] + 1.9); 6) PCWP using E velocity/mitral ﬂow
propagation velocity (PCWP = 5.8 [E/mitral ﬂow propagation] + 4.5; using colour
M-mode). A cut-off value of 9 for E/E’ and a cut-off value of 2 for E/mitral ﬂow
propagation were used for predicting left ventricular ﬁlling pressure higher than 15
mmHg. All measurements were interpreted by two different blinded observers.
Results: Twenty echocardiographic studies and catheters were performed. Mean
2D LVEF was 19 ± 7%. Correlations between echocardiography and Swan-Ganz
catheter were 0.91 for mean right atrial pressure, 0.93 for SPAP, 0.92 for MPAP, 0.81
for aortic output, 0,78 for PCWP, 0.95 for systemic vascular resistance and 0.81 for
pulmonary vascular resistance. Bland-Altman analysis revealed good agreements
between echocardiographic and invasive data Using E/E’ and E velocity/mitral ﬂow
propagation, all patients were well-classiﬁed for estimating left ventricular ﬁlling
pressure higher than 15 mmHg.
Conclusion: These data suggest that echocardiography may be a reliable tool for
the management of patients with end-stage heart failure and have to be conﬁrmed
in a large cohort of patients before substituting Swan-Ganz catheter.
Eur J Echocardiography Abstracts Supplement, December 2003
328
Tissue Doppler echocardiography measurements of cardiac cycle
intervals: comparison with pulsed Doppler mitral ﬂow in healthy subjects
and in patients with heart failure.
M. Plewka, J. Drozdz, M. Ciesielczyk, K. Wierzbowska, P. Lipiec, T. Jezewski,
M. Krzeminska- Pakula, J.D. Kasprzak. Medical University of Lodz, Cardiology
Dept., Lodz, Poland
Tissue Doppler echocardiography allows the quantiﬁcation of cardiac cycle intervals.
The aim of this study was to compare the relationships between tissue doppler
echocardiography measurements of cardiac cycle intervals with mitral Doppler inﬂow derived time intervals in healthy and failing hearts. The study group included
60 healthy subjects (aged 53±12yrs, LVEF 64±2%) and 60 patients with heart failure (aged 55±8 years, EF 29±8%). Using tranthoracic pulsed Doppler echocardiography of mitral and aortic ﬂow we measured time intervals of cardiac cycle from
mitral and aortic ﬂow: preejection period (PEP), ejection period (EP), isovolumic
relaxation time (IVRT), rapid ﬁlling time (RFT), diastasis time (DT) and atrial contraction time (ACT). Than we compared standard time intervals with tissue Doppler
echocardiography time intervals- PEPm, EPm, IVRTm, RFTm, DTm and ACTm. We
found close linear correlation between parameters derived from standard and tissue
Doppler echocardiography in healthy subjects (PEP vs PEPm r=0,899 p<0,0001,
EP vs EPm r=0,829 p<0,0001, IVRT vs IVRTm r=0,910 p<0,0001, RFT vs RFTm
r=0,526 p=0,003
DT vs Dm r=0,894 p<0,0001, ACT vs ACTm r=0,475 p=0,008)
In patients with heart failure due to regional asynchrony the correlation was weak
(PEP vs PEPm r=0,688 p<0,0001, EP vs EPm r=0,486 p=0,006, IVRT vs IVRTm
r=0,288 p=NS, RFT vs RFTm r=0,484 p=0,007, DT vs Dm r=0,782 p<0,0001,ACT
vs ACTm r=0,468 p=0,009).
Conclusion: Regional TDE time intervals of cardiac cycle correlates with standard
echocardiographic measurements in healthy subjects but not in patients with heart
failure.
Abstracts
329
Differentiation of ischaemic and idiopathic dilated cardiomyopathy in
patients with global systolic left ventricular dysfunction.
D. Pellerin 1 , R.S. Sharma 1 , F. Larrazet 2 , P.M. Elliott 1 , W.J. McKenna 1 , C. Veyrat 2 .
1
The Heart Hospital, London, United Kingdom; 2 Institut Mutualiste Monsouris,
Cardiology, Paris, France
Many studies have shown that conventional echocardiographic parameters are unable to distinguish between ischaemic and non-ischaemic aetiologies in patients
with global severe left ventricular dysfunction when history of coronary artery disease lacks. A coronary angiogram is usually performed but an ischemic origin is
rarely found. The aim of this study was to determine whether colour tissue Doppler
imaging and strain could make this distinction. The study cohort comprised 18 controls (53±10y, 9 Males), 37 patients, with idiopathic dilated cardiomyopathy (DCM)
(62±10y, 28 Males, LVEF 30±9%, LV EDD 6.1±0.4cm) and 16 patients with > 3vessel coronary artery disease (IHD) (67±11y, 13 Males, LVEF 29±10%, LV EDD
6.4±0.3cm). Colour tissue Doppler velocities and strain were measured in the left
ventricular posterior wall on M-mode recordings. No patient had akinetic, thin and
echo bright posterior wall. Wall motion score index (2.34±0.39 versus 2.25±0.42)
and the number of akinetic LV segments per patient were not signiﬁcantly different
between patients with IHD and those with DCM. During systole, ejection epicardial velocity measured at the time of peak endocardial velocity was higher in DCM
than in IHD (21±13 versus 10±9mm/s, p=0.04). The ratio of preejection to ejection
endocardial velocity was lower in DCM compared to IHD (25±27 versus 72±44,
p=0.01). During early diastole, peak endocardial velocity (68±33 versus 42±24,
p=0.03), peak epicardial velocity (53±31 versus 26±17, p=0.01), and endocardial
velocity measured at peak epicardial velocity (36±27 versus 10±9, p=0.003) were
higher in DCM than in IHD. Systolic strain and tissue Doppler derived myocardial
velocity gradients were similar in both groups of patients.
Conclusion, analysis of colour tissue Doppler echocardiograms in endocardial and
epicardial layers may be able to identify those patients with global severe left ventricular dysfunction that have ischaemic heart disease.
330
Longitudinal and radial systolic wall motion velocity in transplanted
hearts: diagnostic value for rejection surveillance and early detection of
patients with allograft vasculopathy.
M. Dandel 1 , H. Lehmkuhl 2 , E. Wellnhofer 3 , R. Meyer 1 , R. Hetzer 2 . 1 Deutsches
Herzzentrum Berlin, Cardiothoracic and Vascular Surgery, Berlin, Germany;
2
Deutsches Herzzentrum Berlin, Cardiothoracic and Vascular Surgery, Berlin,
Germany; 3 German Heart Institute of Berlin, Cardiology Dept., Berlin, Germany
Noninvasive acute rejection (AR) surveillance and early detection of transplant coronary arteriopathy (TxCA) are major objectives in the management of heart recipients. Echocardiography is part of post-transplant routine follow-up, but its clinical
value is controversial. Recently attention has been focussed on tissue Doppler wall
motion analysis, which can detect ventricular dysfunction earlier than conventional
echocardiography.
We assessed the usefulness of pulsed wave tissue Doppler (PW-TDI) velocity and
time parameters for AR surveillance and detection of patients with new appearance
or aggravation of TxCA.
Methods: To evaluate the left ventricular (LV) wall motion, we selected the posterior
wall because it enables optimal recording from the same region of both radial and
longitudinal wall motion. In 356 patients, serial PW-TDI recordings were performed
at the basal posterior wall in the parasternal short axis and in the apical long axis
views. We measured the systolic and early diastolic peak velocities Sm and Em,
the systolic time TSm (onset of ﬁrst heat sound to Sm) and the diastolic time TEm
(onset of second heat sound to Em). These parameters were tested for relationship
to cardiac catheterization and biopsy ﬁndings.
Results: For both radial and longitudinal wall motion, all tested parameters showed
signiﬁcant alterations during biopsy-proven AR (p < 0.01). During the early posttransplant period, the sensitivity and speciﬁcity for biopsy-proven rejection of Em
reduction, TEm extension and Em/TEm reduction was > 91%. For late ARs (beyond the 2nd post-transplant year), the sensitivity and speciﬁcity of these diastolic
parameters was lower (78 - 83%). The sensitivity and speciﬁcity of Sm reduction,
TSm extension and Sm/TSm reduction was highest for late ARs (>90%). For PWTDI changes the threshold value of 10% was selected in accordance with the reproducibility of measurements tested during the study. With TxCA, the PW-TDI pattern
(radial and longitudinal) showed signiﬁcant changes (p < 0.01) for both systolic and
diastolic parameters, but the systolic changes were more obvious. Thus, even patients with TxCA visible only by IVUS, showed signiﬁcant alterations (p < 0.01) for all
systolic parameters. At deﬁnite cut-off values for systolic parameters, angiographic
TxCA can be excluded with a probability of up to 93%.
Conclusion: Serial PW-TDI recorded at the basal posterior wall provide useful diagnostic information after heart transplantation, which facilitates the early detection
of AR and TxCA and enables the timing of invasive examinations.
S33
331
Usefulness of systolic left ventricular long-axis function for the
prediction of mortality in patients with severe left ventricular dysfunction
due to ischemic cardiomyopathy.
K. Bouki 1 , T. Kakavas 2 , A. Kranidis 3 , G. Pavlakis 2 , J. Karangis 2 , K. Kostopoulos 2 ,
A. Kotsakis 2 , E. Papasteriadis 2 . 1 General Hospital of Nikea, Cardiology Dept.,
Pireaus, Greece; 2 General Hospital of Nikea, Pireaus, Cardiological, Athens,
Greece; 3 Evaggelismos General Hospital, Cardiology, Athens, Greece
Objectives: To assess the prognostic value of response of left ventricular (LV) longaxis function to dobutamine infusion, in patients with severe heart failure due to
ischemic cardiomyopathy.
Methods: Fifty-one coronary artery disease (CAD) patients, age 62±8 years, with
severe LV dysfunction (EF<35%) and NYHA functional class III or IV were included
in the study. None of the patients was a candidate for revascularization either because absence of myocardial viability or because inappropriate coronary anatomy.
All the patients underwent dobutamine stress echocardiography (DSE). The amplitude of long-axis shortening (LAS) was estimated at rest and at every stage of dobutamine infusion (5-40µgr/Kg/min), using 2D guided M-Mode, towards the four sides
of the left atrioventricular plane (septal, lateral, inferior and anterior), from the apical 2- and 4-champers view. The amplitude of LAS was determined as the average
value of the four, mentioned above, sides. LAS increase>10% during dobutamine
infusion compared with baseline was considered signiﬁcant.
Results: Cardiac mortality during 36±6 months follow up was 59%. The response
of LAS to low-dose dobutamine infusion was independent predictor of cardiac death
in multivariate analysis(p<0.001), whereas LAS response to peak dobutamine infusion had no predictive value. Nineteen patients (37%) demonstrated signiﬁcant increase of LAS at low-dose dobutamine infusion (LAS increase=17±6%). In the rest
32 (63%) patients, LAS did not show any signiﬁcant change (LAS increase=2±5%).
Patients with improved LV long-axis function during low-dose DSE had signiﬁcantly
lower 2-year cardiac mortality compared with the others who didn’t show any positive response to the drug (19 patients with cardiac mortality=26% vs. 32 patients
with cardiac mortality=81%, p=0.001).
Conclusions: The response of LV long-axis function to low-dose dobutamine infusion showed a strong independent prognostic value, in CAD patients with severe
heart failure. Assessment of this parameter during DSE facilitates identiﬁcation of
heart failure patients with extremely high mortality, for whom immediate cardiac
transplantation can be lifesaving.
332
Prognostic value of Tei index before and after dobutamine challenge in
patients with idiopathic dilated cardiomyopathy.
A. Vlahovic 1 , P. Otasevic 2 , Z. Popovic 2 , J. D. Vasiljevic 3 , A.N. Neskovic 1 . 1 Dedinje
Cardiovascular Institute, Cardiovascular Research Center, Belgrade, Yugoslavia;
2
Dedinje Cardiovascular Institute, Cardiovascular Research Center, Belgrade,
Yugoslavia; 3 Institute of Pathology, Cardiovascular Pathology, Belgrade, Yugoslavia
Background: Numerous parameters of left ventricular (LV) systolic and diastolic
function have shown to independently determine prognosis in patients (pts) with
idiopathic dilated cardiomyopathy (IDCM). The presence of myocardial contractile
reserve assessed by the increase of LV ejection fraction on dobutamine echocardiography has been shown to have beneﬁcial effect on prognosis of these pts. Since
pts with IDCM have both systolic and diastolic LV dysfunction, it could be expected
that dobutamine induced changes of Tei index, as a parameter of global myocardial
performance, could give more valuable prognostic information in these pts.
Aim and methods: To assess the prognostic value of changes of Tei index, 29
patients in sinus rhythm with IDCM underwent dobutamine stress echocardiography
test. Maximum dose of 40 µg/kg/min of dobutamine was infused, with incremental
doses of 5, 10, 20, 30 and 40 µg/kg/min at 5 minutes intervals. For the measurement
of Tei index, transmitral inﬂow and the ejection time of LV outﬂow tract were recorded
at baseline and at peak dose of dobutamine. Tei index was calculated as the sum
of isovolumetric contraction and relaxation time, devided by ejection time. For each
patient three consecutive beats were measured and averaged.
Results: The mean age, NYHA class and ejection fraction of patients were 51±10,
2.17±0.54 and 19%±8%, respectively. There was a signiﬁcant decrease of value
of Tei index from 1.02±0.35 at baseline, to 0.75±0.25 at peak dose, p<0.0001.
Analyzing the effect of Tei index on cardiac death, partial left ventriculectomy and
hospitalization for heart failure as combined end-point, higher baseline values were
found to be associated with adverse prognosis at one year follow-up (p=0.026).
On the other hand, the value of Tei index at peak dose of dobutamine showed no
prognostic signiﬁcance (p=0.117). Also, although Tei index did change from base
to peak, this change did not have any effect in terms of prognosis in these pts
(p=0.326).
Conclusions: It appears that in contrast with baseline value, the value of Tei index
at peak dobutamine as well as changes of Tei index before and after dobutamine
challenge, has no prognostic signiﬁcance in pts with IDCM.
Eur J Echocardiography Abstracts Supplement, December 2003
S34
Abstracts
333
Prognostic value of systolic and diastolic echocardiographic parameters
in patients after myocardial infarction after 18-months follow-up.
K. Wierzbowska, J. Drozdz, J.D. Kasprzak, M. Krzeminska-Pakula. Medical
University of Lodz, Cardiology Dept., Lodz, Poland
Purpose: Our aim was to assess role of wide spectrum of echocardiographic parameters in prediction of combined cardiac events (death, myocardial infarction or
exacerbation of heart failure) and cardiac deaths in 18-months follow-up in 60 subjects after myocardial infarction.
Methods: We assessed classic two-dimensional and Doppler parameters, pulmonary vein ﬂow, propagation of mitral waves and mitral annulus motion by pulsed
tissue Doppler. After follow-up period combined endpoints and deaths were registered and on basis of cut-off values found by ROC analysis Kaplan-Meier survival
curves were compared.
Results: The greatest accuracy for detection of patients with combined endpoint
showed: left atrium (LA)>44 mm, area under curve (AUC) 0,909, ejection fraction
(EF) below or equal 34%, AUC 0,784, left ventricle diastolic (LVd)>51 mm, AUC
0,811 and systolic dimensions (LVs)>43 mm, AUC 0,798, early wave deceleration
time (Edt) below or equal 130 ms, AUC 0,798 and difference of atrial reversal and
atrial wave of mitral inﬂow duration (delta At) >23, AUC 0,781. For all above cutoff values comparison of survival curves revealed highly signiﬁcant difference with
p<0,001. Relative risk and 95% conﬁdence intervals for combined endpoint are
shown in table 1. For Edt below 130 ms and delta At above 23 ms all patients
experienced combined endpoint.
Multivariate analysis revealed only one independent predictor of both combined
endpoint and deaths: LA dimension with cutoff values above 44 mm for combined
endpoint (p=0,001) and above 46 mm for deaths, (p=0,004).
335
Natriuretic peptides and myocardial function in chronic heart failure.
L. Spinarova 1 , J. Toman 1 , J. Meluzín 1 , P. Hude 1 , J. Krejci 1 , J. Tomandl 2 ,
J. Vitovec 1 . 1 St Ann’s University Hospital, 1st Dept. of Medicine Cardioangiology,
Brno, Czech Republic; 2 Masaryk University, Biochemical Centre, Brno, Czech
Republic
Conclusions: In our study for subjects after myocardial infarction and without signiﬁcant valvular insufﬁciency left atrium dimension emerged as the best predictor of
both combined cardiac endpoint and death.
Aim: Atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) belong to
the important humoral substances that reﬂect the severity of chronic heart failure.
We compared the patients with high and low levels of pro-ANP and BNP in the
connection with the haemodynamics, function of left and right ventricles.
Study population: 155 patients with chronic heart failure, ejection fraction of left
ventricle (EF LK) below 40%, NYHA II.-IV, mean age 51,8±8,8 years, 129 men, 26
women, coronary artery disease (CAD) 86, dilative cardiomyopathy (DCMP) 69.
Methods: Echocardiography with evaluation of left ventricle dimensions, volumes
and ejection fraction, tissue Doppler imaging (TDI) of tricuspid annulus motion with
measurements of systolic velocity (Sa), early diastolic (Ea) and atrial diastolic velocities (Aa), right heart catheterization with measurement of mean pulmonary artery
pressure (MPAP), pulmonary capillary wedge pressure (PCWP), central venous
pressure (CVP), and pulmonary vascular resistance (PVR). Pro-ANP and BNP levels were measured by ELISA method.
Median pro-ANP was 4,43 nmol/l, median BNP 288 ng/l. Group A had pro-ANP>
4,43 nmol/l, group B< 4,43 nmol/l. Group A’had higher BNP level > 288 ng/l and
group B’< 288 ng/l.
Results: Patients with higher pro-ANP- group A - had larger diastolic and systolic diameters of LV: 71,0±7,1 vs 67,5±9,8 mm, p< 0,05 and 60,4±7,2 vs 56,5±9,9 mm,
p< 0,03, lower EF of left ventricle 22,0±5,9 vs 25,1±5,8%, p< 0,02 and lower Sa
(which reﬂects the right ventricular function) 10,6±2,3 vs 11,4±2,2 cm/s, p< 0,014.
On the contrary the values of right heart catheterization were much higher in group
A patients: MPAP 33,1±11,7 vs 21,7± 11,3 mmHg, p< 0,000006, PCWP 23,0±9,3
vs 14,7±9,0 mmHg, p< 0,00005, PVR 207,5± 150,2 vs 139±93 dyn.s.cm-5, p<
0,011.
Patients with high BNP- group A’ showed larger left ventricular systolic diameter
DS 61,1±8,9 vs 56,3±9,9 mm, p< 0,05 and tendency to lower LV EF 22,2±6,3 vs
25,0±6,6%, p<0,09. Group A’patients had higher MPAP 30,3±13,3 vs 23,5±13,1
mmHg, p< 0,04 and PCWP 20,8± 10,5 vs 15,6± 10,3 mmHg, p < 0,05.
They also showed higher pro-ANP levels: 6,29±3,59 vs 4,25±3,03 nmol/l, p<
0,024.
Conclusion: Natriuretic peptides reﬂect the severity of heart failure, their levels are
higher in patients with marked pulmonary hypertension, decreased ejection fraction
of left ventricle and they are more increased when dysfunction of both ventricles is
present.
334
Prognostic implications of cTnI elevation after elective percutanoeus
interventions (PCI) on global and regional left ventricular function in
prospective, one-year follow-up study.
336
Quantiﬁcation of regional left ventricular function in Q-wave and
non-Q-wave dysfunctional regions by tissue Doppler imaging in patients
with ischaemic cardiomyopathy.
A. gerber 1 , J. Drzewiecki 1 , K. Wita 1 , I. Mroz 2 , M. Trusz-Gluza 1 . 1 Slaska
Akademia Medyczna, I Klinika Kardiologii, Katowice, Poland; 2 Samodz. Publ.
Szpital Kliniczny 7, Analitycal Labolatory, Katowice, Poland
M. Bountioukos 1 , A.F.L. Schinkel 1 , J.J. Bax 2 , B.J. Krenning 1 , E.C. Vourvouri 1 ,
V. Rizzello 1 , D. Poldermans 1 , J.R.T.C. Roelandt 1 . 1 Thoraxcenter, Erasmus
Medical Center, Department of Cardiology, BA302, Rotterdam, Netherlands;
2
Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands
Table 1.
parameter
cut-off value
relative risk
95% CI
LA
LVd
LVs
EF
Edt
delta At
mitral inﬂow restriction
>44 mm
>51 mm
>43 mm
<(=)34%
<(=)130 ms
>23 ms
–
5
3.1
2.7
3.1
*
*
2.1
(2-12.3)
(1.4-6.7)
(1.4-5.2)
(1.5-6.3)
–
–
(1.3-3.2)
Aim of the Study: to assess the incidence of cTnI elevation after elective PCI, with
and without stent insertion, and to examine the impact of minor myocardial injury on
clinical and echocardiographic data in one-year follow-up study.
Methods: A total of 90 pts who underwent elective PCI were included into the
prospective study. Serum levels of cTnI were measured before, 12 and 24 hours
after procedure, by the use of immunoassay (OPUS, Dade-Behring), cut-off point
0,1ug/L. CK-MB was measured 12 and 24 hours after the procedure, using enzyme activity method, (cut-off <24IU/L). Baseline global left ventricle systolic function (LVEF) and 16 segments wall motion score index (WMSI) were assesed.
One -year follow-up comprised clinical and echocardiographic data assessment.
Results: No patient included into the study had abnormal marker value before the
procedure. LVEF ranged from 25 to 60%(mean 50%),calculated WMSI was 1,2
±0,2. 12 h and 24 h after procedure, we noticed a few fold rise of cTnI serum
levels in 66 pts (73%) – cTnI positive group (cTnI +), being the most prominent in
stenting group (0,4±0,2 ug/L).24 pts (27%) presented with normal values of cTnI
after PCI- cTnI negative group (cTnI -). Only 8 of 66 cTnI positive pts had signiﬁcant
(>1,0ug/l) postprocedural cTnI concentration, coexisting with the rise of CKMB 2-3
times upper limit of normal.
One year follow -up comprised 62 pts of TnI (+) group and all 24 pts of cTnI (-) group.
We noticed 7 MACE in cTnI (+) group, including 4 cardiac death cases, versus
no MACE in cTnI(-) group, but this difference did not reach statistical signiﬁcance
(p=0.09). Results of LVEF and WMSI analyzis in both groups are shown in table 1.
Table 1
cTnI (+) 62 pts
cTnI (-) 24 pts
EF & WMSI -no change
rise in EF & fall in WMSI
fall in EF & rise in WMSI
31 pts (50%)
9 pts (80%)
9 pts (14,5%)
5 pts (20%)
22 pts (35,5%)
0 pts
Conclusions: a small rise in serum cTnI concentration is a common ﬁnding after
uncomplicated, elective PCI procedures; in our study it does not signiﬁcantly correlate with adverse outcome, but it may have some negative impact on global and
regional left ventricular systolic function. Stenting procedures seem to be associated
with higher degree of minor myocardial injury
Eur J Echocardiography Abstracts Supplement, December 2003
Objective: To quantify regional myocardial function and contractile reserve in Qwave and non-Q-wave dysfunctional regions in patients with previous myocardial
infarction and depressed left ventricular (LV) function.
Methods: A total of 81 patients underwent electrocardiography at rest and pulsedwave tissue Doppler imaging at rest and during low-dose dobutamine infusion.
LV was divided into 4 major regions (anterior, inferoposterior, septal, and lateral).
Severely hypokinetic, akinetic, and dyskinetic regions on 2D echocardiography at
rest were considered dysfunctional. Regional myocardial systolic velocity (VS) at
rest and the change in VS during low dose dobutamine infusion (DVS) in dysfunctional regions with and without Q waves on surface electrocardiogram were measured.
Results: A total of 220 (69%) regions were dysfunctional; 60 of these regions
corresponded to Q-waves and 160 were not related to Q-waves. VS and DVS
were lower in dysfunctional than in non-dysfunctional regions [VS 6.2±1.9 cm/s vs.
7.1±1.7 cm/s (p<0.001); DVS 1.9±1.9 cm/s vs. 2.6±2.5 cm/s (p=0.009), respectively]. There were no signiﬁcant differences in VS and DVS among dysfunctional
regions with and without Q waves
(Q-wave regions: VS 6.2±1.8 cm/s,
DVS 1.6±2.2 cm/s; non-Q-wave regions: VS 6.3±1.9 cm/s, DVS 2.0±
2.0 cm/s) (see Figure).
Conclusions: Q waves on the electrocardiogram do not indicate more
severe dysfunction, and contractile
reserve is comparable in Q-wave
and non-Q wave dysfunctional myocardium. Hence, in patients with
LV dysfunction due to chronic coronary artery disease, non-invasive
testing for the assessment of viability should be performed irrespective of the presence of Q waves.
Abstracts
S35
337
Regional deformation imaging identiﬁes delayed recovery of myocardial
function after ischaemia induced by dynamic exercise.
339
Prediction of late left ventricular dysfunction after surgical correction of
mitral regurgitation.
R I. Williams 1 , N. Payne 2 , J. D’Hooge 3 , T. Phillips 1 , A G. Fraser 1 . 1 University
Hospital of Wales, Wales Heart Research Institute, Cardiff, United Kingdom;
2
Providence Health System, Portland, Oregon, United States of America;
3
University Hospital Gasthuisberg, Department of Cardiology, Leuven, Belgium
M. Pal, M. Lengyel, A. Temesvári. Gottsegen G.Hung.Inst.of Cardiology, Budapest,
Hungary
Background: There are currently no established echocardiographic tests that can
reliably detect regional myocardial stunning, but these would be useful clinically
to establish if patients who present with recurrent chest pain have had myocardial
ischaemia. We therefore studied patients after cumulative ischaemia induced by
repeated dynamic stress, using tissue Doppler echocardiography (TDE) to investigate if myocardial stunning can be detected non-invasively as delayed recovery of
regional systolic or diastolic contractile function.
Methods: Patients with severe coronary disease and stable angina (>75% area
stenosis in >2 major epicardial vessels, >2mm ST-segment depression on prior
exercise testing) but no history of MI, underwent 2 symptom-limited treadmill exercise tests either 30 min apart (Group A; n=12; 10 men, age 57±12 yrs) or 1 hour
apart (Group B: n=14; 13 men, age 57±9 yrs). Transthoracic echocardiograms at
baseline, immediately after exercise, and at 15 minute intervals after each test, were
analysed for myocardial velocities, strain-rate (SR) and strain (S).
Results: On average, patients exercised for longer during the second exercise test
(p<0.02; no difference between Gps) but all tests provoked ischaemia (ST depression -1.7±1.0mm in Gp A, compared with -2.6±1.1mm in Gp B, p<0.05; similar
subnormal (i.e. ischaemic) peak velocity responses in both Gps). After the second
exercise test, systolic and diastolic myocardial velocities in segments supplied by
stenotic arteries did not differ between Gps; they had returned to baseline values
by 15 mins after exercise and remained normal thereafter. However, peak systolic
SR was still reduced in Gp A after 30 and 60 mins (increments -0.16±0.18/s and 0.01±0.11/s) whereas it increased in Gp B (0.33±0.18/s and 0.21±0.14/s; p<0.05).
Peak systolic S was also reduced in Gp A compared with Gp B (increments -2.6±2.5
v 4.2±2.2% at 15 mins, and -4.1±2.1 v 0.8±1.7% at 60 mins; both p<0.05). Diastolic S during atrial ﬁlling was higher in Gp A than in Gp B (increments 1.06 ±1.4 v
-3.3±1.4% at 15 mins, and 3.26±1.2 v -1.7±1.4% at 60 mins; both p<0.05). These
changes in SR imaging persisted for 60 mins after the second exercise test.
Conclusions: Myocardial systolic strain rate and strain, but not velocities, demonstrate persistent depressed regional function after cumulative myocardial ischaemia
induced by maximal exercise tests 30 mins apart. These changes may be caused
by myocardial stunning, and so abnormal contractile function may be useful as a
marker of prior ischaemia in patients who present with chest pain.
338
Left ventricular remodelling after single acute myocardial infarction in
long term follow-up estimated by new echocardiographic method.
B. Sobkowicz, K. Wrabec. Wojewodzki Szpital Specjalistyczny, Oddzial Kardiologii,
Wroclaw, Poland
Little is known about natural history of left ventricle (LV) after single Q wave acute
myocardial infarction (AMI) in long term observation (FU).
Aim: to evaluate new echocardiographic (ECHO) method of infarct size estimation
for assessment of LV remodelling in patients (pt-s) with single Q wave AMI, to evaluate differences in LV remodelling dependent on AMI localisation.
Material: 51 pt-s of consecutive 155 with ﬁrst Q wave AMI who completed 10 years
FU and who had neither successive AMI nor coronary intervention. 20 of them underwent anterior AMI and 31 inferior. Method: baseline ECHO was done in-hospital,
FU after 1 year and 10 years. Estimation of AMI size: anterior AMI area surface was
obtained in 4 chamber apical view (A1) as a region of impaired LV contractility. Relation between infarct size and LV was expressed as a ratio: A1/LVAD_ap4. Inferior
AMI area surface was traced in parasternal short-axis view (I1). Relation between
infarct size and LV was expressed as a ratio: I1/LVAD_sax. Results: There were no
differences between parameters of a global LV function between in-hospital examination and after 1 year. However signiﬁcant differences were found after 10 years.
LV increased with deterioration of a global function.: EDV 89,2±34 vs. 112,6±89
ml, (p=.02), ESV 42,2±23 vs. 53,2±38 ml, (p=.04) and WMS (1,6±.3 vs. 1,67±.4
p=.003). Localisation dependent differences were found in AMI size after 10 years.
In anterior AMI A1 signiﬁcantly diminished from 8,95±7 to 8±6 cm2 (p=.01) and
A1/LVAD_ap4 ratio from 0.24±0,1 to 0,21±0,1(NS), while in inferior AMI I1 increased from 6,1±3 vs. 8,9±5 cm2 , (p=.01) and ratio I1/LVAD_sax also increased
from 0,29±0,1 to 0,35±0,1 (NS). At baseline ECHO higher degree of LV remodelling was found in pt-s with anterior AMI than in inferior AMI: ESV 50 vs. 37 ml,
(p=.05), WMS 1,48±.2 vs 1,78±.4 (p<.001) and greater infarct size (A1 9,0 vs. I1
6,1 cm2 p=.05). Almost all differences disappeared during FU. After 10 years both
groups were equal in respect of LV function and infarct size.
Conclusions: New ECHO method of the LV assessment in patients with AMI is
useful in the evaluation of LV remodelling. Slow LV remodelling develops even in
unique and uncomplicated AMI. In this particular group of pt-s in long term FU in
anterior AMI remodelling was related mainly to the remote LV with signs of reverse
remodelling of the infarct scare. In contrary, in inferior AMI LV remodelling concerned
mostly the infracted area.
Left ventricular dysfunction (LVD) is the most important predictive factor of long-term
morbidity and mortality after surgary for mitral regurgitation (MR).
The aim of our study was the analysis of factors predisposing to LVD in the late postoperative period. The data of 207 consecutive patients (99 men, 108 women, mean
age 57,4 years) were analized, who underwent surgery for MR and had M-mode
echoes before surgery (I.), and after the 6th postop.month (II.) (mean follow-up 34 ±
26 months). The evaluation of left ventricular function (LVF) was based on the endsystolic diameter (Ds) and ejection fraction (EF), the EF was calculated from the
end-diastolic (Dd) and Ds diameters on M-mode echo. The patients were divided
into subgroups: a) etiology: 114 prolapse or chordal rupture (PR), 61 rheumatic
(R), 32 ischaemic (C), b) preop.echo data: Ds<45 mm+ EF>/=60%: 95 cases,
Ds<45 mm+ EF<60%: 62 cases, Ds>/=45 mm+ EF<60%: 48 cases, Ds>/=45
mm+ EF>/=60%: 2 cases, c) type of surgery: 62 valvuloplasty (V), 81 valve implantation with preservation of the posterior leaﬂet (P), 64 valve implantation with total
resection (T). Analysis was made by paired and unpaired t test and with correlation
analysis. The Dd, Ds and EF decreased in the whole group (W) at the II. measurement (Table). There was correlation between preop. EF, Ds and postop.EF (EF I.
vs. EF II. r: 0,64, p<0,001; Ds I. vs. EF II. r: -0,62, p<0,001). The EF in groups
PR and R was higher than in group C before and after surgery (Table). In case
of preop. Ds<45mm+ EF>/=60% the EF II. was 58,92%; in case of Ds<45 mm+
EF<60% the EF II. was 51,06%, while in case of preop.Ds>/=45 mm+ EF<60%
the EF II. was 39,73%, the difference between these three groups was signiﬁcant,
p<0,00001. There was no difference in EF I. and EF II. between groups V, P and T.
I.
II.
I. vs.II.
Dd W
Ds W
EF W
EF PR
EF R
EF C
PR vs. C
R vs. C
P vs. R
59,57
53,64
****
38,91
37,33
**
56,99
51,97
****
58,96
54,49
****
54,9
52,29
ns
51,25
42,37
****
****
****
*
***
**
ns
*p<0,05 **p<0,01 ***p<0,001 ****p<0,0001
Conclusions: Ischemic etiology or preoperative Ds>/=45 mm + EF<60% are predictive for late postoperative LVD. The type of surgery had no effect on changes in
LVF. Preoperative Ds and EF together are predictive for late postoperative LVF.
340
Can tissue Doppler detect early diastolic left ventricular dysfunction in
patients with coronary artery disease?
W. Li 1 , Q.M. Chen 2 , C. O’Sullivian 2 , D.G. Gibson 2 , M. Henein 2 . 1 Royal Brompton
Hospital, London, United Kingdom; 2 Royal Brompton Hospital, Echocardiography,
London, United Kingdom
Background: Peak early diastolic velocity (E wave) measured by tissue Doppler
imaging (TDI) has been used to detect diastolic ventricular dysfunction particularly
in patients with coronary artery disease (CAD). We aimed to assess this proposition.
Methods: We studied 51 patients with CAD and compared them with 33 age and
gender matched controls. Ventricular long axis function was studied from left and
septal annular motion recorded with M-mode and TDI techniques. Systolic long
axis incoordination was measured by post ejection shortening velocity and time.
Reduced systolic amplitude was taken as <95% lower normal limit.
Results: In normals but not CAD, E wave velocities correlated with age (r=-0.54,
p=0.002). In CAD the main determinant of E velocity was systolic amplitude (r=0.71,
P<0.001). E wave velocity and systolic amplitude were both normal in 31 patients,
while in 12 systolic amplitude and velocity were both reduced. Of the 8 patients with
reduced E velocity but normal systolic amplitude, i.e. those in whom primary diastolic dysfunction might have been present, 7 had systolic incoordination compared
with 9 of the 31 in whom amplitude and E velocity were both normal (Fisher’s exact,
p=0.003).
Conclusion: In coronary artery disease, TDI E wave velocity depends almost exclusively on systolic events; reduced amplitude and systolic incoordination. Thus, in
clinical practice changes in E wave velocity should be considered in the context of
the cardiac cycle events as a whole.
Eur J Echocardiography Abstracts Supplement, December 2003
S36
Abstracts
341
Quantiﬁcation of regional myocardial function by tissue Doppler in
patients with ﬁrst ST- elevation myocardial infarction early and late after
reperfusion.
M. Gaballa 1 , G. Rasmanis 1 , S. Ahnve 1 , J. Linden 2 , L. Kareld 3 , L-A. Brodin 4 .
1
Huddinge University Hospital, Cardiology Dept., Stockholm, Sweden; 2 Huddinge
University Hospitals., Thoracic Surgery and Anaesthesia, Stockholm., Sweden;
3
Cardiology and internal medicine, Uddevalla Hospital, Sweden; 4 Huddinge
University Hospital, Clinical Physiology, Stockholm, Sweden
Objectives: To evaluate the myocardial velocity, Strain rate and Tissue Tracking in
reperfusion after acute non Q-wave myocardial infarction (AMI) by using Doppler
tissue imaging (DTI). Reperfusion was assessed either by restoration of TIMI 3 ﬂow
by percutaneous coronary intervention (PCI) or clinically by complete relief of chest
pain and full resolution of ST segment elevation within 90 minutes after trombolysis.
Patients and Methods: 25 patients (59±7 years) with ﬁrst AMI presented within 6
hours from initial symptoms. 15 patients recieved trombolysis and 10 PCI. 25 agematched healthy individuals served as a control. Wall motion score was analysed
in 16 segments. DTI was acquired before, 90 minutes and 3 months after the intervention. The longitudinal and radial myocardial systolic and diastolic velocities as
well as strain rate were acquired in all segments. Peak systolic wave during ejection
phase (S), peak early and late diastolic wave (E) and (A) respectively.Troponin I and
CK-MB were serially measured. Stress imaging using Technetium 99m -Sestamibi
was done at 3 month to assess the extent of infarct and perfusion.
Results: The longitudinal and radial systolic velocities were consistently lower in
the infarct segments (3,4±1.9 and 1.45± 1.2 cm/sec) compared to control group
(5,6±1,8 and 3.8± 1.3 cm/sec respectively) p< 0.001 and to non-infarct segments
(5,2± 1,8 and 3.1± 1.4 cm/sec.) p<0,01. The radial (S) increased after intervention to 2.7± 1.5 cm/s. P<0,01. There was no signiﬁcant changes in longitudinal
(S) before and after intervention. A relaxation dysfunction with reversed E/A ratio
was observed in infarct segments before 0.56± 0.15 compared to after intervention 0.93± 0.44, p< 0.003. There was a negative correlation between (S) and wall
motion score(r =0,58, p<0.05) There was a concordance between (S) and isotope
study at 3 months.
Conclusion: Longitudinal cardiac muscle-ﬁber shortening is scavengered in patients after non Q-wave AMI even after reperfusion, only the radial muscle ﬁber
function can be restored. The longitudinal muscle ﬁber is mostly found in the subendocardial layer and thus ﬁrstly attacked by ischemia compared to the radial ﬁbers
which are mostly arranged in middle and outer layer near the epicardium. TDI seems
to be a sensitive method in detection and quantiﬁcation of AMI with a good concordance with wall motion index.
342
The value of Tei-index for the echocardiographic diagnosis of heart
failure.
C. Olalla, M.A. Rodríguez, I. Iglesias-Garriz, F. Ereño, C. Garrote, R. Serrano,
F. Corral. Hospital de León, Cardiology, León, Spain
Introduction: Tei-index is a new echocardiographic parameter to assess global myocardial performance. It is calculated as the quotient:(isovolumic relaxation time +
isovolumic contraction time)/ejection time.
The aim of this study was to evaluate the diagnosis role of tei-index in patients with
heart failure either with depressed or preserved systolic function.
Methods: Forty-nine consecutive patients (mean age 64±18 years) submitted
for echocardiographic study due to signs or symptoms of heart failure were included. They were classiﬁed into three groups: 18 controls without evidence of
heart disease(group A), 15 with heart failure and ejection fraction >45%(group
B) and 16 with heart failure and ejection fraction <45% (group C). Tei-index and
echocardiographic-derived parameters indicative of left ventricular end-diastolic
pressure (Doppler parameters of left ventricular ﬁlling, tissue Doppler parameters
of the left lateral mitral annulus and pulsed Doppler of the pulmonary veins) were
calculated.
Results: Tei-index was transformed to its logarithmic value (Ln-T) because it did
not follow a normal distribution. By ANOVA test and Scheffè post-test comparison between groups, we found a signiﬁcant difference between groups (F=18.7;
P<0.001). Group B had lower Ln-T value than group C:-0.63±0,36 vs -0.36;P=0.04.
The difference was also statistically signiﬁcant between groups A and B: 1.03±O.35 vs -0.63±0.36;P=0.008 and between groups A and C:-1.03±0.35 vs
-0.29±0.36;P<0.0001. There was a signiﬁcant linear trend between groups. We
found a signiﬁcant linear regression relationship between Ln-T and ejection fraction
(r=0.67; P<0.001), but we did not ﬁnd any relationship between Ln-T and Doppler
indexes of left ventricular end-diastolic pressure.
Conclusion: Tei-index is a useful parameter to evaluate patients with signs and
symptoms of heart failure. This index is higher in patiens with clinical heart failure, even if sistolic function is preserved. The index increases as ejection fraction
decreases.
Eur J Echocardiography Abstracts Supplement, December 2003
343
Effects of carvedilol on diastolic and systolic function assessed by
Doppler tissue imaging during long term follow-up: also good news.
A. Huelmos 1 , J. serrano 2 , J.M. Grande 1 , J.M. Rubio 3 , I. Fernández-Rozas 1 ,
P. Marcos 3 , C. Cristobal 1 , S. Salcedo 1 , J.I. Martínez 1 , A. Grande 1 . 1 Hospital
Severo Ochoa, Servicio de Cardiología, Leganés, Spain; 2 Hospital Severo Ochoa,
Cardiology, Leganés (Madrid), Spain; 3 Fundación Jiménez Díaz, Servicio de
Cardiología, Madrid, Spain
The beneﬁtial effects of carvedilol on clinical status and left ventricular systolic parameters are well established. However there are limited data about the effects on
diastolic performance.
Objective: To examine the effects of carvedilol on diastolic and systolic parameters in patients(Pts) with a diminished left ventricular ejection fraction (LVEF) using
conventional Doppler indexes and Doppler tissue imaging(DTI).
Methods: Twenty-three consecutive Pts(mean age 66 ± 10 years, 14 male) with
a LVEF<40%(mean 27 ± 9, range 14-40)were included in the study. Eight Pts
had ischemic heart disease and 15 Pts nonischemic cardiomyopathy. All of them
were treated with the highest tolerated carvedilol dose after a careful titration (mean
highest dose/day 32±18 mg). The echocardiographic parameters used were: LVEF
(simpliﬁed Simpsom method), mitral inﬂow velocities by pulsed Doppler and pulsed
DTI velocities at the mitral annulus(septal and lateral wall). All of them were evaluated at baseline and after 6 months of therapy.
Results: Three Pts died during follow-up and 3 Pts did not tolerate carvedilol at any
dose. One Pt was excluded because of pacemaker resynchronization therapy and
another because of the development of persistent atrial ﬁbrillation. In the remaining
15 Pts, the changes in different measurements are shown in table 1. Mean LVEF
increased signiﬁcantly after 6 months of therapy. There were a signiﬁcant increase
in the early and late diastolic pulsed-DTI velocities ratio(E’s/A’s) at the septal mitral
annulus.
Table 1
Baseline
6 Months
LVEF
E/A
E’s/A’s
E’l/A’l
28.8 ± 8.2
35.1 ± 9.7*
0.66 ± 0.34
0.74 ± 0.32
0.63 ± 0.27
0.78 ± 0.23*
0.66 ± 0.4
0.78 ± 0.26
Data presented as mean ±SEE; E an A: early and late diastolic mitral inﬂow velocities; E’s and
A’s: early and late diastolic pulsed-DTI velocities at septal mitral annulus; E’l and A’l: early and
late diastolic pulsed-DTI velocities at lateral mitral annulus; *p<0.05 vs baseline by- t-test.
Conclusions: After 6 months of treatment wit carvedilol the effects on systolic performance results in a signiﬁcant improvement in the LVEF. The diastolic function is
also improved and Doppler tissue imaging is very useful in the evaluation of the Pts.
344
Longitudinal myocardial shortening does not explain the improvement of
the systolic performance in heart failure after carvedilol therapy.
J.M. serrano 1 , A. Huelmos 2 , I. Fernández-Rozas 2 , P. Marcos-Alberca 3 ,
C. Cristobal 2 , J.M. Grande 2 , S. Salcedo 2 , J.I. Martínez 2 , E. Hernando 2 ,
A. Grande 2 . 1 Hospital Severo Ochoa, Cardiac Unit, Leganés(Madrid), Spain;
2
Hospital Severo Ochoa, Cardiac Unit, Leganés (Madrid), Spain; 3 Fundación
Jiménez Díaz, Cardiac Unit, Madrid, Spain
Introduction: It is well known that beta-blocker therapy with carvedilol improves
systolic function in patients (P) with heart failure (HF) and poor left ventricular ejection fraction (LVEF). Moreover, Doppler tissue imaging (DTI) is an established technique to study the mechanics of the systole and diastole in left ventricle. The role
of longitudinal shortening in the increase of LVEF after beta-blocker therapy has not
been established.
Objective: To assess the role of longitudinal shortening in the increase of LVEF
after beta-blocker therapy.
Methods: Patients with heart failure (NYHA functional class 2.05±0.51),
LVEF<40% and without contraindications for beta-blocker therapy were included
in the study. Carvedilol was initiated without roll-up period and titrated as recommended. A complete echocardiographic examination was performed at baseline
and after 6 months. Variation in LVEF was quantiﬁed using Simpson’s rules modiﬁed method for 2D-echocardiography and longitudinal myocardial shortening with
pulsed Doppler tissue imaging (DTI) at septal and lateral mitral annulus.
Results: Twenty-three P were included in the study. Eight P were loss during followup: three P died, three developed HF due to carvedilol, one developed refractory
atrial ﬁbrillation and was excluded due to cardiac resynchronization therapy. 2Dechocardiographyc examination and pulsed DTI exam was available in the remaining 15 P (age 64±11 yo and 9 male). Mean dose of carvedilol was 33.7±18.7mg.
LVEF improved from 28.8±8.2% to 35.1±9.7%(p<0.05). Nonetheless, peak systolic velocity measured with DTI was unchanged: septal mitral annulus 8.4±4.1cm/s
vs 7.3±1.8 cm/s (p=NS) and lateral mitral annulus 7.8±3.1cm/s vs 6.9±2.4cm/s
(p=NS).
In conclusion, changes in longitudinal myocardial shortening does not account for
the improvement of the LVEF with carvedilol therapy in heart failure due to systolic
dysfunction. These results point out a predominant role of radial and circumferential myocardial shortening in the mechanics of left ventricular performance with
carvedilol therapy.
Abstracts
345
Anthracyclines cardiotoxicity monitoring by conventional echo-Doppler
and tissue Doppler imaging: its relationship with pro-BRAIN natriuretic
peptide.
G.M. Benvenuto 1 , P. Morandi 2 , L. Merlini 2 , A. Fortunato 3 , R. Ometto 1 ,
A. Fontanelli 1 . 1 S. Bortolo Hospital Cardiology Dept., VICENZA, Italy;
2
Onco-Hematologic Dept., Vicenza, Italy; 3 Clinical Chemistry Laboratory, Vicenza,
Italy
Introduction: Guidelines for anthracyclines cardiotoxicity (ACT) monitoring required LV ejection fraction (EF%) as unique gold standard parameter for decision
making; but its prediction power for late developing of cardiomiopathy (CM) remains
not strictly and timely accurate.
Methods: We started prospective study for evaluating potential incremental value
of newer markers of ACT: diastolic Doppler indexes, both by conventional technique
and myocardial tissue imaging (TDI), and propeptide brain natriuretic peptide (proBNP, Roche Elecsys 2010). Both at baseline and at end-therapy (ET) we measured:
LVEF%, E/A ratio and DT, Ev and Ev/Av ratio, and pro-BNP.
Results: To today, we collected complete data from 36 breast cancer young patients
(mean 50yrs, range 29-60). At ET time, none pt presented signs of CM, while after
mean 18 months follow-up 4 pts developed overt CM: 2pts NYHA Class II and 2pts
NYHA III (mean LVEF: 38% ±5).Table 1 (part A) shows data both at baseline and
at ET for all 36 pts and (part B) data from the 4-CM pts. At ET time, we observed
mean normal values of LVEF, also in 4 pts developing late CM; otherwise, Doppler
indexes and proBNP mean values were already abnormal in the same time.
Table 1
A) All pts
ET: mean
p-value*
ESV ml/m2
EF%
DT ms
E/A ratio
TDI:
Ea cm/s
Ea/Aa
Base: mean ET: mean p-value* B) 4-CM pts Base: mean
43 ± 10
61 ± 5
190 ± 19
1.3 ± 0.2
46 ±12
53 ± 9
238 ± 32
1.1 ± 0.4
n.s.
0.06
0.07
0.04
45 ± 3
59 ± 3
198 ± 20
1.2 ± 0.3
51 ± 6
50 ± 5
275 ± 35
1.1 ± 0.2
n.s.
0.04
0.06
0.02
16 ± 3
1.4 ± 0.2
11 ± 4
0.7 ± 0.3
0.01
<0.001
15 ± 3
1.4 ± 0.2
9± 2
0.8 ± 0.3
0.01
<0.001
Pro-BNP
77 ± 122
167 ± 235
0.06
105 ± 36
1520 ± 455 <0.001
*paired t-test for Baseline vs ET data. See text for abbreviations.
Conclusions: Our preliminar data suggest LVEF appears late and less sensitive
of ACT. Diastolic Doppler indexes could be more timely and accurately candidate
markers for ACT, specially when considering TDI. Finally, proBNP samplings may
offer an incremental and safer guide for early detection of ACT.
346
Patients admitted with heart failure that have no echocardiography
present a different clinical proﬁle and higher long-term mortality.
M. Martínez-Sellés 1 , J.A. García Robles 1 , L. Prieto 2 , M. Domínguez-Muñoa 1 ,
E. Frades 1 . 1 Madrid, Spain; 2 Universidad Complutense, Biostatistics Dept.,
Madrid, Spain
Introduction: Although echocardiography (echo) is a fundamental tool for the diagnosis and management of pts hospitalized with heart failure (HF), it is not performed
in all and the reasons that determine in which patients is done are not clear.
Methods: A total of 1953 HF diagnosis were done among pts consecutively admitted to our institution during 1996. Their hospital records were retrospectively
checked. After excluding pts with no objective HF data, we studied 1358 admissions
in 1069 patients and: 1) compared patients with and without echo, 2) determined independent predictors of long-term survival.
Results Echo was performed in 706 pts (66%) during hospital admission or during
the six months before. Pts with no echo were older (79.4 vs 72.4 y), more frequently
women (64 vs 55%) and had a higher prevalence of dementia (9 vs 4%), CPD (37
vs 27%) and admission outside the cardiology department (96 vs 71%). However
they presented a lower prevalence of risk factors (smoking -6 vs 22%-, hyperlipemia
-5 vs 15%-), ischaemic heart disease (myocardial infarction -6 vs 19%-, coronary
artery disease -2 vs 11%-, CABG -1 vs 7%-), LBBB (6 vs 12%), cardiomegaly (80
vs 87%), and shorter hospitalizations (12.5 vs 17.1 días). All the differences with
p < 0,01 in univariate analysis. Independent predictors of echo performance are
shown in the table.
Independent predictors of echo
Variable
OR
95% CI
p
Age
Hospitalization days
Cardiology
CPD
Smoking
Hyperlipemia
Previous MI
LBBB
Cardiomegaly
0.95
1.04
5.4
0.68
2.9
1.9
2.3
2.2
2.1
0.94 - 0.97
1.02 - 1.06
2.9 - 10.0
0.5 - 0.93
1.7 - 4.9
1.04 - 3.4
1.4 - 3.8
1.3 - 3.8
1.4 - 3.1
< 0.0001
< 0.0001
< 0.0001
0.015
0.0001
0.036
0.0017
0.0006
< 0.0001
S37
347
Evaluation of myocardial performance after administration of a novel
calcium sensitizing agent.
D.N. Chrissos 1 , E.N. Tapanlis 1 , A.A. Katsaros 1 , A.A. Pantazis 1 , N.C. Corovesi 2 ,
A.E. Androulakis 1 , I.E. Kallikazaros 1 . 1 Hippokration Hospital, State Cardiac
Department, Athens, Greece; 2 Greek Red Cross Hospital, Department of
Laboratory Medicine, Athens, Greece
Introduction: Positive inotropy by calcium sensitization is an evolving approach for
the treatment of congestive heart failure (CHF). Levosimendan, a novel calcium sensitizing agent, improves myocardial contractility without increasing myocardial oxygen demand and is indicated as supplementary therapy of CHF when conventional
drugs - diuretics, ACE inhibitors, b-blockers or digitalis - are insufﬁcient. The rate
of left ventricular (LV) pressure rise (dP/dt), measured by continuous wave Doppler
echocardiography, is a new marker of LV contractility. The purpose of this study is
to estimate the effect of levosimendan on myocardial performance on patients (P)
with CHF.
Methods: 31 consecutive P (25 males and 6 females of mean age 69.39±7.46
years) with CHF - NYHA functional class III or IV and LV ejection fraction (LVEF) less
than 30% - and moderate to severe mitral regurgitation were eligible for the study
for a six-month period (from April to October 2002). 17 P were treated with conventional drugs, whereas 14 P received levosimendan in addition. The two groups
did not differ regarding sex and age. LV function was evaluated by LVEF and by
LV dP/dt on admission and 24-48 hours after the administration of levosimendan.
LVEF was measured by 2-D echocardiography using the Teicholz method. LV dp/dt
is derived from the continuous wave Doppler mitral regurgitation signal by dividing
the magnitude of LV-left atrial pressure gradient rise (dP) between 1 and 3 m/sec
of the mitral regurgitation velocity signal by the time taken for this change (dt). Data
were expressed as "mean value ± standard deviation", statistical analysis was performed using the student’s t-test method and p<0.05 was considered statistically
signiﬁcant.
Results: LVEF and LV dP/dt in P who received levosimendan were increased from
18.50±6.86% to 23.60±5.96% (p<0.05) and from 532.50±178.70 mmHg/sec to
669.64±166.75 mmHg/sec (p<0.05) respectively, while the indices of P treated
with conventional therapy did not change signiﬁcantly - from 21.76±3.77% to
24.26±4.27% (p=NS) and from 605.12±155.99 mmHg/sec to 698.24±169.8599
mmHg/sec (p=NS) respectively. Functional status of P who received levosimendan
was improved (NYHA class from 3.75±0.51 to 3.05±0.68, p<0.01) compared to
that of P with conventional therapy (NYHA class from 3.23±0.44 to 2.88±0.60, p=
NS).
Conclusions: Levosimendan may prove advantageous for patients who suffer from
congestive heart failure, because it seems to enhance myocardial contractility and
improve functional status.
348
Reduction of myocardial blood ﬂow reserve is associated with impairment
in contractility in patients with idiopathic dilated cardiomyopathy.
M.A. Morales 1 , D. Neglia 1 , U. Startari 1 , B. Dal Pino 1 , S. Carabba 1 , A. L’Abbate 2 .
1
CNR, Clinical Physiology Institute, PISA, Italy; 2 Scuola Superiore Studi S Anna,
Pisa, Italy
In idiopathic dilated cardiomyopathy (IDC, also in the early stage, myocardial blood
ﬂow (MBF) during pharmacological vasodilation is depressed. This abnormality,
which is independent of LV ejection fraction (EF), predicts the progression of LV
dysfunction.
Aim of this study was to evaluate the relationship of MBF with Doppler derived
rate of pressure rise (RPR) from mitral regurgitation curve which is known as a
non invasive measure of peak LV dP/dt.Twenty patients (pts) with IDC (15 males,
mean age 64 years, LV EF < 50%, LV EDD > 56 mm, NYHA Class I-II), all in
sinus rhythm, underwent a complete cardiac 2D echo-Doppler exam and a resting/dipyridamole (0.54 mg/Kg in 4’) 13N-NH3 ﬂow Positron Emission Tomography
study in a two days protocol. Rate of pressure rise (RPR) was computed from continuous wave Doppler spectra of mitral regurgitation (MR) on 5 consecutive beats.
Regional MBF values (ml*min-1*g-1) were computed in 6 LV myocardial regions
in the best transaxial slice and averaged to give mean LV MBF. MBF reserve was
deﬁned as dipyridamole/resting mean MBF ratio. Two pts were discarded due to inadequate MR signals. Resting MBF was .67±.22, dipyridamole MBF was 1.49 ± .47
and MBF reserve was 2.41 ± 1.12, all values signiﬁcantly lower than in the control
population (p<0.01). In IDC pts no relation could be reported between resting MBF,
dipyridamole MBF, MBF reserve and both LV EF and LV EDD. Conversely, LV RPR
was directly related with dipyridamole MBF and MBF reserve (r=0.517 and 0.674,
p<0.05 and < 0.002, respectively).Thus, in pts with early stage IDC the severity of
contractile dysfunction, as assessed by RPR, is associated with the extent of MBF
reserve. These data suggest that ﬂow abnormalities may play a pathogenetic role
of in primitive LV dysfunction.
Long-term follow-up (mean 22 months) showed that patients with no echo presented
a higher mortality (multivariate analysis OR 1.4 95%CI 1.2 – 1.7 p =0.0005)
Conclusion: Patients admitted with heart failure and no echo have different clinical
proﬁle and higher long-term mortality.
Eur J Echocardiography Abstracts Supplement, December 2003
S38
Abstracts
349
Non invasive monitoring of levosimendan infusion in patients with
decompensated heart failure.
D. Tsiapras, S. Adamopoulos, E. Iliodromitis, I. Paraskevaidis, I. Rasias,
S. Kirzopoulos, D. Kremastinos. Onassis Cardiac Surgery Centre, Cardiology,
Athens, Greece
Levosimendan has been proposed as an alternative to inotropic drugs treatment in
patients with decompensated heart failure. Data from haemodymamic monitoring
support the favorable effects of the drug. However there are no data regarding non
invasive monitoring. We tested the hypothesis that non invasive monitoring of these
patients treated with levosimendan can be equally successful.
Methods: Fifteen patients(3 dilated and 12 ishemic cardiomyopathy), with decompensated heart failure, treated with levosimendan, were studied. All of them had
a Swan-Ganz catheter for hemodynamic monitoring and blood pressure was measured with sphygmomanometer. Levosimendan was given intravenously as a bolus
(3 µg/kg) and infusion for 24 hours (0,1 µg/kg/min). At baseline and at the end of
infusion a thorough Echocardiographic study was performed. Left ventricular (LV)
dimensions and volumes were measured and ejection fraction was calculated. Mitral inﬂow E & A waves and E wave deceleration time, mitral regurgitation jet area,
and aortic ﬂow velocity and velocity-time integral were also measured and cardiac
output (from LV outﬂow) was calculated. In 10 pts blood samples were collected at
baseline, at 24 and 72 hours for pro b-NP measurement.
Results: There were no complications from levosimendan infusion. Mean blood
pressure decreased (81±11 to 74±8 mmHg, p:0.002) without change in heart rate.
Pulmonary wedge pressure decreased (27±8 to 23±7 mmHg, p<0.01), and cardiac index (CI) increased (2,02±0,52 to 2,26±0,42 l/min/kg, p:0.04) while right
atrial pressure had a decrease of marginal signiﬁcance(13±6 to 11±5 mmHg,
p:0.06). From Echocardiographic study: LV systolic diameter decreased (62±8 to
58±8 mm, p:0.002), LV ejection fraction increased (19±5 to 22±6%, p<0.001), CI
increased (1,7±0,3 to 2,0±0,4 l/min/kg, p:0.005)and inferior vena cava diameter
decreased(24±4 to 22±5 mm, p:0,03).Mitral regurgitation jet area, E wave deceleration time and mitral E/A ratio did not change signiﬁcantly. Two patients without
improvement in hemodynamic parameters were successfully detected by Echo.
Pro b-NP levels decreased signiﬁcantly following therapy (1505±299 fmol/ml to
1300±271 fmol/ml at 24 h and 1045±217 fmol/ml at 72 h, p:0.006)
Conclusion: Improvement in status of patients with decompensated heart failure,
treated with levosimendan, can be successfully assessed non invasively, making
Swan-Ganz catheter optional in patient’s monitoring.
351
Natriuretic peptides changes at stress-echocardiography predicts
myocardial contractile reserve in patients with non-ischemic dilated
cardiomyopathy.
F.I. Parthenakis 1 , A.P. Patrianakos 1 , P.G. Tzerakis 1 , G.F. Diakakis 1 ,
M.I. Chamilos 1 , D.C. Kambouraki 1 , P.E. Vardas 2 . 1 Heraklion University Hospital,
Cardiology Dept., Heraklion, Crete, Greece; 2 Heraklion University Hospital,
Cardiology, Heraklion, Greece
Background: Natriuretic peptides levels are increased, subject to the degree of
systolic and diastolic left ventricular (LV) dysfunction in patients with chronic Heart
Failure, while LV inotropic reserve has been proposed as a useful prognostic index
in these patients. We assessed the relationship between LV inotrope reserve and
natriuretic peptide changes during Dobutamine stress-echocardiography in pts with
Non-Ischemic Dilated Cardiomyopathy (NIDC)
Methods: Twenty eight patients with angiographically proven NIDC, aged
55.6±9.4y, NYHA functional class II-III and LV ejection fraction (EF) 32±9.3%, underwent to a low-dose Dobutamine stress echocardiography (LDDE)(two 5-minutes
stages with 5 and 10 µgr/kgr/min intravenous infusion of Dobutamine).
N-Terminal-pro-Atrial (ANP) and -Brain (BNP) natriuretic peptides levels were measured 15 min before and 60-min after LDDE.
LV was divided into 16 segments and the wall motion score index (WMSI) calculated
at rest(r) and at peak stress(s).
Results: The mean WMSIr was 2.13±0.24 while BNPr and ANPr plasma levels
were 0.77±0.41 and 3.8±2.32 pmol/ml respectively.
According to BNP changes (d) at LDDE, patients divided in those who decreased
BNP (groupI) and those who BNP levels remained stable or increased (groupII).
There were no differences between two groups in age, NYHA functional class, LV
dimensions, LVEF or WMSI.
Group I pts showed greater improve in dWMSI (33 ±10% vs 23±16%, p=0.03),
dLVEF (32.3±11.3% vs 20±17.7%,p=0.03) and signiﬁcant decrease of ANP levels
(15±16% vs 6±3%,p=0.02) compared to group II.
A signiﬁcant correlation was found between dBNP and dANP with dWMSI (r=0.53,
p=0.003 and r=0.48, p=0.04), and dLVEF (r=-0.53, p=0.003 and r=-0.48, p=0.04)
respectively.
Conclusion: Natriuretic peptide changes at LDDE showed a close relationship to
LV inotrope reserve in pts with NIDC. Measurement of natriuretic peptides at stress
may be a useful additional index of LV contractile reserve in those patients.
LEFT-VENTRICULAR FUNCTION
350
Dose-dependent effects of sildenaﬁl on endothelial function of forearm
vessels in heart failure patients: correlation with peak VO2 and exercise
blood ﬂow redistribution.
M. Guazzi, S. Puppa, G. Tumminello, C. Fiorentini. University of Milan, San Paolo
Hosp., Department of Cardiology, Milan, Italy
Background: Sildenaﬁl is a new challenge in the pharmacotherapy of CHF patients.
It is unknown whether an increase in NO availability as induced by PGE5 inhibition
translates into an improvement in exercise peak VO2 and whether this effect may
be: a) endothelium-mediated and b) dose-dependent.
Objectives: To investigate the effects of sildenaﬁl on endothelial function of forearm vessels and their potential role in improving exercise performance and exercise
blood ﬂow redestribution in stable CHF.
Methods: 10 stable HF patients (NYHA class II to III) treated with ACE-inhibitors
and beta-blockers were randomly assigned to receive placebo or sildenaﬁl (25
and 50 mg) according to a double-blind, crossover design. The ﬂow-dependent
endothelial-mediated brachial artery vasodilating response to distal circulatory arrest was explored by Doppler- ultrasound imaging (dual crystal Doppler system, 8
MHz transducer).
Peak VO2 and the linear relationship of VO2 changes vs work rate (delta VO2/delta
WR), an index of exercise peripheral blood ﬂow distribution, were assessed by cardiopulmonary exercise testing (cycle ergometry ramp protocol), in the baseline and
after drug randomization.
Results:
Brachial artery diameter (mm)
Brachial hyperemic ﬂow (ml/min)
peak VO2 (ml/min/kg)
delta VO2/delta WR
Placebo
Sildenaﬁl (25 mg)
Sildenaﬁl (50 mg)
3.8±0.2
420±100
16±4
0.9±0.06
3.9±0.1
470±100
17±3
1.00±0.07
4.1±0.1 *
530±90 *
19±4 *
1.10±0.06
*:p<0.05 vs Placebo
Changes in peak VO2 and delta VO2/delta WR after 50 mg sildenaﬁl were inversely
related with those in brachial ﬂow (r = 0.53, p< 0.01; r =0.73, p<0.001).
Conclusions: In CHF, sildenaﬁl induces a dose-related effect on endothelial function associated with a signiﬁcant amelioration in peak VO2 and exercise blood ﬂow
distribution (delta VO2/delta WR). Long-term use of sildenaﬁl as an adjunctive therapy in stable CHF patients seems a promising opportunity.
Eur J Echocardiography Abstracts Supplement, December 2003
353
An echocardiography-based management program for acute pericarditis.
M. Imazio, B. Demichelis, I. Parrini, E. Cecchi, G. Gaschino, D. Demarie, A. Ghisio,
R. Trinchero. Maria Vittoria Hospital, Cardiology Dept., Turin, Italy
Background: Echocardiography can be very helpful in conﬁrming acute pericarditis
clinical suspicion disclosing even small effusions and to role out complications.
Aim of this work is to investigate the safety and efﬁcacy of an echocardiographybased management program for acute pericarditis risk stratiﬁcation, treatment and
follow-up.
Methods: From January 1996 we included all consecutive cases of acute pericarditis. Patients were selected on the basis of clinical examination, the results of routine laboratory tests(blood cell count, sedimentation rate, acute phase reactans,
creatin kinase, troponin I, serum creatinine) and transthoracic echocardiography
to determinate the amount of pericardial effusion and exclude cardiac tamponade.
Patients without clinical negative predictors(fever>38°C, subacute onset, immunodepression, trauma, oral anticoagulant therapy, myopericarditis, severe pericardial
effusion, cardiac tamponade) were assumed to be idiopathic without a full etiologic
search and considered low risk cases assigned to out-of hospital treatment with
high dose oral aspirin. In case of aspirin failure or with clinical negative predictors
patients were considered high risk cases and hospitalized to perform a full diagnostic evaluation. A clinical and echocardiographic follow-up was performed at 48-72
hours, 1 month, 6 months and 1 year to detect pericardial effusion relapse and
exclude constriction.
Results: We observed 350 cases of acute pericarditis(mean age 53.4 ± 18.0
years, range 16-91 years; 226 males). 298 patients(85.1%) were considered low
risk cases(group I). Initial treatment with ASA was effective in 265 cases(88.9%). 52
patients(14.9%) were considered high-risk patients and admitted to hospital(group
II). Final diagnosis was idiopathic pericarditis in 287 cases(82.0%), a speciﬁc etiology was detected in 63 out of 350 cases(18.0%), but up to 41 out of 52 high
risk patients(80.3%) showing the importance of patients stratiﬁcation to start a full
etiologic search. After a mean follow-up of 38 months no cases of cardiac tamponade were recorded in group I. A higher frequence of relapses and constriction was
recorded in group II compared with group I(respectively 46.0% vs 10.4% for recurrencies and 11.1% vs 0.4% for constriction; for all p<0.001). ASA failure alone was
able to identify patients at higher risk of complications.
Conclusions: An echocardiography based management program for acute pericarditis risk stratiﬁcation is efﬁcacious to select low risk cases to be treated on an
outpatient basis and to detect acute pericarditis complications.
Abstracts
354
Assessing left ventricular function parameters after radiofrequency
catheter ablation.
356
The effect of thrombolysis on LV hormonal and long axis function.
S. Gorgulu, A. Eksik, M. Eren, A. Akyol, I. Erdinler, E. Oguz, K. Gurkan, T. Ulufer,
T. Tezel. Siyami ersek, Cardiology, Istanbul, Turkey
Objective: Radiofrequency (RF) catheter ablation has become standart therapy for
many types of arrhythmias. Radiofrequency energy, by damaging the myocardium,
may cause diastolic dysfunction. The aim of the present study was to assess the
changes in left ventricular diastolic ﬁlling after catheter ablation by using Doppler
echocardiography
Methods: Forty patients (22 women), aged 37±14 years (range15-76 years), underwent catheter ablation for various tachycardias. Routine echocardiogaphic examination was done in all patients. The ratio (E/A) of the diastolic early to late transmitral ﬁlling velocities, deceleration time (DT), isovolumetric relaxation time (IVRT)
were used as left ventricular diastolic function parameters. Tissue Doppler parameters such as Em and Am were also obtained from the lateral side of the mitral
annulus. All diastolic function parameters were assessed before and 1 hour, 1 day,
1 month after the catheter ablation procedure. To avoid any inﬂuence of heart rate
on diastolic function parameters the E/A ratio, DT, and IVRT were adjusted to heart
rate. The changes in left ventricular diastolic function parameters were assessed by
using multivariate repeated measurement analysis.
Results: The results were given in the table
E/A
DT
IVRT
E/Em
Em/Am
S39
Before
1 hour
1 day
1 month
p value
1.43+_0.43
210+_54
111+_22
4.70+_1.29
1.45+_0.56
1.20+_0.40
272+_64
134+_21
4.92+_1.95
1.32+_0.65
1.19+_0.40
255+_60
123+_27
5.03+_1.49
1.22+_0.47
1.30+_0.33
240+_64
117+_19
5.26+_1.68
1.29+_0.46
<0.001
<0.001
<0.001
NS
0.01
P* value: the p value of multivariate repeated measurement analysis
Conclusion: There was no alteration in the diastolic ﬁlling pressure (E/Em) after the
ablation procedure, but the left ventricular diastolic function parameters impaired in
the early period and this lasted at least for one month.
355
Functional mitral regurgitation in patients with prior myocardial infarction
- Quantitative exercise-echocardiographic study.
V. Giga 1 , M. Ostojic 2 , B. Vujisic-Tesic 2 , A. Djordjevic-Dikic 2 , B. Beleslin 2 ,
J. Stepanovic 2 , S. Stojkovic 2 , I. Nedeljkovic 2 , M. Nedeljkovic 2 . 1 Belgrade,
Yugoslavia; 2 Clinical center of Serbia, Institute for cardiovascular disease,
Belgrade, Yugoslavia
Background:
The effects of dynamic exercise on regurgitant volume in patients with functional
mitral regurgitation and ischemic heart disease are not well established yet.
Objective:
The objective of the study was to assess exercise induced changes in regurgitant
volume (RV) in patients (pts) with functional mitral regurgitation (FMR) due to prior
myocardial infarction (MI) and low ejection fraction (EF) and to assess the effects of
myocardial ischemia on RV during exercise-echocardiography (ex-ECHO).
Methods:
Twenty consecutive pts with FMR due to prior MI, low EF < 35% in sinus rhytm
underwent exercise-echocardiographic testing on treadmill using Bruce protocol.
Regurgitant volume, using proximal isovelocity surface area (PISA) method, and EF
(mean value of 2 and 4-apical chamber view values) were measured at rest and
compared with values obtained immediately (60-90 sec.) after the exercise. Rate
pressure product (RPP) was also calculated in all pts. Myocardial ischemia was deﬁned as the presence of new or worsening of preexisting wall motion abnormality
during ex-ECHO. The pts were further divided according to the presence of myocardial ischemia during ex-ECHO in two groups: with (IG+) and without (IG-) myocardial
ischemia. Pts with mitral valve prolapse and other valvular diseases were excluded
from the study.
Results:
In all pts, RV(26±7 ml at rest vs. 43±12 ml after exercise, p<0.01), EF (26 ± 5%
at rest vs. 39 ± 5% after exercise, p<0.01) as well as RPP (10165±1653 mmHg x
bpm at rest vs. 17876±4391 mmHg x bpm after exercise p<0.01) increased signiﬁcantly after exercise. Myocardial ischemia during ex-ECHO was present in 9/20 pts
(IG+) and absent in 11/20 pts (IG-). There were no signiﬁcant differences (p=NS)
in RV (26±9 mL in IG+ vs. 24±8 mL in IG-) and EF (25±5% in IG+ vs. 27±5%
in IG-) between two groups at rest. After exercise EF in IG+ and IG- was 37± 5%
and 40±4%, respectively, p=NS and RPP was 16939±5344 mmHg x bpm in IG+
vs. 19022±2722 mmHg x bpm in IG-, p=NS. However, RV after exercise was significantly higher in IG+ than in IG- 52±9 ml vs. 36±10 ml, p<0.01.
Conclusions:
RV signiﬁcantly increases in pts. with functional MR, prior MI and low EF after exercise. Patients with myocardial ischemia during exercise have more pronounced
increase in RV than pts. without myocardial ischemia apart from the similar hemodynamic changes. However, further investigations on large number of patients are
needed.
I.S. Ramzy 1 , M. Dancy 1 , M. Kemp 2 , J. Hooper 2 , D. Gibson 2 , M. Henein 2 .
1
Central Middlesex Hospital, Cardiology Dept., London, United Kingdom; 2 Royal
Brompton Hospital, Cardiology, Echo Dept., London, United Kingdom
Background: The pattern of ventricular long axis dysfunction differs according to
the localisation of the infarct. Its relationship with cardiac peptides is not clearly
understood.
Aim: To assess cardiac peptides and ventricular long axis behaviour in the subacute
phase of myocardial infarction and the impact of reperfusion therapy.
Methods: 44 patients with acute myocardial infarction (MI); 13 anterior, age 57±12
years (all males) and 31 inferior, age 58±12 years (26 males) were studied following
thrombolysis and a month afterwards. All patients were thrombolysed on admission.
Atrial (ANP) and brain (BNP) natriuretic peptides were measured at the two time
points together with an echocardiogram to assess left ventricular function.
Results: BNP level fell from 61.7±54.3, on day 7, to 34.3±34.1 pmol/L (p<0.01),
on day 30, only in anterior MI but ANP level didn’t change in all patients over the
study period irrespective of the site of infarction. While in anterior MI BNP correlated
inversely with fractional shortening (FS) (r= -0.7, p<0.01) ANP did correlate with E/A
ratio (r= 0.8, p<0.002). BNP and ANP levels correlated with LV free wall long axis
excursion (r= -0.5, p<0.01 each), septum (r= -0.6 and -0.4 respectively, p<0.01
each), posterior and anterior walls (r= -0.5 each, p<0.01 and 0.005 respectively) in
inferior MI. Only BNP correlated with septal long axis excursion (r= -0.6, p<0.01)
in anterior MI. Peak long axis shortening and lengthening velocities correlated with
BNP and ANP levels at the left (r= -0.4 and -0.6, p<0.05 and, p<0.01 respectively),
anterior and posterior walls (r= -0.6, p<0.01 each) in inferior MI.
Conclusion: Thrombolysis for anterior MI is associated with regression of BNP
level, which is related to improvement of systolic function. The close correlation between ANP and haemodynamics reﬂects changes in left atrial pressures. Finally,
peptides-long axis relationship in inferior MI suggests possible subendocardial remodelling.
357
Reference values of M-mode and Doppler echocardiography in normal
Syrian hamster.
V.M.C. Salemi 1 , A.M.B. Bilate 1 , F.J.A. Ramires 1 , M.H. Picard 2 , D.M. Gregio 1 ,
J. Kalil 1 , E. Cunha Neto 1 , C. Mady 1 . 1 University of São Paulo Medical School,
Heart Institute (InCor), São Paulo, Brazil; 2 Massachussets General Hospital,
Boston, MA, United States of America
Introduction: The hamster model has been used increasingly for it mimics many
human heart diseases and tests a variety of therapies. Echocardiography has been
used in small animals research as is an emerging noninvasive method which allows
serial measurements of cardiac diseases. However, reference echocardiographic
values of normal LV function in hamsters is still lacking.
Hypothesis: The purpose of this study was to evaluate cardiac function to provide
the echocardiographic reference range in normal Syrian hamster.
Methods: The study group consisted of 118 ten-week old female outbred Syrian
golden hamsters (Mesocricetus auratus), weighted 73 to 133g, which underwent
to high-resolution M-mode, bidimensional and pulsed-wave Doppler echocardiography. Left ventricular systolic function was assessed by fractional shortening and LV
mass was calculated with the uncorrected cube formula. Peak velocity of early (E)
and late (A) diastolic mitral ﬁlling, E/A, deceleration time of E wave, as well as isovolumic relaxation time were obtained from the mitral inﬂow recording. The myocardial
performance index (MPI) measured the total time spent in isovolumic activity and
reﬂected both systolic and diastolic function.
Results: The mean±SD of LV mass, fractional shortening, and myocardial performance index were 0.19±0.04g, 44.7±6.6% and 0.39±0.1. By linear regression,
the relation of LV mass could be predicted quite accurately from body weight as
LV mass = 0.10573 + 0.0008body weight. As well, MPI = 0.18904 + 0.00197body
weight. Both, LV mass and MPI were not inﬂuenced by heart rate. E and A waves
were distinguished in 52% of the cases of animals with heart rate smaller or equal
than 378bpm with sensibility, speciﬁcity and accuracy of 83.6%, 87.3%, and 85.6%,
respectively.
Conclusions: The present study documents the echocardiographic characteristics
of LV structure and function in normal Syrian hamsters, which could be used as a
control group for further studies.
Eur J Echocardiography Abstracts Supplement, December 2003
S40
Abstracts
358
Ventricular septal defect - not only congenital heart disease.
M. Konka 1 , P. Hoffman 2 . 1 National Insitute of Cardiology, Noninvasine
Department, Warsaw, Poland; 2 Institute of Cardiology, Noninvasive Department,
Warsaw, Poland
Ventricular septal defect (VSD) is one of the most common congenital lesion. However in some situations damage of the interventricular septum (IVS) occurs and an
acquired ventricular septal defect (aVSD) develops.
Study group consisted of: 67 pts, 36 male and 31 female, age from 22 to 84 years;
59 pts (88%) after myocardial infarction (MI), 2 pts (3%) with a knife chest trauma,
1 pt after postsurgical treatment of hypertrophic cardiomyopathy, 1pt after valvulotomy in congenital aortic stenosis, 1 pt after aortic valve replacement and 3 with
endocarditis.
Method: transthoracic echocardiogram and transesophageal examination in selected pts before or during surgical and invasive procedure were performed.
Results: TTE directly visualized the ruptured IVS in all pts with postinfarction and
stab wound VSDs (91% of aVSD). It was neccessary to perfom diagnostic TEE to
demonstrate iatrogenic and postinfectious VSDs (9%).
In group with VSD following MI (in 39 anterior – 66%, in 20 inferior – 34%) mortality
was 27% (16pts); 35 pts were operated (died 13 – 37%); in 8 pts aVSD was closured
with Amplatzer occluder, in 1pt with 2 devices.
In remaining pts with aVSD – 7 of them were sccessfully operated; 1 with HCM died.
Conclusions: 1. VSD could be an acquired lesion. 2. MI is the most common reason of aVSD. 3. Iatrogenic VSD is getting to be more frequent. 4. aVSD is associated with a signiﬁcat mortality. 5. TEE is necessary only in exceptional cases for
diagnosis and decision making or to control surgical or invasive intervention.
359
Automated measurement of pulmonary output using a new
echocardiographic method.
N. Mansencal, F. Digne, F. Martin, T. Joseph, R. Pillière, P. Lacombe, O. Dubourg.
Hôpital Ambroise Paré, Service de Cardiologie, Boulogne Cedex, France
Background: The echocardiographic calculation of pulmonary output remains difﬁcult because of the measurement of pulmonary artery diameter. A new automated
echocardiographic technique for the measurement of cardiac output measurement
(ACM) has been recently developed and validated for aortic output.
The aim of this prospective study was to assess the feasibility and the accuracy of
ACM method for the calculation of pulmonary output.
Methods: In a population of intracardiac shunt (n = 15, mean age 49 years (range
18-74), atrial septal defect (n = 8) or ventricular septal defect (n = 7)), we have
measured the pulmonary output by 2 blinded observers using catheterisation and
echocardiography. The pulmonary output was calculated using 1) Fick output principle with invasive oximetric method; 2) conventional pulsed-wave (PW) Doppler
method; 3) ACM with double integration of Doppler signals in space and in time.
Results: All measurements were available excepted one using ACM and two using PW Doppler. Mean values (±SD) of pulmonary output were 10.3 ± 4.2 l/mn
using catheterisation, 11.4 ± 8.2 l/mn using PW Doppler method and 9.4 ± 5 l/mn
using ACM. Correlations of pulmonary output between catheterisation using oximetric method and echocardiography were 0.81 (for PW Doppler) and 0.88 (for ACM).
Using ACM, Bland-Altman analysis revealed a good agreement with invasive data
(Figure).
Bland-Altman analysis
Conclusion: These data suggest that automated cardiac output measurement is a
feasible and accurate method for the calculation of pulmonary output.
Eur J Echocardiography Abstracts Supplement, December 2003
360
Sensitivity and speciﬁcity of the colour-duplex ultrasound in functional
assessment of the LIMA bypass patency.
J. Madaric 1 , A. Mistrik 1 , I. Vulev 2 , J. Pacak 1 , I. Riecansky 1 . 1 Slovak
Cardiovascular Institute, Department of Cardiology, Bratislava, Slovakia; 2 Slovak
Cardiovascular Institute, Department of Radiology, Bratislava, Slovakia
Purpose: With the extensive use of left internal mammary artery (LIMA) as a coronary bypass the non-invasive diagnostic method is gaining a prior necessity in the
long-term postoperative LIMA follow-up. The aim of this study was to evaluate the
non-invasive colour-duplex ultrasound technique in assessment of the LIMA graft
functional status compare to the angiography as a reference method.
Methods: We examined 451 patients after myocardial revascularization with the internal mammary artery bypass using the Hewllett Packard 2500, 5500 ultrasound
units. Using the 7,5 MHz linear transducer we detected the LIMA from the left supraclavicular approach at rest. We assessed the peak systolic velocity (PSV - cm/s),
peak diastolic velocity (PDV - cm/s), end-diastolic velocity (EDV - cm/s) and we calculated the peak systolic/peak diastolic velocity ratio (SDVR) and resistance index
RI (PSV-EDV/PSV). The ultrasound results of 108 patients we compared to angiography.
Results: We observed the low resistance biphasic Doppler waveform of the patent
coronary artery grafts. In dysfunctional grafts we found decrease of diastolic ﬂow
velocity, which represents altered coronary perfusion through the LIMA graft, and
an increase of RI and SDVR. Compared to angiography the ultrasound detection
rate of the LIMA grafts was 92,59%. Unsuccessfully visualisation of 8 grafts, truth
negative results in 67 cases, truth positive 20, false negative 4, false positive 8. In
one case we detected coronary subclavian steal syndrome. The sensitivity of the
colour-duplex ultrasound was 83,33%, the speciﬁcity was 89,23%. The SDVR of
functional grafts was 1,54±0,36, dysfunctional grafts 3,47±0,89. The SDVR of <
2,0 best showed the absence of LIMA bypass dysfunction.
Conclusion: The colour-duplex ultrasound is a useful non-invasive method for the
postoperative follow-up of patients with the LIMA graft. It allows the assessment
of the impaired LIMA perfusion caused by LIMA stenosis or by atherosclerosis of
the coronary artery distal from LIMA anastomosis. SDVR is the sensitive marker for
exclusion of the bypass failure.
361
Applying ultrasound stethoscope in daily cardiologists practice: more
advantages than disavantages.
V. Vysniauskas, D. Petraskiene. Marijampole Central Hospital, ICU/CCU,
Marijampole, Lithuania
Limited and/or focussed echocardiography (L/F echo) together with the echocardiography of the other organs have been performed since 1987 by cardiologists.
The aim of this study is to evaluate the advantages of the above mentioned consultation.
Methods: Approximately 20 000 pts were consulted from 1987 to 2000. L/F echo
has been performed after the interviews with pts and their physical examination (i.e.,
inspection, palpation, auscultation). Morphological data in standard cardiac views,
basic linear measurements of structures and cavities as well as Doppler blood ﬂow
imaging have been obtained. In case of cardiac derangements, standard full echo
with quantitative Doppler function has been performed. In case of clinical indications, L/F echo of liver, kidney, pancreas,spleen, thyroid, carotid arteries, abdominal
aorta has been performed as well.
Results: This methodology allowed to rapidly diagnose the following cardiac disorders: shunts 137 pts(2.9%), cavity dilation 7400pts(37%), hypertrophy 13000 pts
(65%), pericardial effusion 60 pts(0.3%), emergency tamponada 6 pts(0.03%), wall
motion abnormalities – 5 pts(0.025%). Cardiac abnormalities have been excluded
with a high degree of certainty in 30% cases. The agreements between standard
echo and goal- oriented echo was 95%(kappa value 0.871).
The ultrasound stethoscope screening allowed to rapidly identify unexpected noncardiac disorders: liver diseases in 190(0.95%) cases, aortic abdominal aneurism
in 17(0.09%) cases, kidney diseases in 95(0.48%) cases, pancreas diseases in
23(0.12%) cases, spleen enlargement in 16(0.08%) cases, thyroid diseases in
180(0.9%) cases. All pts with visualised abnormalities of these internal organs have
been sent to see the appropriate specialist.
Conclusions: 1. To fully examine the patient applying echocardiostethoscope
is highly advantageous: 60% of consulted pts needed standard echo protocol.
2.Echo/Doppler examination revealed the limitations of the physical examination
in many clinical situations, particularly in the early stages of the disease. 3.Ultrasound stethoscope helps to rapidly identify incidental non-cardiac disorders in
2.60% cases. 4. It is highly prestigious to apply echostethoscope in cardiologist’s
daily practice. 5.The only disadvantage of the mentioned method is the prolonged
duration of the consultation.
Abstracts
362
The feasibility and efﬁcacy of short courses of echocardiography for
medical students.
P. Szymanski 1 , A. Klisiewicz 1 , P. Michalek 1 , M. Lipczyñska 1 , S. Langner 2 ,
P. Hoffman 1 . 1 National Institute of Cardiology, Noninvasive Cardiology Dept.,
Warsaw, Poland; 2 Medical Academy, Student’s research group, Warsaw, Poland
Echocardiography became an essential study in cardiology and, with introduction
of portable echostethoscopes, might became a tool used by general practitioners.
Therefore it seems appropriate to introduce echocardiography to the curricula of
medical schools. The aim of the study was to analyze the feasibility of short, intensive echocardiographic training of the medical students.
12 students underwent 6 hours course of reading of echocardiographic images,
with emphasis placed on the ability to assess ejection fraction (EF), qualitatively
estimate left ventricular systolic function (deﬁned as: normal, minimally, moderately
and severely impaired), the presence of segmental abnormalities (yes or no for each
visible segment) and valvular regurgitation. Their performance was evaluated on a
series of 12 digitized images of left ventricular performance and mitral regurgitation
(color Doppler images, 0 to +4 scale), and assessed against the standard deﬁned
by 5 experienced cardiologists.
Segmental abnormalities were assessed with moderate agreement (kappa=0.56).
Agreement between students and cardiologists was fair (kappa=0.38) when EF was
assessed, it was good with qualitative assessment (kappa=0.75, Spearman correlation 0.862; P<0.001, see Figure).
The good degree of agreement was observed in the case of mitral regurgitation
(kappa=0.780) and very good (kappa=0.83) when examined were asked to deﬁne
the regurgitant jet as signiﬁcant (+3 or +4) or nonsigniﬁcant (less than +3).
S41
364
Automated quantiﬁcation of mitral ring displacements and velocities.
S.I. Rabben 1 , A.H. Torp 2 , A. Støylen 3 , H. Ihlen 1 , K. Andersen 1 , L.A. Brodin 4 ,
C. Storaa 4 , O.A. Smiseth 1 . 1 Rikshospitalet University Hospital, Institute for
Surgical Research, Oslo, Norway; 2 GE Vingmed Ultrasound, Horten, Norway;
3
NTNU, Institute of Circulation and Imaging, Trondheim, Norway; 4 Huddinge
University Hospital, Clinical Physiology, Stockholm, Sweden
Background: Mitral ring motion by M-mode echocardiography and velocities by
tissue Doppler provide potentially useful measures of LV long axis function. Usually,
the maximal mitral ring motion (MRM) is used to assess systolic function, while
the velocities during early ﬁlling (Ea) and atrial contraction (Aa) are used to assess
diastolic function.
Aim: To determine if measurements of mitral ring displacements and velocities can
be automated.
Method: In 22 patients (age 52-81) we recorded apical four-chamber (4-Ch) and
two-chamber (2-Ch) colour tissue Doppler with a Vivid7 scanner. An algorithm was
developed that automatically identiﬁed the mitral ring, and thereby MRM, Ea and
Aa, by combined use of tissue and colour tissue Doppler data. As reference values
we used respective measurements derived from manually selected points by four
cardiologists.
Results: The automatic detector of the mitral ring only failed in one (4.5%) of the
4-Ch cineloops and two (9%) of the 2-Ch cineloops (failure deﬁned as average
computer-to-observer distance > 1.5 cm). The limits of agreement (mean difference
± 2SD of the differences) for MRM, Ea and Aa were narrow: -0.6-1.3mm, -0.60.8cm/s, and -0.4-1.0cm/s, respectively (ﬁgure). However, the automatic method
systematically overestimated MRM and Aa (p<.01).
Computer-observer differences
Ejection fraction assessment
In conclusion, relatively short time is needed to achieve skills sufﬁcient to perform
a rough estimate of left ventricular function. Short courses of echocardiography are
feasible and effective and can be successfully introduced into the curricula of medical schools.
363
The delay between ECG and spectral Doppler signal is PRF-dependent.
A. Ouss, P.A. Van der Wouw. Onze Lieve Vrouwe Gasthuis, Cardiology,
Amsterdam, Netherlands
Background: Absence of a delay between the occurrence of events on ECG and
spectral Doppler (ECG-Doppler delay) is important in studies of timing and temporal relationship of cardiac events. However, in our experiments a pulse repetition
frequency (PRF) dependent delay became apparent.
Aim: The aim of this study was to describe the relationship between ECG-Doppler
delay and PRF.
Methods and results: Standard pulsed wave (PW) Doppler settings were used to
follow the left ventricular outﬂow tract (LVOT) ﬂow signal using velocity scales in the
range from 46 cm/s (PRF 1.25 kHz) to 440 cm/s (PRF 11.91 kHz) with an ATL HDI
5000 and 40 cm/s (PRF 1.03 kHz) to 500 cm/s (PRF 12.82 kHz) with a Vingmed
System V. The time interval from the R wave until the end of the LVOT ﬂow signal
(interval-PW) was measured in 5 volunteers.
PW tissue Doppler imaging (TDI) settings were used to follow the myocardial velocity signal in the basal anteroseptal wall using velocity scales in the range from 18
cm/s (PRF 500 Hz) to 240 cm/s (PRF 6.25 kHz) with an ATL HDI 5000 and from
20 cm/s (PRF 615 Hz) to 200 cm/s (PRF 6.15 kHz) with a Vingmed System V. The
time interval from the R wave until the peak of the ﬁrst positive wave after the onset
of the Q-wave (interval-TDI) was measured in 5 volunteers.
The relative change of the
intervals-PW, TDI at every
measured PRF relatively to
the intervals-PW, TDI at the
highest PRF within the correspondent settings (relative
ECG-Doppler delay) was calculated for both echomachines (ﬁgure).
Conclusions: The delay between ECG and spectral Doppler signal is inversely related
with PRF. The relationship is curvelinear, is different for standard PW Doppler and
PW TDI settings, and is different for each echomachine.
Conclusion: These results indicate that the automatic method does not detect
the same points as those manually outlined. However, the differences between the
computer-derived and the observer-derived parameters are within clinically acceptable limits. This, probably due to the spatial resolution of the Doppler data and the
fact that neighbour points of the ﬁbrous mitral ring move with almost the same motion.
365
Factorial parametric imaging of the LV contraction: validation of a new
tool for assessing segmental wall motion abnomalities.
B. Diebold 1 , A. Delouche 2 , H. Raffoul 1 , E. Abergel 1 , H. Diebold 1 , F. Frouin 2 .
1
HEGP, Cardiology, Paris, France; 2 INSERM, U 494, Paris, France
Factor Parametric Imaging of left ventricular (LV) B&W images analyzes the time
curve of each pixel of an image sequence, it extracts the most signiﬁcant curves
and the corresponding factorial images.
The present study has tested its ability to automatically detect segmental wall motion abnormalities on 48 patients (including 12 pts with LBBB or pace maker). After
alignment by correlation of each sequence, two factors were extracted (one ﬂat
curve and one curve describing the contraction-relaxation sequence). A synthetic
factorial parametric image (FPI) was built for each sequence with the combination
of the constant in green, the positive values of the second factor in red and the
negative in blue. The FPI were read as follows: wide red = normal, narrow red = hypokinetic, mosaic or green = akinetic, blue = dyskinetic. The evaluation was carried
out on 398 segments (38 apical four-chamber views and 35 apical two-chamber
views). The segments were graded independently (normal, hypokinetic, akinetic, or
dyskinetic) visually and by FPI by three experienced echocardiographers. An absolute concordance was obtained for 68.6% of the segments and a relative concordance (within one grade) for 98.7. The 5 discordant segments were found on the
often confusing basal portion of the septum or the inferior wall. Wall motion indices
derived from this scoring correlated strongly both with the EF and the visual WMS
(r=0.87). The same approach was tested without automatic alignment leading to
false dyskinetic segments in pts with LBBB and weaker correlations with EF and
WMS (r=0.76). In conclusion, the Factorial Parametric Imaging combined with an
alignment is a promising tool to study the regional wall motion of the left ventricle.
Examples
Eur J Echocardiography Abstracts Supplement, December 2003
S42
Abstracts
366
"Near-realtime" transmission of complete echocardiographic
examinations using low bandwith and a prototype software system.
368
Color myocardial Doppler imaging in infants reveals age-dependence of
strain and regional work load distribution.
P. Barbier, D. Cavoretto, M.D. Guazzi. Centro Cardiologico Fondazione Monzino,
IRCCS, Milan, Italy
L.B. Pauliks 1 , M. Kowalski 2 , K.S. Kirby 3 , L. M. Valdes-Cruz 1 . 1 U. of Colorado
Health Sciences Center, The Children’s Hospital Cardiology, Denver, United States
of America; 2 National Institute of Cardiology, Warsaw, Poland; 3 University of
Colorado Health Sciences, The Children’s Hospital Cardiology, Denver, United
States of America
The diffusion of techniques to digitalize echocardiographic images (video clips)
and the increase in available bandwith to transmit video clips have made teleechocardiography feasible. However, the dimensions of video clips produced by
the lossy compression algorythm "Moving Pictures Expert Group" (MPEG)-2 requires expensive, high bandwidth trasmission networks to realize realtime teleechocardiography.
Aim: we designed a transmitter-receiver system to allow effective, broad territorial
use of tele-echocardiography, by integrating transmission over Integrated Service
Digital Network (ISDN) telephone lines with lossy MPEG-4 compression algorythm.
Methods: in the prototype system, 2 laptop computers are connected by a ISDN line
(velocity 128 Kbit/s). The echocardiogram is acquired at the transmitting station as a
sequence of video clips (clinical compression) through an external portable analog
to digital conversion board connected to the s-VHS video output of the ultrasound
unit, preserving original video format (24 bit color, 720 x 576 pixel resolution, 25 fps).
The station automatically edits and converts video clips to MPEG-4 (with variable
bitrate), ensuring minimal ﬁle dimensions and privacy of data. The receiver station
provides decoding and playback of video clips.
Results: we have used the system to: 1) code and transmit video clips of 2D and
color Doppler "markers" (i.e., valve structures, masses, regurgitant jets and shunts)
with no perceptible loss of dynamic image details compared to the original uncompressed images; 2) code and transmit complete echocardiograms, with reduction of
the dimensions of a representative exam (20 3" video clips + 10 still frames) from
2,500 MB to 2.5 MB, and resultant minimum delay in exam trasmission time (between acquisition + transmission and reception + playback), which was kept within
1 video clip clinical compression and acquisition times.
Conclusion: integration of low-cost low bandwith ISDN lines and MPEG-4 video
compression technology has the potential to provide immediate feasibility of "nearrealtime" tele-echocardiography for remote access, overcoming economic barriers.
To this end, reliability in echocardiography of different MPEG-4 lossy compression
algorythms remains to established.
367
Apically directed post-systolic motion of the non-ischemic myocardium.
A. Ouss, P.A. Van der Wouw. Onze Lieve Vrouwe Gasthuis, Cardiology,
Amsterdam, Netherlands
Background: An apically directed postsystolic motion (PSM) of the non-ischemic
left ventricle (LV) was observed in elderly patients with hypertensive LV hypertrophy
(LVH). It is, however, not known whether age or hypertensive LVH is a determinant
of this phenomenon.
Methods: 30 patients (pts) referred for a standard echocardiogram were included:
10 pts without obvious heart disease younger than 30 years (gr 1); 10 pts without
obvious heart disease older than 60 years (gr 2); 10 pts older than 60 years with
hypertensive LVH (gr 3). Color-coded tissue doppler imaging (CTDI) of the LV in the
apical long axis view was obtained with a Vingmed System V at breathhold during
end expiration. An image angle of 28 degrees was used that allowed a temporal
resolution of approximately 5.5 ms. Velocity tracings of the regions of interest (ROI)
were derived off-line from the CTDI signal using EchoPac. ROI was deﬁned as an
area of the basal anteroseptal wall extending 1 cm below the aortic annulus. Any
apically directed acceleration during the time interval from the end of the systolic
wave until the onset of the early diastolic wave was deﬁned as PSM.
Results: Two distinct apically directed PSM’s were found in 29 (97%) patients (Picture 1). There was no difference in peak velocity of PSM I between the groups
(respectively, 2.30±1.75 cm/s; 1.69±1.36 cm/s; 1.35±0.88 cm/s, p=NS). Peak velocity of PSM II was signiﬁcantly lower in gr 1 (0.40±1.10 cm/s) compared with gr 2
(3.15±1.80 cm/s; p<0.001) and gr 3 (3.17±1.74 cm/s; p<0.001).
Conclusions: Two distinct apically directed PSM’s are present along the longitudinal axis in the non-ischemic basal anteroseptal wall. Neither PSM I nor PSM II can
be attributed to hypertensive LVH. PSM II seems to be an age-related phenomenon.
Eur J Echocardiography Abstracts Supplement, December 2003
Background: Contractility is higher in infants than in adults but this is not reﬂected
by conventional non-invasive function tests like FS limiting the value of this marker
in children<1y. Experimental studies in animals now show a high correlation of several color myocardial Doppler imaging (CMDI) markers with the gold standard of
contractility, end-systolic elastance. This study therefore used CMDI to analyze developmental changes of systolic function.
Methods: CMDI was performed in 32 normal infants (0.2±02y) and 20 children
(11.5±3.7y) and stored for off-line analysis of digital raw data. Peak systolic ejection velocity (PSV) and isovolumic acceleration (IVA) were measured in 6 basal
segments and peak systolic strain (strain) and strain rate (SR) were determined in
the mid wall of the RV, septum, anterior, inferior and lateral LV for longitudinal and
posterior for radial deformation.
Results: CMDI was feasible in infants despite their higher heart rates (132±19 vs.
78±16/min; p<0.01). Infants had markedly lower PSV than children (Table). The
velocity proﬁle in infants reminded of adult heart failure patients with a high ratio
of radial (posterior wall) to longitudinal (lateral) PSV (0.87±022 vs. 0.66±0.18 in
children; p<0.01). Longitudinal strain was also markedly lower in 3/5 segments in
infants (Table). However, radial strain, IVA and SR indicated a higher contractility in
infants vs. children.
CMDI function markers in infants <1 year
Segment
PSV (cm/s)
infants
n=32
Posterior
RV
Septal
Lateral
Anterior
Inferior
children
n=20
IVA (m/s2)
infants
n=32
children
n=20
Strain (%)
infants
n=32
children
n=20
3.7±1.0 4.9±1.4* 1.3±0.6 1.0±0.5* 94±33
7.0±1.9 10.4±1.5* 2.0±0.8 1.8±0.5 -33±16
4.4±0.9 6.6±1.6* 1.4±0.5 1.1±0.3* -21±7
4.4±1.1 7.9±2.7* 1.4±0.6 1.2±0.4* -18±8
4.5±1.4 7.6±2.3* 1.6±0.6 1.5±0.5 -18±7
4.7±0.9 6.9±1.5* 1.5±0.6 1.6±0.6 -19±8
50±12*
-34±7
-23±4*
-22±5*
-21±5*
-17±3
SR (1/sec)
infants
n=32
children
n=20
4.5±1.6 3.1±0.8*
-3.8±2.7 -3.2±1.0
-2.4±1.4 -2.1±0.8
-2.4±1.9 -2.3±0.8
-2.4±1.6 -1.9±0.6*
-2.3±2.2 -1.4±0.9*
* p<0.01
Conclusions: CMDI is feasible in infants and appears to be a better tool to monitor
developmental changes of systolic function than conventional markers. Our results
reveal signiﬁcant age-dependence of regional work load distribution and strain in
early childhood. The most promising markers of contractility in infants may be IVA
and SR while PSV is highly age-dependent.
Abstracts
S43
369
Speciﬁcity of echocardiographic criteria in prognosis of restoration of
sinus rhythm in chronic atrial ﬁbrillation.
371
A novel method for real-time quantitative echocardiographic assessment
of myocardial function.
O.V. Solovev 1 , D. Efremov 2 , O.V. Mochalova 1 , A.V. Chapournyh 1 ,
E.L. Onouchina 1 , M.V. Cherstvova 1 , I.Y. Gmyzin 1 . 1 Kirov State Medical Academy
(KGMA), Internal Diseases, Kirov, Russian Federation; 2 KGMA, Cardiology, Kirov,
Russian Federation
M. Leitman 1 , P. Lysyansky 2 , E. Peleg 1 , Z. Vered 1 . 1 Assaf Harofeh Medical
Center, Cardiology, Zeriﬁn, Israel; 2 GE, Ultrasound, Haifa, Israel
Beneﬁts of restoration and following maintenance of sinus rhythm (SR) are obvious
but there are still not enough data on prognosis of these.
Methods: 184 pts undergone external electrical cardioversion (ECV). Mean age
of the pts was 58.19 ± 10.58 years. AF duration was 30,24 ± 65,93 weeks. The
main diagnoses were 127 pts with arterial hypertension (69.02%), 7 pts (3.8%) with
CAD, 25 pts (13.59%) with both arterial hypertension and CAD, 10 pts (5.43%) with
cardiomyopathy, 2 pts (1.09%) with mitral valve prolapsis, and 13 pts (7.07%) with
idiopathic AF. ECV was effective in 137 pts (74.46%). We consider effective ECV as
restoration and maintenance of SR for 24 hours. All pts were divided in two groups
according to presentation of SR 24 hours after ECV, i. e. group 1 (Gr 1) is with
SR, and group 2 (Gr 2) is without. We studied transthoracic echocardiography: left
atrium anterior-posterior dimension (LADap), left atrium superior-inferior dimension
(LADsi), left atrium volume (LAV), end-systolic dimension (ESD), end-systolic volume (ESV), end-diastolic dimension (EDD), end-diastolic volume (EDV), and left
ventricle mass (LVM). Duration of AF and BMI were evaluated too. All these echo
data were obtained at the beginning of treatment before cardioversion. We estimated cut-off points (CoP) as quantitative criteria and speciﬁcity (Sp) of the tests.
We made ranking of our data according to their speciﬁcity.
Objectives: To assess the feasibility of a novel software for real-time quantitative
assessment of myocardial function with echocardiography.
Background: Methods for real-time quantitative assessment of LV function have
been limited.
Methods: Twenty patients with acute/recent myocardial infarction and 10 healthy
volunteers underwent echocardiography. Apical views were stored in a cineloop format for off-line analysis. The novel software (not tissue Doppler imaging) is based
on the estimation that a discrete set of tissue velocities are present per each of
many small elements on the ultrasound image. The operator deﬁnes a region of
interest over the endocardium which tracks cardiac motion in real-time. The region
of interest is modiﬁable if tracking is not optimal. The software permits on line assessment of myocardial velocities, strain and strain rate (see picture). Conventional
analysis of the echocardiographic images was also performed.
Results: In segments with adequate echocardiographic imaging, 87.2% of the infarct segments, 80.3% of the noninfarct segments of the patients and 97.8% of the
normal control segments could be adequately tracked by the software.
Cut-off points and speciﬁcity
Gr 1
sd
Gr 2
sd
p
CoP
Sp
Duration
ESV
EDD
ESD
EDV
LADsi
LAV
BMI
LVM
LADap
14.8
17.98
72.57
112.31
0.0017
6.7
0.90
60.62
33.7
72.84
24.31
0.006
57.6
0.82
50.98
5.69
53.29
4.79
0.019
50
0.76
37.16
5.36
40.22
5.44
0.005
37
0.76
125.88
33.7
139.25
29.21
0.034
122
0.73
71.74
9.14
75.97
7.79
0.022
74.5
0.63
87.78
27.66
104.96
30.93
0.004
105.8
0.63
27.03
3.84
31.41
6.91
0.0003
29.1
0.63
294.06
76.07
332.74
66.31
0.006
323.5
0.62
47.99
5.33
49.79
5.82
ns
*=p value of Student t-test (group 1 vs group2).
Conclusion: 1. More speciﬁc tests in prognosis of SR restoration were AF duration,
ESV, EDD, and ESD. This we may consider as more deep myocardial remodeling
in pts in whom ECV failed. 2. If more AF duration were the less effective ECV would
be. 3. Bigger dimensions and volumes of the heart and its mass have negative
prognosis in SR restoration.
370
Correlations of tissue Doppler derived myocardial velocities and ejection
fraction in patients with left ventricular dysfunction.
M. Plewka, J. Drozdz, M. Ciesielczyk, K. Wierzbowska, P. Lipiec, W. Religa,
M. Krzeminska- Pakula, J.D. Kasprzak. Medical University of Lodz, Cardiology
Dept., Lodz, Poland
Noninvasive accurate evaluation of left ventricular (LV) systolic function is clinically
important. A number of indices of contractility have been proposed and investigated
- including the percent fractional shortening, stroke volume, velocity of circumferential ﬁbers and ejection fraction (EF). Measurements of EF is used in routine clinical
practice, however the accuracy of this method depends strongly on image quality
and endocardial border detection.
To assess the usefulness of the tissue Doppler echocardiography (TDE) systolic velocities (Sm) for the evaluation of LV systolic function we studied 120 patients (pts):
60 with LV dysfunction including 30 pts after myocardial infarction (aged 58±10
years; EF 28±7%) and 30 pts with dilated cardiomyopathy -DCM (aged 43±12
years, EF 25±8%) and 60 healthy volunteers (aged 43±12yrs, LVEF 65±2%). Mean
systolic velocities were measured using puls-TDE in the middle of basal segments
of the LV from the standard apical views in 6 walls: lateral and posterior septum,
anterior and inferior, anterior septum and posterior wall.
Results: We found linear correlation between mean Sm derived from 6 segments and EF (biplane Simpson method): EF=7,97+4,85*Sm (r=0,89;SEE=9.15;
p<0,001). Further, the velocities of single wall correlated well with EF, with best correlation for the velocity of basal segment of the lateral wall: EF = 12,15 + 4,23*lateral
Sm (r=0,87; SEE=9.95; p<0,001).
For mean Sm < 6,5 cm/s diagnosis of systolic left ventricular dysfunction (EF<40%)
can be made with: sensitivity 98% (95%CI: 90-100%), speciﬁcity 91% (95%CI: 8196%), positive predictive value 90% (95%CI:79-96%) negative predictive value 98%
(95%CI: 91-100%) and accuracy 94% (95%CI: 88-98%).
Conclusion: TDE velocities of basal segments can be used as additional parameters of global LV function. Mean velocity below 6,5 cm/s indicates systolic dysfunction of the left ventricle with high clinical accuracy.
Normal/infarct segments quantitation.
Peak systolic strain calculated from the software was siginiﬁcantly higher in the
control and noninfarct segments as opposed to infarct segments 13.2±9.1% and
11.2 ± 7.6% vs 5.8±5.3%, p<0.000001. Average peak systolic velocity over the left
ventricle was signiﬁcantly higher in the control group than in the infarct segments
4.3 ±2.5 cm/s vs. 1.3 ±1.0 cm/s, p<0.000001.
Conclusion: This novel method can accomplish real-time quantitative wall motion
analysis, and may to become a standard for automatic echocardiographic assessment of cardiac function.
372
The contribution of mitral annular excursion to total stroke volume:
quantiﬁcation with 4-Dimensional transoesophageal echocardiography.
C. Carlhäll 1 , L. Wigström 1 , E. Heiberg 1 , M. Karlsson 2 , B. Wranne 1 , A. Bolger 3 ,
E. Nylander 1 . 1 Linköping University Hospital, Clinical Physiology, Linköping,
Sweden; 2 Linköping University Hospital, Biomedical Engineering, Linköping,
Sweden; 3 University of California, Cardiology, San Francisco, United States of
America
Introduction: The mitral annulus has a complex shape and motion, and its excursion has been correlated to both systolic and diastolic ventricular function. The
volume swept in the annulus’ excursion during the cardiac cycle is a portion of the
volume change that accompanies both ﬁlling and emptying of the ventricle. Our objective was to evaluate the annular excursion volume (AEV) in relation to the total
left ventricular (LV) volume change.
Methods: During non-cardiac surgery, 7 healthy subjects aged 53 (45-72) years
underwent transesophageal echocardiography (TEE). Thirty rotated images were
acquired at 6° increments during temporary cessation of mechanical ventilation.
The mitral annulus was outlined in all frames and the 4D coordinates (3D+time)
were ﬁtted to a Fourier series and divided into 100 triangular segments. The AEV
was calculated based on the temporally integrated product of the segments’ area
and their incremental excursion. The 3D LV volumes were calculated by tracing the
endocardial border in 6 coaxial planes.
Results: The AEV (10±2 ml, mean±SD) represented 19±3% of the total LV stroke
volume (53±13 ml). The AEV correlated strongly with LV stroke volume (r = 0.71)
but not with LV ejection fraction (r = 0.22). Of interest, the timing of AEV and LV
volume changes were very similar with respect to E and A contributions (ﬁgure).
Volume change, mean (n=7).
Conclusions: Mitral annular excursion accounts for an important portion of the LV
stroke volume. This novel 4D TEE method allows this to be studied non-invasively,
and will be a tool for investigating the impact of hemodynamic and pathological
conditions on LV performance.
Eur J Echocardiography Abstracts Supplement, December 2003
S44
Abstracts
373
Time to peak systolic strain rate is not a reliable index of regional
myocardial function.
375
Initial results of an open access echocardiographic service in the
Netherlands.
C. Bjork Ingul, A. Stoylen, S.A. Slordahl. NTNU, Dept of Circulation & Medical
Imaging, Trondheim, Norway
L.H.B. Baur 1 , M. Winkens 1 , R. Winkens 2 . 1 Atrium Medical Center, Cardiology,
Heerlen, Netherlands; 2 University Maastricht, Primary Care, Maastricht,
Netherlands
Introduction: Strain rate imaging (SRI) measures regional myocardial deformation
rates by tissue Doppler. There is no data on the simultaneity of peak strain rate
within the left ventricle. If time to peak systolic strain rate (Tsr) is reasonable constant in normal ventricles, Tsr could be an index of regional dysfunction. The aim of
the study was to establish the normal variability of Tsr.
Methods: Thirty healthy subjects (57±12 years, 15 women) with normal coronary
angiography and resting echocardiography, were examined with SRI. Tsr was measured from start of ejection to peak of strain rate and values expressed as percentage of ejection time. Tsr was measured in 16 ASE segments in 3 standard apical
views. Values are given as mean(SD).
Results: Ejection time for all segments (n=430) was 294(29) ms. Tsr could be measured in 90% of the segments. Heart rate was 65(10) beats/minute. Tsr for all segments was 34,4(17,3) % and there was no signiﬁcant difference between basal,
mid or apical level (see table). In septal and inferior wall, Tsr was signiﬁcantly lower
(p<0,05) (see table). Tsr, in % of ejection time, started at 10-29% in 43% of the
segments, and at 30-39% in 35% of the segments.
Table.
Segment level/wall
Tsr in % of
ejection time (SD)
Tsr range in % of
ejection time
Peak systolic
strain rate 1/s(SD)
Basal segments
Mid segments
Apical segments
Septal wall
Lateral wall
Inferior wall
Anterior wall
Inferiolateral wall
Anterioseptal wall
36,0(17,2)
34,2(18,4)
32,6(15,9)
31,6(16,4)*
38,3(16,9)
33,2(14,8)*
36,8(20,5)
35,0(20,1)
35,8(16,2)
21-58
14-54
19-49
13-73
14-66
14-51
14-74
7-83
14-57
-1,41(0,41)
-1,28(0,40)
-1,22(0,37)
-1,25(0,33)
-1,33(0,46)
-1,34(0,39)
-1,29(0,39)
-1,47(0,49)
-1,26(0,32)
Time to peak systolic strain rate and peak systolic strain rate, *p<0,05
Conclusions: The variability of Tsr is too high in normals to be used as an index
of regional myocardial function. The variability of Tsr may partly be due to artifacts,
but also demonstrates the physiological variation in deformation patterns in normal
ventricles. Tsr was signiﬁcantly lower in septal and inferior wall, but these walls give
the best image quality and the difference is probably due to artifacts.
Introduction: General Practitioners (GP’s) see a growing number of pts, who have
complaints of shortness of breath. This is to some extent due to the growing number of older people with heart failure. Frequently, dyspnea is caused by pulmonary
disease, obesity, or other non-cardiac causes. For the general practitioner with his
limited diagnostic facilities it is extremely difﬁcult to differentiate between dyspnea
from cardiac origin and shortness of breath from non-cardiac origin. Echocardiography can help to differentiate between dyspnea due to systolic and diastolic dysfunction and other causes of dyspnea. This can be done next to the measurement of
plasma BNP. Not only the number of people with heart failure, but also the number
of people with cardiac murmers is increasing due to the higher incidence of aortic
valve stenosis and mitral insufﬁciency on older age. Correct diagnosis is not easy
despite a thorough physical exam and auscultation. Therefore we provided the GP’s
the possibility to have free access to echocardiography.
Methods: GP’s were able to ask for an echocardiogram from a patient with suspected for heart failure or a cardiac murmur. They were asked to provide information
about the clinical diagnosis, current medication and the ﬁndings on physical examination. The echocardiogram was performed within one week and the results were
mailed to the GP.
Results: Between december 2002 and may 2003 31 pts were referred. The reason
for referral was in 25 pts dyspnea (5 also had a murmur) and 9 a cardiac murmur. In
two patients there was another reason for referral. Of the patients with dyspnea 67%
used any medication to treat heaft failure (diuretics, ACEI, AT2 antagonists). 52% of
pts with dyspnea had clinical features of heart failure: pulmonary rales or peripheral
edema. Of all pts referred for dyspnea 24% had no structural or functional cardiac
abnormality. 4 pts had an LVEF < 40%, 3 a left ventricular outﬂow obstruction, 2 a
moderate mitral insufﬁciency and 10 diastolic left ventricular dysfunction. Of the 4
patients referred for a cardiac murmur only 50% had structural heart disease.
Conclusion:
About 25% of the patients suspected to have heart failure do have a completely
normal cardiac anatomy and cardiac function. Open access achocardiography can
help the GP in making a correct diagnosis of heart failure or valvular heart disease.
This improves care of these patients in primary practice.
CORONARY FLOW RESERVE
374
Load sensitivity of reperfused myocardium - a confounder in strain
assessment of myocardial function.
T. Vartdal 1 , E. Lyseggen 2 , H. Skulstad 2 , T. Helle-Valle 2 , S.I. Rabben 3 , H. Ihlen 2 ,
O.A. Smiseth 2 . 1 Rikshospitalet National Hospital, Department of Cardiology, Oslo,
Norway; 2 Rikshospitalet National Hospital, Department of Cardiology, Oslo,
Norway; 3 Institute for Surgical Research, University of Oslo, Oslo, Norway
Introduction: Strain Doppler echocardiography (SDE) allows bedside measurement of myocardial strain. Potentially, strain analysis can be used to monitor therapeutic responses in patients with acute myocardial ischemia. Strain however, is not
a direct measure of contractility. The present study investigates load dependency of
myocardial strain during reperfusion.
Methods: In 6 anesthetised dogs we measured pressures and longitudinal strain by
SDE and sonomicrometry. The LAD was occluded for 15 min, and then reperfused
for 3 hours. Subsequent TTC staining conﬁrmed myocardial viability. Afterload was
increased by aortic constriction.
Results: LAD occlusion caused an increase in peak systolic strain by sonomicrometry from -13.6 ± 4.9% to 7.1 ± 1.1%* after 15 min with ischemia, and a decrease to
-8.3 ± 2.6%* after 3 hours reperfusion. When peak LV systolic pressure rose from
88 ± 3 to 111 ± 3* and 128±4* mmHg by aortic constriction after 30 minutes of
reperfusion, strain increased from -5.2 ± 2.1 to 1.2 ± 1.3* and 5.9 ± 2.0%*, respectively. Figure shows a representative experiment. Results were similar for strain by
SDE. *=p<0.05. These were beat to beat changes, and were therefore attributed to
a pure mechanical effect of loading.
377
Efﬁcacy of noninvasive evaluation of left internal thoracic artery (LITA)
graft patency using transthoracic Pulse Doppler echocardiography
(TTPDE).
Y. Suzuki, H. Kanda, T. Tanaka, T. Tajika, H. Kataoka, Y. Morimoto, H. Kamiya,
S. Hayashi on behalf of Coronary Flow. Okazaki City Hospital, Cardiology, Okazaki
city, Japan
Objective: To investigate the usefulness of evaluation of LITA graft patency by
TTPDE.
Method: We analyzed 140 patients with a LITA graft by TTPDE. 18 cases were
excluded due to a large offset angle. Cases were assigned to patent group (P:
n=103) or stenosis group (S: n=19). We compared with both groups.
Results of measurements
angle
SpV
DpV
DpV/SpV
SVTI
DVTI
D fraction
Eur J Echocardiography Abstracts Supplement, December 2003
S (n=19)
p value
44.3±8.9
38.6±18.0
33.9±14.1
1.00±0.54
5.83±2.82
11.5±4.7
0.66±0.10
46.9±7.6
34.8±12.7
17.5±9.0
0.56±0.33
5.67±2.37
6.1±3.6
0.49±1.83
N.S
N.S
<0.0001
0.0008
N.S
<0.0001
<0.0001
SpV; systolic peak velocityDpV; dyastolic peak velocitySTVI; systolic time veolcity integralDVTI;
dyastolic time veolcity integral D fraction=DVTI/(SVTI+DVTI)
Beat to beat aortic constriction
Conclusions: When reperfused myocardium was exposed to moderate increments
in afterload it changed from active systolic shortening to passive lengthening. This
implies that apparent severe aggravation of myocardial function by SDE may not reﬂect reduced intrinsic contractility. These concepts could have implications clinically
when reocclusion is considered as etiology of acutely impaired regional function.
P (n=103)
Results of ROC analysis
Result: The results are shown in the table and ﬁgure. It was suggested that DTVI
and D fraction were more useful than
DpV/SpV. When assigning cutoff values
of DTVI>10cm/sec and D fraction>0.60,
TTPDE evaluation of the LITA graft gave
79% sensitivity and 83% speciﬁcity.
Conclusion: It was possible to evaluate
LITA graft by TTPDE in about 90 percent
of patients. Also, it was suggested that
this examination gave the high sensitivity
and speciﬁcity, and was very useful for the
screening of LITA graft patency.
Abstracts
S45
378
Impact of acute hyperhomocysteinemia on coronary ﬂow reserve in
healthy adults.
380
Angina pectoris caused by reduced coronary vasodilator reserve in
patients without stenosis of coronary arteries.
L. Ascione 1 , M. De Michele 2 , M. Accadia 1 , S. Rumolo 1 , C. Sacra 1 , M. Petti 3 ,
B. Tuccillo 1 , M. De Michele 4 . 1 Ospedale Santa Mare di Loreto, Cardiologia,
Naples, Italy; 2 Federico II University, Clinical and Experimental Medicine, Naples,
Italy; 3 S. Maria Di Loreto Hospital, Clinical Laboratory, Naples, Italy; 4 Portici
(Naples), Italy
S. Cicala 1 , M. Galderisi 1 , A. D’Errico 1 , P. Guarini 2 , F. Piscione 3 , M. Chiariello 3 ,
O. de Divitiis 1 . 1 Federico II University, Clinical and Experimental Medicine, Naples,
Italy; 2 Villa dei Fiori Hospital, Cardiology Dept., Acerra (Naples), Italy; 3 Federico II
University, Cardiology, Naples, Italy
Background: Hyperhomocysteinemia has been related to preclinical structural and
functional arterial abnormalities.
Aim of the present study was to evaluate the impact of hyperhomocysteinemia on
coronary ﬂow reserve.
Methods: Twenty healthy subjects (mean age 41 ± 7 years) were studied twice,
before and after methionine load (100 mg/kg) or placebo, according to a crossover,
double blind design. Homocysteine levels were measured by liquid cromatography
and coronary ﬂow reserve was evaluated by transthoracic echocardiography.
Results: After methionine load, homocysteine levels increased from 10.7 ± 2.8
micromol/L to 30.4 ± 5.1 micromol/L (p < 0.0001) and coronary ﬂow reserve decreased from 3.0 ± 0.4 to 2.3 ± 0.3 (p < 0.001). Coronary ﬂow reserve was inversely related to post-load homocysteine levels (r = -0.21). After placebo, there
was no signiﬁcant change in coronary ﬂow reserve.
Conclusion: In healthy adults, acute hyperhomocysteinemia was associated to a
signiﬁcant reduction in coronary ﬂow reserve.
379
Myocardial inotrope reserve is associated with coronary ﬂow reserve in
patients with dilated cardiomyopathy. A pilot study.
M.I. Chamilos 1 , A.P. Patrianakos 1 , E.I. Skalidis 1 , K. Vardakis 1 , P.G. Tzerakis 1 ,
F.I. Parthenakis 1 , P.E. Vardas 2 . 1 Heraklion University Hospital, Cardiology Dept.,
Heraklion, Crete, Greece; 2 Heraklion University Hospital, Cardiology, Heraklion,
Greece
Background: Coronary ﬂow reserve (CFR) has been shown to be diminished in
patients (pts) with idiopathic dilated cardiomyopathy (IDC) and have been proposed
as a predictor of poor prognosis in those patients (pts). Myocardial inotrope reserve
represent also a prognostic index and has been hypothesized that is related to CFR.
We evaluated the relationship between CFR and cardiac inotrope reserve in pts with
IDC.
Methods: Eleven pts with IDC with LV ejection fraction (EF) <40% and NYHA functional class II-III, underwent CFR measurements, using a 0.0014 inches Doppler
quide wire, in the left anterior desceding (LAD), left circumﬂex (LCx) and in the right
coronary artery (RCA).
Low-dose Dobutamine stress echocardiography (LDDE)(two 5-minutes stages with
Dobutamine infusion 5 and 10 µgr/kgr/min) was performed to all pts within 48 hours
from cardiac catheterazation. LV was divided into 16 segments, 7 in the LAD, 5 to
LCx and 4 to RCA territory. Regional wall motion score index (WMSI) was calculated
at rest (r) and peak stress (s) and cardiac inotrope reserve was deﬁned as the
percentage difference between them (dWMSI=(WMSIr-WMSIs)/WMSIr)×100).
The control group were consisted from ten patients without signiﬁcant coronary
artery disease and LVEF>60%.
Results: Pts with IDC had signiﬁcantly impaired CFR in all three vascular territories
(LAD: 2.63 ± 0.43 vs 3.43 ± 0.49, p<0.05, LCx: 2.57 ± 0.51 vs 3.29 ± 0.41, p<0.05
and RCA: 3.38 ± 0.57 vs 3.89 ± 0.59, p<0.05) compared to controls.
A signiﬁcant decrease of CFR also was found in the LAD compared to RCA in pts.
The WMSI improved at LDDE at 29±7.2%. The regional WMSI in RCA region
exhibited a greater improvement compared to this in LAD region (37.3±11.6 vs
25.2±9.1%,p<0.05).
Simple linear regression analysis revealed a signiﬁcant correlation between CFR
and WMSI changes in both LAD (r=0.80,p=0.003) and RCA vascular territories
(r=0.81, p=0.002).
Conclusions: Pts with IDC have alterations in regional myocardial perfusion and
reduced coronary ﬂow reserve more pronounced in the LAD vascular territory.
The CFR close related with Dobutamine WMSI changes suggest that, CFR may
have a causative relationship to cardiac inotrope reserve in those pts.
Purpose: To assess coronary microvascular function in patients with angina pectoris without epicardial coronary artery stenosis.
Methods: Twenty-two patients with stable angina pectoris but without angiographic
evidence of coronary artery stenosis and 20 controls entered the study. Angina
pectoris was associated to ECG changes during acute event and/or positive treadmill maximal exercise test while inducible myocardial ischemia at dipyridamole (Dip)
SPECT was not considered as inclusion criterion. Patients were excluded for diabetes mellitus, arterial hypertension, valvular heart disease, heart failure, primitive
and congenital cardiomyopathies and use of cardiac drugs. Transthoracic standard
echocardiography and color-guided, second harmonic Doppler analysis of coronary
ﬂow velocities in distal left anterior descending artery were performed in the same
morning. Coronary ﬂow reserve (CFR) was measured as the ratio of coronary ﬂow
diastolic peak velocity after Dip infusion (0.56 mg/Kg I.V. in 4’) to resting coronary
diastolic peak velocity.
Results: The 2 groups were comparable for age, body mass index, heart rate (HR)
and blood pressure (BP). Standard echocardiography showed no difference in left
ventricular mass index and ejection fraction. By analysis of coronary ﬂow, resting
diastolic peak velocity was higher (p<0.01) and Dip-induced, hyperemic diastolic
peak velocity lower (p<0.01) in patients with angina. Thus, CFR was reduced in patients with angina (1.80±0.5) in comparison with controls (2.70±0.3) (p<0.0001),
even after adjusting resting and Dip ﬂow velocities for the respective mean BP
(p<0.001). Only in the group of patients with angina, a negative relation was found
between the double product (HR x systolic BP) measured after Dip infusion and
CFR (r = -0.62, p<0.01).
Conclusions: In patients with angina pectoris but no coronary stenosis CFR is impaired in relation to elevated resting coronary ﬂow velocities and reduced hyperemic
velocities and also to an increased myocardial oxygen consumption during low-dose
Dip infusion. The alteration of coronary microvascular function, whose CFR is a reliable marker in absence of epicardial coronary stenosis, is a possible determinant
of myocardial ischemia in this set of patients.
381
In vivo validation of velocity proﬁles in coronary arteries- the shape factor
is a variable.
F. Matthews, S. Aschkenasy, M. Rofﬁ, P. Kaufmann, M. Namdar, E. Oechslin,
R. Jenni. University Hospital, Echocardiography, Zurich, Switzerland
Background: Current coronary blood ﬂow determination using intravascular
catheter-based Doppler assumes a constant velocity proﬁle. The shape factor (fp)
which characterizes the velocity proﬁle is the ratio between mean velocity (Vm) and
average peak velocity (APV), fp=Vm/APV. It is commonly assumed to be 0.5, corresponding to a parabolic velocity proﬁle. The mean velocity is subsequently computed as Vm = 0.5 x APV. However, it is doubtful whether a constant ratio can be
assumed both at rest and during hyperemia.
Purpose: Our objective was to assess the shape factor in vivo both at rest and
during hyperemic coronary perfusion.
Methods: In ten individuals power based measurements of coronary ﬂow velocities
in normal coronary arteries were performed during coronary angiography using a
commercially available guide wire Doppler system (FloMap , Cardiomedics). Vm
and APV were determined at a gate depth where the Doppler beam intersects the
vessel wall. Vm was calculated from the zeroth (M0) and ﬁrst (M1) Doppler moment
as Vm = M1/M0.
Results: The shape factor was found to be in a range 0.26 - 0.67 (mean 0.47) at
rest and 0.22 - 0.66 (mean 0.38) during hyperemia.
Shape factor
Conclusions: Our measurements reveal fp well below 0.5 even at rest. During hyperemic perfusion fp tends to decrease further, indicating a more accelerated velocity proﬁle. We conclude that the assumption of a constant shape factor of 0.5 for
calculating the mean velocity based on average peak velocity may result in misleading results, which must therefore be read with caution.
Eur J Echocardiography Abstracts Supplement, December 2003
S46
Abstracts
382
The clinical meaning of coronary ﬂow reserve in idiopathic dilative
cardiomyopathy.
F. Rigo 1 , S. Gherardi 2 , V. Cutaia 1 , P. Nicolin 1 , F. Di Pede 1 , G. Grassi 1 ,
G. Turiano 1 , A. Raviele 1 . 1 Umberto I° Hospital, Cardiology, Mestre-Venice, Italy;
2
Bufalini Hospital, Cardiology, Cesena, Italy
Background: It has been demonstrated that the maximal oxygen uptake (VO2max)
is strictly related to functional status (NYHA Class) in patients with idiopathic dilative
cardiomyopathy (IDC) and therefore represents an important clinical predictor. The
VO2max is the physiological trigger to increase the coronary ﬂow reserve (CFR). At
present it is possible noninvasively evaluate the CFR by transthoracic echocardiography on left anterior descending (LAD) coronary artery.
Methods: We have consecutively enrolled 26 patients (pts), 16 Male mean age
64±b12 years, all affected with IDC conﬁrmed by normal coronary artery with angiography. Each of them underwent TTE, evaluating the standard parameters such
as LVEDV, LVESV (ml), EF (%) and Stress-Echo with Dipirydamole (0,84 mg/Kg
over 6 m’) evaluating the LV contractility (WMSI) and simultaneously the CFR on
LAD, calculated as the maximum peak-rest diastolic ﬂow velocity (LADDFVDp-r) ratio, using a high frequency probe in 2ˆ harmonic (7 MHz). We utilized an off axis
apical approach under the guide of color-Doppler and when necessary we injected
a contrast agent (Sonovue 2ml in bolus) to improve the signal-noise coronary ﬂow
ratio. All pts underwent within 24 hour the effort test (treadmill) with gas analysis
evaluating particularly the VO2max (ml/kg/m’) and anaerobic threshold. We considered as clinical parameter the NYHA Class.
Results: We found the following mean values:
EDV = 226 ± 63ml, ESV = 144 ± 52ml, EF = 36 ± 6%, WMSIb = 1,8 ± 0,3,
LADDFVr 31 ± 4cm/s, LADDFVp = 59 ± O8cm/s, CFR = 1,9 ± 0,2, VO2max =
19 ± O6, NYHA Class = 2,3 ± 0,8
The parameters that demonstrated a signiﬁcance linear statistical relationship were:
NYHA Class vs MVO2: r = 0,70 p = 0.002
NYHA Class vs RC: r = 0.92 p = 0.001
VO2max vs CFR: r = 0.60 p = 0.016
VO2max vs LADDFVDr: r = 0.60 p = 0.020
The feasibility of CFR study in pts affected with IDC was excellent: 27/27 pts (100%)
Conclusion: The excellent relationship between the NYHA Class and VO2max and
between CFR and VO2max suggest us to consider the CFR of LAD in daily practice
as an important functional predictor: this, in the next future could have a relevant
therapeutic and prognostic impact in pts with IDC.
383
The impact of cholesterol on coronary ﬂow reserve in hypertensive
patients without evidence of coronary heart disease.
M. Galderisi 1 , S. Cicala 2 , A. D’Errico 1 , M. Pardo 1 , G. de Simone 1 , O. de Divitiis 1 .
1
Federico II University, Clinical and Experimental Medicine, Naples, Italy;
2
Santobono - Pausilipon, Cardiology, Naples, Italy
Purpose: To assess the impact of cholesterol (CHOL) on coronary ﬂow reserve
(CFR) in arterial hypertension, in the absence of overt coronary artery disease.
Methods: The study population included 64 subjects (M/F = 50/14, mean age = 50
years, 44 hypertensives), free of diabetes mellitus and/or heart failure, symptoms
and ECG signs (both at rest and during maximal treadmill exercise) of myocardial ischemia and not treated by cardiac medications and/or hypocholesterolemic
drugs. Blood samples for routine laboratory tests were drawn the same morning
as transthoracic standard echocardiography and Doppler analysis of coronary ﬂow
velocities in distal left anterior descending artery. CFR was measured as the ratio
of coronary ﬂow diastolic velocity after low-dose dipyridamole (DIP) infusion (0.56
mg/Kg I.V. in 4’) to basal coronary ﬂow diastolic velocity. According to CHOL levels, the study population was divided into 2 groups: 24 patients with normal CHOL
(<200 mg/dl) and 40 patients with high CHOL (>200 mg/dl).
Results: The 2 groups were comparable for age, heart rate and fasting glycemia.
Body mass index (BMI), systolic blood pressure (BP) and left ventricular mass were
signiﬁcantly higher in patients with high CHOL (all p<0.001). Triglycerides were also
increased and HDL-CHOL reduced (all p<0.001) in hypercholesterolemic patients.
In the absence of signiﬁcant difference of basal coronary diastolic velocities, the
group with hypercholesterolemia exhibited lower DIP coronary diastolic velocities
(p<0.01). CFR was, therefore, reduced (1.89 ± 0.6 versus 2.16 ± 0.4, p<0.01).
This difference remained signiﬁcant even adjusting for mean BP. In pooled groups,
CFR was related negatively with CHOL (r = -0.41, p<0.001) and fasting glycemia
(r = -0.28,. p<0.02) and positively with HDL-CHOL (r = 0.25, p<0.05). In a multiple
linear regression model, the associations of CHOL and HDL-CHOL with CFR were
independent of the effects of other coronary risk factors including glycemia, cigarette
smoking (yes/no), BMI, mean BP and left ventricular mass.
Conclusions: In a population of both hypertensive and normotensive subjects free
of clinical manifestations of coronary heart disease, vasodilator capacity of coronary microcirculation is reduced when levels of blood cholesterol are elevated. This
association is independent of the effect exerted by other coronary risk factors.
Eur J Echocardiography Abstracts Supplement, December 2003
384
Changes of coronary blood ﬂow in aortic valve prosthetic dysfunction.
Y. Ivaniv 1 , A. Kurkevych 2 , A. Turkin 3 . 1 Lviv, Ukraine; 2 Lviv, Ukraine; 3 Navy
Hospital, Ultrasound diagnosis department, Sevastopol, Ukraine
Hemodynamic alterations related to aortic valve disease contribute to changes in
the resting coronary blood ﬂow (CBF) and velocity proﬁles. The CBF velocity could
be analyzed using TEE PW Doppler.
Background: This study was conducted to examine the CBF of the LAD proximal
portion in patients with aortic valve prosthetic dysfunction.
Material and methods: We examined 9 pts (mean age 47.3±5.7 years; normal
coronarograms) with severe aortic stenosis 3 times: 1st - before surgery; 2nd - in
1-30 months after valve replacement with normal prosthetic function; 3rd - in 3-15
months after the 2nd examination because of prosthetic dysfunction. We used a
5-MHz transducer connected to Acuson 128XP system. PW Doppler signal from
LAD was obtained and systolic and diastolic velocities (Vs, Vd) and velocity time
integrals (VTIs and VTId) were measured. S/D ratio was calculated as VTIs/VTId.
Results: The diastolic CBF parameters were signiﬁcantly higher in aortic stenosis
pts than in controls (* - signiﬁcantly in comparison to control). The systolic parameters were higher, but not signiﬁcantly. The S/D ratio in aortic stenosis was signiﬁcantly lower than in control group indicating the relative diastolic predominance and
systolic ﬂow reduction. After aortic valve replacement with normal prosthetic function all CBF parameters bacame normal. When prosthetic dysfunction occurred the
CBF parameters reversed to those observed in pre-operated status. There was signiﬁcant correlation of valve gradient and Vs (r=.94, P<.01); VTIs (r=.89, P<.01);
Vd (r=.73, P<.05); VTId (r=.69, P<.05). There was correlation of LV mass and Vs
(r=.60, P<.05) and VTIs (r=.62, P<.05). S/D ratio inversely correlated with valve
gradient: r=-.96, P<.01.
Coronary blood ﬂow parameters
1st exam
2nd exam
3rd exam
Control
Vs (m/s)
Vd (m/s)
VTIs (m)
VTId (m/s)
S/D ratio
0.39±0.17
0.27±0.15
0.34±0.16
0.23±0.10
0.98±0.29*
0.50±0.13
0.86±0.18*
0.38±0.010
0.048±0.013
0.036±0.012
0.050±0.009
0.041±0.004
0.171±0.039*
0.093±0.014
0.181±0.023*
0.096±0.016
0.28±0.006*
0.38±0.009
0.28±0.014*
0.42±0.010
Conclusions: The obtained results indicate that hemodynamic alterations occurred
in aortic valve prosthetic dysfunction lead to reversion of CBF parameters initially
normalized after successful repair. The extent of this changes depends on severity
of prosthetic dysfunction.
385
Coronary ﬂow velocity reserve and indices of aortic distensibility in
patients with aortic valve stenosis and a negative coronary angiogram.
A. Nemes, T. Forster, M. Csanady. University of Szeged, 2nd Department of
Medicine, Szeged, Hungary
Background: The coronary and aortic systems and the aortic valve can be affected
by atherosclerosis.
The aim of the present study was to evaluate the coronary ﬂow velocity reserve
(CFR) (providing physiological information regarding the function of the left anterior
descending coronary artery (LAD)), Elastic modulus (E(p)) and Young’s modulus
(E(s)) as indices of the distensibility of the descending aorta in patients with aortic
valve stenosis (AOS) without major coronary artery disease (CAD), and to compare
the results with those on patients with CAD and negative controls.
Patients and Methods: Stress transoesophageal echocardiography (STEE) and
coronary angiography were performed on 105 patients (34 women and 71 men,
average age: 58±10 years). CFR was measured during STEE and was calculated
as the ratio of the maximal averaged peak diastolic ﬂow velocity (APV) to the resting APV. E(p) and E(s) were evaluated from echocardiographic parameters of the
descending aorta and blood pressure data.
Results: Data are presented in the table.
Data of patients
Coronary angiogram
Negative without AOS (17 cases)
Negative with AOS (15 cases)
LAD disease without AOS (31 cases)
Multivessel disease without AOS (42 cases)
CFR
E(p)
E(s)
2.59±1.21
1.81±0.52*
1.75±0.45*
1.96±0.72*
0.45±0.23
0.83±0.62*
0.93±0.54*
0.80±0.55*
5.49±4.22
8.86±6.69*
9.77±6.67*
7.73±6.53*
* p<0.05 vs negative without AOS data
Conclusion: The indices of aortic distensibility were signiﬁcantly increased, while
the CFR was signiﬁcantly decreased in patients with LAD disease/multivessel disease and in AOS patients with normal epicardial arteries as compared with cases
with a normal coronary angiogram without valvular heart disease.
Abstracts
386
Transthoracic echocardiographic assessment of coronary ﬂow reserve in
the right coronary artery for detection of signiﬁcant stenosis.
Comparison with invasive measurements.
H. Lethen, H.P. Tries, S. Kersting, H. Lambertz. Deutsche Klinik für Diagnostik,
Cardiology, Wiesbaden, Germany
Objectives: Evaluation, if signiﬁcant coronary artery stenosis of the right coronary
artery (RCA) can be detected by noninvasive assessment of coronary ﬂow velocity reserve (CFR) using transthoracic Doppler echocardiography (TDE), and if CFR
results are in agreement with intracoronary Doppler ﬂow wire (DFW) CFR measurements.
Background: TDE CFR has proven to be an accurate technique for assessment of
stenosis severity in the left anterior descending artery. Recently, the technique to
visualize the posterior descending branch (RPD) of the RCA has been described.
Methods: 76 consecutive patients (54 men, mean age 62 ± 11) scheduled for coronary angiography were studied. DFW and TDE CFR measurements were performed
in the RPD. TDE (fundamental imaging mode, 2.5 MHz color Doppler, 2.0 MHz
spectral Doppler) ﬂow recordings were taken at rest and during maximal hyperemia, induced by iv adenosine. CFR was calculated from systolic-diastolic average
peak velocities. A CFR cut-off value = 2.0 was deﬁned to detect signiﬁcant coronary
artery disease.
Results: Angiographically the RPD was not occluded in 69/76 patients. CFR could
be taken noninvasively in 88% (61/69); sensitivity and speciﬁcity for TDE CFR detection of RCA stenosis was 89% (17/19) respectively 93% (39/42). Agreement of
TDE CFR and DFW CFR was signiﬁcant (mean difference 0.28 ± 0.08) as well as
interobserver variability (mean difference 0.27 ± 0.11).
Conclusions: TDE is a feasible technique to assess CFR in the RPD of the RCA
noninvasively, with results closely corresponding to DFW measurements. Deﬁning
a CFR cut-off value < 2.0 for signiﬁcant stenosis, the technique has the potential to
detect those lesions reliably.
387
Overweight is not a limitation for coronary ﬂow measurements by
transthoracic Doppler echocardiography.
J. Lowenstein 1 , C. Quiroz 2 , R. Boughen 1 , O. Montaña 2 . 1 Investigaciones
Medicas, Cardiodiiagnostico, Buenos Aires, Argentina; 2 DIM, Echocardiography,
Buenos Aires, Argentina
Coronary ﬂow velocities (CFV) can be measured in the left anterior descending artery (LAD) by transthoracic Doppler-echocardiography (TTDE), but many
echocardiographers believe that obesity could be a limitation to determine it. The
aim of our study was to investigate the feasibility of the measurements of CFV in
the distal LAD by TTDE in an unselected population of overweight patients (pts).
Methods: TTDE was performed in 1137 consecutive pts with a 4-7 MHz transducer,
color map with a Nyquist scale average of 19.2cm, without any contrast agent; 160
pts with a weight ≥ 100 kilograms (kg.), (mean 108.8 ± 9.7 kg, limits 100-150
kg.)formed the study group (141 men, mean age: 57.5 ± 9.8 years, mean body
surface area of 2.25± 0.13 m2 (limits 1.91-2.64 m2 ).The baseline systolic velocity
(BSV), basal diastolic maximal velocity (BDMV) and basal average diastolic velocity
(BDAV) were measured in the distal LAD.
Results: An interpretable Doppler diastolic signal was obtained in 90.6% (145/160)
of the determinations in pts ≥100 kg. vs. 91.7% (896/977) of pts with < 100 kg.
(p= NS). The BDAV of the total group was 16.8 ± 5.4 cm/s and in the obese pts
was 17.4 ± 4.7 cm/s (p= NS), a BSV was obtained in 82.5% of the total group and
88% in the obese pts (p=NS). The average performing time of all the studies was
1.4 ± 2.0 min. The population of the 15 obese pts in which it was not feasible to
determine Doppler recording of the BDV was signiﬁcantly older (62.4 ± 7.9 vs 56.9
± 9.8 years old, p < 0.03). the feasibility in pts ≥ 65 years was 83%, meanwhile
in pts younger than 65 it was 93% (p= NS); in pts with a very bad acoustic window
there were 26.6% of non feasible studies vs 7.6% of pts with good or regular 2D
images; gender, height, body surface area, left diastolic ventricular diameter and
mass index did not mark a difference between the feasible and the non feasible
studies in the overweight pts.
In conclusion, in the daily practice, assessment of coronary ﬂow velocities of the Left
Anterior Descending artery by transthoracic Doppler echocardiography was highly
feasible, independently of the body weight; only a very bad acoustic window and an
age over 65 years could be considered a slight limitation in overweight patients.
S47
388
Transthoracic echocardiographic assessment of coronary artery ﬂow and
reserve in the 3 major coronary arteries: feasibility and results.
F. Rigo, M. Richieri, V. Cutaia, C. Zanella, F. Di Pede, U. Coli, A. Raviele. Umberto
I° Hospital, Cardiology, Mestre-Venice, Italy
Background: Coronary ﬂow reserve (CFR) can be measured by transthoracic
echocardiography (TTE) during vasodilator stress on mid- distal left anterior descending (LAD). Left circumﬂex (LCx) and Right coronary artery (RCA) have remained off- limits for this technique so far.
Aim: To assess the feasibility and results of TTE assessment of CFR in all 3 coronary arteries. Methods: Starting June 2001 to march 2003, 801 consecutive patients
(493 males; age=64±13 years) were referred for stress echocardiography: known or
suspected coronary artery disease (n=645), hypertrophic or dilated cardiomyopathy
(n=76), athletes (n=42), or valvular disease (n=38) In all, TTE (S12-S8 probe, HP
5500, Agilent technology) evaluation of distal left anterior descending (LAD) coronary artery was attempted at baseline and following dipyridamole (0.84 mg/kg). A
modiﬁed two-chamber view with the transducer rotated counterclockwise and angulated anteriorly was employed to image posterior interventricular descending branch
of the RCA; an off-axis 4 chamber view angulated posteriorly (60-90° from the visualization of LAD) was used to image LCx. Wherever color-coded blood ﬂow from
the baseline could not be obtained, contrast enhancement with Levovist (Schering AG) or Sonovue (Bracco) was injected. Peak diastolic coronary ﬂow velocity of
each coronary artery was recorded by pulsed Doppler under the guidance of Color
Doppler ﬂow mapping. CFR was calculated as the ratio of dipyridamole/rest peak
diastolic ﬂow velocity.
Results: Interpretable signals (at baseline and during stress) were observed in 763
patients for LAD,438 pts for LCX and 532 pts for RCA, yelding a feasiblity of 96%,
54% and 66% respectively. The time to coronary artery imaging was 2 min for LAD,
3 for RCA and 5 for LCx (p<0.01). In the 67 patients with angiographically conﬁrmed
normal coronary arteries and interpretable signals from all 3 arteries, CFR values
were not different on LAD (3,2±0,3), LCx (3,1±0,2) and RCA (3,3±0,3).
Conclusion: With last generation, high frequency, contrast-enhanced transthoracic
echocardiography, and a skilled operator, imaging of coronary artery ﬂow and assessment of ﬂow reserve can be feasible, albeit with different success rates, highest
for LAD and lowest with LCx, in all major coronary arteries.
389
Is noninvasive measurement of coronary ﬂow velocity reserve an aid to
dobutamine echocardiography?. A case for the use in patients taking a
beta-blocker.
R. Florenciano 1 , G. De la Morena-Valenzuela 2 , R. Rubio-Patón 2 ,
M. Villegas-Garcia 2 , F. Soria-Arcos 2 , J. Hurtado 2 , F. Teruel-Carrillo 2 ,
M. Valdés-Chávarri 2 . 1 Murcia, Spain; 2 Hosp. Univ. Virgen de la Arrixaca,
Cardiology Dept., Murcia, Spain
Purpose: Noninvasive assessment of coronary ﬂow velocity reserve (CFVR) in the
left anterior descending artery (LAD) can be performed by transthoracic Doppler
echocardiography. Diagnostic ability of dobutamine echocardiography (DE) is lower
in patients who are taking beta-blockers. The objective of our study was to know
whether an impaired CFVR would add diagnostic value to DE to detect LAD stenosis
in patients who are taking beta-blockers.
Methods: We studied 83 patients (70% men, 65±11 years), who were taking
beta-blockers, referred to undergo a coronary arteriography after performing a DE.
CFVR in LAD was measured by transthoracic echocardiography before performing coronary arteriography. We used dipyridamole to produce hyperaemia by 0.84
mg/kg of intravenous infusion over 6 minutes. An echocardiographic contrast agent
(Sonovue) was used to enhance visualization of the Doppler signals. Assessment of
CFR was performed by an experienced observer blinded to DE results. CFVR was
calculated as the ratio of hyperaemia-to-baseline peak diastolic velocities. A cut-off
point of 1.7, was used to deﬁne an impaired CFVR. We considered a signiﬁcative
stenosis if its lumen diameter stenosis was > 70%. Variables derived from DE and
CFVR < 1.7 were included in a stepwise multivariate analysis. The incremental
value of CFVR information over DE data was assessed in two modeling steps.
Results: DE had a positive result in LAD territory in 30 patients (36%). We measured a CFVR < 1.7 in 43 patients (52%). A LAD stenosis was present in 34 patients
(41%). There were not complications. A CFVR<1.7 added diagnostic value to the
results of DE according to the results of the stepwise multivariate analysis showed
in table 1:
Table 1
Model
Parameter
Wald p Value Model chi-square Incremental p Value
DE
Positive result in LAD territory 9.21 0.002
DE + CFVR
CFVR < 1.7
8.88 0.002
9.75
19.30
0.0001
Conclusions: An impaired CFVR adds diagnostic value to DE to detect LAD stenosis in patients who are taking beta-blockers.
Eur J Echocardiography Abstracts Supplement, December 2003
S48
Abstracts
390
Role of nitrates on the measurement of coronary ﬂow velocity reserve by
transthoracic echocardiography. Should we administer them as
pretreatment?
R. Florenciano 1 , G. De la Morena-Valenzuela 2 , R. Rubio-Paton 2 , F. Soria-Arcos 2 ,
M. Villegas-Garcia 2 , J. Hurtado 2 , F. Teruel-Carrillo 2 , M. Valdes-Chavarri 2 .
1
Murcia, Spain; 2 Hosp. Univ. Virgen de la Arrixaca, Cardiology Dept., Murcia,
Spain
Objective: Coronary ﬂow velocity reserve (CFVR) can be inﬂuenced by nitrates
on healthy athletes, so patients without coronary stenosis who are not previously
treated with nitrates, might have abnormal CFVR. Our objective was to determine if
taking nitrates can modify the rate of false-positive results.
Method: We studied 71 patients (64±10 years, 66% men) who underwent coronary arteriography due to suspected coronary artery disease but without signiﬁcant stenosis in the left anterior descending coronary artery. CFVR was measured
by transthoracic echocardiography (Philips Sonos 5500) using a 12 MHz transducer. Dipyridamole (0.84 mg/kg) was used as vasodilator. An echo-contrast agent
(SonoVue) was administered to all patients. We evaluated the rate of patients who
were taking long-acting nitrates before measuring CFVR. Fisher’s test was perfomed to compare proportions.
Results: There was not signiﬁcant difference in the proportion of false or truepositive results according to the therapy with or without long-acting nitrates, as table
1 shows:
Table 1
Nitrates
False-positive results (n=15)
True-positive results (n=56)
9 (19%)
6 (25%)
38 (81%)
18 (75%)
Yes
No
p=0.5 (ns)
Conclusion: In patients with suspected coronary artery disease, rate of falsepositive results is not higher in patients who are not taking long-acting nitrates.
Long-acting nitrates do not inﬂuence CFVR.
391
Effects of smoking on coronary blood ﬂow velocity and coronary ﬂow
reserve.
S.M. Park, W.J. Shim, S.W. Rha, S.W. Park, D.S. Lim, Y.H. Kim, D.J. Oh, Y.M. Ro.
Korea University Hospital, Division of cardiology, Seoul, Korea, Republic of
Backgrounds and Objectives: The effects of smoking on coronary blood ﬂow has not
been well evaluated. Coronary blood ﬂow velocity (CFV) can be measured directly
with transthoracic Doppler echocardiography (TTDE) and conducted immediately
after smoking. The purpose of this study was to evaluate the chronic and acute
effects of smoking on CFV and coronary blood ﬂow reserve (CFR).
Methods: The study population consisted of 20 healthy men (11 smokers and 9
non-smokers). None of this study participants had a history of cardiovascular disease or other risk factors for coronary artery disease except smoking. Smoking
was abstained at least 4 hours before study in smokers. CFV was measured at
the distal left anterior descending coronary artery by TTDE at baseline and during
intravenous adenosine infusion (140ug/kg/min) in all subjects. In smokers, immediately after two consecutive cigarettes smoking, CFV was measured repeatedly
at baseline and during adenosine infusion. CFR after smoking was corrected with
rate pressure product (RPP) because of marked alteration of heart rate and blood
pressure after smoking.
Results: Before smoking, CFR and coronary vascular resistance index (CVRI) did
not differ between non-smokers and smokers (CFR:3.5 ± 0.8 vs 3.6 ± 0.6, p>0.05,
CVRI:0.28 vs 0.28, p>0.05). The acute effect of smoking on coronary blood ﬂow is
shown below.
Acute effects on Coronary Blood Flow
CFR
RPP
CCFR
CVRI
Before smoking
After smoking
3.6 ± 0.6
95 ± 17
2.9 ± 0.6
0.27 ± 0.06
3.5 ± 0.7 *
112 ± 15 *
2.3 ± 0.6 *
0.32 ± 0.07 *
*p <0.05 vs before smoking, CFR; coronary blood ﬂow reserve, RPP; rate pressure product
(mmHg/min*100), CCFR; corrected coronary blood ﬂow reserve derived from the ratio of blood
ﬂow to RPP, CVRI; coronary vascular resistance index
Conclusion: After 4 hours of abstinence from smoking, CFR and CVRI in smokers were similar to those of non-smokers. But, smoking acutely reduced CFR and
increased CVRI in smokers. These ﬁndings suggest that smoking itself can induce
myocardial ischemia, especially in patients with coronary artery disease.
Eur J Echocardiography Abstracts Supplement, December 2003
392
Echocardiographic assessment of coronary ﬂow reserve in patients with
borderline stenosis of LAD. Comparison with exercise echocardiography.
V. Chaloupka 1 , P. Kala 2 , L. Elbl 1 . 1 University Hospital, Dept of Cardiovascular
Testing, Brno, Czech Republic; 2 University Hospital, Clinic of Cardiology, Brno,
Czech Republic
It is widely accepted that the decision for coronary interventions should be based
on objective evidence of ischemia provided by ergometry, myocardial scintigraphy
or stress echocardiography. Coronary ﬂow reserve (CFR) assessment represents
a clinically useful method to evaluate coronary function. In the majority of patients,
the middle and distal segment of LDA can be detected and ﬂow velocity adequately
determined by transthoracic echocardiography.
The aim of our study was to determine the feasibility of echocardiographic CFR
assessment in patients with borderline stenosis of LAD coronary artery and comparison with exercise echocardiography (EE).
We studied 18 patients (16 men and 2 women) with moderately severe coronary
artery stenosis (50-70%) on intravascular ultrasound. In these patients we performed exercise echocardiography and echocardiographic CFR assessment. We
used high frequency transducer (5MHz) or, if we did not obtain sufﬁciently goodquality image, contrast-enhanced second harmonic echo (Levovist).
For coronary artery dilatation we used adenosine 0,14mg/kg/min. The CFR was
calculated as the ratio of hyperemic to basal peak diastolic ﬂow velocity. At 6 patients
we got sufﬁciently quality entry for CFR measurements without use of the contrast
agent.
No major adverse reactions occurred during hyperemia. Infusion of adenosine generally causes a slight increase in heart rate and mild hyperventilation. Arrhythmias
were not observed. One patient complained of intense headache.
The mean value of CFR was 2,2 + 0,37.
Positive exercise echocardiography was in 8 patients. We divided patients according
positivity into two groups. The mean value of CFR in patient with positive EE was
1,9 + 0,1 and in the second group with negative EE was 2,5 + 0,16 (p< 0,01).
In conclusion, transthoracic Doppler echocardiography could be probably a very
precise noninvasive method for assessment of functional importance of LAD stenosis. From technical point of view, the examination has some limitations and requires
training and experience, as well as knowledge of coronary anatomy.
393
Association between coronary ﬂow and myocardial acoustic density in
never treated uncomplicated hypertensive patients.
M. Galderisi 1 , G. de Simone 1 , M. Chinali 1 , S. Cicala 2 , C. Romano 1 , O. de
Divitiis 1 . 1 Federico II University, Clinical and Experimental Medicine, Naples, Italy;
2
Santobono-Pausillipon Hospital, Cardiology, Naples, Italy
Purpose: To analyze the relation between integrated backscatter (IBS) and coronary ﬂow (CF) in uncomplicated arterial hypertension.
Methods: The study population included 28 never-treated, newly diagnosed, stage
I-II WHO, hypertensive patients (M/F = 20/8, mean age = 52 years) without coronary artery disease, cardiomyopathies, diabetes mellitus, valvular or cardiac rhythm
abnormalities. IBS signals were recorded in parasternal long-axis view from speciﬁc regions of interest at the level of proximal anterior septum, basal posterior wall
and posterior pericardium. Acoustic intensity obtained from the analyzed myocardial
structures was corrected for gain setting, depth of the analyzed structure and signal
from posterior pericardium IBS. CF diastolic velocities were obtained from distal left
anterior descendent artery by trans-thoracic harmonic Doppler-echo, both at baseline and after low-dose dipyridamole (Dip) infusion (0.56 mg/Kg iv in 4’): coronary
ﬂow reserve (CFR) was measured as the Dip/basal CF velocity ratio.
Results: Basal CF diastolic peak velocity was positively related to IBS of both septum (r=0.46, p<0.01) and posterior wall (r=0.48, p<0.01). These associations remained signiﬁcant even after Dip infusion (r=0.46 p<0.01 for septum, r=0.39 p=0.04
for posterior wall). Relations of CF to IBS were conﬁrmed at either time, after controlling for diastolic blood pressure (BP) and heart rate. IBS was not signiﬁcantly
related to CFR or to left ventricular mass (LVM), whereas it was positively associated with relative wall thickness (r=0.40 for septal IBS, r=0.45 posterior wall IBS,
both p=0.04). CFR was reduced (i.e.<2) in 12 hypertensives and normal (>2) in 16.
The 2 groups had similar age, body size, BP and HR, wall thickness and LVM. No
signiﬁcant difference of IBS indexes was observed between the 2 groups.
Conclusions: In never-treated, newly diagnosed hypertensive patients, myocardial diastolic acoustic density is positively related to coronary ﬂow diastolic velocities, both at baseline and after vasodilatation. Coronary ﬂow reserve, estimated by
low-dose dypiridamole hyperemic stimulus, is not inﬂuenced by myocardial acoustic
properties.
Abstracts
394
Ultrasonographic assessment of coronary ﬂow reserve to predict
signiﬁcant left anterior descending artery stenosis in patients with
inferior acute myocardial infarction.
L. Ascione 1 , M. De Michele 2 , M. Accadia 1 , S. Rumolo 1 , B. Tuccillo 1 , M. De
Michele 3 . 1 Ospedale Santa Mare di Loreto, Cardiologia, Naples, Italy; 2 Federico II
University, Clinical and Experimental Medicine, Naples, Italy; 3 Portici (Naples), Italy
Background: Non invasive evaluation of coronary ﬂow reserve (CFR) has proven
to be useful in the identiﬁcation of patients with signiﬁcant coronary artery disease.
However, few studies were carried out in subjects with acute myocardial infarction
(AMI).
Methods: Eighty subjects with ﬁrst uncomplicated inferior AMI were included in
the present analysis. The occurrence of ST segment elevation > 1 mm in V1-V4
leads and apical or anteroseptal wall motion abnormalities were exclusion criteria.Coronary ﬂow velocity parameters were recorded on the fourth day post-AMI at
baseline and after dipyridamole infusion (0.84 mg/kg) and a CFR > 2.0 was deﬁned as normal. All patients underwent coronary angiography and a signiﬁcant left
anterior descending stenosis was classiﬁed for lumen narrowing >70%.
Results: Adequate Doppler recordings in the left anterior descending artery was
obtained by transthoracic echocardiography in 75/80 patients. A CFR < 2 had a
sensitivity of 86% and a speciﬁcity of 89% for the presence of signiﬁcant left anterior
descending artery stenosis.
Conclusion: Early CFR assessment is a safe and effective tool to identify a signiﬁcant left anterior descending artery involvement in patients with acute inferior
AMI.
395
Comparision of the morphological and functional characteristics of
internal mammary arterym radial artery and venous saphenous grafts.
I. Hegedûs, Katalin Interberger, Zoltán Galajda, Tibor Szûk. University of
Debrecen, Cardiology, Debrecen, Hungary
Internal mammary coronary grafts have a higher long term pataency rate comparing to venous grafts. Experience from short and intermediate term patency rate of
the radial artery grafts is favorable. Using ultrasound examination we were trying to
ﬁnd some difference between the morphologic and functional characteristics of the
grafts. We evaluated 116 grafts in 45 patients (58 internal mammary arteriy, 38 radial artery and 20 saphenous vein grafts) using ultrasound examination. Coronarography was also performed in all patients. There was no signiﬁcant difference regarding the timing of postoperative examination (45±6 months postoperatively). Using
the diameter and the diastolic ﬂow TVI of the grafts were measured and the grafts
ﬂow was calculated. Based on coronarography 2 LIMA, 3 radial artery and 7 saphenous vein grafts showed signiﬁcans stenosis. The diameter of the patent saphenous
vein grafts was signiﬁcantly larger comparing to the radial, and internal mammary
arteries (VS: 3,35±0,27 mm, AR: 2,91±0,19 mm, LIMA: 2,72 mm). The diastolic
TVI of the saphenous vein grafts were signiﬁcantly higher, than of internal mammary or radial arteries (VS:0,884 ±0,132 m, LIMA:0,653±0,121m, AR:0,714±0,109
m).The calculated ﬂow was also higher in saphenous vein grafts. Diastolic TVI of the
stenotic grafts was signiﬁcantly lower comparing to patent grafts.
Conclusions: 1)ultrasound examination is a promising method for coronary graft
ﬂow evaluation. 2).diastolic TVI and ﬂow is higher in VS grafts. 3) diastolic TVI in
stenotic grafts is signiﬁcantly lower than in patent grafts.
396
Testing LIMA graft permeability by transthoracic echo-Doppler.
I. Madariaga, Raquel Ancin. Area Clínica del Corazón, Cardiology, Pamplona,
Spain
Purpose: Post-operative measurement of graft permeability by angiography is invasive. The aim of this study is to evaluate the utility of transthoracic echo-Doppler
(TTE) in measuring LIMA graft permeability.
Methods: We studied 89 consecutive patients (average age 65 years, range 3779 years) who were revascularized with a LIMA. Graft permeability was evaluated
by both color- and pulsed-Doppler TTE. We measured the following parameters:
systolic velocity peak (SVP), diastolic velocity peak (DVP), average velocity, pulsate
index (PI), resistance index (RI). Of the 89 patients, 60 also underwent angiography.
We considered stenosis to be severe if greater than 70% as indicated by angiography.
Results: We were able to obtain TTE data for 85 patients (95.5%) and of these
57 had angiography too. Doppler registers were biphasic, with both systolic and diastolic components. In patients with grafts functioning normally, registers were predominantly diastolic. When the graft was dysfunctional registers were predominantly
systolic (similar to the register of the mammary artery in its anatomic position). Patients with dysfunctional grafts had higher SVP (p<0.01), higher DVP (p<0.05), and
higher PI (p<0.001). The sensitivity and speciﬁcity of TTE in the detection of severe
graft dysfunction were 86% and 100% respectively. The positive prediction value
was 100%.
Conclusions: TTE has high sensitivity, speciﬁcity and predictive value in determination of LIMA graft permeability. Being non-invasive, TTE is ideal for the follow-up
of patients with LIMA grafts.
S49
397
Noninvasive measurement of coronary ﬂow reserve in the anterior and
posterior descending coronary arteries by transthoracic Doppler.
P. Spedicato 1 , A. Aprile 1 , V. Pucci 1 , E. Mariano 1 , M. Marchei 1 , E. Pisani 1 ,
P. Voci 2 , F. Pizzuto 2 , F. Romeo 1 . 1 University of Rome II "Tor Vergata", Cardiology
Dept., Rome, Italy; 2 University of Rome "La Sapienza", Cardiac Surgery, Rome,
Italy
We measured coronary ﬂow reserve (CFR, hyperemic/resting diastolic ﬂow velocity ratio) in the anterior (LAD) and posterior descending (PD) coronary arteries by
transthoracic color-Doppler Ultrasound during 90 sec intravenous adenosine infusion (140 mcg/kg/min) in 90 patients. We ﬁrst used a non-contrast, and more recently a contrast echocardiographic approach, to improve detection of PD ﬂow.
Non contrast approach. Baseline PD ﬂow was detected in 62/81 (76%) subjects, and
CFR was measurable in 44 of them (54%) because of adenosine-induced hyperventilation. According to angiography, these 44 subjects were divided into 3 groups:
Group 1, 0-29% stenosis; Group 2, 30-69% stenosis; Group 3, >70% stenosis.
PD CFR was 2.62±0.25 in 17 Group 1; 2.33±0.32 in 9 Group 2; 1.40±0.54 in 18
Group 3 subjects (F=41.83, p<0.0001). LAD CFR was 3.31±0.54 in 15 Group 1;
2.49±0.71 in 10 Group 2; 1.12±0.49 in 19 Group 3 subjects (F=65.68, p<0.0001).
A cut-off <2 identiﬁed >70% stenosis in both the artery supplying the PD, and in
the LAD.
Contrast approach. The preliminary experience with contrast echocardiography includes 9 patients receiving intravenous injection of 1-4 mL (5-20 mg) of a novel
ultrasound contrast agent (LK565, Koehler, Germany, 50 mg/vial). Color-Doppler
imaging of the PD was performed by 3.5 MHz and 7 MHz probes. CFR was measured in 8/9 patients. The average length of the visualized PD segment increased
from 5.3 mm without contrast to 11.6 mm with contrast, and the duration of visualization with contrast ranged from 5 to 12 min, allowing easier measurement of CFR
compared to the non-contrast approach.
Conclusions: The ultrasound contrast agent LK565 improves imaging of the PD, regardless of its origin from the right or circumﬂex coronary artery. Coronary Doppler
may change the clinical approach in stress echocardiography, since alteration of
ﬂow rather than ischemia is safely detected in the two most important vascular districts of the heart.
398
Intermediate severity coronary artery stenoses- transthoracic Doppler
coronary ﬂow reserve measurement.
P. Sonecki 1 , A. Ochala 2 , J. Gabryel 1 , Z. Lebek 1 , B. Gabrylewicz 2 ,
P. Kardaszewicz 1 , M. Tendera 2 . 1 St Mary Hospiatal, Dept. of Cardiology,
Czestochowa, Poland; 2 Silesian School of Medicine, III Cardiology Dept, Katowice,
Poland
In this preliminary report, we show usefulness of Transthoracic Doppler Echocardiography (TTDE) for functional evaluation of the intermediate coronary stenosis,
which can serve as a basement for further invasive or noninvasive treatment option
in this group of patient.
We demonstrate our own experiences in application of this method as an accessory
diagnostics, in order to enhance costeffectiveness in CAD treatment. Coronary Flow
Reserve (CFR) was assessed using TTDE in 20 patients with angina in CCS II or
III class, with marginal lesion of LAD in coronary angiogram while other coronaries
were lesion-free. Depending on CFR value, patients were qualiﬁed to IVUS and
eventually to invasive (CFR<2), or to non-invasive treatment (observational group,
CFR>2). CFR<2 (1,44±0,24) was measured in 7 patients (35%). Six of them had
essential stenosis in IVUS, ﬁve patients were directed to PCI, and in one case,
CABG was performed. In one patient no hemodynamically essential lesion of LAD
was found in IVUS examination, despite CFR<2 in TTDE. Every patient after PCI
was controlled in TTDE, showing higher values of CFR (3.03±0.35). In a group of
13 patients with CFR>2, none of them developed Acute Coronary Syndrome (ACS)
during follow up (mean 11.2±3.2 months).
Conclusion: Functional assessment of LAD stenosis, essentially increasing sensitivity and speciﬁcity of non-invasive diagnostics of CAD. Based on grasped experiences, we consider TTDE-CFR measurement as a useful method, allowing creation of patients subgroup with essential myocardial ischemia, which can beneﬁt
from eventual invasive treatment. The usage of this method for patient group with
marginal lesions in coronary angiogram permits for isolation of a subgroup for further interventions more precisely, necessitating IVUS and eventually invasive treatment.
The algorithm we use is helpful in selection of patients group, who should be treated
invasively, avoiding high costs of IVUS in every patient representing marginal lesion
in angiography
Eur J Echocardiography Abstracts Supplement, December 2003
S50
Abstracts
399
Coronary ﬂow velocity reserve and indices of aortic distensibility predict
patients with aortic plaque.
A. Nemes, T. Forster, M. Csanady. University of Szeged, 2nd Department of
Medicine, Szeged, Hungary
Background: The coronary ﬂow velocity reserve (CFR) has proven to be an important diagnostic tool that provides relevant physiological information regarding the
function of the left anterior descending coronary artery (LAD). The Elastic modulus
(E(p)) and Young’s modulus (E(s)) are functional markers of the aortic distensibility.
The aim of the present study was to examine the predictive value of the cardiac
risk factors, CFR, mean CFR, E(p) and E(s) in the evaluation of patients with aortic
plaque (grade 2-3 aortic atherosclerosis).
Methods and Patients: A total of 113 consecutive patients (77 men and 36 women,
aged 31 to 80 years) underwent stress transesophageal echocardiographic assessment of CFR. The CFR was calculated by the ratio of average peak diastolic ﬂow velocity (APV) during hyperemia to resting APV. The mean CFR was calculated by the
ratio of average mean diastolic ﬂow velocity (AMV) during hyperemia to resting AMV.
All patients had stable angina pectoris without previous myocardial infarction. The
coronary angiography was performed in all cases. During transesophageal echocardiography, aortic atherosclerosis (AA) was also evaluated: grade 0: no atherosclerosis, grade 1: intimal thickening, grade 2: aortic plaque <5mm, grade 3: aortic plaque
>5mm, grade 4: mobile parts. Cases with grade 4 aortic atherosclerosis were not
found in this patient population.
Results: The age (ROC area, 90%, p<0.01), the CFR (ROC area, 80%, p<0.01),
the mean CFR (ROC area, 79%, p<0.01), the E(p) (ROC area, 77%, p<0.01) and
the E(s) (ROC area, 65%, p<0.05) displayed good value for the prediction of patients with aortic plaque from cases without aortic atherosclerosis.
Conclusion: The age and the functional parameters of aorta and LAD have a predictive value in the evaluation of patients with grade 2-3 aortic atherosclerosis.
400
Echo transesophageal with power Doppler in the analysis of coronary
circulation.
J. Tress 1 , L.S. Da Costa 2 , R.C. Victer 3 , J.L.S. Machado 3 , R.S. Peixoto 3 ,
T.C.D. Estrada 4 , M.S. Garcia 4 , M.A.R. Torres 5 . 1 Rio de Janeiro, Brazil; 2 Sta Casa
de Misericórdia, Cardiology, Rio de Janeiro, Brazil; 3 Hospital De Clinicas De
Niteroi, Echocardiographic Laboratories, Rio De Janeiro, Brazil; 4 hospital de
clinicas de niteroi, anesthesiology, niteroi, Brazil; 5 Rio Grande do Sul University,
Cardiology, Porto Alegre, Brazil
We aimed to present a proposal in the evaluation of the anatomy and coronary ﬂow
using the Power Doppler (PD) method with Echo Transesophageal (ETE) in the visualization of coronary arteries.Innumerous literary studies have recently described
the evaluation of coronary arteries using the Color-Doppler (CD) method, but presenting percentage variations between the values of coronary arteries that still has
not allowed for the adequate development of this methodology.
Methods: We used the PD technique in the ETE to be able to comparatively deﬁne
both the anatomy of main coronary arteries and improve the accuracy of coronary
ﬂow with the pulsed and continuous Doppler. We studied 96 individuals with the
ETE in CD and PD mode, with normal hemodynamic study, 41 men and 55 women
between 28 and 70. The ETE was performed on all the individuals under general
anesthesia with a hypnotic anesthetic, propofol with a dose of 0.04mg/kg by a qualiﬁed and professional and different to the professional who conducted the test.We
analyzed the left main coronary artery (LMC), the left anterior descending artery
(LAD),left circumﬂex artery (LCA) and right coronary artery (RCA) individualized by
the CD and PD using the Student " T " Test.
Results: We showed the feasibility of carrying out the study of the coronary arteries
using ETE and the superiority of the PD method over the CD, as we shown on
following table
LMC
LAD PROX
LAD MEDIAL
PROX LCA
PROX RCA
PD
CD
100%
100%
100%
100%
100%
100%
100%
30 %
80 %
62%
401
Coronary ﬂow velocity reserve and Elastic modulus of the descending
aorta in patients with different kinds of signiﬁcant single-vessel coronary
artery disease.
A. Nemes, T. Forster, M. Csanady. University of Szeged, 2nd Department of
Medicine, Szeged, Hungary
Background: Coronary ﬂow velocity reserve (CFR) measurements provide physiological information on the severity of left anterior descending coronary artery (LAD)
stenosis. The Elastic modulus (E(p)) is an important index of the aortic distensibility.
The aim of the present study was to evaluate CFR and E(p) in patients with different
kinds of signiﬁcant single-vessel coronary artery disease (CAD).
Patients and Methods: 61 patients (41 male and 20 female, mean age: 54±8
years) with signiﬁcant single-vessel CAD were enrolled in the study. Patients with
normal epicardial coronary arteries (group 1), patients with signiﬁcant LAD disease
(group 2), patients with left circumﬂex coronary artery (CX) disease (group 3) and
patients with right coronary artery (RC) disease (group 4) were investigated. All
patients underwent coronary angiography and stress transesophageal echocardiography as CFR measurement (TEE-CFR). Dipyridamole was used in 0.56 mg/kg
dose for 4 minutes as a vasodilator agent. The CFR was calculated by the ratio of
average peak diastolic ﬂow velocity (APV) during hyperemia to resting APV. E(p)
was also evaluated during TEE-CFR from echocardiographic parameters and blood
pressure data.
Results: Data of patients with different kinds of single-vessel CAD are presented in
the table.
Data of patients
Group 1
Group 2
Group 3
Group 4
No
CFR
E(p)
17
31
6
7
2.60±1.23
1.75±0.54*
2.67±1.16
2.56±0.73
0.45±0.23
0.93±0.45**
0.84±0.55**
0.63±0.56**
*p<0.05 vs groups 1 and 3 and 4; **p<0.05 vs group 1
Conclusions: 1. The CFR of patients with LAD disease was decreased compared
to negative control cases and to patients with CX or RC disease. 2. The Elastic
modulus of the descending aorta was increased in patients with single-vessel CAD
independently the location of the signiﬁcant stenosis.
402
Coronary ﬂow velocity reserve and Elastic modulus of the descending
aorta in patients with aortic stenosis with or without mitral stenosis.
A. Nemes, T. Forster, M. Csanady. University of Szeged, 2nd Department of
Medicine, Szeged, Hungary
Background: The coronary ﬂow velocity reserve (CFR), an important index with
which to assess the function of the left anterior descending coronary artery (LAD).
The Elastic modulus (E(p)) is a functional marker of the distensibility of the descending aorta.
The aim of the present study was to evaluate CFR and E(p) in patients with aortic
valve stenosis (AOS) with normal epicardial arteries with or without mitral valve
stenosis (MS).
Patients and Methods: 32 patients (14 male and 18 female, mean age 56±13
years) with a negative coronary angiogram were enrolled in the study. Patients
without valvular heart disease (group 1), patients with AOS (group 2) and patients
with AOS with MS (group 3) were investigated. All cases underwent stress transesophageal echocardiography as CFR measurement (TEE-CFR). Dipyridamole
was used in 0.56 mg/kg dose for 4 minutes as a vasodilator agent. The CFR was calculated by the ratio of average peak diastolic ﬂow velocity (APV) during hyperemia
to resting APV. E(p) was also evaluated during TEE-CFR from echocardiographic
parameters and blood pressure data.
Results are presented in the table.
Data of patients
P < 0,0001
P < 0,001
P < 0,001
Left Main Coronary Artery = LMCLeft Anterior Descending Artery = LAD Left Circumﬂex Artery
= LCARight Coronary Artery = RCAPower Doppler = PDColor Doppler = CD
Conclusion: The PD with ETE was fundamental in the non-invasive study of coronary arteries and possible routine in the investigation of feasibility and the anatomic
study of coronary ﬂow.
Eur J Echocardiography Abstracts Supplement, December 2003
Group 1
Group 2
Group 3
No
Aortic gradient (mm Hg)
CFR
E(p)
17
10
5
–
89±32
74±22
2.60±1.22
1.80±0.44*
1.84±0.33*
0.45±0.23
0.81±0.66*
0.86±0.61*
*p<0.05 vs group 1
Conclusions: 1. CFR and E(p) were signiﬁcantly different between negative cases
and patients with AOS. 2. There were no further changes in these parameters, when
MS was associated with AOS.
Eur J Echocardiography Abstracts Supplement, December 2003
Poster Session 3
5 December 2003, 8:30 to 12:30
Location: Poster Hall
MODERATED POSTERS
480
Analysis of coronary perfusion with myocardial contrast
echocardiography. Implications and relationship with angiography and
MRI.
V. Bertomeu 1 , V. Bodí 1 , J. Sanchis 1 , M.P. López-Lereu 2 , A. Losada 1 , A. Llácer 1 ,
M. Pellicer 1 , F.J. Chorro 1 . 1 Hospital Clínic i Universitari, Servei de Cardiología,
Valencia, Spain; 2 Hospital Clínic i Universitari, Magnetic Resonance Imaging,
Valencia, Spain
Objectives: We show our initial experience with myocardial echocardiography with
intracoronary injection of contrast (MCE).
Method: Thirty patients with a ﬁrst ST-elevation myocardial infarction (MI) and a
patent infarct-related artery (stent in 22 cases) were studied at ﬁrst week (1w) postMI. Mean perfusion score of the infarcted area was analysed with MCE (0="no reﬂow", .5=patchy, 1=normal), TIMI-Blush grades (angiography) and magnetic resonance imaging (MRI). Normal perfusion= MCE >.75. End-diastolic volume (EDV)
and ejection fraction (EF) were calculated with MRI. At sixth month (6m) all the
explorations were repeated in the ﬁrst 17 patients (all of them with an open artery).
Results: MCE were done without complications (6±2 minutes per study). At 1w
normal perfusion was observed in 74% of patients with TIMI 3 and in 0% of TIMI 2.
In the 27 patients with TIMI 3, normal perfusion was present in 82% of cases with
Blush 2-3 and in 40% of Blush 0-1; in 90% of cases with MRI-perfusion=1 and in
57% of MRI-perfusion <1. MCE was the best perfusion index in predicting EDV (r=.69 p=.002) and EF (r=.72 p=.001) at 6m. MCE improved from 1w to 6m (.73±.34
vs. .82±.32 p=.07). MCE at 6m was the best predictor of late remodeling (increase
of VTD from 1w to 6m: r=-.68 p=.003).
Conclusions: MCE is a feasible, not time-consuming technique and it has not secondary effects. MCE was the most reliable perfusion index to predict late remodeling
and systolic function. To achieve a normal perfusion TIMI 3 is indispensable (but it
is not a guarantee). In TIMI 3 cases, a normal Blush or a normal MRI perfusion
study suggests a good reperfusion but an abnormal result does not exclude normal
perfusion.
481
MCE is superior to DSE in predicting myocardial recovery after
revascularization in patients with occluded left anterior descending
artery.
C.I. Aggeli 1 , M.S. Bonou 2 , N. Georgiadis 1 , C.S. Theocharis 2 , G. Roussakis 1 ,
C. Chatzos 1 , S. Brili 1 , C. Pitsavos 1 , C. Stefanadis 1 . 1 Hippikration Hospital,
Cardiology, Athens, Greece; 2 Polycliniki, Cardiology, Athens, Greece
We assessed the hypothesis that myocardial contrast echocardiography (MCE) and
dobutamine stress echocardiography (DSE) have the ability to predict recovery of
dysfunctional myocardium after revascularization in patients with left anterior descending (LAD) coronary artery disease.
Methods: 41 patients (mean age 62±4 y) with LAD disease, 23 with severe stenosis >70% (group A) and 18 with occluded LAD (group B) and regional dysfunction
underwent coronary angiography and MCE and DSE 2-5 days before revascularization. All patients had multivessel disease. MCE was performed using continuous SonoVue (Bracco) intravenous infusion (120-180 ml/h) with Harmonic Power
Doppler Imaging and incremental triggering (1:1 to 1:8). Contrast score index (3
grade scale) for the LAD supplied area was calculated for perfusion analysis. All patients underwent coronary bypass grafting and rest echocardiography was repeated
2-3 months after revascularization.
Results: There were no differences in age, ejection fraction at rest, and wall motion
score index at rest between the two groups. Of 243 dysfunctional segments in the
LAD territory undergoing revascularization 109 (62 in group A and 47 in group B)
recovered at follow up. In group A, MCE and DSE exhibited similar values of sensitivity, speciﬁcity and accuracy (87% vs. 87%, 62% vs. 72%, 73% vs. 79%, respectively), whereas in group B MCE showed higher sensitivity and negative predictive
value than DSE (81% vs. 57%, p<0.001 and 80% vs. 68%, p<0.05, respectively) in
predicting segmental myocardial recovery. These differences in sensitivity and negative predictive value between MCE and DSE were more pronounced in akinetic
segments of group B (75% vs. 35%, p<0.001 and 75% vs. 56%, p<0.05). Signiﬁcant correlation was observed between the regional contrast score index and both
the follow up regional wall motion score index (r=-0.65 for group A and r=-0.60 for
group B) and the follow up ejection fraction change (r=0.64 for group A and r=0.60
for group B).
In conclusion, triggered MCE demonstrates higher sensitivity and negative predictive value in predicting recovery of dysfunctional myocardium supplied by totally
occluded LAD after revascularization, compared with DSE.
S52
Abstracts
482
Coronary recanalization evaluation after acute myocardial infarction:
comparison between continuous EKG ST monitoring (MIDA) versus
contrast echocardiography for perfusion and coronary ﬂow detection.
P. Colonna 1 , A. Andriani 2 , L. Truncellito 2 , E. De Nittis 2 , M. De Divitiis 2 ,
B. D’Alessandro 2 , I. De Luca 1 . 1 Azienda Policlinico, Cardiology Division, Bari,
Italy; 2 Cardiology Division, Policoro (MT), Italy
Background: After acute myocardial infarction (AMI), the persistent elevation of ST
segment in the surface electrocardiogram (EKG) predicts lack of coronary recanalization and bad prognosis. In these patients the reperfusion may remain impaired
due to the occlusion of the epicardial coronary vessel, or to a process of microvascular injury, detectable with intravenous myocardial contrast echocardiography. We
hypothesized that patients with a rapid ST segment return to baseline have a better
myocardial contrast perfusion and coronary artery patency.
Methods: In 18 patients with a ﬁrst AMI (15 treated with intravenous thrombolysis), a surface EKG with continuous ST monitoring (MIDA) was recorded for 24
hours after admission; the ST elevation was summed in all anterior leads and the
percentage of recovery of the summation at 90 minutes ECG was computed. Intravenous myocardial contrast echocardiography (Sonovue) with harmonic power
Doppler (Agilent Sonos 5500) was performed 2.8±0.9 days after the acute phase
and the coronary ﬂow in the anterior descending coronary artery was investigated
in the 8 patients with anterior AMI.
Results: In 11/18 patients (61.1%) ST segment resolution was >50% of the baseline value, and in 9 of these 11 patients (81.8%) there was optimal perfusion at
contrast echocardiography. Among the 7 with persistent ST elevation only 2 patients (28.6%, p<0.05) showed a good perfusion. In 5 of the 8 anterior AMI patients
the color Doppler ﬂow was visualized in the anterior descending coronary artery,
and all 5 showed a ST recovery and normal perfusion.
Conclusion: After AMI the myocardial perfusion at contrast echocardiography and
the coronary color Doppler ﬂow are related to the ST segment resolution at continuous ST monitoring (MIDA), indicative of coronary artery recanalization.
483
Adenosine contrast echocardiography is a powerful long-term predictor
of serious cardiac events: follow-up of 182 patients up to 60 months.
F.C. Palheiro, A. Moraes, M. Carrinho, F. Brasil, A.B. Martins, C. Medeiros,
A.C. Nogueira, R. Morcerf, E.P. Duarte, F. Morcerf. ECOR - Diagnóstico
Cardiovascular, Rio de Janeiro, Brazil
Background: Myocardial perfusion by echocardiography with intravenous injection
of contrast agents is an useful imaging modality technique for the diagnosis of coronary artery disease (CAD). However its prognostic value has not been studied yet.
So the aim of this study was to evaluate the long term prognostic value of the myocardial contrast echocardiography with adenosine (ACE) in patients with known or
suspected CAD.
Methods: We examined the outcomes of 182 pts (mean age 60±10 years) who
underwent ACE. A positive test was considered an ischemic response. All patients
were followed up for a median of 2.5 years and divided in 3 groups (Group A - 47
pts with conﬁrmed CAD, Group B - 58 pts with high risk for CAD, and Group C - 77
pts ith low to intermediate risk for CAD). The end-points analyzed were hard events
(cardiac death, non-fatal myocardial infarction or a revascularization procedure) and
minor events (stable angina or diagnostic coronary angiography).
Results: Thirty pts experienced hard events: 11 non fatal myocardial infarctions,
3 cardiac deaths, and 16 pts had a revascularization procedure either by PTCA
(n=9) or CABG (n=7), and 12 pts experienced minor events (Table). The cumulative
event free survival was 93% in pts with negative and 72% in pts with positive ACE
(p<0.01).
Positive/Negative ACE
Hard/Minor Event
p
Group A - 47
Group B - 58
Group C - 77
14/33
13/3
< 0.01
13/45
13/4
< 0.01
5/72
4/5
< 0.03
Conclusion: Adenosine Contrast Echocardiography (ACE) is an useful predictor of
late cardiac events in patients with known or suspected CAD and could be used in
the clinical scenario.
484
Analysis of real-time myocardial contrast echocardiograms by Fourier
Phase Analysis.
A. Hansen, A. Filusch, D. Wolf, G. Korosoglou, S. Hardt, H. Kuecherer. University
of Heidelberg, Cardiology Dept., Heidelberg, Germany
Background: Real-time myocardial contrast echo (MCE) is increasingly used to assess myocardial perfusion. However, objective methods for evaluating MCE are not
yet widely available. We sought to validate the ability of Fourier analysis applied to
MCE to assess serial changes in microvascular perfusion during coronary occlusion
and reperfusion.
Methods: Six pigs underwent 45 min of LAD occlusion followed by 120 min of reperfusion. Real time MCE was performed during coronary occlusion and reperfusion.
Signal intensities from replenishment curves were ﬁtted to an exponential function
to obtain plateau A and the rate of SI rise b. MCE images were mathematically
transformed using a ﬁrst-harmonic Fourier algorithm displaying the sequence of
Eur J Echocardiography Abstracts Supplement, December 2003
myocardial intensity changes as phase angles in parametric images. The phase
difference (PD) of posterior versus anterior region was calculated as an index of
myocardial opaciﬁcation heterogeneity and compared to MCE index of myocardial
blood ﬂow Axb.
Results: After initial hyperemia, a progressive reduction in ﬂow was observed during reperfusion. During LAD occlusion signal intensities were signiﬁcantly reduced
in anterior regions (Axb = 0.02±O.01) compared to baseline (1.2±0.3, p<0.01) and
approached higher levels post recanalization (Axb = 1.48±0.6) but gradually decreased during 120 min of reperfusion (A=0.51±0.3, p<0.01). Similarly, proﬁles of
phase angles in LAD perfusion territorities were consistently modiﬁed during reperfusion. The mean PD at baseline was 18°±15, decreased during coronary occlusion
to -108°±38, increased to 29°±19 post recanalization but decreased to -61°±35 after 120 min of reperfusion. PD signiﬁcantly correlated with A (r = 0.8, p<0.0001)
and b (r = 0.73, p<0.0001).
Conclusions: The progressive reduction in postischemic microvascular perfusion
was accurately detected by real-time MCE. Fourier phase imaging is feasible to
quantify dynamics of myocardial opaciﬁcation in a simple and objective format and
is a promising approach for the clinical interpretation of contrast echocardiograms.
485
Cost-effectiveness of second generation contrast agents in stress
echocardiography.
N.T. Kouris 1 , D.D. Kontogianni 2 , E.M. Kalkandi 2 , H.E. Grassos 2 , M.D. Sifaki 2 ,
G.S. Goranitou 2 , D.K. Babalis 2 . 1 Athens, Greece; 2 Western Attica General
Hospital, Cardiology dept, Athens, Greece
Echocardiographic image enhancement with second-generation contrast agents
has been shown to improve image quality in patients (pts) with suboptimal images
during dobutamine stress echocardiography (DSE). Suboptimal images, deﬁned as
poor visualization of endocardial borders, have been referred in as many as 33% of
pts undergoing DSE.
The purpose of our study was to estimate the cost-effectiveness of contrast enhancement (CE) in pts with suboptimal images during DSE, in regard to the need
of performing additional diagnostic testing.
Patients and Methods: One hundred and thirty two pts were referred to our laboratory for DSE, in order to detect or to evaluate coronary artery disease. The study
was considered to be suboptimal due to poor or absent visualization of the endocardial borders of 2 or more left ventricular segments in 1 or more standard views.
Patients with suboptimal baseline images were devided in two groups. Group A included pts who received CE and group B was consisted of the remaining pts who
completed their DSE without CE. We estimated the cost of CE compared to the
cost of additional stress nuclear test (SNT) by using the market price of Levovist (L)
(67.47 euros per vial) and SNT (270.58 euros).
Results: In 40 pts (30%) the study was considered to be suboptimal at baseline.
Thirty pts (75% - group A) received L and the remaining 10 pts (25% - group B) did
not. During the next month, 8 pts of group B underwent a SNT (80%), while 3 pts of
group A (10%) underwent a SNT, due to persistent suboptimal images throughout
the entire DSE. If 100 pts with baseline suboptimal images receive CE during DSE,
it will cost an additional 6.747 euros. If 10% of these pts require an additional SNT, it
will result in an additional cost of 2.706 euros (10 x 270.58). Thus, the total additional
cost on the 100 pts will be 9.453 euros, or approximately 95 euros per patient. If 100
pts with baseline suboptimal images complete the study without receiving CE, 80%
of them will require an additional SNT. Therefore, the additional cost is estimated
to be 21.600 euros (80 x 270) or 216 euros per patient. Thus, the use of CE would
result in an estimated saving of 121 euros.
Conclusion: Our study indicates that appropriate use of 2nd generation contrast
agents in patients referred for DSE is cost-effective, because it favorably impacts
the necessity of performing additional tests for the same clinical indication.
486
Left arial size exponentially increases with age and can be accurately
predicted using an equation.
M.R. Movahed, M. Ahmadi-Kashani, B. Kasravi, R. Gim, M. Hashemzadeh. UCI
Medical Center, Depatment of Medicine/Cardiology, Orange, USA
Introduction: Left atrial (LA) enlargement commonly occurs with increasing age.
However the prevalence of LA enlargement in different age groups is unknown. The
goal of this study was to evaluate the prevalence of LA enlargement in various age
groups using a large echocardiographic database.
Methods: We retrospectively analyzed 21,486 echocardiograms with documented
LA size and age performed at our institution in patients referred for echocardiography over a period of 14 years. We analyzed the occurrence of LA enlargement (deﬁned as over 40 mm measured by M-mode and two-dimensional echocardiography
in parasternal long axis) in patients 16 to 95 years of age. Using a curve estimation
method, we devised a formula that can accurately estimate this prevalence.
Results: Abnormal LA size was present in 9,072 (42.4%) patients. There was a
steady increase in prevalence of LA enlargement with increasing age (R-Square
of 0.909, p-value<0.0001). This association can be accurately measured by the
following exponential equation:
Y= Exp [4.35-(28.14/X)]; Y: Prevalence of abnormal LA size, X: Age
Conclusion: Using a large echocardiographic database, we found that LA size increases exponentially with age. We developed a formula that accurately estimates
this correlation.
Abstracts
S53
487
Early changes of left atrial reservoir function after cardioversion of
paroxysmal atrial ﬁbrillation predict relapse of arrhythmia.
489
Cardiac lipid accumulation associated with diastolic dysfunction in obese
mice.
P. Barbier, R. Chiodelli, M. Alimento, E. Assanelli, G. Marenzi, M.D. Guazzi. Centro
Cardiologico Fondazione Monzino, IRCCS, Milan, Italy
E. Bollano 1 , C. Christoffersen 2 , M.L.S. Lindegaard 2 , E.D. Bartels 2 , J.P. Goetze 2 ,
C.B. Andersen 3 , L.B. Nielsen 2 . 1 Wallenberg Laboratory, Göteborg, Sweden;
2
Rigshospitalet, University of Copenhagen, Department of Clinical Biochemistry,
Copenhagen, Denmark; 3 Rigshospitalet, University of Copenhagen, Department of
Pathology, Copenhagen, Denmark
Atrial ﬁbrillation (AF) causes systolic and diastolic left atrial (LA) dysfunction. Extent
of LA systolic stunning after cardioversion of AF have been evaluated, but do not
predict recurrence of AF.
Aim: to assess LA diastolic (reservoir) function after cardioversion of AF, as predictor of AF relapse 1 month after electrical cardioversion.
Methods: we studied 27 patients with paroxysmal AF > 1 month duration. Echocardiograms were perfomed 24 hours before (baseline) and 1 hour, 24 hours, 15 days
and 30 days after cardioversion. We measured LA reservoir as the difference between LA maximum and minimum biplane volumes (ml), and LA systolic function
(%) as: [(LA end-diastolic, at ECG P wave, volume - minimum LA volume)/enddiastolic volume].
Results: after 1 month, sinus rhythm was maintained in 11 (group 1, 41%), and
AF relapsed in 16 (group 2, 59%; 2 within 24 hours, 13 within 15 and 1 within 30
days) patients. Associated heart diseases, AF duration, and baseline left ventricular mass index and systolic function, LA biplane maximum (group 1: 90±28 ml,
group 2: 90±19, p=ns) volume, and estimated right ventricular systolic pressure
were similar in the 2 groups. Baseline LA reservoir was similarly greatly reduced
(when compared to value at 30 days post cardioversion of group 1) in both groups
(group 1: 16±6 vs 28±7 ml, p<.001; group 2: 13±6 vs 28±7 ml, p<.001; group
1 vs 2, p=ns). In the 2 groups, mean LA volumes did not change during follow-up.
In group 1, LA reservoir increased progressively during follow-up, with maximum
increase rate at 24 hours (baseline= 16±6 ml, 24 hours= 25±9, p<.05), whereas
LA systolic function increased signiﬁcantly only at 30 days (2 hours = 5±7%, 30
days= 15±6, p=.02). In group 2, LA reservoir and systolic functions changes during
follow-up were not signiﬁcant. At multivariate analysis, lack of reservoir increase in
the ﬁrst 24 hours after cardioversion was related to (and predicted) relapse of AF at
30 days (p<.001).
Conclusion: LA reservoir is impaired during AF, and reservoir stunning is associated with systolic stunning after cardioversion. However, LA reservoir recovers
earlier than LA systolic function, and the extent of this recovery in the ﬁrst hours
after cardioversion predicts maintainance of sinus rhythm in the ﬁrst month after
cardioversion.
488
Atrial deformation properties during atrial ﬁbrillation and their prognostic
value: a strain and strain rate imaging study.
G. Di Salvo 1 , P. Caso 2 , R. Lo Piccolo 3 , A. Fusco 1 , A.R. Martiniello 3 ,
A. D’Andrea 3 , N. Mininni 2 , R. Calabrò 3 . 1 Second University of Naples,
Department of Cardiology, Naples, Italy; 2 Monaldi Hospital, Department of
Cardiology, Naples, Italy; 3 Second University of Naples, Paediatric Cardiology,
Naples, Italy
Background: Atrial ﬁbrillation (AF) is a common arrhythmia characterized by a lack
of organized atrial mechanical activity.
Strain (S)(%) and Strain Rate (SR)(1/sec) imaging, derived by ultrasound offer a
new quantitative approach to study regional myocardial deformation. S is the total
amount of deformation while SR is the rate at which deformation takes place.
So far, few data are available about atrial deformation properties, their change during AF, and the value of the new deformation indices in predicting AF recurrence.
Study Aims: 1- to evaluate atrial deformation properties during AF, comparing those
data with that of 30 healthy subjects; 2- to assess the prognostic value of S/SR
imaging in deﬁning the risk of AF recurrence.
Methods: we studied 40 consecutive patients (60% men; range 30-55 years) with
lone AF and 30 healthy subjects.
All patients had duration of AF more than 1 month. The atrial peak systolic S and
SR were measured during AF. All the studied patients underwent successful DC
cardioversion 24 hours after S/SR imaging study. All patients were prospectivelly
followed for a six months period (median 195 days; range 170-439 days). Hospitalization due to AF recurrence were regarded as endpoints. S/SR study was performed from the apical 4 and 2 chamber views, placing the sample volume in the
middle segment of the left atrial walls.
Results: During AF atrial deformation properties were signiﬁcantly reduced in the
studied patients when compared to normals (AF patients: S= 17±16; healthy subjects: S= 80±20, p<0.001).
After 6 moths follow-up period 4 patients (Group I) were hospitalized because of AF
recurrence.
S/SR values, at the inclusion, of Group I were signiﬁcantly reduced when compared
to the other 36 patients (Group II) (S: Group I= 17%±22 vs 22±10, p<0.05; SR:
Group I=0.97±0.39 vs 2.2±0.4, p<0.05).
Conclusion: Atrial deformation properties are severely compromise during atrial
ﬁbrillation.
Patients with more severe reduction of atrial deformation properties seem to be at
higher risk to develop an AF recurrence.
Obesity may confer cardiac dysfunction due to lipid accumulation in cardiomyocytes.
To test this idea, we examined whether obese ob/ob mice display heart lipid accumulation and cardiac dysfunction. Ob/ob mouse hearts had increased expression of
genes mediating extracellular generation, transport across the myocyte cell membrane, intracellular transport, mitochondrial uptake, and beta-oxidation of fatty acids
compared with ob/+ mice. Accordingly, ob/ob mouse hearts contained more triglyceride (6.8 ± 0.4 versus 2.3 ± 0.4 µg/mg, P < 0.0005) than ob/+ mouse hearts. Histological examinations showed marked accumulation of neutral lipid droplets within
cardiac myocytes but not increased deposition of collagen between myocytes in
ob/ob compared with ob/+ mouse hearts. On echocardiography, the ratio of E to
A trans-mitral ﬂow velocities (an indicator of diastolic function) was 1.8 ± 0.1 in
ob/ob mice and 2.5 ± 0.1 in ob/+ mice (P = 0.0001). In contrast, the indexes of
systolic function and heart brain natriuretic peptide mRNA expression were only
marginally affected and unaffected, respectively, in ob/ob compared to ob/+ mice.
The results suggest that ob/ob mouse hearts have increased expression of cardiac
gene products that stimulate myocyte fatty acid uptake and triglyceride storage and
accumulate neutral lipids within the cardiac myocytes. The results also suggest that
the cardiac lipid accumulation is paralleled by affected cardiac diastolic dysfunction
in ob/ob mice.
LEFT-VENTRICULAR HYPERTROPHY
491
Detection of myocardial hypertrophy in patients with unexplained
negative T-waves on ECG.
D. Pellerin, R.S. Sharma, P.M. Elliott, W.J. McKenna. The Heart Hospital, London,
United Kingdom
The diagnosis of hypertrophic cardiomyopathy (HCM) is usually based on the
echocardiographic demonstration of left ventricular hypertrophy (LVH). Despite the
use of harmonic imaging, however, the detection of LVH at the LV apex can be
problematic. In consequence apical hypertrophy can be misinterpreted as akinesia,
apical thrombus or tumour. Left ventricular cavity opaciﬁcation (LVO) using echocardiography contrast agents is commonly used for delineation of endocardial borders
in all myocardial segments. Ten patients with negative T waves on ECG and low
probability of coronary artery disease were studied by echocardiography with harmonic imaging before and during LVO. Two patients had family history of HCM. An
endocardial border deﬁnition score was obtained in each segment as follows: 0 =
not seen, 1 = adequate endocardial visualisation during at least one phase of the
cardiac cycle, and 2 = excellent endocardial visualisation during entire cardiac cycle.
End diastolic wall thickness was measured in the 16 myocardial segments. Four patients had poor visualisation of apical endocardium before LVO. Echocardiography
with grey-scale and low velocity colour Doppler failed to demonstrate abnormalities
in 6 patients and showed large apical akinesia in 4 patients. LVO identiﬁed 7 patients
with apical cardiomyopathy showing a spade-like appearance of the left ventricular
cavity caused by near obliteration of the apex by the hypertrophy. One patient had
mid cavity obstruction with apical aneurysm. The 4 patients with apical akinesia before LVO had hyperdynamic apical motion during LVO. Thus, in 8 out of 10 patients,
the diagnosis of cardiomyopathy would have been missed without the use of contrast agents. Echocardiography with harmonic imaging and LVO should be routinely
used in patients with unexplained negative T waves on ECG and apparent apical
akinesia.
Eur J Echocardiography Abstracts Supplement, December 2003
S54
Abstracts
492
Role of echocardiography in the diagnosis of arrhythmogenic right
ventricular cardiomyopathy: comparison with Magnetic Resonance
Imaging.
494
Tissue Doppler imaging identiﬁes early improvement in left ventricular
systolic and diastolic function after aortic valve replacement for aortic
stenosis.
S. Romano 1 , P. Scipioni 1 , S. Fratini 1 , L. Restauri 2 , F. Pastori 1 , E. Di Cesare 3 ,
C. Masciocchi 3 , M. Penco 1 . 1 Cardiology, Internal Medicine, L’Aquila University,
L’Aquila, Italy; 2 University of L’Aquila, Dept. of Cardiology, L’Aquila, Italy;
3
University of L’Aquila, Dept. of Radiology, L’Aquila, Italy
R.J. Graham 1 , S. Hunter 2 , M.J. Stewart 1 . 1 The James Cook University Hospital,
Cardiology, Middlesbrough, United Kingdom; 2 The James Cook University
Hospital, Cardiothoracic Surgery, Middlesbrough, United Kingdom
Background: The arrhythmogenic right ventricular cardiomyopathy (ARVC) is a
hereditary heart disease of unclear etiopathogenesis, characterized by a gradual
loss of myocites which are replaced by ﬁbro-fatty tissue and consequent right ventricular (RV) dilation and dysfunction. The clinical course is characterized by arrhythmias, sudden death and heart failure. Echocardiography (ECHO) may be useful to
evaluate right ventricular size and function, which are important major and minor
criteria for the diagnosis of ARVC, but since structural abnormalities are slight or
moderate in most cases, they can be easily overlooked. Recently several studies
have investigated the role of other diagnostic techniques such as computed tomography (CT) or magnetic resonance imaging (MRI) to obtain more speciﬁc evidence
of the disease.
Aim of the study: To evaluate the role of ECHO in the diagnostic pathway of ARVC
in a selected cohort of patients undergoing MRI.
Methods: We retrospectively analyzed 78250 MRI performed in MRI lab of L’Aquila
University. One hundred and ﬁfty three patients (pts) underwent MRI for suspected
ARVC. In 108 (70,5%) was performed a color Doppler ECHO. As echocardiographic
ﬁndings of ARVC we considered: dilation, kinetic alterations and systolic dysfunction
of the RV. According to MRI data we considered as probable diagnosis the detection
of at least two of the following criteria: dilation, dyskinesis, adipose substitution.
Results: MRI conﬁrmed diagnosis in 18/46 (40%) pts who had a positive ECHO
for ARVC, whereas it was positive in 6/62 pts (9%) (p<0,001) with a non signiﬁcant
echo. RV dilation was present in 25 (54%) pts with and in 8 (12%) without positive
ECHO (p< 0,0001); adipose substitution was present in 15 (32%) pts with and in
10 (16%) without positive ECHO (p=0,07); kinetic alterations were present in 16 pts
(35%) with and in 7 (11%) without positive ECHO (p<0,001).
Conclusions: Echocardiography may be an useful screening method for ARVC, as
it is conﬁrmed by MRI. It can clearly distinguish slight forms of the disease from
severe ones, and it can give useful informations for further diagnostic exams. In
facts, only 9% of pts with a non signiﬁcant ECHO had a later positive MRI, without
signiﬁcant clinical symptoms.
493
The heart preserves contraction and contractility during maximal
exercise even during moderate hypoxic conditions.
B. Lind, L.A. Brodin, S. Gunnes, L. Kaijser. Huddinge University hospital, Clinical
Physiology, Huddinge, Sweden
Background: It is known that exercise capacity at high altitude is restricted. During
exercise the cardiac metabolism is partly changed from aerobic towards unaerobic
energy delivery at altitudes exceeding 2500-3000 m. Up to that altitude the cardiac performance is compensated by increased coronary ﬂow. The objective of the
present study was to see if cardiac contraction and contractility is unchanged at
maximal exercise with inhaled oxygen tensions comparable with 4500 m altitude.
Methods: 8 healthy young individuals were studied with myocardial tissue Doppler
technique for quantitative evaluation of myocardial velocities. Contractility was estimated from maximal iso-volumetric velocity and contraction from systolic max velocities. Mainly longitudinal function was studied, because the subendocardial ﬁbres
generate that and a reduction in oxygen delivery should therefore give the most pronounced result in that function. Cine loops were acquired for analysis at rest, after
6 min of sub maximal exercise and after 6 min of maximal symptom limited exercise
during breath of normal air. After half an hour of rest the protocol was repeated during breath of air containing 12% of oxygen (comparable with 4500 m height). The
loading was adjusted to similar heart rates (HR) and scaling of effort. The exercise
was performed on a supine bicycle ergometer.
Result: During air breathing a maximal exercise of 208 W (range 170-230) was
achieved. In the hypoxic situation identical HR and effort scaling was reached at
a load of 155 W (range 120-170). The percutaneously measured oxygen saturation fell from 98% to 70%. The myocardial velocities were normal at rest and more
than doubled during maximal exercise. In the hypoxic situation there were similar
myocardial velocities both at rest and during exercise.
Conclusion: In healthy individuals exercise at high altitude could be performed at
least during 15-20 minutes without any decrease in myocardial contraction. This occurs despite there is a signiﬁcant decrease in oxygen tension, which could not be
compensated by increased ﬂow or extraction. Myocardial metabolism must therefore be changed because aerobic energy delivery could only cover 80% of the energy need. With an unchanged contraction work this deﬁcit must be covered from
other sources.
Eur J Echocardiography Abstracts Supplement, December 2003
Background: Whilst it is recognised that signiﬁcant aortic stenosis (AS) is associated with impaired left ventricular (LV) systolic long axis function, its effect on diastolic long axis function and the response to aortic valve replacement (AVR) is less
clear. This study aimed to examine the effects of AVR for AS on cardiac function as
assessed by tissue Doppler imaging (TDI).
Methods: 20 patients (11 male, mean age 74 yrs) undergoing AVR for AS underwent echocardiographic examination prior to surgery and 6 months post operatively.
This included measurement of longitudinal mitral annular velocities by TDI.
Results: (See table)
Table: Echocardiographic parameters
LVMI (g/m2 )
EF(%)
E/A
DCT (ms)
S’ (cm/s)
E’ (cm/s)
Preop
6 months
p
178 (63)
66 (11)
0.68 (0.23)
303 (91)
5.4 (1.2)
4.7 (1.7)
139 (39)
64 (10)
0.77 (0.27)
309 (74)
6.8 (1.3)
7.1 (2.0)
<0.001
0.38
0.12
0.79
0.002
<0.001
Figures quoted mean(SD). LVMI - LV mass index, EF - LV ejection fraction by Simpson’s method,
E/A - ratio of early to late diastolic mitral inﬂow velocities, DCT - deceleration time early diastolic
ﬁlling, S’- systolic mitral annular velocity, E’- early diastolic mitral annular velocity
AVR resulted in signiﬁcant regression of left ventricular hypertrophy at 6 months.
There was no signiﬁcant change in LV ejection fraction or standard mitral inﬂow
Doppler parameters. However, both systolic and early diastolic mitral annular velocities showed signiﬁcant increases.
Conclusion: TDI shows signiﬁcant improvements in both systolic and diastolic left
ventricular long axis function within 6 months of AVR for AS. This improvement is
not detected using conventional echocardiographic parameters.
495
Assessment and monitoring recovery after aortic valve replacement
using tissue Doppler echocardiography: a six-month follow-up study in
elderly.
S. Kastellanos 1 , S. Zezas 1 , S. Castellanos 1 , C. Chrysohoou 2 , C. Aggeli 1 ,
D. Panagiotakos 2 , E. Chlapoutakis 1 , C. Stefanadis 1 . 1 Hippokration Hospital,
University of Athens, Attica, Greece; 2 Athens, Greece
Background: Tissue Doppler Echocardiography (TDE) is a reliable new modality
that assists in the objective evaluation of regional right and left ventricular function.
In this work we monitored left (LV) and right (RV) ventricular function as assessed
by TDE, immediately before, and 15 days, 3 and 6 months after the aortic valve
replacement (AVR) in patients with severe aortic stenosis (peak gradient 91 ± 21).
Methods: During 2002 we enrolled 43 consecutive patients (27 men, 65 ± 12 years
old and 16 women, 69 ± 7 years old) who had undergone AVR. TDE images obtained from the apex, visualizing triscupter and mitral free wall annulus. RV and
LV systolic and diastolic velocities were compared immediately before, as well 15
days, 3 and 6 months after AVR, based on the Analysis of co-variance for repeated
measurements. Mitral and triscupted diastolic velocities (E, A) were also measured.
Results: Systolic (S) velocity in LV showed a signiﬁcant increased after AVR (15d:
11±1 v 3m: 12±2 v 6m: 13±1, p for trend < 0.01), while RV S velocity showed no
statistically signiﬁcant changes (15d: 11±2 v 3m: 12±1 v 6m: 12±1, p for trend <
0.1). Both diastolic E velocities in RV and LV increased signiﬁcantly from 15 days to
6 months after AVR (15d: 5±3 v 3m: 8±3 v 6m: 12±3, p for trend < 0.05 and 15d:
5±1 v 3m: 8±2 v 6m: 16±3, p for trend < 0.01). The ratio E/E(TDI) in LV showed a
signiﬁcant decrease after the AVR (15d: 10±2 v 3m: 9±2 v 6m: 7±2, p for trend <
0.001), while the ratio E/E(TDI) in RV decreased signiﬁcantly between pre and post
operation (pre: 6±2 v 15d: 0.97±1, p = 0.02), but remained constant thereafter AVR
(3m: 0.86±1 v 6m: 0.92±1, p = 0.67).
Conclusion: Signiﬁcant LV systolic improvement was observed after AVR, although
no such improvement observed in RV systolic function. E diastolic velocity was also
increased in both chambers. TDE can provide a simple non invasive quantitative
method for monitoring RV and LV function.
Abstracts
496
Volume dependent miscalculation of left ventricular mass by
echocardiography.
M. Kilickap 1 , S. Turhan 1 , G. Nergizoglu 2 , K. Keven 2 , U. Rahimov 1 , N. Duman 2 ,
G. Akgun 1 . 1 Ankara University School of Medicine, Cardiology, Ankara, Turkey;
2
Ankara University School of Medicine, Nephrology, Ankara, Turkey
Purpose: Increased left ventricular mass (LVM) is an independent risk factor for
cardiovascular mortality and morbidity, and can be calculated by echocardiography. We investigated whether echocardiography miscalculates LVM depending on
the change in left ventricular internal dimension (LVID) caused by the change in
intravascular volume.
Methods: Thirty-eight patients undergoing hemodialysis due to chronic renal failure were constituted the study group (14 women and 24 men, mean age 38.7±10.9
years). LVM was calculated by two-dimensionally guided M-Mode echocardiography using the formula described by Devereux and associates: LVM (grams) =
([IVST+LVID+PWT]3 - [LVID]3 )x1.04x0.8 + 0.6, where IVST and PWT denote interventricular septal thickness and posterior wall thickness, respectively. In order to
demonstrate the possible effect of volumetric changes on the calculation of LVM, all
the parameters were measured before and after dialysis, and then compared.
Results: LVID and the calculated LVM were signiﬁcantly decreased after dialysis
(Table 1). There was a signiﬁcant correlation between the change in LVID and the
change in LVM (p<0.001, r=0,59).
Echocardiographic Parameters
IVST (cm)
PWT (cm)
LVID (cm)
LVM (g)
Before Dialysis
After Dialysis
p
1.00 ± 0.15
0.90 ± 0.14
5.25 ± 0.61
188.79 ± 61.55
1.00 ± 0.15
0.91 ± 0.13
4.74 ± 0.69
160.36 ± 55.76
0.61
0.47
<0.001
<0.001
Conclusion: Change in intravascular volume may result in miscalculation of LVM
by echocardiography, and should be considered while assessing LVM serially.
497
Asymetric regional systolic and diastolic dysfunction associated with left
ventricular hypertrophy: a tissue Doppler and strain rate imaging study.
T. Poerner 1 , B. Goebel 1 , A. Miskovic 2 , T. Geiger 1 , C. Kohl 1 , T. Süselbeck 1 ,
M. Borggrefe 1 , K. K. Haase 1 . 1 University Hospital of Mannheim, 1st Dept. of
Medicine, Mannheim, Germany; 2 University Hospital of Frankfurt/Main, Dept. of
Cardiac Surgery, Frankfurt/Main, Germany
Background: Both idiopathic and acquired left ventricular hypertrophy (LVH) represent major causes of heart failure. However, wall thickness and left ventricular mass
index (LVMI) alone do not reﬂect accurately LV functional impairment and disease
progression.
Aim of the study was to identify speciﬁc patterns of systolic and diastolic regional
myocardial dysfunction in patients with LVH.
Methods: We included in the study 11 patients with hypertrophic obstructive cardiomyopathy (HOCM), 36 patients with severe aortic stenosis (AS), 38 patients with
LVH due to systemic hypertension (SH) and 33 age-matched healthy subjects. All
study patients had normal coronary angiograms and no history of coronary artery
disease. Tissue Doppler with strain rate imaging (TD/SRI) of the septal (IVS) and
lateral wall (LW) was performed on apical views. Peak systolic (VS) and early diastolic (VE) velocities, peak and mean systolic strain rate (SR) and peak systolic
strain (eps) were calculated off-line for basal, middle and apical segments using a
dedicated software. SR and eps could be expressed as mean values for the entire
wall, as both showed no differences between basal and apical segments.
Results: Relevant study ﬁndings are summarized in Table 1.
Table 1 (mean ± SD)
Parameters
Walls
Wall thickness (mm)
Basal Vs (mm/s)
Basal Ve (mm/s)
Mean of peak SR (s-1)
Mean of peak eps (%)
Parameters
Walls
Wall thickness (mm)
Basal Vs (mm/s)
Basal Ve (mm/s)
Mean of peak SR (s-1)
Mean of peak eps (%)
Controls
(n = 33, LVMI = 97 ± 15 g/m2 )
Systemic hypertension
(n = 38, LVIM = 147± 30g/m2 )
IVS
LW
IVS
LW
9.6±1.1
48 ± 14
56 ± 19
-1.1 ± 0.5
-18 ± 8
9.4±1.3
39 ± 18
56 ± 21
-1.3 ± 0.6
-17 ± 8
12±2*
48 ± 10
52 ± 21
-1.2 ± 0.4
-18 ± 8
11.8 ± 2.2
32 ± 18 *
38 ± 22 *
-1.1± 0.6
-14 ± 7 *
Aortic stenosis
(n = 36, LVMI = 221±85 g/m2 )
HOCM
(n = 11, LVMI = 194±64 g/m2 )
IVS
LW
IVS
LW
15 ± 3.2 *°
34 ± 15 *°
43 ± 25
-0.8 ± 0.4 *°
-12 ± 8 *°
13.2 ± 3.2 *
19 ± 12 *°
29 ± 17 *°
-0.7 ± 0.4 *°
-7 ± 6*°
19.9 ± 6.2 *°¶
24 ± 19 *°¶
29 ± 15 *°¶
-0.9 ± 0.5 *°
-12 ± 8 *°
10.2 ± 3.3
3 ± 19 *°¶
4 ± 26 *°¶
-0.85 ± 0.4 *°
-8 ± 5 *°
S55
acterized by markedly decreased long-axis velocities, especially within the lateral
wall. Summarizing, this study demonstrated that both concentric and asymmetric
LVH affects regional systolic and diastolic LV function in a non-uniform way, involving preponderently the lateral LV wall.
ATHLETE
499
Doppler tissue imaging in mitral annulus: differences between the
athlete’s heart and hypertrophic cardiomyopathy without hypertrophy.
P. Marcos-Alberca 1 , B. Ibañez 2 , M. Rey 2 , R. Rábago 2 , J. Pindado 2 , C. Diego 2 ,
P. Barrero 2 , J. Farré 2 . 1 Madrid, Spain; 2 Fundacion Jiménez Diaz, Arrhythmia Unit,
Madrid, Spain
Sudden cardiac death is a major cause of death in young competitive athletes with
hypertrophic cardiomyopathy (HCM). The essential echocardiographic feature in
HCM is left ventricular hypertrophy. Nevertheless and especially in young people,
this can be absent. In young competitive athletes, Doppler tissue imaging (DTI)
would be able to rule out the diagnosis of MCH.
In young competitive athletes (soccer) a complete echocardiogram (2D, Doppler and
DTI of the lateral mitral annulus) was carried out using a Philips Sonos 5500 platform. The dimensions and the myocardial thickness of the left ventricle (LV) were
measured and the LV mass was calculated following the standard recommended
(Devereux) using M-mode image. The parameters analysed in DTI were peak systolic velocities in systole (s wave), early-diastole (e wave) and end-diastole(a wave).
A total of 49 young males were studied, age: 16.5±1.4 years; with 5.8±2.4 years of
competitive sportive practice. Results were compared with 13 historic controls diagnosed of HCM by genetic analysis, but without left ventricular hypertrophy (septum
and posterior wall = 10±1 mm.). The thickness of the septum (9±2 mm.) and the
posterior wall (9±3 mm.) in athletes was normal and lightly lower than the group
with HCM. The LV end-diastolic and end-systolic diameters in athletes were higher
than the group with HCM (48±5 mm. versus 41±2 mm. and 32±5 mm. versus 25±2
mm., respectively, p<0.0001). The LV mass calculated was similar in both groups
(107.1±74 gr. versus 99±10 gr.; p = NS). The parameters calculated with DTI in
the athletes, opposite to the group with HCM were: "s" wave 11.9±2.9 vs. 8.7±1.7
cm/s (p<0.001); "e" wave 20.6±3.6 vs. 9.5±2 cm/s (p<0.0001); "a" wave 7.0±1.8
vs. 9.8±2.2 cm/s (p<0.0001).
In conclusion, in young competitive atheltes, DTI of the lateral mitral annulus show
evident different values, both in the systolic time and in diastole, opposite to patients
with HCM without LV hypertrophy, permitting to rule out this type of cardiomyopathy.
500
Morphofunctional cardiac adaptation in athletes - echocardiographic
study.
I. Tudor, A. Gurghean, D. Spataru, I. Savulescu, S. Iliescu, I. Bruckner. Coltea
Hospital, cardiology, Bucharest, Romania
Objective: To evaluate morphofunctional cardiac adaptation in athelets. We were
studied 72 athletes, males, aged 17-35 years old; they were divided into 3 groups
according to effort type: group A (28) with isometric effort, group B (20) with long
aerobe effort, group C (24) with short aerobe effort; control group of 20 young males,
age matched, non-athletes.
Method: M-mode, 2D and Doppler echocardiography.
Results: – comparing to control group,in all athletes there was a signiﬁcant thickening of interventricular septum (p= 0.0009)and left ventricle (LV) posterior wall (p=
0.0149).
– LV diastolic diameter/body surface was greater in groups B and C comparing to
control group (p=0.0139).
– LV mass/body surface was sidniﬁcantly greater in all athletes (p=0.0001)
– LV diastolic volume/body surface (volume-index) was signiﬁcantly raised in groups
B and C comparing to control group (p= 0.0001)
– LV ejection fraction (LVEF) was not signiﬁcantly modiﬁed in athletes comparing to
control group.
– the diastolic function parameters (E/A, IVRT, DT) were not modiﬁed in athletes
comparing to control group.
Conclusions: 1. The athletes who are making isometric effort are adapted to the effort by concentric hypertrophy of LV, while the athletes who are making aerobe effort
are adapted by LV eccentric hipertrophy. 2. No matter the type of effort (isometric or
aerobe), LV mass is signiﬁcantly greater in all athletes, while volume-index is greater
only in aerobic effort. 3.Athletes have LVEF and diastolic function comparable with
non-athlete population.
*p<0.05 vs. controls, °p<0.05 vs. SH, ¶p<0.05 vs. AS
Conclusions: (1) Beginning LVH in patients with SH affected functionally lateral,
but not septal segments. (2) Severe LVH in patients with AS is associated with
generalized diastolic and systolic regional dysfunction, showing a higher degree of
impairment in the lateral wall. (3) Diffuse subendocardial disease in HOCM is char-
Eur J Echocardiography Abstracts Supplement, December 2003
S56
Abstracts
501
Tei index and aerobic capacity in endurance athletes.
E. kasikcioglu 1 , H. Oﬂaz 2 , H. Akhan 3 , F. Mercanoglu 2 , A. Kayserilioglu 1 .
1
Istanbul Faculty of Medicine, Sports Medicine, Istanbul, Turkey; 2 Istanbul Faculty
of Medicine, Cardiology, Istanbul, Turkey; 3 Ersek Cardiovascular Centre,
Cardiology, Istanbul, Turkey
Background: Recently proposed Tei index (myocardial performans index), deﬁned
as the sum of isovolumic contraction time or mitral valve closure to aortic valve
opening time and isovolumic relaxation time or aortic valve closure to mitral valve
opening time, is a simple measure which enables noninvasive estimation of combined systolic and diastolic function. However, effect of athletic training on Tei index
have not been investigated. This study was designed to compare Tei index in athletes and sedantary controls.
Methods: Thirty-seven elite distance runners and thirty-two age-matched sedentary male controls were included. All subjects were underwent echocardiographic
examination and cardiopulmonary exercise testing. Doppler time intervals were
measured from mitral inﬂow and left ventricular outﬂow tract velocities. Doppler Tei
index was evaluated by obtaining (a-b)/b, where a is the interval between the cessation and onset of Doppler mitral ﬁlling ﬂow and b is the aortic ﬂow ejection time.
Results: The two groups of the study were similar with regard to age and body
surface area. Heart rate was signiﬁcantly lower in athletes than in controls (p
<0.001). Maximal oxygen consumption (VO2max) was signiﬁcantly higher in athletes than control. Tei index signiﬁcantly was lower in athletes compared with controls (0.28±0.07 vs 0.46±0.11). There was positively correlation between Tei and
VO2max.
Conclusion: Tei index signiﬁcantly is different in athletes than controls. It is possible that chronic exercise affects systolic and diastolic functions. In this study, the
Tei appears to be a more useful noninvasive method for detection left ventricular
function end exercise capacity
502
Effects of high intensity endurance training on AV-plane movement
evaluated by Tissue Doppler Imaging.
B. Amundsen, N. Lundsett, U. Wisloff, A. Brubakk, S.A. Slordahl. Faculty of
medicine, NTNU, Dep of Circulation and Medical Imaging, Trondheim, Norway
Purpose: AV-plane motion is a measure of global myocardial function, and correlates with stroke volume. Our aim was to investigate changes in mitral annulus
motion after a training period, using ultrasound Tissue Doppler Imaging (TVI)
Methods: 15 healthy females (22±1 years, 64±9 kg, 170±10 cm) performed supervised aerobic 4 x 4 min interval training at about 90% of maximal heart rate 3
times per week for eight weeks. Maximal oxygen consumption (VO2max) during
treadmill running was measured before and after the training period. Maximum AVplane velocity at four points of the mitral annulus was recorded during systole (AV-S)
and early (AV-E) and late/atrial diastole (AV-A) at rest. Systolic mitral annulus excursion was measured both by integrating the velocity signal (MAEd) and by greyscale
m-mode (MAEm).
Results: VO2max increased by 22±6%, from 42 to 51 ml/(kg*min) after the training
period. Heart rate (HR) decreased from 73 to 66 beats/min, AV-S increased from
7,2 to 7,9 cm/s (p<0,01), AV-E was unchanged (12,8 vs. 13,1 cm/s (p=0,3)), AVA decreased from 5,8 to 5,3 cm/s (p=0,03) and AV-EA-ratio increased (2,4 to 2,7
(p=0,02)). MAEd increased (13,2 to 14,4 (p<0,01)) while MAEm was unchanged
(15,6 vs. 16,1 (p=0,1)). There was no correlation between VO2max and S, E, A,
MAEd or MAEm.
Conclusion: Eight weeks high intensity interval training is very effective in improving VO2max. The increased AV-S can be caused by larger preload at lower HR.
Prolonged diastasis can explain the decreased AV-A. The increased EA-ratio was a
result of the decreased AV-A, more than an increased AV-E. Increased SV at lower
HR caused a larger MAE. Thus, the observed changes seem heart rate-dependent.
Eur J Echocardiography Abstracts Supplement, December 2003
HYPERTENSION
504
Pulsed tissue Doppler is related to myocardial acoustic density in arterial
systemic hypertension.
M. Galderisi, G. de Simone, A. D’Errico, M. Chinali, S. Cicala, C. Romano,
A. Bianco, M. Pardo, O. de Divitiis. Federico II University, Clinical and Experimental
Medicine, Naples, Italy
Purpose: To examine whether myocardial acoustic density assessed by Integrated
Backscatter (IBS) is associated with Tissue Doppler derived left ventricular myocardial function in uncomplicated arterial hypertension.
Methods: 26 never-treated, newly diagnosed, I-II WHO, hypertensive patients (M/W
= 19/7, mean age = 52 years) underwent exam. Patients were in sinus rhythm, without coronary heart, myocardial or valve disease and/or diabetes mellitus. IBS was
recorded in parasternal long-axis view from proximal anterior septum, basal posterior wall and posterior pericardium. Acoustic intensity obtained from the analyzed
myocardial structures was corrected for gain setting, depth of the analyzed structure
and signal from posterior pericardium. Pulsed Tissue Doppler was acquired in apical 4-chamber view placing the sample volume at the level of both basal posterior
septum and left ventricular (LV) lateral mitral annulus. Myocardial velocities (systolic
= Sm, early =Em and atrial = Am, Em/Am ratio) and time intervals (relaxation time
= RTm, pre-contraction time, contraction time) were measured at each level.
Results: In the overall population, Sm of LV mitral annulus was negatively related
to IBS of both posterior wall (r=-0.58, p<0.002) and septum (r=-0.51, p<0.01). In
multiple linear regression analyses, the relations of IBS with Sm of LV mitral annulus
remained independent even adjusting for heart rate (HR), mean blood pressure (BP)
and LV mass. During diastole, as the intensity of IBS of posterior wall increased,
Em of the mitral annulus tended to decrease (r = 0.41, p=0.04) and RTm at the
same level was prolonged (r= 0.49, p<0.01). These relations were conﬁrmed even
after controlling for mean BP and HR. No signiﬁcant relations were found between
IBS and Tissue Doppler measurements of posterior septum or between IBS and
standard Doppler indexes of LV ﬁlling.
Conclusions: In never-treated, newly diagnosed, hypertensive patients, myocardial
diastolic acoustic intensity is negatively and independently associated to myocardial
systolic velocities and is also related to abnormalities of Tissue Doppler derived
diastolic indexes at the level of mitral annulus.
505
Improvement of cardiac function after hemodialysis. Quantitative
evaluation by colour tissue velocity imaging (TVI).
S.Y. Hayashi 1 , L.A. Brodin 2 , A. Alvestrand 1 , B. Lind 2 , P. Stenvinkel 1 ,
M.M. Nascimento 1 , A.R. Qureshi 1 , S. Saha 2 , B. Lindholm 1 , A. Seeberger 1 . 1 Div
Renal Medicine and Baxter Novum, Karolinska Institutet, STOCKHOLM, Sweden;
2
Karolinska Institutet, Clinical Physiology, Huddinge Hospital, Stockholm, Sweden
Background: Overhydration and accumulation of uremic toxins may inﬂuence the
myocardial function in hemodialysis (HD) patients. To evaluate the effects of ﬂuid
and solute removal during a single session of HD on cardiac function, color tissue velocity imaging (TVI) was used. This new echocardiography technique allows
quantitative assessment of myocardial contractility, contraction and relaxation, during the isovolemic and ejection phases of the cardiac cycle and additionally the
systolic and diastolic TVI parameters are less load dependent than conventional
echocardiography.
Methods: Conventional echocardiographic and TVI images were recorded before
and after HD in 13 clinically stable HD patients (62±10 yr, 6M) and 13 sex- and agematched controls. Myocardial tissue velocities (v; cm/s) for isovolumetric contraction
(IVC), peak systole (PS), early (E’) and late (A’) diastolic ﬁlling and strain rate (SR)
were measured.
Results: LV hypertrophy (LVH) was present in 12 patients. Before HD, PSv (5.0±0.8
vs. 6.0±1.2 cm/s, p<0.05), E’ (5.3±2.2 vs. 7.3±2.3 cm/s, p<0.05) and A’ (6.6±1.7
vs. 8.3±2.9 cm/s, p<0.05) velocities were lower in patients than in the controls,
indicating systolic and diastolic dysfunction. There were inverse correlations between systolic contraction (PSv) and contractility (IVCv) and both plasma levels of
phosphate (r=-0.84, p<0.001 and r=-0.66, p<0.05 respectively) and Ca x P product
(r=-0.68 p<0.01 and r=-0.67, p<0.05 respectively). The HD session increased IVCv
(4.0±1.7 to 5.5±1.9 cm/s; p<0.001), PSv (5.0±0.8 to 5.7±0.8 cm/s; p<0.05) and
SR (0.7±0.2 to 0.9±0.2 1/s; p<0.05) indicating improved myocardial contractility
and contraction.
Conclusions: In HD patients, LVH is accompanied by both systolic and diastolic
dysfunction. The systolic function seems to be impaired by high plasma levels of
phosphate and an increased Ca x P product. One single session of HD improved
systolic function as indicated by the observed increases in isovolumetric contraction
velocity (IVCv), peak systolic velocity (PSv) and strain rate (SR).
Abstracts
S57
506
Doppler myocardial imaging differentiates myocardial hypertrophy
induced either by arterial hypertension or aortic stenosis.
508
Diastolic disfunction assesed with echocardiography in offspring of
hypertensive.
K. Harre 1 , F. Weidemann 1 , O. Turschner 1 , G. Ertl 1 , W. Voelker 1 ,
J.M. Strotmann 2 . 1 Medizinische Universitätsklinik, Würzburg, Germany;
2
Medizinische Universitätsklinik, Würzburg, Germany
A. Garzon, F. Soria, M. Villegas, R. Florenciano, G. De la Morena, A. Garcia,
J. Lacunza, R. Lopez-Palop, E. Pinar, M. Valdes. Virgen de la Arrixaca, Cardiology,
Murcia, Spain
Background: Doppler Myokardial Imaging (DMI) has been shown to differentiate
myocardial hypertrophy induced by aortic ligation and exercise in animal models.
The purpose of this clinical study was to compare the impact of aortic stenosis and
arterial hypertension on DMI parameters of regional left ventricular function.
Methods: Twenty patients with arterial hypertension (HTN) and twenty patients with
aortic stenosis (AOS) and exclusion of arterial hypertension were enrolled in the
study. Coronary artery disease was ruled out by coronary angiography and LV angiography was done to measure ejection fraction in both groups. Ten age matched
normals served as control. All patients had a conventional echocardiography study
including a DMI study with an evaluation of the posterior wall derived from parasternal long axis views. The following parameters were assessed: enddiastolic wall
thickness (WTed), peak systolic velocity (pVel), peak systolic strain rate (pSR), LV
enddiastolic diameter (LVEDD) and LV ejection fraction (EF).
Results: Both patient groups showed a normal EF and there was no difference
in WTed. Peak velocity in the AOS group (aortic oriﬁce area 0.6 ± 0.2 cm2 ) was
signiﬁcantly lower compared to normals but did not differ from the HTN group. In
contrast peak strain rate in the AOS group was signiﬁcantly lower compared to both
the HTN group and the normals (see table).
Objectives: Offspring of essential hypertensive parents have a high risk of developping hypertension (HT). However, whether diastolic disfunction and/or morphological changes precede the increase in blood pressure is not well stablished. We used
echocardiography-Doppler to evaluate if there are changes in diastolic function or
cardiac structure that precede to development of HT in offsprings of HT parents
compared with offsprings of normotensive (NT) parents.
Methods: 59 NT patients aged between 15 and 35 were enrolled and divided in two
groups: NT group (both parents NT) and HT group (both parents HT). We assessed
standard demographic and clinical variables. Blinded echocardiography was performed assesing morphological (thicknesses and internal diameters of the left ventricule, left atrium (LA) dimension) and diastolic function paramethers that included:
(1) LV mass,(2) Doppler mitral inﬂow pattern (E and A peak velocities and its ratio
E/A),(3) pulse wave Doppler pulmonary veins pattern, (4) color M-Mode slope (Mcolor), (5) tissue Doppler E’/A’ratio, and (6) the percentage of LV diastolic volume
due to atrial contraction measured with acustic cuantiﬁcation (AQ).
Results: 30 patients in the NT group (aged 25.2±4.9 years) and 29 patients in
HT group (26.9±4.9 years)(p=ns) were included. We found no differences in demographic or clinical variables. Morphological and diastolic function paramethers are
shown in the table.
Normals
HTN
AOS
pVel (cm/s)
pSR (1/s)
WTed (mm)
LVEDD (mm)
EF (%)
5 (0.9)
3.5 (1.2)*
3.3 (1)*
4 (0.7)
2.6 (0.6)*
1.6 (0.6)*#
9 (1)
13 (2)*
13 (2)*
41 (3)
43 (6)
48 (6)*
70 (8)
61 (14)
Data is given as mean and standard deviation of mean in brackets.*indicates signiﬁcant differences to the control group, # indicates signiﬁcant differences to the HTN group.
Conclusion: Doppler myocardial imaging detects differences in strain rate values
in patients with myocardial hypertrophy of different origin in the presence of normal
systolic LV function.
507
Echo-Doppler evaluation of the right ventricular diastolic function in
hypertension.
S. Qirko 1 , T. Goda 2 . 1 University Hospital Center, Department of cardiology,
Albania, Albania; 2 University Hospital Center, Department of Cardiology, Tirana,
Albania
Background: It has been reported that systemic hypertension causes diastolic prior
to systolic dysfunction of the left ventricle (LV).
The aim of this study was the assessment of the RV diastolic function in patients
with systemic hypertension.
Methods: We studied 40 normotensive (NT) and 90 hypertensive subjects (HT).
They were free of any other type of cardiopathy, pneumopathy or pulmonary hypertension. All subjects had normal RV dimensions and function. LV mass index
(LVMI,g/m2 ), left (LA) and right atrium(RA) were measured. LV and RV ﬁllings were
assessed by doppler at the level of the mitral and tricuspid valve by measuring respectively Em, A m and Et, At velocities.
Results: Age and sex propotion were similar for both groups.
Table 1
Group
NT
HT
LVMI
RA
At
Et/At
RV diastolic
dysfunction
Biventricular diastolic
dysfunction
96 ± 20
141±30*
4.5±0.1
4.9±0.1*
41±10
55±10*
1.4±0.2
0.94±0.2*
10%(4/40)
53%(48/90)*
5%(2/40)
45%(41/90)*
*p<0.05 HT vs NT.
Et/At correlated signiﬁcantly to Em/Am (r=0.53), LVMI (r=-0.33) and to LA (r=-0.47)
(p<0.05).
Conclusion: Systemic hypertension in the presence of the LV hypertrophy is accompanied by the diastolic dysfunction of the RV in the absence of any right ventricular structural impairment. This RV involvement is related to the alteration of LV
ﬁlling. It suggests a more severe hypertensive cardiopathy.
LV mass (grs)
A velocity (cm/sc)
E/A ratio
M-Color Slope (cm/sc)
LA dimension (mms)
AQ (%)
NT group (30)
HT group (29)
P
163.9±43.6
51.6±12.4
1.91±0.48
51.2±9.4
33±3.1
22.7±6.7
167.5±51.2
62.6±13.5
1.54±0.35
46.2±9.1
33.2±3.9
27.0±9.6
n.s
0.002
0.002
0.044
n.s
0.048
Diastolic disfunction assesed with echocardiography
Conclusions: Assesment of diastolic function with echocardiography shows signiﬁcant diastolic function abnormalities in normotensive offsprings of essential HT
population well before any increase in blood pressure or any morphological changes
occur, probably meaning that they are genetically-determined rather than due to increased hemodynamic load.
509
Impact of left ventricular diastolic dysfunction on maximal exercise
capacity in hypertensive patients.
M. Dekleva, B. Pencic, V. Bakic-Celic, N. Kostic, S. Ilic, S. Dimkovic. University
Clinical Centre Dr Misovic, Department of Echocardiography, Belgrade, Yugoslavia
Objective: Left ventricular diastolic dysfunction (LVDD) may lead to increased ﬁlling
pressure and pulmonalry congestion during exercise. Peak oxygen uptake (pVO2),
maximal oxygen consumption (VO2 max), ventilatory responce to exercise (VE),
and test duration (RER), measured during cardiopulmonary exercise testing are
an accepted parametars to assess functional capacity and predict survival in heart
failure patients.
We sought to deﬁne the association between degree of LVDD and parametars of
functional capacity measured during exercise testing in hypertensive asymptomatic
patients with normal systolic LV function.
Methods: We studied 30 patients with hypertension (19 male/11 female, aged 55±8
years) without evidence of coronary artery disease, congestive heart failure, diabetes mellitus and thyreoid or renal disease. Each subject performed a simptom
limited bycicle exerciese test with standardized 25 Watt increament stress protocol.
LVDD was evaluated by Doppler echocardiography. In these patients echocardiographic measurements included assesment of mitral ﬂow velocities (E,A), left atrial
size (LA) and ejection fraction (EF).
Results: All patients had preserved systolic function (EF = 58± 15%) and impaired
LV relaxation (E/A= 0,79±15) with slightly dilated LA size (45±0,9 mm).
In hypertensive patients with LVDD, VO2 max was signiﬁcantly reduced, according
to the fraction of predictive value calculating by observed value of VO2 max (FAI
index) and E/A ratio (r=0,736, p=0.003), with an association between the degree
of LVDD and reduction of peak oxygen uptake (E/A vs pVO2; r=0,719, p=0,044).
There was also signiﬁcant correlation between E/A ratio and VE (r=0,736, p=0,040)
and between E/A and RER (r=0,816, p=0,025).
Conclusion: This study demostrated that LV diastolic dysfunction inﬂuences maximal exercise capacity and could explain lower maximal performance observed in
patients with hypertension.
Eur J Echocardiography Abstracts Supplement, December 2003
S58
Abstracts
510
Role of Doppler tissue imaging in the assessment of diastolic
dysfunction in hypertensive patients with and without concentric
geometric remodeling.
M.V. Pitzalis, R. Romito, M. Iacoviello, K. Lucarelli, P. Guida, B. Rizzon, C. Forleo,
P. Rizzon. Institute of Cardiology, Bari, Italy
It has been shown that in patients with essential hypertension and cardiac hypertrophy Tissue Doppler Imaging (TDI) is able to detect impairment of diastolic function
more accurately than pulsed transmitralic Doppler (TD).
The aim of this study was to assess if, in hypertensive patients without cardiac
hypertrophy, there are differences in diastolic function evaluated by using TDI or
TD.
We studied 17 patients (46±9 years, 11 male) with never treated essential hypertension. Echocardiographic evaluation was used to assess the following parameters:
concentric remodelling (CR) pattern, deﬁned as a normal left ventricular mass index
with a relative wall thickness >0.45; global diastolic dysfunction (GDD), detected by
correcting for age the TD ﬂow early to atrial (E/A) ratio values; regional diastolic
dysfunction (RDD) evaluated by TDI, with the sample volume positioned within the
basal septum and deﬁned according to the age-corrected tissue E/A ratio values.
CR was found in 12 patients (70%); among these, 4 showed both GDD and RDD,
while 5 patients showed only RDD. In the absence of CR, no patient showed either
GDD or RDD. At Fisher test analysis, RDD was signiﬁcantly associated with the
presence of CR (p=0.019), whereas no signiﬁcant association was found between
CR and GDD. TDI showed a higher sensitivity in detecting diastolic dysfunction than
TD (75% vs 33%) and a higher negative predictive value (63% vs 38%); both TDI
and TD had a speciﬁcity and positive predictive value of 100%.
In conclusion, in hypertensive patients with cardiac remodeling an abnormal regional diastolic function can be observed more frequently than a global diastolic
dysfunction, thus suggesting that TDI is able to detect early impairment of diastolic
function more accurately than pulsed transmitralic Doppler even in the absence of
cardiac hypertrophy.
511
Arterial distensibility and ambulatory blood pressure as determinant of
left ventricular hypertrophy and intima-media thickeness in elderly
subjects.
L.S. Costa 1 , J.C. Tress 2 , E.C. Zilli 3 , J.V. Libonato 4 , R. Pozzan 3 , A. Brandão 3 ,
C. Drumond Neto 4 , A.P. Brandão 3 . 1 Santa Casa da Misericórdia Hospital,
Cardiology department, Rio de Janeiro, Brazil; 2 Niterói Hospital, Cardiology,
Niterói, RJ, Brazil; 3 Universidade do Rio de Janeiro, Rio de Janeiro, Brazil; 4 Santa
Casa da Misericordia, Cardiology, Rio de Janeiro, Brazil
Morbidity and mortality in hypertension are primary related to arterial damages
that may affect several organs.The aim of this study was to evaluate the ambulatory blood pressure measurement (ABPM) and pulse wave velocity analysis
(PWV) in 3 groups composed by elderly subjects, being selected as "normotensive" (Group I, n=24,72,04±6,02years); "isolated systolic hipertensive" (Group II,
n=32, 72,34±4,55years); and "systolic-diastolic hipertensive" (Group III, n=33,
71,42±5,72years), in an effort to identify, among the assessed variables, those that
could be correlated to the determination of the target organ damage (TOD) deﬁned
as left ventricular hypertrophy (LVH) and intima-media thickness of the left and/or
right common carotid artery (IMT-CCA).The variables analyzed involved: the ABPM
measures; the IMT-CCA measures, by means of carotid ultrasonography; the left
ventricular mass and left ventricular mass index measures, by means of echocardiography; and the PWV measures. The distribution of age, gender and anthropometrical rates showed similarity among the 3 groups, the same occurring to the
analysis of the averages of the biochemical parameters. We also demonstrated a
similar distribution for IMT-CCA in the 3 assessed groups (p=0,200), and for LVH in
the 2 hypertensive groups (p=0,557), the latest showing, however, higher statistical
values when compared to the normotensive group (p<0,001).
The variables with positive correlation to the LVM were: 24hour systolic, diastolic
and pulse pressure; daytime systolic BP; night-time systolic and diastolic BP and
PWV; and the variable with negative correlation was the systolic-nocturnal fall. The
24h systolic BP and pulse pressure, daytime systolic and diastolic BP and PWV
ﬁgured as positive correlates to the IMT-CCA, while the systolic-nocturnal fall and
diastolic-nocturnal fall appeared as negative correlations for IMT-CCA.
By investigating the TOD determinants, we veryﬁed that the 24h systolic BP was
the only variable associated to the LVH (p=0,0161), while the PWV was the only
associated to the IMT-CCA (p=0,033). Thus, we demonstrated that the analysis of
these ABP and PWV variables is a resource of great validity for the investigation of
the target organ in elderly subjects.
Eur J Echocardiography Abstracts Supplement, December 2003
512
Prevalence of hypertension and left ventricular hypertrophy in a
Romanian population. A populational clinical - echocardiographic study.
C. Ginghina 1 , B.A. Popescu 2 , M. Serban 1 , I. Ghiorghiu 1 , M. Parlea 1 , C. Matei 1 ,
I. Kulcsar 1 , E. Apetrei 1 . 1 Institute of Cardiology, Bucharest, Romania; 2 Bucharest,
Romania
Background: Hypertension (HTN) is one of the major risk factors for atherosclerosis and coronary artery disease. Its prevalence has important medical and socioeconomic implications. Left ventricular hypertrophy (LVH) adversely impacts the
prognosis of hypertensive patients (pts).
Aim: To determine the prevalence of HTN and that of LVH in an adult population
(>35 years) in Bucharest, the capital of Romania.
Methods: 363 patients (pts) (50.9% men, mean age 56.3 ± 11 years) from a region
of Bucharest, Romania, selected to constitute a statistically representative sample
group were screened. A complete echocardiographic study was performed on each
patient, including measurements of LV dimensions, ejection fraction (EF), fractional
shortening (FS), and transmitral ﬂow peak E, A, and E/A ratio by PW-Doppler. LV
mass was calculated using the Devereux formula.
Results: Patients (pts) with known HTN (114 pts, 31.4%) constituted group A (57%
men, mean age 57 ± 9). Duration of HTN (mean time from diagnosis to the moment
of examination) was 6.3 ± 7.7 years. Group B consisted of pts without HTN: 249
pts, (48% men, mean age 56 ± 11.8). Pts in Group A had signiﬁcantly higher body
mass-index (28.8 ± 4.6 vs 26 ± 4.9, p < 0.001). LVEF and LVFS were similar in
both groups (p=ns), while the E/A ratio was lower in group A (0.91 ± 0.31 vs 1.06
± 0.31, p<0.001). LV mass was signiﬁcantly higher in group A (202.3 ± 53.5 g
vs 177.4 ± 51 g, p<0.001). Using the Levy height-indexed threshold (143 g/m for
men and 102 g/m for women), LVH prevalence was 36% in the hypertensive group.
Systolic blood pressure (BP) in group A was 166.2 ± 20 mm Hg, diastolic BP was
93.2 ± 12.2 mm Hg, and the proportion of treated hypertensive pts with normal BP
values was of only 15%, reﬂecting poor BP control.
Conclusions: The prevalence of HTN in this population is high, as is the prevalence of LVH. BP control in treated pts with known HTN is poor. These ﬁndings
have important medical and economic implications and should represent the basis for setting-up more efﬁcient programmes for a better BP control in the general
population.
513
Incremental value of a complete echocardiogram to detect left ventricular
dysfunction in hypertensive patients with left ventricular growth.
A. Diaz 1 , D. Martin-Raymondi 1 , J. Barba 1 , L. Tomas 2 , M. Serrano 2 , J. Diez 1 .
1
Clinica Universitaria de Navarra, Cardiology, Pamplona, Spain; 2 Hospital de
Navarra, General Medicine, Pamplona, Spain
Left ventricular growth is a major risk factor of cardiac dysfunction in hypertensive
patients. Although echocardiography allows the study and quantiﬁcation of ventricular dimensions, mass and systolic and diastolic function, not all the parameters
that can be assessed are measured routinely. In this study we investigate whether a
complete echocardiographic study allows to identify subtle functional alterations in
the hypertensive left ventricle. We studied 101 patients newly diagnosed of essential
hypertension. None of the patients exhibited past or current medical history of cardiac disease or cardiac failure. Ofﬁce blood pressure measurements was taken and
2-Dimensional and M-mode Doppler ultrasound recordings were performed. The
following parameters were measured in the echocardiogram: left ventricular mass
index (LVMI), relative wall thickness (RWT), ejection fraction (EF), subendocardial
fractional shortening (SFS), and midwall fractional shortening (MFS). Transmitral
ﬂow velocity was evaluated to obtain the peak E, peak A, E/A ratio, mitral deceleration time (DT) and isovolumetric relaxation time (IVRT). With tissue Doppler (DTI)
of the mitral annulus peak E wave was measured. The patients were divided in
two groups according to the absence (group 1) or the presence (group 2) of left
ventricular growth deﬁned as LVH (LVMI > 110gr/m2 in men and >104 gr/m2 in
women) or concentric remodeling (RWT >0.44). Values of blood pressure were
higher (P<0,01) in group 2 patients than in group 1 patients. As expected LVMI and
RWT were higher (P< 0.01) in group 2 patients than in group 1 patients. Whereas
no differences were found in EF and SFS between the 2 groups, MFS was lower
(P<0.01) in group 2 patients than in group 1 patients. Although no differences were
observed in transmitral ﬂow parameters between the 2 groups, E wave measured by
DTI was lower (P<0,01) in group 2 patients than in group 1 patients. These ﬁndings
suggest that MSF and DTI should be evaluated in hypertensives with left ventricular
growth to identify those patients presenting early compromise of the systolic and
diastolic function, respectively.
Abstracts
514
Left ventricular hypertrophy regression is persistent on antihypertensive
therapy for 3 years.
M. Lengyel 1 , S. Borbás 1 , C.S. Farsang 2 , A. Zorándi 1 . 1 Gottsegen G. Hung.Inst.of
Cardiology, Budapest, Hungary; 2 St. Imre Hospital, Budapest, Hungary
Background: The regression of left ventricular hypertrophy (LVH) has been shown
following antihypertensive treatment, however the longterm persistence of such effect may be questionable.
The objective of this study was to assess the 3 year effect of rilmenidine (R)
monotherapy on LVH in mild-moderate hypertension.
Methods: 45 consecutive patients were included into this prospective phase IV
open echocardiography (echo) study who had baseline LVH, deﬁned as left ventricular mass index (LVMI)>/=110 and >/=130 g/m2 in females and males resp., in
whom blood pressure was well controlled by 1-2 mg/day R monotherapy and who
had measurements at baseline, at 1 year, at 2 years and 3 years. There were 20
males, 25 females, mean age 50±14.7 yrs. Echo measurements were performed by
one "blinded" observer in a central laboratory. LV posterior wall (PW), septum (IVS)
thickness, LV dimensions, E, A velocities, deceleration time (DT) were measured.
LVMI, ejection fraction (EF), relative wall thickness (RWT) and E/A were calculated.
Results: Baseline systolic function was normal (EF=56.8±7.4%), 59.1% had concentric hypertrophy and 59.5% had impaired relaxation (E/A</=1 with DT>/=200
ms). There was no change in LV dimensions EF, E/A and DT. PW, IVS, LVMI and
RWT decreased signiﬁcantly at 1 year and these changes persisted after 3 years
(Table). The frequency of concentric hypertrophy decreased from 59.1 to 24.4, 25.6
and 31%, the rate of abnormal RWT from 59.1 to 34, 42 and 36%.
PW mm
IVS mm
LVMI g/m2
RWT%
Baseline
1 year p
2 years p
3 years p
11.8±1.2
12.2±1.7
162.1±32.4
48.1±9.3
10.3±1.1 xxx
10.5±1.2 xxx
32.9±26.3 xxx
41.9±6.2 xxx
10.5±1.2 NS
10.7±1.2 NS
32.5±24.7 NS
43.9±8.9
10.7±1.3 NS
10.7±1.5 NS
137.5±29.4 NS
43.3±6.4 NS
xxx=p<0.001
Conclusions: There was a signiﬁcant regression of LVH after 1 year R monotherapy due to decrease in wall thickness with an improvement of LV remodelling and
these changes persisted after 3 year monotherapy.
S59
516
Determinants of exercise capacity in hypertensive patients.
W. Kosmala, J. Orzeszko, M. Przewlocka-Kosmala, W. Kuliczkowski. Medical
University, Cardiology, Wroclaw, Poland
An impaired exercise capacity is common in hypertensive patients (pts). Not all
determinants of this pathology remained exactly recognized.
The aim of the study was to investigate factors related to exercise tolerance in hypertensive pts.
Material and methods: Studied group consisted of 41 pts (18 males, 23 females)
mean age 54.2±11.9 with essential hypertension and without coronary artery disease. In each patient echocardiographic study, estimation of plasma levels of ANP
and BNP and treadmill exercise test were performed. Echocardiographic assessment comprised evaluation of left ventricular mass index (LVMI), ejection fraction
(LVEF), velocity of early (E) and late (A) transmitral ﬂow, deceleration time of E
wave (DT), isovolumic relaxation time (IVRT), total ejection isovolume index (TEI),
ﬂow propagation velocity of E wave (Ep), velocity of systolic (S), diastolic (D) and
atrial reversal (AR) pulmonary venous ﬂow. Exercise capacity was assessed by exercise time and total workload expressed in MET.
Results: Impaired exercise tolerance was found out in 25 pts (61%). Groups of pts
with normal and impaired exercise tolerance did not differ with respect to age, LVMI,
LVEF and ANP. Signiﬁcantly higher values of A, S/D and BNP and lower values of
D were noted in pts with diminished exercise capacity. Moreover, in this group of pts
trends toward lower values of E/A and higher values of AR were observed. Significant correlations were found out for MET and: age (r=-0.49, p<0.001), A (r=-0.62,
p<0.001), E/A ratio (r=0.55, p<0.004), D (r=0.55, p<0.004), AR (r=-0.38, p<0.01),
BNP (r=-0.53, p<0.001). Exercise time correlated with A (r=-0.61, p<0.001), E/A ratio (r=0.41, p<0.04), D (r=0.51, p<0.009), AR (r=-0.35, p<0.02), S/D ratio (r=-0.47,
p<0.01), BNP (r=-0.45, p<0.01). Other investigated parameters did not correlate
with both MET and exercise time. By stepwise multiple linear regression analysis D
and AR were the only determinants of MET whereas D and A turn out to be the only
independent predictors of exercise time.
In conclusion: In hypertensive pts: (1) diastolic function of LV is a principle determinant of exercise capacity, (2) BNP is superior to ANP in predicting exercise tolerance.
HYPERTROPHIC CMP
515
Peripheral endothelial dysfunction and left ventricular diastolic
dysfunction in patients with essential hypertension.
518
The localization of the septal ablation lesion is predicted by the septal
contrast depot during echo-guided septal ablation.
W. Kosmala, W. Kuliczkowki, J. Orzeszko, M. Przewlocka-Kosmala. Medical
University, Cardiology, Wroclaw, Poland
D. Hering, D. Welge, D. Fassbender, D. Horstkotte, L. Faber. Heart Center North
Rhine-Westphalia, Department of Cardiology, Bad Oeynhausen, Germany
Similar neurohormonal factors are involved in myocardial and peripheral vascular
endothelial impairment. However, it is not clear whether endothelial abnormalities
are associated with left ventricular (LV) diastolic dysfunction.
The aim of the study was to investigate the relation of LV diastolic function parameters and plasma levels of soluble intercellular (s-ICAM) and vascular (s-VCAM) cell
adhesion molecule and endothelium-dependent ﬂow-mediated dilatation in brachial
artery (FMD) in hypertensive pts.
Material and methods: Studied group consisted of 57 pts mean age 53.5±11.7
with essential hypertension and without coronary artery disease. 18 age-matched
healthy persons served as controls. Echocardiographic assessment of LV diastolic
function comprised velocity of early (E) and late (A) transmitral ﬂow, deceleration
time of E wave (DT), isovolumic relaxation time (IVRT), ﬂow propagation velocity of
E wave (Vp), E (ETT) and A (ATT) wave transit time to the LV outﬂow tract. Plasma
level of s-ICAM and s-VCAM was estimated by ELISA method. FMD was measured
as the change of brachial artery diameter during reactive hyperemia by use of highresolution ultrasound.
Results: Compared to the controls in hypertensive pts increased values of DT,
IVRT, ETT, s-ICAM and s-VCAM and decreased values of E, E/A, Vp and FMD
were demonstrated. No signiﬁcant correlations between FMD and any parameter of
LV diastolic function or s-ICAM and s-VCAM were noted.
Background and Introduction: Percutaneous septal ablation (PTSMA) for symptomatic hypertrophic obstructive cardiomyopathy (HOCM) requires the exact definition of the septal myocardium to be attacked. We tested whether the clinical
and haemodynamic effect is correlated with morphologic measures of the intraprocedural contrast study (ip-MCE) in 33 patients (pts.) who had their echo video
loops archived digitally and who had a complete follow-up after 3 months.
Results: The mean area of the contrast depot (CD) was 8.5±2.5 cm2 , its length
along the left ventricular (LV) endocardial border 1.9±0.6 cm, the proximal edge
1.0±0.3 cm upstream the mitral-septal contact (SAM-C), with the SAM-C covered
in all cases. Septal thickness at this point as measured by 2D echo was 2.8±0.4 cm
(vs. 2.0±0.4 cm by standard m-mode, p<0.01).
A mean ethanol dose of 1.9±0.3 ml was followed by a CK rise up to 529±197 U/l. 2
pts. (6%) needed a pacemaker. After 3 months, all but 1 pt. were in NYHA class I or
II (from 2.9±0.4 to 1.5±0.6), and all but 1 had signiﬁcant reduction or elimination of
the outﬂow gradient (LVOTG; from 61±26 to 8±16 mm Hg; p both <0.001). LA size
was reduced from 50±7 to 45±7 mm (p<0.01). The proximal edge of the ablation
lesion correlated with the proximal edge of the CD (r=0.5 p<0.005); septal thickness
at SAM-C was 1.8±0.4 cm (p<0.01 vs. baseline). No other correlations were found
between the efﬁcacy of PTSMA and measures of the CD during ip-MCE.
Conclusion: The localization of the ablation lesion 3 months after PTSMA is predicted by the localization of the contrast depot with respect to the mitral-septal contact. Standard m-mode measurement underestimates the thickness of the ablation
region. The ﬁnal shape of the ablation lesion and its hemodynamic effect, however,
are not correlated with measures of the contrast depot but seem to follow an individual remodelling process.
FMD [mm]
s-ICAM [ng/mL]
s-VCAM [ng/mL]
studied group
control group
p
0.22 ± 0.12
408.0 ± 90.8
1136.3 ± 524.2
0.40 ± 0.19
259.6 ± 37.4
775.9 ± 262.1
0.003
0.05
0.04
In conclusion: In hypertensive pts there is no relation of LV diastolic function indices and peripheral endothelial function assessed by plasma level of s-ICAM and
s-VCAM and endothelium-dependent ﬂow-mediated dilatation in brachial artery.
These results may indicate various degree of impairment of endothelial function
in coronary and peripheral circulation.
Eur J Echocardiography Abstracts Supplement, December 2003
S60
Abstracts
519
Echocardiographic analysis of patients with hypertrophic obstructive
cardiomyopathy and persisting NYHA class III symptoms during
long-term follow-up after septal ablation.
L. Faber 1 , D. Welge 1 , H. Seggewiss 2 , D. Fassbender 1 , D. Horstkotte 1 . 1 Heart
Center North Rhine-Westphalia, Cardiology Dept., Bad Oeynhausen, Germany;
2
Leopoldina Hospital, Department of Internal Medicine, Schweinfurt, Germany
Background and Introduction: In about 90% of the patients (pts). with symptomatic hypertrophic obstructive cardiomyopathy (HOCM), symptoms and outﬂow
gradient (LVOTG) can signiﬁcantly be reduced by septal ablation (PTSMA). Pts.
with heart failure symptoms during long-term follow-up after PTSMA are not characterized sufﬁciently. We analyzed our long-term cohort of pts. treated between 1996
and 1998 with respect to persisting or recurrent NYHA functional class III symptoms
after PTSMA.
Results: Hospital mortality was 1.7% (VF, pulmonary embolism, and pericardial
tamponade in 1 pt. each). Mean CK rise was 599±300 U/l. A DDD-pacemaker
(DDD-PM) had to be implanted in 13 pts. (7%). Mean follow-up time is now 54±15
months, 8 pts. (5%) were lost to follow-up. Out of the 167 cases analyzed, 12 pts.
(7%) underwent a re-PTSMA and 4 (2%) a myectomy. These cases included, 156
pts. (88%) had complete elimination of obstruction, and 151 pts. (85%) reported
sustained symptomatic improvement at their last follow-up.
Persisting or recurrent class III symptoms, however, were reported by 16 pts. (10%).
LVOTG recurrence or persistence was the suspected reason in only 2 of these
cases, 8 pts. were free from LVOT obstruction, and 6 had provocable gradients
<60 mm Hg considered hemodynamically irrelevant. The leading reason for persisting class III symptoms despite satisfactory LVOTG reduction were marked obesity
(BMI>30/m2 ) in 5, severe diastolic LV dysfunction in 5, and coexistent pulmonary
disease in 4 pts. 8 pts. (5%) died during long-term follow-up: due to stroke (n=2),
extracardiac disease (n=3), or suspected sudden cardiac death (n=3).
Conclusions: PTSMA results in a persistent LVOTG reduction and symptomatic
improvement during long-term follow up. Peri-interventional and long-term mortality
seem to be at least comparable to surgical myectomy. Pts. with marked obesity,
coexistent pulmonary disease, and advanced diastolic LV dysfunction are less likely
to have symptomatic beneﬁt from LVOTG reduction, and need additional treatment
of these abnormalities.
520
Comparative evaluation of BNP plasma levels with left ventricular ﬁlling
pressures and pulsed wave tissue Doppler imaging variables in patients
with hypertrophic cardiomyopathy.
F.K. Panou, V.K. Kotseroglou, I.A. Lakoumentas, I. Armeniakos, G.B. Dounis,
A.I. Karavidas, E.P. Matsakas, A.A. Zacharoulis. Athens General
Hospital"G.Genimatas", Cardiology Department, Athens, Greece
Purpose: From previous studies it has been documented that plasma brain natriuretic peptide (BNP) levels were associated with the clinical severity of hypertrophic
cardiomyopathy (HCM). On the other side ﬁlling pressures of left ventricle (LV) can
be noninvasively estimated with the ratio E/Ea (E: peak velocity of early mitral ﬂow,
Ea: early diastolic velocity of the lateral side of mitral annulus by means of PW TDI).
The purpose of this study was to investigate the possible relation of BNP plasma
levels with TDI variables and the ratio E/Ea.
Methods: In 15 pts with HCM (mean age 55.9±15 yrs) BNP plasma levels were
measured by an immunoradiometric assay (Shionoria BNP by Cis-Diagnostics). A
cut-off point of 18.4 pg/ml was considered as the upper limit of normal values. All pts
underwent complete clinical and echocardiographic examination. Peak E velocity of
mitral ﬂow was calculated by pulsed Doppler spectral display. PW TDI was used to
measure the velocities of movement at the mid segment of interventricular septum
(IVS), as well as at the mid segment of lateral wall and the early diastolic velocity at
the lateral side of mitral annulus (Ea).
Statistical analysis was performed using the Spearman correlation coefﬁcient.
Results: 10 pts had abnormal BNP plasma levels (162.9±19 pg/ml) and 5 pts had
normal BNP levels (12.1±4 pg/ml). BNP plasma levels were found to correlate:
1) positively with the severity of dyspnea (NYHA class) (r: 0.545, p: 0.035).
2) positively with the systolic velocity (7.87±1.48 cm/sec) of the IVS (r: 0.622, p:
0.013).
3) inversely with the Ea velocity (10.18±3.93 cm/sec) (r: -0.536, p: 0.039).
4) positively with the E/Ea ratio (7.58±3.5 cm/sec) (r: 0.650, p: 0.009).
Conclusions: Assessment of BNP plasma levels seems to be of great importance
in pts with HCM, since it was found to be positively related to: 1.the severity of
dyspnea, 2. regional systolic function of the thick IVS 3. LV ﬁlling pressures, as they
are expressed by the E/Ea ratio.
Eur J Echocardiography Abstracts Supplement, December 2003
521
How many patients develop end-stage hypertrophic cardiomyopathy in a
non tertiary center?
E. Biagini, F. Coccolo, C. Pedone, C. Rapezzi, E. Perugini, A. Donti, M.F. Picchio,
A. Branzi. S. Orsola, Institute of Cardiology, Bologna, Italy
Background: Some patients with hypertrophic cardiomyopathy (HCM) develop systolic dysfunction, left ventricular dilatation and wall thinning (end-stage HCM). Most
of the available data on this phase of the disease come from tertiary centres so that
prevalence, incidence, incremental risk factors and prognosis of end-stage HCM in
the "general population" of HCM patients is not known.
Methods: We reviewed 220 patients with HCM (65% men, age 39±21 yrs, obstructive forms = 31%). Mean follow-up was 9.8±7.6 yrs.
Results: Sixteen pts (7.2%) were already in the end-stage phase at the ﬁrst visit
while 8 developed such condition during follow-up. So overall prevalence was 11%
and incidence 3.4 per 1000 person-years. We compared clinical and echo ﬁndings
of end-stage and non end-stage pts (see table).
We compared the 8 pts with subsequent end-stage evolution and those without such
complication: age of diagnosis (27±16 yrs vs 40.7±17.7, p=0,04) and end-diastolic
posterior wall thickness (16±6 vs 13±4 mm, p= 0,038) were the only identiﬁable
incremental risk factors for subsequent end-stage evolution. 79% of end-stage pts
and only 22% of the others died or underwent heart transplantation during f-up (p=
0.0001).
Clinical and Echo Characteristics
Age at diagnosis (yrs)
% pts <16 yrs
Male gender (%)
Obstructive forms (%)
Congestive heart failure (%)
LVED dimension (mm)
I.V. septal thickness (mm)
LPW thickness (mm)
LV EF (%)
Left atrium (mm)
End-stage (24pts)
Non end-stage (196 pts)
P
27±13
20
62
40±17
6
65
35
8
41±6
20±5
13±4
70±8
44±9
0.0004
0.04
NS
0.001
0.0005
0.0001
NS
NS
4
53±13
19±6
14±5
32±12
49±9
0.01
Conclusions: In a large series of HCM pts evaluated at a non-tertiary centre: 1.
Incidence of end-stage evolution is 3.4 per 1000 persons-year. 2.Young age at diagnosis and increased left ventricular posterior wall thickness are incremental risk
factors for such an evolution which carries on an ominous prognosis.
522
Mitral regurgitation decrease after alcohol septal abaltion in hypertrophic
obstructive cardiomyopathy.
A. Wojtarowicz, Z. Kornacewicz-Jach, J. Kazmierczak. Department of Cardiology,
Szczecin, Poland
Mitral valve regurgitation (MVR) is frequent in hypertrophic cardiomyopathy, especially in its obstructive form (HOCM) and inﬂuence on clinical course. Alcohol septal
ablation (ASA) is an efﬁcient therapeutic method in HOCM.
Material and methods: ASA was made in 23 pts (4 women, 19 men) with HOCM
in age 21 to 63 years, (mean 43±12). Follow-up time was 6 months to 5 years,
mean 2.5 year. We assessed by echocardiography: peak LVOT gradient, diastolic
IVS thickness, LA dimension and area (LAa), and diastolic LV dimension. Degree of
MVR we estimated from 0+ (absent) to 4+ (very lararge) and as maximal regurgitant
ﬂow area of in colour Doppler (MRa) and its ratio to LA area (MRa/LAa) in apical
4-chamber view. We estimated followed LV diastolic function parameters: E an A
waves velocity, E/A ratio and IVRT as well. Comparison between values before ASA
and et end of follow-up was made.
Results: peak LVOT gradient decreased from 73±40 mmHg to17,3±16,4 mmHg;
P<0,0001. Only in two pts reduction was less that 50%. IVS thickness reduction we
observed in all pts, mean from 2,4±0,6 cm to 1,4±0,6 cm, P<0,0001. LV dimension was larger in follow-up (4,7±0,6 cm) than at baseline (4,2±0,5 cm); P<0,01.
LA dimension and area not changed signiﬁcantly (LA 4,3±0,6 cm before ASA, and
4,4±0,7 cm after ASA, LAa 19,2±4,6 cm2 before and 18,6±3,8 cm2 in follow-up).
From among diastolic function parameters only IVRT changed signiﬁcantly: shortening from 96,2±18,7 ms to 83,1±20 ms; P<0,02. Before ASA MVR was absent in
2 pts, and degree 3+ has one patient. After ASA in 1 patients without MVR before
ASA we noted 1+. In 5 pts with degree 1+ was no changes in MVR in follow-up, and
in other pts decreased at 1+ to 2+. Mean MVR degree decreased from 1,5±0,7 before ASA to 0,9±0,6 in follow-up (p<0,01). Mean MRa decreased from 3,1±3,1 cm2
before to1,4±1,3 after ASA (P<0,01), and MRa/LAa decreased from 0,15±0,11 to
0,07±0,06 in follow-up (P<0,001)
Conclusion: Alcohol septal ablation in HOCM caused decreasement of mitral valve
regurgitation without inﬂuence on LA dimension.
Abstracts
523
Improvement of left ventricular diastolic function after septal surgical
myectomy or percutaneous septal alcohol ablation in patients with
hypertrophic obstructive cardiomyopathy.
A. Kiotsekoglou, R.S. Sharma, P.M. Elliott, W.J. McKenna, D. Pellerin. The Heart
Hospital, London, United Kingdom
Left ventricular outﬂow tract (LVOT) obstruction and diastolic dysfunction are responsible for dyspnoea in patients with hypertrophic obstructive cardiomyopathy
(HOCM). Surgical myectomy and percutaneous septal alcohol ablation are effective treatments to relieve obstruction in these patients. To assess the effect of (surgical and percutaneous) septal reduction therapy (SRT) on LV diastolic function,
59 HOCM patients were studied at baseline and 3±4 months after septal myectomy (n=37) or alcohol ablation (n=22). There was a signiﬁcant improvement in
NYHA class and in peak oxygen consumption after SRT. LVOT pressure gradient
was markedly reduced to a similar extend by both procedures. The ratio of early to
late peak diastolic LV inﬂow velocities (E/A) and the ratio of early diastolic LV inﬂow
velocity to lateral mitral annular velocity (E/Ea) signiﬁcantly decreased after SRT
(1.5±1.6 versus 0.9±0.8 and 17±9 versus 10±5 respectively). At baseline, 54% of
patients had delayed relaxation and 35% showed a pseudonormal pattern on transmitral inﬂow recording. After SRT, 89% of patients showed delayed relaxation. 80%
of patients with a restrictive LV ﬁlling pattern before SRT had pseudonormal or delayed relaxation after SRT. Left atrial area at end systole decreased form 33±8 to
26±6 cm2 , p<0.05. Total area of mitral regurgitant jet also signiﬁcantly decreased.
There was no correlation between the change in diastolic pattern, E/A and E/Ea
ratios and the change in mitral regurgitation. There were no signiﬁcant differences
in the changes of LV diastolic function indices between septal myectomy and alcohol ablation patients. Conclusion: Echocardiographic diastolic function parameters
improved after SRT in HOCM patients with similar changes after septal myectomy
and septal alcohol ablation. These changes in diastolic parameters were not related
to the decrease in mitral regurgitation. Improvement in LV relaxation and decrease
in LA pressure after SRT may contribute to the clinical amelioration of the patients.
524
Right ventricular function in hypertrophic cardiomyopathy.
S. Mörner 1 , P. Lindqvist 1 , E. Kazzam 2 , A. Waldenstrom 1 . 1 Umea University
Hospital, Dept of Pub. Health & Clin. Medicine, Umea, Sweden; 2 Mälar Hospital,
Department of Medicine, Eskilstuna, Sweden
Background: Hypertrophic cardiomyopathy (HCM) is characterised by hypertrophy
of the left ventricle (LV), but may also involve the right ventricle (RV). While much is
known about the left ventricular function, little has been documented about the RV.
Therefore, the aim of the present study was to evaluate RV systolic and diastolic
function in patients with HCM.
Material and methods: Twenty-ﬁve patients (11 females) with HCM and 26 healthy
individuals (10 females), mean age ± SD, 53 ± 18 and 53±17 years respectively,
were studied by echocardiography. LV fractional shortening (FS) and LV inﬂow ﬁlling pattern (E-and A-wave velocities) were determined. RV function was assessed
by tricuspid annular plane systolic excursion (TAPSE) and Doppler tissue imaging
(DTI).
Results: HCM patients had increased thickness of the interventricular septum and
RV wall. The RV systolic long axis motion (TAPSE) was reduced and isovolumic
contraction time (ICT) was prolonged, compared to controls. There was also a reduced early diastolic (E) velocity and prolonged isovolumic relaxation time (IRT) in
the patients. Systolic (S) and late diastolic (A) velocities did not differ between the
groups.
Table 1
TAPSE, mm
RV thickness, mm
DTI-S, systole, cm/s
DTI-E, early diastole, cm
DTI-A, late diastole, cm/s
DTI ICT, ms
DTI IRT, ms
LV E/A ratio
FS, %
HCM
Controls
P-value
19.8±5.2
5.9±1.8
13.0±5.2
9.5±3.7
15.2±5.6
112±32
95±42
1.5±0.9
45±13
24.1±3.8
3.4±1.2
15.1±3.2
14.3±4.1
15.4±4.1
91±17
52±25
1.2±0.5
41±6
0.001
0.0001
Ns
0.0001
Ns
0.006
0.0001
Ns
Ns
Conclusion: Cardiac hypertrophy was shown to be present in both the left and
right ventricles in patients with hypertrophic cardiomyopathy. Disturbances in right
ventricular function was detected in the systolic as well as the diastolic phase of
the cardiac cycle. The data provide new information on right ventricular function in
hypertrophic cardiomyopathy.
S61
525
Echocardiographic prediction of hemodynamic effect of alcohol septal
ablation for hypertrophic obstructive cardiomyopathy.
J. Veselka 1 , S. Prochazkova 2 , R. Duchonova 2 , I. Bolomova 2 . 1 University Hospital
Motol, Dept. of Cardiac Surgery, Prague 5, Czech Republic; 2 University Hospital
Motol, Dpt. of Cardiac Surg., Div. Cardiology, Prague, Czech Republic
Purpose: Alcohol septal ablation (PTSMA) is an effective method in the treatment
of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). In
this study we studied the capability of echocardiographic parameters in predicting
of left ventricular outﬂow tract (LVOT) pressure gradient decrease six months after
PTSMA.
Methods: The group of patients comprised 29 consecutive patients with
symptomatic HOCM (17 women, mean age 54 ± 14 years) enrolled for
echocardiography-guided PTSMA procedure. Clinical and echocardiographic data
were collected at baseline and six months after PTSMA.
Results: At six-month follow-up, both the maximal resting pressure gradient and
the isosorbide dinitrate provoked gradient decreased signiﬁcantly (69 ± 44 to 19 ±
17 mmHg and 111 ± 53 to 25 ± 22 mmHg; p < 0.01). Left ventricular remodelling
was associated with a signiﬁcant dilation of left ventricle (LVd) (p < 0.05), decrease
of left ventricular ejection fraction (LVEF) (p < 0.01) and basal septum thickness
(IVSd) (p < 0.01). All patients reported an improvement of dyspnoe and angina
pectoris at follow-up (p < 0.01). There were statistically signiﬁcant correlations between LVOT pressure gradient at follow-up and baseline LVd (r = - 0.52; p < 0.01),
IVSd (r = 0.50; p < 0.01) and LVEF (r = 0.44; p < 0.05). The stepwise regression
analysis showed statistical dependence of LVOT pressure gradient at follow-up on
two baseline echocardiographic predictors: IVSd and LVd (r = 0.62, p = 0.002).
Conclusions: PTSMA is effective method in the treatment of symptomatic patients
with HOCM resulting in symptomatic improvement and left ventricular remodelling.
Results of our study suggest that hemodynamic effect of PTSMA could be predicted
by baseline echocardiographic evaluation of IVSd and LVd.
526
Comparative study of left ventricular diastolic function using pulsed
tissue Doppler and cardiac MR in patients with hypertrophic
cardiomyopathy.
R. Faludi 1 , L. Toth 1 , A. Cziraki 1 , I. Repa 2 , L. Papp 1 , T. Simor 1 . 1 University of
Pécs, Heart Institute, Pécs, Hungary; 2 Institute of Diagnostics, University of
Kaposvar, Kaposvar, Hungary
Background: Abnormalities in left ventricular (LV) diastolic function (df) are common in hypertrophic cardiomyopathy (HCM). Traditional pulsed Doppler-derived
transmitral velocity proﬁles are routinely used to evaluate left ventricular diastolic
properties, but two sensitive and preload-independent techniques are available to
assess LV-df: pulsed tissue Doppler echocardiography (PTDI) and cardiac magnetic
resonance imaging (CMR). Our study aims to compare the results of these two different methods in patients with HCM.
Methods: PTDI was performed by ATL HDI 5000 ultrasound system. Myocardial
early diastolic (Ea) and late diastolic (Aa) velocities were measured at the septal
(S) and the lateral (L) mitral annulus (MA). L and S Ea/Aa ratios were calculated.
1.5 T Siemens Vision Plus (Siemens, AG Germany) with a cardiac software package
at the Institute of Diagnostics and Oncoradiology (University of Kaposvár) was used
for cardiac imaging. ECG gated long axis and consecutive, multiple, no slice gap,
8 mm thick short axis plane MR images covering the entire left ventricle (LV) were
acquired to study cardiac function. Gradient-echo, segmented K-space cine imaging
was acquvired and MASS 5.0 (Medis, NL) was used for editing of the MR images.
Time-volume-curve of the global LV was rutinely obtained, evaluated, peak ﬁlling
rate (PFR) and PFR/end diastolic volume (EDV) 1/s were calculated.
Results: 13 patients (6 male, 7 female, mean age 46±11 years) - 7 pts with septal,
3 pts with apical, 3 pts with concentric hypertrophy - were studied.
Decreased df (Ddf), was accepted if Ea in the lateral and septal region was less
then 11 and 8 cm/s, respectively. Ea/Aa equal or less then 1 for both regions was
deﬁened to show Ddf.
MRI derived Ddf was accepted in cases of PFR < 250 ml/s or PFR/EDV < 4,0
EDV/s.
Ea at the L-MA and S-MA showed of 9,1±3,1 (Ddf in 10 pts), and 6,7±2,1 cm/s (Ddf
in 9 pts), and simultaneously Ea/Aa at the lateral and septal walls were 1,03±0,53
(Ddf in 9 pts) and 0,93±0,35 (Ddf in 9 pts), respectively.
PFR of 395,1±148 ml/s (Ddf in 3 pts) and PFR/EDV of 2,99 ±1,06 1/s (Ddf in 11
pts) were determined using MRI. Conﬂicting results from PTDI and CMR were found
in 2 pts.
Conclusion: Both methods show Ddf in HCM patients. The differences, however,
indicate that further studies are necessary to deﬁne pathognomic values for both
methods, while to characterise diastolic function in HCM patients.
Eur J Echocardiography Abstracts Supplement, December 2003
S62
Abstracts
527
Left atrial size is an important predictor of morbidity in patients with
latent obstructive hypertrophic cardiomyopathy.
M. Eriksson 1 , A. Woo 2 , C. Sloggett 2 , E.D. Wigle 2 , H. Rakowski 2 . 1 Department of
Clinical Physiology, Stockholm, Sweden; 2 Toronto General Hospital, Cardiology,
Toronto, Canada
Background: Subaortic obstruction in HCM may be classiﬁed as obstruction at rest
or latent (provocable). Although echo characteristics of hypertrophic cardiomyopathy (HCM) and latent obstruction (LO) have been studied, there is limited information
on long-term morbidity in patients presenting with LO.
The aim of this study was to analyze predictors of morbidity in patients with LOHCM
followed in a tertiary referral center.
Methods: A retrospective study of 125 patients (73% men) with LOHCM diagnosed
from 1975 to 2002 was performed. Inclusion criteria were: unexplained left ventricular hypertrophy with no signiﬁcant outﬂow gradient (LVOTGR) at rest, increasing
to >30 mmHg by pharmacological provocation, documented by echo (n=65) or cardiac catheterization (n=60). Symptoms, clinical ﬁndings, mortality and cardiovascular morbidity were analyzed.
Results: The mean age at presentation was 45.2 ± 16.1 years. At baseline the
mean LVOTGR at rest was 7 ± 8 mmHg and 65± 25 mmHg after provocation, the
mean left atrial diameter was 40 ± 6 mm, the mean septal thickness 18.6 mm ±
4.2 with hypertrophy limited to the basal 1/3 of septum in 71 patients (57%), and to
the proximal 2/3 in 30%. Morbid events occurred in 59 of 127 patients consistent
with cardiovascular morbidity of 46.5%. The probability of event-free survival for patients with LOHCM was 51±6% at 15 years of follow-up. Sixteen patients (13%) had
one or more morbid events at the initial presentation, most frequent event being AF
(n=13), CHF (n=3), MI (n=2) and/or cerebrovascular event (n=2). Two independent
predictors of all cardiovascular morbidity were identiﬁed by a multivariate Cox regression analysis: left atrial enlargement at baseline HR 2.2 (95% CI 1.3 – 4.0) and
a higher age at diagnosis HR 1.03 (95% CI 1.001 – 1.044).
Conclusion: The majority of patients with LO have less extensive hypertrophy and
a more favorable prognosis than other types of HCM. However, in the presence
or left atrial enlargement and older age at presentation LO does have signiﬁcant
cardiovascular morbidity and mortality.
528
Evaluation of subendocardial ischemia by strain Doppler echocardiography in patients with left ventricular outﬂow tract obstruction.
A. Vitarelli, Y. Conde, E. Cimino, R. Colantonio, I. D’Angeli, S. Stellato. La
Sapienza University, Cardiology, Rome, Italy
Background: The purpose of the present study was to assess the subendocardial
wall function using tissue Doppler imaging (TDI) and strain rate imaging (SRI) in
patients with congenital left ventricular outﬂow (LVOT) obstruction.
Methods: We studied with TDI and SRI 19 pts aged 11-31 years with congenital
aortic stenosis (valvular, 12 pts; subvalvular, 6pts; supravalvular, 1pt). 13 age-and
sex-matched subjects with no signs of heart disease were selected as normal controls (CTR). On the basis of LVOT pressure gradient, pts were distinguished in two
groups: group 1 (10 pts), gradient <50mmHg; group 2 (9 pts), gradient >50 mmHg.
TDI wall velocities during systole (Sw), early relaxation (Ew) and atrial systole (Aw)
were measured in both groups in the apical four chambers views. Peak strain (e)
and strain rate (SR) were measured during isovolumic contraction (IC), systole (S),
isovolumic relaxation (IR), early diastole (E) and late diastole (A) in endocardium
(End), myocardium (Myo) and epicardium (Epi) in the same views.
Results: TDI measurements of the three myocardial layers showed no statistically
signiﬁcant difference among velocities in both pts groups although there was a trend
for End velocities to be higher than those of Epi. There was a signiﬁcant difference in
strain and strain rate between the myocardial layers for both isovolumic contraction
and relaxation (End-e -38.1±12.7%, Myo-e -21.7±8.9%, Epi-e -10.8±5.5% during
IC; End-e 31.9±11.3%, Myo-e 20.1±6.3%, Epi-e 10.4±4.9% during IR; End-SR 2.9±1.7 sec-1, Myo-SR -1.7±0.9 sec-1, Epi-SR -0.8±0.5 sec-1 during IC; End-SR
1.9±1.3 sec-1, Myo-SR 1.1±0.3 sec-1, Epi-SR 0.6±0.5 sec-1 during IR). There
was a signiﬁcant correlation between endocardial strain rate (during IC) and LVOT
pressure gradients (r=0.69, p<0.005). Compared to group 1, group 2 pts showed
a signiﬁcant decrease in endocardial strain and strain rate for both isovolumic contraction and relaxation (p<0.001).
Conclusion: Strain and strain rate echocardiography provide a unique insight in
evaluating subendocardial wall dysfunction in pts with signiﬁcant LVOT obstruction.
529
Tissue Doppler imaging in hypertrophic cardiomyopathy: differences
between obstructive and non-obstructive forms.
A. araujo, E. Arteaga, A. Matsumoto, B. Ianni, C. Mady. Heart Institute - Sao Paulo
University, Cardiopatias Gerais, Sao Paulo, Brazil
PURPOSES - we sought to compare the systolic and diastolic tissue Doppler (TD)
longitudinal velocities of the left ventricle (LV) in patients (pts) with hypertrophic cardiomyopathy (HCM) according to the presence or absence of a signiﬁcant outﬂow
obstructive gradient and to determine whether it might be used to discriminate the
LV function between those groups.
Background - Pts with obstructive hypertrophic cardiomyopathy (OHCM) are more
symptomatic and have a worse long term outcome than pts with the non-obstructive
form (NOHCM).
Eur J Echocardiography Abstracts Supplement, December 2003
Methods - 87 HCM pts with a septal thickness >15mm, non-dilated LV and normal
ejection fractions were selected: 52 without gradient (NOHCM) and 35 with a resting
gradient >30 mmHg (OHCM). 40 healthy volunteers served as the control group.
The following pulsed TD parameters were obtained sampling the mitral annulus
on lateral and septal borders: peak systolic velocities (SaL and SaS), peak early
diastolic velocities (EaL and EaS) and late diastolic velocities (AaL and AaS). The
mean Ea/Aa ratio was calculated.Pulsed Doppler mitral inﬂow peak E wave velocity
was measured to determine the E/EaL ratio. Statistical analysis by ANOVA and
Tuckey test; values of p<0.05 were considered signiﬁcant.
Results - the early longitudinal annular diastolic velocity is signiﬁcantly slower in
OHCM than NOHCM. The Ea/Aa ratio is lower and the E/EaL ratio higher in OHCM
as compared to NOHCM. TD systolic velocities are signiﬁcantly slowers in HCM
than in normals and data are more pronounced in OHCM (table).
Results
n
OHCM
35
NOHCM 52
p
Control 40
p
EaL(cm/s) EaS(cm/s)
7.8
11.3
<0.001
20.2
<0.001
6.2
8.3
0.002
15.3
<0.001
E/EaL
12.6
7.4
<0.001
4.0
<0.001
EaM/AaM SaL(cm/s) SaS(cm/s) SaM(cm/s)
0.8
1.0
0.02
1.5
<0.001
8.1
9.8
0.001
13.4
<0.001
7.9
8.8
0.02
10.8
<0.001
8.0
9.3
0.001
12.1
<0.001
Data expressed as mean values
Conclusions - In obstructive hypertrophic cardiomyopathy, the left ventricle diastolic and systolic functions are more impaired than in the non-obstructive form, and
it can be an early indication of adverse long term outcome.
530
Mid-systolic septal deceleration - a new sign of left ventricular outﬂow
tract obstruction obtained by colour-coded tissue Doppler
echocardiography.
O.A. Breithardt 1 , B. Stolle 2 , A. Franke 1 , U. Janssens 1 , P. Hanrath 1 , H. Kuhn 2 .
1
Universitätsklinikum Aachen, Dept. of Cardiology, Aachen, Germany; 2 Klinikum
Bielefeld-Mitte, Dept. of Cardiology, Bielefeld, Germany
Diagnosis of hypertrophic obstructive cardiomyopathy (HOCM) is based on the
identiﬁcation of asymmetric septal hypertrophy, mitral leaﬂet systolic anterior motion (SAM) and a systolic LVOT gradient. Many patients present with no signiﬁcant
resting gradient, but develop signiﬁcant obstruction after provocation manoeuvres
or induced extrasystoles. Doppler evaluation of the LVOT gradient during such manoeuvres remains technically challenging, in particular in difﬁcult cases with suboptimal Doppler angles and concomitant mitral regurgitation. We describe a new
non-invasive sign for LVOT obstruction obtained by colour-coded tissue Doppler
echocardiography (TDI).
Clinical Case: Septal longitudinal motion was studied by TDI in a 69-year old HOCM
patient during transcoronary alcohol ablation of septal hypertrophy (TASH). Invasive
hemodynamics showed only a small LVOT gradient at rest (Figure,left), but a signiﬁcant post-extrasystolic LVOT gradient, which was associated with a abrupt midsystolic deceleration (MSSD) pattern in the simultaneously acquired basal septal
TDI velocity trace (Figure,middle). Immediately after TASH, both the LVOT gradient
and the simultaneously recorded MSSD pattern were signiﬁcantly reduced (Figure,right). A similar MSSD pattern was observed in 5 additional consecutive HOCM
patients with severe LVOT obstruction, but in none of 10 patients with pure aortic
valve stenosis.
Hemodynamics(upper row) vs. TDI (lower)
Conclusions: The presence of an abrupt mid-systolic septal deceleration pattern
in the TDI velocity trace is associated with severe, dynamic LVOT obstruction. It
may constitute a new diagnostic tool for gradient characterisation and may help to
monitor HOCM therapy.
Abstracts
531
Diagnosis of left ventricular outﬂow tract obstruction in hypertrophic
cardiomyopathy by tissue Doppler imaging.
B. Stolle 1 , O.A. Breithardt 2 , A. Franke 2 , H.P. Kühl 2 , P. Hanrath 2 , H. Kuhn 1 .
1
Klinikum Bielefeld-Mitte, Dept. of Cardiology, Bielefeld, Germany;
2
Universitätsklinikum Aachen, Dept. of Cardiology, Aachen, Germany
The presence of left ventricular outﬂow tract (LVOT) obstruction in hypertrophic obstructive cardiomyopathy (HOCM) has important therapeutic implications(surgical
or catheter based treatment). LVOT obstruction in HOCM is diagnosed by asymmetric septal hypertrophy, mitral leaﬂet systolic anterior motion and a systolic LVOT
gradient. We describe a new sign for LVOT obstruction obtained by colour-coded
tissue Doppler imaging (TDI), which may help to identify affected patients (pts) and
to monitor therapy.
Methods: Septal longitudinal motion was studied by TDI (>100 frames/s) in 26 pts
with suspected HOCM (septal wall thickness >15mm). We identiﬁed in 15/26 pts
a characteristic biphasic systolic velocity pattern with an early (S1) and a late (S2)
positive systolic peak velocity, interrupted by an abrupt mid-systolic septal deceleration (MSSD) notch (deﬁned as >25% relative and >1 cm/s absolute decrease
from S1). Isovolumic events were excluded from the analysis by identiﬁcation of onset and end of ejection by aortic valve Doppler. The presence of an MSSD pattern
identiﬁed severe LVOT obstruction (>30mmHg peak gradient at rest) with 92% sensitivity and 91% speciﬁcity. Doppler derived LVOT gradient was signiﬁcantly higher
in pts with MSSD compared to those without MSSD (71±27 vs. 17±10 mmHg,
p<0.001). There was a close temporal relationship between invasive LVOT gradient
development and the MSSD in the septal TDI trace as demonstrated by simultaneous recordings(Figure, post-extrasystolic beat).
S63
reduced WT% (<30%), WT between 17 to 20 mm showed moderately reduced
WT% (30-50%), while WT less then 17 mm showed normal WT%.
It is our conclusion that WT indicates well the regional systolic function in HCM
patients.
533
Intramyocardial coronary ﬂow velocity in patients with various types of
cardiac hypertrophy.
C. De Gregorio 1 , A. Micari 2 , A. Recupero 1 , P. Grimaldi 1 , M.C. Morgesi 2 ,
F. Rizzo 2 , D. Cento 1 , S. Carerj 3 , S. Coglitore 1 . 1 Cardiology & Cardiac Rehabil
Unit., Internal Medicine & Pharmacology, MESSINA, Italy; 2 Graduate School of
Cardiology, Messina, Italy; 3 Cardiology Unit, Messina, Italy
Aims: Ultrasound devices allow investigating the ﬂow velocity in the intramural small
coronary arteries (IMCA) as well as in the left descending coronary artery (LDA),
especially in patients (pts) with hypertrophic cardiomyopathy (HCM). In the present
study we sought to evaluate the coronary ﬂow velocity pattern in 29 adults, aged
69 ± 10, with LV mass > 220 gr and interventricular septum thickness of 14 mm
at least were studied by transthoracic Doppler-echocardiography (TTE). All patients
were divided into three groups: obstructive HCM (group A = 9), nonobstructive HCM
(group B = 12) and left ventricular hypertrophy (LVH) subsequent to aortic valve
stenosis (group C = 8).
Methods: Standard echo measurements were taken. In addition, at baseline, the
ﬂow velocities both in apical IMCA and distal LDA were assessed by using highfrequency transducers in harmonic imaging and without contrast enhancement.
Results: No signiﬁcant between-group differences resulted in LV diastolic diameters, absolute mass and ejection fraction. Coronary artery ﬂow velocities and LV
gradients are displayed in the table below. In all the study population the IMCA diastolic ﬂow was directed from the epicardium to the endocardium edge.
Group A (n=9) Group B (n=12) Group C (n=8) ANOVA (p)
Epicardial arteries
S peak velocity (cm/s)
23.1±4.7
D peak velocity (cm/s)
46.4±6.3
D mean velocity (cm/s)
27.4±9.8
D relative duration (% of R-R cycle)
53.7±7.5
Foreward S-wave
100%
Foreward D-wave
100%
Intramyocardial arteries
D peak velocity (cm/s)
139.2±36.9*
D mean velocity (cm/s)
88.2±29.0*
D time to peak (ms)
59.4±17.3
D relative duration (% of R-R cycle)
53.5±5.4
Backward S-wave
100%
Foreward D-wave
100%
Invasive pressure gradient vs. TDI
Conclusions: The presence of an MSSD pattern in the TDI velocity trace is strongly
associated with severe LVOT obstruction and may constitute a new diagnostic tool
for gradient characterisation, in particular in difﬁcult cases with suboptimal Doppler
angles.
20.5±5.4
43.2±15.7
30.5±14.0
62.8±15.9
100%
100%
22.6±5.8
42.5±9.4
27.1±9.7
56.8±7.7
100%
100%
NS
NS
NS
NS
NS
NS
79.3±24.1
51.8±19.8
53.7±24.5
56.6±9.1
100%
100%
109.7±34.7†
77.1±30.2
46.6±12.4
48.7±6.2
100%
100%
0.0009
0.003
NS
NS
NS
NS
Conclusions: Despite no differences in the LDA ﬂow, the IMCA diastolic velocity
was signiﬁcantly higher in pts with obstructive than non-obstructive HCM. Patients
from group C showed same velocity pattern as those from the group A. These ﬁndings likely suggest a relationship between IMCA diastolic ﬂow behaviour and presence of LV systolic gradient in severe cardiac hypertrophy. Various can the mechanisms be leading to this occurrence, ﬁrst of all the "milking-like" phenomenon subsequent to the higher wall stress.
532
MRI study for the measurement of regional left ventricular function in
hypertrophic cardiomyopathy.
T. Simor 1 , L. Toth 1 , R. Sepp 2 , A. Palinkas 2 , M. Csanady 2 , T. Forster 2 , L. Papp 1 .
1
University Of Pecs, Heart Institute, Pecs, Hungary; 2 University of Szeged,
Department of Medicine, Szeged, Hungary
Hypertrophic cardiomyopathy (HCM) is adequately investigated by echocardiography (ECHO). MRI, as a gold standard, is capable for the direct measurement
of global left ventricular (LV) function. Furthermore MRI is able to measure regional/segmental wall thickness/thickening for the entire heart. The aim of our study
was to correlate wall thickness (WT) and thickening (WT%) in HCM patients and
thus decide whether WT may specify WT%.
Method: 1.5 T Siemens Vision plus (Siemens, AG Germany) with a cardiac software
package at the Institute of Diagnostics and Oncoradiology (University of Kaposvár)
was used for cardiac imaging. ECG gated long axis (4, 3 and 2 chamber view) and
consecutive, multiple, no slice gap, apex to base, 8 mm thick short axis plane MR
images covering the entire left ventricle (LV) were acquired to study morphology
and cardiac function. Gradient-echo, segmented K-space cine imaging with an FOV
of 450 mm, TR/TE/Flip 10 ms/7 ms/25o and 256x256 image resolution was set
for the measurement of global cardiac function. MASS 5.0 (Medis, NL) was used
for the analysis of MR images. LV muscle regions were determined based on the
16 segment model. WT and WT% parameters were determined in each of the 16
segments.
Results: Our study included 14 men and 4 women. Ages ranged from 12 to 64
years (mean, 38±16 years) and HCM was already diagnosed by ECHO. A total of
288 segments (18 x 16) were analyzed. WT was less then 10, 10 to 15, 15 to 20,
20-25 and larger then 25 mm in 114, 97, 53, 19 and 5 segments, respectively. WT
and WT% was correlated for all segments and the following formula was calculated:
WT%== -6.8285 WT + 167.5, R2= 0,4845.
Conclusion: A signiﬁcant negative correlation was found between WT and WT%.
WT larger then 25 mm was akinetic, WT between 20 to 25 mm indicated severely
Eur J Echocardiography Abstracts Supplement, December 2003
S64
Abstracts
LEFT-VENTRICULAR ASYNCHRONY AND
RESYNCHRONIZATION
535
The temporal relationship between mitral and aortic valves opening and
closure and the myocardial velocity curve.
A. Ouss, P.A. Van der Wouw. Onze Lieve Vrouwe Gasthuis, Cardiology,
Amsterdam, Netherlands
Isovolumetric contraction (IVC) in a tissue Doppler imaging (TDI) curve is deﬁned
as a period between the onset of the Q wave on ECG and the onset of the systolic
wave (Sm). Isovolumetric relaxation (IVR), correspondingly, from the end of the Sm
wave to the onset of the early diastolic wave (Em). This assumes that the mitral
valve (MV) closes at the onset of QRS, the aortic valve (AV) opens at the onset and
closes at the end of the Sm wave and the MV opens at the onset of the Em wave.
The aim of this study was to verify this assumption.
Methods: Color TDI (CTDI) of the apical long axis view, 180 frames per second, was
performed with a Vingmed System V in 50 patients (48±19 years) without obvious
heart disease referred for a standard echocardiogram. The moment of closure (C)
was deﬁned as the last frame during closing movement when the valve moved with
aliasing velocity, the moment of opening (O) was deﬁned as the ﬁrst frame during
the opening movement when the valve acquired aliasing velocity. Velocity tracings
of the aortic annulus (AA) were derived from CTDI using EchoPac. Time intervals
between expected and observed moments of opening and closure were measured.
Results: MVC occurred 36 ms (17 to 53) later than expected, AVO 0 ms (-7 to
6), AVC 29 ms (13 to 41) later than expected, MVO 30 ms (-43 to 6) earlier than
expected. Interestingly, the MV and the AV closed within 11 ms after the onset of
AA acceleration directed basally during IVC and apically during IVR (ﬁgure).
537
Use of pulsed Doppler tissue imaging for the monitoring of cardiac
resynchronization therapy.
M. Gessner, M. Gruska, C. Dornaus, G. Blazek, W. Kainz, G. Gaul. Hanusch
Krankenhaus, 2. Medizinische Abteilung, Vienna, Austria
Limited data are available concerning the effect of cardiac resynchronization therapy (CRT) on left ventricular systolic myocardial velocities and the intraventricular
systolic asynchrony (LVSA) in patients (pts) with dilated cardiomyopathy (DCM).
Methods: Before biventricular pacemaker implantation 22 pts with DCM and heart
failure NYHA class III underwent a standard and pulsed Doppler tissue imaging
(PDTI) echocardiography examination. We measured the peak myocardial systolic
velocity (PSV), the interval between Q wave in the electrocardiogram and the beginning of the systolic velocity proﬁle ([Q – Sb] recorded from 4 basal segments [septal,
lateral, anterior, inferior] of the left ventricular wall from an apical approach. Follow up echocardiography examination was done 1 and 6 months after biventricular
pacemaker implantation. LVSA was calculated from the maximal Q-Sb difference.
Results: Out of 22 patients undergoing CRT 2 patients (9%) died because of worsening heart failure during follow up period. In the surviving 20 patients there was a
signiﬁcant improvement in LVEF (24 ± 6% vs 36 ± 5%; p < 0.0001), 6 min walk
test (332 ± 86 m vs 435 ± 78 m; p < 0.001), LVSA (79 ± 31 ms vs 37 ± 14 ms; p
< 0.001). Peak systolic velocities were signiﬁcantly higher in septal (4.1 ± 1.5 cm/s
vs 6.2 ± 2.0 cm/s; p < 0.001) and LV- inferior (4.7 ± 1.5 cm/s vs 6.5 ± 1.7 cm/s; p
< 0.001) segments in contrast to LV anterior (5.6 ± 1.4 cm/s vs 6.3 ± 1.7 cm/s; p =
ns) and lateral (5.7 ± 2.2 cm/s vs 6.0 ± 1.9 cm/s; p = ns) segments.
Conclusions: Pulsed Doppler tissue imaging is a very useful tool for selection and
follow up monitoring of patients with CRT. PDTI demonstrates two main mechanism
of improvement of cardiac function during CRT: left ventricular resynchronization
and increasing of systolic velocities in septal and LV - inferior segments.
538
Cardiac resynchronisation therapy in refractory heart failure: effect on LV
reverse remodeling and BNP levels.
G. Belotti, M.E. Bellebono, A. Piti’. Cardiology Department, Treviglio, Italy
Conclusions: The IVC and IVR periods in a TDI curve do not represent "real" isovolumetric intervals. The MV and the AV close shortly after the onset of respectively
early systolic basally directed and early diastolic apically directed AA acceleration.
536
Cardiac resynchronization therapy: which place in the treatment of heart
failure patients ?
G. Girod, M. Fivaz-Arbane, X. Lyon, M. Fromer, L. Kappenberger. CHU Vaudois,
Service of Cardiology, Lausanne, Switzerland
Background: Among patients (pts) who present left ventricular dysfunction and
symptoms of heart failure although optimal medical therapy, several showed also
signs of cardiac dyssynchrony. Wide QRS complex is a clear manifestation of this
phenomenon.
The aim of this study was to determine the incidence of pts eligible for cardiac
resynchronization therapy among pts in a tertiary university hospital centre.
Methods: We retrospectively analysed all hospitalised pts with moderate to severe
left ventricular systolic dysfunction during one year in our centre. Left ventricular
ejection fraction was 0.35 or less. Resynchronization criteria were the following:
NYHA class 3 or 4 of heart failure in spite of optimal medical therapy, left ventricular
dilation (>32 mm/m2 ) and wide QRS complex (150 ms or more). For pts with QRS
duration between 120 and 150 ms, 2 echocardiographic dyssynchrony criteria had
to be met: an aortic pre-ejection delay of 140 ms or more and an interventricular
mechanical delay of 40 ms or more.
Results: Among 191 pts who were analysed, (135 M, 66 W, mean age 69±12 y.,
ejection fraction 0.28±0.05), 77 (40%) suffered NYHA class 3 or 4 heart failure,
68 pts (35%) had left ventricular dilation, 29 pts (15%) presented with wide QRS
complex. Fifteen pts (20% among pts with NYHA class 3 or 4) met all the criteria for
cardiac resynchronisation therapy. Nevertheless, one third of those pts were brought
back in NYHA class 2 after maximal medical therapy. Thus, 10 pts (13% of NYHA
class 3 or 4 pts) were candidate for cardiac resynchronisation.
Conclusion: Among pts with advanced heart failure, 20% met the criteria for cardiac resynchronization therapy. A non untidy part of those pts could be improve by
more aggressive medical treatment. Anyway, at lest one of seven pts with moderate to severe left ventricular dysfunction should ﬁnd advantage from biventricular
pacing. Indeed, this therapy showed clear beneﬁt on symptoms in heart failure pts.
Eur J Echocardiography Abstracts Supplement, December 2003
Background: Heart failure (HF) is associated with increase of brain natriuretic peptide (BNP) levels. Cardiac resynchronisation therapy (CRT) showed to improve cardiac function in refractory HF. However, the impact of CRT on the BNP levels in
relation to the effect of CRT on cardiac function is not known.
Methods: We studied 33 pts (mean age 68±4 yrs) with ischaemic or idiopathic cardiomyopathy underwent CRT for refractory HF, NYHA class III or IV despite optimal
drug treatment, QRS duration >150ms and echocardiographic interventricular mechanical delay (inter-d) >40ms. We performed BNP levels assessment (Triage BNP,
Biosite) and Doppler echocardiography before CRT and after 1,3,6,12 months; we
measured inter-d, LV eccentricity index (ratio of longitudinal to transverse diameter,
apical 4-chamber) at end-systole (s-EI) and end-diastole (d-EI), E wave-septal separation (ESS), LV end-diastolic diameter (ED-d) and volume (EDV), ejection fraction
(EF) and diastolic function by measuring the ratio of E and A-wave (E/A), isovolumic
relaxation time (IVRT) and E-deceleration time (E-dt) on transmitralic ﬂow and the
ratio of the systolic and diastolic component of pulmonary venous ﬂow (S/D).
Results: After one month, we observed signiﬁcant increase of EF(31.5±7 vs 25±6,
p<.01), reduction of E/A (1.1±0.5 vs 1.8±0.9, p=.03) with increase of E-dt (194±65
vs 133±34ms, p=.01), IVRT (110±33 vs 95±35, p=.02) and S/D (1.3±0.7 vs
0.8±0.5, p=.02), persistent after three months. After 6 months, we also had a significant reduction of ESS (25±10 vs 28±13mm, p=.04), LV diastolic volume (182±66
vs 194±27 ml, p=.03), with improvement of s-EI (1.8±0.8 vs 1.5±0.2, p=.02) and
d-EI (1.8±1.2 vs 1.4±0.3, p=.02); all modiﬁcations persisted after 12 months. The
BNP showed a progressive reduction that became signiﬁcant after 12 months (baseline: 718±215 pg/ml, 1 mo: 653± 203, 3 mos: 405±267, 6 mos: 506±120, 12 mos:
278±134 pg/ml, p=.03).
Conclusions: In this selected population, the mechanical resynchronisation by
biventricular pacing resulted in early improvement of systolic and diastolic function, with later reduction of the LV dimensions and of the LV spherical shape. CRT
was associated with a signiﬁcant BNP reduction, after a sustained ventricular global
reverse remodeling. The LV function and shape modiﬁcations associated with neurohormonal compensation might have prognostic implications.
Abstracts
S65
539
Selection of candidates for cardiac resynchronization therapy (SCART):
study design and preliminary results.
541
Asynchrony indices in patients with heart failure- a tissue Doppler
echocardiography study.
C. Peraldo 1 , A. Puglisi 1 , M. Sassara 2 , G. Giarratana 3 , A. Cesario 4 , F. Laurenzi 5 ,
M. Di Segni 5 , G. Apicella 6 , A. Denaro 7 . 1 Fatebenefratelli Hospital, Rome, Italy;
2
Belcolle Hospital, Viterbo, Italy; 3 Villa Maria Eleonora Hospital, Palermo, Italy; 4 G.
B. Grassi Hospital, Ostia, Italy; 5 S. Camillo Hospital, Rome, Italy; 6 Medtronic Italy,
Clinical & New Bisness Development, Rome, Italy; 7 Rome, Italy
M. Plewka, J. Drozdz, M. Ciesielczyk, P. Lipiec, J.Z. Peruga, M. KrzeminskaPakula, J.D. Kasprzak. Medical University of Lodz, Cardiology Dept., Lodz, Poland
Background: Cardiac resynchronization therapy (CRT) has been demonstrated to
be effective in patients (pts) with advanced congestive heart failure (HF) and ventricular dysynchrony (VD).
The observation of variable efﬁcacy of CRT has resulted in efforts to predict the
response to this approach.
Purpose: Identiﬁcation of new parameters for the selection of candidates to CRT.
Method: 42 pts (76% male, age 71±8.4) with advanced HF (NYHA class 3.1±0.6),
low EF (EF 26.2±7.7%) and VD were enrolled in the SCART study, a prospective
multi-center study.
Three different method were used to assess VD.
1) electrocardiography: QRS>150ms.
2) echocardiography (QRS<150ms): inter-V delay (IVD)>40ms and intra-V delay
expressed as posterolateral LV wall activation delay (Q-LW)>290ms and/or Q-LW
> Q to wave-beginning of LV ﬁlling interval (Q-E).
3) Tissue Doppler Imaging (TDI) (QRS<150ms): inter-intra-V delay expressed as
time between LV lateral wall systole (S) and RV free wall S (LV-RV) > 70 ms and V
septum S (LV-IVS) > 50 ms, respectively.
Baseline, implant and FU visits at 1, 3, 6, 9 and 12 mos were programmed.
Results: 25 pts were enrolled according to QRS (group 1) and 15 pts according to
echo-criteria (group 2). At 1 mo FU, group 1 decreased NYHA class (from 3.2±0.8
to 2.2±0.7,P<0.005) and IVD (from 59.5±25.7 to 12.4±25.5, P<0.001) improved
EF (from 23.2±7.8 to 31±11, P<0.001) and diastolic ﬁlling time (from 424±97.8
to 442.2±94.9, P=n.s.). Similarly, group 2 decreased NYHA class (from 3.1±0.3
to 2.2±0.6, P<0.005) and IVD (from 47.6±19.5 to 17.1±15.1, P<0.001) improved
EF (from 26.6±5.4 to 33±13, P<0.05) and diastolic ﬁlling time (from 435±165 to
458±179, P=n.s.). No statistical differences were observed in term of clinical and
hemodynamic improvement between two groups.
Conclusion: from these preliminary data appears that echo-parameters despite
QRS duration are good indicators to CRT. Further analyses in a larger population
are needed in order to identify responders.
540
Asynchrony of cardiac contraction and ﬁlling in patients with congestive
heart failure and different QRS duration.
D. Koziara, W. Brzozowski, T. Widomska - Czekajska. Medical University,
Cardiology Dept., Lublin, Poland
The objectives of our study were to analyze the difference in ﬁlling and contraction
patterns in groups with normal or wide QRS (wider than 130 ms).The group of 55
pts with CHF was divided into subgroups with normal - 31 pts and wide QRS - 24
pts. Mean EF was 29,7%.Mean QRS width in narrow QRS group was 112,5 ms vs.
180,67 in wide QRS group.
The parameters of interventricular, and intraventricular asynchrony were estimated
and compared between two groups.Interventricular asynchrony was presented as
a difference in onset and duration of pulmonary and aortic ﬂows (QAo-QPA,LVETRVET).Intraventricular asynchrony was measured as differences between movement of wall segments or mitral ring segments.The distances from Q to maximal
systolic movement of the segments were measured.The differences between septal and posterior wall segments (QIVSS-QPWS); lateral and septal ring segments
(QL-QS); posterior and septal ring segments (QP-QS) and posterior and lateral
ring segments (QP-QL) were estimated.The measurement of time from Q wave to
the beginning of E wave (QE), the presence of one wave ﬁlling (E ﬁllers, A ﬁllers)
described left ventricular ﬁlling, and in our opinion should reﬂect atrioventricular
asynchrony.
Selected measurements for NQRS and WQRS
QAo - QPA (ms)
QE (ms)
number of E ﬁllers
number of A ﬁllers
QRS narrow
QRS wide
16,71
470,56
2
0
37,41*
540,9*
9*
1
statistically signiﬁcant * p < 0,05
Conclusions: 1. wider QRS duration is connected with delayed left ventricular ejection -signiﬁcant interventricular asynchrony
2. QRS duration of 130 ms as a borderline value does not allow to deﬁne the group
with distinct differences in the movement of left ventricular segments (intraventricular asynchrony-delay)
3. The onset of left ventricular ﬁlling is signiﬁcantly delayed in the group with wide
QRS, one wave ﬁlling pattern is more common in wide QRS group than in the group
with QRS duration less than 130 ms and indicates atrioventricular asynchrony
The assessment of left ventricular (LV) asynchrony has important clinical implication
in patients (pts) with chronic heart failure (CHF) and can help in the selection and
monitoring of resynchronization therapy. However, echocardiographic estimation of
segmental LV contractility is routinely accomplished through visual and subjective
assessment.
The aim of the study was to quantify the LV asynchrony in pts with CHF using pulswave tissue Doppler echocardiography (TDE).
The study group comprised of 60 pts with LV dysfunction- 30 pts after myocardial
infarction (MI group, aged 58±10 yrs; LVEF 28±7%) and 30 pts with dilated cardiomyopathy –(DCM group; aged 43±12 yrs, LVEF 25±8%). Etiology was detected
by coronary angiography. Control group consisted of 60 healthy volunteers (aged
43±12yrs, LVEF 65±2%). We measured peak TDE myocardial velocities: systolic,
early and late diastolic and time intervals: preejection period (PEPm), ejection, isovolumic relaxation (IVRTm), rapid ﬁlling, diastasis and atrial contraction time in six
basal segments in standard apical views. Following indices of heterogeneity were
calculated: dispersion of velocities and time intervals (a ratio of standard deviation
to the mean value of TDE parameter of 6 sampled basal segments) and asynchrony
of systole and diastole (the delay of PEPm or IVRTm). Dispersion of systolic velocities in MI group was signiﬁcantly higher than in DCM and control groups (33,1±6,0
vs 12,6±3,7 vs 15,9±5,6; p<0,001) similar, dispersion of diastolic velocities was
higher in MI group. Dispersion of all time intervals was signiﬁcantly higher in pts
with CHF than in controls with no differences between MI and DCM groups. Asynchrony of diastole was higher in pts with CHF than in controls, and in MI group than
in DCM group (124,1±64,9 vs 93,8±28,8 ms; p=0,023). Asynchrony of systole was
also higher in pts with CHF than in controls, but does not differ between MI and
DCM groups (50,2±25,1 vs 46,3±19,5 ms; p=NS).
Conclusion: TDE allows the quantiﬁcation of systolic and diastolic asynchrony in
pts with CHF. Best index of heterogeneity is dispersion of systolic velocities, which
differs among pts with ischemic and idiopatic cause of CHF.
542
Interventricular and intraventricular delay assessment by pulsed wave
tissue Doppler imaging in heart failure disease.
T. Chiriaco, G. Pelargonio, C. Ierardi, M. Santamaria, G. De Martino, A. Dello
Russo, T. Sanna, A. Lombardo, P. Zecchi, F. Bellocci. Catholic University,
Department of Cardiology, Rome, Italy
Background:
Current criteria of interventricular (InterV) electro-mechanical (EM) asynchrony includes a QRS duration more than 150 msec.
The aim of our study is to evaluate the InterV and intraventricular (IntraV) dissynchrony by Pulsed Wave Tissue Doppler Imaging (PW-TDI) in patients (pts) with
heart failure (HF) and left bundle branch block (LBBB), and to correlate it with QRS
duration.
Methods: We studied 59 pts (age 68±9 yrs, M 49) with HF, NYHA class III/IV
(35/24) and LBBB at ECG. Standard 12-lead ECG, echocardiogram and PW-TDI
were performed. We deﬁned EM delay of left ventricular lateral wall (LW), InterV
septum (IVS), and right ventricular free wall (RW) as the time interval between the
onset of QRS at ECG and the onset of S wave at PW TDI on the respective wall
segments (QS interval). The difference between LW and IVS QS intervals, and between LW and RW QS intervals, were deﬁned respectively IntraV and InterV dissynchrony. Pts were divided in a univentricular (UNIV) and biventricular (BIV) group if
the underlying disease involved only left or both left and right ventricle (RV) (with at
least moderate pulmonary hypertension and/or tricuspidal regurgitation and/or RV
dilation) respectively.
Results: We assessed mean QRS duration (182±26 msec), EF (24±6%), InterV
dissynchrony (70±53 msec) and IntraV dissynchrony (54±63 msec) in all pts. We
found a greater InterV and IntraV time interval in UNIV group than BIV group (respectively: 93±48 msec vs 47±48 msec, p=0.0002; 73±61 msec vs 33±58 msec,
p=0.007), with no differences as regards QRS duration, EF and NYHA class. In all
pts and in both groups we found a correlation between IntraV and InterV dissynchrony (r=0.67, p<0.0001), while there were not signiﬁcant correlations between
each of these two parameters and QRS duration, EF, and NYHA class.
Conclusions: EM dissynchrony isn’t only related to a prolongation of electrical activation, but also to a mechanical activation delay of a damaged myocardial wall due
to a volume or pressure overload. So PW-TDI is better than QRS duration to assess
the interV and intraV asynchrony, because it can perform serial and quantitative assessment of regional cardiac function and synchronicity. This study suggests that
PW-TDI may play a role in the selection of pts who might be suitable for resynchronization therapy.
Eur J Echocardiography Abstracts Supplement, December 2003
S66
Abstracts
543
Beneﬁcial effect of coronary revascularization on left ventricular
remodeling in patients with ischemic cardiomyopathy: the role of viable
myocardium.
V. Rizzello 1 , B. Krenning 2 , J.J. Bax 3 , A.F.L. Schinkel 2 , F.B. Sozzi 2 ,
E.C. Vourvouri 2 , J.R.T.C. Roelandt 2 , D. Poldermans 2 . 1 The Catholic University,
Cardiology Department, Rome, Italy; 2 Thoraxcenter Erasmus MC, Cardiology
Department, Rotterdam, Netherlands; 3 Leiden University Medical Center,
Cardiology Department, Leiden, Netherlands
Background: In patients (pts) with left ventricular (LV) dysfunction due to chronic
coronary artery disease, preserved myocardial viability not always implies left ventricular function recovery after revascularization. However, additional beneﬁts may
be present.
Aim: To test the hypothesis that myocardial viability may prevent LV remodeling
after revascularization, independently of the effect on functional recovery.
Methods: Dobutamine stress echocardiography (DSE) was performed in 88 pts
with ischemic cardiomyophaty, already scheduled for revascularization, to detect
the presence of viable myocardium. Resting 2D-echocardiography was performed
at a mean of 4,5 months and 2,8 years after revascularization. LV volumes and
the LV sphericity index (LVSI: D/L) were measured to evaluate LV remodeling (LV
volumes and LVSI increase). Radionuclide ventriculography was performed before
and at a mean of 4,5 months after revascularization to assess LV function.
Results: After revascularization, progressive remodeling was observed in overall
35 pts (40%). In these pts, the end-diastolic volume increased from 173 ± 42 to
207 ± 56 (at 4,5 months, p<0.01) and to 242 ± 55 ml (at 2,8 years, p<0.05). The
end-systolic volume increased from 109 ± 39 to 142 ± 24 (at 4,5 months, p<0.01)
and to 169 ± 58 ml (at 2,8 years, p<0.05). The LVSI increased over the follow-up
in 23 pts (66%) with LV volume increase. Clinical characteristics were similar in pts
with and without remodeling, however, a substantial amount of viable myocardium
(major or equal to 25%) was more often present in pts with no remodeling (81%
vs 9%, p<0.0001). The number of viable segments was a strong predictor of no
remodeling (OR 3, p<0.0001). The likelihood of no remodeling increased proportionally with the number of viable segments. The predictive value remained even
after correction for LV function recovery after revascularization(OR 3.1, p<0.0001).
After revascularization, LV ejection fraction increased signiﬁcantly (major or equal to
5%) in 28 of 46 pts (61%) with substantial amount of viable myocardium. However,
LV remodeling did not occur (preserved LV volumes and LVSI) in 17 of 18 pts (94%)
with viable myocardium that did not recover in function.
Conclusions: The presence of viable myocardium in pts with ischemic cardiomyopathy strongly prevents progressive LV remodeling. This beneﬁt is independent of
functional recovery after revascularization.
1
1
1
1
B.A. Popescu, M. Brieda, F. Zardo, F. Antonini-Canterin, R. Piazza, D. Pavan,
E. Hrovatin, G.L. Nicolosi. Ospedale Civile, Cardiologia, Pordenone, Italy
Background: Biventricular pacing in patients with severe heart failure (HF) and long
QRS improves symptoms and hemodynamics.
Aim: To assess the long-term clinical and echocardiographic beneﬁt in this setting.
Methods: We studied 35 patients (pts)(28 men, 70 ± 11 years) with dilated cardiomyopathy (idiopathic in 17 pts, ischemic in 17, and valvular in 1). A complete
echocardiographic study, including measurements of left ventricular ejection fraction
(LVEF), E-wave deceleration time (Edt), LV myocardial performance index (MPI, calculated as the sum of isovolumic intervals divided by ejection time), and assessment
of mitral regurgitation (MR) and tricuspid regurgitation (TR) severity (0-3/3) was performed at baseline, and repeated post-implantation. The ﬁrst echo study performed
post-implantation (before discharge) was considered for immediate result, the last
study available was considered for long-term follow-up.
Results: The group had the following baseline characteristics (before biventricular pacing): mean NYHA class, 3.1 ± 0.4; QRS duration, 200 ± 33 ms, LVEF, 27
± 7%. Atrial ﬁbrillation was present in 6 pts (17%). Mean follow-up duration was
330 ± 257 days. Clinical improvement was noted in 31/35 pts (89%). NYHA class
improved from 3.1 ± 0.4 to 2.1 ± 0.6 (p <0.001). At the ﬁrst examination after
resynchronization (immediate results), LVEF increased from 27 ± 7% to 32 ± 7%
(p =0.02), MR decreased from 1.8 ± 0.6 to 1.4 ± 0.7 (p = 0.01), and TR decreased
from 1.5 ± 0.7 to 1.1 ± 0.5 (p = 0.01). Edt increased from 118 ± 19 to 164 ± 50
ms (p <0.01), while the MPI decreased from 0.87 ± 0.24 to 0.64 ± 0.26 (p <0.01).
Eight pts (18%) died during follow-up.
Considering the group of pts (n=16) with a follow-up duration >1 year (mean followup 18 ± 3 months), the number of hospitalizations for HF was 0.7 ± 1.4 postimplantation, as compared to 2.8 ± 1.6 during the 9 months before implantation
(p <0.001). The mean duration of hospitalization decreased from 30 ± 21 days
before to 9 ± 20 days after implantation (p <0.01). The beneﬁt was maintained on
the long-term: NYHA class at last visit was 1.7 ± 0.6, p <0.001 compared to preimplantation NYHA class, and LVEF remained signiﬁcantly higher compared to the
baseline value (34 ± 5 vs 27 ± 7%, p <0.01).
Conclusions: This study conﬁrms the beneﬁts of biventricular pacing in pts with
severe HF and long QRS duration. Both clinical and echocardiographic parameters
improved after resynchronization, and the beneﬁt was maintained during long-term
follow-up.
546
Optimization of atrioventricular delay improves the rate of pressure rise
in the left ventricle in patients with severe congestive heart failure treated
with resynchronization therapy.
544
Prognostic impact of reverse left ventricular remodeling after
reynchronisation therapy as demonstrated by repeated 2D
echocardiography.
1
545
Long-term clinical and echocardiographic follow-up after biventricular
pacing in patients with severe heart failure.
M.A. Morales, U. Startari, L. Panchetti, M. Piacenti. CNR, Clinical Physiology
Institute, PISA, Italy
2
L. Faber , Y. Kim , N. Bogunovic , J. Vogt , J. Heintze , B. Hansky ,
D. Horstkotte 1 , B. Lamp 1 . 1 Heart Center North Rhine-Westphalia, Cardiology
Dept., Bad Oeynhausen, Germany; 2 Heart Center North Rhine-Westphalia, Dept
of Thorac Cardiovasc Surg, Bad Oeynhausen, Germany
Background and Introduction: Cardiac resynchronisation therapy (CRT) in patients (pts.) with severe congestive heart failure (CHF) due to coronary artery disease (CAD) or dilated cardiomyopathy (DCM) and left bundle branch block (LBBB)
results in clinical and functional improvement, and in a subset of patients in a decrease of left ventricular (LV) size, known as reverse remodeling (LV-R). The aim of
the present study was to evaluate whether clinical variables differ between pts. with
and without LV-R during long-term follow-up of CRT.
Results: We analysed the data of 112 patients treated with CRT for more than 12
months, with a mean echo follow-up of 22±9 months. Mean pt. age was 60±11
years. CHF resulted from DCM in 68, CAD in 35, and from valvular lesions in 9
cases. LV-R deﬁned as volume reduction >10% as measured by 2D echo (Simpson’s rule) was seen in 66 pts., while in 46 pts. LV volumes remained stable or
increased (LV-nR).
There were no signiﬁcant differences between the LV-R and the LV-nR groups concerning age, NYHA class, QRS width, oxygen uptake at CPX, 6-minute walking
distance, quality of life (Minnesota questionnaire), and 2D echo measurements of
LV size and function at baseline. However, in the LV-nR group 24 pts. (52%) had
CAD vs. 11 pts. (17%) in the LV-R group (p<0.0001). During follow-up there were
3 pump failures and 1 sudden cardiac death (6%) in the LV-R group in contrast to 9
such events (20%) in the LV-nR group (p= 0.01). In all pts. it was obvious after 12
months whether or not LV-R occurred.
Conclusion: During an average echocardiographic follow-up of 22 months after
CRT, pts. who show LV-R have a signiﬁcantly lower incidence of pump failure and
cardiac death. LV-R seems to occur more frequently in CHF of nonischemic origin.
If LV-R does not occur after >12 months of CRT, other treatment options should be
considered.
Eur J Echocardiography Abstracts Supplement, December 2003
Invasive measurements of intracardiac pressures have documented that the active
contribution of the left atrial systole to left ventricular (LV) ﬁlling is a major determinant of improvement in dP/dtmax in patients (pts) with biventricular (BV) stimulation.
This isovolumic phase index of LV function can be non invasively derived by the rate
of pressure rise (RPR) in the LV from the continuous wave Doppler spectrum of
mitral regurgitation.
Purpose of this study was to assess the inﬂuence of atrioventricular (AV) delay on
RPR in pts with BV stimulation for congestive heart failure (CHF).
Nineteen pts, 13 males, mean age 67 ± 15 years in sinus rhythm, treated with
resynchronization therapy for NYHA Class III-IV CHF and baseline mean ejection
fraction 23 ± 7% were enrolled in the study. A complete echo Doppler exam was
performed 12 ± 9 months after implantation as part of clinical follow up. Optimal AV
delay by pulsed Doppler echo of the transmitral ﬂow pattern was deﬁned as the one
which allowed completion of end diastolic ﬁlling prior to left ventricular contraction.
Rate of pressure rise was calculated according to the formula: 32 mmHg/dt, where
dt was the time required to go from 1 to 3 m/sec. An AV delay scanning from 80 to
160 ms in 10-ms steps, each lasting 7 minutes, was performed.
The echo Doppler exam was completed in 17 pts since 2 of them did not show an
adequate mitral regurgitation signal after pace maker implantation.
Optimal AV delay, as derived by transmitral ﬂow pattern, was 120 ± 12 ms and was
associated with the best RPR: 525 ± 150 mmHg/sec, with a % increase from lowest
to highest RPR values of 42 ± 15% during AV delay scanning.
In conclusion, optimization of left ventricular ﬁlling improves contractility in pts with
CHF, as assessed by RPR in the LV derived from Doppler mitral velocity curve.
This non invasive approach may provide a more accurate follow up and deﬁne the
best pacemaker settings in pts with severe LV dysfunction under resynchronization
therapy.
Abstracts
547
Cardiac resynchronisation therapy in refractory heart failure: relation of
LV diastolic function to BNP levels.
G. Belotti, M.E. Bellebono, A. Piti’. Cardiology Department, Treviglio, Italy
Background: Heart failure (HF) results in increase of brain natriuretic peptide
(BNP) levels; the restrictive left ventricular diastolic pattern is associated with higher
levels of this peptide. Restrictive LV diastolic pattern and elevated BNP levels had
negative prognostic value in HF. Cardiac resynchronisation therapy (CRT) showed
to improve cardiac function in refractory HF. However, the impact of CRT on the
diastolic function in relation to the BNP levels is not known.
Methods: We studied pts with ischaemic or idiopathic cardiomyopathy underwent
CRT for refractory HF, NYHA class III or IV, despite optimal drug treatment, QRS
duration >150ms and echocardiographic interventricular mechanical delay (inter-d)
>40ms. We performed BNP levels assessment (Triage BNP, Biosite) and Doppler
echocardiography before CRT and after 1,3,6,12 months to evaluate the left ventricular diastolic function; restrictive diastolic pattern was deﬁned by the combination of
E-deceleration time (E-dt) < 120 ms, ratio of E and A-wave (E/A) on transmitralic
ﬂow > 1 and ratio of the systolic and diastolic component of pulmonary venous ﬂow
(S/D) >1.
Results: Diastolic function parameters were complete and evaluable in 19 pts
(mean age 66±3 yrs). At baseline, 9 pts showed the restrictive pattern; out of them,
6 pts (67%) had regression of this pattern during follow up, while the remaining 3
pts had persistent restriction. The BNP levels were higher at baseline in persistent
(947±139pg/ml) than both in reversible restrictive pattern (433±64 pg/ml, p<.01)
and in not restrictive pattern (572±205 pg/ml). Furthermore, the reversal of the restrictive pattern was associated with signiﬁcant reduction of BNP levels (12 mos:
130 ± 55 pg/ml vs baseline: 433±64 vs, p< 0.01), while the BNP levels did not
change during the follow up in the other groups.
Conclusions: In this selected population, the mechanical resynchronisation by
biventricular pacing resulted in the regression of LV restrictive diastolic pattern in
the majority of patients with refractory HF; this behaviour of the diastolic pattern is
associated with signiﬁcant decrease of BNP levels. The persistence of restrictive LV
diastolic pattern despite CRT is associated with high BNP levels at baseline. The
reversal of restrictive diastolic pattern and the reduction of BNP levels might have
prognostic implications.
549
Comparative study of angle-corrected tissue velocity, displacement,
strain and strain rate imaging to characterize mechanical dysynchrony in
left bundle branch block.
L.ELIF. Sade 1 , D.A. Severyn 2 , H. Kanzaki 2 , K. Dohi 2 , K. Edelman 2 , J. Gorcsan
IIIrd 2 . 1 Baskent University, Cardiology, Ankara, Turkey; 2 University of Pittsburgh,
Cardiology, Pittsburgh, United States of America
Background: Advent of resynchronization therapy has made the characterization
of LV dysynchrony of clinical importance. Our objective was to test the hypothesis that a new generation tissue Doppler (TD) approach with angle correction can
objectively characterize mechanical dyssynchrony and that wall deformation indices
(strain, strain rate) would be superior to wall motion (displacement, velocity) indices.
Methods and Results: Twenty-three patients with LBBB and 22 normal controls
were studied. Digital TD velocity (V) data were angle-corrected and then converted
to quantitative color coded tissue Displacement (D), Strain (S) and Strain Rate
(SR) images by custom software. Transmural time-V, time-D, time-S and time-SR
curves were constructed from the anteroseptum (AS) and posterior wall (PW) at
the mid-short axis view. Delay between these segments was signiﬁcantly higher in
LBBB patients as compared to controls (V:33±21ms vs 138±67ms, D:23±19ms vs
162±86ms, S:29±26ms vs 208±91ms, SR:24±25 vs 181±105ms; all p<0.001).
However angle-corrected tissue S and SR detected greater delays than anglecorrected tissue D and V (p=0.04 and p=0.05; respectively) in LBBB patients. Also
AS-PW delay was associated with the QRS duration for all indices (velocity r=0.76,
Displacement r=0.82, Strain r=0.84, Strain Rate r=0.76; all p<0.01). Timing was
corrected by Bazett’s formula.
Angle Corrected Strain Proﬁle
548
Contractile response and mitral regurgitation after withdrawl of
biventricular pacing.
R.R. Brandt, R. Reiner, J. Sperzel, H.F. Pitschner, C.W. Hamm. Kerckhoff Heart
Center, Cardiology Dept., Bad Nauheim, Germany
Biventricular pacing (BVP) is a promising treatment modality for patients with symptomatic heart failure (HF) and mechanical dyssynchrony in the setting of left bundle branch block or intraventricular conduction delay. Clinical studies have shown
short-term improvement in contractile function and long-term improvement in clinical status in association with reverse left ventricular (LV) remodeling. The aim of
this study was to investigate the hemodynamic consequences of late biventricular
pacing (BVP) withdrawal.
Twenty patients (16 men and 4 women, mean age 64±7 years) received a BVP
system because of severe HF (NYHA class III and IV) due to dilated (n=14) or ischemic (n=6) LV dysfunction and a QRS interval >150 msec. Patients were studied
449±219 days after continuous BVP. Thereafter, the biventricular mode was deactivated (Off) and patients were restudied after an equilibration period of 72 hours
keeping all medications constant. The maximal rate of LV systolic pressure rise
(dP/dt) was estimated by measuring the time interval between 1 and 3 m/sec on
the mitral regurgitation (MR) continuous-wave Doppler spectrum. MR severity was
assessed by the color Doppler jet area and the proximal isovelocity surface area
(PISA) method.
In the BVP mode, systolic blood pressure (122±17 vs. 106±23 mm Hg, P<0.001)
and LV ejection fraction (29±12 vs. 25±10%, P<0.01) were higher, LV diastolic
ﬁlling time was longer (426±67 vs. 395±65 msec, p<0.01), and heart rate was not
different (71±5 vs. 68±5/min, NS).
Echocardiographic data
dP/dt (mm Hg/s)
MR jet area (cm2 )
ERO (mm2 )
RV (ml)
RF (%)
S67
BVP
Off
p value
747+_261
4+_3
5+_6
8+_8
12+_11
480+_142
6+_3
10+_9
16+_11
20+_13
<0.001
<0.05
<0.001
<0.001
<0.001
ERO, effective regurgitant oriﬁce area; RV, regurgitant volume; RF, regurgitant fraction
Late withdrawal of biventricular pacing leads to a decline in left ventricular systolic performance and an increase in functional mitral regurgitation despite a lower
blood pressure. These results indicate a sustained long-term hemodynamic beneﬁt
of biventricular pacing independent of a reverse left ventricular remodeling process.
Conclusion: The new TD imaging with angle correction seems to be promising to
quantify regional mechanical dyssynchrony in LBBB patients. Angle corrected tissue
strain and strain rate imaging could be more advantageous than angle-corrected
tissue displacement and velocity.
550
Use of pulsed Doppler tissue imaging for the monitoring of cardiac
resynchronization by optimized neurohumeral therapy.
M. Gessner, C. Dornaus, M. Gruska, G. Blazek, W. Kainz, G. Gaul. Hanusch
Krankenhaus, 2. Medizinische Abteilung, Vienna, Austria
Limited data are available concerning the effect of optimized neurohumeral therapy
on left (LV) intraventricular systolic asynchrony (LVSA) in patients (pts) with dilated
cardiomyopathy (DCM).
Methods: We investigated 157 pts with DCM and heart failure NYHA class II and III
by a standard and a pulsed Doppler tissue imaging (PDTI) echocardiography examination. The interval between Q wave in the electrocardiogram and the beginning of
the systolic velocity proﬁle ([Q – Sb] recorded from 4 basal segments [septal, lateral,
anterior, inferior] of the left ventricular wall was measured from an apical approach.
Follow up echocardiography examination was done 12 months after optimized neurohumeral therapy including beta blockers and ACE inhibitors in optimal dose. LVSA
was calculated from the maximal Q-Sb difference.
Results: In 43% (68 pts. Group A) LVSA decreased from 48 ± 23 ms to 23 ± 17 ms
(p < 0.000001). In this group LV- ejection fraction (LVEF) improved from 34 ± 8% to
38 ± 9% (p < 0.001). In 15% (23 pts group B) there was no change of LVSA (38 ±
23 ms to 38 ± 23 ms; p = ns) and LVEF (33 ± 9% vs 34 ± 10%; p = ns). In 42% (66
pts group C) LVSA was increased from 38 ± 23 ms to 64 ± 36 ms (p < 0.000001)
without signiﬁcant change in LVEF (31 ± 7% vs 32 ± 10%; p = ns). There was a
signiﬁcant difference between group A and B versus group C in respect to the QRS
duration at the time of randomization (QRS duration group A: 126 ± 32 ms vs group
C: 142 ± 32 ms; p < 0.01; group B 114 ± 27 ms vs group C: p < 0.001).
Conclusions: Pulsed Doppler tissue imaging is a very useful tool for detection of
LVSA. Improvement of LVEF due to optimized neurohumeral therapy reduces LVSA.
Despite optimized neurohumeral therapy, patients with long QRS duration represent
the ideal group of cardiac resynchronization therapy due the lack of improvement of
LVSA.
Eur J Echocardiography Abstracts Supplement, December 2003
S68
Abstracts
551
Physiological range of left ventricular asynchrony: an ultrasonic velocity
and strain rate imaging study.
T. Poerner, B. Goebel, T. Geiger, T. Süselbeck, M. Borggrefe, K.K. Haase.
University Hospital of Mannheim, 1st Dept. of Medicine, Mannheim, Germany
Background: Left ventricular (LV) asynchrony occurring in patients with heart failure can be successfully restored by cardiac resynchronisation therapy (CRT). However, there is still lack of consensus regarding the choice of the most suitable parameter to quantify asynchrony and to guide CRT.
Aim of the study was to assess the physiological ranges of systolic and diastolic
mechanical asynchrony in normal hearts.
Methods: Sixty-one subjects aged 40-84 years with normal coronary angiograms
and 12-lead ECG recordings, without LV hypertrophy or wall motion abnormalities
underwent tissue Doppler and strain rate imaging. Long-axis function was determined at rest in 4 basal and 4 middle-wall LV segments. Maximal differences between LV walls in time-to-peak tissue displacement (async_D), respectively timeto-peak strain (async_S) and time-to-peak systolic (async_Vs) and early diastolic
(async_Ve) velocities were measured and expressed as values corrected for heart
rate (after dividing by the square root of the cardiac cycle duration).
Results: The highest values were found for async_S (168 ± 141 ms), followed
by async_D (80 ± 92 ms), async_Vs (66 ± 43 ms) and async_Ve (48 ± 24 ms).
Async_S and async_Vs correlated linearly with the age of the patients (r = 0.63,
p < 0.001 for async_S and r = 0.53, p = 0.004 for async_Vs), while async_D and
async_Ve were not age-dependent. All parameters reached their maximal values
within the basal segments.
Conclusions: (1) Peak systolic strain showed the highest degree of asynchrony
under physiologic conditions. (2) A certain delay between LV walls in peak long-axis
displacement (<150 ms) can be accepted as a normal ﬁnding. (3) Systolic asynchrony implying both motion and especially deformation increases proportionally
with the age, reﬂecting the degree of cardiac heterogeneity. (4) In normal hearts
peak relaxation is less affected by intraventricular mechanical asynchrony compared to the myocardial contraction.
CONGENITAL HEART DISEASE
553
Left ventricle dysfunction in adolescents and adults with patent ductus
arteriosus 15-20 years after surgery.
A. Siwinska 1 , O. Trojnarska 2 , B. Mrozinski 1 , W. Bobkowski 1 ,
H. Gorzna-Kaminska 1 , M. Pawelec-Wojtalik 3 , M. Wojtalik 4 . 1 University of Medical
Sciences, Department of Pediatric Cardiology, Poznan, Poland; 2 University of
Medical Sciences, Department of Cardiology, Poznan, Poland; 3 University od
Medical Sciences, Department of Pediatric Radiology, Poznan, Poland; 4 University
of Medical Sciences, Department of Pediatric Cardiosurgery, Poznan, Poland
Background: The majority of the patients after ligation of patent ductus arteriosus
(PDA) in infancy and early childhood have no clinical symptoms. However, some
patients may present left ventricle (LV) dysfunction.
Methods: The aims of this study were Doppler echocardiographic (ECHO) quantify
LV end-diastolic volume index (LVEDVI) and LV diastolic and systolic function in 60
pts aged between 16 and 25 (18.3±3.6 yrs) 15-20 years (17.3±5.5 yrs) after ligation of PDA (PDA-1 group, pts operated at the 1 year of live, n=30; PDA-2 group,
pts operated > 2 year of live, n=30). ECHO parameters were compared with similar
variables in 50 healthy adolescents and adults (N). These measurements were performed according to the guidelines of the American Society of Echocardiography.
Results: LV systolic and diastolic dysfunction was observed in 30 pts (PDA-1
group-20 pts, PDA-2 group- 10 pts) before ligation of PDA. LVEDVI was signiﬁcantly higher in PDA-2 group than in the PDA-1 group and healthy adolescents and
adults (PDA-1=69,6±4.2cm3 /m2 ; PDA-2=90.4±8.4cm3 /m2 ; N=67.6±5.39cm3 /m2 ;
p<0,05) 15-20 yrs after PDA surgery. LV relaxation abnormalities were observed
in 1 patient from PDA-1 group and 4 patients from PDA-2 group (PDA-1: MV E/A=
1.39±0.12, DCT=166.0±6.6ms, IVRT=45.0±2.6ms; PDA-2: MV E/A=1.12±0.12,
DCT=179.3±6.8ms, IVRT=41.3±2.2ms; N: MV E/A=1.94±0.14, DCT=150.3ms,
IVRT= 71.4±6.3ms; p<0.05). There was signiﬁcant correlation between value of
IVRT and the age of patient at the time of PDA surgery (r=-0.1235; p<0.05). There
was not signiﬁcant correlation between value of IVRT and the period after PDA
surgery (r=-0.0357; p>0.05). LV systolic dysfunction (LVEF<45%) was observed in
2 patients from PDA-2 group. There was signiﬁcant correlation between the age of
patient at the time of PDA surgery and LVEF before and after surgery (r=-0.1241
and r=-0.1276, respectively; p<0.05). The worse result of ligation was in patients
with LV systolic and diastolic dysfunction operated >2 yr of life (3 pts from PDA-2
group with LVEF before ligation <45% and LV restrictive diastolic abnormalities).
Conclusions: 1. LV dysfunction in adolescents and adults is more common in patients with PDA operated > 2 year of life and LV dysfunction before surgery. 2. LV
diastolic dysfunction may cause heart failure in adolescents and adults after ligation
of PDA in spite of normal LV systolic function. 3. LV diastolic dysfunction is more
common than systolic dysfunction in patients after ligation of PDA.
Eur J Echocardiography Abstracts Supplement, December 2003
554
Impact of pulmonary regurgitation and age at surgical repair on textural
and functional right ventricular myocardial properties in patients
operated on tetralogy of Fallot.
G. Pacileo 1 , M. Verrengia 1 , G. Di Salvo 2 , V. Limatola 1 , A. Rea 1 , D. Mutone 1 ,
A. Rossi 1 , P. Calabro’ 1 , M.G. Russo 1 , R. Calabro’ 1 . 1 Second University of
Naples, Paediatric Cardiology, Naples, Italy; 2 Second University of Naples,
Department of Cardiology, Naples, Italy
Study aim was to identify non-invasively the potential impact of pulmonary regurgitation and age at surgical repair on the right ventricular (RV) textural and functional
myocardial properties in pts operated on tetralogy of Fallot (TOF).
Methods: We assessed the averaged intensity (Int.IB) and the cyclic variation
(CVIB) of the echo backscatter curve in 30 pts (mean age 16.2±8.3 yrs), who had
undergone corrective surgery for TOF (mean age at repair 3.2±2.6 yrs, range 0.211 yrs). They were divided into three age- and BSA-matched subgroups according
to the results of the surgical repair: 12 pts had no signiﬁcant postsurgical sequelae
(Group I), 12 pts had isolated moderate-severe pulmonary regurgitation (Group II)
and 6 pts had pulmonary regurgitation associated with signiﬁcant (>30 mmHg) RV
outﬂow tract obstruction (Group III). In addition, 30 age-, sex- and BSA-matched
normal subjects were identiﬁed as the controls.
Results: CVIB was decreased (7.86±2.5 vs 10.6±1.4 dB;p<0.001) and Int.IB was
increased (-18.6±4.1 vs -21±2.8 dB;p=0.01) compared to controls. Comparison
between controls and each subgroup of TOF pts showed: a) comparable values of
CVIB and Int.IB in Group I; b) Int.IB signiﬁcantly differed only in Group III (p<0.0001)
c) CVIB differed either in Group II and Group III (p<0.001). Group III pts, which had
the most signiﬁcant RV dilatation, compared to Group II (p=0.038) and Group I
(p<0.001), showed the lowest values of CVIB (5.56±1.8 dB) and the highest values
of Int.IB (-13.3±4.6 dB). Finally, in our study population, both the degree of RV
dilatation and the age at surgical repair signiﬁcantly correlated with Int.IB (r=0.5 and
0.4; p=0.05 and 0.03 respectively) and inversely correlate with CVIB (r= -0.55 and
-0.53; p=0.002 and 0.003 respectively).
Conclusions: in pts operated on TOF a) IB analysis is able to identify pts with
signiﬁcant RV myocardial abnormalities related to postsurgical sequelae; b) residual
PR, particularly if associated to pulmonary stenosis, strongly affects RV myocardial
properties; c) an earlier repair of TOF may result in better preservation of myocardial
characteristics.
555
Echocardiographic follow-up of patients after surgical correction of
atrioventricular septal defect.
A.D.J. ten harkel 1 , B.C.C. Heinerman 1 , A.J.J.C. Bogers 2 , W.Y.C. Hop 3 ,
A.H. Cromme-Dijkhuis 1 . 1 Sophia Childrens Hospital, Pediatric Cardiology,
Rotterdam, Netherlands; 2 Erasmus MC, Cardiothoracic Surgery, Rotterdam,
Netherlands; 3 Erasmus MC, Epidemiology and statistics, Rotterdam, Netherlands
Introduction: Patients who are operated for atrioventricular septal defect (AVSD)
can develop left-sided atrioventricular valve regurgitation (LAVVR) during follow-up.
This LAVVR is the main indication for reoperation in these patients. Until now, the
ideal time for reoperation is difﬁcult to assess. We sought to determine the outcome
of severe LAVVR, both medically treated or reoperated.
Methods: Retrospective review of echocardiographic, clinical and operative data
was performed. Echocardiography was performed preoperatively and postoperatively at regular intervals, using a Sonos 5500 (Philips Medical Systems, Andover,
Massachussetts). The degree of LAVVR was measured by color Doppler echocardiography. It was graded as none or mild (a thin jet extending to the wall of the
atrium), moderate (a broad jet extending to the wall of the atrium) or severe (a
broad jet occupying more than half of the left atrium). All studies that gave unequivocal results were reviewed by two of the investigators. From 1990 until 2001 164
patients, aged less than 16 years, underwent correction of their AVSD. Six Patients
died in the immediate postoperative period, and 2 patients were lost to follow-up.
Ninety-four patients (60%) had Down syndrome.
Results: During follow-up (9 months to 12 years; median 6 years), 30 patients
(19%) developed severe LAVVR. Sixteen of these patients had severe LAVVR in
the immediate postoperative period. Of these 16 patients 4 patients showed spontaneous regression to near-normal valve function during follow-up. The other 14 patients developed severe LAVVR during further follow-up. Sixteen out of 30 patients
with severe LAVVR were reoperated. Of these 16 patients 11 underwent valvuloplasty of the mitral valve once, in 2 patients valvuloplasty was necessary twice, in
2 patients valvuloplasty was followed by mitral valve replacement, and one patient
underwent primary valve replacement. After reoperation 3/16 (19%) patients died,
all 3 because of severe congestive heart failure related to persistent mitral insufﬁciency. Risk factors for the development of severe LAVVR and reoperation after the
primary operation were severe preoperative LAVVR and when no valvuloplasty was
performed.
Conclusions: Severe LAVVR develops in a signiﬁcant number of patients (19%)
after correction of AVSD. The main risk factor is the presence of preoperative severe LAVVR. Although reoperation can be performed with an acceptable risk and
usually results in good valve function, spontaneous regression after the immediate
postoperative period should be waited for.
Abstracts
S69
556
Successful device closure of atrial septal defect after the ﬁfth decade of
life: effect on symptoms and ventricular function.
558
Do adult patients, particularly those of advanced age, beneﬁt from
transcatheter atrial septal defect closure? A single center experience.
W. Li 1 , M. Henein 2 , M. Gatzoulis 3 , M. Mullen 3 . 1 Royal Brompton Hospital,
London, United Kingdom; 2 Royal Brompton Hospital, Echocardiography, London,
United Kingdom; 3 Royal Brompton Hospital, Adult Congenital Heart Disease,
London, United Kingdom
R. Rosenhek, H. Gabriel, M. Heger, T. Binder, P. Probst, G. Maurer,
H. Baumgartner. University of Vienna, Cardiology Dept., Vienna, Austria
Background: Device closure of secundum atrial septal defect (ASD) is now well
established as a therapeutic tool. However its beneﬁcial effect in older patients remains disputable.
Aim: To assess beneﬁcial effect of ASD device closure on symptoms and ventricular
function in patients >50 years of age.
Methods: We studied right and left heart size and function in 18 patients, age 64±8
years, 12 female who underwent successful ASD device closure procedure. Patients
were clinically as well as echocardiographically assessed before and 2-18 months
after procedure.
Results: 16 patient reported signiﬁcant symptomatic improvement following the
procedure, in whom the right atrial size (transverse diameter) fell from 6.0±1.2
to 4.9±1.1 cm, p<0.01 as did the right ventricle (inlet diameter) from 5.2±0.9 to
4.1± 0.9 cm, p<0.001. Peak pulmonary ﬂow velocity also dropped from 110±30
to 90±20 cm/s, p<0.05, while aortic velocity increased from 105±25 to115±25
cm/s after procedure. The left ventricular size modestly increased (end-diastolic dimension) from 4.2±0.5 to 4.7±0.7 cm, p<0.002. The remaining 2 patients who
had additional coronary artery disease, reported no change in symptoms despite
successful device implantation. In them, the left ventricle was at the upper limit of
normal before procedure and dilated afterwards while the left atrium was already dilated before procedure (>5 cm) and increased further in diameter during follow-up.
Left ventricular ﬁlling demonstrated signs of raised left atrial pressure before procedure (short isovolumic relaxation time and dominant E wave with short deceleration
time <120 ms) and became more restrictive afterwards.
Conclusion: The symptomatic improvement with ASD device closure in the elderly
is associated with right ventricular remodeling and increased left ventricular size
and stroke distance. However, careful patient selection should be considered, particularly in those with coronary artery disease and left ventricular dysfunction that
could be masked by the ASD.
557
Echocardiograhic exam accuracy in evaluation of cardiac ﬁndings
spectrum in Marfan syndrome.
C. Ginghina, I. Stoian, B. A. Popescu, M. Serban, I. Arsenescu, A. Popa,
I. Ghiorghiu, R. Ionascu, I. Coman, E. Apetrei. Bucharest, Romania
The diagnosis criteria in Marfan Syndrome (MS) include phenotypic expression at
bone skeletal structure, eyes, cardiovascular system, lungs and central nervous system.
Aim: The study of echocardiographic (ECHO) ﬁndings spectrum in MS; the appreciation of ECHO contribution in evaluation of patients (pts) with MS.
Methods: There were analyzed 41 pts with MS (aged between 18-61 years old,
25 males) admitted in a ten years period 1992-2003. All pts had clinical and paraclinical (ECG, x-ray, ECHO) evaluate; to 18 pts we made cardiac catheterisation
and aortography; 15 pts had a CT exam; 11 pts had MRI. The ECHO study was
made in 2D, M-mode, spectral and color Doppler, TTE and TEE. We calculated the
aortic (Ao) dilatation by appreciation of absolute diameter (diam), progression rate,
Ao distensibility (syst. Ao area-diast.Ao area)/(diast. Ao area puls pressure) and Ao
rigidity index (syst.pressure/diast. pressure multiplied by diast.Ao diam.)/(syst. Ao
diam– diast. Ao diam). We also studied their ﬁrst-degree relatives.
Results: The spectrum of ECHO ﬁndings of the 41 pts with MS included modiﬁcation of Ao rooth- 37 patients (90%); mitral valve (MV)- 13 pts (32%); pulmonary
artery (PA) dilatation- 5 pts (12%); tricuspid valve prolaps (TVP)- 4 pts (8%); interatrial septum aneurysm (IASA)-3 pts. Also the most affected structure in MS is the
MV, in our cases it was the aortic valve. There was no correlation between the Ao
dilatation and Ao regurgitation. The dissection risk risen with Ao diam (correlation
coefﬁcient r=0,95). The Ao dilatation progression rate was 1,7mm/year. The ECHO
study in families with MS has allowed an early noninvasive diagnosis for cardiac lesions, an early initiation of treatment (beta-blockers) and comparison with data from
pts without family history (Ao diam 47±9mm vs. 40 ± 7mm, P <0,001. The surgical
proper moment was established on ECHO data, for asymptomatic pts (Ao diam >55
mm). ECHO examination was also used for the postoperative follow-up: 1 aneurysm
at the anasthomosis level, 1 prosthesis dysfunction and 2 distal dissections).
Conclusions: The spectrum of ECHO ﬁndings in MS was complex: Ao determination dominated in frequency, followed by MV modiﬁcation, PA dilatation, TVP, IASA.
Multiple determinations of several cardiac structures were more frequent (68%) than
the single lesions (32%). The ECHO exam in MS allowed: an early diagnosis, the
follow-up of the progression rate, appreciation of indication for medical or surgical
treatment, postoperative follow-up and the evaluation of ﬁrst degree relatives.
Background: Transcatheter atrial septal defect (ASD) closure has been shown to
be feasible and safe in children as well as adults. However, little is known about the
clinical beneﬁt of this procedure in adult pts, particularly those of advanced age.
Methods: We performed transcatheter ASD closure with the Amplatzer Septal Occluder in 105 adults (mean age 51 ± 17 years, 73 female) of whom 76 were older
than 40 years (up to 82 yrs). Patients were followed for up to 4 years.
Results: In all pts ASD was successfully closed (occluder size 24 ± 5 mm, range
10 - 34mm). No major complications occurred. Minor complications were atrial ﬁbrillation (2), transient AV-block (1) and transient ST-elevation (2). At follow-up, a mild
residual left-to-right shunt was found in 3 pts. Right ventricular diameter (4-Ch view)
decreased from 43 ± 6 mm to 35 ± 6mm at 3 months with the most decrease occurring already on the ﬁrst day post intervention (p < 0.0001). Pulmonary artery
pressure decreased from 39 ± 16 mmHg to 30 ± 12 mmHg at 3 months (p <
0.0001).
Prior to intervention, 54 pts were symptomatic. Of these, 44 pts were older than 40
years. Limited exercise capacity and shortness of breath (NYHA class 2-3 or 3 in
20 pts) were the most frequently reported symptoms. At follow-up, all pts improved
but two. These patients remained in NYHA class 3 but had persistent marked pulmonary hypertension. All other patients were asymptomatic or had only mild exertional shortness of breath. All of the 26 pts who were 65 yrs or older and who were
treated because of signiﬁcant symptoms markedly improved.
Conclusion: Transcatheter atrial septal defect closure can be safely and successfully performed in adults. Regression of RV size and pulmonary artery pressure as
well as symptomatic improvement can generally be expected even in patients of
advanced age.
559
Right ventricular function evaluation by means of 3D echocardiography in
postoperative hypoplastic left heart syndrome (HLHS) patients.
O. Milanesi 1 , E. Reffo 1 , G. Markar Aragi 1 , R. Biffanti 1 , A. Cerutti 1 , G. Stellin 2 .
1
Università di Padova, Dipartimento di Pediatria, Padova, Italy; 2 Università di
Padova, Cardiochirurgia Pediatrica, Padova, Italy
Background: Three-D echocardiography has been validated as a reliable tool to
evaluate RV volumes and function in pediatric pts. Long term fate of pts with HLHS
lies on the durability of the RV as the solo pumping chamber of the heart.
Methods: We evaluated 16 pts with HLHS by means of 3-D echo, 5 after II stage, 11
after Fontan completion Mean age was 5 yrs (range 2-9yrs) and the mean follow-up
after the II stage (unloading procedure) was 4.6 yrs (range 0.7-8.5 yrs). HP Sonos
5500 echocardiographer was employed in all, with a standard transthoracic 4 MHz
rotating probe; the images were 3-D reconstructed by means of the summation
disks method. No sedation was necessary in all.
Results: At least 1 acquisition elegible for the 3-D reconstruction was obtained in
15/16 pts, the mean time of acquisition was 6 min (3-9) and the mean time of offline 3-D recontruction was 45 min (30-60min). The mean RVEDV was 65.49 ml/m2
(range 35.5-99.73), the mean RVESV was 38.8 ml/m2 (range21.4-59.36) and the
mean EF was 41.3% (range 31.5-52). Comparison between the measured RVED,
ES volumes and the EF and the normal values of the literature for the same parameters showed that pts with HLHS have larger volumes and reduced EF than normal.
Bivariate regression analysis, considering the time interval between the echo examination and the date of birth, II stage and Fontan operation, showed that the RVED
volume tends to decrease signiﬁcatively during time, after the II stage. The same
trend was shown by the RVES volume, while the ejection fraction was lower than
normal but did not change in time.
Conclusion: 3-D echo is a reliable tool for evaluating RV volumes and function in
pediatric age. Pts with HLHS have larger ED and ES RV volumes and reduced EF
in comparison to normal population, but volumes tend to decrease after the II stage
and the EF does not tend to reduce with time.
Eur J Echocardiography Abstracts Supplement, December 2003
S70
Abstracts
560
Quantiﬁcation of left ventricular function in patients with hypertrophic
cardiomyopathy: an ultrasound based regional strain and strain rate
imaging study.
G. Di Salvo 1 , G. Pacileo 2 , M. Verrengia 2 , M. Pascotto 2 , F. Cerrato 2 ,
G. Limongelli 2 , A. Rossi 2 , M.G. Russo 2 , R. Calabro’ 2 . 1 Dept. of Cardiology,
2
Paediatric Cardiology, Second University of Naples, Naples, Italy
Background: The echocardiographic evaluation of myocardial systolic function in
pts with hypertrophic cardiomyopathy (HCM) is still unsatisfactory. This disease has
been shown to exhibit LV relaxation and ﬁlling abnormalities despite normal LV ejection fraction (EF). However, EF only detects radial motion and the normal value of
systolic function described in HCM pts may be due to a relative insensitivity of the
used technique. Strain (S) and Strain Rate (SR) imaging is a new technique able
to quantify both radial and longitudinal regional myocardial deformations and potentially is more sensitive compared to 2D grey scale imaging.
Methods: We studied 25 HCM pts (aged 16±3 yrs) using standard grey scale echocardiography and S/SR imaging. Regional peak systolic longitudinal function was
assessed from the apical views while regional peak systolic radial function was
evaluated from the parasternal views. We studied also the time to peak systolic deformation (from the onset of ECG Q wave to the peak systolic S) for both radial and
longitudinal function, in the mid segment of posterior wall from the apical 3 chamber
view and the parasternal view, respectively. Data were compared with that of 33 age
comparable healthy subjects.
Results: All pts showed a normal LVEF. Radial peak systolic S and SR in HCM
pts were comparable to healthy subjects. Conversely, regional longitudinal function
was signiﬁcantly reduced when compared to healthy subjects (S [%]: HCM=10±6
vs healthy subjects =25±5, p<0.01; SR[1/s]: HCM = -1.2±0.6 vs healthy subjects = -1.8±0.3, p<0.01). This reduction was also found in? apparently? nonhypertrophied segments. In HCM pts the time to both radial and longitudinal systolic
peaks were signiﬁcantly prolonged when compared to healthy subjects. Moreover,
while in healthy subjects the time to longitudinal systolic peak (290±37ms) was
shorter than the time to radial systolic peak (310±37 ms), in HCM pts the time to
longitudinal systolic peak (388±56 ms) was longer than the radial one (344±28 ms).
Conclusions: Despite a normal LVEF, systolic longitudinal deformation is signiﬁcantly reduced in HCM pts and this reduction is present also in the? apparently?
normal segments. S/SR imaging demonstrated in HCM that longitudinal function
not only is reduced but is also delayed in this disease.
561
Exercise-induced regional diastolic dysfunction identiﬁes persistent
coronary stenosis in asymptomatic children with history of kawasaki
disease.
T. Poerner 1 , B. Goebel 1 , R. Arnold 2 , T. Süselbeck 1 , M. Borggrefe 1 , K. K. Haase 1 ,
H. E. Ulmer 2 . 1 University Hospital of Mannheim, 1st Dept. of Medicine, Mannheim,
Germany; 2 University Children’s Hospital, Dept. of Paediatric Cardiology,
Heidelberg, Germany
Background: Kawasaki disease is an acute systemic vasculitis in children, which
causes aneurysm formation in 10-15% of patients during its acute stage, as well as
residual aneurysms and persistent stenosis in some cases at long-term follow-up.
Aim of the study was to assess regional myocardial function in children with documented coronary artery involvement due to Kawasaki disease.
Methods: Eighteen asymptomatic children aged 13 ± 4 years (range 6-19 years)
with history of coronary vasculitis in whom coronary angiograms during acute stage
and at 5-years follow-up were available were included in the study. Twenty age- and
gender-matched healthy subjects served as a control group. All children underwent
echocardiography with tissue Doppler and strain rate imaging (TD/SRI) at rest and
during a submaximal bicycle exercise test (heart rate 128 ± 8 beats/minute). TD/SRI
examination of the left ventricle (LV) was performed from apical 2- and 4-chamber
views and included peak systolic (Vmax-S) and early diastolic (Vmax-E) velocities,
peak systolic strain and peak systolic and diastolic strain rate, which were calculated
for a 16-segment LV-model.
Results: Long-axis measurements were available at rest and during exercise in
225 of 456 LV segments. There were no differences evaluable between normal and
formerly affected coronary arteries concerning visible wall motion abnormalities,
systolic velocities, strain or strain rate both at rest and during submaximal exercise.
However, Vmax-E during exercise decreased signiﬁcantly in LV segments which
were supplied by arteries with actually relevant stenosis (Table 1).
Table 1 (mean ± SEM)
Vmax-E (mm/s)
Controls
(n=126)
Healed aneurysm
(n = 39)
Persistent aneurysm
(n = 36)
Relevant stenosis
(n = 24)
LV base: at rest
LV base: exercise
Mid LV: at rest
Mid LV: exercise
LV apex: at rest
LV apex: exercise
106 ± 7
135 ± 5
90 ± 4
114 ± 6
64 ± 5
96 ± 7
96 ± 10
100 ± 8
95 ± 4
89 ± 9
72 ± 7
55 ± 16
112 ± 8
145 ± 16
94 ± 7
116 ± 18
49 ± 9
64 ± 20
97 ± 26
65 ± 11 *¶
77 ± 13
24 ± 43 *¶
66 ± 9
18 ± 30 *¶
*p < 0.05 vs. controls, ¶p < 0.05 vs. segments with persistent aneurysms
Conclusions: An exercise-induced regional diastolic dysfunction revealed by tissue
Doppler imaging can identify persistent coronary stenosis at long-term follow-up in
asymptomatic children with history of Kawasaki disease.
Eur J Echocardiography Abstracts Supplement, December 2003
562
Prognostic value of strain and strain rate imaging in patients with
isolated congenital aortic regurgitation.
G. Di Salvo 1 , G. Pacileo 2 , M. Verrengia 2 , A. Rea 2 , D. Mutone 2 , V. Limatola 2 ,
A. Rossi 2 , M.G. Russo 2 , R. Calabro’ 2 . 1 Dept. of Cardiology, 2 Paediatric
Cardiology, Second University of Naples, Naples, Italy
Background: Deﬁnition of the exact timing for cardiac surgery in asymptomatic
patients with isolated congenital aortic regurgitation (iCAR) represents still a challenge. Indeed, if the operation is deferred until patients become symptomatic there
is a very high risk of irreversible left ventricular (LV) dysfunction. The conventional
echocardiographic assessment of LV function, a non-quantitative, subjective and
experience dependent evaluation, showed a very low predictive value in deﬁning
the time to surgery in iCAR patients. A more sensitive, non-invasive, quantitative
approach could be crucial in the management of those patients. Strain (S) (%) and
Strain Rate (SR) (1/s) imaging as well as Integrated Backscatter (IBS), are new
echocardiographic technique which allow to asses regional deformation properties
and textural properties, respectively.
Aims: 1 - To deﬁne the ability of these non-invasive techniques to unmask subtle
functional abnormalities in asymthomatic patients with iCAR. 2 - to evaluate the
prognostic value of these functional abnormalities.
Methods: We studied 15 patients (age 18±6 yrs) with moderate to severe iCAR by
standard grey-scale echocardiographic indices, IBS and S/SR imaging, comparing
data to those of age and BSA matched healthy subjects. We prospectively followed
iCAR patients for a 6 months period to evaluate the onset of symptoms and the
need for surgery.
Results: Standard grey scale echocardiographic indices showed that compared
to normals iCAR patients presented increased LV end diastolic diameter (5.6±0.5
vs 4.2±0.6 cm, p<0.01) and a comparable shortening fraction (36±5 vs 37±3%,
p=NS). Cyclic variation at IBS analysis was reduced at both septal (9±1.7 vs
10.1±1.6, p<0.05) and posterior wall (7.6±1.4 vs 10.8±1.3, p<0.0001). Peak systolic S/SR were reduced for both longitudinal (SR: -1.5±0.7 vs ?1.9±0.5; S: -21±6
vs -25±5, p<0.05) and radial (SR: 3.1±1.1 vs 3.7±0.9, p<0.05; S: 42±14 vs
55±12, p=0.003) deformation properties. Radial S was signiﬁcantly correlated with
Jet/LVOT (p=0.04; R=-0.77), while longitudinal SR was signiﬁcantly correlated with
age (p=0.0031; R=0.77). In the 6 months follow-up period, 2/15 iCAR patients became symptomatic and thus the indication for surgery was posed. Of note, these 2
iCAR patients presented the lowest value of peak systolic SR
Conclusions: In asympthomatic iCAR patients, IBS and S/SR imaging are able
to early detect functional abnormalities. S/SR indices, related to both duration and
degree of aortic regurgitation, seems to have prognostic value in iCAR patients.
563
Left ventricular remodelling and mechanics after successful repair of
aortic coarctation: prognostic implications of the ultrasonic tissue
characterization.
G. Pacileo 1 , M. Verrengia 1 , V. Limatola 1 , M. De Divitiis 1 , G. Di Salvo 2 , A. Rea 1 ,
D. Mutone 1 , A. Rossi 1 , M.G. Russo 1 , R. Calabro’ 1 . 1 Paediatric Cardiology, 2 Dept.
of Cardiology, Second University of Naples, Naples, Italy
Background: Pts after aortic coarctation repair (AoCor) may have multiple pattern
of left ventricular(LV) geometry. It is crucial as in hypertensive pts a relationship
exists between LV hypertrophy and/or geometry and cardiovascular risk.
Aim: to assess in AoCor pts LV remodeling and mechanics and to deﬁne the ability
of integrated backscatter (IBS) to differentiate pts with(+) vs without(-) LV hypertrophy(LVH) and with different pattern of LV remodeling.
Methods: we studied 30 normotensive AoCor pts (aged 20 ± 12 yrs)(age at repair
7±6.6 yrs). Sex- and age-speciﬁc cutoff levels for LV mass/height2.7 (LVMI) and relative wall thickness (RWT) were deﬁned to assess LV geometry, as normal (N), concentric remodeling (CR), concentric hypertrophy (CH), eccentric hypertrophy (EH).
Also the relation between the midwall rate-corrected velocity of circumferential ﬁber
shortening (mwVCFc) and meridional end-systolic stress (ses) was deﬁned. LV diastolic function was evaluated by the peak E, peak A, E/A ratio, DT and IVRT. By
IBS analysis the magnitude of cyclic variation (CV) and the averaged myocardial
intensity (Int.) normalized to pericardium were calculated. In addition 35 age- and
BSA-matched normal subjects were used as control group (CG).
Results: LV geometry was abnormal in 16/30 pts (8 CR, 4 CH, 4 EH) (53%). Among
the 8 pts with LV hypertrophy 4 had value of LV mass/height2.7 > 51 g/m2 .7 The
midwall VCFc-ses relation was normal or mildly increased in all pts. Comparisons
among groups of pts with different patterns of LV remodeling showed no differences of mitral ﬂow indexes and IVRT. At IBS analysis, CV was grouped according
to LV mass and geometry both at interventricular septum (IVS) and posterior wall
(PW)(Table).
IVS-CV (dB)
PW-CV (dB)
CG
LVH (+)
LVH (-)
N
CR
EH
CH
9.3±0.4
9.5±0.3
7±0.9
7.1±0.8
8.3±1.2¶
8.7±1¶
9±0.5
9.1±0.8
7.9±1.2
8.1±1.2
7.3±1.2*
7.1±0.7*
6.6±0.6*
7.1±1*
¶ p<0.001 LVH(+) vs LVH(-); *p<0.005 vs N
Conclusions: In normotensive AoCor pts, IBS analysis is able to distinguish pts
+ vs - LVH and to categorize them according to the pattern of LV geometry, even
though conventional diastolic and myocardial contractility indexes are still normal.
Thus, IBS characterization could allow an early identiﬁcation of subgroups of young
pts at higher risk of cardiovascular complications.
Abstracts
S71
564
Transoesophageal echocardiographic assessment of infective
endocarditis in grown-up congenital heart disease.
566
Lack of correlation between right heart reverse remodeling and improved
exercise capacity after transcatheter closure of atrial septal defect.
D. Bedeleanu, N. Shuka, A. Serban, A. Lazar, L. Strimbu. Heart Institute,
Cardiology, Cluj, Romania
R.R. Brandt, M.W. Weber, T. Neumann, M. Rau, V. Mitrovic, C.W. Hamm. Kerckhoff
Heart Center, Cardiology Dept., Bad Nauheim, Germany
Although a relatively rare problem, infective endocarditis is one of the most dreaded
complications of structural grown-up congenital heart disease (CHD). Development
of new techniques, specially transesophageal echocardiography improved the possibility to diagnose vegetations and recognize their complications at patients with
CHD.
Aim: to evaluate grown-up CHD infective endocarditis (IE) and their complications
using multiplane transesophageal echocardiography (TEE).
Material and methods: We studied a number of 51 consecutive patients (36 M,
15 F), mean age 32,2 y, (range between 15- 47 y) with CHD and IE (Duke modiﬁed
criteria) examined by TEE between 1996-2002.Type of CHD, localization, eventually
second localization of vegetations and their complications found on TEE were noted.
Results: From 2446 TEE exams performed, 134 pts (5.47%) had IE and vegetations on TEE. CHD and vegetations were found in 51/134 pts (38.05%). The remaining 83 pts with vegetations on TEE (61.95%) had IE on rheumatic or degenerative valvulopathy. In CHD vegetations were found on bicuspid aortic valve –22 pts
(43.13%), valvular and subvalvular congenital aortic stenosis - 1 pt (1.96%), prolapsed mitral valve-13 pts (25.49%); hypetrophic cardiomyopathy and mitral regurgitation was found in 2 pts (3.12%), VSD in 16 pts (31.37%), ASD in 4 pts (7.84%)
(2 pts ostium secundum and 2 pts atrio-ventricular canal), PDA in 2 pts (3.12%),
Fallot- 1 pt (1.96%) and Ebstein and tricuspidal regurgitation-1 pt (1.96%). A second localization of vegetations was found in 8 pts (15.68%)-in 6 pts with VSD (1
vegetation on the each side of interventricular septum, in 3 vegetations on tricuspid
valve and on pulmonary valve, and 3 vegetations on the right side of VSD and at the
level of an aortic regurgitant valve); 1 pt had vegetation on aortic stenotic valve and
a second localization on a LVOT hypertrophy. In a Fallot pt vegetations were found
on tricuspid and pulmonary valves.
Ruptured valves and acute heart failure were noted in 14 pts (27,45%); ruptured
valves were: 7 prolapsed mitral valves, 5 bicuspid aortic valves and 1 tricuspid valve
in a Fallot pt. Abscesses were found in 7(13.72%) pts, 5 in pts with aortic bicuspidy
and 2 on prolapsed mitral valve.
Conclusions: The incidence of IE on uncorrected grown-up congenital heart disease is still high. Transesophageal multilane echocardiography is a very valuable
method in assessing vegetations, multiple localization and complications of IE (valve
rupture, abscesses) in uncorrected grown-up CHD endocarditis.
Transcatheter closure of atrial septal defect (ASD) is increasingly performed as an
alternative to corrective surgery.
The aim of the present study was to serially analyze changes in right heart geometry
in relation to cardiopulmonary exercise capacity in patients after transcatheter ASD
closure.
Thirty-two patients (15 men, 17 women) with a mean age of 43±16 years underwent transcatheter closure of a signiﬁcant secundum-type ASD (QP:QS 2.1±0.9).
Doppler transesophageal echocardiography demonstrated complete occlusion without residual shunt in all patients. All patients underwent serial transthoracic echocardiographic examinations before, 1, 6, and 12 months after ASD closure. Right atrial
area at end-systole (planimetry), right atrial volume (area-length-method), right ventricular end-diastolic diameter (inﬂow tract) and right ventricular volume were measured in the apical four-chamber view. Right ventricular fractional area change was
utilized as a surrogate for right ventricular function.
At baseline, right heart chambers were dilated compared to a control group of agematched healthy individuals. The extent of right heart reverse remodeling was not
related to age, gender, shunt size, mean pulmonary artery pressure, and atrial ﬁbrillation by multivariate analysis. Oxygen consumption at the anaerobic threshold
as an objective measure of cardiopulmonary exercise performance increased from
11.6±2.9 to 13.5±2.9 ml/min/kg (P<0.05) at 12 months without a direct correlation
to geometric right heart changes.
Data adjusted for body size
Right atrial area (cm2 /m2 )
Right atrial volume (ml/m2 )
Right ventricular diameter (cm/m2 )
Right ventricular volume (ml/m2 )
Right ventricular fractional area
change (%)
Transcatheter closure of secundum atrial septal defect [ASD] using Amplatzer occluder is effective treatment method with extremely rare serious complications.
Hemopericardium have occurred in only few cases in adults. The explanation is that
the edge of the device can induce the erosion of the left atrial wall and the aorta.
Typically, it occurs in absence of aortic rim. We present a case of severly symptomatic patient with tamponade due to hemopericardium related to device closure
of ASD.
52 yrs old woman underwent transcatheter closure of secundum ASD (diameter of
16mm) with Amplatzer occluder (N. 24) 36 month ago. Aortic rim was 3mm. The
3 yrs follow-up was eventfree, the symptoms and signs of right ventricle overload
disappeared. A tort she was syncopated and severly hemodynamic compromised.
Emergency echocardiography revealed tamponade, occluder correctly placed. Immediate pericardial centesis was performed, 500ml of blood was evacuated. Due to
high suspicion of late complication of device closure patient was refered to surgical
removal of the device together with repair of the ASD and of the perforation of left
atrial wall.
In conclusion, despite the ASD closure by Amplatzer occluder is considered as a
safe and feasible method, serious complications like hemopericardium can occur.
Attention shoud be payed to patients with no or very little aortic rim like in our patient.
In these cases it is recommended to use a device 3 to 4mm larger than the stretched
diameter.
month after
after closure
months after
after closure
2 months after
after closure
11.3±2.1
34.4±9.9
2.1±0.2
107.7±22.2
9.2±1.4*
24.2±5.7*
1.8±0.2*
85.2±18.7*
8.9±2.1*
23.6±9.6*
1.7±0.2*¶
76.0±14.4*¶
8.5±1.5*
22.8±7.9*
1.7±0.1*¶
71.1±13.8*¶
30.6±6.5
30.7±5.2
34.6±4.8¶#
38.2±7.7*¶
*P<0.001 vs before closure, ¶P<0.01 vs 1 month, #p<0.05 vs before closure
Interventional closure of atrial septal defect causes early regression of right heart
volume overload and delyed improvement in right ventricular systolic function in
association with increased exercise capacity independently of each other.
565
Hemopericardium as late complication following device closure of
secundum atrial septal defect.
I. Simkova, P. Chnupa, I. Riecansky, V. Fridrich. Slovak Inst. of Heart and Vascular
Dis, Cardiology, Bratislava, Slovakia
Before
closure
RIGHT VENTRICLE
568
Efﬁciency of a combined strategy of ultrasounds according to the
localization of pulmonary embolism.
N. Mansencal 1 , T. Joseph 1 , A. Vieillard-Baron 2 , A. Redheuil 1 , F. Jardin 2 ,
P. Lacombe 3 , O. Dubourg 1 . 1 Hôpital Ambroise Paré, Service de Cardiologie,
Boulogne; 2 Hôpital Ambroise Paré, Service de réanimation, Boulogne; 3 Hôpital
Ambroise Paré, Service de radiologie, Boulogne, France
Background: Echocardiographic disorders are associated with important pulmonary embolism (PE). But, little is known about the accuracy of a combined strategy using transthoracic echocardiography (TTE) and venous ultrasonography (VU)
according to the localization of PE.
The aim of this study was to assess the efﬁciency of TTE combined with VU in
patients with PE.
Methods: We studied 173 consecutive patients (88 men, mean age 61 ± 16 yrs)
presenting with proven PE. All patients underwent TTE and VU. The diagnosis of
acute cor pulmonale (ACP) was made if the right to left ventricular end-diastolic
area ratio was higher than 0.6 using 2D echo in apical four-chamber view, with
paradoxical septum. The diagnosis of deep venous thrombosis (DVT) rested on
vein incompressibility using VU.
Results: The incidences of ACP and DVT were 56% and 75% respectively. The
incidence of ACP was signiﬁcantly different according to the localization of PE (p
<0.0001, table). The incidence of DVT was similar whatever the localization of PE.
Using both echographic techniques, the incidence of ACP and/or DVT was 89%,
with an incidence signiﬁcantly different according to the localization of PE (p =
0.001). Only 11% of our patients had no positive echographic criteria. All patients
with proximal pulmonary embolism had ACP and/or DVT. Echocardiography with VU
had improved the diagnostic value of VU in only 4% of patients with distal PE (p =
0.65).
Table
ACP (%)
DVT (%)
ACP and/or DVT (%)
Proximal PE
Lobar PE
Distal PE
P value
87
74
100
58
78
88
17
73
77
< 0.0001
0.93
0.001
Conclusion: These data suggest that TTE with VU may improve their diagnostic
value in proximal or lobar PE. However, it seems that this combined strategy fails in
distal PE and should be mostly recommended in a population of resting intensive
care unit patients.
Eur J Echocardiography Abstracts Supplement, December 2003
S72
Abstracts
569
Ultrasonic strain rate imaging identiﬁes right ventricular dysfunction after
mild to moderate acute pulmonary embolism.
571
Pulmonary embolism in patients with deep venous thrombosis:
diagnostic algorithm.
T. Poerner 1 , B. Goebel 1 , S. Bibrack 1 , A. Miskovic 2 , C. Kohl 1 , M. Borggrefe 1 , K.
K. Haase 1 . 1 University Hospital of Mannheim, 1st Dept. of Medicine, Mannheim,
Germany; 2 University Hospital of Frankfurt/Main, Dept. of Cardiac Surgery,
Frankfurt/Main, Germany
A.W. Andraos 1 , W.A. Radwan 1 , A.H. ElSherif 1 , A.H. Ibrahim 1 , M. Mostafa 2 ,
M.S.H. Mokhtar 1 . 1 Kasr AlAiny, Critical Care Medicine, Guiza, Egypt; 2 Kasr Al Ainy
University Hospitals, Radiology Department, Cairo, Egypt
Background: While right ventricular (RV) wall motion abnormalities (WMA) are essential signs of massive acute pulmonary embolism (PE), few consistent data are
available on RV function after mild to moderate PE.
Aim of the study was to investigate regional RV free wall mechanics after hemodynamically stable PE.
Methods: Twenty-nine patients (pts.) aged 60 ± 11 years with suspected acute PE
and 15 pts. having chronic pulmonary hypertension (CPH) with tricuspid regurgitation (TR) pressure gradients (PG) of 57 ± 21 mm Hg (10 pts. with severe mitral
regurgitation, 2 pts. with aortic stenosis, 3 pts. with coronary heart disease) were
investigated by conventional echocardiography and tissue Doppler with strain rate
imaging (TD/SRI). Segmental or subsegmental PE were found by multislice chest
CT in 15 patients and had a benign clinical course. The other 14 patients presenting with non-cardiac chest pain built the control group. Long-axis TD/SRI measurements included peak systolic and diastolic velocities, peak systolic strain and peak
systolic strain rate of basal, middle and apical RV free wall. An accurate signal could
be obtained in all analyzed segments and the examiner was blinded to CT results.
Results: Within the PE group we found 2 pts. with middle RV wall hypokinesis, no
pts. with RV enlargement and no signiﬁcant TR (PG 19 ± 5 mm Hg). Analysis of
myocardial velocities and strain rate showed no signiﬁcant differences between patient groups. Peak systolic strain in the middle and apical segments was signiﬁcantly
altered both in pts. with PE (-0.22 ± 10) and with CPH (-0.22 ± 8), as compared to
the control group (-0.36 ± 14, p < 0.05). Among patients with suspected PE a peak
systolic strain value in the middle or apical RV wall > -0.27 predicted acute PE with
a sensitivity of 75%, a speciﬁcity of 72%, providing an area under the ROC curve of
0.8 (p = 0.03).
Conclusions: Acute mild to moderate PE without RV overload is associated with
pathologic deformation properties of the middle and apical RV wall, comparable to
those observed in CPH. Assessment of peak systolic strain by TD/SRI is a valuable
clinical tool superior to conventional echocardiography for detection of subclinic RV
injury.
570
Right ventricular diastolic myocardial performance index and pulmonary
artery pressure.
P. Lindqvist 1 , G. Wikström 2 , A. Waldenström 1 , E. Kazzam 3 . 1 Umeå University
Hospital, Clinical Medicine, Umeå, Sweden; 2 Uppsala University Hospital,
Cardiology, Uppsala, Sweden; 3 Mälar Hospital, Cardiology, Eskilstuna, Sweden
Purpose: Assessment of right ventricular (RV) function is difﬁcult and is not easy
to achieve due to its complex anatomy and geometry. Recently, myocardial performance index (MPI), a Doppler derived index and a measurement of both systolic
and diastolic events, was suggested as useful parameter for assessing RV function
and was found to be well correlated to the presence of pulmonary hypertension
(PH). Aim of the present study was to explore the relation between pulmonary pressure to traditional MPI and to evaluate if the ratio of isovolumic time to RV ﬁlling
time, as a measurement of RV diastolic performance index (RVDMPI) better estimates pulmonary pressures.
Methods: Twenty-three patients (6 females and 17 males) mean age 54 years
(range 31-68 years) were studied with simultaneous cardiac catheterization and
Doppler/Echocardiography. All patients were in sinus rhythm. RV non-ﬁlling time
(RVnft), pulmonary ejection time (Paet) and RV ﬁlling time (RVft) were measured
by Pulsed Doppler echocardiography. RVDMPI was calculated as the ratio RVnftPaet/Rvft. The peak pulmonary artery systolic (PASP) and diastolic (PADP) pressures were recorded from cardiac catheterization,
Results: The RVDMPI was highly signiﬁcantly correlated to both PASP
(r=0.66,p<0.001) and PADP (r=0.68, p<0.001). On the other hand the traditional
RV MPI was weakly correlated to PASP (r=0.45, p<0.05) and to PADP (r=0.43,
p<0.05).
RVDMPI and SPAP
Conclusion: MPI has been used to estimate right ventricular function and pulmonary pressure. We have demonstrated that a better estimation is achieved when
isovolumic periods are related to ﬁlling time rather than ejection time. This also
demonstrates the important relation between pulmonary pressures and RV diastolic function.
Eur J Echocardiography Abstracts Supplement, December 2003
Diagnosis of pulmonary embolism (PE) is based on clinical, ECG, lab tests, echocardiography (TTE) and ventilation perfusion lung scan (V/Q). Pulmonary angiography (PA) is the golden standard for deﬁnitive diagnosis of PE.
The aim of our study is to evaluate the predictive value of TTE in detection of PE in
patients (pts) with deep venous thrombosis (DVT) compared to both V/Q & standard
PA.
Patients & Methods: 20 pts with Duplex proven DVT have been studied. The pts’
mean age is 41+ 16, 9 males & 11 females. Pts were subjected to clinical assessment, lab investigations, ECG, arterial blood gases, TTE, V/Q & PA. TTE is considered +ve for PE in the presence of RV overload (right ventricular (RV) dilatation,
increased RV/LV ratio, pulmonary hypertension (PH) & paradoxical septal motion in
absence of other cardiopulmonary disease).
Results: PA revealed PE in 6 pts (gp I). Gp II (14pts) showed normal PA. Compared
to pts of gp II, gpI exhibited lower systolic BP (112+15 vs 128+24, respectively,
p=0.04), & lower PaO2 (64+12 vs 86+19 respectively, P<0.002). No signiﬁcant differences were detected in both gps as regards lab tests, nor ECG. V/Q was +ve in
6 out of 6 pts with PE (GpI) (100%). Echo criteria of PE were shown in 4 out of the
latter 6 pts (67%), while TTE was totally normal in all 14 pts with no angiographic
evidence of PE (GpII) (100%) (vs 57% of gpII detected +ve by V/Q). With PA as
the golden standard for diagnosis of PE, V/Q exhibits a sensitivity of 100% and a
speciﬁcity of 43% with NPV (100%) and PPV (43%) while TTE shows a speciﬁcity
of 100% & a sensitivity of 67% with PPV of 100% and NPV of 87%. TTE showed
higher diagnostic accuracy (80% vs.60% for V/Q).
Table
20DVT pts
V/Q+ve
TTE+ve
PE-gpI(6pts)
gpII (14pts)
SP
SENS
PPV
NPV
6/6(100%)
4/6(67%)
8/14(57%)
0/14(0%)
43%
100%
100%
67%
43%
100%
100%
87%
Comparison between V/Q and TTE
Conclusions: Compared to V/Q, TTE is a bedside, cost- effective tool, with excellent PPV & good NPV in diagnosis of PE. We suggest that DVT pts could be
subjected to the following algorithm:
Routine TTE to detect pts with RV overload indicating PE. Pts with -ve results should
be subjected to V/Q excluding PE with excellent NPV, while those with suspicion of
PE should be subjected to PA for deﬁnitive diagnosis, specially in the presence of
symptoms & hypoxia.
572
Exercise stress echocardiography in patients with severe pulmonary
hypertension. Preliminary data.
C. Cotrim. Hospital Garcia de Orta, Cardiology, Setúbal, Portugal
Introduction: Severe pulmonary hypertension (PH), primary or secondary, is a rare
clinical entity that is restrictive of patients’ functional capacity and seriously shortens
life expectancy. We have been using stress echocardiography (SE) to evaluate the
pressure gradient between the right ventricle and the right atrium (RV/RAg) in patients with several diseases and with light to moderate pulmonary hypertension. In
these patients, the RV/RAg decreases with the assumption of the standing position
and increases signiﬁcantly during treadmill stress testing.
Objective: The aim of our study was to evaluate RV/RAg variations with standing
and with isotonic exercise in treadmill stress testing in patients with severe pulmonary hypertension.
Methods: We studied 6 patients with severe PH, 5 women mean aged 42±12,8
(age range, 23 to 56 years), 3 with primary PH, 2 with PH secondary to pulmonary
thromboembolism, and 1 patient with celiac sprue. We determined the RV/RAg using continuous wave Doppler with colour ﬂow mapping - in left lateral decubitus
(LLD) before exercise testing, in standing position (SP) and at peak workload (PW)
before exercise testing termination (modiﬁed Bruce protocol). In 2 patients who initiated treatment with bosentan, the echocardiogram was repeated one weak later in
LLD and SP. All imaging was recorded in VCR.
Results: Stress testing duration averaged 126±148 seconds (time range, 20 to 413
seconds), indicating poor functional capacity (only one patient taking diltiazem for
more than one year surpassed the ﬁrst stage). The RV/RAg in LLD was 88±36
mmHg (range 30 to 141), the SP RV/RAg was 86±37 mmHg (range 25 to 137), the
PW RV/RAg was 112±41 mmHg (range 55 to 177). In two patients, the echocardiogram was repeated one weak after the initiation of therapy with bosentan 62,5mg
bid. We veriﬁed that after one week of therapy, not only there was a decrease in the
RV/RAg in LLD but also a decrease in SP RV/RAg.
Conclusions: 1.In a group of patients with severe pulmonary hypertension, the
standing position does not decrease the RV/RAg, contrary to what was observed
by the authors in another group of patients with light to moderate pulmonary hypertension. 2. Not only the initiation of therapy with bosentan in 2 patients caused a
decrease in LLD RV/RAg, but also induced the "normalisation" of the RV/RAg response to the standing position. 3. As seen in patients with less severe forms of
the disease, the dynamic exercise during treadmill testing in patients with severe
pulmonary hypertension causes a signiﬁcant increase in RV/RAg.
Abstracts
573
Routine evaluation of three echo-Doppler and DTI indexes provides a
simple and accurate measure of right ventricular function.
G. Tamborini 1 , M. Pepi 2 , F. Celeste 2 , C. Galli 2 , A. Maltagliati 2 , M. Muratori 2 ,
G. Pontone 2 . 1 Fondazione Monzino, IRCCS, Centro Cardiologico, Milan, Italy;
2
Fondazione Monzino, IRCCS, Centro Cardiologico, Milan, Italy
Echocardiographic assessment of the right ventricular (RV) systolic function is very
difﬁcult owing to the complex geometric shape of the ventricle. In the last years
tricuspidal annular plane systolic excursion (TAPSE), Doppler tissue imaging evaluation of systolic tricuspidal annular motion (SDTI) and percentage of systolic change
in area in the apical four-chamber view (FSA) have been proposed as useful methods to analyse RV function, however they have been validated in small series of
cases
Aims of this study were: a) to evaluate the routine use of these 3 echo-Doppler and
DTI parameters as a measure of RV systolic function in a series of 1000 consecutive
patients; b) to determine the relationship between these and other echo-Doppler RV
and LV function indexes.
During a routine transthoracic examination TAPSE (mm), SDTI (cm/sec) and FSA
(%) were measured in the apical view and correlated with the systolic pulmonary
pressure (SPP, mmHg, calculated through the tricuspid velocity and inferior vena
cava collapsability) and the left ventricular ejection fraction (LVEF, %). These data
were compared in normal subjects (Group 1, 218 cases) and patients (Group 2, 782
cases).
Results: In all cases measurements of these 3 parameters were easily and rapidly
(mean time 3±1’) obtained, with a low inter- and intra-observer variability. TAPSE
(20±5 vs 24±4), SDTI (16±6 vs 19±4) and FSA (50±11 vs 54±10) were signiﬁcantly lower in Group 2 in comparison with Group 1. Each parameter correlated with
the other two and with LVEF. TAPSE and SDTI correlated negatively to SPP. Subanalysis of selected groups showed that in pts with inferior myocardial infarction
TAPSE (18±5) and SDTI (15±4) were signiﬁcantly reduced without any correlation
with LVEF. Interestingly, in pts after cardiac surgery TAPSE (13±2) and SDTI (13±2)
were signiﬁcantly lower in comparison with the pre-operatory values (23±4 p<0.001
and 20±5 p<0.001, respectively), while FSA (from 49.5±12 to 51±11n.s.), LVEF
(from 61±10 to 58.5±8 n.s.) and SPP (34.5 ±5 vs33.5±7 n.s.) did not change.
In conclusion: a) TAPSE, SDTI and FSA may be easily and rapidly included in a
routine echo-Doppler examination; b) values of these indexes in a large series of
cases showed differences in normal subjects from patients; c) TAPSE and SDTI are
very sensitive indexes of RV systolic function showing changes of longitudinal shortening of the RV in pts with inferior myocardial infarction and after cardiac surgery
independently on LVEF and SPP values.
574
Effect of age on the right ventricular function. A Doppler tissue imaging
study. The Umeå general population heart study.
P. Lindqvist 1 , M. Henein 2 , S. Mörner 1 , E. Kazzam 3 , A. Waldenström 1 . 1 Umeå
University Hospital, Clinical Medicine, Umeå, Sweden; 2 Royal Brompton Hospital,
Clinical Cardiology, London, United Kingdom; 3 Mälar Hospital, Cardiology,
Eskilstuna, Sweden
Purpose: In the Western Countries the aging population is increasing rapidly. Aging
is responsible for important changes in cardiac and vascular function. Therefore, it
is sometimes a great challenge to distinguish between physiological changes due
to normal aging from those due to different cardiac diseases. While much is known
about the effect of age on left ventricular function, little has been documented about
the right ventricle (RV). The aim of the present study was to assess the regional and
global RV function in a wide population.
Methods: We studied 256 healthy individuals randomly selected from Umeå (Sweden) General Population Register, 125 females and 131 males, mean age ± SD,
58±19 (range 22-89) years. Doppler tissue imaging was used to record myocardial
velocities at 3 levels across the RV free wall, basal, mid cavity and apical, taken
from the apical 4-chamber view. Systolic, early (E) and late (A) diastolic velocities
were measured at each segment and RV E/A ratio was calculated. Conventional
Doppler ﬁlling velocities of the RV was used to assess global RV function.
Results: While systolic myocardial velocities were conserved over ages, there was
a decrease in E/A ratio with age at basal (r=-0.67, p<0.001) and mid level (r=-0.62,
p<0.001) and modest reduction at apical level (r=-0.28,p<0.01). Similar relation
was found in RV ﬁlling velocities with a reduced E/A ratio (r=-0.57,p<0.001). Furthermore, a signiﬁcant correlation was found between global and regional E/A ratio
at basal (r= 0.59, p<0.001) and mid cavity (r=0.46, p<0.001) but not at apical level.
Conclusions: Right ventricular function is determined mainly from its basal segment. Systolic velocities behave independently of age whereas diastolic ones seem
to be age related regionally as well as globally. These differences are important
when interpreting data in patients with different cardiac diseases and for the understanding of age related cardiovascular changes.
S73
575
Assessment of right ventricular functions with myocardial performance
index method in patients with chronic obstructive pulmonary disease.
Comparative study with healty subjects.
A. onbasili 1 , M. Polatlý 2 , T. Tekten 1 , C. Ceyhan 1 , M. Kaya 1 . 1 Adnan Menderes
University, Cardiology, AYDIN, Turkey; 2 Adnan Menderes University, Chest
Disease, Aydin, Turkey
It is important to evaluate right ventricular functions in patients with chronic obstructive pulmonary disease (COPD) because of the presence of right ventricular failure
has an important value on prognosis. However, all invasive and non-invasive imaging techniques which evaluate the structure and functions of the right ventricle have
important limitations due to right ventricular complex geometry. Myocardial performance index (MPI) (Tei-index) which is a new Doppler index combining systolic and
diastolic time intervals has been reported to be useful for the assessment of global
right ventricular functions in adults.
The purpose of this study was to: compare the MPI method with the convantional
methods to assess the right ventricular functions and assess the correlation among
respiratory function tests and arterial blood gas analysis parameters with right ventricular MPI in COPD patients.
Methods: Twenty-ﬁve patients (mean age 69±4 years) who have stable COPD
were included to study. COPD patients were divided to 2 groups. Group I included
10 patients whose pulmonary artery pressures (PAP)>35 mmHg, group II included
15 patients whose PAP < 35 mmHg or PAP could not be measured by echocardiography. Group III included healthy 16 persons (mean age 66±5). Right ventricular
diastolic and sistolic functions were evaluated with transthrocic echocardiography in
all groups after respiratory function tests and arterial blood gas analysis performed.
Right ventricular MPI was calculated according to following formula: MPI= izovolumetric contraction time + izovolumetric relaxation time/ejection time.
Results: Right ventricular MPI was higher in Group I (53.6±2.6) and II (47.8±3.5)
than Group III (32.2±4.1)(p<0.001). Right ventricular EF, FS, EDT and E/A ratio
were not different among 3 groups. There were no correlation between right ventricular EF, FS, EDT, E/A ratio and respiratory function test and arterial blood gas analysis parameters. However, respiratory function tests and arterial blood gas analysis
parameters were corraleted well with MPI.
Conclusion: MPI method determined right ventricular dysfunction which could not
be assessed by conventional echocardiographic methods, and found that right ventricular dysfunction correlated with respiratory function tests and arterial blood gas
analysis parameters in COPD patients.
576
Right atrial dilatation is independent predictor of recidivant atrial
ﬁbrillation.
T. Potpara 1 , B. Vujisic 1 , J. Marinkovic 2 , B. Radojkovic 1 . 1 Clinical Center of Serbia,
Institute for Cardiovascular Diseases, Belgrade, Yugoslavia; 2 Medical Faculty,
Institute for Medical Statistics, Belgrade, Yugoslavia
Introduction: atrial ﬁbrillation (AF) has most commonly been related to the dilatation of left atrium (LA), among numerous pathogenetic mechanisms.
Aim of present study is to examine the relevance of the dilatation of right atrium
(RA) in the genesis of AF.
Methods and Results: out of 378 patients (pts), the very ﬁrst episode of nonvalvular AF was present in 335 pts (group I), while 43 pts have already had intermittent
AF during previous 1 to 20 years (group II). We compared the following clinical
and echocardiographic features between these two groups: mean age was 54.0
years (17-78) in group I and 58.5 years (21-75) in group II. Idiopathic AF was diagnosed in 124 pts (37.0%) and in 16 pts (37.2%) respectively. On routine transthoracic echocardiogram (TTE) LA was normal (<4cm) in 137 pts (40.9%) of group
I and in 16 pts (37.2%) of group II, RA was normal (<4,5cm) in 317 pts (94.6%)
and in 37 pts (86.0%), left ventricle (LV) was not dilated in 253 pts (75.5%) and in
29 pts (67.4%), while LV ejection fraction (EF) was normal in 267 pts (79.7%) and
in 29 pts (67.4%) respectively. As appeared, the group with recidivant AF (group
II) was signiﬁcantly older (T-test –2.418, p<0.05). These pts more commonly had
decreased LVEF (Chi-square test 6.036, p<0.05) and dilated RA (Chi-square test
7.844, p<0.05). Moreover, the model of multiple logistic regression, which included
data for all of 378 pts, with dependent variable "recidivant AF" and independent variables echocardiographic parameters as listed above, identiﬁed only the dilated RA
as independent predictor of recidivant AF, with relative risk 2.18 within 95% conﬁdence interval (B 0.7802, SE 0.4097, Wald 3.6268, df 1, p 0.050, RR 2.1820, lower
0.9775, higher 4.8708).
Conclusions: compared to other patients with atrial ﬁbrillation, patients with dilated
right atrium have 2.2 times greater risk of recidivant arrhythmia, independently of
other echocardiographic features. This may have important implications in decisionmaking regarding the treatment of such patients.
Eur J Echocardiography Abstracts Supplement, December 2003
S74
Abstracts
577
The pattern of right ventricular function recovery after acute myocardial
infarction, as assessed by serial echocardiographic follow-up. The
GISSI-3 Echo Substudy.
B.A. Popescu, F. Antonini-Canterin, P. Giannuzzi, P.L. Temporelli, E. Bosimini,
R. Piazza, E. Cervesato, G.L. Nicolosi on behalf of The GISSI-3 Echo Substudy
Investigators.. Centro Studi ANMCO, Florence, Italy
Background: The prognostic importance of right ventricular (RV) function in patients (pts) with acute myocardial infaction (AMI) is still controversial. Moreover, the
pattern of recovery in RV function determined by a serial echocardiographic followup in pts with low risk AMI has not been studied yet.
Aim: To assess the pattern of RV function change and its correlations with left
ventricular ejection fraction (LVEF) at baseline and during follow-up in pts with lowrisk AMI. Furthermore, to determine if changes in RV function are different in pts
with low, as opposed to pts with preserved, LVEF.
Methods: We studied a group of 592 pts (493 men, 60.6 ± 11.8 years) from the
GISSI-3 Echo Substudy, who survived 6 months after AMI, in whom complete and
accurate echocardiographic follow-up data were available. Each patient had 4 echo
studies performed: at 24-48 hours from admission (S1), at discharge (S2), at 6
weeks (S3), and at 6 months (S4), which were analyzed in the Core Laboratory by
experts blinded to all clinical data. The following echo parameters were measured
at each visit: LVEF, mitral inﬂow E, A, and E/A ratio, and tricuspid annular plane
systolic excursion (TAPSE, cm), measured by 2-D echocardiography from the apical
4-chamber view. Analysis of variance for repeated measures was used for timechanges of echo parameters.
Results: In this low-risk MI population, no differences in TAPSE with respect to
the site of infarction were found. Overall, there was a signiﬁcant increase in TAPSE
during follow-up (from 1.79 ± 0.5 at S1 to 1.9 ± 0.5 cm at S4, p<0.001), reﬂecting
recovery in RV function, which was already present at S2 (1.86 ± 0.5 cm, p<0.001).
At S1, TAPSE correlated weakly, but signiﬁcantly, with LVEF (r=0.13, p=0.002), a
correlation that was maintained during follow-up (p=0.03 at S4). In pts with LVEF
<40% (gr. A), TAPSE was lower than in pts with LVEF ≥40% (gr. B): 1.69 ± 0.4
vs 1.8 ± 0.4 cm, p=0.038. This difference became not signiﬁcant at S4 (1.83 ± 0.5
in gr. A vs 1.91 ± 0.5 cm in gr. B, p=0.09), because although TAPSE increased
signiﬁcantly in both groups during follow-up, the late increase was higher in gr. A.
Conclusions: Our data suggest that in pts with low-risk AMI, recovery in RV function occurs throughout follow-up and is already signiﬁcant at discharge. RV function
recovery occurs both in pts with low and in pts with preserved LVEF, but the difference in TAPSE between these two groups, signiﬁcant at S1, becomes not signiﬁcant
at six months, because late recovery in RV function is greater in patients with lower
LVEF at S1.
578
The assessment of LV function and morphology in patients with
suspicion of ARVD.
P.K. Klimeczek 1 , M. Pasowicz 2 , P. Podolec 2 , C. Zorkun 2 , W. Piwowarska 3 ,
W. Tracz 4 . 1 John Paul II Hospital, Dept. of Radiology, Krakow, Poland; 2 John Paul
II Hospital, Krakow, Poland; 3 John Paul II Hospital, Dept. of Coronary Artery
Disease, Krakow, Poland; 4 John Paul II Hospital, Dept. of Cardiac and Vascular
Diseses, Krakow, Poland
Introduction: Arrhythmogenic Right Ventricular Dysplasia (ARVD) is one of the
most common primary diseases of right ventricle. MRI examination can show us
speciﬁc morphologic abnormalities which are used as diagnostic criteria at the early
stage of ARVD.
Aim: We evaluated right and left ventricular function and morphology with the use
of MRI to detect major and minor symptoms of ARVD
Method: From January 2001 to March 2003, 24 patients (2 W), 13-55 (38 ± 11.5)
years of age were enrolled in this study after 24-hour ECG monitoring and echocardiography ﬁndings of ARVD. All these patients had RV dilatation, and ventricular
arrhythmias (Ventricular Extrasystolia > 1000/24 h – 21 pts, Late potentials - 6 pts,
QRS prolongation – 6 pts, T wave inversion – 4 pts, VT history -3 pts); 8 pts had
a family history of sudden cardiac death. The MRI was performed using Magnetom Vision Plus 1.5 T and Sonata Maestro Class 1.5 T. MRI protocol consist of: RV
evaluation - ejection fraction (EF), diameter, and wall motions abnormalities (WMA)
were assessed and fatty inﬁltration detection. LV evaluation: EF, wall motions abnormalities, contractility, wall thickness and thickening, tissue morphology (heavy
weighted T2 and late enhancement (LE) study 6 pts) Post processing data and LV
and RV functions measurements were performed using Leonardo Workstation (Argus software).
Results: In MRI examination we found RV dilatation in all 24 pts (mean - 40 ± 6
mm, 35-50), RV EF were decreased in 18 pts (total average = 38 ±11%, 19 – 60%).
The fatty inﬁltrations were found in 4 patients only in RV-free wall, the aneurysms of
RV-free wall were found in 12 pts. The RV WMA were detected in 14 pts.
Decrease of EF was found in 10 pts (mean 54% ± 12, 32% – 65%), the LV –
hyperthrophy was detected in 10 pts. WMA was found in 10 patients. In 1 of 6 pts
the subendocardial region of LE was detected.
Conclusion: The left ventricular function was decreased in signiﬁcant number of
studied patients.
Eur J Echocardiography Abstracts Supplement, December 2003
579
Assessment of right ventricular function in ARVC/D patients by 2D ECHO.
I.I. Vranic, M. Petrovic, B. Vujisic-Tesic, M. Ostojic, S. Pavlovic. Clinical Centre of
Serbia, Institute for cardiovascular diseases, Belgrade, Yugoslavia
Background: Right ventricular function evaluation remains a diagnostic challenge,
both for non-invasive and invasive methods. Tricuspid anterior plane systolic excursion (TAPSE) has been shown to correlate with its overall function (in adults)
particularly in systole, as assessed by ejection fraction. Due to its complex anatomy
RV systolic function can be objectively estimated by radionuclide ventriculography
(RNV) which is done in a standard way.
Aim: We wanted to describe the echocardiographic ﬁndings in patients with
ARVC/D matching RVOT fs % and TAPSE parameter with RVEF measured by RNV.
Methods: 30 patients with ARVC diagnosis (based on the score of clinical signs
obtained from an ESC/WHF expert consensus including major and minor criteria)
were included in this study. Their age was 22-48 years, gender female (13) and
male (17). We compared RVEF with TAPSE and RVOT fs % in those patients with
a control group of 20 normal subjects and matched them in age and gender.
Results: As shown in the table TAPSE correlated well with the progressive lost of
RVEF power, as well as with RVOT fs% which appears to show remarkable load
sensitivity in those patients, as compared to control subjects.
Correlation in estimation of RV function
Total No pts
ARVC/D pts
Control subjects
TAPSE
RVOT fs%
RVEF%
12±2
24±4
22±6
65±9
40±8
56±4
*p<0,05
Conclusion: Assessment of right ventricular function in ARVC/D patients by 2D
ECHO measuring TAPSE and RVOT fs% seems a reasonable and easy to apply
clinical method in selecting those patients with poorer prognosis.
580
Pathognomonic sign of ARVC/D by ECHO?
I.I. Vranic, M. Petrovic, B. Vujisic-Tesic, M. Ostojic, M. Ristic. Clinical Centre of
Serbia, Institute for cardiovascular diseases, Belgrade, Yugoslavia
Background: ARVC/D is characterized by ﬁbro-fatty replacement of mostly located
in right ventricular (RV) myocardium. This situation is associated or not with ventricular arrhythmias of RV origin carries the risk of sudden death in the young and/or RV
dysfunction. Diagnosis of ARVC/D is based on the score of clinical signs obtained
from an ESC/WHF expert consensus including major and minor criteria. However
no pathognomonic sign of ARVC/D has been reported yet.
Methods: We have studied with 2D Echo a group of 13 patients (age 25-48,gender
M 7, F 6) fulﬁlling the WHF criteria for a positive diagnosis of ARVC/D. This series is
compared with a control group including 446 patients studied before or after cardiac
surgery for various etiologies (Ischemic n=148, Valvular n=88, Congenital n=16,
Normal hearts n=150, Other ethiology n=44), age 18-80; gender M=234, F=212).
Results: Our results are presented in a table below. A distinct abnormal displacement of the posterior septum has been observed in apical four chamber view in
all ARVC/D patients and none in the control group.Also it was possible to notice it
in short axis view on the level of mitral valave. This abnormality may be in agreement with localized cell–cell adhesion protein distortion suspected in this condition
or localized apoptosis demonstrated in the postero septal part of crista supraventricularis by Dr Thomas James.
Septal posterior displacement in 2D ECHO
Total No of pts.
Apical 4CH view
2 PS LAx view
2 PS SAx MV view
Control group
ARVC/D group
0/446
13/13*
0/446
0/13
0/446
13/13*
*P<0,05
Conclusion: An abnormal displacement of posterior septum observed with 2D
Echo four chamber view seems a distinct pathognomonic feature of ARVC/D.
Abstracts
581
Right and left ventricular functions in patients with asthma.
V.Y.U. Goloskokova 1 , A.L. Alyavi 2 , I.A. Yuldasheva 2 . 1 Tashkent, Uzbekistan;
2
Tashkent, Uzbekistan
Objectives: The study was performed to estimate right and left ventricular (RV and
LV) functions in patients with asthma.
Methods: 65 patients with asthma and 33 healthy voluntaries were investigated
with echocardiography method. All patients were undergone to pulmonary tests
(PT) to estimate presence and degree of ventilation disorders. According to PT
results and clinical investigations all patients were divided into the two groups. The
ﬁrst group (I) consisted of 24 patients with asthma III step, while the second (II)
group consisted of 41 patients with asthma IV step. LV ejection fraction (EF), RV
diastolic dimension, LV and RV PE/PA ratios were assessed. Pulmonary vascular
resistance (PVR) was calculated with conventional method, pulmonary artery pressure (PAP) was calculated with A.Kitabatake method. As it was found the LF systolic
function wasn’t altered in patients with asthma in compare with healthy voluntaries.
LV EF was 60,96±5,09% in I group and 58,42±6,02% in II group (compare with
59,81±7,70% in control, p>0,05). In patients with asthma LV diastolic ﬁlling wasn’t
changed, but LV PE/PA ratio in the II group was signiﬁcantly less than in control
and in I group (I group - 1,35±0,21 vs. II group - 1,07±0,30, p<0,01, II group vs.
1,41±0,37 in control, p<0,01). RV diastolic function was signiﬁcantly altered. There
were 51 (78,46%) patients with altered relaxation compare with 3 persons (9,09%)
in control (χ 2 =40,91, p<0,001). All patients with IV-step asthma had RV diastolic
dysfunction whereas only 10 patients in the I group had it (χ 2 =17,65, p<0,001).
RV PE/PA ratio in the I group was 1,05±0,25 (p>0,05 vs. control), in the II group
was 0,57±0,13 (p<0,01 in compare with the I group and with control), 1,27±0,30
in control. Patients with IV-step asthma had higher degree of PAP than patients
of the I group and control (I 26,32±4,67cmH2O, II 40,08±9,19 cmH2O, control
27,45±8,42 cmH2O, p<0,001 between I and II groups, p<0,001 between II and
control). PVR was signiﬁcantly increased in patients with asthma comparing with
control (488,41±166,78 din*sec*cm5 vs 295,06±59,43 din*sec*cm5 , accordingly
(p<0,001)). PVR in I group was signiﬁcantly less than in the II one (330,45±104,63
din*sec*cm5 vs 580,88±120,30 din*sec*cm5 , accordingly (p<0,001)).
Conclusions: LV alterations in patients with asthma were minimal and included LV
diastolic dysfunction in patients with IV-step asthma. Patients with asthma have RV
diastolic dysfunction; PAP and PVR were increased. These alterations deteriorated
as asthma step increased.
582
Severity of obstructive sleep apnea syndrome is associated with right
heart function.
B. Shivalkar 1 , M. Kerremans 1 , C. Van De heyning 1 , D. Rinkevich 2 ,
J. Verbraeckem 3 , W. De Backer 3 , C. Vrints 1 . 1 University Hospital Antwerp,
Department of Cardiology, Edegem, Belgium; 2 University of Virginia, Cardiology,
Charlottesville, United States of America; 3 University of Antwerp, Lung Disease,
Edegem, Belgium
Introduction: Obstructive sleep apnea syndrome (OSAS) may coexist in patients
with heart failure. Echocardiographic assessment of right ventricle (RV) morphology
and function is technically difﬁcult, and data over right heart alterations and function
in patients with obstructive sleep apnoea syndrome (OSAS) are inconsistent. We
sought to investigate left and right heart function in OSAS patients by echocardiography and assess the relationship with the severity of OSAS.
Methods: Twenty patients (M/F: 16/4) with OSAS, and 14 age matched controls
(M/F: 10/4) had a routine 2-D and Doppler echocardiographic examination, as well
as pulsed wave tissue Doppler (PWTD) mapping of systolic (Sm) and diastolic
(early, Em; late diastolic Am) velocities of the mitral (MA), tricuspid annulus (TA)
and the RV free wall. The RV performance index (PI) was determined from the ratio
of the sum of the isovolumic times and ejection time, which conceptually combines
systolic and diastolic performance. All patients also had lung function tests, arterial
blood gas analysis and a polysomnography.
Results: Clinically there was absence of full blown right heart failure in all OSAS
patients. There was no signiﬁcant difference (p>0.1) between patients and controls regarding age: 58±13 versus 54±8 years, and left ventricle ejection fraction:
64±6 versus 66±4%. However signiﬁcant differences could be seen between, body
mass index: 32.7±6.5 versus 23.3±1.7; systolic blood pressure (BP): 159±27 versus 131±9 mmHg; diastolic BP: 90±20 versus 74±6 mmHg; RV end diastolic dimension: 3.2±0.5 versus 2.1±0.3 cm; pulmonary arterial systolic pressure: 35±10
versus 19±4 mmHg; RV PI: 0.30±0.06 versus 0.22±0.03; MV Sm: 9±3 versus
13±3; TA Sm: 13±2 versus 15±2 cm/s; and RV Sm: 11±2 versus 14±1 cm/s (for
all variables p<0.02). The apnea- hypopnea index (AHI) was 41±24, tiffeneau ratio
102±9; PCO2 38±3 mmHg, and PO2 83±10 mmHg. Regression analysis showed
a strong correlation between AHI versus PWTD derived indices of RV function (TA
Sm: r=0.62, RV Sm: r=0.60; p<0.01).
In conclusion, we found a strong correlation between AHI and tissue Doppler derived systolic indices of RV function. PWTD imaging is a quantitative and technically
simple way of assessing RV function, and may be potentially useful in the follow up
and assessment of the effects of treatment in OSAS.
S75
583
Assessment of right ventricular function in patients with chronic
obstructive pulmonary disease using standard and tissue Doppler
echocardiography of the triscupid annulus.
F.K. Panou 1 , E. Loizides 1 , N. Betsimea 1 , I. Lakoumentas 1 , A. Karakatsani 2 ,
E. Matsakas 1 , D. Orfanidou 2 , A. Zacharoulis 1 . 1 Athens General Hospital
"G.Genimatas", Cardiology Department, Athens, Greece; 2 Athens Chest Disease
Hosp."Sotiria", Respiratory Dep.Of Athens University, Athens, Greece
Purpose: Aim of this study was to investigate whether evaluation of the tricuspid annulus function, using Tissue Doppler Echocardiography (TDE), provides additional
information to standard echocardiography for the determination of right ventricular
(RV) function in patients (pts) with Chronic Obstructive Pulmonary Disease (COPD).
Methods: 22 pts with COPD aged 67±10 years were enrolled in this study. We
measured the following parameters: a) From an apical four chamber view the ratio
RV (long diameter)/RV (short diameter) as an index of RV size, b) Diameter of the
inferior vena cava (IVC) and its respiratory variation, c) RV systolic pressure (RVSP)
from the tricuspid regurgitation CW Doppler signal, d) Tricuspid annular systolic and
diastolic velocities (S,E,A), using the TDE, e)QS (the interval between the beginning
of the QRS complex to the onset of S wave from the TDE – an already known marker
of RV systolic function), f) FEV1, FEV1%, FEV1/FVC, PO2 and PCO2 as indices of
respiratory function.
Statistical analysis of our data was performed using Pearson Correlation.
Results: All pts exhibited an E/A < 1 at the tissue Doppler signal of the tricuspid
annulus. We also found the following positive and negative correlations:
A) Positive: 1. E/A with FEV1 (r: 0.622, p: 0.002), 2. E/A with FEV1% (r: 0.722, p:
0.002), 3. E/A with FEV1/FVC (r: 0.588, p: 0.004), 4. E/A with PO2 (r: 0.512, p:
0.015), 5. RVSP with PCO2 (r: 0.620, p: 0.002).
B) Negative: 1. E/A with PCO2 (r: -0.439, p: 0.041), 2. QS with the ratio RV (long
diameter)/RV (short diameter) (r: -0.626, p: 0.002), 3.Inspiratory variation of IVC
with A (r: -0.596, p: 0.003).
Conclusions: Both RV systolic and diastolic function, as were estimated using
TDE, seem to be impaired in pts with COPD. RV dysfunction was found to be well
correlated with established respiratory variables.
584
Left and right ventricular diastolic function in patients with chronic
obstructive pulmonary disease.
M. Bianchi 1 , A. Zuccarelli 2 , M.G. Castiglioni 1 . 1 Cisanello, Internal medicine, Pisa,
Italy; 2 Ospedale Pontremoli, Internal Medicine, Pontremoli, Italy
Chronic obstructive pulmonary disease (COPD) is a common cause of pulmonary
parenchimal disease that cause pulmonary hypertension and right ventricular disfunction.
Purpose: aim of the study was to investigate the effects of chronic obstructive pulmonary disease (COPD) on right and left ventricular diastolic indices.
Methods: 48 patients with severe COPD were studied. Patient were divided into
2 subgroups according to pulmonary artery sistolic pressure: 25 patients (16 male
and 9 female, age 60,2±2,5)
with pulmonary hypertension (group1) and 23 (13 male and 10 female, age 56,8
±3,9) patients with normal pulmonary artery pressure (group 2). As a control group,
25 (13 male and 10 female, age 57,4 ± 4,1) normal subjects were studied (group
3).
Results: Patients in group 1 had higher tricuspid peak A velocity (58.9 ± 3 cm/s
> 54.7 ± 7.6>43.8 ± 3.7 cm/s), lower tricuspid E velocity (31.1 ± 3 < 59.9 ±
28.8 < 57.2 ± 7.2 cm/s), longer isovolumic relaxation time (IVRT 103.2 ± 5.4 >
87 ± 10 > 76.6>9.9 ms), higher mitral A wave (70.4 ± 3.1>56.1 ± 3.6 > 54.4 ±
3 cm/s), lower mitral E wave(61.9 ± 2.8>65 ± 18.8 > 70.4 ± 3 cm/s) than group
2 and 3. There was no signiﬁcant difference between left ventricular diastolic ﬁlling
parameters between group 2 and 3.(P value group 1vs2 <.0001, group 2vs3 <.001)
Conclusion: Patients with COPD and pulmonary systolic hypertension have left
and right ventricular diastolic dysfunction. However, patients with COPD and normal
pulmonary artery pressure have normal left and right ventricular diastolic function.
In patients with COPD the development of pulmonary hypertension leads to the
disfunction of both ventricle because they share a common ventricular septum and
pericardium.
Eur J Echocardiography Abstracts Supplement, December 2003
S76
Abstracts
585
Right ventricular hypertrophy and diastolic dysfunction in patients with
systemic sclerosis: an isolated phenomenon.
586
Heart chamber measurements in patients with congestive heart failure in
the detection of impaired exercise capacity.
P. Lindqvist 1 , K. Caidahl 2 , G. Neuman-Andersen 3 , S. Rantanpää-Dahlqvist 3 ,
A. Waldenström 1 , E. Kazzam 4 . 1 Umeå University Hospital, Clinical Medicine,
Umeå, Sweden; 2 Sahlgrenska University Hospital, Clinical Physiology,
Gothenburg, Sweden; 3 Umeå University Hospital, Rheumatology, Umeå, Sweden;
4
Mälar Hospital, Cardiology, Eskilstuna, Sweden
R. Dankowski, M. Michalski, W. Biegalski, M. Kandziora, K. Poprawski,
M. Wierzchowiecki. University of Medical Sciences, 2nd Department of Cardiology,
Poznan, Poland
Purpose: In patients with systemic sclerosis (SScl) cardiac involvement carries bad
prognosis. Little is known about right ventricular (RV) function, in particular diastolic
function. The aim of the present study was to assess RV systolic and diastolic function in patients with SScl and to relate the ﬁnding to the clinical features of the
disease.
Methods: Eighteen consecutive patients (15 females & 3 males) with SScl (mean
age 57 years) according to the American Rheumatology Association Criteria and
22 (18 females & 4 males) age and sex matched controls (mean age 56 years)
were studied. Doppler/echocardiography and Doppler tissue imaging was used to
evaluate cardiac function.
Results: In patients, RV free wall thickness (p<0.01) and right atrial systolic area
(p<0.05) were increased. Furthermore, RV late atrial ﬁlling velocity was increased
(36±13 vs. 25±7 cm/s, p<0.001) and Doppler E/A ratio was reduced (p<0.001).
The global isovolumic relaxation time was prolonged (p<0.001). In spite of these
diastolic disturbances RV systolic function was found to be normal, RV to right atrial
retrograde peak gradient was not different but pulmonary acceleration time was
shortened (114±34 versus 140±26 ms, p<0.01) among patients. LV systolic, diastolic function and stroke volume did not differ between patients and controls. Neither
age nor heart rate was related to the RV diastolic disturbances.
Conclusion: Right ventricular diastolic function was impaired in presence of signs
of RV hypertrophy and right atrial dilatation without inﬂuence of age and heart rate.
It seems that the observed right ventricular diastolic abnormality is an isolated phenomenon since left ventricular function was found to be normal. To our knowledge,
these results were not previously reported.
Eur J Echocardiography Abstracts Supplement, December 2003
Aim of the study was to analyze possible relations between heart chamber dimensions and results of six minute walk test (6MWT) in patients with congestive heart
failure (CHF).
Methods: The study group consisted of 51 pts (37 men, mean age 64±9 years)
with diagnosed CHF. At the time of 6MWT (performed at the day of discharge from
the hospital) the studied subjects were in a stable state - NYHA functional class II
to III (II - 29, III - 22 pts). 6MWT was performed in all pts according to the standardized protocol. Based on the median value of distance walked in six minutes
(six minutes walked distance; 6MWD) pts were divided into two groups: group I included pts with 6MWD <230 m (n=28), group II included pts with 6MWD >230 m
(n=23). Echocardiographic examination was performed at the same day before the
6MWT. Following echocardiographic measurements were analyzed: left ventricular
end-diastolic diameter (LVd), left atrial size (LA), right ventricular end-diastolic diameter (RVd) and left ventricular ejection fraction (LVEF). Statistical analysis was
made using t-test.
Results: Results of analyzed variables are presented in the table.
Parameter
Group I (6MWD<230 m)
Group II (6MWD>230 m)
p value
6MWT (m)
LVd (cm)
LA (cm)
RVd (cm)
LVEF (%)
158,6±48,1
6,3±1,2
4,3±0,7
4,0±0,8
37±17
296,9±40,5
6,3±1,0
4,4±0,6
3,5±0,6
46±18
<0,0001
NS
NS
0,028
NS
Conclusion: In patients with congestive heart failure and decreased exercise capacity the diameter of the right ventricle is signiﬁcantly increased. The measurement
of right ventricle could be of value in the diagnosis of patients with congestive heart
failure connected with impaired exercise performance.
Eur J Echocardiography Abstracts Supplement, December 2003
Poster Session 4
5 December 2003, 14:00 to 18:00
Location: Poster Hall
MODERATED POSTERS
662
Association of the ratio of peak E-wave velocity to ﬂow propagation
velocity with left ventricular pathology and ﬁlling pressures.
A Doppler-catheterization study.
1
2
3
3
3
A.C. Popescu , B.A. Popescu , M.S. Feinberg , E. DiSegni , V. Guetta ,
S. Rath 3 , M. Eldar 3 , E. Schwammenthal 3 . 1 University Hospital, Cardiology
Department, Bucharest, Romania; 2 Institute of Cardiology, Bucharest, Romania;
3
Heart Institute, Sheba Medical Center, Tel Hashomer, Israel
Background: Noninvasive assessment of left ventricular (LV) diastolic function and
ﬁlling pressures is an important, yet elusive goal, because of the confounding opposing effects of impaired relaxation and high ﬁlling pressures on the transmitral
ﬂow pattern. While peak E velocity is related directly to LV ﬁlling pressures and inversely to tau, ﬂow propagation velocity (Vp) has a strong inverse correlation with
tau. Therefore, with increasing severity of LV pathology and increased ﬁlling pressures peak E-wave increases, while Vp decreases.
Aim: We hypothesized that the ratio of peak E to Vp (E/Vp) is directly correlated
with the severity of LV pathology and with LV ﬁlling pressures.
Methods: We examined 96 consecutive subjects (75 men, 59±22 years), who were
divided into four groups, according to the severity of LV pathology: 25 normals, 26
patients (pts) with left ventricular hypertrophy and normal ejection fraction (EF), and
45 pts with reduced EF (22 with EF between 30 and 50%, and 23 with EF<30%).
A complete echocardiographic study, including measurements of mitral inﬂow peak
E, A, E/A ratio by PW-Doppler, and Vp, by Color M-Mode echocardiography was
performed. Clinical events of pulmonary congestion (elevated ﬁlling pressures) were
searched for in the history of each patient and substantiated by review of medical
records. In addition, in a group of 20 consecutive pts (18 men, 65±10 years) LV enddiastolic pressure (LVEDP) was measured within 24 hours from echocardiography,
during a diagnostic left heart catheterization study.
Results: While the E/A ratio showed no correlation to the severity of LV pathology describing an U-shaped curve, E/VP showed a direct linear correlation (r=0.79,
p<0.001). Among all Doppler parameters of LV ﬁlling, E/Vp had the best accuracy
in separating pts with from those without pulmonary congestion. Analysis of the
receiver-operating characteristic (ROC) curve showed the best separation for a cutoff value of E/Vp of 1.84 (area under the ROC curve of 0.84, sensitivity, 88%; speciﬁcity, 87%; and accuracy, 87%). In the group with invasive measurements, both
peak E-wave and E/A ratio had only weak correlations with LVEDP (r=0.45, p=0.04
for each), while E/Vp showed a signiﬁcant direct correlation (r=0.63, p=0.003).
Conclusions: E/Vp ratio increases directly with the severity of LV pathology and
has a good correlation with directly measured LVEDP. This combined index can
accurately separate pts who are prone to pulmonary congestion from those who
are not.
663
Value of color M-mode time delay and Doppler isovolumic relaxation
period and their ratio in assessment of left ventricular systolic and
diastolic function.
A.M. Hamdy, H.M. Fereig. Cairo, Egypt
Purpose: Inter-relation of systolic and diastolic left ventricular (LV) function is a
known cardiac phenomenon. The purpose of this work is to study the value of two
intervals namely color M-mode time delay (TD) and isovolumic relaxation period
(IVRP) and their ratio (TD/IVRP), in assessment of both systolic and diastolic LV
function.
Methods: This study included 57 cases (43 pts with a variety of nonvalvular
heart disease known to affect diastolic function & 14 normal subjects). Conventional echo-Doppler was done to identify cases with impaired systolic function from
those with normal ejection fraction (EF), and to identify cases with normal diastolic
function (NL) from those with diastolic dysfunction of relaxation abnormality (RX),
pseudonormal pattern (PN) or restrictive ﬁlling pattern (RF). We measured TD using color M-mode, and IVRP using Doppler technique, and we calculated their ratio
(TD/IVRP). Each of the 3 measures (TD, IVRP and TD/IVRP) was compared in
cases with, versus those without systolic dysfunction and in cases with any pattern
of diastolic dysfunction versus NL.
Results: 21 cases had impaired EF, while 36 had normal EF. 23 cases had RX,
5 cases had PN and 15 cases had RF. TD was higher in cases with impaired
EF versus those with normal EF (126.8±78.3 Vs 79.4±29.0, p<0.001). IVRP was
lower in cases with impaired EF compared to those with normal EF (63.3±32.1 Vs
82.2±18.8, p<0.005). TD/IVRP was higher in cases with impaired EF versus those
with normal EF (2.27±1.33 Vs 1.04±0.57, p<0.0001). There was no signiﬁcant correlation between IVRP and EF, while there was a weak negative correlation between
TD and EF (r=-0.34, p<0.01) and somewhat better negative correlation between
TD/IVRP and EF (r=-0.45, p<0.001). TD was signiﬁcantly higher in pts with RX, PN,
and RF compared to NL (102.2±63.0, 102.0±13.0, 122.1±66.4 and 59.3±11.4 respectively), (p<0.0001 for RX versus NL, p<0.001 for PN versus NL and p<0.0005
for RF versus NL). IVRP was signiﬁcantly different in NL (79.3±8.3 msec) compared
to RX (93.0±23.8, p<0.05) and compared to RF (46.0±9.9, p<0.0001), but was not
signiﬁcantly different from normal in PN (70.0 ± 25.5, p=NS). The ratio of TD/IVRP
showed signiﬁcant progressive increase with progression of the pattern of diastolic function from NL (0.74±0.13) to RX (1.16±0.74, p<0.05), to PN (1.57±0.44,
p<0.005), with the higher value in RF (2.67±1.28, p<0.0001).
Conclusion: TD, IVRP and TD/IVRP are easily obtainable and reliable measures
for identiﬁcation of left ventricular systolic and diastolic dysfunction.
S78
Abstracts
664
Early diastolic ﬁlling dynamics in patients with diastolic dysfunction.
G. King 1 , J.B. Foley 2 , P. Crean 2 , M.J. Walsh 2 . 1 St James Hospital, Cardiology,
Dublin, Ireland; 2 Trinity College,and St James Hospital, Cardiology, Dublin, Ireland
Objective: To explore the relationship between peak early diastolic mitral annular
tissue velocity (Ea) as a surrogate for recoil and the acceleration of early transmitral
ﬂow (ventricular ﬁlling) in patients with diastolic dysfunction and in normal subjects.
Methods The relationship between the acceleration of early passive diastolic transmitral ﬂow and peak early mitral annular tissue velocity in 22 normal controls and
25 patients with clinical, echo and Doppler evidence of diastolic dysfunction without
pseudonormalisation was studied. All patients had normal systolic function. From
the apical views Doppler tissue imaging was performed by placing a sample volume
at the lateral mitral annulus. Conventional Doppler blood ﬂow velocities were also
recorded across the mitral valve from the apical view.
Results: The diastolic dysfunction group had a lower mitral annular relaxation velocity than the normal group (Ea) (6.1 ± 1.6 cm/sec vs. 10.8 ± 2.9 cm/sec, p<
0.001), which positively correlated to the acceleration of early diastolic ﬁlling (R =
0.66, p< 0.05). The normal group did not show a correlation between the acceleration of transmitral ﬂow and mitral annular relaxation velocity (r=0.18, p < 0.22).
Those with diastolic dysfunction also had a lower E/A ratio than the normal group
(0.7 ± 0.2 vs. 1.9 ± 0.5, p < 0.001), a higher time-velocity integral of the atrial
component (11.7 ± 3.2 cm vs. 5.5 ± 2.1 cm, p < 0.0001) and a lower rate of
acceleration of blood across the mitral valve (549.2 ± 151.9 cm/sec2 vs. 871 ±
128.1cm/sec2 , p<.001).
Conclusions In diastolic dysfunction where the inﬂuence of preload is minimal, recoil and the acceleration of early diastolic blood ﬂow are reduced compared to normals. Also the rate of ﬂow across the mitral valve was found to be strongly related to
mitral annular tissue velocity. This relationship reveals the inﬂuence of recoil on ﬂow
in diastolic dysfunction. However in normal subjects the acceleration of early diastolic blood ﬂow and recoil are not correlated. Recoil in normal provides the potential
energy for rapid early diastolic ﬁlling and occurs during isovolumic relaxation before
ﬁlling. Therefore rapid early diastolic ﬁlling under the inﬂuence of preload occurs
after isovolumic relaxation and no relationship exists. This supports the existence of
an early diastolic mechanism in normal.
665
Early mitral annular diastolic velocity is superior to propagation velocity
in diagnosing "isolated" diastolic dysfunction.
R.J. Graham, M.J. Stewart. The James Cook University Hospital, Cardiology,
Middlesbrough, United Kingdom
Background: Both early mitral annular velocity (E’) from tissue Doppler imaging
and propagation velocity of early diastolic ﬁlling (Vp) have been proposed as preload
independent markers of diastolic dysfunction (DD), however there are reports that
Vp is inﬂuenced by left ventricular systolic function. This study aimed to test the
hypothesis that E’ is a better marker of diastolic dysfunction in subjects with normal
LV ejection fraction (EF) than Vp.
Methods: The study group comprised 20 patients with DD and EF>45% (Isol DD),
19 patients with DD and EF<45% (Imp LV) and 20 age matched normal controls.
DD was diagnosed on the basis of mitral inﬂow and pulmonary vein Doppler according to European Working Group guidelines. E’ was calculated as the mean of
lateral and septal peak annular velocities. Vp was measured from colour M-mode.
Comparison of predictive value for DD of Vp and E’ was made with receiver operator
characteristic curves.
Results: E’ was signiﬁcantly lower in both Imp LV and Isol DD groups than control
(5.1 ± 1.5 vs 5.0 ± 1.2 vs 8.2 ± 1.8, p< 0.001). Vp, however, showed no difference
between Isol DD and control (55 ± 25 vs 59 ± 13, p=0.51) although in the Imp LV
was signiﬁcantly reduced (31 ± 8, p<0.001 vs control). ROC curve analysis reveals
inferior predictive value of Vp compared to E’(see table). This is most marked in
subjects with preserved EF.
Table: Predictive value of E’ and Vp
All subjects
E’ (cm/s)
Vp (cm/s)
AUC
0.92
0.78
Sens
90%
85%
Normal EF only
Spec
75%
74%
AUC
0.90
0.59
Sens
85%
50%
Spec
75%
90%
(AUC - area under curve, sens - sensitivity, spec - speciﬁcity using cutoffs E’<6.5cm/s, Vp <
45cm/s)
Conclusion: E’ appears to be a better discriminator of diastolic dysfunction than
Vp. This results from a low sensitivity of Vp in subjects with isolated diastolic dysfunction.
Eur J Echocardiography Abstracts Supplement, December 2003
666
Effect of percutaneous and surgical revascularization on left ventricular
diastolic function in patients with preserved left ventricular systolic
performance.
W. Kosmala, M. Przewlocka-Kosmala. Medical University, Cardiology, Wroclaw,
Poland
There are no precise data whether percutaneous (PTCA) and surgical (CABG)
revascularization of myocardium exert the same effect on left ventricular diastolic
function (LVDF).
Aim: To evaluate the inﬂuence of PTCA and CABG on Doppler indices of LVDF in
patients with preserved LV systolic performance.
Material and methods: Studied group consisted of 123 pts aged 64.7±11.2 yrs
with stable effort angina and LVEF>50%. 81 pts were reffered for PTCA and 42 for
CABG. Echo study was performed before and 3 days, 1, 3 and 6 months after PTCA
and 1, 3 and 6 months after CABG and included estimation of: peak velocity of
early (E) and late (A) transmitral ﬂow, deceleration time of E wave (DT), isovolumic
relaxation time (IVRT), total ejection isovolume index (TEI), E (ETT) and A (ATT)
wave transit time to the LV outﬂow tract, ﬂow propagation velocity of E wave (Ep).
Results: In PTCA group 3 days after angioplasty none of evaluated parameters changed signiﬁcantly, after 1 month ETT decreased from 134±28 at baseline to 120±27ms (p<0.01), after 3 months Ep increased from 46.8±19.3 to
52.7±19.9cm/s (p<0.02), E/Ep decreased from 1.46±0.43 to 1.26±0.36 (p<0.03)
and after 6 months IVRT decreased from 106±22 to 97±21ms (p<0.03).
In CABG group after 1 month ETT decreased from 142±28 at baseline to
120±31ms (p<0.01), ETT/ATT from 2.60±0.44 to 1.98±0.57 (p<0.001), DT from
216±50 to 191±31 ms (p<0.03) and A from 68.1±15.3 to 63.2±10.5cm/s (p<0.01)
and ATT increased from 55.5±14.4 to 63±11.6ms (p<0.01).After 3 months significant increase in Ep from 43.4±11.5 to 49.7±9.4cm/s (p<0.02) and decrease in
E/Ep from 1.51±0.52 to 1.33±0.45 (p<0.01) was found out. Other Doppler parameters both in PTCA and CABG group did not alter during observation.
Conclusions: In patients with stable angina and preserved LV systolic performance: (1) improvement in LVDF can be demonstrated 1 month after surgical or
percutaneous revascularization; (2) PTCA improves mainly LV relaxation that is indicated by decrease in ETT, E/Ep and IVRT and increase in Ep; (3) CABG improves
both LV relaxation and compliance which is evidenced by decrease in ETT, ETT/ATT,
DT, A, E/Ep and increase in ATT and Ep.
667
Tissue Doppler analysis of mitral annulus motion in patients with severe
diastolic heart failure.
T. Butz 1 , L. Faber 1 , Y. Kim 1 , N. Bogunovic 1 , W. Scholtz 1 , H.K. Schmidt 1 ,
R. Koerfer 2 , D. Horstkotte 1 . 1 Heart Center North Rhine-Westphalia, Cardiology
Dept., Bad Oeynhausen, Germany; 2 Heart Center North Rhine-Westphalia, Dept
of Thorac Cardiovasc Surg, Bad Oeynhausen, Germany
Background and Introduction: It has been suggested that tissue Doppler (TD)
analysis of mitral annulus (MA) motion might be helpful to further differentiate severe
diastolic heart failure (D-HF) as demonstrated by a restrictive left ventricular (LV)
ﬁlling pattern. We studied the relationship between the early transmitral ﬂow velocity
(E), the early component of MA motion by TD (E’) and LV ﬁlling pressures in 20
consecutive patients (pts.) with D-HF of either proven myocardial origin (RCM) or
from constrictive pericarditis (CP).
Results: Out of the 20 pts. (mean age: 60±13 years) 11 had CP, and 9 RCM.
NYHA class III symptoms were reported by 12/20 pts (60%), 11 pts. (55%) had
sinus rhythm, and 9 (45%) atrial ﬁbrillation (AF). Mean left atrial (LA) diameter was
50±11 mm, mean pulmonary wedge pressure (PCW) 21±7 mmHg. Transmitral E
was 92±22 cm/s, deceleration time of E 137±39 ms without a signiﬁcant difference
between RCM and CP. Systolic LV function was normal in all CP pts., while it was
slightly abnormal in 3, and moderately abnormal in other 3 pts. with RCM. Pts. with
CP showed a higher E’ both on the septal and lateral side of the MA (14±6 cm/s
vs. 4±2 cm/s, and 13±4 cm/s vs. 5±2 cm/s, resp.; p<0.001). E’ was <8 cm/s in all
RCM pts. and >8 cm/s in all CP pts. (see ﬁgure).
Conclusion: Among pts. with severe D-HF, those with RCM frequently also have
slight to moderate impairment of systolic LV function. TD analysis of MA motion
seems to clearly differentiate pts. with RCM from CP independent of cardiac rhythm
with a cut-off value of E’ <8 cm/s.
Abstracts
668
Evidence of elevated left ventricular ﬁlling pressure in hypertensive
hypertrophic patients despite impaired relaxation pattern of Doppler
transmitral ﬂow.
E. Abergel, M. Sirol, H. Raffoul, B. Diebold. Hôpital Européen Georges Pompidou,
Cardiologie, Paris cedex 15, France
Pulsed Mitral ﬂow pattern measured by echocardiography has frequently a morphology of low early diastolic peak velocity (Em) and high late diastolic (Am) peak
velocity in hypertensive patients. It is generally considered as reﬂecting an impaired
relaxation with normal left ventricular ﬁlling pressure (LVFP) at rest. The present
study has been designed to evaluate the ﬁlling pressures with more sophisticated
diastolic index in these patients, in particular using pulsed tissue Doppler early peak
velocity of the mitral annulus (Ea), which has been validated in hypertrophic cardiomyopathy.
Methods: Echocardiogram were prospectively performed in 166 hypertensive patients (70 females), mean age 53 years old. The following parameters were measured for characterization of diastolic function: Em, Am, Em deceleration time (DT),
and Am duration (Amd) for mitral inﬂow. Ea, mean of medial and lateral annulus
early peak velocities. Atrial contraction duration (Apd) of pulmonary venous ﬂow.
Early diastolic LV ﬂow propagation using color M-mode (Vp). Deﬁnition of LV hypertrophy (LVH) was indexed LV mass greater than 111 g/m2 in men and 106 g/m2 in
women.
Results: 100 patients (60.2%) had Em/Am ratio less than 1, 24 with LVH (LVH+)
and 76 without LVH (LVH-). Results according to LVH are presented in the table
Diastolic parameters according to LVH
Index
DT(ms)
Amd-Apd(ms)
Em/Vp
Em/Ea
LVH+(n=24)
LVH-(n=76)
p
217±49
202±57
.25
26±20
25±22
.8
1.31±.63
1.16±.18
.17
8.8±3.4
6.9±2.0
.0012
A poor correlation was found between Em/Ea and Em/Vp (r=.24). Using the usual
threshold of Em/Ea > 10 to deﬁne high LVFP, 6 patients (25%) in LVH+ had high
LVFP, while 3 patients (4%) in LVH- had high LVFP. The signiﬁcance of a high
Em/Ea ratio (>10) was further conﬁrmed by the values of systolic pulmonary pressure (tricuspid regurgitation): 34.2±6.8 mmHg in the group with Em/Ea > 10 versus
31.0±5.0 mmHg in the group with Em/Ea < 10, p=.005.
Conclusion: In hypertensive patients, a Em/Am ratio below 1 can be associated
with elevated LVFP, particularly in LVH. In addition, Em/Ea and Em/Vp, which theoretically represent a comparable approach of evaluating LVFP, are poorly correlated.
S79
670
The correlation between left ventricular early diastolic and systolic
function.
M. Birgander 1 , R. Winter 2 , P. Gudmundsson 2 , G. Ericsson 2 , G. Tasevski 2 ,
R. Willenheimer 2 . 1 Universitetssjukhuset MAS, Cardiology, Malmö, Sweden;
2
Universitetssjukhuset MAS, Cardiology, Malmö, Sweden
Purpose: Left ventricular (LV) systolic and diastolic functions are in clinical practice determined using echocardiography and have been considered to be more or
less independent of each other. However, the early LV diastolic properties may be
dependent on the recoil caused by the LV contractile force. The objective of this
study was to further assess the relationship between LV early diastolic and systolic
functions.
Methods: Standard transthoracic echocardiography (TTE) was performed in 67 patients with chronic heart failure. Three early diastolic parameters were determined;
(1) the M-mode atrioventricular plane displacement (AVPD) early diastolic downward slope (EDS), (2) the maximum early diastolic tissue Doppler velocity (E’) and
(3) the early diastolic LV colour-M-mode ﬂow propagation velocity (Vp). E’ is the
mean of the four maximum tissue Doppler velocities recorded during early diastole
at the basal LV septal, lateral, inferio-posterior and anterior walls. Vp is the registration of the early diastolic inﬂow to the LV in the apical four-chamber view. The
early diastolic parameters were compared with two LV systolic parameters, ejection
fraction (EF) and AVPD. The early diastolic parameters were also compared with
LV diastolic function expressed by a traditional four-grade scale, based on a combination of the Doppler derived transmitral early/atrial maximum velocity ratio (E/A),
E-wave deceleration time (Edt) and systolic/diastolic ratio of the pulmonary venous
inﬂow (S/D).
Results: In linear regression analysis and Spearman rank correlation test, respectively, all three early diastolic parameters correlated more closely with LV systolic
function than with traditional LV diastolic function. LVEF correlated signiﬁcantly with
E’ (p<0.0001, R=0.494), EDS (p=0.0003, R=0.437) and Vp (p=0.0047, R=0.349).
AVPD correlated signiﬁcantly with E’ (p=0.0055, R=0.380) and EDS (p=0.0016,
R=0.422) but not with Vp (p= 0.2124, R=0.176). Traditional LV diastolic function
did not correlate with E’ (p=0.8457, R=0.036), EDS (p=0.8935, R=0.079) or Vp
(p=0.9049, R=0.049).
Conclusions: Parameters reﬂective of LV early diastolic function correlate more
closely with LV systolic function than with LV diastolic function as assessed by traditional Doppler evaluation. This may indicate that suction created by elastic recoil
from energy stored during LV contraction is a major determinant of early diastolic
ﬁlling.
ISCHAEMIC HEART DISEASE
669
Aerobic capacity impairment in chronic heart failure caused by left
ventricular dysfunction is related to diastolic dysfunction.
J. Saavedra 1 , P. Talavera 2 , P. Awamleh 2 , E. García 2 , M.T. Alberca 2 , A. Karoni 2 ,
F.G. Cosio 2 . 1 Hospital Universitario de Getafe, Cardiology, Getafe, Spain;
2
Hospital de Getafe, Cardiology, Getafe, Spain
Introduction: Aerobic capacity (AC) impairment as well as diastolic dysfunction has
been related to a worse prognosis in patients with heart failure (HF).
Objectives: We sought to analyze the correlation between AC and diastolic function
(DF) parameters in a group of patients with HF due to left ventricular dysfunction
(LVD).
Patients and Methods: We studied 39 consecutive patients, 32 men with mean age
54±11 y. 52% of them had coronary heart disease an 48% dilated cardiomyopathy.
73% were in N.Y.H.A. class II and 27% in class III. Their mean ejection fraction was
24±7%. An exercise test was performed measuring the gas interchange. We also
made a transthoracic echocardiography. We measured usual DF parameters. Mitral
Doppler ﬂow parameters included peak E, peak A, E/A ratio, deceleration time and
isovolumic relaxation time. Pulmonary vein ﬂow parameters included: systolic (S)
and diastolic (D) velocities, time-velocity integrals (S area and D area), S/D ratio
and the difference between A duration in mitral and pulmonary vein ﬂows. According to those measurements we classiﬁed our patients into three groups: relaxation
impairment, pseudonormal, and restrictive ﬁlling pattern.
Results: After excluding patients with positive stress tests for ischaemia (n=8,
20%), mean peak oxygen consumption was 15±7 ml/Kg/min. The mean of the
proportion of the peak oxygen consumption in relation to the sex and age theoric was 51,6%. This proportion was signiﬁcantly lower in patients with restrictive
and pseudonormal ﬁlling pattern (47%) versus those with impaired relaxation pattern (56,7%), p=0,03. We did not found differences in aerobic capacity according to
diagnosis or in relation to ejection fraction.
Conclusion: Diastolic dysfunction and not ejection fraction determines aerobic capacity in patients with left ventricular dysfunction.
672
Can left ventricular ejection fraction and volumes be used for prediction
of clinical endpoints after coronary artery bypass grafting in coronary
artery disease patients?
B. Obrenovic-Kircanski 1 , B. Parapid 2 , P. Mitrovic 2 , B. Vujisic-Tesic 2 , P. Djukic 2 ,
M. Kocica 2 , S. Subotic 2 . 1 Institute for Cardiovascular Diseases, Dept. of
Cardiology, Belgrade, Yugoslavia; 2 Institute for Cardiovascular Diseases, Belgrade,
Yugoslavia
Objective: It still remains undetermined which patients (pts) who have undergone
coronary artery bypass grafting (CABG) are at risk of future clinical cardiovascular events. We intended to determine if non-invasive cardiovascular investigation of
left ventricular ejection fraction (LVEF) and volumes (LVV) - performed early after
surgery - were able to stratify the risk of cardiovascular events in the given population.
Patients and Methods: In a prospective study, we evaluated 120 consecutive pts
hospitalized at our Institute for coronary artery disease (CAD) treated with CABG.
Early post-op, we determined LVEF and LVV (both telesystolic and telediastolic).
Over a 5 year follow up, we analyzed recurrence of angina, acute myocardial infarction (AMI), sudden cardiac death and all other clinical cardiovascular events that
required in-hospital treatment and investigated if their appearance correlated with
disturbance of the echo parameters we studied.
Results: The mean age of our pts was 59±6.4 yrs (ranging 41-71 yrs), with male in
majority (82%) and more than a half (61%) with an AMI prior to CABG. Post-op, mild
and moderate LVEF reduction was observed in 49/120 (41%) of pts, while 29/120
(24%) of pts had increased both LVV. New coronary events occurred in 15 pts who
devloped angina (12.5%), 5 pts had a new AMI (4.16%) and 2 pts died suddenly
(1.66%), while congestive heart failure (CHF) was present in 16 pts (13.3%). Reduced LVEF and increased LVV haven’t been proven predicitive of new coronary
events, but they deﬁnitely have a predictive value for CHF (p<0.05).
Conclusion: Reduced LVEF and increased LVV early after CABG have no inﬂuence
on appearance of new coronary events, but do predict developement of CHF.
Eur J Echocardiography Abstracts Supplement, December 2003
S80
Abstracts
673
Can resting 2D echocardiography identify patients with ischemic
cardiomyopathy and low likelihood of functional improvement after
revascularization?
V. Rizzello 1 , E. Biagini 2 , A.F.L. Schinkel 2 , J.J. Bax 3 , M. Bountioukos 2 ,
E.C. Vourvouri 2 , J.R.T.C. Roelandt 2 , D. Poldermans 2 . 1 The Catholic University,
Cardiology Department, Rome, Italy; 2 Thoraxcenter Erasmus MC, Cardiology
Department, Rotterdam, Netherlands; 3 Leiden University Medical Center,
Cardiology Department, Leiden, Netherlands
Background: To evaluate the potential of a simple and widely available technique
such as 2-dimensional echocardiography to identify patients with ischemic cardiomyopathy and low likelihood of functional improvement after revascularization.
Methods: Two-dimensional echocardiography was performed in 101 patients with
left ventricular (LV) dysfunction due to chronic coronary artery disease, already
scheduled for revascularization. Segmental wall motion abnormalities, wall motion score index (WMSI), end-diastolic wall thickness (EDWT), LV volumes and LV
sphericity index (LVSI: DŁ) were evaluated. The LV ejection fraction (LVEF) was
assessed by radionuclide ventriculography (RNV), before and 9 to 12 months after revascularization. An improvement in the LVEF > or = to 5% was considered
clinically signiﬁcant.
Results: On the analysis 999 segments were severely dysfunctional (WMSI:
2.75±0.7); 149 (15%) had an EDWT < or = to 6 mm and were considered scar
segments. Severe LV dilatation was present in 24 patients (25%) and a spherical
shape of the LV was observed in 35 patients (37%). After revascularization, a significant improvement in the LVEF (from 30±8% to 39±9%, p<0.0001) was observed
in 30 patients (32%). Clinical and echocardiographic characteristics were similar in
patients with and without improvement except for LV volumes (EDV: 140±36 versus
172±51 ml and ESV: 86±34 versus 117±43 ml, p<0.0005 for both). On univariate analyses the EDV (OR 1.05, CI 1.03-1.08, p<0.005) and the ESV (OR 1.02,
CI 1.01-1.03, p<0.005) were predictive of no improvement. On multivariate analysis, ESV remained predictor of no improvement in LVEF (OR 1.02, CI 1.01-1.03,
p<0.01). The likelihood of improvement in the LVEF declined as the ESV increased.
The cut-off value of ESV > or = to 140 ml had the best accuracy to identify patients
that virtually never improve. LVEF improvement after revascularization was present
only in 1 (4%) patient with ESV > or = to 140 ml as compared to 29 (41%) patients
with ESV <140 ml (p<0.005).
Conclusions: In patients with ischemic cardiomyopathy, the presence of severe LV
enlargement signiﬁcantly reduce the chance of functional improvement after revascularization. Hence, the assessment of LV volumes, by an extremely widespread
diagnostic technique as 2-dimensional echocardiography at rest, can be an initial
screening tool to identify patients in which further viability testing could be avoided.
674
Assessment of myocardial viability by acoustic densitometry in patients
with left ventricle dysfunction due to coronary artery disease.
R. Panovsky 1 , J. Meluzín 1 , V. Kincl 1 , B. Fischerová 1 , F. <QTA>?</QTA>tìtka 2 .
1
St. Anne’s University Hospital, 1st Internal - Cardioangiological Dep., Brno, Czech
Republic; 2 , CKTCH, Brno, Czech Republic
Aim: The purpose of our study was to assess whether acoustic densitometry could
distinguish between viable and ireversible dysfunctional myocardium in patients with
coronary artery disease before myocardial revascularization.
Methods: Seventy patients with chronic coronary artery disease and dysfunctional
myocardial segments before planned myocardial revascularization were examined
by acoustic densitometry. Fifty four patients had revascularization of at least one
coronary artery supplying dysfunctional segments. Control echocardiography of
these patients was performed after 3 months after bypass surgery or percutaneous
coronary intervention for assessing contractility of revascularized, initially dysfunctional myocardial segments. The dysfunctional segments were deﬁned as viable if
they exhibited improvement in their thickening after revascularization. Wall motion
was scored using 16-segment model of left ventricle, acoustic densitometry was
evaluated from parasternal long axis view, parasternal short axis view at the level of
papilary muscles and apical four-chamber and two-chamber views.
Amplitude of cyclic variation of integrated backscatter (CVIB) was evaluated from
each dysfunctional segment. The receiver operating characteristics curve analysis
was applied to determine the optimal cut off value of CVIB for distinction between
viable and ireversible dysfunctional myocardium.
Results: Cut off values for anteroseptal, posterior, interventricular septal, lateral,
inferior and anterior segments were 4,1; 4,3; 4,4; 4,2; 4,5; 4,0 and 4,2 decibels,
respectively. Sensitivity, speciﬁcity, positive and negative predictive values for identiﬁcation of myocardial viability by acoustic densitometry using this cut off values
were 91%, 81%, 87%, and 86%, respectively.
Conclusion: Acoustic densitometry can differentiate viable and ireversible dysfunctional myocardium in patients with coronary artery disease before myocardial revascularization.
Eur J Echocardiography Abstracts Supplement, December 2003
675
Echocardiographic outcome in patients with low ventricular ejection
fraction after coronary bypass grafting.
M. Gomez, E. Larrousse, J. López Ayerbe, M.L. Cámara, L. Delgado, C. Sureda,
X. Ruyra, V. Valle. Germans Trias University Hospital, Cardiology, BADALONA,
Spain
Objectives: To evaluate the outcome of systolic function and ventricular diameters in patients with low ejection fraction underwent by-pass grafting. To study the
echocardiographic characteristics of patients underwent surgical anterior ventricular
restoration (restore).
Methods: 150 consecutive patients (118 men and 32 women, mean age 62±11.1
years) with low ejection fraction (mean EF 32.4%) underwent coronary by-pass
grafting. Mean Euroscore 5.67±3.47. 83.5% of patients presented three vessels
disease and 21% there was left main coronary disease. In 92.5% was implanted
internal mammarian artery graft and 81% of patients were fully revascularisated.
All patients had had previously angina or demonstrated ischemia. We performed an
echocardiogram: before surgery, in 7th post-operative day and in 6th post-operative
moth.
Results: There were a signiﬁcant improvement between pre-operative EF and 7th
post-operative day (32.4% vs 40.1%, p<0.05) and poor improvement between 7th
post-operative day and 6 month post-operative EF (40.1% vs 42.7%, p NS). Mean
LVEDD/LVESD were 69/51 mms (pre-operative), 65/49 mms (7th post-operative
day) and 63/48 mms (6th post-operative month) (p<0.05). In-hospital mortality was
5.1%. 20 patients, with previous anterior myocardial infarction and aneurysm, underwent surgical anterior ventricular restoration (restore). In this subgroup: mean
diameters were 76/56 mms to 66.6/46 mms (7th post-operative day) and 64/42
mms (6th post-operative month), with improvement of mean EF since 24.6% (1241%) to 36% (7th post-operative day) and 37% (6th post-operative month) (p<0.05);
post-operative echocardiogram showed remaining dyskinetic segments in 29% and
akinetic segments in 58%. Mortality in restore subgroup was 5%.
Conclusions: There was a signiﬁcant improvement (7.7 points) in EF at 7th postoperative day and poor improvement between this and 6th post-operative month
EF. Surgery can be performed in this group with acceptable mortality. In postoperative echocardiogram of patients underwent ventricular restoration frequently
can be identiﬁed remaining diskinetic segments
676
Value of evaluation of right ventricular function, postsystolic left
ventricular contraction and pulmonary venous ﬂow for prediction of post
myocardial infarction remodeling.
R. Jurkevicius 1 , J. Vaskelyte 2 , D. Luksiene 3 , J. Janenaite 2 . 1 Kaunas, Lithuania;
2
Kaunas University of Medicine, Departament of Cardiology, Kaunas, Lithuania;
3
Institute of Cardiology, Kaunas, Lithuania
Increase in left ventricular size after myocardial infarction is associated with increased risk for adverse complications including death, recurrent myocardial infarction, heart failure.
The aim of the study was to evaluate predictive value of pulmonary venous ﬂow, tricuspid annulus motion, postsystolic contraction (as additive methods for evaluation
of cardiac function) for dilatation of left ventricle.
Material and methods: For this purpose forty patients with ﬁrst myocardial infarction (age 55 ± 10 yrs) were investigated on the 2-3 day of myocardial infarction and
repeatedly after 2-3 month. Left ventricular systolic function, diastolic function and
left and right ventricular long axis functions were evaluated using echocardiography.
The study population was divided into two groups in respect of increase of left ventricular end-diastolic diameter (LVEDD) - I group - with left ventricular dilatation (19
patients); II group - 21 patient without ventricular dilatation.
Results: There was statistically signiﬁcant difference between the two groups in
baseline LVEDD (4.69 ± 0.53 cm in I group, versus (vs) 5.25 ± 0.40 cm in II group),
ejection fraction (EF respectively 38 ± 9% vs. 48 ± 14%), time velocity integral of
diastolic pulmonary venous ﬂow (Dipl 4.15 ± 1.74 cm vs. 6.84 ± 2.04 cm), systolic
amplitude of tricuspid annulus motion (Vta - 1.00 ± 0.30 cm vs. 1.31 ± 0.36 cm). In
I group postsystolic shortening (PSS) of the left ventricle in long axis was more frequently and longer in duration. In multiple regression analysis the best predictors of
changes in LVEDD were baseline EF, wall motion score index, left ventricular posterior wall thickness, systolic amplitude of mitral annulus motion, Vta, and amplitude
of PSS; r2 =0.91, p < 0.05.
In conclusion: variables of left ventricular systolic function, pulmonary venous ﬂow,
left and right ventricular long axis function, postsystolic contraction can predict left
ventricular remodeling after myocardial infarction.
Abstracts
677
Tissue velocity imaging of mitral annulus in cad patients after 10 weeks
of training at different intensities.
B. Amundsen 1 , G. Hatlen 2 , O. Rognmo 1 , A. Stoylen 2 , S.A. Slordahl 1 . 1 Faculty of
medicine, NTNU, Dep of Circulation and Medical Imaging, Trondheim, Norway; 2 St
Olavs Hospital, Dep of cardiology, Trondheim, Norway
Purpose: Physical exercise is strongly recommended in both primary and secondary prevention of coronary artery disease (CAD), but data on effects of exercise
intensity are sparse. Thus, the aim of the study was to evaluate the effects of two
different aerobic exercise-training programs of uphill treadmill walking on maximum
oxygen uptake (VO2peak) and myocardial function evaluated by ultrasound Tissue
Doppler Imaging (TDI).
Method: 17 subjects with angiographically documented CAD were enrolled in the
study. They were randomly assigned to either moderate (M) (40 min continuos walking at 50-60% of VO2 peak) or high (H) intensity exercise (4 x 4 min interval walking
at 80-90% of VO2peak). Training was carried out under supervision 3 times per
week for 10 weeks. Peak systolic (S), diastolic (D) and atrial (A) velocities were
recorded at rest before and after training, and mitral annulus excursion during systole (MAE) was calculated from the integrated velocity signal. All values are mean
of four points of the annulus. Changes in each group were compared using analysis
of covariance (ANCOVA).
Results: VO2peak increased more in the H than in the M group (32 to 38 vs. 32
to 34, p<0,05). Heart rate, end-diastolic volume (EDV) and ejection fraction (EF)
were unchanged after training in both groups (pretest-values from both groups together: 60±1 beats/min, 112±20 ml, 54±9%). For S, E, A and MAE, there was no
difference from pre- to posttest when the H and M groups were analysed together,
neither was there any difference in the change after training between the H and M
groups (values at pretest for both groups: S=5,7±0,9 E=5,7±1,8 A=7,3±1,3 cm/s
MAE=11±1,4 cm). E/A-ratio for annulus velocities was also unchanged from pre- to
posttest in both groups (pretest value for both groups: 0,86±0,4). A signiﬁcant correlation between VO2peak and E was found in pretest (Spearman’s r=0,49,p<0,05),
but only a trend was found in posttest (r=0,45,p=0,068). There was no relation between VO2peak and S, MAE, EDV or EF.
Conclusion: 10 weeks of aerobic endurance training improved VO2peak signiﬁcantly in CAD patients, but did not change mitral annulus velocities or MAE. There
was no effect of different training intensities. Diastolic function at rest seems to be
closer related to maximum exercise capacity than systolic function.
678
Comparison of cardiac chamber size and left ventricular function in
normotensive unstable angina patients with and without chronic
obstructive pulmonary disease.
I. Dahnyuk 1 , T.I. Chaban 1 , R.Y. Gritsko 2 , L.E. Lapovets 3 , G.Y. Soloninko 1 .
1
Medical University of UAPM, Hospital therapy chair, Kiev, Ukraine; 2 Medical
University, Infection disease chair, Lviv, Ukraine; 3 Medical University, Clinical lab
diagnostics chair, Lviv, Ukraine
The effect of chronic obstructive pulmonary disease (COPD) comorbidity on cardiac
chamber size and left ventricular (LV) function in unstable angina (UA) patients (pts)
has not been described in detail. The aim of this study was to compare cardiac
chamber size and LV function in UA pts with and without COPD.
Methods: M-mode, 2-dimensional and Doppler echocardiography were performed
on 42 pts with UA and 42 pts with UA+COPD. All pts were normotensive. The patients of two groups were matched.
Results: The results were as follows (table, *p<0.05, **p<0.01):
Chamber size and LV function
Variable
LV diastolic dimension (cm)
LV end-systolic stress (g/cm2 )
LV mass/height index (g/cm)
LV fractional shortening (%)
LA dimension (cm)
RV dimension (cm)
Transmitral E/A ratio
UA
UA+COPD
5.5±0.4
156±21
161±17
29±3
3.2±0,2
1.8±0.1
1.18±0.20
6.4±0.4**
202±28**
217±22**
23±2*
3.8±0.3*
2.3±0.2*
0.77±0.13*
S81
679
Clinical value of tei index in the late postinfarction phase.
N S. Nearchou, A K. Tsakiris, C D. Flessa, M D. Lolaka, I. Zarkos, A
T. Gianacopoulou, P D. Skoufas. Hellenic Red Cross Hospital, 1st Cardiology
Dept., Athens, Greece
Introduction: The prognostic value of the Doppler-derived index (DI) -Tei Index-,
has been sufﬁciently proven in the early postinfarction phase. The aim of the present
study was the deﬁnition of the prognostic value of DI in the late postinfarction phase,
purpose which has been inadequately detected up today.
Methods: It is a retrospective study of 94 patients (pts) (69 males), of mean age
59.9±9.9 (SD) years, who had been hospitalized in our department for their ﬁrst
acute myocardial infarction (AMI). We measured the DI on the 8.07±0.96 (SD)
postinfarction day and we correlated it with the pts clinical outcome. The mean duration of their follow-up was 21.2±15.03 (SD) months (range 0.2-53.8) and the end
points of the study were: a) the coronary revascularization therapy and b) the new
cardiac event. Standard formulas were used for calculating sensitivity and speciﬁcity.
Results: The attendance was possible in 71 out of the 94 pts of which, 31 had
uncomplicated postinfarction outcome (UC), 31 underwent coronary revascularization therapy (CR), and 9 showed a new cardiac event (CE). The index of pts of
group UC (0.54±0.03) was signiﬁcantly lower than that of pts of groups CR and
CE (0.72±0.03; p=0.0006, 0.75±0.011; p=0.008 respectively), whereas did not different among pts of groups CR and CE (p=NS). An index value (>=0.60) had the
best sensitivity (73.7%) and speciﬁcity (72.7%) in the tracking of pts with the end
points and also pts with that index value (>=0.60) had relative risk 7.6 (x2=15.25,
p<0.001) in the incidence of the above points.
Conclusions: 1) Tei index has strong prognostic value in the clinical outcome of pts
with AMI, and is considered to be a sensitive and a specialist method in the postinfarction evaluation of them. 2) Pts of category CR and CE may be characterized by
the same severity and extension of coronary artery disease.
680
Inﬂuence of 28-day valsartan treatment on endothelium-mediated
vasodilatation in patients with Q-wave myocardial infarction.
A. Alyavi 1 , M. Kremkova 2 , M. Yakubov 3 , M. Kendjaev 4 , N. Dadamyants 3 ,
M. Nazarova 5 . 1 The First State Medical Institute, Internal Medicine Department,
Tashkent, Uzbekistan; 2 Tashkent, Uzbekistan; 3 Research Center of Emergency
Medicine, Diagnostic Deparment, Tashkent, Uzbekistan; 4 Research Center of
Emergency Medicine, Intensive Therapy Deparment, Tashkent, Uzbekistan;
5
Research Center of Emergency Medicine, Department of Cardiology, Tashkent,
Uzbekistan
Purpose: The effect of 28-day valsartan treatment on the endothelial function in patients with Q-wave myocardial infarction (Qw MI) was studied, and effect of valsartan
and enalapril on endothelium-mediated vasodilatation (EMVD) in these patients was
compared.
Methods: Fifty patients with Q-wave anterior or posterior MI (36% females, aged
63±7.5 years) were randomized into two groups: group 1 received the routine therapy (heparin, beta-blockers, acetylsalicylic acid) + valsartan 40-80 mg/day for 28
days (24 patients) or group 2 received the routine therapy + enalapril 5-10 mg/day
for 28 days (26 patients). Ultrasonography was used to measure blood ﬂow and
percentage the brachial artery diameter change to reactive hyperemia induced by
4-minute forearm blood ﬂow cuff-occlusion. The results were expressed as percentage change in the brachial artery diameter at seconds 5, 60, 180, 300 and 600 after
blood ﬂow occlusion compared to the baseline diameter. The endothelial function
was studied before the treatment and at days 1-3, 5-7, 10-14 and 28.
Results: There was no vasodilatation or there was vasoconstriction after 4-minute
blood ﬂow occlusion in 71% patients of valsartan group and in 72% patients of
enalapril group before initiation of the study. Both, valsartan and enalapril had improved EMVD by day 10-14. By day 28, we had observed improvement of EMVD in
66.6% patients of valsartan group and in 70.3% patients of enalapril group (p<0.05
compared with the data before the treatment), but there were no signiﬁcant differences between two groups.
Conclusions: Both enalapril and valsartan improve EMVD in patients with Qw MI
receiving the routine therapy. These two drugs may have vaso- and cardioprotective
effects mediated, in part, by improvement of the endothelial function.
Demographic data (age, gender, and associated other medical problems) were not
statistically different between the two groups. Our results failed to show evidence
for a relationship between longivity of combined disease and chamber size. There
was conﬁrmation though that chamber size is related to severity of COPD.
Conclusions: Unstable angina patients with chronic obstructive pulmonary disease
comorbidity have signiﬁcantly larger cardiac chamber dimensions, higher left ventricular wall stress, greater left ventricular mass, more impaired left ventricular systolic function and diastolic ﬁlling than those without chronic obstructive pulmonary
disease comorbidity.
Eur J Echocardiography Abstracts Supplement, December 2003
S82
Abstracts
681
Echocardiographic features in acute myocardial infarction of
nonagenarian patients: prognostic implications.
683
Left ventricular diastolic performance and risk factors for heart failure
development due to coronary artery disease.
T. Datino, M. Martínez-Sellés, H. Bueno, A. Puchol. Madrid, Spain
D.N. Chrissos 1 , E.N. Tapanlis 1 , A.A. Katsaros 1 , N.C. Corovesi 2 , A.N. Kartalis 1 ,
P.N. Stougianos 1 , D.S. Sirogiannidis 1 , A.A. Pantazis 1 , I.E. Kallikazaros 1 .
1
Hippokration Hospital, State Cardiac Department, Athens, Greece; 2 Greek Red
Cross Hospital, Department of Laboratory Medicine, Athens, Greece
Background: Echocardiographic characteristics and their implication in the outcome of elderly patients hospitalised with acute myocardial infarction are largely
unknown.
Methods: We studied 92 consecutive patients 89 years of age or older admitted
from January 1998 to December 2002 to our institution with an acute myocardial
infarction with ST-segment elevation and/or left bundle branch block on their ﬁrst
12 lead ECG, 74 (80.4%) had an echocardiographic study and were the population
of interest, although 5 echocardiographys were performed in an acute situation to
conﬁrm heart rupture and only provided data concerning pericardial effusion.
Results: Age ranged from 89 to 97, mean 91.3±2.2 years. There were 60 women
(65.2%).
Echocardiographic features:
1) Left ventricle. Ejection fraction: Normal 13 patients (18.8%), 0.41-0.5 14 patients(20.3%), 0.31-0.4 9 patients (13.0%), <0.31 33 patients (47,8%). Dilatation
17 (25.4%). Hypertrophy 26 (38.8%), moderate/severe hypertrophy 11 (16.4%).
2) Moderate/severe valvular disease: Mitral regurgitation 24 (35.3%), Aortic stenosis
7 (10,5%).
3) Severe pericardial effusion: 6 (8.1%), all of them died during hospital admission.
In-Hospital mortality was higher among patients with left ventricle ejection fraction
<0.31 36.4% vs 5.6% in pts with left ventricle ejection fraction>0.3, p=0.007 and
among patients with severe pericardial effusion: 100% vs 15% in patientswith moderate or less pericardial effusion, p<0.001. We also found a trend towards a higher
mortality in patients with moderate/severe aortic stenosis 28.6% vs. 16.6% in patients with no signiﬁcant aortic stenosis, p=0.4.
Conclusion Patients aged 89 years or older with an AMI present frequently with
severely depressed LVEF, severe pericardial effusion, and signiﬁcant aortic stenosis. Each of these echocardiographic parameters could increase in-hospital mortality.
682
TEI-Pulsed tissue Doppler imaging index in the detection of viability in
akinetic left ventricular segments.
I. Karabinos 1 , A. Papadopoulos 2 , A. Kranidis 3 , S. Koulouris 3 , D. Triantaﬁllis 2 ,
E. Karvouni 2 , D. Katritsis 2 . 1 Athens, Greece; 2 Euroclinic Hospital, Cardiology
Dept., Athens, Greece; 3 Evangelismos Hospital, 1st Cardiology Dept, Athens,
Greece
TEI-Pulsed tissue Doppler imaging (TDI) has been applied for the assessment of
ischemia in normal portions of left ventricle (LV).
The aim of our study was to use this TEI-TDI index comparatively with other TDI
indices for detection of viability in akinetic segments of left ventricle.
Methods: We studied 30 patients (pts), with a previous myocardial infarction who
underwent a dobutamine stress echocardiography (DSE) study (20µgr/kgr/min)
for detection of possible viability of akinetic myocardial segments. All pts had a
transthoracic echocardiographic study documenting at least one akinetic segment
in septal (S), anterior (A), lateral (L), inferior (I) and posterior (P) wall of LV. We
studied 150 left ventricular portions, of which 72 where found to contain at least
one akinetic segment, while the rest 78 contained segments of normal or reduced
contractility. Prior to DSE, Pulsed TDI was employed to evaluate the motion of S,
A, L, I, and P segment of mitral annulus (MA), from the apical views. We measured
the following pulsed TDI indices in the different segments of MA: peak velocity of
S wave (peak S)(cm/sec), time to peak S (tpeakS)(msec), deceleration time of E
wave (decE)(msec), isovolumic contraction time (IVCT) and isovolumic relaxation
time (IVRT).In addition we calculated the TEI -TDI index according to the equation:
TEI=ICT+IVRT/ET, where ET=ejection time.
Results: Twenty out of 72 portions contained a viable akinetic segment. No differences were identiﬁed in any index between normal/hypokinetic and akinetic segments. However we demonstrated a statistical (Mann- Whitney test) signiﬁcant difference between viable and non viable akinetic segments in IVCT (p=0,03), IVRT
(p=0,05) and peak S (p<0,0009) but not in decE, tpeakS and TEI-TDI index. Logistic regression analysis revealed that IVCT (p=0,02), IVRT (p=0,01) and Peak S
(p=0,001) are predictors of viability in akinetic portions. However multivariate conditional logistic regression analysis revealed that peak S (p=0,001) is an independent
predictor of myocardial viability regarding age, sex, ejection fraction of LV, presence
of hypertrophy of LV, end diastolic diameter of LV, Wall Motion Score Index, IVCT,
IVRT, tpeakS, decE, TEI-TDI index. Peak S velocity >7 cm/sec was found to predict
viability with sensitivity 90% and speciﬁcity 92%.
Conclusions: Peak S velocity of MA as opposed to to TEI-TDI of MA is a sensitive
index to discriminate viable from non viable akinetic myocardial portions without
performing DSE in pts with a prior myocardial infarction.
Eur J Echocardiography Abstracts Supplement, December 2003
Introduction: Coronary artery disease (CAD) is the major contemporary etiology
of heart failure (HF). Arterial hypertension, diabetes mellitus, dyslipidemia, tobacco
use and obesity are identiﬁed as important risk factors (RF) for development of HF,
especially on patients (P) with CAD. The purpose of this study is to determine the
association between the above RF and noninvasive echocardiographic indices of
left ventricular (LV) diastolic function on P with HF due to CAD.
Methods: We recorded 238 consecutive P with HF due to CAD (185 males and 53
females of mean age 67.62±13.09 years), who were hospitalized from September
2001 to December 2002. The P were divided in three groups: with no RF (group
I), 1-2 RF (group II) and >/=3 RF (group III) and underwent 2-D, Doppler and color
M-mode echocardiographic study. As HF index was considered LV ejection fraction
(LVEF) less than 40%, which was measured by 2-D echocardiography using the
Teicholz method and did not differ between the three groups. LV diastolic function
was evaluated by: 1) E/A ratio in the pulsed-wave Doppler transmitral ﬂow (TMF),
and 2) the color M-mode Doppler velocity of ﬂow propagation (VFP) (cm/sec). The
restrictive TMF pattern (E/A >2) indicates severe diastolic abnormality. Data were
expressed as "mean value ± standard deviation", statistical analysis was performed
by the student’s t-test method and p<0.05 was considered statistically signiﬁcant.
Results: We detected 44 P (18.49%) in group I, 133 P (55.88%) in group II and 61
P (25.63%) in group III. 6/44 P (13.63%), 33/133 P (24.81%) and 18/61 P (29.51%)
respectively showed the restrictive TMF pattern. Signiﬁcant differences appeared
between group I and group III only regarding the restrictive pattern. It was found:
E/A (TMF) 2.395±0.43 versus 2.952±0.68 (p<0.05) and VFP 36.96±5.08 cm/sec
versus 31.56±8.50 cm/sec (p<0.05).
Conclusions: More than half of the patients with heart failure due to coronary artery
disease have a history of one or two risk factors for heart failure development. It
seems that the presence of at least three risk factors predisposes to advanced
diastolic dysfunction of the restrictive ﬁlling pattern. Moreover, only patients with
such a severe abnormality on echo-Doppler study appear to be seriously affected
by the number of the above factors regarding indices such as E/A(TMF) and VFP.
684
Not left atrial contribution but contractility is better following primary
angioplasty than after thrombolysis: an echocardiographic study.
M. Uzun, C. Genc, H. Karaeren, A. Kirilmaz, O. Baysan, K. Erinc, C. Sag, C. Koz,
M. Ozkan, E. Demirtas. GATA, Cardiology, Ankara, Turkey
Background: Left atrial (LA) function is important for an optimal ﬁlling of the left
ventricle. Acute myocardial infarction (AMI) results in not only left ventricular but
also left atrial dysfunction.
In this study, we aimed at ﬁnding out the left atrial function in acute myocardial
infarction after thrombolysis (T) and angioplasty (A).
Methods: We performed 2-D echocardiography and pulsed Doppler echocardiography in 48 consecutive patients at sixth month after acute myocardial infarction. The
AMI patients without thrombolysis or primary angioplasty were accepted as control
group (C). LA contribution was assessed by atrial ejection force (AEF). AEF was
calculated from maximal late diastolic velocity and mitral oriﬁce area. Left atrial contractility was assessed by atrial fractional shortening (AFS), which was estimated
from m-mode echocardiography on parasternal long axis. The left atrial diameters
just before and after the P wave of ECG (D1 and D2, respectively) were used in the
formula: AFS=(D1-D2)/D1. LA volume (LAV) immediately before the onset of atrial
contraction was calculated by the following formula: LAV= 8 A1 x A2/3L, in which
A1= LA area on four-chamber view, A2= LA area on two-chamber view, L:the common length in each view. The comparisons are made by Mann-Whitney U test. The
statistical signiﬁcance of p value was set at 0,05.
Results: Results are shown on the table.
Parameter
A (n=20)
T (n=16)
C (n=12)
Statistics
Age (years)
M:F ratio
LAV (ml)
AEF(%)
AFS(%)
62 ± 7
14:6
47 ± 4
16 ± 4
28 ± 4
66 ± 8
12:4
51 ± 4
21 ± 4
21 ± 4
64 ± 8
10:2
56± 4
19 ± 4
17 ± 3
No signiﬁcance
No siginiﬁcance
C>T>A
A=T=C
A>T>C
Conclusions: 1. Atrial ejection force, which is an indicator of left atrial contribution
to left ventricular ﬁlling, is not different among the groups.
2. Atrial fractional shortening, which is an indicator of left atrial contractility, is better in those patients with angioplasty, followed by thrombolysis and conservative
therapy, consecutively. These results can be explained by increased atrial volume
following thrombolytic therapy.
Abstracts
685
Value of diastolic dysfunction as assessed by tissue Doppler
echocardiography in diagnosing ischemic heart disease in young male
patients with typical angina.
M. Uzun, O. Baysan, A. Kirilmaz, C. Koz, C. Sag, K. Erinc, H. Karaeren, C. Genc,
M. Ozkan, E. Demirtas. GATA, Cardiology, Ankara, Turkey
Background: Although the history and physical examination is the main part of
the examination, echocardiography plays a very important role in diagnosing heart
diseases. Tissue Doppler is becoming a routine part of the echo examinations.
Purpose: In this study, we aimed at ﬁnding out the role of tissue Doppler echocardiography in diagnosing ischemic heart disease in young male patients with typical
angina.
Material and methods: The study included 66 young male patients with typical
angina (age=42±9 years.). The patients with previously diagnosed other entities
that may inﬂuence tissue Doppler ﬁndings such as diabetes and hypertension were
excluded. In addition to the routine parameters, these parameters were also obtained from ﬁve consecutive beats: mitral E-peak velocity(E), mitral A peak velocity (A), annular E peak velocity (Em), annular A peak velocity (Am), annular peak
systolic velocity (Sm), isovolumetric contraction peak velocity (IVC), isovolumetric
relaxation peak velocity (IVR), mitral E/A and annular Em/Am. Tissue doppler parameters were obtained from lateral annulus on A4C view. Validity of each parameter was tested by receiver operating characteristics (ROC), comparisons between
ischemic and nonischemic patients were tested by Mann-Whitney U test. Statistical
signiﬁcance was set at 0,05.
Results: Only Em and Em/Am was signiﬁcantly different between ischemic and
nonischemic patients(p=0,027 and p=0,023), while E and E/A was at borderline
signiﬁcance (p=0,073 and p=0,055). None of the parameters showed a good ROC
analysis result as assessed by area under ROC curve. The results are summarized
on the table.
S83
687
Use of B-Blockers in the treatment of a soubgroup of patients with
Syndrome X.
C. Cotrim 1 , I. João 2 , M. Loureiro 2 , P. Cordeiro 2 , O. Simões 2 , J. Guardado 2 ,
M. Oliveira 2 , M. Carrageta 2 . 1 Hospital Garcia de Orta, Cardiology, Setúbal,
Portugal; 2 Cardiology, Almada, Portugal
Sens-90: cut-off value that has 90% sensitivity; Spec-90: cut-off value that has 90% speciﬁcity.
Introduction: The development of intraventricular gradients during dobutamine
stress echocardiography occurs frequently and is usually associated with the development of symptoms during pharmacologic stress. The development of intraventricular gradients during exercise stress echocardiography seldom occurs. In a
previous study we used exercise echocardiography (EE) to study a group of 32 patients (pts) with the Syndrome X. We detected the development of intraventricular
gradients in 11 pts of these pts - 73±31mmHg - and there was clear identiﬁcation
of systolic anterior motion of mitral valve in 7 pts.
Objective: The aim of our study was to evaluate B-blockers effectiveness in preventing the appearance of these gradients as well as in preventing the appearance
of angina, in pts with angina, positive exercise ECG testing, and no coronary artery
disease (CAD) on coronary arteriography.
Methods: We studied 10 pts, 6 men with ST segment depression of more than 1mm
for 80 msec in exercise ECG testing, normal echocardiogram – no left ventricular
hypertrophy –, no CAD on coronary arteriography and in which the previous EE
had shown the development of signiﬁcant intraventricular gradient. We repeated the
EE two hours after the administration of 20 mg of propranolol per os, using twodimensional echocardiography and continuous wave Doppler, before, during and
after exercise. Patients were prescribed 50mg of atenolol qd and were clinically
re-evaluated one month after the initiation of therapy.
Results: The intraventricular gradients during EE before propanolol administration
were 76±32mmHg. After propanolol administration 6 pts didn’t develop an intraventricular gradient, 3 pts showed a decrease in the intraventricular gradient and one
patient developed an intraventricular gradient similar to the one calculated in the ﬁrst
EE. In the clinical evaluation performed one month after, 7 pts reported signiﬁcant
improvement in angina symptoms.
Conclusions: 1. In patients described has having X Syndrome in which an intraventricular gradient was detected during exercise, propanolol administration per os
prevented the development of this gradient or decreased its degree signiﬁcantly. 2.
The administration of 50mg of atenolol per os qd for 30 days signiﬁcantly reduced
angina symptoms in these pts.
Conclusion: None of the parameters were excellent in discriminating the ishemic
ones from nonischemic ones, however there are some cut-off values that may promote the using or not using the further more sophisticated tests.
688
Transthoracic echocardiographic detection of coronary atherosclerosis.
Results (most signiﬁcant parameters)
Em (m/s)
Em/Am
E (m/s)
E/A
Sens-90
Spec-90
Area under ROC curve
11
0,85
42
0,65
19,5
1,78
95
2,1
0,338
0,332
0,368
0,294
686
New perspective in Syndrome X.
C. Cotrim 1 , I. João 2 , P. Cordeiro 2 , J. Guardado 3 , M. Loureiro 2 , O. Simões 3 ,
M. Oliveira 2 , M. Carrageta 4 . 1 Hospital Garcia de Orta, Cardiology, Setúbal,
Portugal; 2 Cardiology, Almada, Portugal; 3 Cardiology, Almada, Portugal;
4
Cardiology, Almada, Portugal
Peak intraventricular gradients (IVG) during dobutamine stress echocardiography
are a common ﬁnding and they are usually associated with symptoms during the
exam. During exercise IVG have been rarely reported and only develop in a few
patients usualy with left ventricular hypertrophy. In a young male, with a positive
teadmill test, a structural normal heart, normal coronary angiography, we perform
an exercise stress echocardiography and during the exam we detect a signiﬁcant
IVG.
Objective: Assess the ocurrence of IVG during exercise echocardiography in patients with changes sugestive of ischaemia in a previous exercise test and normal
coronary angiogram.
Methods: 32 patients, 17 males, mean age 47±10 years (range: 23-64), with documented ST depression in a treadmill exercise electrocardiogram (at least 0,1 mV;
0,08 s; horizontal or downsloping, in two consecutive leads), and a normal coronary
angiogram and without left ventricular hypertrophy on echocardiogram. All patients
were submitted to treadmill exercise echocardiography, including Doppler study during exercise. A signiﬁcant IVG was deﬁned as a midventricular gradient, late peaking, with an increment in velocity of at least 1 m/s from baseline.
Results: In 3 patients we found segmental wall motion abnormalities at peak exercise, 11 patients (34%) developed signiﬁcant intraventricular gradients: mean
73±31mmHg (range 38-140) that were absent at baseline. The electrocardiographic
changes were reproduced in all patients during the exercise echocardiogram.
Conclusions: IVG were present in a signiﬁcant number of the patients studied. We
suggest that a causal association of IVG and ST segment changes during exercise
could exist in this particular group of patients.
P. Sonecki, J. Gabryel, Z. Lebek, J.J. Gabryel, L. Popielska-Lebek, P. Zolcinski,
S. Foremny, P. Kardaszewicz. St Mary Hospiatal, Dept. of Cardiology,
Czestochowa, Poland
It is well known that transthoracic echocardiography (TTE) allows for coronary artery
assessment in signiﬁcant number of patients. The aim of this study was to use
TTE as a screening method to detect coronary atherosclerosis during routine echocardiography. One hundred patients scheduled for coronary angiography (used as
standard) were examined with ultrasonic transducer with a frequency 2.5MHz. Second harmonic mode in B-mode and fundamental mode for Doppler examination
was used. A modiﬁed short axis view was utilized to identify blood ﬂow in left main
coronary artery and proximal part of left anterior descending artery and circumﬂex
artery. Diagnostic quality of visualization was obtained in 90 patients (90%).
In coronary angiography obstructive coronary artery disease (i.e. at least 1 vessel
with 50% obstruction) was observed in 41 patients. In echocardiography, coronary
stenosis was diagnosed when maximal ﬂow velocity of at least 1.5 m/s was found.
We tested this method as a screening during routine echocardiography, so we were
looking for ﬂow jet no longer than 3 min. In such conditions, speciﬁcity of transthoracic echocardiography for stenosis detection was high -89%, but sensitivity was
lower, only 50%. These results indicate, that ﬁnding of high velocity jet of blood ﬂow
in coronary arteries could be a simple and useful method, indicating the presence of
ﬂow limiting narrowing, but it should not be used to exclude coronary artery disease.
Conclusions: Doppler examination of the proximal left coronary artery during routine transthoracic echocardiography could be a clinically valuable tool in identiﬁcation of coronary atherosclerosis.
Eur J Echocardiography Abstracts Supplement, December 2003
S84
Abstracts
689
Contrast-enhanced magnetic resonance imaging versus thallium
scintigraphy in the detection of myocardial viability.
691
Does coronary artery bypass grafting correct ischemic mitral
regurgitation ?
M. Solar 1 , J. Zizka 1 , L. Klzo 1 , J. Dolezal 1 , J. Vizda 1 , J. Tintera 2 . 1 Hradec
Králové, Czech Republic; 2 Prague, Czech Republic
J. Kochanowski, P. Scislo, D. Kosior, S. Stawicki, G. Opolski. The Warsaw Medical
University, Dept of Cardiology, Warsaw, Poland
Purpose: Contrast-enhanced magnetic resonance imaging (MR) is a new method
in the assessment of myocardial viability. The aim of this study was to compare it to
SPECT-Thallium scintigraphy.
Methods: The the patients with documented coronary artery disease and impaired
left ventricular systolic function deﬁned by ejection fraction less than 45% were enroled. Myocardial viability study was performed both by SPECT using 201Thallium
and contrast-enhanced magnetic resonance imaging. SPECT of the myocardium
was performed four hours after 201Thallium chloride administration. Cardiac MR
imaging was done 20-30 minutes after administration of gadolinium contrast agent
(0.2 mmol/kg). Short axis views of the myocardium were divided into segments. In
each segment myocardial viability was scored semiquantitatively according to the
201Thallium activity (SPECT) and the relative amount of contrast enhanced tissue
(MR). The results of viability assessment were compared in corresponding segments.
Results: 25 patients were included. The mean ejection fraction was 35.2%. The
total number of myocardial segments evaluated was 907. Myocardial viability assessed by SPECT was normal in 52.9%, impaired in 13,9% and absent in 26.8% of
segments evaluated. On MR viability study there were 59.7% of segments with no
contrast enhancment showing no irreversible injury, 37.2% of segments contained
both contrast enhanced and viable tissue and in 3.2% there was a predominance of
contrast-enhanced irreversibly changed tissue.
Comparing the two methods the results of viability assessment corresponded in
51.3% of segments. 42.7% showing no irreversible injury, 5.3% displaying impaired
viability and 3.2% with prevailing irreversible injury. In 23.7% of segments that were
assessed as non-viable by Thallium scintigraphy there were signs of viability using
contrast-enhanced MR study and almost one third of these segments showed no
contrast-enhanced tissue. In 16.5% of segments that displayed normal Thallium
activity there were signs of irreversible injury using MR. On the other hand in 8.6%
of segments with decreased thallium activity there was no contrast enhancement
on MR study.
Conclusion: According the results of our study it seems possible that in comparison
to Thallium scintigraphy the contrast-enhanced MR imaging can more accurately
diagnose irreversible myocardial injury and better detect viable myocardium. The
latter ﬁnding may be important in selecting the eligible candidates for myocardial
revascularisation.
The aim of the study was to assess coronary artery bypass grafting (CABG) impact
on ischemic mitral regurgitation (IMR) observed before surgery.
Materials and methods: We analyze consecutive 120 patients (pts) (63±12 years
old, men 78, women 42) with history of Q-wave myocardial infarction (MI) during
last 6 months, qualiﬁed to CABG. In transthoracic echocardiography (TTE) before
CABG we found no MR in 38 pts (group I), small MR in 46 pts (group II), moderate
MR in 29 pts (group III) and severe MR in 7 pts (group IV). Two weeks after CABG
TTE was done for MR evaluation. TTE was made using Philips Sonos 5500 and
Hewlett-Packard 2500 and recorded on magnetooptic disc and SVHS tape for later
assessment by 2 independent cardiologists.
At 7 pts with severe IMR CABG with mitral plasty was done, others 113 pts has
CABG alone.
Results: Table 1. Analysis of IMR after CABG
690
Free-Breathing, three-dimensional, bright blood coronary artery magnetic
resonance angiography – Comparison of sequences.
S. Pujadas, O. Weber, A.J. Martin, C.H.B. Higgins. University of California San
Francisco, Radiology, San Francisco, United States of America
Purpose: To compare six free-breathing, three-dimensional, magnetizationprepared magnetic resonance angiography sequences with respect to their suitability to depict the coronary arteries.
Materials and Methods: Six bright blood sequences were evaluated: Cartesian
turbo ﬁeld echo (C-TFE); radial turbo ﬁeld echo (R-TFE); spiral turbo ﬁeld echo
(S-TFE); spiral fast ﬁeld echo (S-FFE); Cartesian balanced turbo ﬁeld echo (CbTFE); and radial balanced turbo ﬁeld echo (R-bTFE). The right coronary artery
was imaged in ten healthy volunteers using all six sequences in randomized order.
Images were evaluated with respect to signal to noise ratio (SNR), contrast to noise
ratio (CNR), visible vessel length, vessel edge sharpness, and vessel diameter, by
two independent observers. A repeated-measure analysis of variance with TukeyKramer post-test was performed.
Results: C-bTFE depicted the coronary artery over the longest distance with high
vessel sharpness, good SNR, and excellent background suppression. C-TFE provided similar SNR and CNR, but more vessel blurring and visualized the vessels
over a shorter length. S-FFE provided highest values of SNR and CNR, but reduced visible vessel length and sharpness. S-TFE was the fastest sequence used
but showed reduced SNR and CNR. The radial approaches resulted in images with
the highest vessel sharpness, excellent background suppression, and fair visible
vessel length, but an increased noise level.
Conclusion: C-bTFE provided visualization of the longest length of the coronary
artery, whereas S-FFE provided best SNR and CNR in the proximal vessel segment.
Echo data of pts with IMR before CABG
n
MI antero-lateral
MI inferior
LA (cm)
LVDD (cm)
EF (%)
WMSI
No change
Decreased IMR
Increased IMR
p
8
25
23
3.9±0.4
5.5±0.7
41±10
1.8±0.5
2
17
5
4.0±0.4
5.4±0.5
40±11
1.8±0.5
2
6
6
3.9±0.4
5.5±0.7
39±9
1.9±0,5
NS
NS
NS
NS
In group I - there were no change in 27(71%) pts, 0 pts with decreased IMR and
11 pts with increased IMR. In group 2 we found no change of IMR in 29(63%) pts,
7 pts had decreased IMR and 10 pts increased. In group III there were no change
of IMR in 19(65%) pts, 8 pts has decreased IMR and 2 pts increased. In group IV
there were no IMR change in 0 pts, decreased IMR in 7 pts and increased in 0 pts.
Conclusions: 1. CABG alone has no signiﬁcant impact on frequency and severity
of mild and moderate IMR
2. In group with decreased IMR were mainly pts with history of antero-lateral MI but
the groups were similar in aspect of other echo parameters (LA, LVDD, EF, WMSI)
before CABG.
692
Closed chest assessment of coronary anastomoses with a 13 MHz
epicardial mini-transducer.
R.P.J. Budde, T.C. Dessing, R. Meijer, P.F.A. Bakker, P.F. Grundeman. UMC, Heart
Lung Center, Utrecht, Netherlands
Objective: Epicardial ultrasound is under renewed interest for intra-operative quality
assessment of anastomoses in CABG. The capacity of a 13 MHz epicardial minitransducer to visualize patent and erroneously constructed coronary anastomoses,
in open and closed chest condition, was evaluated.
Methods: Both ITA’s were grafted to the LAD in 8 pigs (71-78 Kg), with anastomoses constructed to be fully patent (n=8) or contain an intended suture cross-over
construction error (n=8). After chest closure and stabilization with a novel EndoOctopus, the mini-transducer (15 x 6 x 9 mm, Aloka, Japan) was introduced through
a port (diameter 15mm) and manipulated by the da Vinci telemanipulation system (real-time scan image displayed on master console) to obtain still longitudinal
and transverse images and transverse sweeps using B-Mode and Doppler imaging. Subsequently, the chest was opened and scanning repeated manually. Anastomoses were macroscopically inspected post mortem.
Results: All anastomoses were visualized in both open and closed chest condition.
One control anastomosis revealed an irregularity at the level of the anastomotic
oriﬁce and outﬂow corner. Endoscopically measured dimensions (mm) of the anastomotic oriﬁce, outﬂow corner and LAD distal to the anastomosis were 2.9 ± .9
(mean ± SD), 1.8 ± .5 and 1.9 ± .3 for control anastomoses and 2.5 ± .2, 1.7 ±
.4 and 1.8 ± .3 for erroneous anastomoses respectively. For manual scanning this
was 3.0 ± .9, 1.6 ± .2 and 1.6 ± .2 (patent) and 2.9 ± .3, 1.8 ± .7 and 2.0 ± .7
(erroneous). Scanning images corresponded with macroscopic inspection.
Cross-over anastomosis, longitudinal
Conclusions: The 13 MHz ultrasound mini-transducer enabled both open and
closed chest visualization and assessment of patent and erroneously constructed
anastomoses.
Eur J Echocardiography Abstracts Supplement, December 2003
Abstracts
S85
693
Ventricular aneurysm complicating myocardial infarction with patent
coronary arteries.
695
Comparison of peak treadmill exercise echocardiography and peak
supine bicycle exercise echocardiography for the detection of ischaemia.
R. Apriotesei 1 , C. Ginghina 2 , M. Marinescu 3 , D. Dragomir 4 , E. Apetrei 2 . 1 Fundeni
Clinical Institute, Anaesthesiology - Intensive Care, Bucharest, Romania; 2 C C
Iliescu Cardiovascular Institute, Cardiology, Bucharest, Romania; 3 Floreasca
Emergency Hospital, Cardiology, Bucharest, Romania; 4 Prof. Dr. D. Gerota Clinical
Hospital, Cardiology, Bucharest, Romania
I. Garrido, J. Peteiro, L. Monserrat, R. Perez, M. Piñeiro, A. Castro-Beiras. juan
canalejo hospital, Cardiology, A Coruña, Spain
Background: In a minority of patients, the coronary angiograms performed in the
early post-infarction period have shown either normal coronary arteries or nonobstructive coronary lesions.
Purpose: To evaluate the main characteristics of the patient with acute myocardial
infarction (AMI) and patent coronary arteries in terms of clinical ﬁndings and postinfarction events.
Methods: A retrospective study in Prof. Dr. C. C. Iliescu Institute of Cardiovascular Diseases, Bucharest, Romania, including 124 patients admitted with AMI, which
were subjected to a coronary angiogram within the ﬁrst 30 days post-infarction. The
study group (S), including 62 patients with patent coronary arteries, was compared
to an age- and sex-matched control group (C) consisting of 62 patients with signiﬁcant coronary lesions. The mean follow-up was 6 months (1-11 months).
Results: During the post-infarction period, the echocardiography identiﬁed mechanical complications in 12 patients (19.4%) of the S group and in 16 patients (25.8%)
of the C group, p=NS. There were 11 (17.7%) ventricular aneurysms and one acute
mitral regurgitation in S group and 14 (22.6%) ventricular aneurysms and 2 (3.2%)
new installed mitral regurgitation in C group. The average age of the patients with
patent coronary arteries and ventricular aneurysm was 40±12 yr. vs. 38±8 yr. in the
patients with ventricular aneurysm and signiﬁcant stenoses and vs. 37±9 yr. in the
whole S group. Among the patients with ventricular aneurysm, 6 (54.5%) of those
in S group and 12 (85.7%) of those in C group were smokers and 4 (36.3%) in S
group and 12 (85.7%) in C group had dyslipidemia.
The association of other adverse events among the patients with patent coronary arteries and ventricular aneurysm vs. the rest of the study group was: 5 (45.4%) intraventricular thrombi vs. 3 (5.8%); 6 (54.5%) arrhythmias vs 12 (23.5%); 3 (27.2%) peripheral emboli vs. 2 (3.9%); 3 (27.2%) haemodynamic disturbances vs. 8 (15.7%);
4 (36.3%) ischaemic events vs. 20 (40.3%).
Conclusions: The incidence of the mechanical complications in patients with AMI
and patent coronary arteries was comparable with the one in the group with
signiﬁcant stenoses. The subgroup with patent coronary arteries and ventricular aneurysm had a higher average age than the group with signiﬁcant stenoses
and ventricular aneurysm and also than the whole study group. The ventricular
aneurysm was associated with a higher incidence of other complications, outlining
a subgroup at important risk after the AMI with patent coronary arteries.
694
Left ventricular long axis function during dobutamine stress
differentiates ischaemic from non-ischaemic cardiomyopathy with greater
sensitivity than standard wall motion analysis.
A. Duncan, C. Porter, D. Gibson, M. Henein. The Royal Brompton Hospital,
Echocardiography Department, London, United Kingdom
Background:
Regional wall motion abnormalities do not reliably distinguish ischaemic from nonischaemic cardiomyopathy. Changes in wall motion score index (WMSI) during
dobutamine stress echocardiography can identify coronary artery disease (CAD)
in dilated cardiomyopathy (DCM). However, the technique may be inconclusive in
patients with co-existing left bundle branch block (LBBB). Left ventricular (LV) long
axis function is sensitive to ischaemia and conduction abnormalities.
Aim: To compare LV long axis function with standard WMSI for the detection of CAD
in patients with DCM, with or without LBBB.
Methods: 73 patients with DCM, 48 with CAD (16 with LBBB), and 25 without CAD
(10 LBBB) were studied during dobutamine stress echocardiography. LV long axis
M-mode and tissue Doppler echograms at the lateral, septal, and posterior LV walls
were obtained. Average long axis systolic amplitude (SA) and early diastolic velocity
(EDvel) were assessed at rest and peak stress, and compared with changes in
WMSI.
Results: Failure to increase SA by 2mm or EDvel by 1.1cm/s were the best discriminators for CAD (SA: sensitivity 85%, speciﬁcity 86%; EDvel: sensitivity 71%, speciﬁcity 94%). Both had greater predictive accuracy than WMSI (sensitivity 67%, speciﬁcity 76%, p<0.001). The predictive accuracy of changes in septal long axis function
alone was similar to those of average long axis function (SA cut-off = 1.5mm, EDvel
cut-off = 1.5cm/s). In patients with LBBB, failure of septal SA to increase by 1.5mm
during stress identiﬁed CAD with sensitivity of 94% and speciﬁcity 100%, which
was signiﬁcantly greater than the predictive accuracy of either changes in septal
EDvel (sensitivity 67% speciﬁcity 78%, p<0.01) or overall WMSI (sensitivity 69%,
speciﬁcity 50%, p<0.001).
Conclusions: Adding long axis behaviour to the conventional wall motion protocol
should increase the predictive accuracy of dobutamine stress echocardiography in
identifying coronary artery disease in dilated cardiomyopathy, even in patients with
left bundle branch block.
Although treadmill (Tr) is the most frequently used modality for exercise echocardiography (EE), images are usually acquired during the immediate postexercise period
as opposed to supine bicycle (Bc) EE. The aim of this study was to compare the
value of Tr-EE obtaining images at peak stress versus peak Bc-EE for the detection of ischemia in patients (pts) with known or suspected coronary artery disease
(CAD).
Methods: We performed peak Tr- and peak Bc-EE (Bruce protocol) in a ramdom
order within 10 days (6±2) in 38 patients (mean age 61±9 years) with known or
suspected CAD who underwent or were likely to undergone coronary angiography
(CA) within 6 weeks. CA was performed in 31 pts showing CAD (>49% luminal
narrowing) in 25 pts (multivessel-CAD in 12 pts and 1-vessel CAD in 13). Each peak
image with both stress modalities was scored from 0 to 6 points according to the
number of clearly visualized endocardial segment borders and systolic excursion by
view (4-, and 2-chamber apical and short-, and long-axis parastenal views).
Results: The duration of the test was longer with Bc (11±5 min. vs. 8±3 min,
p<0.001). Peak heart rate (HR) was higher with Tr (142±19 bpm vs. 123±20 bpm,
p<0.001), whereas blood pressure (BP) was higher with Bc (209±33 mmHg vs.
170±29 mmHg, p<0.001), resulting in similar product HR x BP x 1000 (26±6 with
Bc vs. 24±6 with Tr, p=NS). ST-segment depression and peak wall motion score
index were greater with Tr (1.4±1.3 mm vs. 1.0±1.4 mm, and 1.5±0.4 vs. 1.4±0.4,
p<0.05 and p<0.01, respectively), and peak LVEF lower with Tr (54±12 vs. 57±12,
p<0.01). The score of views was similar with Tr and Bc (4-ch apical: 5.8±0.7 vs.
5.8±0.5; 2-ch apical: 5.7±0.8 vs. 5.9±0.5; long-axis: 5.1±1.0 vs. 5.4±0.9; shortaxis: 4.4±1.9 vs. 4.5±1.9). CAD was detected in 24 pts with T(Sensitivity 96%) and
in 22 pts with Bc (Sensitivity 88%). Speciﬁcity was 100% with Bc, whereas Tr obtained false positive results in 3 pts without CAD (Speciﬁcity 50%, p=NS). Sensitivity
and speciﬁcity for the prediction of multivessel CAD were 83% and 68% with Tr, and
58% and 74% with Bc, respectively (p=NS).
Conclusion: Although the product heart rate x blood pressure is similar with supine
Bc and Tr, ischemia is more pronounced with Tr, suggesting that peak treadmill EE
is more sensitive for the detection of CAD.
696
Value of ﬁrst-pass and delayed contrast-enhancement by magnetic
resonance imaging for the prediction of left ventricular wall motion
recovery after reperfused acute myocardial infarction.
I. Garrido 1 , J. Peteiro 1 , R. Soler 2 , E. Rodriguez 2 , L. Monserrat 1 ,
A. Castro-Beiras 1 . 1 Juan Canalejo Hospital, Cardiology, A Coruña, Spain; 2 Juan
Canalejo Hospital, Radiology, A Coruña, Spain
Magnetic resonance imaging (MRI) with contrast administration may evaluate microvascular injury and ﬁbrosis. We sought to determine whether ﬁrst-pass (FP) and
delayed contrast-enhancement (DCE) RMI predicts recovery of LV function after
acute myocardial infarction (AMI).
Methods: We included 28 patients (pts) (mean age 55±12 years) with AMI (anterior
AMI in 20) submitted to percutaneous transluminal coronary angioplasty with stent
implantation. FP and DCE with gadolinium were performed within 4 weeks after
AMI. 2-dimensional echocardiography (2-DE) was performed within 7 days after
AMI and at follow-up (9±1 week) to measure wall motion score index (WMSI). A
17-segment LV model was used for perfusion whereas a 16-segment model was
used for 2-DE.
Results: Follow-up 2-DE was available in 27 pts that were subdivided in 2 groups:
Recovery (RG) (n=17) and no recovery group (NRG) (n=10). Peak creatine phosphokinase was higher in the NRG (p<0.05). No signiﬁcant differences in other
clinical, angiographic and 2-DE variables were found between groups at baseline.
Global and regional WMSI improved from 1.3±0.3 to 1.1±0.2 (p<0.001) and from
1.5±0.5 to 1.2±0.3 (p<0.001) in the RG, and impaired from 1.4±0.2 to 1.5±0.2
(p<0.05) and from 1.7±0.4 to 1.9±0.3 (p<0.05) in the NRG. The number of
segments with FP defect was not different in both groups (2.2±3.0 vs. 1.6±2.6)
whereas the number of segments with DCE was greater in the NRG (4.2±2.2 vs.
1.9±2.6, p<0.05). The transmural extension of the defect was 53±36% in the NRG
and 26±35% in the RG (p=NS). DCE affecting less than 2 segments was the more
accurate MRI index to predict LV recovery with positive predictive value of 91% and
negative predictive value of 60% (p<0.05).
Conclusion: DCE by MRI has high positive predictive value for recovery of LV function after reperfused AMI.
Eur J Echocardiography Abstracts Supplement, December 2003
S86
Abstracts
697
Changes in peak myocardial power and its timing immediately after
CABG.
X. Jin 1 , J.R. Pepper 2 . 1 John Radcliffe Hospital, Surgical Echo Lab, Cardiac
Surgery, Oxford, United Kingdom; 2 Imperial College & Royal Brompton Hosp, Dept
Cardiac Surgery, London, United Kingdom
Background: In clinical setting, reliable and objective assessment of myocardial
contraction after CABG remains a challenge.
This study was aimed to deﬁne the pattern changes in the intensity and timing of
myocardial contraction early after CABG.
Methods: We studied 20 patients (15 unstable anginas and 5 poor LVs with
hibernating myocardium) with mean age 63±7 yr, and 14 were males. Transoesophageal Echo and high ﬁdelity LV pressures recordings was performed immediately before cardiopulmonary bypass and 9 hours after CABG operation. Transverse LV cavity dimension and wall thickness were derived from mid-cavity M-mode
echocardiograms along with LV pressure by digitising. Cardiac index and LV stroke
volume index was measured by Swan-Ganz pulmonary catheter. The magnitude
and timing (with respect to ECG’s q wave) of regional peak Vcf, peak systolic wall
stress and peak myocardial power were determined. LV mean ejection rate and
mean global power were also measured.
Results: The mean graft was 3.2±0.7, and the aortic cross clamp time was 61±22
min. 9 hours after operation, heart rate and LV ﬁlling pressure did not change.
However, LV ejection time was shortened (231±31vs 286±41,msec), while cardiac index (2.6±0.5 vs 1.9±0.5, l/min/m2 ), LV stroke volume index (28±7 vs 23±9,
ml/m2 ), LV mean ejection rate (122±25 vs 79±23, ml/sec/m2 ), LV mean power output (1.35±0.38 vs 0.91±0.33, W/m2 ) and LV peak +dP/dt (1126±253 vs 974±221,
mmHg/sec) all increased signiﬁcantly, all p<0.01. In regional contraction, there was
also a signiﬁcant increase in peak Vcf (1.9±0.6 vs 1.5±0.6, cir/sec), peak myocardial power (30±11 vs 22±10, mW/cm3 ) and a signiﬁcant shortening of time from q
wave to these peaks (178±40 vs 214±54, msec; 167±33 vs 194±41, msec, both
p<0.01). LV peak systolic wall stress did not change, but its peak was also occurred
earlier (149±30 vs 189±46, msec, p<0.01)
Conclusion: Early after successful CABG, there is a clear pattern change in LV
contraction. This is manifested in both the rate and the timing of peak contraction.
Tracking both aspects during CABG operation may provide a more robust physiological judgement in clinical setting.
698
Coronary ﬂow in pre and post immediate by echo transesophageal with
power Doppler in myocardial revascularization surgery.
J. Tress 1 , M.R. Amar 2 , R.C. Victer 3 , J.C. Jazbick 2 , J. Coutinho 2 , C. Tagliaferri 2 ,
C.M. Barros 4 , L.A. Vieira 5 . 1 Rio de Janeiro, Brazil; 2 Hospital de Clínicas de
Niterói, Cardiac Surgery, Rio de Janeiro, Brazil; 3 Hospital De Clinicas De Niteroi,
Echocardiographic Laboratories, Rio De Janeiro, Brazil; 4 Hospital de Clínicas de
Niterói, Cardiology, Rio de Janeiro, Brazil; 5 Hospital de Clínicas de Niterói,
Perfusionist, Rio de Janeiro, Brazil
Objective: to demonstrate the type and standard of coronary arterial ﬂow evaluated by echo transesophageal (ETE) in intra-operation pre-revascularization and
immediately after myocardial revascularization surgery (MR).
Serial work in literature has presented analysis of coronary ﬂow by ETE mainly with
the left anterior descending artery (LDA) and the variation of the ﬂow in obstructive
coronary arterial disease related to proximal LDA with an increase in speed of diastolic ﬂow, as well as the alteration and normalization of ﬂow post angioplast and/or
STENT placement, but, not any modiﬁcation in the standard ﬂow after MR with the
implantation of mammary or radial artery bridges or even magna safena vein.
Methods: we evaluated 140 consecutive myocardial revascularization surgeries involving the implantation of mammary or radial artery bridges or even magna safena
vein in LDA, left circumﬂex artery and/or right coronary artery (ventricular or posterior descending) on 62 women and 78 men between 38 and 80, weighing between
37 and 106 kilos and 145 to 190 cm tall.
Results: we obtained adequate analysis of LDA ﬂow both pre and post immediate.
We observed a modiﬁcation in standard of ﬂow with elevated diastole and characteristically anterograde pre revascularization, for normal speed of ﬂow in diastole
and retrograde characteristics in LDA territory, of circumﬂex artery and right coronary in immediate post revascularization. In 15% of patients we even had a direct
intra-operative inﬂuence on the requested revision of bridges not modiﬁed or initial
improvement and return to the pre-op standard of ﬂow with excellent response described by the surgery team and consequent normalization of the retrograde ﬂow
standard.
Conclusion: We deduced that the presence of the intra-operative ETE in myocardial revascularization surgery is unique and vital as it allows for adequate and
speedy analysis of the normalization and modiﬁcation of the standard of coronary
ﬂow, as well as indicates problems with the implantation of coronary bridges in decisive terms for post-operative excellence.
Eur J Echocardiography Abstracts Supplement, December 2003
STRESS ECHOCARDIOGRAPHY
700
Coronary acute syndrome stratiﬁcation: additional prognostic value of
the dobutamine stress echocardiography to clinical variates.
G. Rosas Cervantes, M. Pombo Jiménez, E. González Cocina, F. Ruiz Mateas.
Hospital Costa del Sol, Cardiologia, Marbella, Spain
Stress echocardiography (SE) bring prognostic information in non selected patients
with coronary acute syndrome (CAS).
The aim of this study is to know the additional prognostic value to clinical variates
in patients (p) with CAS, selected for a dobutamine stress test echocardiography
(DSE) because an uninterpretable EKG ad or a non conclusive excercise test.
Methods: 90 consecutive patients (56 m,age: 64±9,7years) with CAS in wich a
DSE was indicated for prognostic stratiﬁcation following 14 months (1-30).
Incidence of death, myocardial infarction (MI) and recurrence of angina like combinates events was registered.
Clinical risk stratiﬁcation was made by score TIMI.
Results: During follow-up were 20 p with events (2 death, 2 non fatal MI and 16 recurrence of angina).20p had coronary revascularization (and were censored).In 33
p (36%) the result of DSE was positive for ischemia and in 57 (64%) was negative.
The score TIMI wa 3.22±1.6. From p with DSE positive, 80% had events vs 20% of
those with a negative DSE, (p:0.0001). Only ischemia in DSE was the independent
prognostic predictor in multivariate analysis (table)
Univariate
RR
CI (95%)
P
DSE (+)
Score TIMI
Multivariate
DSE (+)
ScoreTIMI
3.9
1.9
RR
3
1.5
(1.4-10.8)
(1.01-3.7)
CI(95%)
(1.1-9)
(0.7-3)
0.008
0.04
P
0.04
0.2 ns
Conclutions: Patients with coronary acute síndrome and risck TIMI low to moderate dobutamine stress echocardiography bring adittional prognostic information to
clinical variates, identiﬁng subgroups of low and high risk.
701
Stress-echocardiography: additional prognostic value to TIMI risck score
in unestable angina or acute myocardial infarction without st elevation
stratiﬁcation.
G. Rosas Cervantes, M. Pombo Jiménez, F. Ruiz Mateas, E. González Cocina.
Hospital Costa del Sol, Cardiologia, Marbella, Spain
Stress echocardiography (SE) bring prognostic information in non selected patients
(p) with coronary acute syndrome.
The Aim of this study is to know the prognostic value of SE in p with unestable
angina/acute myocardial infarction without st elevation (UA/AMINST) selected for
a SE, because an uninterpretable EKG and/or a non conclusive excercise test
(ACC/AHA Task-Force indication class I-IIa) in relation to clinical variates.
Methods: 101consecutive p (47 m, Age:63.9±8.4years) with UA/AMINST in wich a
pharmacologic SE was indicated (53 dobutamine and 48 dypiridamole) for prognostic stratiﬁcation following 14 months (1-30), incidence of death, myocardial infarction
(MI) and angina like combinates events were registered.
Risck stratiﬁcation by clinical criteria, was made with the TIMI risck score.
Statistical methods:T student and Chi Square, uni and multivariate Cox proporcional
Hazards models analysis and Kapplan-Meier curves.
Results: During follow-up were 24 p with events (one death, 1 non fatal MI and 22
recurrence of angina). In 27 p (27%) the result in the SE was positive for ischemia
and in 74 (73%) was negative.From p with positive SE, 57% had events vs 18% of p
with negative SE (p: 0.001).From p with positive SE, 83% had coronary desease vs
17% with normal coronary arteries. Score TIMI was 2.68±1.2, and signiﬁcativally
higher (3.57±1.3 vs 2.47±1.4, p: 0.004) in p with complications. In Kapplan-Meier
curves 80% of patients with a negative SE were free from events vs 20% of those p
with a positive SE (p:0.002).
Ischemia in SE was the independent prognostic predictor in multivariate analysis,
[RR:6 (2.29-16) p:0.0003].
Conclutions: In patients with unestable angina or AMI without ST elevation and low
TIMI risck, stress echocardiography bring additional prognostic information to clinical variates, identiﬁng hihg and low risck subgroups.
Abstracts
702
Dypiridamole-echocardiography: additional prognostic value to score
TIMI in short and long term coronary acute syndrome stratiﬁcation.
G. Rosas Cervantes, F. Ruiz Mateas, M. Pombo Jiménez, L. Iñigo García. Hospital
Costa del Sol, Cardiologia, Marbella, Spain
Stress echocardiography (SE) bring prognostic information in non selected patients
(p) with coronary acute syndrome (CAS).
The aim of this study is to know the short and long term prognostic value of the
dypiridamole SE (DypSE), in p with coronary acute syndrome selected for this
test,with class I-IIa indication ACC/AHA task-force and the additional prognostic
value in relation to clinical variates stratiﬁed by score TIMI.
Methods: 60 consecutive p (28 m, age:65.2±9.11years) with CAS in wich a DypSE
was indicated for prognostic stratiﬁcation, following 14 months (1-30), incidence of
angina myocardial infarction (MI) and death like combinates events were registered.
Results: During follow-up were 15 p with events (12 recurrence of angina, one
death and 2 non fatal MI). In 16 p (26.7%) the result of DypSE was positive for
ischemia and in 44p (73.3%) negative.TIMI score was 2.8±1.2, it was signiﬁcativally
higher in group with events (3.8± 0.9 vs 2.7±1.3, p: 0.005).
From p with positive DypSE (44%) had events vs 12% of p with negative DypSE,
(p<0.003) and 90% of p with negative DypSE has been free from events in KapplanMeier curves.
From p with positive DypSE,90% have coronary desease vs 10% de pacientes with
normal coronary arteries, P: 0.001, Pearson correlation, r:0.8.
Ischemia in DypSE was signiﬁcativally associated with incidence of events in univariate analysis:RR= 5.7 (1.6-19.6) p:0.006, RR TIMI: 1.4 (0.6-3.18) p:0.4.
Conclutions:
1) Patients with coronary acute syndrome and low score TIMI, dypiridamole stress
echocardiography bring additional prognostic information to clinical variates, identiﬁng high and low risck subgroups.
2) The risk associated to DypSE result has the prognostic value at short and
longterm.
703
Intergrated evaluation of brain natriuretic peptide and cytocine changes
induced by dobutamine stress echo: implications for evolution of
ischaemic heart failure.
G. Athanassopoulos 1 , G. Hatzigeorgiou 2 , D. Degiannis 2 , I. Ekonomides 3 ,
M. Marinou 2 , G. Karatasakis 2 , J. Lekakis 3 , D.V. Cokkinos 2 . 1 Onassis Cardiac
Surgery Center, Cardiology Dept, Athens, Greece; 2 Onassis Cardiac Surgery
Center, Cardiology Dept., Athens, Greece; 3 Alexandra State Hosp, Therapeutics
Dep, Athens, Greece
Introduction: Interleukin 6 (IL6) mediates the ischemia-reperfusion myocardial injury and is elevated in acute coronary syndromes. BNP is produced by the ventricles
due to increased wall stress and is a marker of left ventricular dysfunction.
Aim of the study was to assess changes of these parameters during Dobutamine
Stress Echo (DSE) and the prognostic implications of their intergrated evaluation for
the prediction of the evolution of ischemic heart failure.
Methods: We studied 55 consecutive patients (pts) with stable coronary artery disease (6 women, age 60±9, ejection fraction 40±12, 22 with previous myocardial
infarction). The IL6 was measured at rest (R), peak (P) and during recovery (Rec),
15min post DSE. BNP was estimated at R and Rec.
A 16 segments model was used for DSE analysis.
During follow up (f-up) of 67±12 (range 22-78) months, 19 pts had cardiac events
(CE) (8 deaths, 11 decompensation to NYHA class III-IV).
Results: Pts who died had greater BNP (R) (3553±25 vs 1981±30, p<0.05) but
similar IL6 (P) compared with pts having uneventful f-up (N). Group CE compared
with N had differences on EF (32±11 vs 44±10, p<0.0001), score (R) (30±8
vs 21±6, p<0.001), IL6 (P) (4.2±4.3 vs 2±1.4, p=0.02) and a trend in BNP (R)
(291±242 vs 198±130, p=0.08)
For prediction of CE, ROC analysis showed the following cut off points and respective sensitivity/speciﬁcity: EF=32%: 0.63/0.90, Score (R)=27: 0.58/0.87, BNP
(R)=230: 0.42/0.77, IL6 (P)= 2.75: 0.50/0.86.
In stepwise logistic regression analysis (SLRA) for prediction of CE including EF,
score(R), IL6(P)>2.75, BNP>230 parameters and DSE ourcome, then only IL6 (P)
>2.75 had independent contribution (exp(b)=0.0754, p=0.045).
In SLRA for prediction of CE including DSE outcome, BNP>230 and IL6 >2.75,
then DSE outcome was not selected in the model(exp(b)=3.5 and 0.11 for BNP and
IL6(P) respectively, p<0.01).
Pts with a positive DSE could be further stratiﬁed for CE by IL6 (P) >2.75 (KaplanMeier log rank p=0.052)
Pts with a negative DSE and EF> 30% could also be further stratiﬁed for CE by IL6
(P) >2.75 (Kaplan-Meier log rank p=0.03).
Among pts interrogated for viability, those with presence of viability had a worse
prognosis in the presence of a BNP baseline value > 230 (Kaplan-Meier log rank
p=0.027).
Conclusions: Intergrated evaluation of cytokines and BNP both contribute for the
evaluation of evolving ischemic heart failure. IL-6 or BNP contribute to stratiﬁcation
incrementaly to functional changes by DSE.
S87
704
Long-term prognostic value of pacing stress echocardiography
compared with dipyridamole Tl201 computed tomography in patients with
permanent pacemaker and known or suspected coronary artery disease.
S. Shimoni, S. Goland, S. Livschitz, G. Lutati, O. Azulai, R. Levi, A. Caspi,
M. Epstein. Kaplan hospital, Cardiology Dept., Rehovot, Israel
Background: Myocardial ischemia is difﬁcult to assess by noninvasive methods in
patients with permanent pacemaker (PP). Recently, pacing stress echocardiography (PCE) using external programming of the PP has been used successfully for
this purpose. However, the prognostic value of this method is unknown.
Methods: We compared the long-term prognosis of PCE and radionuclide tomography (SPECT) in 46 patients (mean age 75 yr) with PP and known or suspected
coronary artery disease. All patients underwent PSE with increasing pacing rate
up to 100% of age predicted maximal heart rate or upper limit of pacemaker rate.
Forty-one pts underwent dipyridamole SPECT. Patients were followed for a median
of 570 days (range, 60-870 days) after testing.
Results: The PSE was negative in 17 and positive in 29 patients. The SPECT
was negative in 8 and positive in 33 patients. During follow up there were 15 cardiac events (death, myocardial infarction and need for revascularization). The actuarial two year event-free survival was 81±13% in patients with normal PSE and
24%±18% when the PSE was abnormal (p=0.03). SPECT predicted two years
event-free survival of 88±11% and 41±19% in patients with normal and abnormal
SPECT, respectively (p=NS).
Conclusions: In patients with PP, PSE allows effective risk stratiﬁcation in patients
with known or suspected coronary artery disease. PSE predicted long-term occurrence of cardiac events better than SPECT in this population.
705
Can we predict better functional recovery after coronary revascularization
in mildly hypokinetic segments?
V. Rizzello 1 , J.J. Bax 2 , A.F.L. Schinkel 3 , E. Biagini 3 , M. Bountioukos 3 , C. Colizzi 1 ,
J.R.T.C. Roelandt 3 , D. Poldermans 3 . 1 The Catholic University, Cardiology
Department, Rome, Italy; 2 Leiden University Medical Center, Cardiology
Department, Leiden, Netherlands; 3 Thoraxcenter Erasmus MC, Cardiology
Department, Rotterdam, Netherlands
Background: In mildly hypokinetic segments the contractile reserve (CR) during
low-dose dobutamine stress echocardiography (DSE) may represent subendocardial scar with normal contraction of the outer layers of the myocardium or hibernating myocardium. Therefore, many mildly hypokinetic segments do not recover
after revascularization. Whether the high-dose DSE may improve the prediction of
functional outcome in mildly hypokinetic segments is not yet clariﬁed.This issue was
addressed in the present study.
Methods: Resting 2D echocardiography and low-high dose DSE were performed
before revascularization in 114 consecutive patients with ischemic cardiomyopathy.
Resting 2D echocardiography was repeated 3 to 6 months after revascularization.
Segmental function (wall motion and thickening) was scored as follows: 1=normal,
2=mildly hypokinetic, 3=severely hypokinetic, 4=akinetic, 5=dyskinetic. Functional
recovery after revascularization was assessed in mildly hypokinetic (group 1) and
severely dysfunctional segments (score 3 to 5, group 2). For each segment, recovery of function was deﬁned as an increase in the functional score > or = to 1 grade
compared to the pre-revascularization resting score.
Results: Group 1 consisted of 270 mildly hypokinetic segments and group 2 of
1124 severely dysfunctional segments. After revascularization, 97 (36%) group 1
segments and 355 (32%) group 2 segments had functional recovery (P=NS). During
low-dose DSE (up to 10 µg/kg/min), 183 (68%) segments in group 1 and 438 (39%)
segments in group 2 had CR (p<0.0001). However, at follow-up, functional recovery was less common in group 1 segments with CR than in group 2 segments with
CR (41% versus 55%, p 0.002). The high-dose DSE (up to 40 µg/kg/min) elicited a
biphasic response in 50 (27%) segments with CR in group 1 and in 226 (51%) segments with CR in group 2(p<0.0001). After revascularization, functional recovery
occurred more often in segments with biphasic response as compared to segments
with only CR to low-dose DSE both in group 1 and group 2 (78% vs 41%, p<0.0001
and 70% vs 51%, p<0.0001, respectively). Conclusions. In mildly hypokinetic segments, as well as in severely dysfunctional segments, the use of an high-dose DSE
protocol improves the prediction of functional outcome after revascularization as
compared to low-dose DSE. The biphasic response during high-dose dobutamine
infusion may help to distinguish subendocardial scar from hibernating myocardium.
Eur J Echocardiography Abstracts Supplement, December 2003
S88
Abstracts
706
The assessment of myocardial perfusion improves the prognostic value
of dipyridamole stress echocardiography.
708
QT dispersion correlates to myocardial viability assessed by dobutamine
stress echocardiography in patients with ischemic cardiomyopathy.
J.D. Kasprzak, P. Wejner-Mik, M. Krzemiñska-Pakula, M. Ciesielczyk, M. Plewka,
K. Wierzbowska, J. Drozdz. Medical University, Cardiology IMW, Lodz, Poland
M. Bountioukos, A.F.L. Schinkel, J.J. Bax, V. Rizzello, J.R.T.C. Roelandt,
D. Poldermans. Thoraxcenter, Erasmus Medical Center, Department of Cardiology,
BA302, Rotterdam, Netherlands
Myocardial perfusion can be visualized during contrast echocardiography but the
prognostic usefulness of this approach is yet unsettled. We performed a prospective study of a group of patients (pts) studied with high-dose dipyridamole stress
echocardiography (DSE) with contrast myocardial perfusion imaging (MPI).
Methods: 87 consecutive pts admitted for diagnosis of chest pain (24 females, 63
males, age 56±8, height 170cm, weight 79kg) underwent DSE with MPI at baseline and peak stress (triggered harmonic imaging 1:4, repeated boluses of Optison
0.3-0.5ml, visual assessment by consensus of 2 experienced observers) and coronary angiography. Patients were prospectively followed-up with respect to mortality,
revascularization, infarction and unstable angina (UA) for a period of 518±155 days,
range 90-940). The prognostic value of resting (r) and inducible(i) wall motion abnormalities (WMA) and perfusion defects (CPD) was compared.
Results: Events occurred in 48 pts (5 deaths, 2 infarctions, 14 UA and 41 revascularizations). Mortality was thus low and poorly predicted by WMA or CPD separately,
but test with inducible WMA and CPD carried a hazard ratio HR=7.0 (p=0.037)
and negative predictive value 97%. Event-free survival was predicted by absence
of i-WMA (HR=0.48, p=0.0099) and even better by absence of i-CPD (HR=0.45,
p=0.0093) and best- by absence of any inducible abnormality (HR=0.44, p=0.0031)negative and positive predictive value 71% and 67%.
Kaplan-Meier curves
Conclusions: Even using simple triggered harmonic imaging and visual assessment, MPI enhances the prognostic value of DSE in patients undergoing diagnostics for chest pain. Normal dual test optimally predicts low mortality in 17-months
follow-up.
707
Prognostic value of dobutamine stress echocardiography in patients with
previous coronary revascularization.
M. Bountioukos, A. Elhendy, R.T. Van Domburg, B.J. Krenning, A.F.L. Schinkel,
J.R.T.C. Roelandt, D. Poldermans. Thoraxcenter, Erasmus Medical Center,
Department of Cardiology, BA302, Rotterdam, Netherlands
Objectives: The aim of this study was to assess the prognostic value of dobutamine
stress echocardiography (DSE) in patients with previous myocardial revascularization.
Methods: A total of 332 consecutive patients with previous percutaneous or surgical coronary revascularization underwent DSE. Follow-up was successful in 331
(99.7%) patients. Thirty-eight patients who underwent early revascularization (>3
months) after the test were excluded from analysis. Cox proportional-hazards regression models were used to identify independent predictors of the composite of
cardiac events (cardiac death, nonfatal myocardial infarction and late revascularization).
Results: During a mean of 24±20 months, 37 (13%) patients died, and 89 (30%)
had at least one cardiac event (21[7%] cardiac deaths, 11[4%] non-fatal myocardial
infarctions, and 68 [23%] late revascularizations). In multivariate analysis of clinical
data, independent predictors of late cardiac events were hypertension (hazard ratio
[HR]: 1.7, 95% conﬁdence interval [CI]: 1.1-2.6), and congestive heart failure (HR:
2.1, 95% CI: 1.3-3.2). Reversible wall motion abnormalities (ischemia) on DSE were
incrementally predictive of cardiac events (HR: 2.1, 95% CI: 1.3-3.2).
Conclusions: Myocardial ischemia during DSE is independently predictive of cardiac events in patients with previous myocardial revascularization, after controlling
for clinical data.
Eur J Echocardiography Abstracts Supplement, December 2003
Objectives: QT dispersion is prolonged in numerous cardiac diseases, representing a general repolarization abnormality. Our aim was to evaluate the inﬂuence of
viable myocardium on QT dispersion in patients with ischemic cardiomyopathy.
Methods: A total of 103 patients with chronic coronary artery disease and poor
left ventricular ejection fraction (LVEF: 25±6%, range: 10 to 35%) were studied.
Patients underwent 12-lead electrocardiography to assess QT and rate-corrected
(QTc) dispersions, and 2-dimensional echocardiography to identify segmental dysfunction. Dobutamine stress echocardiography (DSE) was then performed to detect
residual viability. A patient was classiﬁed as viable in the presence of ≥ 4 dysfunctional viable segments.
Results: Resting echo demonstrated 1260 dysfunctional segments; of these, 476
(38%) were viable. Sixty-two (60%) patients had substantial viability (>= 4 viable
segments on DSE). QT dispersion was lower in these patients, than in patients
without viability (55±17 ms vs. 65±22 ms, P = 0.012). The number of viable segments signiﬁcantly correlated to QT dispersion (r=-0.333, P = 0.001)(see Figure). In
contrast, there was no correlation between LVEF and QT dispersion (r=-0.001, P =
NS). Results for QTc dispersion were comparable.
Conclusions: QT dispersion correlates signiﬁcantly to the number of viable segments assessed by DSE. Patients with ischemic cardiomyopathy and a low QT dispersion probably have a substantial amount of viable tissue. Conversely, in patients
with a high QT dispersion the likelihood of substantial viability is reduced.
709
Pronostic value of exercise echocardiography in diabetic patients with
known or suspected coronary artery disease.
I. Garrido, J. Peteiro, L. Monserrat, J. Garcia-Lara, G. Aldama, R. Perez,
A. Castro-Beiras. Juan Canalejo Hospital, Cardiology, A Coruña, Spain
Coronary artery disease (CAD) is the leading cause of death in diabetic patients
(pts). Currently there is a lack of data regarding to the value of exercise echocardiography (EE) for prognostic risk stratiﬁcation in these pts.
The aim of this study was to determine the prognostic value of EE in diabetics.
Methods: 214 consecutive diabetic pts (mean age 64 ± 8 years, 130 men) with
known or suspected CAD who were referred for treadmill EE were included. Followup (F-U) data were obtained by reviewing clinical history and telephonic interview.
Of the 214 pts, F-U data was available in 207 (97%).
Results: Cardiac events during a F-U of 44 ± 16 months occurred in 48 pts: unstable angina in 22, nonfatal myocardial infarction in 7 and cardiac death in 19. A total
of 52 pts underwent revascularization, 40 because of the result of EE and 12 after
a later event.
Ischemia was detected in 104 pts (50%) by EE (LV wall motion score index impairment at exercise) and in 69 pts (33%) by exercise ECG (p<0.001). Total cardiac
event and cardiac death rate at F-U were lower in the 103 pts without ischemia on
EE (49%) than in the 104 pts with ischemia (51%): total cardiac event: 15% vs 31%,
p<0.01; cardiac death: 3% vs 15%, p<0.01. Previous myocardial infarction (OR:
1.83, 95%; CI: 1.02-3.27, p=0.04) maximal workload (OR: 0.84, 95% CI: 0.75-0.94,
p<0.01), insulin dependent diabetes (OR: 1.95, 95% CI: 1.09-3.48, p=0.02) and ischemia detected on EE (OR 2.14, 95% CI: 1.16-3.94, p=0.01) were independent
risk factors for predicting cardiac events by multivariate Cox’s analysis. Ischemia
detected on EE (OR: 5.39, 95% CI: 1.56-18.59, p<0.01) and insulin dependent diabetes (OR: 3.34, 95% CI: 1.34-8.34, p=0.01) were independent risk factors for the
prediction of cardiac death.
Conclusions: Ischemia detected by EE is an independent predictor of cardiac
events and death in diabetic patients with known or suspected CAD.
Abstracts
710
Comparison of peak and postexercise imaging during treadmill exercise
echocardiography with the use of continuous harmonic imaging
acquisition.
R. Perez, J. Peteiro, I. Garrido, L. Monserrat, M. Piñeiro, A. Castro-Beiras. juan
canalejo hospital, Cardiology, A Coruña, Spain
Previous reports have demonstrated the superiority of peak (Pk) exercise echocardiography (EE) either with treadmill or bicycle in comparion with post-EE for the
diagnosis of coronary artery disease (CAD). However most of these studies used
fundamental imaging and view by view imaging acquisition. Technical advantages
in stress echocardiography include harmonic imaging and continuous imaging capture.
Methods: To compare the feasibility and accuracy of peak- and post-EE using continuous harmonic imaging acquisition, we studied 240 consecutive patients (pts)
referred for EE (age 60±13 years; 149 males). The only exclusion criteria was inability for exercise.
Results: Postexercise images were acquired within 60 seconds after exercise
(30±9). Mean heart rate (bpm) was 141±22 at Pk vs. 128±33 at post-exercise
imaging (p<0.0001). The number of clearly visualized segments by view was similar
at Pk- and post-EE except for the short-axis view (4-Ch apical: 5.9±0.4 vs. 5.9±0.3,
p=NS; 2-ch apical: 5.9±0.4 vs. 5.9±0.3, p=NS; parasternal long-axis: 4.2±0.8 vs.
4.2±0.7, p=NS; parasternal short-axis: 4.9±1.6 vs. 5.1±1.4, p<0.01). Interpretable
Pk and postexercise images (at least 2 views with >4 clearly visulized segments by
view) were obtained for all the patients. LV wall motion score index and LVEF were
worse at Pk than at post-exercise in patients with positive EE (1.5±0.3 vs. 1.4±0.3,
and 50±13 vs. 54±13, respectively, both p<0.001). For analysis of diagnostic capability we included 93 patients: 58 were included on the basis of having had an
EE and a coronary angiography (CA) within 4 months of the EE. To avoid bias to
CA a subgroup of 35 consecutive non-diabetic patients with pretest probability of
CAD<10% that had atypical chest pain or were asymptomatics were also included
and considered as having no CAD. CAD (>49% diameter stenosis in at least 1 vessel) was conﬁrmed in 46 patients, whereas 47 patients were considered to have no
CAD. Positive EE was deﬁned as ischemia or necrosis in at least 1 coronary artery
territory. Sensitivity, speciﬁcity and accuracy for CAD were 91%, 81% and 86% with
Pk-EE and 75%, 85% and 82% with post-EE, respectively (p=0.08 for sensitivity).
Sensitivity for the prediction of multivessel CAD was 74% with Pk-EE and 63% with
post-EE (p=NS).
Conclusion: Peak treadmill EE is as feasible as post-EE. Ischemia is more easily
detected at peak than at postexercise. Therefore, in the clinical setting peak-EE
should be peformed for diagnostic purposes.
711
Prognostic value of noninvasive permanent pacemaker stress
echocardiography.
V. Chubuchny 1 , A. Varga 2 , L. Guarracini 1 , U. Baldini 1 , S. Orazi 1 , R. Perticucci 1 ,
V. Coppola 3 , M. Agrusta 3 , G. Mottola 3 , E. Picano 4 . 1 CNR, Institute of Clinical
Physiology, Pisa, Italy; 2 University of Szeged, II Dept of Int Med and Card Center,
Szeged, Hungary; 3 Montevergine Clinic, Div. of Invasive Cardiology, Mercogliano
(AV), Italy; 4 CNR, Institute of Clinical Physiology, Pisa, Italy
Background: Noninvasive pacemaker stress echocardiography (PASE) is simple
and efﬁcient option for noninvasive diagnosis of coronary artery disease in the expanding population of patients with permanent pacemaker.
Aim: We investigated the prognostic value of PASE in patients with known or suspected coronary artery disease.
Methods: Seventy six patients (50 men, age 67 ± 11 years) with permanent pacemakers underwent PASE by external programming (10 bpm increment up to evidence of ischemia or target heart rate). All patients were prospectively evaluated
during mean follow-up of 17±8 months.
Results: A positive result of stress echocardiography was detected in 30 (39%)
patients. During follow-up, there were 3 cardiac deaths, 2 myocardial infarctions,
10 clinically-driven coronary revascularizations and 8 unstable angina. The overall
event-free survival was lower in patients with positive PASE (p <0.001). (Picture). In
a multivariate analysis positive result of stress echocardiography was independently
associated with increased risk (hazard ratio = 6.8; 95% conﬁdence interval: 2.1 to
13.0; p < 0.001).
Conclusions: Positive noninvasive PASE is a strong prognostic factor in patients
with suspected or known coronary artery disease.
S89
712
The prognostic meaning of ultrasonically assessed coronary ﬂow reserve
in dilated cardiomyopathy.
F. Rigo 1 , P. Santagata 2 , J. Drodz 2 , A. Kopff 2 , S. Ghelardi 1 , L. Pratali 2 ,
M. Richieri 1 , U. Coli 1 , A. Raviele 1 , E. Picano 3 . 1 Umberto I° Hospital, Cardiology
Dept, Mestre, Italy; 2 CNR, Institute of Clinical Physiology, Pisa, Italy; 3 CNR,
Institute of Clinical Physiology, Pisa, Italy
Background: Coronary ﬂow reserve (CFR) can be impaired in idiopathic dilated
cardiomyopathy (DC), unmasking a coronary microcirculatory dysfunction of potential prognostic impact.
Aim: To evaluate the prognostic value of CFR in patients with DC.
Methods: We evaluated 58 DC patients (39 male; age= 62±12 years) by transthoracic (n=36) or transesophageal (n=22) dipyridamole (0.84 mg/kg in 10’) stress
echocardiography. All patients had an ejection fraction <45% and angiographically
normal coronary arteries. CFR was assessed on LAD by pulsed Doppler as the
ratio of maximal vasodilation (dipyridamole) to rest peak diastolic ﬂow velocity.
Results: Mean CFR value was 2.1±0.6. At individual patient analysis, 25 patients
had normal CFR>2 (Group 1) and 33 patients had abnormal CFR <2 (Group 2).
At a mean follow-up of 19 months, there were 19 events: 8 cardiac deaths, 11 new
hospital admissions. Event-free survival was 54.5% in pts with CFR<2.0 and 84%
in pts with CFR>2 (p=0.03): see ﬁgure.
Conclusion: In DC patients, assessment of CFR is feasible by either transthoracic
or transesophageal echocardiography. CFR is often impaired. A reduced CFR is
associated with worse prognosis.
713
Does the presence of angina during stress testing inﬂuence prognosis in
patients with ischemia during stress echocardiography?
E. Biagini 1 , A.F.L. Schinkel 2 , A. Elhendy 2 , G. Rocchi 1 , V. Rizzello 2 ,
E. Vourvouri 2 , M. Bountioukos 2 , D. Poldermans 2 , J.R.T.C. Roelandt 2 . 1 S. Orsola,
Institute of Cardiology, Bologna, Italy; 2 Thoraxcenter Erasmus MC, Cardiology,
Rotterdam, Netherlands
Background: Stress induced ischemia during dobutamine stress echocardiography (DSE) is associated with an increased risk of cardiac events. The aim of this
study was to compare the prognosis of patients having silent versus symptomatic
ischemia during DSE.
Methods: We studied 615 patients (mean age 60 ± 11 years, 446 men) with stress
induced myocardial ischemia during DSE, who were followed up for cardiac events
(cardiac death and myocardial infarction). Follow-up was successful in 612 of 615
patients (99.5%). Forty patients underwent revascularization within 60 days after
DSE and were excluded, hence the prognostic data are based on 572 patients. Cox
regression models were used to identify independent predictors of cardiac events.
Results: Angina occurred in 226 (40%) patients during DSE, whereas 346 (60%)
were considered to have silent ischemia. There was no signiﬁcant difference between both groups with regards to number of dysfunctional segments at rest
(8.5±5.1 vs 8.6±4.8, respectively, p=0.8) or number of ischemic segments (3.4±2.0
vs 3.5±2.5; p=0.7). During 3.2±2 years of follow up, there were 124 (22%) deaths
and 82 (14%) nonfatal infarction. There was no signiﬁcant difference between patients with and without angina with regards to annual rate of cardiac death (3.0%
vs 3.1%) or cardiac death and myocardial infarction (4.1% vs 4.2%). Independent
predictors of cardiac death in a multivariate analysis model were age (HR 1.05 CI
1.02-1.07) and number of ischemic segments (HR 2.05 CI 1.3-3.2).
Kaplan Meier survival curve.
Conclusion: The clinical outcome of patients with ischemia during DSE is not inﬂuenced by the presence of angina in association with transient wall motion abnormalities.
Eur J Echocardiography Abstracts Supplement, December 2003
S90
Abstracts
714
Left atrial electrical and mechanical function during dobutamine stress in
coronary artery disease.
716
Predictive value of bicycle-echocardiography in stable coronary artery
disease.
C. O’Sullivian 1 , W. Li 2 , A. Duncun 1 , C. Daly 2 , M. Henein 1 . 1 Royal Brompton
Hospital, Echocardiography, London, United Kingdom; 2 Royal Brompton Hospital,
London, United Kingdom
D. Duplyakov, L. Svetlakova, V. Emelyanenko, S. Goleva, E. Sysuenkova. VAZ
Medical Center, Cardiology, Togliatti, Russian Federation
Background: Long standing coronary artery disease (CAD) is frequently complicated by atrial ﬁbrillation, the exact mechanism of which remains to be determined.
Aim: To study left atrial (LA) electrical and mechanical function at rest and during
dobutamine stress in patients with CAD.
Methods: We studied 33 patients with triple vessel CAD, age 59±9.5 years, 31
males, using conventional dobutamine stress Doppler echocardiography protocol
and compared them with 15 controls mean age 58±10 years. LA diameter was
measured from the standard aortic root - left atrial echogram. LA longitudinal amplitude of motion and shortening velocity were measured from the M-mode and tissue
Doppler recordings of mitral ring movement, respectively (taken as the mean of the
left, septal and posterior sites). LA ejection velocity was measured from the transmitral pulsed wave Doppler recording in late diastole. P wave duration and amplitude
were measured from V1-V2 on the concurrently recorded 12 lead ECG.
Results: At rest - LA diameter was larger in patients compared to controls 4.3±0.6
vs 3.4±0.3 cm, p<0.001. LA amplitude of motion was increased 7.1±2 vs 5.9±1.2
mm, p<0.001 as was its shortening velocity, p<0.001. LA ejection velocity did not
differ between patients and controls. P wave duration was longer in patients 122±16
vs 105±12 ms, p<0.001 but its amplitude was not different 1.6±0.5 vs 1.8±0.5 mm,
NS.
At peak stress: In contrast to controls, LA amplitude of motion failed to increase
in patients, 0.66±0.14 cm, NS although the shortening velocity increased by 28%
as it did in controls, p<0.001. LA ejection velocity increased equally in patients and
controls, p<0.01. P wave duration fell by 15±2 ms in patients compared to 32±3 ms
in controls, p<0.001 and while its amplitude did not change in controls it increased
in patients to 2.4±0.7, p<0.001.
Conclusion: Patients with CAD have disturbed atrial electrical and mechanical
function at rest. This behavior deteriorates further with stress as manifested by the
failure of its amplitude to increase and depolarisation to accelerate. The maintained
LA ejection velocities seem to be preserved only at the expense of raised atrial
pressure as demonstrated by the voltage increase of P wave on the surface ECG.
715
Late color M-Mode ﬂow propagation as an index of left atrial function in
pts with non-ischemic dilated cardiomyopathy. Effects of Dobutamine.
A.P. Patrianakos 1 , F.I. Parthenakis 1 , G.F. Diakakis 1 , P.G. Tzerakis 1 ,
M. Chamilos 1 , D.C. Kambouraki 1 , P.E. Vardas 2 . 1 Heraklion University Hospital,
Cardiology Dept., Heraklion, Crete, Greece; 2 Heraklion University Hospital,
Cardiology, Heraklion, Greece
Background: Atrial (ANP) and Brain (BNP) natriuretic peptides are primarily released from the atria and ventricles in response to volume and pressure overload.
The ﬂow propagation of early transmitral ﬂow (Ep) determined from color M-mode
has been considered as a useful index of LV diastolic function while data about late
transmitral velocity propagation (Ap) be lacking.
We assessed the relationship of Ap and its changes during Dobutamine stress
echocardiography with ANP and BNP levels in pts with non-ischemic dilated cardiomyopathy (NIDC).
Methods: Twenty eight pts with angiographically proven NIDC, NYHA functional
class II-III and LVEF 30.57±7.22%, underwent to low-dose Dobutamine echocardiography (LDDE)(two 5-minutes stages with 5 and 10 µgr/kgr/min). ANP and BNP
levels were measured at rest and 60-min after LDDE. Left Ventricular (LV) were divided into 16 segments and the wall motion score index (WMSI),LV volumes, Ep
and Ap and were calculated before and after peak stress.
Results: Non-signiﬁcant changes in heart rate, blood pressure or Ep were found at
LDDE while there was a trend of increased Ap (0.69±0.25 vs 0.53±0.21, p=0.06).
The WMSI(2.1 ±0.24 vs1.54±0.36,p<0.001) was reduced. ANP (3.7±2.4 vs
3.3±2.3pmol/ml, p=0.02) and BNP (0.77±0.41 vs 0.71±0.39 pmol/ml, p=0.01) levels showed also a signiﬁcant reduction at LDDE. A signiﬁcant correlation was found
between the resting Ep/Ap ratio with resting BNP levels (r=0.59, p=0.004) while the
Ap changes at Dobutamine was correlated with ANP changes(r=0.53,p=0.04).
Conclusions: The Ep/Ap ratio is related to BNP levels suggesting that it may be
a useful index in assessing LV ﬁlling pressures in NIDC pts. The relationship of Ap
changes to ANP changes at LDDE propose that Ap may depends to LA stretch
alterations in those pts.
Eur J Echocardiography Abstracts Supplement, December 2003
The aim of the present study was to assess predictive value of bicycleechocardiography in risk stratiﬁcation of patients with stable coronary artery
disease. Methods. Department’s data base was analyzed retrospectively since
Jan.1999 till Apr. 2002. Altogether 441 patients (age 36-68 years, mean 53.4±6.2;
91% men) were enrolled in the study. All patients were followed up for minimally
12 moths, and maximally for 42 months (aver. 20+11 months). End points were
deﬁned as cardiac death, nonfatal MI and revascularization. Results. In the period
of follow-up a total 69 events were observed: 14 deaths, 20 nonfatal MIs and 35
revascularizations. Both groups (event-positive and event-negative) snowed no statistical signiﬁcant baseline difference (age, sex,diabetes,previous MI and revascularization procedures), except hypertension (75.4% vs 53.4%, respectively,p<0.01).
At rest echocardiography event-positive patients had statistically higher LV mass index (161.2±52.4 g/m2 vs. 132.8±41.7 g/m2 , p=0.02), while there were no difference
for other parameters. The prevalence of ST-depression, angina, and wall motion abnormalities during exercise was 36.2%, 68.1%, 85.5% in event-positive group, comparing to 19.1%, 26.1%, 35,6% in event-negative group (p<0.05 for all variables).
Achieved mean maximal heart rate and MET were 131±21 bpm vs. 143±25 bpm,
and 5.95±1.6 vs. 7.3±2.5 (p=0.01). The peak LV EDV, ESV, EF and WMSI were
124±27 ml vs 113±39 ml (p=0.01), 58±25 ml vs. 47±33 ml (p=ns), 53±12% vs.
62±14% (p<0.01) and 1.59±0.3 vs. 1.34±0.35 (p=0.02), respectively. Twenty one
clinical, echocardiography and stress-echocardiography variables were analyzed by
the Cox proportional hazards regression model, and Kaplan-Meier survival analysis was performed thereafter. Main predictor of subsequent events was positive
echocardiographic result. Besides it predictive ability were observed for the whole
duration of the test in minutes, LV mass index, MET, angina within the test and history of hypertension. Patients who had negative result of exercise echocardiography
were at low risk (3%) of future severe cardiac events (cardiac death and nonfatal MI), whereas positive result was associated with dramatically 5-fold increase of
such a risk (15%). Adding revascularization as a surrogate end point we found approximately 7-fold difference between negative (5%) and positive (34%) predictive
ability of exercise echocardiography. Conclusions. Bicycle stress-echo is safe, and
effective method in prognostic assessment of ambulatory patients with stable CAD.
717
Quantiﬁcation of regional myocardial function detects super-silent
myocardial ischaemia in diabetic patients.
S. Ilic 1 , M. Deljanin Ilic 2 , B. Ilic 1 , D. Djordjevic 2 , D. Petrovic 1 . 1 Institute of
Cardiology, Clinical Cardiology, Niska Banja, Yugoslavia; 2 Institute of Cardiology,
Echo lab, Niska Banja, Yugoslavia
The aim of the study was a quantitative assessment of regional systolic and diastolic myocardial velocities (m.v.) changes in the presence of stress induced myocardial ischemia (m.i.) in diabetic patients (pts) using pulsed wave Doppler myocardial
imaging (PW-DMI).
Methods: In the study group of 48 diabetic pts with known or suspected CAD exercise stress echocardiography (ExE) was performed. ExE identiﬁed ischemia by the
occurrence of wall motion abnormalities (WMA) with stress - positive ExE. Apical
views were used to assess m.v. (Acuson-Sequoia, PW DMI) on baseline and at the
peak stress. The sample volume was placed in each of 11 segments in which the
left ventricle was divided, and we calculated peak m.v. of systolic (S), early (E) and
late (A) diastolic waves and their ratio E/A.
Results: Myocardial velocities were measured in 445 (84.3%) out of 528 possible myocardial segments. During ExE in 29 (60.4%) pts WMA were detected in
104 (37.8%) out of 275 adequately visualized segments, while in 19 (39.6%) pts
WMA were not appeared. Out of 29 pts with ExE provoked WMA, in 13 (44.8%)
pts symptomatic and in 16 (55.2%) pts silent m.i. was appeared. In segments with
ExE provoked symptomatic WMA ratio E/A decreased from 0.97 ± 0.34 to 0.74 ±
0.32 (P<0.001) and S m.v. decreased from 8.0 ± 3.2 to 6.3 ± 3.0 cm/s (P<0.001).
In segments with ExE provoked silent WMA ratio E/A decreased from 1.05 ± 0.38
to 0.83 ± 0.36 (P<0.001) and S m.v. decreased from 8.3 ± 3.5 to 7.1 ± 3.3 cm/s
(P<0.005) compared to baseline values. Out of 341 segments without ExE induced
WMA 19 (5.6%) segments (5 in pts with positive and 14 segments in 4 (21%) pts
with negative ExE) demonstrated inversion of E/A ratio after ExE (from 1.02 ± 0.07
to 0.94 ± 0.08, P<0.005). Evaluation of m.v. in other 322 segments without WMA
showed signiﬁcant increased of E/A ratio (P<0.001) and S m.v. (P<0.005) after
ExE.
Conclusion: Quantiﬁcation of regional m.v. during conventional ExE in diabetic pts
showed that symptomatic as well as silent m.i. is associated with signiﬁcant decreased of E/A ratio and S m.v. Inverted regional E/A ratio may uncover super-silent
m.i. which is not sufﬁcient to provoke WMA.
Abstracts
718
Application of tissue tracking and dobutamine stress echocardiography
in the diagnosis of coronary artery disease.
C.Z. Pan, X.H. Shu, C.A. Jiao, N.S. Cai. Zhongshan Hospital, Fudan University,
Department of Cardiology, Shanghai, China
Objective: The combination of tissue tracking technique and Dobutamine stress
echocardiography were studied to evaluate the ischemic regions in patients with
coronary artery disease (CAD).
Method: A total of 25 patients with suspected CAD underwent dobutamine stress
echocardiography, and the systolic mitral annular displacement (MAD) was determined at rest and during stress by tissue tracking technique. Apical four chamber, three chamber and two chamber views were used to determine the MAD at
6 sites (post interventrial septum PIVS, anterior interventrial septum AIVS, anterior
ANT, lateral LAT, posterior POST and inferior INF). Coronary arteriography was performed within 1 week after echocardiographic examination. All patients were divided
into two groups according to the result of coronary arteriography. Group A included
23 patients with more than 70% stenosis in left anterior descending coronary artery
(LAD). Group B consisted of 27 patients with no signiﬁcant stenosis of LAD.
Result: (1)The systolic MAD at rest 10ug/kg/min, 20ug/kg/min, 30ug/kg/min
were not signiﬁcantly different between group A and group B(P>0.05), but at
40ug/kg/min, the systolic MAD in ANT in group A was lower than that in group B
(P<0.01). The systolic MAD at other sites was not signiﬁcantly different between the
group A and group B(P>0.05). (2) The systolic MAD of group A in ANT and AIVS
during stress were not signiﬁcantly different from that at rest (P>0.05). However it
was higher in POST and LAT at 30ug/kg/min, 40ug/kg/min, and in INF and PIVS
at 20ug/kg/min, 30ug/kg/min, 40ug/kg/min than that at rest in group A (P<0.050.01).The systolic MAD at the 6 sites during stress was higher than that at rest in
Group B (p<0.01).
Conclusions: Tissue tracking imaging combined with dobutamine stress echocardiography can early and accurately detect abnormal mitral annular displacement in
patients with coronary artery disease.
719
Application of a novel non tissue doppler based method for real-time
quantitaon of myocardial function in normal subjects during exercise
echocardiography.
M. Leitman 1 , P. Lysyansky 2 , Z. Vered 1 . 1 Assaf Harofeh Medical Center,
Cardiology, Zeriﬁn, Israel; 2 GE, Ultrasound, Haifa, Israel
Objectives: To assess the feasiability of a novel software for real-time quantitative
assessment of myocardial function in normal subjects during exercise echocardiography.
Background: Reliable methods for quantitative assessment of myocardial function
for stress echocardiography are limited.
Methods: 12 patients underwent standard exercise echocardiography. Apical views
at baseline and peak exercise were stored in a cineloop format for off-line analysis.
The novel software is based on the estimation that a discrete set of tissue velocities per each of many small elements on ultrasound image show only mild shift
on subsequent frames. Tracking can be controlled in real-time by the operator. Tissue velocities, strain and strain rate at baseline and at peak exercise were obtained
and displayed in real time by the software. We also introduced a new parameter:
Strain acceleration index - the ratio of systolic strain and time to peak systolic strain
corrected for heart rate.
Results: 216 myocardial segents were assessed. Adequate tracking of the myocardium by the new software was possible in 93% of the segments at rest and in
80% at peak exercise.
Velocities were maximal in basal segments. Strain was homogenous over the myocardium. Velocities, strain and strain rate were signiﬁcantly higher at peak exercise.
Corrected time to the peak systolic strain was shorter at peak exercise than at rest;
strain acceleration index was higher at peak exercise than at rest (Table).
Quantitative parameters during exercise
Basal velocities (cm/sec)
Mid velocities (cm/sec)
Apical velocities (cm/sec)
Strain rate (sec -1)
Strain (%)
Time to peak strain (CU)
SAI (%/CU)
Before exercise
Post exercise
p value
6.22 ± 1.26
4.2 ± 1.3
1.87 ± 0.93
1.02 ± 0.39
16.71 ± 5.06
11.4 ±5.23
1.42 ± 0.63
6.94 ± 1.43
5.28 ± 1.6
2.34 ± 1.43
1.43 ± 0.6
18.09 ± 6.23
14.94 ±9.69
1.88 ± 0.97
<0.004
<0.00001
0.03
<0.00001
<0.03
<0.00001
<0.00001
CU - corrected units (corrected for heart rate), SAI - strain acceleration index=strain/time to peak
strain (%/CU)
Conclusion: This novel non-Doppler based software may provide real-time quantitative assessment of global and regional myocardial function at rest and during
exercise echocardiography.
S91
720
Dobutamine versus levosimendan stress echocardiography for the
prediction of recovery of left ventricular dyssynergies after
revascularization.
K. Bouki 1 , G. Pavlakis 2 , T. Kakavas 2 , E. Bougatiotis 2 , V. Foulidis 2 , K. Komninos 2 ,
K. Kostopoulos 2 , E. Papasteriadis 2 . 1 General Hospital of Nikea, Cardiology Dept.,
Pireaus, Greece; 2 General Hospital of Nikea, Pireaus, Cardiological, Athens,
Greece
Objectives: To compare the accuracy of levosimendan (L) and dobutamine stress
echocardiography (DSE) for the prediction of recovery of left ventricular dyssynergies after revascularization.
Methods: Twenty eight patients with left ventricular dysfunction due to previous
myocardial infarction scheduled for revascularization (18 PTCA and 10 CABG) underwent low-dose DSE (5-10µgr/kgr/min) and LSE. Levosimendan was infused at
least 1h after dobutamine infusion, at 2 doses of 12 and 24µgr/kgr, over a 5 min
period each. Left ventricular wall motion score was assessed using a 16-segment
model. Myocardial viability was detected if improvement of >/=1 grade of regional
wall motion score in at least two contiguous segments was noted, during either
dobutamine or levosimendan infusion. All patients also underwent resting echocardiography within 6 months after successful revascularization.
Results: Of the 448 segments studied, 212 (47%) was dyssynergic at rest. Dobutamine infusion resulted in augmented contraction in 98/212 (46%) abnormal segments while 88(90%) of these showed functional improvement after revascularization. During LSE 110/220(52%) dyssynergic segments improved and 100(91%) of
these recovered function after revascularization. Analysis of results showed a signiﬁcantly lower sensitivity of DSE compared with LSE (73% vs 94% respectively,
p<0.01) but a similar speciﬁcity (89% vs 90%, respectively, p=ns) for the prediction
of postrevascularization recovery of left ventricular dysysnergies.
Conclusions: LSE can predict postrevascularization recovery of left ventricular
dydsynergies with higher accuracy than DSE.
721
Evidence for interplay between cytokines, macrophage colony
stimulating factor and brain natriuretic peptide plasma levels changes
during dobutamine stress echo irrespectively from test postitivity.
G. Athanassopoulos 1 , D. Degiannis 2 , I. Ekonomides 3 , G. Hatzigeorgiou 2 ,
M. Marinou 2 , G. Karatasakis 2 , J. Lekakis 3 , D.V. Cokkinos 2 . 1 Onassis Cardiac
Surgery Center, Cardiology Dept, Athens, Greece; 2 Onassis Cardiac Surgery
Center, Cardiology Dept., Athens, Greece; 3 Alexandra State Hosp, Therapeutics
Dep, Athens, Greece
Introduction: Cytokins (interleukins - IL, tumour necrosis factor - TNF) and macrophage colony stimulating factor (MCSF) plasma levels are mediators in pathophysiology of acute coronary syndromes. Brain natriuretic peptide (BNP) is produced due
to increased cardiac wall stress and implies left ventricular (LV) dysfunction. Dobutamine stress echo (DSE) may induce acute ischemia and ventricular dysfunction.
Aim of the study was to assess dynamics of these parameters during DSE and their
potential interrelationships.
Methods: We studied 75 consecutive pts by DSE (age 60±11, 10 women, with
ejection fraction-EF 40±11%, a previous myocardial infarction documented in 26).
The IL1, tumor necrosis factor (TNF), IL6, MCSF were measured at rest (R), peak
(P) and during recovery, 15min post DSE (Rec). BNP was measured at R and Rec.
Interleukin 1 (IL1) and tumor necrosis factor (TNF) were measured in a subgroup of
11 consecutive pts. A 16 segments model was used for DSE analysis.
Results: BNP at R had a weak negative relationship with EF at R (r=-0.24, p=0.07)
and wall motion changes at P (r=0.30, p=0.023).
BNP at Rec had strong relationship with BNP at R (r=0.90, p<0.0001), but both
absolute and the % changes were independent from its R values.
The BNP changes had no relationship with heart rate-blood pressure product
changes.
The % changes of BNP was related to peak IL6 (r=0.25, p=0.05), recovery MSCF
(r=0.29, p=0.036) and at R (r=0.29, p=0.023).
TNF at Rec had close relationship with both absolute and % BNP (r=-0.53,
p=0.05,r= -0.74, p=0.016 respectively).
A similar trend was found between IL1 and %BNP (P: r=-0.50, p=0.06, Rec: r=-0.52,
p=0.06).
When pts with ischemic DSE were analyzed separately, then BNP Rec was correlated exclusively with MCSF at R (r=0.33, p=0.02) and at P (r=0.44, p=0.02).
In contrast when pts without an ischemic DSE response were analysed, then both
absolute and % BNP changes were related with IL6 at R and P (IL6 R/P: r=0.54,
p=0.038 for both and r=0.47, p=0.07/r=0.55, p=0.034 respectively).
Conclusions: DSE is related with changes in both BNP and inﬂammatory indices
irrespectively from the detectable wall motion abnormalities.
Even in the absence of an ischemic DSE response, an increase of IL6, an inﬂammatory marker, is related to an increase of BNP, thus implying subtle LV function.
Eur J Echocardiography Abstracts Supplement, December 2003
S92
Abstracts
722
Noninvasive assessment of left ventricular contractility by pacemaker
stress echocardiography.
724
Inﬂuence of beta-blockade on results of low-dose dipyridamole
echocardiography tests for myocardial viability.
T. Bombardini 1 , A. Varga 2 , R. Pap 2 , N. Natsvlishvili 1 , F. Solimene 3 , F. Coltorti 3 ,
M. Agrusta 3 , G. Mottola 3 , E. Picano 4 . 1 CNR, Institute of Clinical Physiology, Pisa,
Italy; 2 University of Szeged, II Dept of Int Med and Card Center, Szeged, Hungary;
3
Montevergine Clinic, Div. of Invasive Cardiology, Mercogliano (AV), Italy; 4 CNR,
Institute of Clinical Physiology, Pisa, Italy
A. Djordjevic-Dikic, M. Ostojic, B. Beleslin, I. Nedeljkovic, J. Stepanovic, V. Giga,
S. Stojkovic, M. Nedeljkovic, Z. Petrasinovic, A. Arandjelovic. Institute for
Cardiovascular Disease, Cardiology, Belgrade, Yugoslavia
Background: Estimation of contractility of left ventricle is an important, and as
yet elusive, goal with noninvasive techniques. Positive inotropic interventions are
mirrored by smaller end-systolic volumes and higher end-systolic pressures. An
increased heart rate progressively increases the force of ventricular contraction
(Bowditch treppe or staircase phenomenon).
Aim: To assess the feasibility of a non-invasive estimation of force-frequency relation (FFR) during pacing stress in the echo lab in patients with permanent pacemaker.
Methods: Transthoracic stress pacing echocardiography was performed in22 patients with a permanent pacemaker (17 men; age 68±12 years). Seven patients
has normal function at baseline and during stress ("normals"); 9 had angiographically assessed coronary artery disease (3 with and 6 without induced ischemia with
stress echo); 6 patients had dilated cardiomyopathy. To build the FFR, the force
was determined at different steps as the ratio of the systolic pressure (SP, cuff
sphygmomanometer)/end-systolic volume index (ESV, biplane Simpson rule/body
surface area). Heart rate was determined from ECG.
Results: The absolute value of the FFR slope was highest in controls and lowest in
DC patients (ﬁgure). A ﬂat-downsloping FFR was found in 0/7 normals and in 11/15
patients (p<0.1).
Introduction: In everyday clinical practice patients with chronic ischemic cardiomyopathies are usually under beta-blockade protection. It is always a safety issue
should beta blockers be withdrawn when diagnostic tests for ischemia and viability are performed.
Objective: The aim of this study was to examine the inﬂuence of beta –blockade
on diagnostic potential of low-dose dipyridamole echocardiography test for viability.
Methods: Forty patients with resting dyssynergy, due to previous myocardial infarction, underwent low-dose dipyridamole (0.28mg/kg in 4 minutes interval) echocardiography test. Beta-blockers were present in 19 pts. Criterion for viability was
improvement in systolic thickening of dyssinergic segments of 3 1 grade. Coronary
angiography performed in all pts revealed multivessel coronary artery disease in 29
patients and one vessel disease in 11, (diameter stenosis 3 50% of at least one major coronary artery). Mean EF was 39±10% and WMSI 1.88±0.44. Total number of
dysfunctional segments at resting echocardiography was 315.
Results: During low- dose dypiridamole test WMSI signiﬁcantly decreased in group
of pts on beta-blocker therapy (1.76±0.36, p<0.05 vs. WMSI at rest) as well as in a
pts off beta-blockers (1.78±0.43, p< 0.05 vs. WMSI at rest). Low dose dypiridamole
identiﬁed 97 segments as viable in dysfunctional regions.
Conclusion: According to our results diagnostic potential of low-dose dipyridamole
echocardiography test is not inﬂuenced by beta-blocker therapy and this could be
recommendation for its use in everyday clinical practice when it is not possible to
rule out therapy for safety reasons.
725
Tissue Doppler imaging with dipyridamole provocation predicts
signiﬁcant coronary artery disease.
Conclusions: Non-invasive PASE is a simple and efﬁcient option to assess left
ventricular contractility in patients with permanent PM.
723
Echocardiographic detection of coronary artery disease during
dobutamine infusion in patients with moderate aortic stenosis and
normal left ventricular systolic function.
E. Plonska 1 , Z. Gasior 1 , A. Szyszka 2 , J. Kasprzak 3 , M. Maciejewski 3 ,
I. Hegedus 4 , P. Gosciniak 1 , A. Gackowski 1 . 1 Medical University, Szczecin,
Poland; 2 Medical University, Poznan, Poland; 3 Medical University, Lodz, Poland;
4
Cardiology, Debrecen, Hungary
Background: Resting ECG in patients (pts) with aortic stenosis (AS) often reveals
ST segment abnormalities due to hypertrophy and/or dilatation of the left ventricle
(LV), making the diagnosis of coronary artery disease (CAD) on the basis of exercise ECG uncertain. However usefulness of dobutamine echocardiography (DE) in
patients with AS has not been determined.
Aim: To assess the usefulness of DE for detection of CAD in patients with normal LV
function with moderatly increased transvalvular gradient through the stenotic aortic
valve.
Materials: 123 pts (mean age 59 yrs, 18-81, 59,9% male) with AS and maximal
aortic gradient in the range 25-65mmHg, without contraindication to DE, with normal
LV systolic function. 52% were hypertensive.
Methods: All pts underwent standard DE (doses 5-40mcg/kg/min) in the framework
of multicenter study involving 10 centers from Poland and Hungary. Classical DE
termination criteria were used. Reaching maximal aortic gradient of 100mmHg during DE was also a reason for test termination. Diagnostic value of DE was assessed
in relation to the signiﬁcant coronary stenosis (>50%).
Results: Peak dobutamine dose was 32+11mcg/kg/min. Peak heart rate was
115+26bpm, systolic arterial pressure – 141+24 and diastolic pressure –
80+14mmHg. Transaortic mean and peak gradient increased from 31+13 and
48+15mmHg at rest up to 49+20 and 83+29mmHg (p<0,001) during peak dobutamine dose, respectively. Aortic valve area did not change signiﬁcantly during DE.
DE was positive for ischaemia in 17,9% of pts, negative – 45,5%, nondiagnostic –
36%.
Sensitivity of DE was 64%, speciﬁcity – 87%, positive predictive value – 72,7%,
negative predictive value 87%.The reason for test termination was submaximal
heart rate reached in 54(43,(%), maximal dobutamine and atropine dose reached
in 10(8,1%), new wall motion abnormalities in 23(18,7%), side effects in 36(29,2%)
and patient’s wish in 1(0,8%). No dangerous complications such as infarction, ventricular ﬁbrillation or death were observed.
Conclusions: DE in pts with moderate AS is a valuable non-invasive method for
studying LV contractility and coronary circulation. Pts can safely undergo DE. Although side effects occur more often than in pts diagnosed for CAD, they are mild
and resolve without medical treatment. In pts with AS relatively high percentage of
nondiagnostic DE tests was found.
Eur J Echocardiography Abstracts Supplement, December 2003
H. Kato 1 , Y. Saito 2 , A. Kato 2 , K. Watanabe 2 , T. Ohnishi 3 , N. Maekawa 3 ,
H. Takahashi 3 , H. Murakita 3 , M. Yamamoto 3 . 1 Fukui Kosei Hospital, Internal and
Cardiovascular Medicine, Fukui city, Japan; 2 Fukui Kosei Hospital, Division of
Laboratory, Fukui city, Japan; 3 Fukui Kosei Hospital, Internal Medicine, Fukui city,
Japan
Introduction: Diastolic dysfunction precedes systolic dysfunction in myocardial ischemia and therefore may be a more sensitive parameter in stress echocardiography. We assessed the hypothesis that diastolic myocardial velocity measured by
tissue Doppler imaging (TDI) can predict coronary artery stenosis.
Methods: Forty-ﬁve patients (mean age, 64.2 ± 11.9 years; 31 men and 14 women)
underwent TDI before and just after dipyridamole infusion (0.56 mg/kg/4 min + 0.28
mg/kg/2 min). At six sites (septal and lateral; anterior and inferior; antero-septal
and posterior left ventricular wall) adjacent to the mitral annulus, the early diastolic
myocardial velocities (Em) were measured by TDI echocardiography in the apical 4chamber, 2-chamber, and long-axis views, respectively. In each segment, the delta
Em was calculated as the Em immediately after dipyridamole infusion minus the
Em prior to dipyridamole infusion. The minimum delta Em in the six segments was
assessed as the marker of ischemia. Each patient also underwent quantitative coronary angiography, and 22 patients were found to have signiﬁcant coronary artery
disease (CAD) deﬁned as stenoses >50%, and the remaining 23 patients did not.
Results: The average delta Em of the six segments was lower in patients with
CAD than in those who did not (mean ± SD, 1.34 ± 1.71 cm/s vs. 3.57 ± 2.62
cm/s, P<0.005). The minimum delta Em in the six segments was lower in patients
with CAD than in those without CAD (mean ± SD, -1.43 ± 2.09 cm/s vs. 1.24 ±
2.48 cm/s, P < 0.0005). The Em decreased in at least one of the six segments
after dipyridamole infusion in 19 of the 22 patients (86%) with CAD. In contrast,
Em increased in all six segments after dipyridamole infusion in 16 of the 23 patients (70%) without CAD. Therefore, a decrease in Em in at least one segment
after dipyridamole infusion predicted CAD with a sensitivity of 86%, a speciﬁcity of
70%, a positive predictive value of 73%, a negative predictive value of 84%, and a
diagnostic accuracy of 78%. No major side effects or complications occurred in any
patients during the examination.
Conclusion: Dipyridamole stress TDI predicts signiﬁcant CAD noninvasively.
Abstracts
726
Mental stress and myocardial ischemia: hemodynamic and
echocardiographic parameters.
J. Stepanovic 1 , M. Ostojic 1 , D. Lecic-Tosevski 2 , O. Vukovic 3 , M. Pejovic 2 ,
A. Djordjevic-Dikic 1 , I. Nedeljkovic 1 , B. Beleslin 1 , V. Giga 4 , S. Stojkovic 1 . 1 Clinical
center of Serbia, Institute for cardiovascular disease, Belgrade, Yugoslavia;
2
Institute for mental health, Belgrade, Yugoslavia; 3 Clinical Center of Serbia,
Institute for psychiatry, Belgrade, Yugoslavia; 4 Belgrade, Yugoslavia
Introduction: Indirect evidences have suggested a link between mental stress and
coronary artery disease (CAD). Recent research in CAD patients has conﬁrmed the
observation that mental stress is a potent trigger of myocardial ischemia.
Objective:
The aim of this study was to evaluate the feasibility of mental stress test and the
relation between mental stress and occurrence of myocardial ischemia as evaluated
by echocardiography.
Methods: All laboratory sessions began at noon, and the patients were studied
off antianginal therapy. Study population included 38 patients with angiographically
proven CAD (31 male, 7 female, mean age 48±10 years; multivessel CAD in all
patients) and previous positive exercise stress test (development of chest pain and
ST depression >1mv, 0.08 sec after J point). 12-leads ECG, blood pressure, and
echocardiography for wall motion abnormalities were continuously monitored. Test
protocol consisted of rest phase (30 min in a partially darkened room), mental task
phase: mental arithmetic (5 min, subtract 7s’ serially from a 4-digit number) and simulated public speech task (10-15 min, describing their personal faults and shortcomings). After mental stress test, in all patients submaximal Bruce treadmill protocol
was performed.
Results: Mental stress test was successfully performed in all patients (feasibility
100%). During mental stress test, chest pain occurred in 5/38 pts (13%), ischemic
ECG changes developed in 9/38 pts (24%, p=ns vs. angina) and new or worsening
of wall motion abnormalities was observed in 22/38 (58%, p< 0.05 vs. angina and
ECG). Exercise stress echocardiography test after mental stress test was positive
in 35/35 pts (100%; in 3 pts exercise stress test was not performed because of
hypertensive reaction during mental stress test).
Conclusion: These results showed excellent feasibility of mental stress test and
direct evidence that myocardial ischemia in signiﬁcant number of pts with severe
coronary artery disease is related to mental stress.
727
Value of transesophageal dobutamine stress echocardiography in patient
qualiﬁcation towards ischaemic mitral insufﬁciency cardiosurgical
treatment.
J. Kochanowski, P. Scislo, S. Stawicki, D. Kosior, G. Opolski. The Warsaw Medical
University, Dept of Cardiology, Warsaw, Poland
Aim: The aim of this study was to evaluate the optimal surgical treatment of patients
(pts) with severe post-myocardial infarction mitral regurgitation (MR), based upon
transesophageal dobutamine stress echocardiography (TEE-DASE) results.
Material: The study group comprised 170 pts (105 men, 65 women; aged 64±11)
with a history of MI following echo and coronary angiography (2-8 weeks post-MI).
In this group small and mild MR was observed in 64 pts (38%), severe in 17 pts
(10%). Detailed analysis was performed in 17 pts with severe MR. All this pts had
multiple vessel coronary disease, signiﬁcant contractility disturbances (EF<40%,
WMSI ≥1.7) and were qualiﬁed to coroanry artery bypass graft (CABG).
Method: All patients, prior to surgery underwent TEE examination for evaluation
of mitral valve aparatus and TEE-DASE examinations for the evaluation of muscle
viability and MR. TEE-DASE was performed using Philips Sonos 5500 and 2500
with Omniplane I and II probes. Dobutamine was infused in 5-3-3-3 minutes stages
between 10 - 40 mcg/kg/min. Atropine was added when required to achieve 85%
maximum heart rate. Each test was recorded for later assessment by 2 independent
experienced cardiologists.
Results: Inﬂuence of TEE-DASE on MR. In group 1 there were 6 pts with signiﬁcant
MR decrease(at least 2+). In group 2 we observed 11 pts without inﬂuence on MR
or MR decreased without WMSI changes. Patients were qualiﬁed towards CABG if
MR and WMSI deterioration during TEE-DASE (Group 1), while those without DASE
inﬂuence on MR or decreased MR without WMSI changes (Group 2) underwent
CABG and mitral plasty or valve replacement. Further patient analysis, according to
administered treatment
Table 1. Degree of MR following treatment
n=17
Small MR
Mild MR
Severe
Group 1
Group 2
After CABG
4
2
0
After CABG +mitral plasty
9
2
0
S93
728
Force-frequency relationship during dobutamine stress echo:
noninvasive exercise-independent assessment of left ventricular
contractility.
A. Grosu 1 , T. Bombardini 1 , M. Senni 1 , N. Natsvlishvili 1 , A. Varga 2 , E. Picano 3 .
1
CNR, Institute of Clinical Physiology, Pisa, Italy; 2 University of Szeged, II Dept of
Int Med and Card Center, Szeged, Hungary; 3 CNR, Institute of Clinical Physiology,
Pisa, Italy
Background: Force-Frequency relationship (FFR) is a methodologically robust approach to evaluate left ventricular contractility during exercise echo.
Aim: To assess the feasibility of a noninvasive estimation of FFR during dobutamine
stress in the echo lab.
Methods: We enrolled 33 consecutive patients (27 males, age 66±12 years) referred for dobutamine stress echo (up to 40 mcg/kg/min). Ejection fraction was
41±15%. To build the FFR, the force was determined at different steps as the ratio of the systolic pressure (SP, cuff sphygmomanometer)/end-systolic volume index
(ESV, biplane Simpson rule/body surface area). Heart rate was determined from
ECG at different dobutamine steps.
Results: Dobutamine stress was uneventfully completed in all patients. The FFR
could be obtained in all. The 15 pts with ischemic echo response (new or worsening
dyssynergy) had a ﬂat-downsloping FFR slope (1.5 ±2.5 x 10-2); the 18 patients
with normal–viable response showed an upsloping FFR slope (3.2 ±1.9 x 10-2,
p<0.05 between groups) (ﬁgure), in spite of comparable resting ejection fraction.
Conclusions: A noninvasive estimation of FFR is feasible during dobutamine stress
in the echo lab. It unmasks a substantially heterogeneous contractile response in
patients with similar values of conventional indices of left ventricular function.
729
Assessing the effect of low dose dobutamine on various diastolic
function indexes.
S. Gorgulu, M. Eren, B. Uzunlar, S. Celik, A. Yýldýrým, N. Uslu, B. Dagdeviren,
T. Tezel. Siyami ersek, Cardiology, Istanbul, Turkey
Objective: Despite the well known effect of low dose dobutamine (LDD) in patients
with left ventricular dysfunction, its effect on various diastolic function parameters in
patients with normal wall motion is not clear.
The aim of this study was to evaluate the effect of LDD infusion at a dosage of
5mcg/kg of body weight, which usually does not increase the heart rate, on various
diastolic function parameters.
Methods: Thirty-one volunteer patients who had no regional wall motion abnormality were included in the study. There were 16 (51%) men and 15 (49%) women, ranging in age from 31to 76 years (mean±SD 53 ± 12). Echocardiographic measurements were taken both at pre-dobutamine and during LDD. The second echocardiographic examination begun at least 5 minute after the infusion was started. Left
ventricular ejection fraction (EF) was calculated with the modiﬁed Simpson’s method
The peak E velocity, A velocity, the E/A ratio, deceleration time (DT),isovolumetric
relaxation time (IVRT), myocardial performance index (MPI), ﬂow propagation velocity (FPV) were assessed as left ventricular diastolic function parameters. Early (Em)
and late (Am) diastolic mitral annulus tissue Doppler velocities were also obtained
in order to calculate the E/Em and Em/Am ratio.
Results: No signiﬁcant changes were observed in heart rate, E velocity, A velocity,
E/A ratio, E/Em ratio, Em/Am ratio, systolic and diastolic blood pressure with LDD
(5µg/kg of body weight per minute). With LDD, DT (239±40 vs. 201±31, p<0.001),
IVRT (109±12 vs 94±11, p<0.001), MPI (459±35 vs. 423±39 p<0.001) were found
to be decreased, while there was an increase in FPV (45±8 vs 59±10, p<0.001)
and EF (64±6 vs. 66±7, p<0.05).
Conclusion: Low dose dobutamine (5mcg/kg of body weight) improves left ventricular relaxation in patients with normal wall motion, while it has no effect on left
ventricular ﬁlling pressure.
Conclusions: 1. TEE-DASE enables to select patients with signiﬁcant MR, in whom
CABG improves mitral valve functioning.
2. TEE-DASE enables patient selection, in whom CABG should be performed with
mitral plasty or valve replacement.
Eur J Echocardiography Abstracts Supplement, December 2003
S94
Abstracts
730
Systolic mitral annular Doppler velocities immediately after dobutamine
stress echocardiography predict left ventricular ischemia.
732
Limitation of stroke volume during dobutamine stress by left ventricular
ﬁlling time in patients with coronary artery disease.
D. Sharif 1 , S. Amal Sharif-Rasslan 2 , S. Camilia Shahla 1 , G. Edward Abinader 1 .
1
Bnai Zion Medical Center, Cardiology, Haifa, Israel; 2 Technion, Science and
Tecnology, Haifa, Israel
A. Duncan, C. Porter, D. Gibson, M. Henein. The Royal Brompton Hospital,
Echocardiography Department, London, United Kingdom
Longitudinal systolic left ventricular contraction is complementary to radial performance and can be assessed by tissue Doppler imaging (TDI).
Aim: Evaluation of the contribution of mitral annular systolic velocities using TDI
after dobutamine stress echocardiography (DSE) in the assessment of coronary
artery disease.
Methods: Fifty subjects with suspected coronary artery disease and chest pains
were examined using DSE as well as TDI imaging of the mitral annulus at the septal,
lateral, inferior, anterior, posterior regions and the proximal anteroseptal region from
the apical views, before and immediately after DSE.
Results: 26 subjects had wall motion abnormalities (WMA) with wall motion score
index (WMSI) of 1.166±0.21 at rest and 1.34±0.18 after DSE, while 24 were normal. In both groups systolic annular mitral velocity (Sa) at all 6 regions, increased
after DSE by more than 40%, p<0.00002. The most prominent difference after DSE
was in septal Sa, 19.2±3.8 in normals and 14.6±2.5 cm/sec in those with WMA,
P<0.0003. A signiﬁcant decrease in Sa occurred when WMSI exceeded 1.25. Septal Sa<17 cm/sec after DSE had a sensitivity, speciﬁcity and diagnostic accuracy for
detecting WMA of 92%, 80%, and 88% respectively while these values for post/pre
DSE Sa ratio<1.5 were 85%, 88% and 86% respectively.
Conclusions: 1) Systolic mitral annular velocities increase after DSE. 2) In patients
with WMA the increase in these velocities are less than in normal subjects and can
differentiate patients from normal subjects.
731
Mechanisms of symptom development during dobutamine stress.
A. Duncan, C. Porter, D. Gibson, M. Henein. The Royal Brompton Hospital,
Echocardiography Department, London, United Kingdom
Background: Mechanisms of symptom development at peak stress in patients with
heart disease remain unclear.
Methods: 94 patients with stress-related symptoms were studied: 22 had coronary
artery disease (CAD) and normal left ventricular (LV) cavity size (EDD <5.6cm), 25
had non-ischemic cardiomyopathy (EDD >5.6cm), and 47 had ischemic cardiomyopathy (EDD>5.6cm). All underwent dobutamine stress echocardiography. Stress
end-points were 85% predicted target heart rate, chest pain, breathlessness, arrhythmia (including run >5 ventricular ectopic beats) or >20mmHg drop in systolic
blood pressure. Ventricular long axis M-mode echograms were recorded at the lateral, septal, and posterior sites of the mitral ring. Segmental incoordination was
measured as post-ejection shortening (PES). Cardiac output (CO) was calculated
at the level of the LV outﬂow tract.
Results: Reasons for terminating dobutamine stress test are presented in Table 1.
All patients with CAD and normal LV cavity size, and 37/47 patients with ischemic
cardiomyopathy developed PES with stress. No patient with non-ischemic cardiomyopathy developed PES. Stress-induced chest pain was closely associated with the
development of PES (chi-square = 17.0, p<0.001).
CO increased in patients with CAD and normal LV cavity size (by 4.8±2.0l/min,
p<0.001), in non-ischemic cardiomyopathy (by 4.3±2.1l/min, p<0.001), and in patients with ischemic cardiomyopathy who developed chest pain (by 2.0±1.7l/min,
p<0.01). CO however failed to increase in those patients with ischemic cardiomyopathy who developed breathlessness, hypotension, or ventricular ectopic beats at
peak stress (by 1.9±2.6 l/min, p=ns).
Table 1. Reason for terminating stress test
Peak HR
Chest pain
Breathlessness
Hyotension/VEs
No DCM, CAD
DCM, no CAD
DCM, CAD
2
18
2
0
22
0
1
2
0
29
5
13
Conclusion: Stress-related chest pain is associated with development of subendocardial long axis incoordination. Breathlessness, hypotension, and arrhythmia reﬂect LV dysfunction and failure to increase CO with stress. Knowledge of these
ﬁndings may assist in optimising management of patients with stress-related symptoms.
Eur J Echocardiography Abstracts Supplement, December 2003
Background: Stress-induced left ventricular (LV) dysfunction in patients with coronary artery disease (CAD) may be associated with signiﬁcant changes in LV ﬁlling
pattern, particularly ﬁlling time.
Aims: To determine diastolic time reserve in normal subjects and in patients with
CAD, and to ascertain the relationship between diastolic time reserve and changes
in stroke volume during stress.
Methods: 69 subjects were studied during dobutamine stress; 33 were normal
controls and 39 had CAD (normal LV cavity size at rest: EDD 5.0±0.5cm, ESD
3.3±0.5cm). Relative ﬁlling time, expressed as a percentage of total diastole, was
calculated by dividing LV ﬁlling time (LVFT) by total diastolic time (measured as the
interval between aortic valve closure and mitral valve closure). Stroke volume (SV)
was measured using Doppler echocardiography at the level of the LV outﬂow tract.
All measurements were made at rest and repeated at peak stress.
Results: In normal controls, relative ﬁlling time increased with stress (from 85±3%
to 92±2%, p<0.001), suggesting the presence of diastolic time reserve (7%), and
SV also increased (from 69±17mls to 96±19mls, p<0.001). In patients with CAD,
relative ﬁlling time was not different from controls at rest, but shortened with stress
(from 83±5% to 74±5%, p<0.001), representing a loss in diastolic time reserve of
9%, and SV failed to increase (rest: 76±20mls, stress: 74±16mls, p=NS). Stressinduced changes in diastolic time reserve correlated with changes in SV in patients
with CAD (r=0.60, p<0.001), but not in controls.
Conclusion: In patients with CAD, stress-induced ischaemic dysfunction is associated with loss of diastolic ﬁlling reserve that determines stroke volume. This loss of
early diastolic reserve may itself affect diastolic coronary artery ﬁlling, and consequently perpetuate myocardial perfusion instability.
733
Left ventricular geometry is the major component of abnormal
mid-ventricular gradients during negative dobutamine stress
echocardiography.
M. Carrinho 1 , A. Moraes 2 , W.Q. Pereira 1 , T.C. Xavier 1 , M. Castier 1 ,
A.C. Nogueira 1 , R. Morcerf 1 , A.L. Cantisano 1 , F. Salek 1 , F. Morcerf 1 . 1 ECOR Diagnóstico Cardiovascular, Rio de Janeiro, Brazil; 2 ECOR - Diagnóstico
Cardiovascular, Rio de Janeiro, Brazil
Background: Dobutamine stress echocardiography (DSE) is a useful method to detect myocardial ischemia by increasing oxygen demand. Mid-ventricular systolic gradient (MSG - peak systolic velocity >2m/s) have been reported as a consequence
of the inotropic effect of dobutamine mainly in pts with negative tests. However the
inﬂuence of LV size and shape has not been studied yet. We therefore hypothesized
that MSG is primarily dependent on LV geometry.
Methods: 118 pts with normal standard (high-dose) DSE were included in this study
divided into 2 groups according to the presence of MSG. Group A (with): 19 pts,
13 female, 56.2±9.6 years and Group B (without): 99 pts, 60 female, 61.8±12.2
years. For both groups LV wall thickness (WT), diameters (D), volumes and ejection
fraction were obtained. Geometry was deﬁned as the diastolic WT/D ratio.
Results: MSG was observed in 19/118 pts (16%). There were no statistical differences for gender distribution (p=0.701) and age (p=0.059). Table shows the results
for LV parameters.
Group A
Group B
p
WT - cm
D - cm
WT/D
0.99 ± 0.15
0.88 ± 0.14
0.002
4.66 ± 0.39
5.04 ± 0.81
0.048
0.22 ± 0.04
0.18 ± 0.04
< 0.0001
Conclusion: MSG is a common ﬁnding in pts with negative DSE and strongly correlated with higher WT/D ratio independently of LV hypertrophy.
Abstracts
S95
734
"Ischemic cascade" during dipyridamole stress echocardiography in
patients with stable coronary heart disease.
736
Automated classiﬁcation of wall motion abnormalities by analysis of left
ventricular endocardial contour motion patterns.
A. Sestito 1 , F. Pennestrì 2 , G. Sgueglia 2 , F. Infusino 2 , F. Crea 2 , G.A. Lanza 2 .
1
Università Cattolica del Sacro Cuore, Istituto di Cardiologia, Rome, Italy;
2
Policlinico A. Gemelli, Istituto di Cardiologia, Rome, Italy
J.G. Bosch 1 , F. Nijland 2 , S.C. Mitchell 3 , B.P.F. Lelieveldt 1 , O. Kamp 2 , M. Sonka 3 ,
J.H.C. Reiber 1 . 1 Leiden University Medical Center, Radiology, Leiden,
Netherlands; 2 Vrije Universiteit Medical Center, Cardiology, Amsterdam,
Netherlands; 3 University of Iowa, Electrical Engineering, Iowa City, United States
of America
Background: Previous studies have shown that transmural myocardial ischemia
caused by sudden epicardial coronary artery occlusion determines a typical sequence of events characterized, in order, by left ventricular wall motion abnormalities, ST segment ischemic modiﬁcations and, only at the end, angina.
In this study, we investigate if this typical "ischemic cascade" presents with the same
modalities also during subendocardial ischemia induced by dipyridamole infusion.
Patients and Methods: A total of 41 patients (63±9 years; 12 women) with chronic
stable angina and angiographically documented coronary artery disease (1-vessel:
14 [34%]; 2-vessel: 8 [19%]; 3-vessel: 19 [46%]) underwent dipyridamole stress
echocardiography (total dose: 0,84 mg/kg iv). Cardiac images were acquired by a
2.5 MHZ probe connected to a Toshiba set, Power Vision 8000.
Results: During test, 39 patients (95%) had left ventricular wall motion abnormalities, 31 patients (75%) had ST segment depression and 32 patients (78%) had
angina. The ﬁrst manifestation of ischemia was left ventricular wall motion abnormalities in 7 patients (17%), ST segment depression in 16 patients (39%) and
angina in 9 patients (22%). When considering only the 21 patients who developed
all three manifestations of ischemia during dipyridamole stress echocardiography,
left ventricular wall motion abnormalities were the ﬁrst manifestation of ischemia
(alone or in association with ST segment depression or angina) in 5 patients (24%),
ST segment depression was the ﬁrst manifestation of ischemia (alone or in association with left ventricular wall motion abnormalities or angina) in 14 patients (66%)
and angina was the ﬁrst manifestation of ischemia (alone or in association with
left ventricular wall motion abnormalities or ST segment depression) in 8 patients
(38%).
Conclusion: Our data indicate that dipyridamole induced subendocardial ischemia
results in a very variable sequence of events, which doesn’t seem to reproduce the
typical "ischemic cascade" described after sudden coronary artery occlusion. The
heterogeneity of the response among patients likely depends on a variable association of interindividual differences in the extension of ischemia, in the sensitivity
of cardiac neuronal algogenic receptors and in the adenosine-mediated effects of
dipyridamole on cardiac perception of pain and on electrophysiological characteristics of myocardial cells.
735
Cultural evolution of digital description of coronary artery disease
severity potential of inducing myocardial ischemia during exercise stress
echocardiography.
I.P. Nedeljkovic 1 , M. Ostojic 2 , B. Beleslin 2 , A. Djordjevic-Dikic 2 , N. Milic 2 ,
M. Nedeljkovic 2 , J. Stepanovic 2 , S. Stojkovic 2 , Z. Petrasinovic 2 , V. Giga 2 .
1
University Institute for CVD, Cardiology, Belgrade, Yugoslavia; 2 Univ.Institute for
CVD, Cardiology Dept., Belgrade, Yugoslavia
Objective: To determine, if other characteristics including not just severity and localization of coronary stenosis but also the amount of myocardium at jeopardy, would
better correlate with the potential of provoking ischemia by exercise than classical
number of diseased coronary vessels.
Background: Althought simply and easy, coronary artery disease severity described by the number of diseased vessels, may underestimate the potential importance of coronary anatomy, as well as the importance of myocardium at risk to
develop myocardial ischemia during exercise stress echocardiography test.
Methods: We evaluated 211 consecutive pts (171 male, 40 female; mean age
51±10 years; 103 with previous myocardial infarction, 108 with angina pectoris) by
exercise stress echocardiography according to Bruce treadmill protocol and coronary arteriography (one-vessel CAD, 114 pts; multi-vessel CAD, 45 pts). Myocardial
jeopardy score is calculated for each vessel as a sum of all signiﬁcant lesions represented as a product of: (1) myocardial kinetic status (0 for akinetic, 0.5 for hypokinetic, and 1 for each normokinetic myocardial segment subserved by the vessel
with equal or more than 50% diameter stenosis), (2) diameter stenosis of signiﬁcantly stenosed coronary vessel (scored from 3-5), and (3) weighting ﬂow factor for
particular localisation.
Results: Univariate logistic regression analysis showed signiﬁcant correlation between number of diseased vessels, % diameter stenosis, weighting ﬂow factor, myocardial jeopardy score, with the results exercise stress echocardiography
(p>0.0001 for all). However, in multivariable analysis signiﬁcant predictor of stress
test results was only myocardial jeopardy score (p<0.0001). Cut-off value of myocardial jeopardy score best predictive for stress test outcome was 9.5.
Conclusion: Global myocardial jeopardy score was the only mutivariate predictor of
stress echocardiography test results containing the information of functional stenosis signiﬁcance (severity and localization) and amount of myocardium at risk. Thus,
this is the best digital description of coronary artery disease potential for provoking
ischemia by exercise.
Objective: fully automated border detection (ABD) and classiﬁcation of wall motion
abnormalities (WMA) is highly desired for objective analysis of stress echo.
Methods: We developed a fully automated ABD technique based on Active Appearance Motion Models (AAMM), which learns typical shape-motion patterns from
a set of example image sequences. AAMM uses Principal Component Analysis to
ﬁnd eigenvariations of shape/motion, including typical normal and pathological endocardial contraction patterns, and expresses each shape as a linear combination
of these. We hypothesized these AAM modal shape coefﬁcients (MSCs) would allow WMA classiﬁcation.
Experiments: Low-dose dobutamine (LDD) stress echo was performed on 129 infarct patients split randomly into training (TRN, n=65) and test set (TST, n=64).
Expert-veriﬁed endocardial contours (MAN) were available in 4-chamber (4c) and
2-chamber sequences for baseline and LDD. AAMMs were generated from TRN
and ABD was tested on TST sets. Resulting borders (AUTO) were compared to
MAN borders, in average point distance (APD, mm) and LV endocardial area (LVA,
cm2 ). MSCs for all sequences were extracted and statistically related to segmental
and global Visual Wall Motion Scoring (VWMS).
Results: on 4c baseline TST, AAMM ABD succeeded (APD<8mm) in 97% of cases
(APD Mean±SD: 3.3±1.2mm, LVA regression: AUTO=0.91*MAN+1.7cm2 , r=0.87).
Multivariate linear regression showed clear correlations between MSCs and global
(R2 =0.84) and segmental (average R2 =0.60) VWMS. Discriminant analysis showed
good prediction of both segmental (85±6% correctness) and global WMA (90%
correctness).
Regression MSC/Visual for Total&Apex WMS
Conclusion: AAMM allows fully automated endocardial border detection and its
MSCs show promising accuracy for automated classiﬁcation of WMA.
737
Positive pre-ejection velocity changes during dobutamine stress test in
identifying hibernating myocardium and predicting functional recovery.
C.I. Aggeli 1 , M.S. Bonou 2 , G. Roussakis 1 , S. Brili 1 , C.S. Theocharis 2 ,
M. Vavouranakis 1 , C. Pitsavos 1 , C. Stefanadis 1 . 1 Hippikration Hospital,
Cardiology, Athens, Greece; 2 POLYCLINIKI, Cardiology, Athens, Greece
Introduction: The value of pre-ejection velocity changes recorded by tissue
Doppler imaging (TDI) during dobutamine stress echocardiography to predict functional recovery has not been studied.
Purpose: The aim of this study was to evaluate the accuracy of TDI velocity
changes during low-dose dobutamine stress echocardiography (up to 20 µg/kg/min)
in identifying hibernating myo-cardium and its prognostic value to predict recovery
after revascularization.
Methods: Dobutamine stress echocardiography using TDI was performed in 41 patients with coronary artery disease and left ventricular dysfunction, 2-5 days before
revascularization. TDI ejection (E) and PE as well as early (Ea) and late (Aa) diastolic velocities were recorded during rest and dobutamine stress echocardiography.
Rest echocardiography was repeated 3 months after revascularization.
Results: Left ventricular ejection fraction increased from 24±4 to 35±4% at followup (p<0.001). Of the 408 revascularized segments with severe dysfunction, 188
(45%) improved at follow-up. E, PE and Ea velocities (cm/sec) changed signiﬁcantly dobutamine stress echocardiography vs. rest (4.8±1.2 vs. 5.9±1.6, 4.9±1.13
vs. 6.5±1.95, 4.8±0.9 vs. 5.6±1.4, respectively, p<0.001), whereas Aa velocities
(cm/sec) did not change (6.3±1.4 vs. 6.4±1.3). The use of receiver operating curves
identiﬁed a stress-induced increase of 0.5 cm/s in E velocity as the optimal cut-off
value for viability, which predicted recovery of myocardial function with a sensitivity
of 80% and a speciﬁcity of 88%. Interestingly, a stress-induced increase of PE velocity by 0.6 cm/sec was identiﬁed as having superior sensitivity of 91% and speciﬁcity 90% in predicting functional recovery. A cut-off point of 0.44 cm/sec change in
Ea velocity during Dobutamine stress echocardiography had a high also sensitivity
(80%) and speciﬁcity (81%) to predict myocardial recovery function.
In conclusion, pre-ejection velocity increase is the most accurate index, for the identiﬁcation of hibernating myocardium during dobutamine stress echocardiography,
concerning prediction of functional recovery. This is maybe due to lower tethering
effect during pre-ejection period.
Eur J Echocardiography Abstracts Supplement, December 2003
S96
Abstracts
738
Assesment of myocardial viability in patients with myocardial infarction:
comparison of low dose dipyridamole radionuclide ventriculography with
dipyridamole stres echocardiography.
Z. Petrasinovic, M. Ostojic, B. Beleslin, A. Djordjevic-Dikic, D. Sobic-Saranovic,
S. Pavlovic, J. Saponjski, S. Stojkovic, M. Nedeljkovic, V. Obradovic. Institute for
Cardiovascular Disease, Cardiology, Belgrade, Yugoslavia
The purpose of the study was to compare diagnostic value of low dose dipyridamole
radionuclide ventriculography (DIPY-RNV) and low dose dipiyidamole echocardiography (DIPY-ECHO) for the prediction of functional recovery of viable myocardium
in the medium term follow up.
Twenty patients (18 male; 51±10 years) with previous myocardial infarction and
resting wall motion dyssynergy were studied before angioplasty of infarct related
artery (IRA), by RNV and ECHO at rest, as well as during dipyridamole infusion
(0,28 mcg/kg/min over 2min). RNV as well as ECHO was repeated at rest, 12
weeks after successful angioplasty. Five percent increase of regional ejection fraction (REF) by RNV was used as criterion for functional improvement of infarcted
regions. By ECHO, viability was deﬁned as improvement of wall thickening or contractile improvement of grade one or more, utilizing wall motion score index (WMSI).
Out of 180 examined (20x9) segments by RNV, 51 were dyssynergic and they had
abnormal REF (29±10%). Out of these 51 segments functional improvement was
documented in 33 on low DIPY. Sensitivity for predicting functional recovery after 12
weeks follow up was 63%, and speciﬁcity was 77%. WMSI assessed by ECHO was
1.35±0.22, 1.16±0.20 and 1.13±0.14 for rest, low DIPY and rest follow up, respectively (p<0.05). Sensitivity of low DIPY-ECHO for predicting functional recovery was
80%, and the speciﬁcity was 90% (p=ns vs low DIPY-RNV).
In conclusion, both techniques, RNV and ECHO are comparable diagnostic predictors of myocardial viability in medium term follow up.
739
The value of early ambulatory cardiac rehabilitation program after
myocardial infarction on parameters of left ventricle in patients with left
ventricular dysfunction.
L. Elbl 1 , V. Chaloupka 2 , S. Nehyba 2 , I. Tomaskova 2 , P. Kala 3 , J. Schildberger 3 ,
B. Semrad 3 . 1 Brno, Czech Republic; 2 University Hospital, Cardiopulmonary
Testing, Brno, Czech Republic; 3 Faculty Hospital, Cardiology, Brno, Czech
Republic
Aim of Study: The assessment of the inﬂuence of the early ambulatory cardiac
rehabilitation program on the parameters of left ventricular (LV) function at rest and
stress echocardiography and the changes in gas exchange analysis.
Methods: The patients hospitalized with ﬁrst acute myocardial infarction were included in 8-weeks early rehabilitation program. Aerobic (60% VO2max) as well as
isometric exercise program was performed in all patients. Before and after the training symptom-limited dynamic stress echo and spiroergometry were done. The rest
and exercise ejection fraction (EF) and pVO2 analysis were calculated.
Patients: 86 patients (79male/7female) of the age 56+11 yrs were enrolled into
study. The patients were divided in two subgroups in accord to the enter EF: group
I 15 pts with EF < 50% (40+6%) and group II of 71 pts with EF > 50% (60+4%).
Results: The aerobic exercise program increased signiﬁcantly exercise tolerance
(p<0.001) and pVO2 (p<0.001) in both subgroups. However, the rest and exercise
EF after training was signiﬁcantly increased only in subgroup I (p<0.05). The subgroups did not differ in training exercise tolerance as well as circulatory response to
the aerobic exercise.
Conclusions: The early ambulatory rehabilitation program (including isometric exercise) is safe for patients with depressed LV function. The program has positively
inﬂuenced the parameters of LV function as well as parameters of gas exchange
analysis in subgroup of patients with depressed EF due the myocardial infarction.
Early aerobic and isometric exercise does not worse the process of LV remodeling
after myocardial infarction.
740
Sequential dobutamine stress echocardiography and TL-201 scintigraphy
for the detection of viable myocardial tissue in patients with a previous
myocardial infarction.
N.T. Kouris 1 , D.D. Kontogianni 2 , M.D. Sifaki 2 , G.S. Goranitou 2 , E.M. Kalkandi 2 ,
H.E. Grassos 2 , D.K. Babalis 2 . 1 Athens, Greece; 2 Western Attica General Hospital,
Cardiology dept, Athens, Greece
Tl 201 scintigraphy (Tl) with reinjection and dynamic stress echocardiography (DSE)
with dobutamine are both characterized by satisfactory sensitivity and speciﬁcity
when used for the detection of viable myocardial tissue after myocardial infarction
(MI).
The aim of our study was to clarify whether the sequential performance of both
methods in the same patients (pts) provides additional information, capable of
changing our therapeutic decisions.
Patients and Methods: Twenty consecutive pts (15 male, 5 female), mean age 65±
9 years with a history of MI during the previous 13 months, underwent DSE for the
detection of myocardial viability, followed by Tl the day after. DSE was performed
in two 3-min stages using low-dose dobutamine (5 and 10 µg/kg/min respectively),
while Tl SPECT study consisted of 3 stages (i.e. exercise, rest, redistribution phases
and reinjection of 1mCi of Tl-201). Left ventricle was divided in 16 segments for
the evaluation of wall motion abnormalities and perfusion defects. These segments
Eur J Echocardiography Abstracts Supplement, December 2003
were identical and comparable to those used during Tl quantitative analysis (bull’s
eye), provided that apex itself belongs to apical segments. During DSE, myocardial
segments were regarded to be viable if they were hypokinetic or akinetic but with
improved contractility after dobutamine administration. During Tl viable segments
were those that demonstrated a reversible perfusion defect with or without Tl reinjection (Tl uptake>50% ROI).
Results: We studied a total of 320 myocardial segments (20 pts, 16 segments
each); 144 segments (45%) demonstrated regional wall motion abnormalities
(RWMA) on DSE; 36 of them (25% of the dysfunctional segments:ds) were viable
(V). On Tl SPECT 150 out of 320 segments (47%) had a perfusion defect; 52 of
these defects (35% of ds) were reversible and considered as V. When both methods
were performed, 61 V segments were detected (36% of ds). Results were evaluated
by the ANOVA test for repeated measurements. The percentage of viable segments
detected by the combination of the two methods was found to be signiﬁcantly higher
than the percentage detected by DSE alone (p=0,025). On the contrary, no difference was found in the number of segments detected by the combination method
and Tl alone.
Conclusion: The sequential performance of DSE and Tl SPECT is feasible and
seems to increase the likelihood for the detection of myocardial viability after MI,
particularly in cases that DSE alone fails to detect a satisfactory number of viable
segments, capable of providing an indication for revascularization.
741
Apically directed postsystolic motion of the basal anteroseptal wall
during stress-echo.
A. Ouss, P.A. Van der Wouw. Onze Lieve Vrouwe Gasthuis, Cardiology,
Amsterdam, Netherlands
Background: An apically directed postsystolic motion (PSM) is present in the basal
anteroseptal wall and consists of two distinct waves PSM I and PSM II. Our goal
was to study changes in peak velocity of PSM II in the basal anteroseptal wall
during stress-echo.
Methods: 33 consecutive patients (mean age 60±10 years) referred for high-dose
dobutamine stress-echo were included. 18 (55%) of the patients had proven coronary artery disease (CAD). A standard stress-echo protocol was used. Pulsed wave
tissue doppler imaging of the basal anteroseptal wall in the apical long axis view was
performed at rest and during peak stress. Peak velocity of the apically directed PSM
II was measured.
Results: Basal anteroseptal wall at rest was normokinetic in 31 patients, hypokinetic in 1 and akinetic in 1. In all studied patients no ischemia was detected during stress-echo in the basal anteroseptal wall. Heart rate was 72±13/min at rest,
and 132±10/min during peak stress (88±10% of the calculated peak heart rate).
Peak velocity of the apically directed PSM II increased from 3.0±1.7 cm/s at rest to
7.9±2.6 cm/s during peak stress (p<0.001), mean increase of 4.9±2.0 cm/s. In the
subgroup of patients with proven CAD the mean increase did not differ from that of
the whole group. In 7 patients with a positive stress-echo (5 RCA, 1 LAD, 1 RCX
territory) the mean increase was 5.3±1.8 cm/s (p=NS vs the whole group).
Conclusion: Peak velocity of the apically directed PSM II in the non-ischemic basal
anteroseptal wall increases with approximately 160% during peak stress.
742
Routine assesment of left ventricular diastolic dysfunction in coronary
artery disease by Doppler exercise stress testing.
D. Bastac. Internisticka Ordinacija "Dr Bastac", ZAJECAR, Yugoslavia
To evaluate left ventricular (LV) diastolic function parameters before and pick exercise -provoked myocardial ischaemia, transmitral was studied in 48 patients with
proven coronary artery disease (CAD) and Control group with 32 normal subjects
using pulse Doppler echocardiography. The pick ﬂow velocity of left ventricular rapid
ﬁlling (E), that of atrial contraction (A) and the ratio of E to A (E/A), deceleration time
of E and time of isovolumetric relaxation.
Of the 48 patients with CAD 41 (85%) patients developed ishaemia-ECG ST
changes and wall motion anomalies after pick Exercise. In this subgroup patients 11
develop restrictive Doppler patern (E greater fourfold then A), 8 pseudonormalisation pattern and 22 worsen E/A ratio in sense delayed relaxation pattern. Those
changes were statistical signiﬁcant in relation to rest and pick exercise in normal subjects(p< 0.01). In patients without developing ischaemia Doppler indices
changed with less extent but statistically signiﬁcant versus normal (p< 0.05) and
patients with presence of myocardial ischemia. Mitral regurgitation may changed
diastolic parameters.
These results suggest that in acute myocardial ishaemia changes in Doppler diastolic indices reﬂect extent and severity of myocardial ischemia. Both systolic wall
motion abnormalities in pick stress exercise test and Assesmant of diastolic parameters contributs to non invasive determination of severity and extent of coronary
artery disease.
Abstracts
743
Strain rate best quantiﬁes regional contractile reserve during dobutamine
stress echocardiography in patients with ischaemic left ventricular
dysfunction.
R I. Williams 1 , N. Payne 2 , A. Tweddel 3 , J. D’Hooge 4 , A G. Fraser 1 . 1 University
Hospital of Wales, Wales Heart Research Institute, Cardiff, United Kingdom;
2
Providence Health System, Portland, Oregon, United States of America;
3
University Hospital of Wales, Cardiology Dept., Cardiff, United Kingdom;
4
University Hospital Gasthuisberg, Department of Cardiology, Leuven, Belgium
Background: Detection of viability in myocardium that contracts poorly due to recurrent ischaemia is clinically important because hypokinetic or akinetic segments
may recover function if treated promptly by revascularisation. Experiments suggest
that non-invasive diagnosis may be possible using tissue Doppler echocardiography (TDE). Myocardial velocity responses to dobutamine can indicate ischaemia in
patients with normal resting function, but changes in regional deformation indices
may be more speciﬁc to diagnose viability since they are less inﬂuenced by motion
of adjacent segments. We studied which TDE parameters can quantify functional
reserve before and after coronary bypass surgery (CABG).
Methods: 23 patients (21 men) aged 61±10 years, who had multivessel coronary
artery disease and poor left ventricular (LV) function (ejection fraction (EF) <35%
on Technetium 99 blood pool scan) underwent graded dobutamine stress echocardiography, and also nitrate-enhanced rest-redistribution Thallium 201 perfusion
imaging, both before and 6 months after CABG. TDE parameters were analysed
off-line in basal, mid-wall and apical segments, imaged from the apex (SPEQLE,
University of Leuven). Perfusion images were analysed and scored from polar plots
scaled to 100%, using a 16-segment model with a cut-off of 50%.
Results: EF did not change after CABG (32±17% pre-op v 34±13% post-op) but
mean segmental perfusion scores improved (6.7±2.7 to 9.8±2.7; p<0.02). By TDE,
peak systolic velocity in basal myocardial segments increased during dobutamine
both before (from 2.7±0.2 to 6.1±0.6 cm/s; p<0.001) and after CABG (from 2.0±0.2
to 4.8±0.5 cm/s; p<0.001). Segmental functional reserve was also demonstrated by
increases in maximal systolic strain rate at peak dobutamine dose, both before (from
-0.7±0.1 to -1.0±0.1/s; p<0.001) and after CABG (from -0.7±0.1 to -1.1±0.1/s;
p<0.001). In contrast, systolic strain in basal segments fell slightly from rest to peak
dobutamine stress before CABG (from -8.4±0.9 to -6.1±0.7%; p<0.05) and after
CABG it did not change (-8.2±0.9 to -7.1±0.7%, ns).
Conclusion: In patients with ischaemic LV dysfunction, regional myocardial reserve
cannot be demonstrated by measuring segmental strain at peak dobutamine stress,
probably because strain is a load-dependent index. Changes can be observed in
myocardial velocities but these are non-speciﬁc since they are inﬂuenced by tethering. Thus in patients with suspected viable myocardium, responses to dobutamine
should be assessed using systolic strain rate as the most useful parameter of regional deformation.
744
Stress echocardiographic left ventricular systolic response to adenosine
differs from that of dobutamine and supine bicycle exercise: a tissue
Doppler study on healthy volunteers.
S.K. Saha 1 , L-A. Brodin 1 , B. Lind 1 , E. Strååt 2 , S. Gunnes 1 . 1 Huddinge University
Hospital, Clinical Physiology Dept., Stockholm, Sweden; 2 Huddinge University
Hospital, Department of Cardiology, Stockholm, Sweden
Background: Published data on dobutamine stress echocardiography (DSE) quantiﬁed by tissue Doppler (TVI) have provided useful clinical data. However, quantiﬁcation of other stress modalities e.g., adenosine stress echo (ASE) and exercise stress
echo (ESE) are also necessary for assessing the physio (patho)logical differences
of different forms of stress.
Methods: 24 healthy men and women volunteered to undergo ASE and DSE on the
same day. A subgroup of them (n=10) also underwent ESE on a different day. Left
ventricular (LV) apical images at rest and peak stress (max) were post processed
using TVI on a GE System V equipment. ECG QRS duration (QRSD,ms), heart
rates (HR,bpm), basal systolic velocities (S2V,cm/s), ejection time (S2T,ms), and
strain (S%) were compared. *p=0.04, **p=0.005.
Results: Data for ASE, DSE, and ESE were (For max HR: 84±12**,
142±19, 137±27,), (For QRSD: 92 ±18*, 74±13, 79±9), (For S2T: 306.78
±33.97**, 175.03±53.44, 191.90±24.96), and (for S%: 25.83±2.79, 21.20±7.33,
22.10±5.12) respectively. Resting S2V was 6.5±0.7 while that at max varied from
10-15 for DSE and ESE and between 7.4 to 7.6 for ASE. Velocity response was lowest for ASE, highest for DSE and somewhat intermediate during ESE (all p<0.05
except for septum during ESE vs. DSE, vide Fig.).
S97
Conclusion: ASE evokes signiﬁcantly weaker LV systolic response compared with
the DSE & ESE. However, an increased velocity (p<0.05 vs. rest) and strain
(p>0.05) response at a much lower HR indicates that adenosine has some minor inotropic effects presumably secondary to hyperemia. Powerful chronotropic response to DSE & ESE is probably a prerequisite for strong velocity response albeit
at the expense of strain.
745
Echo transesophageal stress with dobutamine: better screening for
coronary artery disease.
J. Tress 1 , L.S. Da Costa 2 , R.C. Victer 3 , J.L.S. Machado 3 , R.S. Peixoto 3 ,
T.C.D. Estrada 4 , M.R. Dantas 4 , M.A.R. Torres 5 , R. Schult 4 . 1 Rio de Janeiro; 2 Sta
Casa de Misericórdia, Cardiology, Rio de Janeiro; 3 Hospital De Clinicas De Niteroi,
Echocardiographic Laboratories, Rio De Janeiro; 4 Hospital de Clinicas de Niteroi,
Anesthesiology, Niteroi; 5 Rio Grande do Sul University, Cardiology, Porto Alegre,
Brazil
Analysis of ischemia in Coronary Artery Disease (CAD) has been conducted in
numerous ways, but few at the patient’s bedside, others present difﬁculties in terms
of physical capacity, age, or sex.
Aims and Methods: We performed our study of dobutamine stress with echo transesophageal echocardiography (ETED) and the help of Power Doppler (PD) on 200
individuals with suspected CAD, 115 men and 85 women, between the ages of 30
and 84, weighing between 40 and 168 kg and 140 to 188 cm tall.We achieved a
100% success rate in testing individuals, all being sedated with propofol without
undue problems.We used the protocol for dobutamine stress with 5, 10, 20 and 30
mcg/kg/min and up to 2 mg of atropine when necessary to obtain cardiac frequency
of 85% of the maximum expected for the patient’s age.We analyzed 16 segments
of the left ventricle using ETED according to criteria established by the American
Society of Echocardiography. Using the PD technique, we evaluated the coronary
ﬂow in the trunk, anterior descending artery, circumﬂex artery and right coronary
artery to determine the degree of estenose of the reserve coronary ﬂow and the
rate of coronary vascular resistance.
Results: The method was 92% in terms of sensitivity and its speciﬁcity corresponded to 96%, the predictive negative value over 6 months was 98%. The predictive positive value of coronary artery disease of hemodynamic signiﬁcance, according to the analysis of coronary ﬂow, was 100% in relation to the angiographic
study with lesions to more than 70% of anterior descending arteries, but the negative predictive value was 44% in relation to all coronary vessels. The response to
endocardic viability in relation to the coronary reperfusion by hemodynamic and/or
surgery was 100% in 6 months.
We concluded that echocardiography for Echo Transesophageal dobutamine stress
with Power Doppler is the best test for determining whether or not it is an obstructive ischemic coronary disease and the one with the best result of all methods of
investigation and It is easy to perform, even at the bedside, and regardless of the
patient’s physical capacity, age and sex.
746
Is there any role for baseline brain natriuretic peptide and its changes
post dobutamine stress echo for myocardial viability interrogation?
G. Athanassopoulos 1 , D. Degiannis 2 , I. Ekonomides 3 , M. Marinou 2 ,
G. Hatzigeorgiou 2 , G. Karatasakis 2 , J. Lekakis 3 , D.V. Cokkinos 2 . 1 Cardiology
Department, 2 Cardiology Department, Onassis Cardiac Surgery Center, Athens,
Greece; 3 Alexandra Hosp, Cardiology Department, Athens, Greece
Introduction: Brain natriuretic peptide, a marker of heart failure, is produced mainly
by the left ventricle (LV) and is related with regional wall tension, reﬂecting LV enddiastolic pressure. There are no data concerning its dynamic changes induced by
dobutamine stress echo (DSE) during interrogation of viability.
Methods: We studied 31 consecutive pts for viability (age 59±8, male/female 28/3,
16 with previous transmural myocardial infarction, ejection fraction 33±11%, range
15-55). All underwent conventional DSE (16 segments model) and the DSE score
was estimated. Sampling of BNP was performed at rest (R) and during recovery
(Rec), 15 min post discontinuation of DSE. During a 68±10 months follow-up (fup)5 pts died and 10 deteriorated to NYHA class III/IV.
Results: Twenty four/31 pts had a positive DSE for viability. 6/24 pts had a biphasic
response. Nine/24 pts had at least 4 viable segments. Viability was detected in LAD
territory in 14/24 pts. Overall, pts manifesting viability had similar changes of BNP
compared with a negative DSE.
However, pts having viability in the LAD territory had a trend for increase in BNP
(Rec) compared with those having viability in other zones (absolute changes:
49±123 vs -24±63 respectively p=0.06). Using ROC analysis, an increased BNP
(Rec) compared with R, had sensitivity 0.71 and speciﬁcity 0.70 for prediction of
LAD viability. Biphasic response did not inﬂuence BNP (Rec) levels.
Pts with at least 4 viable segments had lower BNP (R) levels compared to those
with <4 viable segments (161±66 vs 321±244 p=0.03). Using ROC analysis for
prediction of at least 4 viable segments, then a cut off value of 240 was found for
resting BNP (sens=1, spec=0.5). At follow-up, among pts with detection of viability
those with a resting BNP >230 had a greater incidence of cardiac events (KaplanMeier log rank, p=0.027).
Conclusion: Low BNP baseline levels may predict the presence of an appreciable amount of viable tissue by DSE. Increased BNP during DSE are related with
detection of viability in the LAD territory. Increased BNP levels at rest are related
independently from detection of viable tissue with a worse cardiac prognosis.
Eur J Echocardiography Abstracts Supplement, December 2003
S98
Abstracts
747
Spinal cord stimulation effects in patients with angina and normal
coronary arteries.
750
Geometrical linearization of aortic contour: angiographic sign in acute
intramural aortic hemorrage detected with transesophageal echo.
A. Sestito 1 , G.A. Sgueglia 2 , F. Infusino 2 , F. Pennestrì 2 , F. Bellocci 2 , F. Crea 2 ,
G.A. Lanza 2 . 1 Università Cattolica del Sacro Cuore, Istituto di Cardiologia, Rome,
Italy; 2 Policlinico A. Gemelli, Istituto di Cardiologia, Rome, Italy
F. Bovenzi 1 , P. Colonna 2 , L. De Luca 2 , N. Signore 2 , F. Fusco 2 , L.B. Corlianò 2 ,
A. Roma 3 , I. De Luca 2 . 1 Azienda Ospedaliera Policlinico, Division of Cardiology,
Bari, Italy; 2 Azienda Ospedaliera Policlinico, Division of Cardiology, Bari, Italy;
3
PolisEngineering Studio, Milan, Italy
Background: Spinal cord stimulation (SCS) has been shown to improve anginal
symptoms and exercise tolerance in a signiﬁcant number of patients with refractory
angina and normal coronary arteries.
The aim of this study was to assess the inﬂuence of SCS on anginal symptoms and
on electrocardiographic and echocardiographic evidences of myocardial ischemia
induced by pharmacological stress.
Methods: We studied 6 patients (59,6 ± 6,1 years; 4 women) with cardiac syndrome X (angina, positive exercise test and normal coronary arteries at angiography) treated with SCS because of chest pain refractory to full drug therapy. Stress
echocardiography was performed in all patient in random order during SCS switched
on and after a 15 days period of SCS suspension. The cardiac images were acquired by a 2.5 MHZ probe connected to a Toshiba set, Power Vision 8000. Dobutamine was infused starting with a dose of 5 mcg/kg/min over 5 minutes with successive incremental steps of 10 mcg/kg/min every 3 minutes up to a maximal dose of
40 mcg/kg/min. Arterial pressure, 12-lead electrocardiography and two-dimensional
echocardiography were monitored during the infusion of the drug and in the recovery period.
Results: In all patients, global and segmentary contractility was normal at rest and
during the test. Test duration with SCS switched on was 15±2,4 versus 14,5±1,2
minutes with SCS switched off (p=NS). With SCS switched on compared to SCS
off, angina was experienced by 4 patients vs. 5 patients (p=NS), but angina duration and angina onset time appeared to be respectively shorter (9± 7,9 vs. 12,5±7,3
minutes) and delayed (11,6±3,5 vs. 9±1,7 minutes), although not reaching statistical signiﬁcance. With SCS switched on, ST segment depression was present less
frequently than with SCS off (3 patients vs. 6 patients; p=0,03) and appeared latter
during the execution of the test (13,3±2,1 vs. 9±1,7 minutes from start; p=0,04),
respectively.
Conclusion: The data of this preliminary study indicate that SCS decreases the incidence of electrocardiographic signs of ischemia among patients with cardiac syndrome X. This ﬁnding is consistent with previous observation of an anti-ischemic
suppressor effect of SCS on the intrinsic cardiac nervous system. Also, SCS shows
a tendency toward improvement of angina (which doesn’t reach statistical significance possibly because of the little number of patients studied). However, SCS
inﬂuence doesn’t appear to be mediated by improvement in left ventricular contractility since it remains normal during stress, both with SCS switched on and off.
VASCULAR FUNCTION
749
Heterogeneity of vessel distension within the common carotid artery wall:
implications for functional analysis.
P. Segers 1 , S.I. Rabben 2 , J. De Backer 3 , J. De Sutter 3 , T.C. Gillebert 3 , L. Van
Bortel 4 , P. Verdonck 5 . 1 Ghent University, Hydraulics Laboratory, Ghent, Belgium;
2
Rikshospitalet University Hospital, Institute for Surgical Research, Oslo, Norway;
3
Ghent University Hospital, Cardiology Department, Ghent, Belgium; 4 Ghent
University Hospital, Department of Pharmacology, Ghent, Belgium; 5 University of
Ghent, Hydraulics laboratory, Ghent, Belgium
We measured diameter distension (DD) and circumferential strain (DD/D) at the
lumen-intima (inner wall) and intima-adventitia (outer wall) boundaries for the common carotid artery in 39 subjects covering a wide range of ages (18 – 83 years)
and clinical conditions using a prototype ’wall tracking’ system based on the Vivid7
scanner. Additionally, data were compared to Pie-medical Wall Track System (WTS)
measurements on the same subjects. Tracking the inner and outer wall, diastolic diameter (Ddia) is 5.70 ± 0.80 and 6.91 ± 0.98 mm, respectively, DD is 0.54 ± 0.16
and 0.49 ± 0.16 mm and DD/D yields 0.096 ± 0.030 and 0.071 ± 0.026, respectively. For WTS, Ddia, DD and DD/D are 7.04 ± 1.02 mm, 0.45 ± 0.14 mm and 0.066
± 0.022, respectively. An intersession intra-observer variability on a subgroup of 10
subjects yielded coefﬁcients of variation of 3.7% for Ddia, 6.8% for DD and 7.9%
for DD/D for the inner wall; for the outer wall, these numbers become 2.9%, 3.8%
and 4.8%, respectively, while
WTS yields 4.5%, 7.5% and
7.5%. Our data clearly demonstrate a strain heterogeneity
within the vessel wall due to
systolic wall thinning, DD and
DD/D being on average 10%
and 25% higher on the inner
than on the outer wall, respectively (ﬁgure). Follow up studies in larger cohorts trials are
mandatory to assess the clinical relevance of circumferential
strain heterogeneity and to assess whether tracking the inner
wall yields distension parameters with a higher cardiovascular prognostic potential.
Eur J Echocardiography Abstracts Supplement, December 2003
Background: In suspicion of aortic dissection (AD), the presence of a intramural
hematoma (IMH) may appear negative at aortic angiography, but visible at transesophageal echocardiography (TEE). We hypothesized that the linearization of angiographic aortic contour can be considered an angiographic sign for ascending
aorta IMH.
Methods: We studied 83 patients with suspected thoracic aorta dissection with
color Doppler TEE and, because of uncertain diagnosis, 69 of them with contrast
aortic angiography. In 49/69 patients the diagnosis of AD was conﬁrmed at surgery,
at autopsy or with the concordance of TEE and angiography. In a geometrical model
of aortic angiography, measuring the tangential angles to the two circumference
arches of the outer (AB and BC) and the inner (DE) contour, a linearization of the
aorta was diagnosed if the sum of the two outer angles was <30° (ﬁgure left) or the
inner angle was >130° (ﬁgure right).
Results: Among the 20 patients without dissection or IMH at TEE and angiography,
only one patient showed linearization of the inner contour of the aorta (speciﬁcity
95%). All the 4 patients without overt AD at angiography, but showing IMH at TEE
and at surgery, showed linearization of the aortic contour (sensitivity 100%): of the
sum of outer angles (1pt), of the inner angle (1pt) of both inner and outer angles
(2 pts). Linearization was not calculated in the 45 patients with an angiography
diagnostic for AD.
Angiographic aortic linearization
Conclusion: In patients with suspect for AD and a negative contrast angiography,
linearization of the thoracic aorta raise a suspicion for IMH, especially if preceded
by a TEE suspicion.
751
Comparison of echocardiography and magnetic resonance imaging in the
evaluation of the aorta in patients with Turner syndrome.
L. Lanzarini 1 , G. Prete 2 , D. Larizza 3 , V. Calcaterra 3 , G. Meloni 4 , C. Klersy 5 .
1
Cardiology Department, Pavia, Italy; 2 Cardiology Dept., 3 Pediatrics Dept.,
4
Radiology, 5 Biometry Service, IRCCS Policlinico S. Matteo, Pavia, Italy
Patients with Turner syndrome (TS) may have proximal aortic dilatation and thus suffer aortic dissection. Magnetic resonance imaging (MRI) and transthoracic echocardiography (TTE) may be used to measure aorta, but TTE is less expensive, widely
available and repeteable.
The aim of this study was to evaluate aortic diameters (AD) with TTE and MRI to
asses the agreement between the 2 methods in measuring AD(AR=aortic root, AscTA=ascending thoracic aorta, AArch=aortic arch, DTA=descending thoracic aorta,
AbA=abdominal aorta). 75 consecutively karyotipically proven TS pts aged 3-39 yrs
(mean age 22±9yrs) were included in the analysis. 6% pf pts had aortic coarctation operated before the study. MRI was performed in 57/75 pts (76%). The reason
why MRI was not performed were: 12% refusal by the pts, 7% long waiting list, 4%
presence of metallic material inside the body, 1% lost to follow-up. To assess the
agreement between TTE and MRI, the Bland and Altman method together with the
calculation of the Lin concordance correlation coefﬁcient and 95% CI, was used.
The table shows the results of the analysis. To better understand the reason for
discrepancies, we also calculated the absolute differences at each measurement
level (considering irrelevant differences =/<1mm and overestimation by TTE or MRI
for differences >1mm). Identical measurements were obtained in 45.6% of cases
at AR, 29% at AscTA and 23.5% at DTA. TTE overestimated MRI measurements in
69.1% of cases at AArch level, whereas MRI usually overestimated TTE values at
the other levels.
AR (mm)
AscTA(mm)
AArch(mm)
DTA(mm)
AbA(mm)
Paired
differences
Limits of
agreement
Concordance correlation
coefﬁcient
95% CI
95% CI
0.21
-0.86
3.1
-1.6
-2.3
-4.6;5.1
-5.3;3.5
-4,3;10.6
-7;3.9
-5.9;1.2
0.81
0.86
0.22
0.42
0.58
0.72-0.89
0.79-0.92
0.10-0.35
0.24-0.60
0.44-0.73
Conclusions: 1) accuracy of TTE and MRI for measuring AR diameters is almost
identical; 2) measurements of distal thoracic aorta are more precisely obtained with
MRI; 3) because AR dilatation is the major risk factor for dissection of the aorta,
TTE may be considered the method of ﬁrst choice for screening purposes and to
follow-up aortic disease in TS pts.
Abstracts
752
Aortic wall thickness and pulsatility - do they represent the same aspect
of atherosclerosis?
754
Evaluation of the association between intima-media thickness and
stiffness of the common carotid artery.
J. Drozdz 1 , L. Chrzanowski 2 , M. Krzeminska-Pakula 2 , P. Lipiec 2 , M. Plewka 2 ,
M. Ciesielczyk 2 , K. Wierzbowska 2 , J.D. Kasprzak 2 . 1 Medical University Lodz,
Cardiology, Lodz, Poland; 2 Medical University, Cardiology Dept, Lodz, Poland
K. Niki, D. Chang, M. Sugawara. Tokyo Women’s Medical University,
Cardiovascular Sciences, Tokyo, Japan
The ability to render the volume of a speciﬁed structure by three-dimensional (3-D)
transesophageal echocardiography (TEE) provides the opportunity for quantitation
of atherosclerosis by measuring its two components: atherosis (wall thickness) and
stiffness (aortic pulsation). The purpose of the study was to quantify intima-media
complex volume and the volume of selected aortic segments’ lumen in systole and
diastole.
Study group consisted of 38 consecutive patients referred for the routine TEE.
Thoracic aorta was scanned by rotational 3-D TEE. Reformatted datasets were
reviewed and the lumen-intima and media-adventitia interfaces were determined.
Serial volumetric calculations of 2 cm segments at three levels of the thoracic aorta
were performed.
The volume of lumen of two-centimeter segments measured at three levels of the
thoracic aorta (30 cm, 35 cm and 40 cm from incisors) varied from 7.3 to 17.6 cm3
(mean 12.0±3.2, 11.5±3.1 and 10.9±2.5 cm3 respectively). The volume of intimamedia complex varied from 0.5 to 5.0 cm3 (mean 1.8±1.0, 1.6±1.0 and 1.7±1.1
cm3 respectively). Aortic pulsation deﬁned as the difference between the largest and
the smallest lumen volume of the same aortic segment varied from 0.0 to 2.8 cm3
(mean 1.3±0.5, 1.1±0.7 and 1.1±0.6 cm3 respectively). The intima-media complex
volume was correlated with the aortic lumen volume (R2=0.55, p<0.001), but not
with the aortic pulsation (R2=0.02, p=NS).
The differences in the measurements of aortic lumen volume, aortic pulsation
and intima-media complex volume by the same observer were 0.22±0.10 cm3 ,
0.07±0.08 cm3 and 0.21±0.06 cm3 respectively, whereas by two observers
0.23±0.15 cm3 , 0.14±0.13 cm3 and 0.17±0.03 cm3 respectively. Following risk
factors were independently related to the intima-media complex volume: hypertension (p<0.001), hyperlipidemia (p=0.032) and cigarette smoking (p=0.045). Age
(p<0.001), diabetes (p=0.002), masculine gender (p=0.014) and family history
(p=0.014) were related to the aortic pulsation.
Conclusions: Aortic intima-media complex volume and aortic pulsation represent
different aspects of aortic properties and are related to different clinical risk factors
of atherosclerosis.
753
Impaired response of the brachial artery to nitroglycerine in patients with
limb-girdle muscular dystrophy.
N. Giatrakos 1 , M. Kinali 2 , F. Muntoni 2 , P. Nihoyannopoulos 3 on behalf of NHLI,
ICSM Hammersmith Hospital, Cardiology dept., London, UK. 1 London, United
Kingdom; 2 Dept of Paediatrics, ICSM, Dubowitz Neuromuscular Centre, London,
United Kingdom; 3 Hammersmith Hospital, Cardiology dept, NHLI, ICSM, London,
United Kingdom
Background: Sarcoglycan-deﬁcient Limb-Girdle Muscular Dystrophies (SD-LGMD)
are caused by mutations in one of the genes of the sarcoglycan (SG) complex
[alpha, beta, gamma and delta], encoding for transmembrane proteins part of the
dystrophin-glycoprotein complex. The alpha and gamma SGs are expressed in the
skeletal and cardiac muscle while beta, delta are also expressed in smooth muscle cells (SMC), where they form a complex along with epsilon SG and sarcospan.
Dilated cardiomyopathy is a frequent complication of the SD-LGMD, especially of
beta and delta and this led to the suggestion that smooth muscle dysfunction could
have a contributory role. This was also suggested by previous in vivo studies in
animal models and in humans with SD-LGMD which showed abnormal coronary
function. The aim of this study was to identify a vascular SMC dysfunction in SDLGMD patients. In order to determine the maximum vasodilator response we used
nitroglycerin (NTG) that served as an exogenous NO donor. That would be a measure of endothelium independent vasodilatation, reﬂecting the function of the SMC
of the arterial wall.
Methods: The brachial artery was assessed in 6 patients with conﬁrmed diagnosis of SD-LGMD (4 F, 2 M) mean age 20.5 yrs (range 7.5-32.5). Four patients had
mutations in beta and 2 in gamma SG. They were compared to six age matched
controls (4 F, 2 M). None of the subjects had history or risk factors for cardiovascular disease, were non-smokers and did not drink coffee or tea for at least 24 hours.
They all had normal classic echocardiograms. A high dose of 0.8mg NTG spray was
given sublingually. Imagining was performed using the HDI 5000 ultrasound system
(Philips Medical Systems) with a 5-12 MHz linear transducer. The images were digitally stored and analysed off-line using dedicated software (HDI-lab, Philips Medical
Systems). The ECG was recorded during image acquisition and all measurements
were performed at end diastole.
Results: NTG induced dilatation was impaired in patients with LGMD when compared to controls (12.9±2.3% vs.22.7±2%, p=0.01).
Conclusion: Vasodilator response to NTG is impaired in patients with LGMD irrespective of the primary genetic defect. These results might indicate a vascular SMC
dysfunction in SD-LGMD.
S99
Background: Intima-media thickness (IMT) and stiffness of the common carotid
artery are indices of atherosclerosis and arteriosclerosis. Both indices increase with
age. However, the relationship between IMT and arterial stiffness is not clear. The
purpose of this study was to investigate whether an increase in IMT is associated
with an increase in stiffness.
Methods: We obtained carotid arterial IMT and stiffness parameter, beta, from 171
subjects (total:311 sites, age, 16-80 years). With an echo-tracking system (Aloka
SSD-5500, Japan), we measured pulsatile changes in carotid arterial diameter, systolic (Ps) and diastolic (Pd) pressure in the brachial artery, and calculated beta,
which is deﬁned as beta = ln(Ps/Pd)/[(Ds-Dd)/Dd]. Here, Ds is the maximum diameter and Dd the minimum diameter. After the measurements, we calculated the
mean IMT in the whole study group, and deﬁned subgroup A as having an IMT
greater than the mean IMT.
Results: IMT was 0.70 ± 0.25 mm and beta was 12.0 ± 5.1. IMT and beta were
correlated with age (IMT: r= 0.62, beta: r= 0.72), and IMT was correlated with beta
(r=0.52, p < 0.0001) in the whole study group. However, in subgroup A (148 sites),
IMT did not correlate with beta (r = 0.08, P = 0.3)(Figure).
Relationship between IMT and beta
Conclusions: In the group with IMT greater than 0.7mm, IMT did not correlate with
arterial stiffness.
755
Endothelial function, blood pressure and lipids in pre-eclamptic patients
one year after delivery.
M. Eriksson 1 , R. Raﬁk Hamad 2 , K. Bremme 2 . 1 Department of Clinical Physiology,
Stockholm, Sweden; 2 Karolinska Hospital, Department of Woman and Child
Health, Stockholm, Sweden
Background: Pre-eclampsia (PE) remains a major cause of maternal and fetal mortality. It is believed that inadequate trophoblast invasion of uterine spiral arteries
leads to placental ischemia and release of factors that damage maternal vascular
endothelium.
The aim of this study was to investigate vascular endothelial function, lipid proﬁle
and ambulatory blood pressure one year after delivery, in patients with previous PE
and in age-matched healthy controls (CON).
Methods: Flow-mediated vasodilatation (FMD) of the brachial artery was determined non-invasively by ultrasound technique, in 18 patients with previous PE and
16 age-matched, healthy CON, one year after delivery. FMD, blood pressure and
lipids were examined during the follicular and luteal phases of the menstrual cycle.
Results: FMD was decreased in the PE group, 3± 3% versus Con 10±2%
(p<0.0001), while the diameter of the artery and ﬂow response did not differ between the two groups. There was no difference in FMD or NTG between the two
phases of the menstrual cycle. The systolic and the diastolic blood pressure was
higher in the PE group, 111/74 mm Hg, versus 102/65 mm Hg in Con, (p=0.011 and
p=0.003). Total cholesterol was higher in the PE group, but only in the luteal phase.
Conclusion: Our results showed that PE is associated with higher blood pressure
and decreased endothelial-dependent vasodilatation, one year after delivery in patients with previous PE. These ﬁndings suggest that the impairment of the endothelial function is prolonged and may be of clinical importance for future cardiovascular
events.
Eur J Echocardiography Abstracts Supplement, December 2003
S100
Abstracts
756
High doses of simvastatin in acute coronary syndromes and ﬂow
mediated dilation in long-term observation.
K. Mizia-Stec 1 , Z. Gasior 1 , J. Janowska 2 , E. Jastrzebska-Maj 1 , A. Szulc 1 ,
M. Piekarski 1 , S.Z. Gomulka 1 , Z. Mucha 2 , B. Zahorska-Markiewicz 2 .
1
Department of Cardiology, 2 Department of Pathophysiology, Silesian University
School of Medicine, Katowice, Poland
Background: There is an increasing evidence that statins exert pleiotropic effects,
e.g., they modify vascular dysfunction observed in CAD. Flow-mediated dilation
(FMD) in brachial artery (BA) is a non-invasive measure of endothelial function.
The aim of our study was to compare the inﬂuence of standard and high doses
statin therapies on the FMD in CAD patients in long-term follow-up.
Material and Methods: We examined 44 patients with CAD randomized in two
groups: Group S (+): 22 patients with acute coronary syndromes who were administered high doses of simvastatin (80mg per day) over a period of one month from
cardiac event; Group S (-): 22 patients with acute coronary syndromes treated by
standard doses of other statins according to lipid proﬁle. After one year obsevation
clinical data, pharmcotherapy, concominat diseases, and FMD were all assessed.
FMD was measured as the percent change of BA diameter after 3 min occlusion
(FMD%), and after nitroglycerin administration (FMD-NTG%).
Results: In one year-follow-up we did not ﬁnd any difference between clinical data
of the groups examined. Pharmacotherapy were also comparable in study groups all subjects were treated with standard doses of statins and their lipid proﬁles were
within normal range. However, differences in FMD% were noted (see Table 1). The
FMD-NTG% were comparable in the study groups.
FMD in groups: S (+) and S (-).
Brachial artery (mm)
FMD%
FMD-NTG%
Simnastatin (+)
Simvastatin (-)
41.5 ± 5.0
10.2 ± 4.8 *
15.2 ± 5.9
40.7 ± 6.9
7.3 ± 4.3
13.9 ± 8.6
* (p<0.05)
Conclusions: High doses of simvastatin used in acute coronary syndrome regardless of serum lipids are of positive value for endothelial function improvement in
long-term observation.
757
Distal, but not proximal, aortic dissection is associated with severe
thoracic aortic atherosclerosis. A transoesophageal echocardiographic
study.
J.D. Barbetseas, A.G. Marinakis, G.P. Vyssoulis, S.V. Brili, C.J. Aggeli,
A.A. Fragoudaki, C.I. Stefanadis, P.K. Toutouzas. Athens University, Cardiology
Department, Athens, Greece
Background: Aortic dissection (AD) is the most frequent fatal disease in the spectrum of the chest pain syndromes, and all mechanisms that weaken the aortic wall
may result in this condition.The aim of our study was to evaluate the association
between thoracic aortic atherosclerosis (TAA) and AD.
Methods: We assessed TAA in 71 patients (pts) (49 males, 22 females, mean age
62 years) with aortic dissection, who underwent transesophageal echocardiography
at our laboratory during a 10-year period. Forty eight pts had proximal (Stanford type
A) and 23 pts had distal(Stanford type B) dissection.
Results: Severe TAA, with plaques thicker than 3mm were detected in 30/71 (42%)
pts, while the others had mild (40%) or no (18%) TAA. Thick plaques were found
in 18/23 (78%) of type B and only in 12/48(25%) of typeA dissection (p=0.00002).
In addition, pts with distal dissection were older (70 vs 58 years, p=0.00007), more
frequently hypercholesterolemic (65 vs 38%, p=0.03),and did not differ (p=NS) in
smoking (30 vs 44%) and diabetes (13 vs 17%). In both groups there was a high incidence of hypertension (83 and 63% respectively), but without statistical signiﬁcant
difference (p=NS).
Conclusion: Severe TAA is associated mainly with distal and not with proximal aortic dissection. These ﬁndings indicate that atherosclerosis, which is a lesion of the
intima, possibly contributes to the increased vulnerability of the descending thoracic
aorta in this group of patients.
758
Stentless aortic bioprosthesis competence and aortic root geometry.
W. Li 1 , X.Y. Jin 1 , P. Kumar 1 , C. O’Sullivan 2 , M. Henein 2 , J. Pepper 1 . 1 Royal
Brompton Hospital, London, United Kingdom; 2 Royal Brompton Hospital,
Echocardiography, London, United Kingdom
Background: Long term competence of stentless aortic bioprosthesis is critical to
its clinical durability. We prospectively assess the incidence of stentless valve regurgitation and its relation to the changes in aortic root geometry.
Methods: Aortic root geometry and valve competence were studied in 50 patients
(mean age 65±9 years) who received a stentless bioprosthesis between 1992 and
1996. Doppler echocardiographic studies were performed at 2±0.6 and 6±1.4 years
after the aortic valve replacement. The degree of aortic regurgitation was graded as
1-4/4 using color Doppler. The diameters of aortic annulus, sino-tubular junction
and ascending root were measured from 2D echo at peak systole and indexed to
the valve size implanted.
Eur J Echocardiography Abstracts Supplement, December 2003
Results: Of 50 patients studied, 12 patients had AR with 2.0±1.7 grade at late
echo follow up. This group of patients were associated with signiﬁcant increase
in the diameter of sino-tubular junction (14±23 vs -4±18, % of prosthesis size,
p=0.008) and ascending root (23±24 vs -6±19, % of prosthesis size, p<0.001) than
those with no late AR. Preoperative valve disease (AS vs AR), early post-operative
AR, and the present of bicuspid cusp did not affect the late changes in aortic root
geometry.
Conclusion: Long term incompetence of stentless aortic bioprosthesis results in a
signiﬁcant dilatation of native aortic root which can further trigger more severe AR
and thus bioprosthesis dysfunction. Given the signiﬁcant incidence of late AR with
unclear underlying clinical mechanism, an annular echo follow up appears necessary for patients received a stentless aortic bioprosthesis.
759
Role of imaging techniques in diagnosis of aortic intramural haematoma.
G. Avegliano 1 , A. Evangelista 1 , R. Dominguez 1 , M.C. Sebastiá 1 , Z. Gomez
Bosch 2 , M.T. Gonzalez-Alujas 1 , A. Salas 1 , J. Soler-Soler 1 . 1 Hospital Valle de
Hebron, Cardiologia, Barcelona, Spain; 2 Hospital valle de hebron, Cardiologia,
Barcelona, Spain
Aortic intramural haematoma forms part of the acute aortic syndrome and early
diagnosis is required.
Purpose: The aim of the present study was to assess the role of imaging techniques
in intramural haematoma (IMH) diagnosis.
Methods: Of 325 consecutive patients with suspected acute aortic syndrome, 78
were diagnosed by transoesophageal echocardiography (TEE), computed tomography (CT), magnetic resonance imaging (MRI) or anatomically of IMH. Two imaging
techniques were indicated in all cases and a third if disparity existed. The imaging
technique diagnosis was blinded.
Results: TEE yielded 4 false positive diagnoses in type B IMH (2 laminar atelectasias of the lung and 2 intraluminary thrombi) and 2 false negatives in the upper
third os ascending aorta. CT gave a false positive and false negative type B IMH in
descending aorta due to intraluminal aortic thrombosis. MRI made no false positive
or negative diagnoses.
Sensitivity
Speciﬁcity
TEE
CT
MRI
97%
94%
99%
98%
100%
100%
Conclusions: In the diagnosis of aortic intramural haematoma, CT and mainly MRI
are superior to TEE. These data should be borne in mind when acute aortic syndrome is suspected.
760
Aortic atherosclerosis-association with carotid and valvular aortic
sclerosis in elderly.
G.R. Badea 1 , C. Carp 2 , M. Dumitrescu 1 , M. Bolog 1 . 1 Prof Agrippa Ionescu
Hospital, Cardiology, Bucharest, Romania; 2 Prof.Dr.CC Iliescu Institute,
Cardiology, Bucharest, Romania
Nowaday aortic sclerosis is considered to be a form of atherosclerosis and the main
substrat for the development of aortic stenosis.It is associated with a great risk in
cardiovascular morbidity and mortality
Aim: To analyse the relation between transthoracic and transesophageal measurements of the aortic cusps.To investigate the relation between the severity
of aortic sclerosis,the transvalvular ﬂow velocity and aortic area assessed by
transesophageal ecography.To analyse the prevalence and the degree of carotid
atherosclerosis in elderly with aortic sclerosis compared to normal valves.
Method: 41 pts >60 years were examined by transthoracic and transesophageal
echocardiographyand, aortic valve abnormalities were examined and thickness of
the cusps was determined at base,medium level and tip for each cusp. Presence of
aortic sclerosis was the inclusion criteria for groupA (30 pts),normal valve morphology was included in group B (11pts). We also measured aortic area (planimetric)
and transvalvular ﬂow velocities using Doppler method.The ascending aorta, aortic
arch and descending thoracic aorta were imaged by TEE in multiplane long and
short axis.Aortic atherosclerosis was deﬁned as irregular intimal thickening (IMT)
> 2mm-with increased echogenicity. Carotid atherosclerosis -deﬁned as an intimamedia thickness ≥ 1 mm) has been evaluated by bilateral bidimensional echography
of the common carotid artery and bifurcation.
Results: There is a good correlation (r>0.85) between transthoracic measurements
of right and noncoronarian cusp compared to transesofagian method; for the left
cusp the correlation index is low (r=0.61). GroupA has greater transvalvular velocity compared to group B although aortic area and cuspal movement is not restricted.Aortic and carotid atherosclerosis had a higher incidence in group compared to group B.
Conclusion: Transthoracic echocardiography is a good and available method for
the assessment of the aortic valvular morphology. Aortic valvular sclerosis is associated with carotid and aortic atherosclerosis and considered to be a form of valvular
atherosclerosis.
Eur J Echocardiography Abstracts Supplement, December 2003
Poster Session 5
6 December 2003, 8:30 to 12:30
Location: Poster Hall
MODERATED POSTERS
836
Are the clinical and echocardiographic data predictive for the success of
cardioversion of atrial ﬁbrillation?
L. Janoskuti 1 , A. Zsáry 1 , K. Keltai 1 , Z.S. Förhécz 1 , P. Sármán 1 , A. Vereczkei 1 ,
T. Fenyvesi 1 , M. Lengyel 2 . 1 IIIrd Dept. Med., Semmelweis Univ., Budapest,
Hungary; 2 Gottsegen Gy. Institute of Cardiology, Budapest, Hungary
Background: The role of various echocardiographic parameters for assessing the
outcome of CV in patients with AF is controversial.
Objectives: This prospective study evaluated the role of various clinical and
echocardiographic parameters, including the left atrial appendage (LAA) anterograde ﬂow velocity and the pulmonary vein (PV) ﬂow pattern, for prediction the success of electrical cardioversion (CV) in patients with atrial ﬁbrillation (AF).
Methods: Clinical, transthoracic echocardiographic and transesophageal echographic data were analyzed in 100 consecutive patients (54 men, 46 women, 64
with hypertensive, 28 with ischemic, 8 with valvular heart disease) with AF. The age
of the patients, the duration of AF (2-30 days or >30 days), antiarrhythmic treatment
before CV, left atrial (LA) diameter, left ventricular ejection fraction (LVEF), the mean
anterograde ﬂow velocity of LAA, and the systolic (S) to diastolic (D) PV ﬂow velocity ratio were determined. Two groups were compared: successful CV-groupI.: 85
patients, unsuccessful CV-groupII.: 15 patients. Mann-Whitney U test and Fischer t
test were used for statistical analysis.
Results: There was no association between the success of electrical CV and the
following data: the age of the patients (mean age in groupI: 71,6±10,1, in groupII:
71,1±7,9 years p= 0,57), the antiarrhytmic pretreatment (no pretreatment in groupI:
57, in groupII: 12 patients p=0,31), the LA diameter (in groupI: 41,1±9,2, in groupII:
41,8±8,4mm p= 0,65), the LVEF (in groupI: 52,0±11,8, in groupII: 54,9±11,8%
p=0,39), the mean LAA anterograde ﬂow velocity (in groupI: 30,75±14,0, in groupII:
23,8±6,4cm/sec p=0,073), the PV ﬂow (S/D<1 in groupI: 72, in groupII: 14 patients
p=0,68). Only the duration of AF was moderately predictive (<30 days in groupI: 52,
in groupII: 5patients p= 0,044).
Conclusion: Except the long duration of atrial ﬁbrillation, neither clinical, nor
echocardiographic data are predictive for the outcome of electrical CV.
837
Clinical and echocardiographic predictors of 30-days sinus rhythm
maintenance in patients with nonvalvular atrial ﬁbrillation
K. Keltai 1 , A. Zsáry 1 , L. Jánoskuti 1 , A. Róka 1 , C. Juhász 1 , A. Vereckei 1 ,
P. Sármán 1 , T. Fenyvesi 1 , M. Lengyel 2 . 1 Semmelweis University, 3rd Dept. of
Medicine, Budapest, Hungary; 2 National Institute of Cardiology, Budapest,
Hungary
Echocardiographic variables for assessing long-term sinus rhythm (SR) maintenance after successful cardioversion (CV) of nonvalvular atrial ﬁbrillation (AF) are
not accurately deﬁned.
Aim of Study: to evaluate the role of various clinical and echocardiographic parameters for prediction of the long-term preservation of SR in patients with successful
cardioversion (CV) of nonvalvular atrial ﬁbrillation (AF).
Methods: Clinical, transthoracic echocardiographic (TTE) and transesophageal
echocardiographic (TEE) data of 44 consecutive patients (26 men, mean age: 71 ±
10 years) with nonvalvular AF (30 hypertensive, 10 ischaemic, 4 lone), lasting >48
h who had sinus rhythm at one day after successful electrical CV were analyzed for
assessment of 30-day maintenance of SR.
Results: At one-month follow-up, 33 of 44 (75%) patients had SR. The duration of
AF<30 days (33/33, vs 6/11) and the use of amiodarone treatment (12/33 vs. 1/11)
predicted the maintenance of SR. There was no signiﬁcant difference in the left
atrial appendage (LAA) peak emptying ﬂow velocity (28,7 vs 33,8 cm/sec p=0,08)
measured by TEE before CV and left atrial size, ejection fraction (EF), E/A ratio and
deceleration time (DT) between patients with AF and SR neither at day 1 nor at day
30 after CV. At one month the E/A ratio decreased signiﬁcantly compared to day 1
(1,91 vs 1,31, p<0,001). Similarly, the A wave increased signiﬁcantly (55,9 vs 74,3
cm/sec, p<0,0003), while no signiﬁcant difference was seen in the DT. The E/A ratio
measured after CV showed positive linear correlation with the initial LAA peak ﬂow
velocity both at 1 day (r=0,542, p<0,0001) and at day 30 (r=0,475 p<0,0001) in
patients with SR.
Conclusions: Echocardiographic parameters do not, but the duration of AF and
the antiarrhythmic treatment - can identify patients with greater likelihood to remain
in SR at one month after successful CV. Shortly after electric CV the assessment
of the E/A ratio is of limited value in determining the left atrial and the diastolic left
ventricular function. The improvement of the left atrial function was seen already at
30 day in patients with SR. The correlation between the pre-CV LAA peak ﬂow velocity and the post-CV E/A ratio allows to follow-up the patients using transthoracic
echocardiography instead of repeated TEE examinations.
S102
Abstracts
838
Direct measurement of left ventricular outﬂow tract by newly developed
transthoracic real-time-3D-echocardiography increases accuracy in
assessment of aortic valve stenosis.
R. Schnabel 1 , R.S. Von Bardeleben 1 , A.V. Khaw 2 , C. Strasser 1 , S. Mohr-Kahaly 1 .
1
University Mainz, II. Medical clinic, Mainz, Germany; 2 The Neurological Institute
of New York, Columbia Presbyterian Medical Center, New York City, United States
of America
Background: Evaluation of aortic valve stenoses is one to the most important
current clinical applications of echocardiography. The widely employed continuity
equation requires measurement of the left ventricular outﬂow tract (LVOT) area. We
aimed at investigating whether direct measurement in a volume data set is superior
to conventional calculation from the LVOT-diameter.
Methods: We performed left ventricular outﬂow tract measurement in 20 normal
subjects and 15 patients with moderate to severe aortic stenosis with a newly
developed transthoracic real-time three-dimensional echocardiography technique
(SONOS 7500, Philips, Best, Netherlands). The off-line 3D-evaluation software
(TomTec, Munich, Germany) allows free choice of section plains within the acquired
volume data set. The aortic valve area was calculated by two independent observers
according to the continuity equation from the mean of LVOT area values as determined from several sequential systolic frames. These results were compared to
area estimates obtained by M-mode LVOT-diameters (area = Pi * (d/2)exp2). Additionally the sonographically calculated aortic valve oriﬁces were compared to direct
planimetry by transesophageal examination or invasive measurements.
Results: In all cases both observers found a signiﬁcant reduction in LVOT-area during systole (p<0,01). Frequently, the contraction of the LVOT resulted in an elliptical
shape, as underscored by a signiﬁcant decrease of the longitudinal/transverse axis
ratio (p<0,01).
Determination of aortic valvular oriﬁce deviated less from invasively or planimetrically measured values (mean difference: 0,04cm2 ) than conventionally calculated
LVOT-areas based on M-mode (mean difference: 0,16cm2 ).
Conclusion: The transthoracic real-time 3D-echocardiography technique offers
better estimates of aortic valve area, approximating planimetric and invasive measurements, as compared to application of the continuity equation to conventional
M-mode echocardiography.
839
Can plasma NTproBNP assess right ventricular overload in patients with
acute pulmonary embolism?
M. Kostrubiec 1 , A. Bochowicz 1 , M. Szulc 1 , G. Styczyñski 1 , H. Gurba 1 ,
A. Kuch-Wocial 1 , M. Kurzyna 2 , A. Fijalkowska 2 , A. Torbicki 2 , P. Pruszczyk 1 . 1 The
Medical University of Warsaw, Departament of Hypertension, Warsaw, Poland;
2
Institute of Tuberculosis, Department of Chest Medicine, Warsaw, Poland
Objective: Right ventricular (RV) dysfunction can be echocardiographically detected in half of pts with acute pulmonary embolism (APE*). Plasma NTproBNP
released upon myocardial stretch reﬂects left ventricular dysfunction in congestive
heart failure. Therefore we assessed if NTproBNP relates the degree of RV overload
in APE.
Material and Method: We investigated 74 pts (27M, aged 63±17 years) with proven
APE. On admission blood samples were collected for NTproBNP assay (Roche,
ECLIA) and TTE was performed for the determination of RV overload.
Results: APE group comprised 54(73%)pts with RV overload (RV+) deﬁned by
RV/LV >0,6 and/or TVPG>30mmHg with acceleration time of plumonary ejection <80ms, while 20(27%) others showed no alteration in RV morphology or
function(RV-). Plasma NTproBNP was signiﬁcantly lower in RV- than in RV+ (median
183pg/ml (range: 16-31168) vs 4619pg/ml (range: 161-60958),p<0,001). Signiﬁcant correlations between echocardiographic indices of RV overload and NTproBNP
were found (table).
Parameter
r plasma NTpro BNP (pg/ml)
RV/LV
IVC exp
(mm)
TVPG
(mmHg)
RV
(mm)
RRs
(mmHg)
SO2
(%)
0,53
p<0,001
0,49
p<0,001
0,40
p=0,003
0,38
p=0,003
-0,32
p=0,01
-0,34
p=0,008
Correlation between NT-proBNP and echocardiographic indices of RV overload.
Moreover, ROC curve analysis revealed that plasma NTproBNP >200pg/ml showed
98% sensitivity and 55% speciﬁcity for the detection of RV overload.
Conclusions: Plasma NTproBNP reﬂects its severity of RV overload and may be
helpful in its detection in patents with acute pulmonary embolism.
840
Mechanism and prevention of tricuspid regurgitation in patients
transplanted according to the biatrial anastomosis technique: an
echocardiographic study on 150 patients.
M. Dandel, C. Knosalla, S. Buz, O. Gauhan, Y. Weng, M. Pasic. Deutsches
Herzzentrum Berlin, Cardiothoracic and Vascular Surgery, Berlin, Germany
Background: Tricuspid regurgitation (TR) is a common post-transplant complication, especially after biatrial anastomosis. We investigated the mechanism of TR
development after biatrial anastomosis in order to prevent this complication.
Methods: 150 patients with biatrial anastomosis (post-transplant times: 1-12 years)
underwent comprehensive echocardiographic assessments, including morphological and functional tricuspid valve (TV) evaluations, right atrial (RA) geometry measurements, and measurements of the tricuspid annulus (TA) systolic excursion and
tissue Doppler wall motion velocity at different levels of the TA and atrial anastomosis, in addition to invasive hemodynamic evaluations.
Results: Patients with TR equal or higher than grade I had higher RA anterior
wall donor/recipient (D/R) length ratios than those without TR (1.03 ±0.13 vs. 0.80
±0.16; p=0.0011) and in those without TR the RA anterior wall D/R ratios were
lower than the D/R ratios at the interatrial septum (p=0.0001). The RA anterior wall
D/R ratios were predictive for post-transplant TR. With D/R ratios <1, the probability of TR was only 2.2%, whereas for D/R equal or higher than 1.1 the probability
of TR reached 91.7%. We found a positive correlation between D/R ratios and TR
intensity (p <0.01; r=0.69). The ratio between the systolic excursion of the anterior
and septal TA was higher in patients without TR than in those with TR (p=0.003).
The negative correlation (r= - 0.56; p<0.01) found between the RA anterior wall
D/R ratios and the TA anterior/septal systolic excursion ratios suggests that TA systolic excursion is highly dependent on the ratios between the length of different wall
segments. We also found a negative correlation (p<0.01; r= - 0.58) between the
TA anterior/septal systolic excursion ratios and TR. The higher tension of the RA
anterior wall in comparison to the septal wall in patients with D/R >1 and the lower
tension at the anterior RA wall in patients with D/R ratios <1 was proven by tissue
Doppler wall motion velocity measurements. We found no signiﬁcant correlation between pulmonary artery pressure and TR.
Conclusions: Our data suggest that TV competence after biatrial anastomosis is
related to the tension of the anterior RA wall. In patients with relatively short RA anterior wall length due to a short recipient component (D/R >1) the resulting higher
wall tension limits the systolic movement of the anterior TV annulus and consequently impedes optimal valve closure. The preservation of long recipient RA anterior wall segments (D/R <1) prevents the development of TR.
841
Tissue Doppler imaging (TDI) in patients with aortic valve stenosisclinical usefulness and diagnostic accuracy.
C. Bruch, M. Grude, J. Stypmann, G. Breithardt. WWU Muenster, Innere Medizin
C, Muenster, Germany
Background: Mitral annular velocities derived from by tissue Doppler imaging (TDI)
complement traditional variables in the evaluation of left ventricular (LV) performance. The mitral E/E’-ratio has been suggested as an estimate of LV ﬁlling pressures in selected subsets of patients (pts.). However, the diagnostic usefulness of
TDI has not been studied in patients with moderate or severe aortic valve stenosis
(AS).
Methods & Results: 17 pts. with moderate or severe AS (aortic valve area 0.8±0.4
cm/m2 , mean pressure gradient 61±13 mmHg, age 64±11 y., AS group) and
29 age-matched asymptomatic controls (age 60±11 y., CON group) underwent
echocardiographic measurements of ejection fraction (EF) and mitral inﬂow velocities (E, A, E/A-ratio). Mitral annular velocities (S’, E’, A’) derived from pulsed TDI
were obtained at the septal mitral annulus. In AS pts., LV end-diastolic pressure
(LVEDP) and cardiac index (CI) were derived from left and right heart catheterization.
Group
EF
(%)
Mitral
E/A ratio
S’
cm/s)
E’
cm/s)
A’
cm/s)
E/E’
(l/min)
CI
LVEDP
(mmHg)
CON (n=29) 67±8 1.20±0.35 8.3±1.3 10.2±3.0 10.1±2.0 6.5±1.5
AS (n=17)
60±11 1.12±0.84 5.5±1.22 5.6±1.62 8.3±2.61 13.6±4.42 2.6±0.5
1
17±6
p<0.05, 2 p<0.01 vs. CON group.
In AS pts., E/E’ was signiﬁcantly related to LVEDP (r=0.92, p<0.001). Derived from
receiver operating characteristic curve analysis, an E/E’ > 13 identiﬁed pts. with
LVEDP > 15 mmHg with a sensitivity 78% of and a speciﬁty of 88% (area under
the curve: 0.91±0.07). In these pts., CI was signiﬁcantly correlated to S’ (r=0,34,
p<0.001), but not to EF (r=0.01, p=ns).
Conclusion: In pts. with moderate or severe AS, E/E’ is a reliable estimate of ﬁlling
pressures. Despite preserved EF, systolic long axis function (S’) is impaired in AS
pts. In this population, S’ seems to reﬂect cardiac performance (i.e. CI) better than
EF.
ROC curve of NTproBNP for RV overload
Eur J Echocardiography Abstracts Supplement, December 2003
Abstracts
S103
842
Research regarding atherosclerotic risk factors and inﬂammation in
valvular aortic sclerosis compared to aortic stenosis in elderly.
844
Safety of dobutamine stress echocardiography in patients with aortic
stenosis.
G.R. Badea 1 , C. Carp 2 , M. Dumitrescu 1 , L. Toma 1 , C. Cristea 1 . 1 Prof Agrippa
Ionescu Hospital, Cardiology, Bucharest, Romania; 2 Prof.Dr.CC Iliescu Institute,
Cardiology, Bucharest, Romania
M. Bountioukos, M.D. Kertai, E.C. Vourvouri, V. Rizzello, E. Biagini, B.J. Krenning,
J.R.T.C. Roelandt, D. Poldermans. Thoraxcenter, Erasmus Medical Center,
Department of Cardiology, BA302, Rotterdam, Netherlands
The valvular aortic sclerosis/stenosis is presently considered the consequence of an
active and complex process having common elements speciﬁc to the atherosclerosis.
Purpose: Evaluation of the inﬂammatory and atherosclerotic risk factors in patients
with aortic sclerosis or stenosis and its association with carotid atherosclerosis compared to nomal aortic valves in elderly (>60 years old). Determination of transaortic
ﬂow velocity and its relation with the aortic morphology.
Method: Aortic valve morphology was assed by transthoracic echography in 282
subjects (162 M,120W), >60 years old.Aortic sclerosis was graded as light-medium
(groupB=49 pts.) and medium-severe (group C=58pts.) accordindg to the degree of
valve alerations. Aortic stenosis was represented by group D (126) and controls by
groupA (49 pts). We also analysed the lipidic proﬁle (the plasmatic level of cholesterol, LDLc, HDLc and thriglycerides), the inﬂammatory proﬁle (VSH,the plasmatic
level of the C reactive protein and ﬁbrinogen), the presence of arterial hypertension,
diabetes,body mass index and smoking history. The carotidal atherosclerosis has
been evaluated by Duplex echography made bilateral at the level of common carotid
artery and bifurcation.
Results: CRP and ﬁbrinogen is signiﬁcantly increased in alerated aortic morphology groups (B,C,D) regardless the degree of lesions (groups A-C: p<0.001 for ﬁbrinogen and for CRP; groups A-D: p<0.001 for ﬁbrinogen and for CRP). High level of
cholesterol (p<0.01 for A-C analyse and A-D analyse), LDLc (p<0.05 for both A-C
and A-D analyse), triglycerides (p<0.01 for A-C and p<0.05 for A-D analyse), arterial hypertension (p<0.001for both A-C and A-D analyse), smoking (p<0.01 for A-C
and A-D analyse). The carotidal score has been signiﬁcantly increased in all groups
with aortic stenosis or sclerosis compared to controls (p<0.001) and it seems to be
corelated with the degree of the lesions in the sclerotic groups (r=0.77).
Conclusion: Aortic stenosis and valvular aortic sclerosis share common
atherosclerotic, inﬂammatory risk factors (incrased level of cholesterol, triglyceride,
C-reactive protein, ﬁbrinogen) and clinical conditions (history of hypertension, smoking) Transaortic ﬂow velocity is increased in aortic sclerosis and gradually increases
in aortic stenosis. These data suggest that aortic stenosis and aortic sclerosis represent different stages of the same atherosclerotic-like process involving the aortic
leaﬂets. Association of these valvular lesions with carotid atherosclerosis is another
argument for this ipothesis.
Objectives: Aortic valve disease is becoming one of the most important cardiac diseases in the western society. Low-dose dobutamine stress echocardiography (DSE)
is recommended in patients with low gradient aortic stenosis (AS) and severe left
ventricular (LV) dysfunction. Also, DSE is used in patients with AS and moderately
reduced or normal LV function for diagnostic purposes. Our aim was to assess the
safety of DSE in the setting of AS and various degrees of LV dysfunction.
Methods: We reviewed 75 patients with AS who underwent DSE at our center between 1997 and 2001. Group A consisted of 20 patients with severely reduced LV
function and underwent a low-dose DSE. Group B included 55 patients with moderate to normal LV function and underwent a high-dose DSE. The mean pressure
gradient, valve area, and side effects were evaluated.
Results: Serious cardiac arrhythmias occurred in 10 patients. In group A, 4 (20%)
patients developed non-sustained ventricular tachycardia (NSVT). In group B, 2
(4%) patients had NSVT, 4 (7%) paroxysmal supraventricular tachycardias, and 2
(4%) severe hypotension (see Figure). Among the 20 patients with evidence of ischemia on DSE, 3 patients developed side effects (P=NS as compared to patients
without ischemia). Fourteen patients received atropine during DSE and 1 of them
developed NSVT after atropine administration.
843
Regional myocardial function in patients with chronic severe aortic
regurgitation before and after aortic valve surgery.
T. Poerner 1 , A. Miskovic 2 , C. Stiller 2 , C. Kohl 1 , B. Goebel 1 , T. Geiger 1 ,
S. Kralev 1 , T. Aybek 2 , K. K. Haase 1 , A. Moritz 2 . 1 University Hospital of
Mannheim, 1st Dept. of Medicine, Mannheim, Germany; 2 University Hospital of
Frankfurt/Main, Dept. of Cardiac Surgery, Frankfurt/Main, Germany
Background: Preload-dependent ejection phase indices overestimate myocardial
function in patients with chronic aortic regurgitation (AR). Tissue Doppler - derived
strain rate imaging (SRI) enables quantiﬁcation of left ventricular (LV) regional function by assessing myocardial deformation.
Aim of the study was to determine the inﬂuence of AR-induced volume overload on
regional myocardial function using SRI before and after aortic valve surgery.
Methods: Twenty-one patients aged 47 ± 22 years with isolated chronic AR and
ejection fraction (EF) > 65% in whom coronary artery disease has been ruled out
underwent transthoracic high-frame SRI before and 7 ± 3 days after successful
aortic valve surgery. The control group consisted of 31 age-matched subjects with
normal coronary angiograms and LV function. Long-axis SRI measurements with
a dedicated software included: peak systolic velocity (V), peak systolic strain (eps)
and mean systolic strain rate (SR). As no signiﬁcant differences between basal and
apical segments were found, e and SR could be expressed as mean values for the
whole LV.
Results: As displayed in the table (Mean ± SD. ¶p < 0.05 vs. controls, *p < 0.05 vs.
baseline), deformation parameters (eps, SR) were signiﬁcant decreased in patients
with AR compared to the control group and showed no further changes after aortic
valve replacement (17 patients) or reconstruction (4 patients).
Parameters
Control group
(n = 31)
AR at baseline
(n = 21)
AR postoperative
(n = 21)
eps (%)
SR (s-1)
V (mm/s)
LV end-diastolic diameter (mm)
LV end-systolic diameter (mm)
Echocardiographic EF (%)
-18 ± 4
-0.72 ± 0.12
51 ± 18
48 ± 5
29 ± 5
71 ± 8
-13 ± 4¶
-0.5 ± 0.14¶
52 ± 18
57 ± 12¶
33 ± 14
73 ± 8
-13 ± 4¶
-0.46 ± 0.16¶
50 ± 13
49 ± 9*
33 ± 13
65 ± 10¶*
Conclusions: (1) All patients with severe AR presented with signiﬁcant long-axis
systolic regional dysfunction despite normal values for ejection fraction and myocardial systolic velocities. (2) Postoperative changes in LV diameter and EF reﬂect
variations of the loading conditions and not of the myocardial contractility. (3) Analysis of regional deformation by SRI is a valuable tool to assess functional myocardial
damage and disease progression in patients with aortic regurgitation.
Conclusions: Serious cardiac arrhythmias occur frequently during both low-dose
and high-dose DSE in patients with AS. Side effects do not relate to stress-induced
ischemia or atropine addition.
845
Echocardiography during treadmill exercise testing in pulmonary artery
systolic pressure evaluation. A new method.
C. Cotrim 1 , I. João 2 , P. Cordeiro 3 , M. Loureiro 2 , O. Simões 3 , N. Mendes 3 ,
M. Oliveira 3 , M. Carrageta 4 . 1 Hospital Garcia de Orta, Cardiology, Setúbal,
Portugal; 2 Cardiology, Almada, Portugal; 3 Cardiology, Almada, Portugal;
4
Cardiology, Almada, Portugal
Introduction: Pulmonary artery systolic pressure (PASP) evaluation at rest, using Doppler echocardiography (determined from the pressure gradient between the
right ventricle and the right atrium - RV/RAg), or using right heart catheterization is
very useful in the assessment of disease severity as well as its prognosis.
Objective: The aim of our study was the non-invasive assessment of the RV/RAg
under dynamic exercise during treadmill testing in patients with tricuspid regurgitation and without coronary artery disease.
Methods: From a total of 35 patients (pts) referred to our echo laboratory we completed the study in 31 pts (88%), 22 women mean aged 55±10 years (39 to 70
years). We studied 17 pts with mitral valve stenosis (EKG: sinus rhythm), 7 pts with
mitral mechanical prosthesis, 3 pts with aortic valve stenosis and 4 pts with aortic mechanical prosthesis. We determined the RV/RAg – using continuous wave
Doppler – in left lateral decubitus (LLD) before exercise testing, in standing position (SP) and at peak workload (PW) before treadmill exercise testing termination
(modiﬁed Bruce protocol). All imaging was recorded in VCR.
Results: The RV/RAg in LLD was 36,6±14,7 mmHg (range 14 to 74), the SP
RV/RAg was 30±11 mmHg (range 18 to 62) p<0,0001 vs LLD RV/RAg, the PW
RV/RAg was 57±18,7 mmHg (range 34 to 130) p<0,0001 vs SP RV/RAg. When
comparing the 17 pts with mitral valve stenosis (MS), mean aged 51±8 years, to
the 14 non-mitral valve stenosis (NMS) pts, mean aged 60±10 years, p=0,01, we
veriﬁed that though MS pts are younger they had higher values for LLD RV/RAg =
42±15mmHg, SP RV/RAg = 33±12,5 mmHg and PW RV/RAg = 65±20mmHg than
NMS in which LLD RV/RAg = 29,6±10,1mmHg (p=0,01 vs MS group), SP RV/RAg
= 26±6,5mmHg (p=0,03 vs MS group) and PW RV/RAg = 46,4±8,4mmHg (p=0,002
vs MS group). Stress testing duration averaged 506±206 seconds in the MS group
and 606±211 seconds in the NMS group, p=NS. The stress echocardiography results in MS pts were used to aid in therapeutic decision.
Conclusions: 1. Echocardiography during treadmill exercise testing was possible
in a great percentage of pts. 2. The RV/RAg decreases considerably in response
to the standing position. 3. The RV/RAg rises considerably with exercise and more
noticeably in MS pts. 4. The authors think that this method can be a valuable tool
in patient assessment, symptoms correlation and therapeutic guidance of heart disease patients with tricuspid regurgitation.
Eur J Echocardiography Abstracts Supplement, December 2003
S104
Abstracts
TRANSOESOPHAGEAL ECHOCARDIOGRAPHY
847
Evaluation of temporary changes in transmitral and left atrial appendage
ﬂow velocity patterns after cardioversion of atrial ﬁbrillation.
1
1
2
2
849
Detection of left coronary artery stenoses using transesophageal Doppler
assessment of coronary ﬂow reserve in the coronary sinus.
A. Vrublevsky, A. Boshchenko, R. Karpov. Cardiology Research Institute,
Department of Coronary Artery Disease, Tomsk, Russian Federation
2
E. Antonielli , S. Dogliani , P. Costantini , P. Allemano , L. Solavagione ,
A. Coppolino 1 , T. Montaldo 1 , B. Doronzo 1 . 1 SS. Annunziata Hospital, Dept. of
Cardiology, Savigliano, Italy; 2 Medicine Dept, Saluzzo, Italy
Background: Stunning of the left atrial chamber immediately after cardioversion
(CV) of atrial ﬁbrillation (AF) has been demonstrated by measuring temporary
changes in peak atrial systolic velocities of transmitral ﬂow (by transthoracic echocardiography) or in left atrial appendage (LAA) emptying ﬂow (by transesophageal
echo). However, studies on the correlation between transmitral and LAA ﬂows have
provided conﬂicting results.
Aim: To investigate the temporary changes in the pattern of LAA and transmitral
ﬂow after CV of AF and examine the potential relation between LAA and left atrial
mechanical function.
Methods: The study consisted of 11 patients (9 men, mean age 63±10 years) with
nonvalvular AF treated with electrical (n=8) or chemical (n=3) CV. Using transthoracic and transesophageal echocardiography we recorded transmitral and LAA ﬂow
velocity patterns before, 1 hour, 1 day, 1 week and 1 month after successful CV.
Results: Three pts demonstrated no left atrial stunning after CV, while in the remaining 8 pts LAA ﬂows decreased after CV, increasing then gradually with time,
along with A wave velocity. The peak LAA emptying velocities after CV correlated
positively with mitral inﬂow A waves in all different time intervals (ﬁgure).
The aim of our study was the detection of hemodynamically signiﬁcant stenoses
in the territory of the left coronary artery (LCA) using transesophageal Doppler assessment of coronary ﬂow reserve (CFR) in the coronary sinus (CS).
Methods: We studied 60 CAD pts (men, mean age 51±8 years): 36 - with isolated left anterior descending artery (LAD) or left circumﬂex artery (Cx) stenosis
>50%; 24 - with both LAD and Cx stenoses >50%. The control group consisted
of 31 healthy volunteers (men, mean age 34±5 years). Transesophageal Doppler
assessment of coronary blood ﬂow in the CS was performed at baseline and after intravenous dipyridamole (0,56 mg/kg for 4 minutes) using ultrasound diagnostic
systems HDI 5000 SonoCT and Ultramark 9 HDI CV (Philips-ATL). CFR in the CS
was calculated in two ways: 1) as ratio of hyperemic to baseline peak antegrade ﬂow
velocity (CFR by Vp); 2) as ratio of hyperemic to baseline volume blood ﬂow velocity
(CFR by VBF). The level of the CBF<2 in both ways of calculation was diagnosed
as reduced.
Results: CAD pts compared to healthy volunteers had signiﬁcantly lower CFR in
the CS both by Vp (1,51±0,45 and 2,25±1,24; p<0,001) and VBF (2,57±0,79 and
5,43±2,83, p<0,001). Sensitivity and speciﬁcity of CFR<2 in the CS as a predictor
of hemodynamically signiﬁcant stenoses of the LCA were for Vp 89% and 76%, and
for VBF - 49% and 97%, respectively. CFR <2 in the CS by Vp was registered in
96% of CAD pts with two-vessel lesion and in 81% of CAD pts with single-vessel
lesion, while CFR <2 in the CS by VBF was revealed in 79% of CAD pts with
two-vessel lesion and only in 25% of CAD pts with single-vessel lesion. Sensitivity
and speciﬁcity of CFR <2 in the CS by VBF in the diagnostics of hemodynamically
signiﬁcant two-vessel lesion of the LCA were 79% and 87%.
Conclusion: Thus, the reduced CFR in the CS is a sensitive and speciﬁc predictor
of LCA stenoses. Decrease of CFR <2 in the CS both by Vp and VBF is a predictor
of hemodynamically signiﬁcant two-vessel lesion of the LCA, while a decrease of
CFR <2 in the CS only by Vp is a predictor of single-vessel lesion of the LCA.
850
Usefulness of contrast echocardiography in aortic dissection
assessment by TEE.
Conclusion: Our preliminary results demonstrate a very good correlation between
LAA function and left atrial mechanical function after CV, showing the same temporary changes in time. If these results are conﬁrmed on a larger scale, mitral inﬂow
A wave can be used as a surrogate of LAA function, at least in the time period
following CV of AF.
848
Relationship between atherosclerotic changes of the carotid arteries and
the thoracic aorta in patients with ischaemic insult - which patients
require a TEE?
M. Handke 1 , A. Harloff 2 , A. Hetzel 2 , A. Geibel 1 . 1 University Hospital Freiburg,
Cardiology and Angiology, Freiburg, Germany; 2 University Hospital Freiburg,
Neurology, Freiburg, Germany
Background: Atherosclerotic changes of the thoracic aorta are coupled with elevated risk of cerebral-ischemic events, especially with a plaque thickness of >4mm.
Increased intima-media thickness of the carotid arteries is considered a marker for
generalized atherosclerosis and is also associated with elevated vascular risk. However, there are only few data on the exact relationship between these changes. The
objectives of the study were (1) to determine the correlation between atherosclerotic changes in the carotid arteries and the thoracic aorta and (2) to evaluate the
necessity for transesophageal echocardiography (TEE) of the aorta for the diagnostic procedure in stroke patients.
Method: 311 patients (62±12 years) with ischemic insult were examined after
admission to the Stroke Unit. The intima-media thicknesses of the carotids (IMTCarotid) were determined in B-mode-sonography on both sides and averaged.
The thoracic aorta was examined by multiplane TEE, the aortic plaque thickness
(Plaque-Ao) was measured at the site of the most pronounced changes. Sonography of the carotid arteries and TEE were performed independently by different
examiners.
Results: The mean IMT-Carotid was 1.0±0.2 mm (0.6-2.1 mm), the Plaque-Ao
2.9±1.7 mm (0.6-10.0 mm). Both IMT-Carotid and Plaque-Ao correlated signiﬁcantly with age (r=0.45, p<0.001, r=0.51, p<0.001, respectively). There was a signiﬁcant correlation between IMT-Carotid and Plaque-Ao (r=0.49, p<0.01). 93 of 97
patients with an IMT-Carotid <0.9 mm had only mild atherosclerosis with PlaqueAo of <4mm (negative predictive value: 96%). In the other 4 of 97 patients with an
IMT-Carotid <0.9 mm, the Plaque-Ao was <4.5mm. The positive predictive value of
an IMT-Carotid of >0.9 mm for a Plaque-Ao of >4.0 mm was only 28% (60 of 214
patients).
Conclusion: Due to the high negative predictive value of the IMT-Carotid, TEE of
the thoracic aorta appears to be dispensable in patients with ischemic insult and an
IMT-Carotid <0.9 mm. An elevated IMT-Carotid increases the probability of relevant
atherosclerosis of the aorta, but is not deﬁnitively predictive in the individual case.
Therefore, sonographic examination of the carotid arteries should be supplemented
with transesophageal echocardiographic examination of the aorta in these patients.
Eur J Echocardiography Abstracts Supplement, December 2003
Z. Gomez Bosch 1 , A. Evangelista 2 , G. Avegliano 2 , T. Gonzalez-Alujas 2 ,
A. Carrizo 2 , H. Garcia del Castillo 2 , A. Salas 2 , J. Soler-Soler 2 . 1 Hospital valle de
hebron, Cardiologia, Barcelona, Spain; 2 Hospital Valle de Hebron, Cardiologia,
Barcelona, Spain
TEE is limited in deﬁning all morphologic and dynamic characteristics of thoracic
dissection which may be important for prognosis and treatment.
The aim of this study was to ascertain the beneﬁt of contrast in TEE information
regarding: entry tear location, true and false lumen identiﬁcation, retrograde dissection and main trunk involvement diagnoses.
30 patients with aortic dissection (AD) underwent TEE. 9 patients had previously
undergone surgery of type A AD. Two blinded observers evaluated standard and
contrast TEE information.
Results: Contrast permitted location of non-visualized entry tear in the upper ascending aorta or arch in 7, retrograde dissection diagnosis in 5, arterial trunk involvement in 5 and true lumen identiﬁcation in 3.
In 12 cases (33%), the additional information obtained by contrast echo was considered clinically signiﬁcant.
Conclusion: Contrast in TEE is highly useful in aortic dissection assessment, particularly when the entry tear is not deﬁned, in retrograde dissection and arterial
trunk.
Abstracts
851
Echo-guided inhaled prostacyclin therapy in primary pulmonary
hypertension.
K. Karlocai. National Koranyi Institution, Cardiology, Budapest, Hungary
The recent therapeutic modalities offer much better prognosis in primary pulmonary
hypertension (PPH) than the classic methods. These new drug classes include various forms of prostacyclin. The continuous infusion was the ﬁrst way and dozens
of studies have proven it’s effectiveness. However the life quality is seriously altered due to pump dependency. Inhaled prostacyclin is much more comfortable to
patients but the exact dynamism and duration of action has to be proven. Serial
Doppler echocardiography was used to verify the effect and to guide the therapy.
Patients, Methods. 10 PPH pts underwent Swan Ganz catheterization and invasive vasodilator test. Four non-responder patients have been selected. Increasing
doses of Iloprost was given 6 times a day, beginning with 25 ug/day until 100 ug/day.
Doppler echo was performed at baseline and than every other week. Maximal duration of therapy was 3 month.
The mean calculated pulmonary artery pressure was 82 ± 19 mmHg at baseline and decreased to 66 ± 17 mmHg. The cardiac output increased. The biggest
change in the pressure drop could be recorded between the 4th and 6th weeks.
The therapy was well tolerated by two patients and marked clinical improvement
could be achieved. One pt has stopped the therapy after 6 weeks due to serious
gastrointentinal side effects, vomitus, and pain. One patient underwent lung transplantation. The dose increment was safe when the Doppler derived parameters did
not differ more than 20% from the previous test. After 3 month of therapy one pt had
signiﬁcantly better EF, smaller left ventricle, ticker walls.
Conclusion: Inhaled prostacyclin is effective in PPH, the dose-monitoring is simple
with serial Doppler echocardiography. Side effects are common but the therapy can
be continued
852
Transesophageal echocardiography in the diagnosis of celiac trunk and
superior mesenteric artery involvement in aortic dissection.
G. Avegliano 1 , Z. Gomez Bosch 2 , A. Evangelista 1 , M.T. Gonzalez-Alujas 1 ,
A. Carrizo 1 , M.C. Sebastiá 1 , H. García del Castillo 1 , J. Soler-Soler 1 . 1 Hospital
Valle de Hebron, Cardiologia, Barcelona, Spain; 2 Hospital valle de hebron,
Cardiologia, Barcelona, Spain
Althoug TEE is one of the most useful techniques for the diagnosis of aortic dissection (AD), its role in the assessment of celiac trunk (CTR) and superior mesenteric
artery (SMA) complications has not been established.
In 41 consecutive patients with AD who underwent TEE and angio-CT, dissection
of trunks, dynamic ostium compression by false lumen, and connection with true or
false lumen were assessed.
Results: No disparities were observed between TEE and CT methods.
Table
Celial Trunk
Mesenteric Art.
Visualization
FL Connect.
Dissection
Compression
38 (93%)
24 (59%)
7 (17%)
3 (13%)
5 (13%)
2 (8%)
7 (18%)
1 (4%)
Conclusions: TEE is highly useful in the diagnosis of celiac trunk involvement in
aortic dissection, although mesenteric artery is observed in only 60% of cases. TEE
should include routine assessment of celiac and arterial trunk involvement in aortic
dissection.
853
Transesophageal echocardiography to evaluate the anatomic course of
anomalous coronary arteries and the ischemia at stress-rest scintigraphy
in adults.
F. Bovenzi 1 , L. De Luca 1 , P. Colonna 1 , B.L. Corlianò 1 , N. Signore 1 , G. Rubini 2 ,
I. De Luca 1 . 1 Azienda Ospedaliera Policlinico, Division of Cardiology, Bari, Italy;
2
University of Bari, Nuclear Medicine Dept., Bari, Italy
Background: Nowadays X-ray cineangiography has been the imaging modality of
choice for coronary arteries assessment. However, this technique does not reliably
delineate the proximal course of anomalous coronary arteries (ACA) in relation to
the aorta or pulmonary trunk. This information is often critical to the management of
these patients (pts). This study describes the importance of integration of data obtained from digital coronary angiography with Multiplane Transesophageal Echocardiography (MTE) in evaluating the anomalous origin and course of coronary arteries
and their haemodynamic signiﬁcance.
Methods: ACA were detected by coronary angiography (from November 1998 to
September 2001) in 19 pts (12 males, 56.8±8.3 years old). All pts underwent MTE
to evaluate the relationship of the ACA with Aorta and Pulmonary Artery. In all cases
a Stress/Rest 99mTc Sestamibi myocardial perfusion single photon emission tomography (SPECT) was performed.
Results: The MTE showed a course of the ACA between the aorta and the pulmonary trunk in the 7 pts with right coronary artery originating form the left sinus of
Valsalva and in the 2 pts with single coronary artery originating form the right sinus
of Valsalva; all these 9 pts had a perfusion defect at SPECT. In the other 10 pts (6
with circumﬂex coronary artery form the right sinus of Valsalva and 4 pts with a high
right coronary artery) the MTE showed a course of the ACA anterior or posterior to
the aorta and the pulmonary trunk and no perfusion defect was detected at SPECT.
S105
Conclusion: MTE is a non-invasive and accurate technique for detecting anomalous origin of coronary arteries. In this series, MTE correctly identiﬁed every anomalous course; an anomalous course between Aorta and Pulmonary artery was associated with a myocardial perfusion defect detected by SPECT. Evaluation of the
haemodynamic importance of the ACA can be useful in programming corrective
surgery.
854
Transcranial Doppler or transoesophageal echocardiography for the
detection of venous-to-arterial circulation shunts.
S. Sastry 1 , K. Daly 2 , A. MacNab 1 , S.G. Ray 1 , C.N. McCollum 2 . 1 Department of
Cardiology, Manchester, United Kingdom; 2 Department of Academic Surgery,
Manchester, United Kingdom
Background: Contrast transcranial Doppler ultrasound (TCD) is simple, noninvasive and detects both cardiac and pulmonary venous-to-arterial circulation
shunts (v-aCS). We compared the TCD detection of v-aCS with transoesophageal
echocardiography (TOE) for patent foramen ovale (PFO).
Methods: We studied 39 patients aged 15-39 following ischaemic stroke (33) or
myocardial infarction (6). "Standardised" TCD was performed two weeks before "simultaneous" TCD and TOE. A microbubble emulsion as ultrasound contrast was injected into an antecubital vein twice at rest and twice each with cough and Valsalva
provocation. In standardised TCD, the patient sat up and the Valsalva manoeuvre
was to a pressure of 40mmHg for ﬁve seconds immediately after contrast injection.
During simultaneous TCD and TOE the patient was lying the left lateral position,
coughing was difﬁcult and Valsalva was by epigastic pressure. TCD and TOE were
analysed independently by operators blinded to each other’s results.
Results: On TOE, 16 of the 39 patients had a PFO, all also having more than 15
microbubble emboli on TCD within 12 cardiac cycles of intravenous contrast injection. In 14 of the 16, paradoxical embolisation was spontaneous and did not need
provocation on standardised TCD. The number of microbubble emboli, at a median
[IQR] of 20 [3-135] on standardised TCD was uniformly higher than on simultaneous
TCD (7 [1-43]) and on TOE (13 [6-42]), perhaps due to sedation, the lying position
or inadequate provocation. No patient with a maximum of < 15 microbubbles, many
of which occurred after 12 cardiac cycles, was found to have a PFO. The size of
the PFO on TOE correlated closely with the number of microbubble emboli on standardised TCD (rs = 0.83, [0.70, 0.91]).
Conclusions: TOE is relatively insensitive to v-aCS as it is difﬁcult to achieve adequate cough or Valsalva provocation. Standardised TCD is sensitive to the detection
of v-aCS and PFO with more than 15 microbubbles within 12 cardiac cycles universally detecting PFO.
855
Monocuspid, bicuspid and quadricuspid aortic valves diagnosed by
transesophageal echocardiography - incidence, functional assessment
and associated lesions.
B. Schneider 1 , R. Bauer 2 , E. Schlemminger 3 , H.H. Sievers 4 . 1 Sana Kliniken,
Klinik für Kardiologie, Lübeck, Germany; 2 Allg. Krankenhaus St. Georg, II.
Medizinische Abteilung, Hamburg, Germany; 3 Allg. Krankenhaus St. Georg,
Herzchirurgische Abteilung, Hamburg, Germany; 4 Universitätsklinikum, Klinik für
Herzchirurgie, Lübeck, Germany
Background: The bicuspid aortic valve (BAV) is the most frequent congenital malformation of the heart, whereas monocuspid (MAV) and quadricuspid aortic valves
(QAV) are very rare. Incidence and associated lesions in patients undergoing TEE
have not been well described.
Methods and Results: Over a 10-year period, 4827 adult pts were studied by TEE
and prior TTE. Diagnosis of acommissural MAV was made in 1 patient (age 45)
with pure aortic regurgitation of grade IV due to high leaﬂet redundancy and associated endocarditis. QAV was present in 3 pts (0.06%). One patient (age 32) with
associated ventricular septal defect had 4 equal valve cusps and showed normal
QAV function. The second patient (age 59) with associated ﬁbromuscular subaortic stenosis had 1 small and 3 large cusps with grade IV aortic regurgitation. A
third patient (age 46) with isolated QAV had 4 unequal cusps with grade II aortic regurgitation. No QAV had evidence of stenosis or endocarditis. BAV was diagnosed in 38 pts (0.8%, 8f, 30m, mean age 48 y) and was regurgitant (n=17),
stenotic (n=2), both stenotic and regurgitant (n=12) or showed normal BAV function
(n=7). Associated lesions were: aortic valve (n=5) or mitral valve prolapse (n=1),
aortic aneurysm/dissection (n=3), mitral valve aneurysm (n=5), and subvalvular aortic stenosis, sinus of Valsalva aneurysm, aortic coarctation or aortic arch atresia (1
pt each). Infective endocarditis was present in 11 pts (active n=9, remote n=2, only
BAV n=5, BAV and/or mitral valve n=6). 1 MAV, 1 QAV and 19 BAV pts underwent
aortic valve replacement with surgical conﬁrmation of the valve morphology and
associated lesions. The incidence of congenitally abnormal valves in TEE patients
compares well with the ﬁgures reported in the literature for autopsy cases.
Conclusion: QAV is rare, in case of unequal cusps regurgitant, and occurs alone
or in association with other congenital abnormalities. BAV is found more frequently,
may be stenotic and/or regurgitant and is prone to infective endocarditis. Associated
lesions in BAV patients may be congenital but frequently are acquired. MAV in adults
is extremely rare and may present with pure aortic regurgitation without stenosis.
Eur J Echocardiography Abstracts Supplement, December 2003
S106
Abstracts
856
Diagnostic value of ecofree space around the aortic prosthesis for
infective endocarditis.
858
Transoesophageal echocardiographic study in 50 patients affected by
rheumatoid arthritis.
L. Iliuta 1 , C. Savulescu 2 , H. Moldovan 1 , D.P. Gherghiceanu 1 , R. Vasile 1 ,
D. Filipescu 3 , C. Macarie 4 , V. Candea 1 . 1 "C.C.Iliescu" Heart Institute, Cardiac
Surgery Dept., Bucharest, Romania; 2 Fundeni Clinical Institute, Internal Medicine,
Bucharest, Romania; 3 "CC Iliescu" Heart Institute, Anaestheology, Bucharest,
Romania; 4 C.C.Iliescu Heart Institute, Cardiology Dept., Bucarest, Romania
M. Turiel 1 , G. De Blasio 2 , M. Llambro 2 , L. Delﬁno 2 , G. Bigatti 2 , D. Ali Youssef 1 ,
F. Atzeni 3 , P. Sarzi-Puttini 3 . 1 Istituto Galeazzi University of Milan, Servizio di
Cardiologia, Milan, Italy; 2 Istituto Galeazzi, Servizio di Cardiologia, Milan, Italy;
3
Hospital L.Sacco, Rheumatology Unit, Milan, Italy
Background: In spite of frequent misinterpretation of ecofree space around the
aortic prosthesis revealed by transoesophageal ecography as aortic abscess, there
are no studies which it was evaluated its diagnostic value for infective endocarditis.
Aim: Assessment of the diagnostic signiﬁcance for infective endocarditis of the
ecofree space revealed by transoesophageal ecography in patients with aortic prosthesis.
Material and method: We have taken into study 123 patients with aortic prosthesis
who underwent transoesophageal ecography. Taken into consideration the ﬁndings
on transoesophageal ecography, there were identiﬁed two groups: Group A: 68 patients with ecofree space around aortic prosthesis (42 patients with circular ecofree
space between the aortic wall and prosthesis annulus and 26 patients with extralumenal ecofree space separated from the aortic lumen by aortic wall) and Group B:
55 patients without ecofree space around the aortic prosthesis. Statistical analysis
used SYSTAT and SPSS programs for correlation coefﬁcient calculations and for
simple and multiple linear regression analysis.
Results: 1. Among patients with ecofree space around aortic prosthesis, only 8
(11.76%) developed an infective endocarditis according to Duke criteria. Among
these, in 2 patients we have revealed circular ecofree space and in the other 6
patients we have revealed extralumenal ecofree space. Among patients without
ecofree space around the aortic prosthesis, only one patient was diagnosed with
infective endocarditis. 2. The extralumenal ecofree space is signiﬁcantly correlated
with infective endocarditis according to the equation y=1.7x+5.2, p<0.001, R2 =0.71.
3. There was shown a signiﬁcant correlation between the presence of extralumenal
ecofree space revealed by transoesophageal ecography and annular abscess conﬁrmed intraoperatively in patients who underwent aortic valve replacement for infective endocarditis on aortic prosthesis and haemodinamic signiﬁcant paravalvular
leak (R2 =0.28, p<0.0001).
Conclusions: 1.The circular ecofree space is frequently revealed by transoesophageal ecography around aortic prosthesis and it has a low speciﬁcity for infective endocarditis. 2.The extralumenal ecofree space has an important diagnostic
value and an increased speciﬁcity for abscess of the aortic radix, its presence being
an indication for early surgical intervention in these patients.
857
Role of transoesophageal echocardiography in the differential diagnosis
of aortic ulcers.
Z. Gomez Bosch 1 , A. Evangelista 2 , G. Avegliano 2 , M.T. Gonzalez-Alujas 2 ,
A. Salas 2 , M. Sebastiá 2 , R. Dominguez 2 , J. Soler-Soler 2 . 1 Hospital valle de
hebron, Cardiologia, Barcelona, Spain; 2 Hospital Valle de Hebron, Cardiologia,
Barcelona, Spain
Prognosis and therapy of penetrating aortic ulcers (PAU) vs ulcer-like images (ULI)
differ greatly, however, the differential diagnosis between both entities by imaging
thechniques is not well established. The aim of the present study was to assess the
role of TEE in the differential diagnosis of aortic ulcers (AU) deﬁned by CT or MRI.
Twenty-ﬁve patients (23 men, 2 women; age range: 50-82y), were diagnosed of aortic ulcer (13 PAU and 12 ULI) during an acite aortic syndrome (n: 20) or incidentally
(n: 5).
22 CT-classiﬁed: 9 PAU, 5 ULI, 4 non-speciﬁed AU and 4 non-diagnosed. 10 MRI
revealed 3 PAU, 3 ULI and 4 non-speciﬁed AU. TEE agreed with CT in 10 cases
(45%), ruled out PAU in 3 and classiﬁed the AU type in 4. TEE agreed with MRI in
5, ruled out PAU in 1 and classiﬁed the ulcer type 4. Therefore, TEE ruled out PAU
diagnosed by CT or MRI in 11 cases, showing ULI localised dissection in intramural
haematoma evolution.
Conclusions: TEE is highly useful in the differential diagnosis of penetrating aortic ulcers and ulcer-like images diagnoses by CT or MRI. Some penetrating aortic
ulcers remained undetected by conventional CT; thus, TEE is mandatory in aortic
ulcer assessment.
Eur J Echocardiography Abstracts Supplement, December 2003
Objectives: To determine the incidence and type of heart lesions in rheumatoid
arthritis (RA), we coupled transthoracic (TTE) with transesophageal echocardiography (TEE), which is more sensitive and more accurate.
Methods: 50 unselected RA patients (41 F and 9 M aged 25 to 73 years, with a
mean age of 54.6 ± 14.4 years) free of known progressive heart disease underwent
a chest radiography, an electricardiogram, laboratory tests, and TTE coupled with
TEE. Results were compared with those in age and sex-matched patients which
were free of rheumatic diseases and underwent TEE to investigate different clinical
disorders.
Results: Mitral regurgitation (MR) was evidenced in 40 cases (80%). Among the
controls, only 15 (30%) had MR (P<0.01). Aortic regurgitation was found in 15
cases (30%), versus 3 controls (P<0.02). Ten cases (20%) versus only 4 controls
(7.9%) had tricuspid valve abnormalities (NS). Mitral valve prolapse (MVP) was observed in 10 patients (4 of posterior leaﬂet and 6 of anterior leaﬂet).
Pericardial effusion was found in 39 cases (78%) and in none of controls. Six
patients evidenced diastolic dysfunction. Two patients presented interatrial septal
aneurism. Twenty patient (40%) had ﬁbrosis and/or calciﬁcations of the aortic valve,
and 10 patients of the mitral valve. Echo-generating nodules were seen on a mitral valve in 5 cases and on an aortic valve in 2. No signiﬁcant correlations linking
cardiac lesions to clical or laboratory features of RA was observed.
Conclusions: Cardiac involvement, particularly of the mitral valve, was extremely
common in RA patients. Diastolic dysfunction was rarely observed but systolic function was normal. No correlation was observed between cardiac abnormalities, disease severity and treatments. TEE was useful to identify echo-generating nodules
and calciﬁcations of cardiac valves.
859
Is it necessary to perform transoesophageal echocardiography before
electrical cardioversion in patients with atrial ﬁbrillation? An alternative
strategy.
D.N. Chrissos, E.N. Tapanlis, H.G. Sotiropoulos, A.A. Katsaros, A.N. Kartalis,
P.N. Stougianos, A.K. Avgeropoulou, I.E. Kallikazaros. Hippokration Hospital, State
Cardiac Department, Athens, Greece
Introduction: It is well known that patients (P) suffering from atrial ﬁbrillation (AF),
develop progressive dilatation of the left atrium and they have an increased risk for
thromboembolic events. The electrical cardioversion (EC) in P with AF of more than
two days’ duration is performed either directly guided by transesophageal echocardiography (TEE), either 3-4 weeks later after receiving anticoagulant therapy (AT)
and without prior TEE, in order to diminish the possibility of thromboembolism. The
purpose of this study is to point out the safety of an alternative therapeutic procedure in P with AF, which is the EC of the AF after three weeks’ AT with preceding
TEE, so as to exclude the existence of thrombi.
Methods: 128 P (70 males and 58 females, mean age 62.8 years) with AF of
prolonged duration, lasting from one month to one year, received AT with acenocoumarol for 3-4 weeks to achieve an international normalized ratio (INR) of 2.2
to 3.0. TEE was performed after this period and EC followed, if no thrombus was
found. If sinus rhythm was restored, AT was administered for the next 3-4 weeks. If a
thrombus was detected, the AT continued for other 3-4 weeks and the EC followed,
only when the thrombus had been dissolved, otherwise the EC was cancelled.
Results: The TEE disclosed a left atrium thrombus in 12 P (9.38%) and the EC was
postponed. Finally, EC was not performed in 6 out of all patients (4.72%). 122 P
(95.31%) underwent EC. The EC failed in 14 P (10.93%) and recurrence of the AF
was observed in 46 P (35.93%). The heart rhythm remained sinus (for a period of
one month to one year) in 61 P (47.66%). Thromboembolic events, cerebrovascular
incidents, transient ischemic attacks, or major/minor bleeding complications were
not noticed.
Conclusions: High percentage of patients (one out of ten) develops left atrium
thrombi before the electrical cardioversion, despite of the anticoagulant therapy they
receive. The described approach in preventing thromboembolic events, which may
accompany the electrical cardioversion of atrial ﬁbrillation, seems to be absolutely
safe, causes no complications and, consequently, could be a strategy of choice
especially on patients of high thromboembolic risk.
Abstracts
860
Is transesophageal echocardiography helpful in patients with stroke?
L. Golan, A. Linhart, K.H. Charalampidi, T. Palecek, Z. Hlubocka, K. Novackova,
J.C. Lubanda, M. Aschermann. The Charles university hospital, IInd Department of
Internal Medicine, Prague 2, Czech Republic
Introduction: Embolism within the central nervous system is a frequent cause of
stroke. Transesophageal echocardiography (TEE) enables detection for its potential
sources. It is not clear however whether TEE is helpful in all patients with stroke. The
following study is an analysis of TEE being used on patients with stroke, examined
in our echocardiography laboratory.
Methods: We selected all patients with stroke from an echocardiography database,
who were examined by TEE in the IInd Department of Internal Medicine. We evaluated the presence of intracardial thrombosis, spontaneous echocontrast, size of left
atrium, speed of left auricular emptying, presence of patent foramen ovale (PFO) or
atrial septal defect (ASD) and plaques in aorta. We compared patients with stroke
to a controlled group consisting of patients examined by TEE from other indications.
Excluded from both groups were patients with atrial ﬁbrillation since it is an obvious
potential cause of cardiac embolism.
Results: From November 2000 to April 2003 we examined 69 patients with stroke
and 221 controls. Intracardial thrombi were present in 4 (5.8%) of patients and in 12
(5.4%) of controls. Spontaneous echocontrast was found in 19 (27.5%) of patients,
resp. 44 (19.9%) controls. Low left auricular emptying was found in 10 (14.5%) of
patients and 26 (12.0%) controls. ASD or PFO was found in 15 (21.7%) of patients and 53 (24.0%) controls. Simultaneous ﬁnding of ASD or PFO and atrial
septal aneurysm was observed in 7 (10.1%) of patients and 18 (8.1%) controls.
The differences were not statistically signiﬁcant (p>0.05). 45 (65.2%) patients and
111 (51.3%) controls had plaques in aorta; 29 (42.0%), resp. 22 (10.0%) of the
plaques were considered to have high risk for embolization according their morphology (p<0.05). There were no serious and only one minor complication.
Conclusion: We found a trend of more frequent spontaneous echocontrast and
low left auricular emptying and statistically signiﬁcant difference in occurrence of
atherosclerotic plaques for patients with stroke. We have not found a more frequent
intracardial thrombosis or ASD or PFO.
TEE is a safe method for discovering the potential source of embolism. However,
the indication of TEE in patients with stroke should be carefully considered, since
other factors such as the impact on therapy and cost-effectiveness should be taken
into account.
SOURCE OF EMBOLISM
862
Evaluation of echocardiographic risk factors for thromboembolism in
patients with paroxysmal atrial ﬁbrillation.
I. Vlasseros, D. Syrogiannidis, A. Kartalis, P. Dilaveris, E. Tapanlis, A. Katsaros,
G. Zervopoulos, I. Kallikazaros. Hippokration Hospital, State Cardiology Clinic,
Athens, Greece
Introduction: Chronic Atrial Fibrillation (cAF) is correlated with thromboembolic
complications. On the other hand, the role of paroxysmal Atrial Fibrillation (pAF)
in thromboembolism is not known over the long term. In patients (pts) with cAF,
the dilation of left atrium (LA), the systolic dysfunction of left ventricle (LV), the low
velocity ﬂow in the left atrial appendage (LAA) and the spontaneous echogenic contrast (SEC) in LA and LAA the atheromatous plaques in thoracic aorta (THA) and
mainly the detection of thrombus in LA and LAA are echocardiographic risk factors for thromboembolic complications. We sought to evaluate the aforementioned
echocardiographic risk factors in pts with pAF.
Methods: We evaluated 36 pts 66±15 years old (19M, 17F) with history of pAF.
Study pts were considered those without moderate or severe mitral valve regurgitation or rheumatic heart disease. All pts underwent a thorough transthoracic and
transesophageal echocardiographic examination. We evaluated the ejection fraction
(EF) of LV, the dimension of LA, the ﬂow velocity in the LAA, the presence of SEC
in LA (little or signiﬁcant degree) and ﬁnally the presence of atheromatous plaques
into thoracic aorta. All the pts were in sinus rhythm during their echocardiographic
examination, without antigoagulative treatment.
Results: Dilated left atrium (>40 mm) was found in 16/36 (44%) pts, SEC was found
in 25/36 (69%) pts [20/36 (55%) little and 5/36 (14%) signiﬁcant degree], the ﬂow
velocity in the LAA was >20 cm/sec in 32/36 pts (89%) and in 4 (11%) of them was
<20 cm/sec and atheromatous plaques in THA was found in 14/36 (39%) pts and
noone had thrombus in LA and LAA. Finally, EF<45% was found in 7/36 (19%) pts.
In 9 to 31 months follow up one pt with history of pAF died suddenly by unknown
cause which had big LA and signiﬁcant SEC.
Conclusions: In this preliminary study, little spontaneous echogenic contrast in the
LA was present in most of the pts with history of pAF, the LA was found dilated and
atherosclerotic disease of THA was present in many pts. Low ﬂow velocity in the
LAA was not a common ﬁnding. The predictive value of these echocardiographic
risk factors for thromboembolism does seem to be valid in pts with pAF. It has to be
proven by adequate studies.
S107
863
Poliparametric functional evaluation of left atrial appendage obtained
with transthoracic echocardiography: comparison with transesophageal
echocardiography.
P. Colonna, M. Sorino, B. Del Salvatore, L.B. Corlianò, V. Ostuni, L. De Luca, I. De
Luca. Azienda Policlinico, Cardiology Division, Bari, Italy
Transesophageal echocardiography (TEE) is the gold standard to evaluate the left
atrial appendage (LAA) function, useful for anticoagulation therapy in cardioverting
patients with atrial ﬁbrillation (AF).
Aim of this study is to evaluate the feasibility of a poliparametric evaluation of LAA
at II harmonic transthoracic echocardiography (TTE) with LAA emptying velocities
(vel) plus a completely new monodimensional parameter of LAA contraction, and to
test the accuracy versus the TEE LAA vel.
Method: We studied 75 patients (39 in sinus rhythm and 36 in AF), measuring LAA
vel at TEE. Prior to TEE, we performed a II harmonic TTE, determining 1) the TTE
LAA vel and 2) the TTE M-mode LAA medial wall thickening (D), related to the
emptying and ﬁlling LAA phases.
Results: We obtained an adequate visualization of TTE LAA vel in 60/75 patients
(80%) and of D in 71/75 patients (95%). In the patients with a TTE LAA vel a
good correlation was observed between TTE LAA vel and TEE LAA vel (r=0.87,
p<0.0001). A cutoff value of TTE AuV <0.30 cm/s showed a sensitivity of 85%
(11/13 patients) and a speciﬁcity of 95% (20/21 patients) in identifying patients with
a TEE AuV <30cm/s. A cutoff value of D<0.25 cm showed a sensitivity of 94%
(29/31 patients) and a speciﬁcity of 83% (33/40 patients) in identifying patients with
a TEE AuV <30cm/s.
TTE parameters vs TEE vel
Conclusion: Flow and M-mode parameters, thanks to their feasibility, can be useful
to evaluate LAA function with II harmonic TTE. This information could be useful for
anticoagulation therapy of AF patients.
864
A new sign of left atrial appendage function obtained with
monodimensional transthoracic 2nd harmonic echocardiography.
P. Colonna, M. Sorino, B. Del Salvatore, L. De Luca, L.B. Corlianò, I. De Luca.
Azienda Policlinico, Cardiology Division, Bari, Italy
In the study of left atrial appendage (LAA) function during sinus rhythm (SR)
and atrial ﬁbrillation (AF) for anticoagulation therapy indication, the gold standard
to measure LAA emptying velocity (LAAV) is transesophageal echocardiography
(TEE). Conversely, conventional transthoracic echocardiography (TTE) LAA study
has been poorly feasible. The aim of this study is to evaluate the feasibility of a new
TTE monodimensional parameter of LAA function and to compare it with TEE LAAV.
Method: In 75 patients, 39 with SR and 36 with AF enrolled for DC-shock cardioversion (C), we performed TTE and TEE to study LAA function. With 2nd harmonic TTE
in modiﬁed apical 2 chamber view, using a single M-mode beam perpendicular to
LAA wall, we determined the extent of LAA medial wall thickening (D), also related
to the LAA contraction and relaxation phases. We considered a D > 0.25 cm as a
sign of normal LAA function.
Results: The LAA was visualized with M-mode 2nd harmonic TTE in 71/75 patients
(95%); in all the patients LAAV were obtained by TEE. In these 71 patients there
was a good correlation between TTE D and TEE LAAV (r=0.54, p<0.001).
A value of TTE D<0.25 cm showed a sensitivity of 94% (29/31 patients) and a
speciﬁcity of 85% (34/40 patients) in identifying patients with a TEE LAAV<30cm/s.
In the 4 patients showing a LAAV <30 cm/sec at 24 hours post-C (mean LAAV
22+5.1 cm/sec), the TTE D was 0.39+0.11 cm at pre-C, 0.16+0.09 cm (p<0.05 vs
pre-C) at 24 hours post-C, and 0.34+0.12 cm (p<0.05 vs 24 hours post-C) at 7 days
post-C (when the TEE LAAV increased to 48.2+16.8 cm/sec, p<0.05 vs 24 hours
post-C).
Conclusion: Our data indicate that this new TTE 2nd harmonic M-mode parameter
is easily obtainable, can provide information related to TEE LAAV and could be
useful in AF patients for post-C anticoagulation therapy.
Eur J Echocardiography Abstracts Supplement, December 2003
S108
Abstracts
865
Hyperhomocysteinemia is associated with the presence of left atrial
spontenous echo contrast and or thrombus in stroke patients with
nonvalvular atrial ﬁbrillation.
N. Ozer 1 , H. Kýlýc 1 , E.M. Arsava 2 , E. Atalar 2 , H. Ay 2 , S. Aksöyek 1 , K. Övünç 1 ,
L. TokgözoÕlu 1 , O. Sarýbas 2 , S. Kes 1 . 1 Hacettepe University, Medical School,
Cardiology Dept., Ankara, Turkey; 2 Hacettepe, Neurology, Ankara, Turkey
Blood stasis is the fundamental mechanism leading to thrombus formation in the
venous system. Homocysteine also poses a signiﬁcant risk for venous thrombosis through its endothelial toxic and prothrombotic properties. In the present study,
we hypothesized that high homocysteine might be related with spontaneous echo
contrast (SEC) and thrombus formation in left atrial appendage (LAA).
Methods: Sixty-one patients with ischemic stroke caused by nonvalvular atrial ﬁbrillation were included into study. Total fasting plasma homocysteine levels were measured. All patients were evaluated by transesophageal echocardiography for the
presence of a left atrial appendage (LAA) spontaneous echo contrast ±thrombus,
LAA minimum (LAA min) and maksimum areas (LAA max), LAA ﬂow velocities, LAA
wall velocities (by Tissue Doppler imaging). Homocysteine levels were compared
between groups with or without LAA spontaneous echo contrast +/- thrombus.
Results: Transesophageal echocardiography revealed LAA spontenous echo
contrast+/-thrombus in 23 patients. LAA ﬂow velocities(27±11 vs 49±13), LAA wall
velocity (5.9 ±2.3 vs 12±9.6), were lower and LAA min (2.7±0.5 vs 1.6±0.3) and
max areas (5.7±2.8 vs 3.5±2.4) greater in patients with SEC+/- thrombus. Mean
homocysteine levels were signiﬁcantly higher in patients with LAA SEC+/-thrombus
(19.1 versus 13.4 micromol/L, P<0.001). Homocysteine levels were also corrleted
with LAA min and max areas and LAA velocities (p<0.05).
Conclusions: High plasma homocysteine is related with the presence of spontaneous echo contrast and or thrombus formation in the left tarial appendage. This
ﬁnding further supports the thrombogenic role of high homocysteine in conditions
associated with blood stasis.
866
Can left atrial appendage dimensions and contractility inﬂuence the type
of cerebral ischemic event?
A. Timoteo, L M. Branco, N. Pelicano, J. Feliciano, A. Fiarresga, A. Leal, A. Abreu,
J. Abreu, C S. Salomão, J. Quininha. Santa Marta Hospital, Cardiology
department, Lisbon, Portugal
Background: Left atrial appendage (LAA) thrombi and/or spontaneous contrast
may be the cause of cerebral and systemic embolism. The velocities of LAA emptying and replenishment detected by Doppler ﬂow may inform about LAA function and
susceptibility to embolism. LAA size and fractional area shortening can inﬂuence
the potential for ischemic cerebral embolism.
Objectives: To study the inﬂuence of LAA area and function in the extent of ischemic cerebral events.
Population and Methods: In 139 patients, referred to our department after a stroke
(n=106, 52 ± 15 years, 59% male) or cerebral transient ischaemic attack (TIA)
(n=33, 53 ± 14 years, 73% male, p=NS), conﬁrmed by a CT scan, a transesophageal echocardiogram (TEE) was performed to search for a cardiac source of
embolism (only patients with a normal transthoracic echocardiogram were included
in the study). TEE was performed with a 5 MHz probe and different potential cardiac
sources of embolism were searched. Moreover, LAA area was measured in diastole
and systole and fractional area shortening of LAA was calculated. In 99 patients (80
in the stroke group and 19 in the TIA group), maximal velocities of emptying and
replenishment of the LAA were measured with pulsed Doppler echocardiography.
Results: There were no differences between both groups in what concerns LAA
area in diastole (283 ± 180 vs. 285 ± 136 mm2 , respectively, p=NS) and LAA maximal velocities (55 ± 22 vs. 57 ± 16 cm/sec., respectively, p=NS). LAA systolic area
(127 ± 144 vs. 81 ± 68 mm2 , p=0.002) and fractional area shortening (59 ± 26 vs.
72 ± 20%, p<0.001) were signiﬁcantly different between both groups. There were
thrombi/spontaneous echo in 9% vs. 0%, respectively, p=NS).In the stroke group
we identiﬁed another potential embolic source in 3 patients and none in TIA group.
Conclusions: In patients with stroke, the LAA systolic area is bigger and its fractional area shortening is smaller than in patients with TIA. This may represent a
worse LAA function and greater predisposition for larger thrombi to develop.
867
Is surgical closure of the left atrial appendage useful for preventing
cardioembolic events?
B. Schneider 1 , C. Stöllberger 2 . 1 Sana Kliniken, Klinik für Kardiologie, Lübeck,
Germany; 2 Krankenanstalt Rudolfstiftung, II. Medizinische Abteilung, Vienna,
Austria
Background: Closure of the ﬁbrillating left atrial appendage (LAA) has been recommended during valve surgery to decrease the future risk of embolic events. However, patients undergoing surgical LAA closure have not consistently been reevaluated by transesophageal echocardiography (TEE) for complete LAA obliteration.
Methods and Results: During a 12-month period, 6 female patients (age 61-81
years) with intermittent (n=3) or permanent (n=3) atrial ﬁbrillation underwent surgical LAA closure at the time of mitral and/or aortic valve surgery. TEE performed
23–159 (mean 51) days after the procedure demonstrated complete LAA ligation in
only 1/6 patients. The LAA cavity in this case was obliterated by a large clot separated from the circulation by an echogenic membrane. In the remaining 5 patients
Eur J Echocardiography Abstracts Supplement, December 2003
incomplete LAA closure was found due to disruption of the closure line and partial
recanalization of the sutured oriﬁce. The size of the LAA oriﬁce ranged from 3 to
20 mm. All 5 patients demonstrated a relatively high ﬂow velocity at the LAA oriﬁce (0.33-2.2 m/sec) whereas the ﬂow in the LAA body was very low (<0.2 m/sec).
Compared to the preoperative TEE, spontaneous echocardiographic contrast was
much more intense in the LAA body than in the LA cavity in all cases. In 1 patient
a thrombus within the LAA was detected which had not been present on the preoperative TEE. One patient suffered a stroke 4 weeks after attempted LAA closure
despite an optimal level of anticoagulation.
Conclusion: Surgical LAA closure was incomplete in most patients, resulting in
blood stagnation and an increased likelihood of clot formation. Facilitated by a high
velocity jet, thrombi form the LAA may pass through the narrow LAA oriﬁce into
the systemic circulation. Thus, incomplete surgical LAA closure may promote rather
than reduce the risk of stroke. Intraoperative TEE is mandatory to verify complete
LAA obliteration.
868
Longer longitudinal atrial dimensions and D-dimer might be a possible
predictor of presence of left atrial spontaneous echo contrast in patients
with persistent atrial ﬁbrillation.
M. Randjelovic, S. Apostolovic, Z. Perisic, M. Pavlovic, S. Salinger, M. Burazor,
N. Karanovic, S. Ciric-Zdravkovic, B. Randjelovic. Clinic of Cardiology CC Nis, Nis,
Yugoslavia
Large atrium are known to be a important factor for occurrence of persistent atrial
ﬁbrillation (PAF) but it‘s inﬂuence on possible LA blood stasis in those patients remains doubtful as well as different markers for coagulation.
We studied 38 patients with PAF (27 men and 11 women) that were randomized
for treatment including transesophageal and transthoracic echocardiographic measurements that were performed in standard M-mode and the apical 4-chamber view
during end-systole and venous blood samples were collected for D-dimer measurements at the beginning of the study.
Left atrial spontaneous echo contrast (SEC) was found by TEE in 12 of the 38
patients with PAF. The longitudinal dimension of the LA was longer in patients with
SEC unlike the patients without SEC (58.25:53.17,p<0.002). However, there were
no signiﬁcant differences in the transverse and standard M-mode dimension of LA
between those two groups of patients. D-dimer was signiﬁcantly higher in patients
with SEC then in other patients (0.31:0.26,p<0.01) with it‘s values always higher
than 0.3 in presence of SEC.
In conclusion we can suggest that prolongation of the longitudinal LA dimension in
patients with PAF in combination with higher values of D-dimer may be a possible
predictor of presence of LA SEC.
869
Incidence of cerebral embolism in high risk patients with atrial ﬁbrillation
- a prospective and serial study using cerebral MRI.
P. Bernhardt 1 , H. Schmidt 1 , M. Hackenbroch 2 , T. Sommer 2 , B. Luederitz 1 ,
H. Omran 1 . 1 University of Bonn, Department of Cardiology, Bonn, Germany;
2
University of Bonn, Department of Radiology, Bonn, Germany
Background: Patients (pts) with atrial ﬁbrillation (AF) and spontaneous echo contrast (SEC) have an increased stroke risk.
The aims of this prospective study were (1) to evaluate the prognosis of pts with
dense SEC and (2) to assess the incidence of cerebral embolism with MR-imaging
(MRI) under continued oral anticoagulation therapy.
Methods: The study group consisted of 64 pts with SEC and AF. 28 pts with sinus
rhythm served as controls. All pts received oral anticoagulation therapy during the
follow-up period (an INR > 2 was deﬁned as effectively anticoagulated). To document the incidence of cerebral embolism all pts underwent the following examinations at admission and at 1, 3 and 12 months: transthoracic and transesophageal
echocardiography, cranial MRI including diffusion- weighted MRI, assessment of the
anticoagulation level and neurological assessment.
Results: 2 pts had clinically silent cerebral embolism at the index examination. Two
patients (3%) had cerebral embolism with a neurological deﬁcit during the follow-up
period. Four (6%) pts died during the observation period due to stroke. 11 (17%) pts
had focal diffusion abnormalities in the MRI during the follow-up. 45 (70%) pts were
effectively anticoagulated, 19 (30%) pts were anticoagulated inadequately during
the 12 months. One patient with inadequate anticoagulation had an embolic lesion
during the follow-up, 12 pts who received effective anticoagulation had cerebral
embolism or died during the follow-up (p=0.22). Controls did not display cerebral
lesions during the study period. Pts with cerebral embolism had lower left atrial appendage peak empty velocities (0.22 ± 0.14 vs. 0.38 ± 0.21; p<0.01) and denser
SEC (2.8 ± 1.1 vs. 1.6 ± 1.4; p<0.01) than pts without cerebral events.
Conclusions: Pts with AF and SEC have an increased risk of cerebral embolism
despite oral anticoagulation therapy. Low peak empty velocities of the left atrial appendage and dense SEC are echocardiographic predictors for a cerebral event. The
ﬁndings of this study have important implications for the clinical management of high
risk pts with AF.
Abstracts
870
Assessment of left atrial appendage wall velocities in patients with
stroke.
N. Ozer 1 , H. Kýlýc 1 , G. Abalý 1 , H. Ay 2 , E. Atalar 1 , S. Aksoyek 1 , K. Övünç 1 ,
L. TokgözoÕlu 1 , F. Ozmen 1 , S. Kes 1 . 1 Hacettepe University, Medical School,
Cardiology Dept., Ankara, Turkey; 2 Hacettepe, Neurology, Ankara, Turkey
The left atrial appendage (LAA) is an important source of systemic embolic events.
The purpose of this study was to evaluate the LAA function with tissue Doppler
echocardiography and compare them with the classical LAA function parameters
especially in patients with spontaneous echo contrast.
To assess left atrial appendage (LAA) wall velocities, 115 stroke patients underwent tissue Doppler echocardiography during a clinically indicated transesophageal
echocardiography procedure. The LAA ﬂow velocity, LAA minumum and maximum
areas, LAA oriﬁce size, LAA ﬂow propagation velocity and mitral ﬂow propagation
velocity (MFPV) were also evaluated.
Results: Patients with spontaneous echo contrast (37 patients) have higher LAA
min (3.3±1.0 vs1.8±0.9, p=0.0001) and max areas (5.7±2.3 vs 3.7±1.2, p=0.0001)
and lower left atrial appendage ﬂow velocity (just before the QRS complex) (0.5±0.2
vs. 0.3±0.1, p=0.001). Tissue Doppler derived LAA outﬂow positive wave just before the onset of QRS complex (LAAa) is lower in patients with SEC (4.7±2.2 vs
9.3±3.6, p=0.0001) but the negative wave just after the onset of QRS complex
(LAAs) and the positive wave before the electrocardiographic P wave (LAAp) are
not signiﬁcantly different between patients with and without SEC, p>0.05). LAAa
is correlated with LAA ﬂow velocities but the LAAs and LAAp does not correlate.
Patients with lower LAAa have larger LAA areas (For LAA min: p=0.001, r=-0.4, for
LAA max: p=0.006, r=-0.38) and lower LAA ﬂow velocity (p=0.004, r=0.34). MFP
velocity is only correlated LAAp (r=0.32, p=0.005).
Conclusions:
1)From the left atrial appendage wall velocities the outﬂow positive wave just before
the onset of QRS complex (LAAa) is more useful clinical paremeter for the evaluation of patients with spontaneous echo contrast
2) Patients with spontaneous echo contrast have lower LAA wall velocity
3) Left atrial appendage wall velocity is correlated with LAA ﬂow velocity.
4) The positive wave before the electrocardiographic P wave may be related with
the left ventricular diastolic functions.
Thus, conventional TEE examination with the integration of tissue Doppler analysis
can be useful for a comprehensive assessment of left atrial appendage function.
871
Left ventricular hypertrabeculation/noncompaction is not associated with
stroke or peripheric embolism.
C. Stoellberger 1 , J. Finsterer 2 . 1 Vienna, Austria; 2 KA Rudolfstiftung, Vienna,
Austria
Since its ﬁrst description left ventricular hypertrabeculation/noncompaction (LVHT)
is reported to be associated with embolism. Aim of the study was to assess the
number of stroke or embolism in LVHT patients and in control patients matched with
regard to age, sex and left ventricular systolic function.
Design, Setting, Patients and Results: Included in this retrospective study were patients in whom LVHT was diagnosed echocardiographically between 1995-2002.
The control group comprised age-, sex-, and left ventricular fractional shortening
matched patients who had undergone echocardiography between July and September 2002. Both groups of patients were contacted by telephone between October
and December 2002 and were asked if they have ever suffered from stroke or peripheric embolism. Among the 62 patients with LVHT (14 female, 48 male, mean age
53 years, left ventricular fractional shortening 6–53%) 5 patients had suffered from
stroke and 1 patient from peripheric embolism during their lifetime. Among the 62
control patients (14 female, 48 male, mean age 54 years, left ventricular fractional
shortening 6–48%) 9 patients had suffered from stroke during their lifetime.
Conclusions: This study shows that strokes or peripheric embolic events are not
increased in patients with LVHT when compared with age-, sex-, and left ventricular
fractional shortening-matched controls. LVHT by itself does not seem to be a risk
factor for stroke or embolism and thus, not an indication for oral anticoagulation.
872
Importance of transesophageal echocardiography for detection of cardiac
source of embolism according to age groups.
S109
atrium, atrial septum defect (ASD), atrial septum aneurysm (ASA), patent foramen
oval (PFO), prominent plaques in the thoracic aorta, mitral valve disease, valvular
endocarditis and intra-cardiac tumours.
Results: There were strokes in 73, 77 e 74% of patients (p=NS), transient ischemic
attacks in 22, 15 and 11% (p=0.03 for Group I vs. II) and peripheral embolism in
6, 8 and 15% of patients (p=0.04 for Group I vs. III), respectively. The ﬁndings are
reported in the table (*p<0.05, GI vs GII or GIII, GII vs GIII).
n (%)
Group I
Group II
Group III
ASD
PFO
ASA
Thrombi
SC*
Aortic plaques*
Positive*
>=2 embolic sources*
3 (0.9)
23 (7)
19 (6)
13 (4)
11 (3)
13 (4)
85 (26)
1 (0.3)
4 (1)
44 (6)
27 (7)
44 (11)
66 (17)
74 (19)
195 (50)
18 (5)
0
3 (6)
1 (2)
4 (7)
14 (26)
24 (44)
35 (65)
9 (17)
Results
Conclusions: There was a better diagnostic capacity of TEE in elderly patients,
where there was frequently an association between several potentially embolic
sources. Spontaneous echo contrast and prominent aortic plaques were the predominant ﬁndings in patients above 50 years of age.
VALVULAR HEART DISEASE
874
Prevalence of diastolic dysfunction in patients with aortic stenosis and
preserved left ventricular systolic function.
L.A. Smith 1 , G.S. Hillis 2 , S.J. Cowell 1 , A.C. White 3 , D.E. Newby 1 , N.A. Boon 1 ,
D.B. Northridge 3 . 1 University of Edinburgh, Cardiovascular Research, Edinburgh,
United Kingdom; 2 Aberdeen Royal Inﬁrmary, Cardiology, Aberdeen, United
Kingdom; 3 Western General Hospital, Cardiology, Edinburgh, United Kingdom
Purpose Historical data suggest that approximately 50% of patients with aortic
stenosis (AS) and normal systolic function have evidence of diastolic dysfunction.
These data predate the identiﬁcation of several novel echocardiographic indicators
of impaired left ventricular (LV) relaxation and increased LV ﬁlling pressures. These
include early mitral annulus velocity (e’), ratio of early diastolic ﬁlling velocity to early
mitral annulus velocity (E/e’) and left atrial volume indexed for body surface area
(LAVi). We hypothesised that the combination of these parameters and traditional
methods would identify a higher prevalence of diastolic dysfunction than previously
reported.
Methods Transthoracic Doppler echocardiography was performed in 63 patients
(age 65±12 years) with AS (mean gradient 27±12 mmHg; aortic valve area (AVA)
1.1±0.4cm2 ). Patients with atrial ﬁbrillation, greater than mild mitral regurgitation
or LV systolic dysfunction were excluded. Diastolic function was assessed by measurement of transmitral E- and A-wave velocity, E-deceleration time (DT), isovolumic relaxation time (IVRT), Doppler tissue imaging of the early septal mitral annulus
velocity (e’) and LAVi. Mean and peak aortic valve gradients, AVA and LV mass
indexed for body surface area (LVMi) were recorded. E/A ratio >2, DT <150ms,
E/e’ ratio >15 or LAVi >32mL/m2 were considered indicative of increased LV ﬁlling
pressures. E/A ratio <0.7 and/or DT >240ms and/or IVRT >90ms and/or e’ <5cm/s
were considered indicative of impaired relaxation.
Results 30 patients (48%) had evidence of elevated LV ﬁlling pressures: E/A ratio
>2 in 1 (1%), DT <140ms in 2 (3%), E/e’ >15 in 20 (32%), and LAVi >32ml/m2 in
11 (17%). An additional 19 patients had evidence of impaired relaxation. In total,
therefore, 49 patients (78%) had evidence of diastolic dysfunction. There were no
signiﬁcant univariate correlations between severity of AS and E/A ratio, DT, IVRT
and LAVi. There were, however, weak correlations between peak and mean aortic
valve gradients and e’ (r=-0.26, p=0.05 and r=-0.29, p=0.02) and E/e’ ratio (r=0.31,
p=0.02 and r=0.32, p=0.01). LVMi did not correlate with E/A ratio, DT, IVRT or severity of AS. However, LVMi did correlate signiﬁcantly with e’ (r=-0.32, p=0.01), E/e’ ratio
(r=0.32, p=0.02) and LAVi (r=0.49, p<0.001).
Conclusions At least 78% of patients with AS and preserved LV systolic function
have some evidence of diastolic dysfunction and almost 50% have evidence of elevated LV ﬁlling pressures. LVMi is inversely correlated with e’ velocity and directly
with E/e’ ratio and LAVi.
A. Timoteo, L M. Branco, J. Abreu, A. Abreu, L. Sousa, N. Pelicano, A. Fiarresga,
J. Feliciano, C S. Salomão, J. Quininha. Santa Marta Hospital, Cardiology
department, Lisbon, Portugal
Background: Transesophageal echocardiography (TEE) is a very useful diagnostic
tool to identify cardiac source of systemic embolism. Is the diagnostic capacity and
the identiﬁed anomalies detected the same for different age groups?
Objectives: We sought to evaluate the diagnostic capacity and the ﬁndings detected by TEE in the search for a cardiac source of systemic embolism according to
age.
Population and Methods: Retrospective analysis of 771 consecutive patients submitted to TEE from 1994 to 2003 to exclude cardiac embolic source. Patients were
divided into 3 groups: Group I: <50 years (n=324, 39±8 years, 46% males); Group
II: 50-74 years (n=392, 61±7 years, 55% males); Group III: ≥75 years (n=54, 78±3
years, 33% males). We evaluated the type of embolic phenomenon, the presence
of spontaneous echo contrast (SC) or thrombi in left atrial appendage and/or left
Eur J Echocardiography Abstracts Supplement, December 2003
S110
Abstracts
875
Distal color ﬂow jet width measured using transesophageal
echocardiography: a new method for quantiﬁcation of mitral
regurgitation.
E. Garbarz 1 , S. Janower 1 , D. Messika-zeitoun 1 , E. Di angelantonio 2 , B. Iung 3 ,
P-L. Michel 1 . 1 Tenon, Paris, France; 2 Saint Antoine Hospital, Cardiology, Paris,
France; 3 Bichat Hospital, Cardiology, Paris, France
Introduction: Quantiﬁcation of mitral regurgitation (MR) by echocardiography remains frequently challenging in routine clinical practice. Both the PISA and the
vena contracta width methods have several limitations. A majority of pts have a
jet with, at least initialy, a cylindric shape by color Doppler imaging. The width of
this jet, distal to the regurgitant oriﬁce (DJW) is easy to mesure using a transoesoephageal/transgastric approach. We investigate wether DJW could be used as
an indicator of MR severity.
Methods: DJW was obtained in 52 pts with MR (male 63%, mean age 63 years)
using transesophageal (0° or 120°) or transgastric (90°) views and compared with
the effective regurgitant oriﬁce (ERO), the pulmonary venous ﬂow systolic reversal,
and the Sellers’ angiographic grade whenever available.
Results: MR etiology included degenerative (42%), ischemic (25%), functional
(21%), infective (8%), rheumatic (4%). Mean ± SD ERO and DJW were 0.45 ± 0.39
cm2 and 0.9 ± 0.35 cm respectively. Fair correlations were observed between DJW
and ERO (r=0.71, p<0.0001), even when the analysis was restricted to pts with eccentric jets and valve prolapse (r=0.72, p=0.004), in pts with LVEF< 50% (r=0.69,
p=0.013) or AFib(r=0.71, p=0.0001). DJW also correlated with the occurrence of
pulmonary venous ﬂow systolic reversal (r=0.87, p<0.01) and Sellers’ angiographic
grading (r=0.47, p=0.015). A DJW >/= 0,9 cm predicted an ERO >/= 0,3 cm2 with
76% sensitivity (95% CI 65-88%), 82% speciﬁcity (95% CI 71-92%), 85% positive
predictive value (95% CI 75-95%), 72% negative predictive value (95% CI 59-84%)
and an overall accuracy of 78% (95% CI 67-89%).
Conclusions: In this study, the DJW measured by color Doppler during TEE correlated well with the other methods of MR evaluation. This measure could provide an
additional and accurate tool to be validated in larger populations.
876
Detection of coronary artery disease by dobutamine echocardiography
stress test in patients with moderate aortic stenosis in subgroups with
and without hypertension: safety and accuracy.
E. Plonska 1 , A. Szyszka 2 , J. Kasprzak 3 , Z. Gasior 4 , M. Maciejewski 3 ,
A. Gackowski 1 , P. Gosciniak 1 . 1 Medical University, Szczecin, Poland; 2 Medical
University, Poznan, Poland; 3 Medical University, Lodz, Poland; 4 Medical University,
Katowice, Poland
Background: Angina cannot discriminate in favour of coronary artery disease
(CAD) because the same symptom accompanies aortic stenosis (AS), either due to
left ventricular (LV) enlargement, increassed wall stress or hypertrophy with subendocardial ischaemia. Resting ECG in patients (pts) with AS or hypertension (HT)
often reveals ST segment abnormalities due to hypertrophy and/or dilatation of the
LV, making the diagnosis of CAD on the basis of exercise ECG uncertain. However
usefulness of dobutamine echocardiography (DE) in patients with AS and HT has
not been determined.
Aim: To assess the usefulness of DE for detection of CAD in patients with AS depending on the presence of HT.
Materials: 162 pts (mean age 59 yrs, 18-81, 64,2% male) with AS and maximal
aortic gradient in the range 25-65mmHg, without contraindication to DE. According
to WHO criteria 79(48,8%) were hypertensive (HT+) and 83(51,2%) – non hypertensive (HT-) pts.
Methods: All pts underwent standard DE (doses 5-40mcg/kg/min) in the framework
of multicenter study involving 10 centers from Poland and Hungary. Classical DE
termination criteria were used. The reason for test termination was also reaching
100mmHg of maximal aortic gradient during DE. Diagnostic value of DE was assessed in relation to the signiﬁcant coronary stenosis (>50%).
Results: Peak dobutamine dose was 32+10mcg/kg/min in group NT+ and
31+10mcg/kg/min in group NT- (NS), peak heart rate was 112+26 and 117+bpm
(NS), systolic arterial pressure – 144+26 and 139+24mmHg (p<0,05) respectively.
Transaortic mean gradient and peak gradient changed signiﬁcantly during DE in
both groups (p<0,001). Above mentioned parameters were not statistically different
in comp