Comparison of Echocardiographic Markers of Cardiac Dyssynchrony and Latest Left Ventricular Activation Site in Heart Failure Patients with and without Left Bundle Branch Block

Background: Several echocardiographic markers have been introduced to assess the left ventricular (LV) mechanical dyssynchrony. We studied dyssynchrony markers and the latest LV activation site in heart failure patients with and without left bundle branch block (LBBB). Methods: Conventional echocardiography and tissue velocity imaging were performed for 78 patients (LV ejection fraction ≤ 35%), who were divided into two groups: LBBB (n = 37) and non-LBBB (n = 41). Time-to-peak systolic velocity (Ts) was measured in 12 LV segments in the mid and basal levels. Seven dyssynchrony markers were defined: delay and standard deviation (SD) of Ts in all and basal segments, septal-lateral and anteroseptal-posterior wall delay (at the basal level), and interventricular mechanical delay (IVMD). Results: The LBBB patients had significantly higher QRS duration and IVMD. The posterior wall was the latest activated site in the LBBB and the inferior wall was the latest in the non-LBBB patients. The most common dyssynchrony marker in the LBBB group was the SD of Ts in all segments (73%), whereas it was Ts delay in the basal segments in the non-LBBB group (48.8%). Ts delay and SD of all LV segments, septal lateral delay, septal-to-posterior wall delay by M-mode, pre-ejection period of the aortic valve, and IVMD were significantly higher in the LBBB group than in the non-LBBB group. Also, 29.3% of the non-LBBB and 10.8% of the LBBB patients did not show dyssynchrony by any marker. The number of patients showing dyssynchrony by ≥ 3 markers was remarkably higher in the LBBB patients (73% vs. 43.9%, respectively; p value = 0.044). Conclusion: The LBBB patients presented with a higher prevalence of dyssynchrony according to the frequently used echocardiographic markers. The latest activation site was different between the groups

Decision making in Ischemic cardiomyopathy: variability in physicians’ approaches and patients’ adherence

Ischemic cardiomyopathy (ICM) is a common cardiovasculardisease with conflicting evidence regardingits management and a high risk profile for revascularizationprocedures that seems to have resulted invariable approach of physicians toward its management,and likewise, significant patient non-adherence to physicianrecommendation. We included patients with 3-vesseldisease and left ventricular ejection fraction (LVEF)<45%(ICM group; n=825), and patients with LM diseaseand LVEF ≥45% (LM group; n=162), detected by coronaryangiography at Tehran Heart Center. Variation of recommendationsamong cardiologists was evaluated. The rateof coronary artery bypass graft (CABG) non-adherencewas also determined, as well as its predictors and outcomein ICM group. Decision making was more variable inICM group, compared to LM group. CABG non-adherencewas significantly more common in ICM group (32.4%),compared to LM group (10.0%) (P<0.001). Advancedage, being female, absence of angina, creatinine >2mg/dl,severe left ventricular dysfunction, absence of LM diseaseand moderate or severe mitral regurgitation were predictorsof CABG non-adherence. ICM patients with CABGnon-adherence had significantly more all-cause mortality(Hazard Ratio [HR]: 1.97, 95% confidence interval [CI]:1.28-3.04), and more all-cause mortality, revascularizationor hospitalization due to cardiac disease (HR: 1.94, 95%CI: 1.41-2.67), than those who received CABG. WhileICM is a common disorder encountered frequently in dailypractice of cardiologists, there is a significant variability indecision making, as well as a significant non-adherencetolifesaving recommendations for these patients

Response to Cardiac Resynchronization Therapy in Cardiomyopathy Patients with Right Bundle Branch Block

Background: The use of cardiac resynchronization therapy (CRT) in heart failure patients with right bundle branch block (RBBB) is under debate. We present early and late echocardiographic characteristics of a series of heart failure patients with RBBB who underwent CRT.  Methods: In this retrospective descriptive study, 18 patients with RBBB in the surface electrocardiogram underwent CRT between 2005 and 2015. All the patients had the New York Heart Association functional class III/IV, a left ventricular ejection fraction (LVEF) ≤35%, and a QRS duration ≥120 milliseconds. The median follow-up duration was 19 months. The echocardiographic response was based on a ≥5% increase in LVEF.  Results: Within 48 hours after CRT implantation, LVEF increased from 24.58%±7.08% before to 28.46±8.91% after CRT (P=0.005) and to 30.00±9.44% at follow-up (P=0.008). Among the 18 patients, 12 (66.7%) were responders within 48 hours after CRT. The following baseline echocardiographic parameters were higher in the responders than in those without an increased LVEF, although the difference did not reach statistical significance: septal-to-lateral wall delay (48.33±33.53 vs 43.33±38.82 ms), anteroseptal-to-posterior wall delay (41.7±1.75 vs 38.33±18.35 ms), and interventricular mechanical delay (48.50±21.13 vs 31.17±19.93 ms). The mean QRS duration was higher in the responders than in the non-responders (183.58±40.69 vs 169.00±27.36 ms). Death was reported in 3 out of the 18 patients (16.7%) at follow-up. The 3 deceased patients had a higher baseline interventricular mechanical delay than those who survived.  Conclusion: Our results indicated that patients with RBBB might benefit from CRT. Further, patients with higher intra and interventricular dyssynchrony and a wider QRS may show better responses

Evaluation of Longitudinal Tissue Velocity and Deformation Imaging in Akinetic Non-viable Apical Segments of Left Ventricular Myocardium

Introduction: The use of tissue velocity and strain rate imaging is proposed for the quantification of non-viable myocardium. This study is aimed at investigating the differences in tissue velocity and strain rate imaging indices between non-viable left ventricular apical segments and the normal segments using segment-by-segment comparison.Materials and Method: Thirty-two patients with akinetic left ventricular apical segments and without viability were selected using two-dimensional echocardiography and dobutamine stress echocardiography; 32 individuals with normal echocardiography and coronary angiography formed the normal group. Peak systolic velocity, peak systolic strain, and strain rate were measured in the four left ventricular apical segments and the apex 17th segment.Results: The patient group had a significantly lower ejection fraction (26.88±6.06% vs. 56.56±2.36%; p<0.001). Overall, the patient group had significantly lower resting peak systolic velocity, systolic strain, and strain rate. In the segment-by-segment comparison, only systolic strain showed a remarkable reduction in the patient group, while reduction in Sm and strain rate were not significant in all the segments. After dobutamine stress echocardiography, only systolic strain showed an insignificant increase compared to the resting values. In the apex 17th segment, Sm showed significant reduction in the patient group.Conclusion: The ST in apical segments may be used as a quantitative index for detecting akinesia both at rest and after dobutamine infusion. Reduction in Sm can be used as a marker of akinesia in the apical cap at rest

Longitudinal Tissue Velocity and Deformation Imaging in Patients with Significant Stenosis of Left Anterior Descending Artery

 Introduction: Myocardial longitudinal tissue velocity imaging (TVI) and strain rate imaging (SRI) indices may have a role in the prediction of significant proximal stenosis of left anterior descending (LAD) by echocardiography. Materials And Methods: Total 20 patients with proximal LAD stenosis >70% by angiography and ejection fraction ≥50%, without wall motion abnormality at resting echo (stenotic group) and 20 angiographically normal coronaries subjects with normal echocardiography (non-stenotic group) were included in the study. SRI and TVI were performed in nine segments of the LAD territory at rest. Parameters of interest included: peak systolic strain (ST, %), strain rate (SR, Second-1), and peak systolic velocity (Sm, cm/s). Results: Overal mean ST and SR showed a significant reduction in the stenotic group compared to non-stenotic group (P<0.001), while the mean Sm had no significant difference. A segment-by-segment comparison revealed a reduction of ST in 4/9 (two apical and two anteroseptal) and SR in 5/9 (three apical, septal, and anteroseptal midportion) in the stenotic group (P<0.05). Both ST and SR showed a significant reduction in three segments: anterior-apical, lateral-apical, and anteroseptal-midportion. When both ST and SR decreased in one segment, specificity and sensitivity for the diagnosis of proximal LAD stenosis was more than 80% and 55%, respectively, by Roc analysis. Conclusion: There is an overall reduction in the mean ST and SR in the segments of LAD territory with significant proximal stenosis and normal wall motion at rest and an acceptable specificity and sensitivity of SRI for the detection of stenosis in these segments

The Impact of the COVID-19 Pandemic on Hospitalization Rates due to Prosthetic Valve Thrombosis

Backgrounds: Studies have shown a decline in the admission rates of various diseases during the COVID-19 pandemic. Prosthetic valve thrombosis (PVT) is a rare condition followed by surgical or transcatheter valvular interventions. Considering the lack of data on hospitalization rates due to PVT during the pandemic, this study evaluated the implications of the COVID-19 pandemic on PVT admissions and characteristics in a tertiary referral center. Methods: Data from all the consecutive patients hospitalized due to PVT between February 2020 and February 2021 (the first year of the pandemic) were collected from medical records and compared clinically with the corresponding time before the pandemic (February 2019 through February 2020). Variables of interest included the number of hospitalization, patient and valve characteristics, diagnostic and management strategies, and in-hospital events. Results: Forty patients (32.5% male, age: 54.0 [46.5-62.0 y] comprised the study population. We observed a considerable decline in hospitalization rates during the pandemic, from 31 to 9 patients. Admitted patients were 8 years younger, had a higher proportion of the New York Heart Association functional class III or IV symptoms (44.4% vs 22.6%), were more often treated with fibrinolysis (33.3% vs 22.6%) or surgical approaches (33.3% vs 22.6%), and were discharged 6 days sooner. Conclusion: We described a reduction in PVT hospitalization. Patients presented with a higher proportion of severe dyspnea and had increased treatment with fibrinolysis/surgical approaches. These observations highlight the necessity of the active surveillance of patients with prosthetic valves by caregivers for timely diagnosis and appropriate management during the pandemic

Comparing the effect of cardiac biomarkers on the outcome of normotensive patients with acute pulmonary embolism

Acute pulmonary embolism (PE) is a cardiovascular challenge with potentially fatal consequences. This study was designed to observe the association of novel cardiac biomarkers with outcome in this setting. In this prospective study, from 86 patients with a confirmed diagnosis of PE, 59 patients met the inclusion criteria (22 men, 37 women; mean age, 63.36±15.04 y).The plasma concentrations of N-terminal pro-brain natriuretic peptide (NT-proBNP), growth differentiation factor-15 (GDF-15), heart-type fatty acid-binding protein (H-FABP), tenascin-C, and D-dimer were measured at the time of confirmed diagnosis. The endpoints of the study were defined as the short-term adverse outcome and long-term all-cause mortality. Totally, 11.8% (7/59) of the patients had the short-term adverse outcome. The mean value of logNT-proBNP was 6.40±1.66 pg/ml. Among all the examined biomarkers, only the mean value of logNT-proBNP was significantly higher in the patients with the short-term adverse outcome (7.88±0.67 vs. 6.22± 1.66 pg/ml; OR, 2.359; 95% CI, 1.037 to 5.367; P=0.041). After adjustment, a threefold increase in the short-term adverse outcome was identified (OR, 3.239; 95% CI, 0.877 to 11.967; P=0.078).Overall, 18.64% (11/59) of the patients had expired by the long-term follow-up. Moreover, adjustment revealed an evidence regarding association between increased logNT-proBNP levels and long-term mortality (HR, 2.163; 95%CI, 0.910 to 5.142; P=0.081). Our study could find evidences on association between increased level of NT-proBNP and short-term adverse outcome and/or long-term mortality in PE. This biomarker may be capable of improving prediction of outcome and clinical care in non-high-risk PE

Assessment of Myocardial Viability: Selection of Patients for Viability Study and Revascularization

The aim of this article is to review the application of current imaging techniques used for the detection of viable myocardium. Each technique is discussed briefly, and the more commonly used techniques are compared. The imaging techniques reviewed herein are dobutamine stress echocardiography, single photon emission tomography, magnetic resonance imaging, positron emission tomography with F-18 fluorodeoxyglucose, and recently introduced tissue Doppler imaging. The estimation of the amount of viable myocardium that could predict a better outcome after revascularization being a challenging issue, the present article also reviews a variety of cut-off points suggested by different investigators as adequate viable myocardium for revascularization and presents a summary of clinical, angiographical, and echocardiographic findings that could assist in selecting patients for viability study

Transesophageal Echocardiographic Characteristics of Secundum-Type Atrial-Septal Defect in Adult Patients

Background: Given the dearth of data in the existing literature on the size and morphologic variability of secundumtype atrial-septal defect (ASD-II) in adult patients, we aimed to address this issue in a series of consecutive adult patients evaluated by transesophageal echocardiography (TEE).Methods: A total of 50 patients (68.0% female) with isolated ASD-II underwent TEE for the evaluation of the defect. The morphological characteristics of the defect were evaluated, and the largest defect size was measured. The ASD rim wasdivided into 6 sectors: the superior-anterior, superior-posterior, superior, inferior-anterior, inferior-posterior, and inferior.The minimal length of the defect rims was determined.Results: Mean age at the time of evaluation was 33.62±14.48 years. Mean defect diameter in the all the study patients was 20.80±8.17 mm. Thirteen morphological variations were detected. Deficiency of one rim was detected in 14 (28%) patients,two in 16 (32%), three in 2 (4%), and four in 2 (4%). Deficiency of the superior anterior rim was found in 24% of the patients as the most frequent morphology. There was a significant correlation between the defect size and number of deficient rims (γ=0.558, P value<0.001). Forty-eight (96%) patients emerged for defect closure: 22 (46.2%) suitable for percutaneousclosure and 26 (53.8%) for surgical closure. Two patients with small defects were recommended for medical treatment and follow-up.Conclusion: ASD-II is larger and more morphologically variable in adults than in children. Based on the findings of the present and previous studies and given the advantages of percutaneous treatment, it is advisable to make a decision on ASD-II closure as soon as possible before it outgrows the transcatheter closure suitability criteria

Anatomy of Atrioventricular Node Artery and Pattern of Dominancy in Normal Coronary Subjects: A Comparison between Individuals with and without Isolated Right Bundle Branch Block

Background: Isolated right bundle branch block (RBBB) is a common finding in the general population. The atrioventricular node (AVN) artery contributes to the blood supply of the right bundle branch. Our hypothesis was that the anatomy of the AVN artery and the pattern of dominancy differ between subjects with and without RBBB. Methods: We retrospectively studied the coronary angiography of 92 patients with RBBB and 184 age- and gender- matched controls without RBBB. All the subjects had angiographically proven normal coronary arteries. The dominant circulation and precise origin of the AVN artery were determined in each subject. Obtained data were compared between the two study groups. Results: There was no significant difference between the two groups in terms of dominancy (p value = 0.200). Origination of the AVN artery from the right circulatory system was more common in both groups, but this pattern was more prevalent in the cases than in the controls (p value = 0.021). There was a great variation of the AVN artery origin. In the total study population, the AVN artery was more commonly separated from a non crux origin than from the crux area. The prevalence of the non-crux origination of the AVN artery was significantly higher in the cases than in the controls (p value < 0.001). While the origination of the AVN artery from the right circulatory system was more common in both groups, the prevalence of the right origin of the AVN artery was significantly higher in the cases than in the controls. We observed that the AVN artery most commonly originated from the dominant artery but not necessarily from the crux. Conclusion: The anatomy of the AVN artery but not the pattern of dominancy is somewhat different in subjects with RBBBcompared with normal individuals