Importance of the right ventricle in valvular heart disease

The importance of the right ventricle as a determinant of clinical symptoms, exercise capacity, peri-operative survival and postoperative outcome has been underestimated for a long time. Right ventricular ejection fraction has been used as a measure of right ventricular function but has been found to be dependent on loading conditions, ventricular interaction as well as on myocardial structure. Altered left ventricular function in patients with valvular disease influences right ventricular performance mainly by changes in afterload but also by ventricular interaction. Right ventricular function and regional wall motion can be determined with right ventricular angiography, radionuclide ventriculography, two-dimensional echocardiography or magnetic resonance imaging. However, the complex structure of the right ventricle and its pronounced translational movements render quantification difficult. True regional wall motion analysis is, however, possible with myocardial tagging based on magnetic resonance techniques. With this technique a baso-apical shear motion of the right ventricle was observed which was enhanced in patients with aortic stenosi

Patterns and timing of Doppler-detected intracavitary and aortic flow in hypertrophic cardiomyopathy

This study describes the velocity characteristics of left ventricular and aortic outflow in 25 patients with hypertrophic “obstructive” cardiomyopathy. Systematic pulsed and continuous wave Doppler analysis combined with phonocardiography and M-mode echocardiography was used to establish the pattern and timing of outflow in the basal and provoked states. This analysis suggests that 1) the high velocity left ventricular outflow jet can be reliably discriminated from both aortic flow and the jet of mitral regurgitation using Doppler ultrasound; 2) the Doppler velocity contour responds in a characteristic fashion to provocative influences including extrasystole and Valsalva maneuver; 3) the onset of mitral regurgitation occurs well before detectable systolic anterior motion of the mitral valve; 4) left ventricular flow velocities are elevated at the onset of systolic anterior motion of the mitral valve, suggesting a significant contribution of the Venturi effect in displacing the leaflets and chordae; 5) the high velocities of the outflow jets are largely dissipated by the time flow reaches the aortic valve; and 6) late systolic flow in the ascending aorta is nonuniform, with formation of distinct eddies that may contribute to “preclosure” of the aortic valve

LEFT VENTRICULAR MOTION STUDY WITH STATISTICAL SHAPE ANALYSIS

Left ventricular motion was assessed in echocardiographic records of chronic heart failure patients and healthy volunteers using statistical shape analysis. Features were extracted in unsupervised manner that describe aspects of left ventricular shape and motion and characterize pathological heart.Работа поддержана грантом РНФ № 19-14-00134

Comparison of two-dimensional echocardiographic wall motion and wall thickening abnormalities in relation to the myocardium at risk

Previous 2DE studies have suggested that left ventricular wall thickening determinants of regional left ventricular function may be more precise than left ventricular wall motion parameters in the assessment of myocardial ischemia and infarction. To study the relationship between regional wall motion and regional wall thickening abnormalities relative to myocardial ischemia, we performed 2DE in 27 dogs at baseline and following 1 hour of circumflex coronary occlusion. A 2DE circumferential map of regional wall motion and regional wall thickening was generated at 22.5-degree intervals over 360 degrees using a fixed centroid. With the use of three consecutive beats, 95% normal tolerance levels were derived for each individual left ventricular function map. The circumferential extent of left ventricular dysfunction was measured at the curve intercepts of the occluded and normal maps. The left ventricular ischemic area at risk for the corresponding 2DE slice was determined by technetium-99 autoradiography. Following coronary occlusion, left ventricular end-diastolic area increased (p p p p p = NS). In addition, the circumferential extent of regional wall motion overestimated regional wall thickening by 54% (p < 0.0005). We conclude that regional wall thickening abnormality corresponds better to actual area at risk and that regional wall motion overestimates the extent of regional dysfunction. This overestimation most likely relates to the use of the centroid method of analysis which influences regional wall motion more than regional wall thickening.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/26256/1/0000337.pd

Left Ventricular Dyssynchrony Acutely After Myocardial Infarction Predicts Left Ventricular Remodeling

ObjectivesWe sought to identify predictors of left ventricular (LV) remodeling after acute myocardial infarction.BackgroundLeft ventricular remodeling after myocardial infarction is associated with an adverse long-term prognosis. Early identification of patients prone to LV remodeling is needed to optimize therapeutic management.MethodsA total of 178 consecutive patients presenting with acute myocardial infarction who underwent primary percutaneous coronary intervention were included. Within 48 h of intervention, 2-dimensional echocardiography was performed to assess LV volumes, LV ejection fraction (LVEF), wall motion score index, left atrial dimension, E/E′ ratio, and severity of mitral regurgitation. Left ventricular dyssynchrony was determined using speckle-tracking radial strain analysis. At 6-month follow-up, LV volumes, LVEF, and severity of mitral regurgitation were reassessed.ResultsPatients showing LV remodeling at 6-month follow-up (20%) had comparable baseline characteristics to patients without LV remodeling (80%), except for higher peak troponin T levels (p < 0.001), peak creatine phosphokinase levels (p < 0.001), wall motion score index (p < 0.05), E/E′ ratio (p < 0.05), and a larger extent of LV dyssynchrony (p < 0.001). Multivariable analysis demonstrated that LV dyssynchrony was superior in predicting LV remodeling. Receiver-operating characteristic curve analysis demonstrated that a cutoff value of 130 ms for LV dyssynchrony yields a sensitivity of 82% and a specificity of 95% to predict LV remodeling at 6-month follow-up.ConclusionsLeft ventricular dyssynchrony immediately after acute myocardial infarction predicts LV remodeling at 6-month follow-up

Comparison of wall thickening and ejection fraction by cardiovascular magnetic resonance and echocardiography in acute myocardial infarction

<p>Abstract</p> <p>Objectives</p> <p>The purpose of this study was to compare cardiovascular magnetic resonance (CMR) and echocardiography (echo) in patients treated with primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) with emphasis on the analysis of left ventricular function and left ventricular wall motion characteristics.</p> <p>Methods</p> <p>We performed CMR and echo in 52 patients with first AMI shortly after primary angioplasty and four months thereafter. CMR included cine-MR and T1-weighted first-pass and late-gadolinium enhancement (LGE) sequences. Global ejection fraction (EF_CMR, %) and regional left ventricular function (systolic wall thickening %, [SWT]) were determined from cine-MR images. In echo the global left ventricular function (EF_echo, %) and regional wall motion abnormalities were determined. A segment in echo was scored as "infarcted" if it was visually > 50% hypokinetic.</p> <p>Results</p> <p>EF_echorevealed a poor significant agreement with EF_CMRat baseline (r: 0.326; p < 0.01) but higher correlation at follow-up (r: 0.479; p < 0.001). The number of infarcted segments in echocardiography correlated best with the number of segments which showed systolic wall thickening < 30% (r: 0.498; p < 0.001) at baseline and (r: 0.474; p < 0.001) at follow-up. Improvement of EF was detected in both CMR and echocardiography increasing from 44.2 ± 11.6% to 49.2 ± 11% (p < 0.001) by CMR and from 51.2 ± 8.1% to 54.5 ± 8.3% (p < 0.001) by echocardiography.</p> <p>Conclusion</p> <p>Wall motion and EF by CMR and echocardiography correlate poorly in the acute stage of myocardial infarction. Correlation improves after four months. Systolic wall thickening by CMR < 30% indicates an infarcted segment with influence on the left ventricular function.</p

Use of a regional wall motion score to enhance risk stratification of patients receiving an implantable cardioverter-defibrillator

AbstractObjectives. We postulated that preoperative assessment of both regional wall motion and left ventricular ejection fraction would serve as an accurate prognostic indicator of long-term cardiac mortality and functional outcome in patients treated with an implantable cardioverter-defibrillator.Background. Long-term cardiac mortality has remained high in patients receiving an implantable cardioverter-defibrillator. The ability to risk stratify patients before defibrillator implantation is becoming increasingly important from a medical and economic standpoint.Methods. The hypothesis was retrospectively tested in 74 patients who had received an implantable cardioverterdefibrillator. Left ventricular ejection fraction and regional wall motion score, derived from centerline chord motion analysis, were calculated for each patient from the preoperative right anterior oblique contrast ventriculogram. Wall motion score was the only significant independent predictor of long-term cardiac mortality and functional status by multivariate analysis because of its enhanced prognostic capability in patients with an ejection fraction in the critical range of 30% to 40%.Results. Patients with an ejection fraction >40% had a 3-year cardiac mortality rate of 0% compared with 25% for those with an ejection fraction of 30% to 40% and 48% for those with an ejection fraction <30% (p < 0.05). Similarly, 75% of patients with an ejection fraction >40% were in New York Heart Association functional class I or II during long-term follow-up compared with 59% of those with an ejection fraction 30% to 40% and 29% of those with an ejection fraction <30%. Among patients with an ejection fraction of 30% to 40%, those with a wall motion score >16% had a 3-year cardiac mortality rate of 0% compared with 71% of those with a wall motion score ≤ 16% (p = 0.002). In addition, 86% of patients with a wall motion score >16% were in functional class I or II during long-term follow-up compared with 13% of those with a wall motion score ≤16% (p = 0.001).Conclusions. Long-term cardiac mortality and functional outcome in patients receiving an implantable cardioverterdefibrillator can be predicted if the left ventricular ejection fraction and regional wall motion score are measured preoperatively

Pre-Processing Edge Detection Image Enhancement and Spatial Object Velocity Estimation for Echocardiograph Diagnostic Test

Echocardiograph imaging is a primary modality in the diagnosis of heart disease. Compared to other imaging techniques, such as X-Ray, MRI, and PET, echocardiograph imaging owes its great popularity to the fact that it is a safe and non-invasive procedure for visualizing the heart and vasculature. The echocardiograph image however is corrupted by speckle noise and low contrast, which make feature detection and tracking difficult. This thesis focuses on two important issues for the clinical applications of medical echocardiograph images: speckle suppression and motion estimation. The thesis first presents visualization enhancement method to clarify the heart structure and the movement of the valves. This method is designed to extract the contours of heart boundaries from a sequence of echocardiograph images, where it started with pre-processing to reduce noise and get better image quality. These pre-processing operations involved the use of median filtering, morphological opening and contrast adjustment. Thereafter, Sobel edge detection was applied and the resulted image combined with image after opening stage. This method validated visually by medical students using real echocardiograph images. Performance improvement of this method evaluated as it provides very significant speckle suppression and edge enhancement for the purposes of visualization and automatic structure detection. Second issue in this thesis is improving the detection of wall motion abnormality by quantitative analysis. The analysis of the left ventricular wall motion in routine is mostly based on visual interpretation of echocardiograph image. The interpretation of these images is widely dependent on operator training and is subject to large variability. To reduce this inter and intraobservers variability, the utilization of optical flow technique presented to estimate the left ventricular wall motion and create a cardiac motion profile based on the anatomical structure of the left ventricular wall in cross sectional view. This profile presenting the anatomical structure provides an additional means for functional imaging and eliminates the need to build a large dataset containing specific parameters of the patient to obtain an accurate diagnosis. In addition, the segmentation into three parts corresponding to the three major coronary arteries was meaningful for cardiac surgery. As a result, this method achieves an estimation of regional myocardial function with percentage of validations 71.4%, which is encouraging. In conclusion, estimation of regional myocardial deformation from intracardiac echocardiography by depending on anatomical knowledge is feasible.This work could be an important aid to improve and support diagnostic accuracy and the prognostic method for left ventricular diseases

Early predictors of adverse left ventricular remodelling after myocardial infarction treated by primary angioplasty

Background: Progressive left ventricular dilatation (PLVD) occurs after myocardial infarction (MI), and this may take place in the area of primary percutaneous coronary intervention (PCI). The factors predicting PLVD after primary PCI still need to be clarified. The aim of the study was to assess the prevalence and to define the baseline clinical and echocardiographic predictors of PLVD in patients with STEMI treated by primary PCI. Methods: Of the 90 patients initially selected for the study 88 (29 women and 59 men, mean age 67.1 &#177; 5.6 years) with first ST-elevation myocardial infarction (STEMI) treated with primary PCI were examined. Echocardiographic examination was performed in all patients at discharge (M1) and after 6 months (M2). The following factors influencing PLVD were evaluated: type of infarct-related artery (IRA), infarct size expressed as wall motion score index (WMSI) &#8805; 1.5, left ventricular end-diastolic volume index (LVEDVI) &#8805; 80 ml/m2, ejection fraction (EF) &#8804; 45%, restrictive pattern of transmitral flow, time to reperfusion, left ventricular mass index (LVMI) &#8805; 125 g/m2 and coronary risk factors. Results: The overall prevalence of PLVD (according to the criterion of 20% LVEDVI increase from M1 to M2) was 24%. Univariate regression analysis revealed that the following were the significant baseline M1 predictors of adverse PLVD: left anterior descending as IRA (relative risk: rr = 2.3, p < 0.05), WMSI &#8805; 1.5 (rr = 4.29, p < 0.005), EF &#8804; 45% (rr = 2.89, p < 0.005) and a restrictive pattern of transmitral flow (rr = 2.4, p < 0.01). Multivariate logistic analysis showed that the only independent determinant of PLVD was WMSI &#8805; 1.5. Conclusions: Both regional and global left ventricular systolic dysfunction indices as well as severe left ventricular diastolic abnormalities but not left ventricular dilatation at discharge are significant predictors of adverse cardiac remodelling after STEMI in patients treated with primary PCI. However the only independent determinant of PLVD was WMSI &#8805; 1.5 expressing the infarct size. (Cardiol J 2007; 14: 238-245