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M-mode echocardiography (using the septal-to-posterior wall motion delay [SPWMD]) and color-coded tissue Doppler imaging (TDI; using the septal-to-lateral delay in peak systolic velocity) have been proposed for assessment of left ventricular (LV) dyssynchrony and prediction of response to cardiac resynchronization therapy (CRT). In this study, a head-to-head comparison between M-mode echocardiography and color-coded TDI was performed for assessment of LV dyssynchrony and prediction of response to CRT. Consecutive (n = 98) patients with severe heart failure (New York Heart Association class III/IV), LV ejection fraction ≤35%, and QRS duration >120 ms underwent CRT. Before pacemaker implantation, LV dyssynchrony was assessed by M-mode echocardiography (SPWMD) and color-coded TDI (septal-to-lateral delay). At baseline and 6 months after implantation, clinical and echocardiographic parameters were evaluated. SPWMD measurement was not feasible in 41% of patients due to akinesia of the septal and/or posterior walls or poor acoustic windows. Conversely, the septal-to-lateral delay could be assessed in 96% of patients. At 6-month follow-up, 75 patients (77%) were classified as responders to CRT (improvement ≥1 New York Heart Association class). The sensitivity and specificity of SPWMD were lower compared with those of septal-to-lateral delay (66% vs 90%, p <0.05; 50% vs 82%, p = NS, respectively). In conclusion, LV dyssynchrony assessment was feasible in 59% of patients with M-mode echocardiography compared with 96% (p <0.05) when color-coded TDI was used. Color-coded TDI was superior to M-mode echocardiography for prediction of response to CRT. [Copyright &y& Elsevier]

Cardiac resynchronization therapy (CRT) is beneficial in selected patients with moderate to severe heart failure (New York Heart Association [NYHA] classes III to IV). Patients with mildly symptomatic heart failure (NYHA class II) are currently not eligible for CRT and the potential beneficial effects in these patients have not been well studied. Fifty consecutive patients in NYHA class II heart failure and 50 consecutive patients in NYHA classes III to IV (control group) were prospectively included. All patients had left ventricular (LV) ejection fraction ≤35% and QRS duration >120 ms. The effects of CRT in NYHA class II patients were compared with the results obtained in both groups. The severity of baseline LV dyssynchrony (assessed with color-coded tissue Doppler imaging) was comparable between patients in NYHA class II versus those in NYHA classes III to IV (83 ± 49 vs 96 ± 51 ms, p = NS); resynchronization was achieved in all patients. NYHA class II patients showed a significant improvement in LV ejection fraction (from 25 ± 7% to 33 ± 10%, p <0.001) and reduction in LV end-systolic volume (from 168 ± 55 to 132 ± 51 ml, p <0.001) after CRT, similar to patients in NYHA classes III to IV. In addition, only 8% of NYHA class II patients had progression of heart failure symptoms. In conclusion, CRT had comparable effects in patients in NYHA class II and in NYHA classes III to IV heart failure in terms of LV resynchronization, improvement in LV ejection fraction, and LV reverse remodeling. [Copyright &y& Elsevier]

In the present study, the effects of cardiac resynchronization therapy (CRT) in elderly patients were evaluated. The study included 170 consecutive patients whose clinical and echocardiographic improvements were evaluated after 6 months of follow-up. Survival was evaluated up to 2 years. The effects of CRT in elderly patients (age ≥70 years) were compared with those in younger patients (age &#60;70 years). [Copyright &y& Elsevier]

Cardiac resynchronization therapy (CRT) is considered a major advance in the treatment of patients with heart failure. The presence of left ventricular (LV) dyssynchrony seems mandatory for a positive response to CRT. Currently, only patients with wide QRS complexes are considered for CRT, although patients with narrow QRS complexes may also have LV dyssynchrony. In the present study, the incidence of LV dyssynchrony was prospectively evaluated in 64 patients with heart failure and narrow QRS complexes using tissue Doppler imaging. [Copyright &y& Elsevier]

To evaluate immediate success and 6-month restenosis rate, 70 Micro Stents II were implanted for 65 stenoses in 63 patients (age 59+/-9 years). Stable angina pectoris was present in 47% of the patients (38% class I to III; 9% class IV), whereas 32% had postinfarction angina and 21% had unstable angina. Indications for stent implantation were elective in 62% and semi-elective in 38% of the patients. Sixty-two percent of the patients received ticlopidin and acetylsalicylic acid for 28 days, whereas 38% of the patients received only acetylsalicylic acid. All stents were deployed successfully at the target site. Subacute closure occurred in 2 patients (3%), both of whom were not treated with ticlopidin. Two other patients (3%) developed non-Q-wave infarction after side branch occlusion during the procedure. The minimum lumen diameter increased from 1.0+/-0.5 mm to 2.8+/-0.4 mm after stent implantation. At follow-up the loss in diameter was 0.9+/-0.6 mm, indicating a net gain of 0.9+/-0.8 mm. Late clinical events (4 weeks to 6 months) were coronary angioplasty of a stented segment (3%), coronary angioplasty of a nonstented segment (10%), and coronary artery bypass grafting (2%). No deaths or myocardial infarction occurred. The procedural success rate was 94% and the event-free survival at 6-month follow-up was 79%. Micro Stent II implantation can be done with a high rate of immediate success and good 6-month outcome. The Micro Stent II has proven to be a versatile device that can also be used in patients with less favorable coronary anatomy or lesion characteristics. [ABSTRACT FROM AUTHOR]

Differences in recurrence rate of aortic regurgitation (AR) and extent of left ventricular (LV) remodeling across the different surgical options in patients operated for type A aortic dissection remain unknown. The present evaluation compared the AR recurrence rate and changes in LV volumes and systolic function in valve-sparing aorta replacement (VSAR), supracoronary ascending aorta replacement (SCAR), and aortic valve and aorta replacement (AVAR). A total of 97 patients (58 ± 12 years, 62% men) with acute type A aortic dissection who underwent VSAR (n = 24), SCAR (n = 43), or AVAR (n = 30) were evaluated. Changes in LV volumes and function between postoperative and follow-up were compared using linear mixed models. Postoperative AR grades were not significantly different between groups. However, after median follow-up of 47 months, AR grade ≥2 was significantly more often observed in SCAR (55%) and VSAR (25%) compared to AVAR (0%, p <0.001). LV volumes remained stable in VSAR and AVAR but increased significantly in SCAR (LV end-diastolic volume: from 99 ± 4 to 131 ± 6 ml; p <0.001; LV end-systolic volume: from 49 ± 3 to 66 ± 5 ml; p = 0.002). In patients with recurrent AR grade ≥2 at follow-up, LV volumes increased, whereas patients without recurrent AR did not show significant LV dilatation. In conclusion, patients with acute type A aortic dissection who underwent SCAR or VSAR showed more frequently AR grade ≥2 recurrence compared to AVAR. However, only patients who underwent SCAR experienced adverse LV remodeling at follow-up. Recurrence of AR grade ≥2 was associated with adverse LV remodeling. [ABSTRACT FROM AUTHOR]

Significant coronary artery disease is highly prevalent in patients who underwent transcatheter aortic valve implantation (TAVI). Timing of staged percutaneous coronary intervention (PCI) in TAVI candidates remains debated. The present study assessed the impact of timing of the staged PCI on TAVI outcomes. Ninety-six patients (age 81 ± 5 years, 57% men) who had undergone staged PCI within 1 year before TAVI were included. The population was dichotomized according to the median time elapsed between PCI and TAVI (<30 and ≥30 days). Inhospital events and 30-day outcomes after TAVI were defined according to Valve Academic Research Consortium-2 definitions. Forty-eight patients underwent PCI <30 days and 48 patients underwent PCI ≥30 days before TAVI. Patients treated with PCI <30 days had lower hemoglobin levels at baseline (7.2 ± 0.9 mmol/L vs 7.9 ± 0.9 mmol/L, p = 0.002), more frequently atrial fibrillation (27% vs 13%, p = 0.018), and a shorter time interval between computed tomography acquisition and TAVI (7 days [2 to 10] vs 22 days [6 to 39], p <0.001) than their counterparts. Minor bleedings (13% vs 0%, p=0.011) and overall vascular injury (27% vs 8%, p = 0.016 [minor injury: 17% vs 2%, p = 0.014; major injury: 10% vs 6%, p[0.460]) were more frequently recorded in patients with staged PCI <30 days before TAVI. There were no differences in the incidence of other events and in 2-year survival. In conclusion, shortly (<30 days) or remote (≥30 days) staged PCI before TAVI resulted in comparable outcomes with the exception of minor vascular injury and minor bleeding events which were more frequently observed in patients treated with shortly staged PCI. [ABSTRACT FROM AUTHOR]

Right ventricular (RV) function after ST-segment elevation myocardial infarction (STEMI) has important prognostic implications. However, the changes in RV function over time after STEMI and the incidence of RV remodeling remain unknown. The present study evaluated changes in RV dimensions and function in contemporary patients with first STEMI and assessed the independent determinants of RV dysfunction at follow-up. Patients with first STEMI (n [ 940, 60 - 11 years, 77% men) treated with primary percutaneous coronary intervention underwent echocardiography at baseline and 6- and 12-month follow-up. The prevalence of RV dysfunction (tricuspid annular plane systolic excursion [TAPSE] ⩽15 mm) decreased significantly at 6 months follow-up (from 15% to 8%, p <0.001) and the incidence of RV remodeling (increase in RV end-diastolic area [RVEDA] ⩾20%) was observed in 200 patients (25%). Absolute changes in RVEDA were independently associated with absolute changes in wall motion score index and left ventricular (LV) remodeling (p <0.001 for both parameters), whereas absolute changes in TAPSE were independently related with absolute changes in wall motion score index and mitral regurgitation grade (p <0.001 for both parameters). Independent correlates of RV dysfunction at 6 months follow-up were multivessel coronary disease (odds ratio [OR] 2.13), peak cardiac troponin T (OR 1.05), angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers use (OR 0.27), baseline LV ejection fraction (OR 0.96) and baseline TAPSE (OR 0.88). In conclusion, despite the non-negligible incidence of RV remodeling in patients with first STEMI, RV function improves early after STEMI. Multivessel coronary disease, infarct size, baseline LV ejection fraction and TAPSE and the nonuse of angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers are independent determinants of RV dysfunction. [ABSTRACT FROM AUTHOR]

The underlying mechanism of mitral regurgitation (MR) because of isolated annulus dilation (Carpentier type I) remains controversial in patients with atrial fibrillation (AF). The present study evaluated changes in mitral valve geometry of patients with AF and structurally and functionally normal left ventricles and mitral leaflets. Grade of MR and left ventricular (LV) function was evaluated with echocardiography. Changes in mitral valve geometry were evaluated with multidetector row computed tomography (MDCT) performed before radiofrequency catheter ablation for AF. From a cohort of 480 patients with drug-refractory AF referred for catheter ablation, 170 patients (mean age 58 ± 10 years, 67% men) with structural and functional normal left ventricles and mitral leaflets were included. The intercommissural and anteroposterior diameter, perimeter, and area of the mitral annulus and left atrial volume were assessed with MDCT and correlated with the grade of MR as assessed with echocardiography. A total of 49 patients (29%) had MR ≥2+. These patients had larger mitral annulus area compared with patients with MR <2+ (665.0 ± 100.6 mm2/m2 vs 530.5 ± 66.6 mm2/m2, p <0.001), whereas LV size and function (ejection fraction 64.9 ± 6.3% vs 63.1 ± 5.7%, p = 0.08) were similar. After adjusting for age, type of AF, hypertension, left atrial volume, and LV end-systolic volume and ejection fraction, the mitral annulus dimensions remained independently correlated with MR ≥2+. In conclusion, in AF patients with structural and functional normal left ventricles and mitral leaflets, MDCT demonstrated that mitral annulus dilation is independently associated with type I MR. [ABSTRACT FROM AUTHOR]

Cardiac resynchronization therapy (CRT) induces left ventricular (LV) reverse remodeling by synchronizing LV mechanical activation. We evaluated changes in segmental LV activation after CRT and related them to CRT response. A total of 292 patients with heart failure (65 – 10 years, 77% men) treated with CRT underwent baseline echocardiographic assessment of LV volumes and ejection fraction. Time-to-peak radial strain was measured for 6 midventricular LV segments with speckle-tracking strain imaging. Moreover, the time difference between the peak radial strain of the anteroseptal and the posterior segments was calculated to obtain LV dyssynchrony. After 6 months, LV volumes, segmental LV mechanical activation timings, and LV dyssynchrony were reassessed. Response to CRT was defined as ‡15% decrease in LV end-systolic volume at 6-month follow-up. Responders (n[177) showed LV resynchronization 6 months after CRT (LV dyssynchrony from 200 – 127 to 85 – 86 ms; p <0.001) by earlier activation of the posterior segment (from 438 – 141 to 394 – 132 ms; p[0.001) and delayed activation of the anteroseptal segment (from 295 – 155 to 407 – 138 ms; p <0.001). In contrast, nonresponders (n [ 115) experienced an increase in LV dyssynchrony 6 months after CRT (from 106 – 86 to 155 – 112 ms; p[0.001) with an earlier activation of posterior wall (from 391 – 139 to 355 – 136 ms; p[0.039) that did not match the delayed anteroseptal activation (from 360 – 148 to 415 – 122 ms; p [ 0.001). In conclusion, responders to CRT showed LV resynchronization through balanced lateral and anteroseptal activations. In nonresponders, LV dyssynchrony remains, by posterior wall preactivation and noncompensatory delayed septal wall activation. [ABSTRACT FROM AUTHOR]

The simultaneous occurrence of cancer and coronary heart disease is increasing in the Western world. Nevertheless, the influence of cancer on ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) has not been investigated extensively. This multicenter registry included patients with STEMI treated with primary PCI from 2006 to 2009. Patients were stratified according to history of cancer, and primary focus lay on all-cause and cardiac mortalities during 1-year follow-up. Adjusted effect sizes were calculated using Cox proportional hazard models. In total, 208 patients had a history of cancer (diagnosed ≼6 months ago in 20.7%, 6 months to 3 years ago in 21.7%, and >3 years ago in 57.6%) and 3,215 patients had no history of cancer. Chemotherapy had been administered previously to 23% of patients with cancer. Patients with cancer were older, more frequently women, and more commonly known with previous myocardial infarction or anemia. Reperfusion rates were similar after PCI. Patients with cancer showed greater all-cause (17.4% vs 6.5% in other patients) and cardiac mortalities at 1 year (10.7% vs 5.4% in other patients) because of high early cardiac death (23.8%) in recently diagnosed patients with cancer. After adjustment, a recent cancer diagnosis predicted cardiac mortality at 7 days (hazard ratio 3.34, 95% confidence interval 1.57 to 7.08). The adverse prognosis was partly explained by anemia and occurrence of cardiogenic shock, whereas outcome was independent of cancer treatment. In conclusion, patients with cancer showed greater mortality after STEMI. A cancer diagnosis in the 6 months before primary PCI was strongly associated with early cardiac mortality. [ABSTRACT FROM AUTHOR]

Multidetector row computed tomographic (MDCT) assessment of aortic annulus dimensions and frame position and deployment have been associated with paravalvular aortic regurgitation (PAVR) after transcatheter aortic valve implantation (TAVI). The present evaluation investigated the (pre- and postprocedure) MDCT associates of PAVR ≥2+. In total, 123 patients referred for TAVI underwent clinical evaluation, transthoracic echocardiography, and pre- and post-TAVI MDCT. Pre-TAVI MDCT measurements of the aortic annular dimensions and post-TAVI MDCT evaluation of the position and deployment of the prosthesis in the native annulus were performed. At 1-month follow-up, PAVR ≥2+ was observed in 25 patients (20%). The difference between the MDCT-derived maximum aortic annulus and the nominal diameters of the implanted prosthesis (odds ratio 1.912, p = 0.002) and shallow position of the frame in the left ventricular outflow tract (<2 mm) (odds ratio 4.865, p = 0.017) were independently related to significant PAVR. A maximum annulus diameter ≥2 mm larger than the nominal frame diameter had 72% sensitivity and 61% specificity to predict PAVR. In conclusion, in patients undergoing TAVI, ≥2-mm difference between maximum aortic annulus and nominal prosthesis diameters and depth of the frame into the left ventricular outflow tract of <2 mm are independently associated with PAVR ≥2+. [ABSTRACT FROM AUTHOR]

Advances in antithrombotic therapy for ST elevation myocardial infarction (STEMI) enhancethe risk of bleeding. Therefore, the incidence, determinants, and prognostic implicationsof in-hospital major bleeding after primary percutaneous coronary intervention for STEMI were investigated. In 963 consecutive patients, the incidence of bleeding was evaluated according to commonly used classifications including Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA guidelines, Thrombolysis In Myocardial Infarction, Global Use of Strategies To Open coronary arteries, and Bleeding Academic Research Consortium. Multivariate regression analyses investigated determinants of bleeding and the relation between bleeding and 1-year all-cause mortality. Large variability in incidence existed depending on classification (1.3% to 21%). Female gender, heart rate, creatinine, multivessel disease, cardiogenic shock, and procedural failure were independently associated with bleeding. One-year mortality reached 10.2% in bleeders versus 2.0% in nonbleeders (p <0.001). Bleeding was independently associated with an increased risk of 1-year mortality (hazard ratio [HR] 2.41, p <0.017). Assessment of individual classifications confirmed the increased risk of mortality for Bleeding Academic Research Consortium (HR 2.27, p [ 0.048), but not for Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA guidelines, Thrombolysis In Myocardial Infarction, and Global Use of Strategies To Open coronary arteries bleeding. Thrombotic events occurred more frequently inbleeders (5.8% vs 1.5%, p <0.001); however, bleeding remained independently related to mortality with a negligible reduction in HR (2.25, p [ 0.028) after adjustment. In conclusion, in-hospital major bleeding was frequently observed after STEMI, but a widespread variation in incidence existed depending on the applied definition. Patient and procedural characteristics were related to bleeding, allowing identification of high-risk patients. In-hospital major bleeding was independently associated with 1-year all-cause mortality; however, not all bleeding classifications proved equally relevant to prognosis. The relation between bleeding and mortality was shown not to be driven by the higher rate of thrombotic events among bleeders. [ABSTRACT FROM AUTHOR]

The feasibility of transcatheter mitral valve therapy (edge-to-edge or valve-in-ring technique) in patients with significant mitral regurgitation (MR) recurrence after surgical restrictive mitral valve annuloplasty remains unknown. The aim of the present study was to investigate the eligibility for transcatheter mitral valve therapy of high-surgical-risk patients with significant MR recurrence after initial successful restrictive mitral valve annuloplasty. A total of 47 patients (age 67 ± 10 years, 47% men) with significant MR recurrence (effective regurgitant orifice area ≥20 mm², regurgitant volume ≥30 ml/beat, or vena contracta ≥3 mm) after restrictive mitral valve annuloplasty were identified. The long-term outcome of patients dichotomized according to the surgical risk was evaluated. The echocardiographic parameters of mitral valve geometry and hemodynamics at the moment of diagnosis of MR recurrence were assessed to evaluate the eligibility for transcatheter valve therapy. During a median follow-up of 3 years, 23 patients (48.9%) died. The patients with a high-surgical risk (logistic European System for Cardiac Operative Risk Evaluation score ≥20%) had significantly worse long-term survival than those with a low-surgical risk (logistic European System for Cardiac Operative Risk Evaluation score <20%; 50% and 88%, respectively; p = 0.002). All high-surgical-risk patients showed geometric mitral valve features that would allow transcatheter mitral valve therapy (mitral annular area 7 ± 2.0 cm², coaptation length 6 ± 1.6 mm, anterior and posterior mitral leaflet length 24 ± 2.8 mm and 15 ± 3.1 mm, respectively). In conclusion, patients with significant MR recurrence after initial successful restrictive mitral valve annuloplasty and a high risk of redo mitral valve surgery had lower long-term survival rates than patients who could undergo repeat surgery. [ABSTRACT FROM AUTHOR]

Quantitative assessment of aortic regurgitation (AR) remains challenging. The present study evaluated the accuracy of 2-dimensional (2D) and 3-dimensional (3D) transthoracic echocardiography (TTE) for AR quantification, using 3D 3-directional velocity-encoded magnetic resonance imaging (VE-MRI) as the reference method. Thirty-two AR patients were included. With color Doppler TTE, 2D effective regurgitant orifice area (EROA) was calculated using the proximal isovelocity surface area method. From the 3D TTE multiplanar reformation data, 3D-EROA was calculated by planimetry of the vena contracta. Regurgitant volumes (RVol) were obtained by multiplying the 2D-EROA and 3D-EROA by the velocity-time integral of AR jet and compared with that obtained using VE-MRI. For the entire population, 3D TTE RVol demonstrated a strong correlation and good agreement with VE-MRI RVol (r = 0.94 and -13.6 to 15.6 ml/beat, respectively), whereas 2D TTE RVol showed a modest correlation and large limits of agreement with VE-MRI (r = 0.70 and -22.2 to 32.8 ml/beat, respectively). Eccentric jets were noted in 16 patients (50%). In these patients, 3D TTE demonstrated an excellent correlation (r = 0.95) with VE-MRI, a small bias (0.1 ml/beat) and narrow limits of agreement (-18.7 to 18.8 ml/beat). Finally, the kappa agreement between 3D TTE and VE-MRI for grading of AR severity was good (k = 0.96), whereas the kappa agreement between 2D TTE and VE-MRI was suboptimal (k = 0.53). In conclusion, AR RVol quantification using 3D TTE is accurate, and its advantage over 2D TTE is particularly evident in patients with eccentric jets. [ABSTRACT FROM AUTHOR]

The clinical use of advanced imaging modalities for early determination of infarct size and prognosis is limited. As a specific indicator of myocardial necrosis, cardiac troponin T (cTnT) can be used as a surrogate measure for this purpose. The present study sought to investigate the use of peak and serial 6-hour fixed-time high-sensitive (hs) cTnT for estimation of infarct size, left ventricular (LV) function, and prognosis in consecutive patients with ST-segment elevation myocardial infarction. The infarct size was expressed as the 48-hour cumulative creatine kinase release. LV function at 3 months was assessed using the echocardiographic wall motion score index and LV ejection fraction using radionuclide ventriculography. Adverse outcomes, comprising all-cause death, implantable cardioverterdefibrillator implantation, or hospitalization for heart failure, were recorded at 1 year of follow-up. In 188 patients, the peak and all fixed-time values correlated significantly with the 48-hour cumulative creatine kinase release, wall motion score index, and LV ejection fraction. The hs-cTnT value at 24 hours demonstrated the greatest correlation (r [ 0.86, r [ 0.47, and r [ L0.59, respectively; p <0.001 for all). In the multivariate regression models adjusted for the clinical parameters, almost all were independently associated with the 48-hour cumulative creatine kinase release, wall motion score index, and LV ejection fraction, with the hs-cTnT value at 24 hours having the largest effect. Moreover, all cTnT values independently predicted adverse outcomes, again, with the hs-cTnT value at 24 hours showing the largest influence (hazard ratio 3.77, 95% confidence interval 2.12 to 6.73, p <0.001). In conclusion, not only peak, but all fixed-time hs-cTnT values were associated with infarct size, LV function at 3 months, and adverse outcomes 1 year after ST-segment elevation myocardial infarction. The value 24 hours after the onset of symptoms had the closest associations with all outcomes. Therefore, serial sampling for a peak value might be redundant. [ABSTRACT FROM AUTHOR]

Previous studies investigating the influence of gender on ST-segment elevation myocardial infarction have reported conflicting results. The aim of this study was to assess the influence of gender on ischemic times and outcomes after ST-segment elevation myocardial infarction in patients treated with primary percutaneous coronary intervention in modern practice. The present multicenter registry included consecutive patients with ST-segment elevation myocardial infarctions treated with primary percutaneous coronary intervention at 3 hospitals. Adjusted mortality rates were calculated using Cox proportional-hazards analyses. In total, 3,483 patients were included, of whom 868 were women (25%). Women were older, had a higher risk factor burden, and more frequently had histories of malignancy. Men more often had cardiac histories and peripheral vascular disease. Ischemic times were longer in women (median 192 minutes [interquartile range 141 to 286] vs 175 minutes [interquartile range 128 to 279] in men, p=0.002). However, multivariate linear regression showed that this was due to age and co-morbidity. All-cause mortality was higher at 7 days (6.0% in women vs 3.0% in men, p <0.001) and at 1 year (9.9% in women vs 6.6% in men, p = 0.001). After adjustment, female gender predicted 7 day all-cause mortality (hazard ratio 1.61, 95% confidence interval 1.06 to 2.46) and cardiac mortality (hazard ratio 1.58, 95% confidence interval 1.03 to 2.42) but not 1-year mortality. Moreover, gender was an independent effect modifier for cardiogenic shock, leading to substantially worse outcomes in women. In conclusion, ischemic times remain longer in women because of age and comorbidity. Female gender independently predicted early all-cause and cardiac mortality after primary percutaneous coronary intervention, and a strong interaction between gender and cardiogenic shock was observed. [ABSTRACT FROM AUTHOR]

Identification of patients with reversible left ventricular (LV) dysfunction has important prognostic implications after acute myocardial infarction (AMI). This study aimed to determine the value of LV segmental and global longitudinal strains assessed with 3-dimensional (3D) speckle-tracking analysis in predicting improvement of LV function after AMI. One hundred fifty-three patients (80% men, 59 ± 11 years old) with AMI and treated with primary percutaneous coronary intervention underwent 3D echocardiography. LV segmental and global 3D longitudinal strains were assessed with speckle-tracking analysis using a novel dedicated software. At 6-month follow-up, improvement in segmental LV function was defined as a decrease of ≥1 grade in segmental wall motion score. Improvement in global LV function was defined as an absolute improvement ≥5% in LV ejection fraction. Segments with functional improvement at follow-up showed a significantly higher baseline 3D longitudinal strain compared to segments without improvement (−16.4 ± 4.0% vs −7.6 ± 3.5%, p <0.001). A cut-off value of −11.1% for segmental 3D longitudinal strain had 92% sensitivity and 91% specificity in predicting functional improvement. In addition, 67 patients (44%) showed an improvement in global LV function at 6-month follow-up. These patients showed significantly higher baseline global 3D longitudinal strain compared to patients without improvement (−16.7 ± 2.1% vs −13.3 ± 2.6%, p <0.001). Global 3D longitudinal strain provided incremental value over clinical and conventional echocardiographic variables in predicting global LV function improvement (c-statistic improved from 0.64 to 0.71 to 0.84). In conclusion, longitudinal strain assessed by 3D speckle-tracking analysis is an important predictor for segmental and global LV function improvement after AMI. [ABSTRACT FROM AUTHOR]

The risk scores developed for the prediction of an adverse outcome in patients after ST-segment elevation myocardial infarction (STEMI) have mostly addressed patients treated with thrombolysis and evaluated solely all-cause mortality as the primary end point. Primary percutaneous coronary intervention in patients with STEMI has improved the outcome significantly and might have changed the relative contribution of different risk factors. Our patient population included 1,484 consecutive patients admitted with STEMI who had undergone primary percutaneous coronary intervention. The clinical, angiographic, and echocardiographic data obtained during hospitalization were used to derive a risk score for the prediction of short-term (30-day) and long-term (1- and 4-year) cardiovascular mortality and hospitalization for heart failure. During a median follow-up of 30 months, 87 patients (6%) died from cardiovascular mortality or were hospitalized for heart failure. Multivariate Cox regression analyses identified age ≥70 years, Killip class ≥2, diabetes, left anterior descending coronary artery as the culprit vessel, 3-vessel disease, peak cardiac troponin T level ≥3.5 μg/L, left ventricular ejection fraction ≤40%, and heart rate at discharge ≥70 beats/min as relevant factors for the construction of the risk score. The discriminatory power of the model as assessed using the areas under the receiver operating characteristic curves was good (0.84, 0.83, and 0.81 at 30 days and 1 and 4 years, respectively), and the patients could be allocated to low-, intermediate-, or high-risk categories with an event rate of 1%, 6%, and 24%, respectively. In conclusion, the current risk model demonstrates for the first time that 8 parameters readily available during the hospitalization of patients with STEMI treated with primary percutaneous coronary intervention can accurately stratify patients at long-term follow-up (≤4 years after the index infarction) into low-, intermediate-, and high-risk categories. [ABSTRACT FROM AUTHOR]

The impact of left ventricular (LV) dyssynchrony on the long-term outcomes of patients with acute myocardial infarction (AMI) remains unknown. The purpose of the present study was to evaluate the prevalence of LV dyssynchrony after AMI and the potential relation with adverse events. A total of 976 consecutive patients admitted with AMI treated with primary percutaneous coronary intervention were evaluated. Two-dimensional echocardiography was performed <48 hours after admission. LV dyssynchrony was assessed with speckle-tracking imaging and calculated as the time difference between the earliest and latest activated segments. Patients were followed up for the occurrence of all-cause mortality (the primary end point) or the composite secondary end point (heart failure hospitalization and all-cause mortality). Within 48 hours of admission for the index infarction, mean LV dyssynchrony was 61 ±79 ms, and 14% of the patients demonstrated a ≥130-ms time difference, defined as significant LV dyssynchrony. During a mean follow-up period of 40 ±17 months, 82 patients (8%) reached the primary end point. In addition, 36 patients (4%) were hospitalized for heart failure. The presence of LV dyssynchrony was associated with an increased risk for all-cause mortality and hospitalization for heart failure during long-term follow-up (adjusted hazard ratio 1.06, 95% confidence interval 1.05 to 1.08, p <0.001, per 10-ms increase). Moreover, LV dyssynchrony provided incremental value over known clinical and echocardiographic risk factors for the prediction of adverse outcomes. In conclusion, LV dyssynchrony is a strong predictor of long-term mortality and hospitalization for heart failure in a population of patients admitted with ST-segment elevation AMI treated with primary percutaneous coronary intervention. [Copyright &y& Elsevier]

Location of aortic valve calcium (AVC) can be better visualized on contrast-enhanced multidetector row computed tomography. The present evaluation examined whether AVC severity and its location could influence paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation. A total of 79 patients (age 80 ± 7 years, 49% men) with preprocedural multidetector row computed tomography were included. Volumetric AVC quantification and its location were assessed. Transesophageal echocardiography was performed to assess the presence and site of AR after transcatheter aortic valve implantation. Receiver operating characteristic curves were generated to evaluate the usefulness of AVC in determining paravalvular AR at a specific site. Postprocedural AR of grade 1 or more was observed in 63 patients. In most patients (n = 56, 71%), AR was of paravalvular origin. Calcium at the aortic wall of each valve cusp had the largest area under the curve (0.93, p <0.001) in predicting paravalvular AR at the aortic wall site compared to calcium at the valvular edge or body (area under the curve 0.58 and 0.67, respectively). Calcium at the valvular commissure was better than calcium at the valvular edge (area under the curve 0.94 vs 0.71) in predicting paravavular AR originating from the corresponding commissure. In conclusion, contrast-enhanced multidetector row computed tomography can be performed to quantify AVC. Both AVC severity and its exact location are important in determining paravalvular AR after transcatheter aortic valve implantation. [ABSTRACT FROM AUTHOR]

Triplane tissue synchronization imaging (TSI) and real-time 3-dimensional echocardiography (RT3DE) provide different characterizations of left ventricular (LV) mechanics and dyssynchrony. Triplane TSI assesses differences in time to peak systolic segmental myocardial tissue velocities, whereas RT3DE evaluates differences in time to minimum end-systolic regional volumes. Whether an approach using the 2 3D techniques predicts better significant reverse remodeling after cardiac resynchronization therapy (CRT) remains unknown. In 166 patients (mean age 66 ± 9 years, 78% men) treated with CRT, baseline LV dyssynchrony was assessed using RT3DE and triplane TSI. LV dyssynchrony was defined by a systolic dyssynchrony index ≥6.4% when assessed with RT3DE and SD of time to peak velocity of 12 segments (Ts-SD-12) ≥33 ms with triplane TSI. CRT response was defined by ≥15% decrease in LV end-systolic volume at 6-month follow-up. Mean LV dyssynchrony using Ts-SD-12 was 48 ± 26 ms and mean systolic dyssynchrony index was 8.51 ± 3.81%. Response to CRT was observed in 86.3% of patients showing LV dyssynchrony with the 2 methods. In contrast, 97% of patients who did not show significant LV dyssynchrony with any of the techniques were nonresponders (p <0.001). Importantly, systolic dyssynchrony index and LV dyssynchrony using Ts-SD-12 were independent predictors of response to CRT (p <0.001 for each technique). Assessment of LV dyssynchrony with the 2 techniques showed incremental value for prediction of significant LV reverse remodeling over its assessment with only 1 technique (chi-square 90.18, p <0.001). In conclusion, the combined use of 2 different 3D techniques to assess LV dyssynchrony permits accurate prediction of response to CRT. [ABSTRACT FROM AUTHOR]

A considerable number of patients with an acute coronary syndrome (ACS) who present with a 0 or low calcium score (CS) still demonstrate coronary artery disease (CAD) and significant stenosis. The aim of the present study was to evaluate the relation between the CS and the degree and character of atherosclerosis in patients with suspected ACS versus patients with stable CAD obtained by computed tomography angiography and virtual histology intravascular ultrasound (VH IVUS). Overall 112 patients were studied, 53 with ACS and 59 with stable CAD. Calcium scoring and computed tomography angiography were performed and followed by VH IVUS. On computed tomography angiography each segment was evaluated for plaque and classified as noncalcified, mixed, or calcified. Vulnerable plaque characteristics on VH IVUS were defined by percent necrotic core and presence of thin-cap fibroatheroma. If the CS was 0, patients with ACS had a higher mean number of plaques (5.0 ± 2.0 vs 2.0 ± 1.9, p <0.05) and noncalcified plaques (4.6 ± 3.5 vs 1.3 ± 1.9, p <0.05) on computed tomography angiography than those with stable CAD. If the CS was 0, VH IVUS demonstrated that patients with ACS had a larger amount of necrotic core area (0.58 ± 0.73 vs 0.22 ± 0.43 mm2, p <0.05) and a higher mean number of thin-cap fibroatheromas (0.6 ± 0.7 vs 0.1 ± 0.3, p <0.05) than patients with stable CAD. In conclusion, even in the presence of a 0 CS, patients with ACS have increased plaque burden and increased vulnerability compared to patients with stable CAD. Therefore, absence of coronary calcification does not exclude the presence of clinically relevant and potentially vulnerable atherosclerotic plaque burden in patients with ACS. [ABSTRACT FROM AUTHOR]

Cardiac resynchronization therapy (CRT) is an established treatment of patients with heart failure. Several baseline characteristics can influence the CRT outcomes, and little is known about the effect of gender. The aim of the present study was to elucidate the gender-related differences in long-term survival after CRT. A total of 578 consecutive patients with heart failure underwent CRT. At baseline and 6 months after CRT, the clinical and echocardiographic parameters were obtained. All-cause mortality was compared between the men and women. The study population included 431 men (67 ± 9 years) and 147 women (65 ± 11 years). No differences in the clinical and echocardiographic characteristics were observed between the men and women, except for left bundle branch block and a nonischemic etiology of heart failure, which were more frequent in women (81% vs 68% and 63% vs 33%, respectively; p <0.01), and atrial fibrillation, which was more prevalent in men (20% vs 10%, respectively; p = 0.01). During a mean follow-up of 34 ± 25 months, 197 patients died (158 men and 39 women). Kaplan-Meier analysis showed a significant difference in long-term survival between the women and men (p = 0.007). The 2-year all-cause mortality rate was 15% in men and 8% in women (p = 0.025). Cox proportional hazard analysis revealed female gender is an independent predictor of long-term survival, together with heart failure etiology and renal function. In particular, women with heart failure due to a nonischemic etiology showed the best long-term survival rate. In conclusion, female gender and nonischemic etiology were independently associated with better long-term survival after CRT. [ABSTRACT FROM AUTHOR]

Coronary computed tomographic angiography allows direct evaluation of the vessel wall and thus positive remodeling, which is a marker of vulnerability. The purpose of this study was to assess the association between positive remodeling on computed tomography angiogram (CTA) and vulnerable plaque characteristics on virtual histologic intravascular ultrasound (VH IVUS) images. Forty-five patients (78% men, 58 ± 11 years old) underwent computed tomographic angiography followed by VH IVUS. On CTA, the remodeling index was determined for each lesion by a blinded observer using quantitative analysis. Positive remodeling was defined based on a remodeling index ≥1.0. Percent necrotic core and presence of thin-capped fibroatheroma (TCFA) were used as markers for plaque vulnerability on VH IVUS images. Ninety-nine atherosclerotic plaques were evaluated, of which 37 lesions (37.4%) were identified as having positive remodeling on CTA. Higher levels of plaque vulnerability were identified in lesions with positive remodeling compared to lesions without positive remodeling. Percent necrotic core was significantly higher in lesions with positive remodeling (15.7 ± 7.8%) compared to lesions without this characteristic (10.2 ± 7.2%, p <0.001). Furthermore, significantly more TCFA lesions were identified in positively remodeled lesions (n = 16, 43.2%) than in lesions without positive remodeling (n = 3, 4.8%, p <0.001). In conclusion, lesions with positive remodeling on CTA are associated with increased levels of plaque vulnerability on VH IVUS images including a higher percent necrotic core and a higher prevalence of TCFA. Thus evaluation of remodeling on CTA may provide a valuable marker for plaque vulnerability. [Copyright &y& Elsevier]

Approximately 20% of patients with heart failure have left bundle branch block (LBBB) on surface electrocardiogram (ECG). In this group of patients, detection of right ventricular (RV) dilatation on standard ECG can be of clinical relevance because RV enlargement is an important prognostic marker. Consequently, the aim of this study was to evaluate diagnostic accuracy for several electrocardiographic criteria in determining significant RV dilatation in these patients. Standard 12-lead ECGs were obtained in 173 patients with heart failure and known LBBB. From the ECG, 3 criteria for RV dilatation were defined: presence of terminal positivity in lead aVR (late R wave in lead aVR), low voltage (<0.6 mV) in all extremity leads, and an R/S ratio <1 in lead V5. In addition, all patients underwent comprehensive echocardiographic evaluation including assessment of RV dimensions. Measurements were performed blinded to electrocardiographic results. Significant RV dilatation was defined as an RV base-to-apex length ≥86 mm or an RV diastolic area ≥33 cm2. Eighty-six patients (50%) had a late R wave in lead aVR, 36 patients (21%) had low voltage in extremity leads, and 67 patients (39%) had an R/S ratio <1 in lead V5. An RV base-to-apex length ≥86 mm was present in 67 patients (39%), and 62 patients (36%) had an RV diastolic area ≥33 cm2. Any combination of 2 to 3 positive criteria could predict an RV base-to-apex length ≥86 mm with a positive predictive value of 89% and a negative predictive value of 88%. Similarly, an RV diastolic area ≥33 cm2 was predicted with a positive predictive value of 80% and a negative predictive value of 88%. In conclusion, combining 2 to 3 distinct electrocardiographic criteria allows for accurate detection of RV dilatation in patients with heart failure and LBBB. [Copyright &y& Elsevier]

Multislice computed tomography (MSCT) is commonly acquired before radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) to plan and guide the procedure. MSCT allows accurate measurement of the left atrial (LA) and pulmonary vein (PV) dimensions and classification of the PV anatomy. The aim of the present study was to investigate the effect of LA dimensions, PV dimensions, and PV anatomy on the outcome of circumferential RFCA for AF. A total of 100 consecutive patients undergoing RFCA for AF (paroxysmal 72%, persistent 28%) were studied. The LA dimensions, PV dimensions, and PV anatomy were evaluated three dimensionally using MSCT. The PV anatomy was classified as normal or atypical according to the absence/presence of a common trunk or additional veins. After a mean follow-up of 11.6 ± 2.8 months, 65 patients (65%) maintained sinus rhythm. The enlargement of the left atrium in the anteroposterior direction on MSCT was related to a greater risk of AF recurrence. No relation was found between the PV dimensions and the outcome of RFCA. In addition, normal right-sided PV anatomy was related to a greater risk of AF recurrence compared to atypical right-sided PV anatomy. Multivariate analysis showed that an anteroposterior LA diameter on MSCT (odds ratio 1.083, p = 0.027) and normal right-sided PV anatomy (odds ratio 6.711, p = 0.006) were independent predictors of AF recurrence after RFCA. In conclusion, enlargement of the anteroposterior LA diameter and the presence of normal anatomy of the right PVs are independent risk factors for AF recurrence. No relation was found between the PV dimensions and outcome of RFCA. [ABSTRACT FROM AUTHOR]

Most patients with chronic ischemia and an implantable cardiac defibrillator (ICD) for primary prevention do not experience therapies for ventricular arrhythmias on follow-up. The present study aimed to identify independent clinical, electrocardiographic, and echocardiographic predictors of death and occurrence of ICD therapy in patients with chronic ischemic cardiomyopathy and ICD for primary prevention. A total of 424 patients with chronic ischemic cardiomyopathy, ejection fraction ≤35%, and New York Heart Association (NYHA) class ≥II were recruited. All patients underwent echocardiography before ICD insertion. Primary outcome was all-cause mortality; secondary outcome was occurrence of appropriate ICD therapy on follow-up. Primary and secondary outcomes occurred in 84 and 95 patients, respectively. Patients who died were more likely to have diabetes (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.00 to 2.79, p = 0.049), higher NYHA class (HR 1.96, 95% CI 1.15 to 3.33, p = 0.013), lower peri-infarct strain on echocardiogram (HR 1.25, 95% CI 1.07 to 1.46, p = 0.005), and lower glomerular filtration rate (HR 1.01, 95% CI 1.00 to 1.03, p = 0.022). Only peri-infarct strain (HR 1.22, 95% CI 1.09 to 1.36, p <0.001) predicted the occurrence of ICD therapy on follow-up. In conclusion, in chronic ischemic patients with an ICD for primary prevention, the presence of diabetes, renal dysfunction, higher NYHA class, and impaired peri-infarct zone function were predictors of all-cause mortality. In contrast, only impaired peri-infarct zone function determined the occurrence of appropriate ICD therapy on follow-up. [ABSTRACT FROM AUTHOR]

Left ventricular (LV) diastolic filling is characterized by the formation of intraventricular rotational bodies of fluid (termed “vortex rings”) that optimize the efficiency of LV ejection. The aim of the present study was to evaluate the morphology and dynamics of LV diastolic vortex ring formation early after acute myocardial infarction (AMI), in relation to LV diastolic function and infarct size. A total of 94 patients with a first ST-segment elevation AMI (59 ± 11 years; 78% men) were included. All patients underwent primary percutaneous coronary intervention. After 48 hours, the following examinations were performed: 2-dimensional echocardiography with speckle-tracking analysis to assess the LV systolic and diastolic function, the vortex formation time (VFT, a dimensionless index for characterizing vortex formation), and the LV untwisting rate; contrast echocardiography to assess LV vortex morphology; and myocardial contrast echocardiography to identify the infarct size. Patients with a large infarct size (≥3 LV segments) had a significantly lower VFT (p <0.001) and vortex sphericity index (p <0.001). On univariate analysis, several variables were significantly related to the VFT, including anterior AMI, LV end-systolic volume, LV ejection fraction, grade of diastolic dysfunction, LV untwisting rate, and infarct size. On multivariate analysis, the LV untwisting rate (β = −0.43, p <0.001) and infarct size (β = −0.33, p = 0.005) were independently associated with VFT. In conclusion, early in AMI, both the LV infarct size and the mechanical sequence of diastolic restoration play key roles in modulating the morphology and dynamics of early diastolic vortex ring formation. [Copyright &y& Elsevier]

Cardiac resynchronization therapy (CRT) is considered a class I indication in treatment of patients with New York Heart Association (NYHA) functional class III and IV heart failure. However, only small numbers of patients in large clinical trials have been in NYHA functional class IV. Therefore, little is known about the effects of CRT in this group. Therefore, we evaluated the effects of CRT in patients with NYHA functional class IV heart failure. Of all patients referred for CRT implantation, 61 patients with symptoms according to NYHA functional class IV were included. All patients were evaluated before implantation and at 6-month follow-up for clinical changes according to the clinical composite score and changes in left ventricular (LV) volumes and function. In addition, survival was evaluated during long-term follow-up. At 6-month follow-up, 9 patients (15%) had died and 2 patients (3%) were admitted for worsening heart failure. The remaining 39 patients (64%) showed improvement according to the clinical composite score. Decreases in LV end-systolic volume (from 167 ± 88 to 147 ± 93 ml, p = 0.009) and LV end-diastolic volume (from 211 ± 100 to 199 ± 113 ml, p = 0.135) were observed, as was a significant increase in LV ejection fraction (from 22 ± 8% to 28 ± 9%, p <0.001). During a mean follow-up of 30 ± 26 months, 36 patients (59%) died, 27 (75%) from worsening heart failure. Respective 1- and 2-year mortality rates were 25% and 38%. In conclusion, CRT decreases LV volumes and improves cardiac function in patients with NYHA functional class IV heart failure. Nevertheless, (heart failure) mortality remains high in these patients. [ABSTRACT FROM AUTHOR]

The analysis of left ventricular (LV) mechanics provides novel insights into the effects of cardiac resynchronization therapy (CRT) on LV performance. Currently, advances in speckle-tracking echocardiographic analysis have permitted the characterization of subendocardial and subepicardial LV twist. The aim of this study was to investigate the role of the acute changes in subendocardial and subepicardial LV twist for the prediction of midterm beneficial effects of CRT. A total of 84 patients with heart failure scheduled for CRT were recruited. All patients underwent echocardiography before and <48 hours after CRT implantation and at 6-month follow-up. The assessment of LV volumes, ejection fractions, and mechanical dyssynchrony (systolic dyssynchrony index) was performed with real-time 3-dimensional echocardiography. The assessment of subendocardial and subepicardial LV twist was performed with 2-dimensional speckle-tracking echocardiography. A favorable outcome was defined as the occurrence of a reduction ≥15% in LV end-systolic volume associated with an improvement of ≥1 New York Heart Association functional class at 6-month follow-up. At 6-month follow-up, 53% of the patients showed favorable outcomes. Ischemic cause of heart failure, baseline systolic dyssynchrony index, immediate improvement in the LV ejection fraction, immediate improvement in systolic dyssynchrony index, and immediate improvement in subendocardial and subepicardial LV twist were significantly related to favorable outcomes. However, in multivariate logistic regression analysis, only the immediate improvement of subepicardial LV twist was independently related to favorable outcomes (odds ratio 2.31, 95% confidence interval 1.29 to 4.15, p = 0.005). Furthermore, the immediate improvement of subepicardial LV twist had incremental value over established parameters. In conclusion, the immediate improvement of subepicardial LV twist (but not subendocardial LV twist) is independently related to favorable outcomes after CRT. [Copyright &y& Elsevier]

Patients who develop new-onset atrial fibrillation (AF) after acute myocardial infarction (AMI) show an increased risk for adverse events and mortality during follow-up. Recently, a novel noninvasive echocardiographic method has been validated for the estimation of total atrial activation time using tissue Doppler imaging of the atria (PA-TDI duration). PA-TDI duration has shown to be independently predictive of new-onset AF. However, whether PA-TDI duration provides predictive value for new-onset AF in patients after AMI has not been evaluated. Consecutive patients admitted with AMIs and treated with primary percutaneous coronary intervention underwent echocardiography <48 hours after admission. All patients were followed at the outpatient clinic for ≥1 year. During follow-up, 12-lead electrocardiography and Holter monitoring were performed regularly, and the development of new-onset AF was noted. Baseline echocardiography was performed to assess left ventricular and left atrial (LA) function. LA performance was quantified with LA volumes, function, and PA-TDI duration. A total of 613 patients were evaluated. LA maximal volume (hazard ratio 1.07, 95% confidence interval 1.04 to 1.11), the total LA ejection fraction (hazard ratio 0.96, 95% confidence interval 0.93 to 0.99) and PA-TDI duration (hazard ratio 1.05, 95% confidence interval 1.04 to 1.06) were univariate predictors of new-onset AF. After multivariate analysis, LA maximal volume and PA-TDI duration independently predicted new-onset AF. Furthermore, PA-TDI duration provided incremental prognostic value to traditional clinical and echocardiographic parameters for the prediction of new-onset AF. In conclusion, PA-TDI duration is a simple measurement that provides important value for the prediction of new-onset AF in patients after AMI. [Copyright &y& Elsevier]

Decreased cerebral blood flow is frequently observed in patients with heart failure, and this could be the result of impaired cardiac systolic function. Cardiac resynchronization therapy (CRT) improves cardiac function and heart failure symptoms in selected patients. The effects of CRT on cerebral blood flow have not been previously evaluated. In the present study, left ventricular systolic function and cerebral blood flow were assessed in 35 patients with heart failure, before and 6 months after CRT. Additionally, 15 patients with heart failure, who were not candidates for CRT, were included as a control group. The peak systolic velocity, end-diastolic velocity, mean velocity, and pulsatility index ([peak systolic velocity − end-diastolic velocity]/mean velocity) were obtained using transcranial Doppler from the right middle cerebral artery from the temporal window in all subjects. Response to CRT was defined as a reduction in the left ventricular end-systolic volume of ≥15%. At 6 months of follow-up, the peak systolic velocity had significantly increased from 83 ± 20 cm/s to 100 ± 20 cm/s (p = 0.001), the end-diastolic velocity had increased from 29 ± 7 cm/s to 37 ± 8 cm/s (p <0.001), and the mean velocity had increased from 47 ± 10 cm/s to 58 ± 11 cm/s (p <0.001) only in the responders to CRT. In contrast, no significant changes in cerebral blood flow were observed in the nonresponders and the controls. In conclusion, CRT induced an increase in cerebral blood flow in patients with heart failure. This increase in cerebral blood flow was related to the improvement in left ventricular systolic function. [Copyright &y& Elsevier]

To compare the long-term efficacy and safety of sirolimus-eluting stents (SES) to those of bare-metal stents (BMS) for ST-segment elevation myocardial infarction, outcomes were assessed in 310 patients (mean age age 59 ± 11 years, 78% men) included in the randomized MISSION! Intervention Study: A Prospective Randomised Controlled Trial to Evaluate the Efficacy of Drug-Eluting Stents Versus Bare-Metal Stents for the Treatment of Acute Myocardial Infarction after a median follow-up period of 38 months. All patients were treated with aspirin (lifelong) and clopidogrel for 1 year after stent implantation. Except for a significant difference between reference vessel diameters (SES 2.76 mm vs BMS 2.92 mm, p = 0.02), there were no significant differences in baseline and angiographic characteristics between the treatment groups (158 SES, 152 BMS). A significant difference between SES and BMS patients for all revascularization end points was found after the first year of follow-up. However, at 3 years of follow-up, although there was still a trend toward better clinical outcomes in SES-treated patients, differences were no longer significant (death 4.4% vs 6.6%, p = 0.41; target vessel–related myocardial infarction 2.5% vs 4.6%, p = 0.32; target vessel revascularization 8.9% vs 15.8%, p = 0.06), target lesion revascularization 6.3% vs 12.5%, p = 0.06; and target vessel failure 12.0% vs 19.7%, p = 0.06). Three cases of very late (definite) stent thrombosis were observed in the SES group (1.9%) versus none in the BMS group (p = 0.14). In conclusion, the significant SES benefit (compared to BMS) in patients with ST-segment elevation myocardial infarctions at 1-year follow-up in terms of target vessel revascularizations decreased to some extent because of more similar target vessel revascularization rates during the 2 subsequent years. Rates of death and nonfatal recurrent MI remained comparable. [Copyright &y& Elsevier]

Several studies have demonstrated a relation between left ventricular (LV) dyssynchrony and response to cardiac resynchronization therapy (CRT). Many methods of determining LV dyssynchrony have been proposed, including a value of 65 ms as assessed by tissue Doppler imaging. The aim of the present validation study was to prospectively test the predictive accuracy of the 65-ms cutoff for LV dyssynchrony in a large cohort of patients with heart failure undergoing CRT. The study included 361 patients who had undergone CRT. The clinical and echocardiographic parameters were assessed at baseline and at 6 months of follow-up. The clinical response was defined as an improvement of ≥1 New York Heart Association class, and the echocardiographic response was defined as a reduction in LV end-systolic volume of ≥15%. At 6 months of follow-up, 259 patients (72%) had a clinical response and 187 patients (52%) had an echocardiographic response. The patients with a response had more LV dyssynchrony than did those without a response (91 ± 49 ms vs 50 ± 44 ms for the clinical response and 101 ± 46 ms vs 55 ± 45 ms for the echocardiographic response). On multivariate analysis, LV dyssynchrony remained predictive of the response, independent of other characteristics. In conclusion, LV dyssynchrony of ≥65 ms was an independent predictor of both the clinical and the echocardiographic response in patients with heart failure who underwent CRT in this validation study. [Copyright &y& Elsevier]

Multidetector computed tomographic coronary angiography (CTA) image quality is inversely related to the heart rate (HR). As a result beta-blocking medication is routinely administered before investigation. In the present study, the use, contraindications, and efficacy of prescan beta blockade with regard to HR reduction and CTA image quality were assessed. In 537 patients referred for CTA, the baseline HR and blood pressure were measured on arrival, and contraindications for beta blockade were noted. Unless contraindicated, a single dose of metoprolol was administered orally 1 hour before data acquisition in patients with a HR of ≥65 beats/min according to a predefined medication protocol. After 1 hour, the HR was remeasured. A total of 283 patients (53%) had a HR of ≥65 beats/min. In this group, beta blockade was contraindicated in 46 patients (16%). Metoprolol was administered to the remaining 237 patients. However, 26 patients (11%) received suboptimal (lower dose than prescribed by protocol) beta blockade because of contraindications. Of the 211 patients receiving optimal beta blockade, 57 (27%) did not achieve the target HR. Of the patients with contraindications to beta blockade, 43 (60%) did not achieve the target HR. Compared to patients with optimal HR control, those receiving no or suboptimal beta blockade because of contraindications had significantly fewer examinations of good image quality (40% vs 74%, p <0.001), and significantly more examinations of poor image quality (20% vs 6%, p <0.001). In conclusion, most patients require HR reduction before CTA. Contraindications to beta blockade are present in a substantial proportion of patients. This results in suboptimal HR control and image quality, indicating the need for alternative approaches for HR reduction. [Copyright &y& Elsevier]

This study examined the prognostic value of novel diastolic indexes in ST-elevation acute myocardial infarction (AMI), derived from strain and strain rate analysis using 2-dimensional speckle tracking imaging. Echocardiograms were obtained within 48 hours of admission in 371 consecutive patients with first ST-elevation AMI (59.7 ± 11.6 years old). Indexes of diastolic function including mean strain rate during isovolumic relaxation (SRIVR), mean early diastolic strain rate (SRE) and mean diastolic strain at peak transmitral E wave (E) were obtained from 3 apical views. Mean early diastolic velocity from 4 basal segments by color-coded tissue Doppler imaging was measured. Indexes of diastolic filling including E/SRIVR, E/SRE, E/diastolic strain at E, and E/early diastolic velocity were calculated. The primary end point (composite of death, hospitalization for heart failure, repeat MI, and repeat revascularization) occurred in 84 patients (22.6%) during a mean follow-up of 17.3 ± 12.2 months. Mean SRIVR (p <0.001), multivessel disease (p <0.001), Thrombolysis In Myocardial Infarction grade 0 to 1 flow after percutaneous coronary intervention (p = 0.004), and left ventricular ejection fraction (p = 0.008) were independent predictors of the combined end point on Cox regression analysis. Mean SRIVR showed incremental prognostic value over baseline clinical and echocardiographic variables (global chi-square increase from 41.0 to 51.6, p <0.001). After dividing patient population based on median SRIVR, patients with SRIVR ≤0.24/second had significantly higher event rates than others (hazard ratio 2.74, 95% confidence interval 1.61 to 4.67, p <0.001). In conclusion, SRIVR was incremental to left ventricular ejection fraction, Thrombolysis In Myocardial Infarction grade 0 to 1 flow after percutaneous coronary intervention, and multivessel disease and superior to other diastolic indexes in predicting future cardiovascular events after AMI. SRIVR may be useful in identifying high-risk patients soon after AMI. [Copyright &y& Elsevier]

Data evaluating gender- and age-specific differences in plaque observations on multislice computed tomography (MSCT) are scarce. Accordingly, the aim of this study was to evaluate coronary plaque patterns in men and women in relation to age using MSCT. The findings were compared to observations on grayscale intravascular ultrasound (IVUS) and virtual histology (VH) IVUS. In total, 93 patients (59 men, 34 women) underwent 64-slice MSCT followed by conventional coronary angiography with IVUS. Plaque extent and composition were assessed on MSCT, grayscale IVUS, and VH IVUS. Coronary plaque patterns were compared between men and women in 2 age groups (<65 and ≥65 years old). In patients aged <65 years, more plaques were observed on MSCT in men (6 ± 4 vs 2 ± 2 in women, p <0.001). Also, a larger plaque burden was observed on grayscale IVUS in men (45.7 ± 11.4% vs 36.3 ± 11.6% in women, p <0.001). Similarly, more mixed plaques were observed in men (3 ± 3 vs 1 ± 1 in women, p = 0.003), whereas a larger arc of calcium was detected on grayscale IVUS in men (91.7 ± 93.5° vs 25.7 ± 51.0° in women, p <0.001). On VH IVUS, the prevalence of thin-cap fibroatheroma was higher in men (31% vs 0%) compared to women. In patients aged ≥65 years old, no important differences in plaque patterns were observed between men and women. In conclusion, more extensive atherosclerosis and more calcified lesions were observed in men than in women. These differences were predominantly present in patients aged <65 years and were lost in those aged ≥65 years. [Copyright &y& Elsevier]

The impact of left ventricular (LV) dyssynchrony after acute myocardial infarction (AMI) on LV ejection fraction (EF) is unknown. One hundred twenty-nine patients with a first ST-elevation AMI (58 ± 11 years, 78% men) and QRS duration <120 ms were included. All patients underwent primary percutaneous coronary intervention. Real-time 3-dimensional echocardiography and myocardial contrast echocardiography were performed to assess LV function, LV dyssynchrony, and infarct size. LV dyssynchrony was defined as the SD of the time to reach the minimum systolic volume for 16 LV segments, expressed in percent cardiac cycle (systolic dyssynchrony index [SDI]). Myocardial perfusion at myocardial contrast echocardiography was scored (1 = normal/homogenous; 2 = decreased/patchy; 3 = minimal/absent) using a 16-segment model; a myocardial perfusion index, expressing infarct size, was derived by summing segmental contrast scores and dividing by the number of segments. SDI in patients with AMI was 5.24 ± 2.23% compared to 2.02 ± 0.70% of controls (p <0.001). Patients with AMI and LVEF <45% had significantly higher SDI compared to patients with LVEF ≥45% (4.29 ± 1.44 vs 6.95 ± 2.40, p <0.001). At multivariate analysis, SDI was independently related to LVEF; in addition, the impact of SDI on LV systolic function was incremental to infarct size and anterior location of AMI (F change 16.9, p <0.001). In conclusion, LV synchronicity is significantly impaired soon after AMI. LV dyssynchrony is related to LVEF and has an additional detrimental effect on LV function, beyond infarct size and the anterior location of AMI. [Copyright &y& Elsevier]

Noninvasive assessment of subclinical atherosclerosis by multislice computed tomographic (MSCT) coronary angiography and demonstration of significant, flow-limiting coronary artery disease (CAD) by stress testing may improve patients'' risk stratification. However, data relating the complementary information provided by these noninvasive techniques to traditional risk assessment are scarce. In 255 subjects (45% women, mean age 54 ± 12 years) without known CAD, 64-slice MSCT coronary angiography and stress testing (exercise electrocardiographic test or myocardial perfusion imaging) were performed. Framingham risk score (FRS) was calculated from baseline characteristics (50% low, 22% intermediate, 28% high). Angiograms showing atherosclerosis were classified as obstructive (≥50% luminal narrowing) CAD or not. Stress tests were classified as normal or abnormal. Multislice computed tomogram identified 155 patients (61%) with CAD, of whom 78 (31%) showed obstructive CAD. A positive stress test result was observed in 36 patients (46%) with obstructive CAD. In line with increasing FRS categories, a significant increase in the prevalence of functionally relevant obstructive CAD was observed (6% low vs 45% intermediate vs 63% high, p <0.001). In conclusion, a strong positive relation exists between FRS and prevalence of functionally relevant obstructive CAD. Selective use of MSCT coronary angiography and stress testing may refine the traditional risk assessment of CAD events, especially in patients deemed at intermediate and high risk. [Copyright &y& Elsevier]

Multislice computed tomographic coronary angiography (MSCT) can accurately detect the presence of atherosclerosis noninvasively. However, a discrepancy has been observed between MSCT and noninvasive functional imaging. The purpose of the present study was to evaluate the correlation between MSCT and invasive fractional flow reserve (FFR) in men with known coronary artery disease. Thirty-three patients (mean age 57 +/- 11 years) clinically referred for coronary angiography underwent MSCT and FFR analysis. Coronary angiography and MSCT were evaluated for nonsignificant (30% to 50% luminal narrowing) and significant (>50% luminal narrowing) stenosis. Abnormal FFR was defined as < or =0.75. A total of 36 vessels were evaluated for FFR, with 8 (22%) showing reduced FFR. Results on MSCT were normal (completely normal or <30% luminal narrowing in 11 vessesl [31%], nonsignificant lesions in 13 vessels [36%], and significant stenoses in 12 vessels [33%]). Abnormal FFR was observed in only 58% of vessels with lesions >50% on MSCT. Nevertheless, the agreement between normal results on MSCT and normal FFR was excellent; FFR was normal in all 11 vessels with normal results on MSCT. In conclusion, significant stenoses on MSCT frequently do not result in reduced FFR. Normal results on MSCT, however, can accurately rule out the presence of hemodynamically significant lesions in men with known coronary artery disease. [ABSTRACT FROM AUTHOR]

The relation between cardiac troponin T (cTnT) and regional strain in patients with acute myocardial infarction (AMI) was investigated. Furthermore, the effect of symptoms-to-balloon time on impairment in regional strain after AMI was evaluated. A total of 157 consecutive patients with AMI who underwent primary percutaneous coronary intervention were included. Two-dimensional echocardiography soon after percutaneous coronary intervention was performed. Speckle-tracking analysis was applied to assess left ventricular global and regional longitudinal peak systolic strain (LPSS). Infarcted area was defined based on the culprit vessel. Mean left ventricular ejection fraction was 47 ± 7%. Global LPSS was −14.4 ± 3.2%. The infarcted area LPSS was significantly decreased compared with global LPSS (−11.3 ± 4.5%, p <0.001). The major reflector of cTnT was infarcted area LPSS (beta 0.47, p <0.001). Mean symptoms-to-balloon time was 212 ± 92 minutes. Based on this time, the study population was divided in tertiles. In the group with the shortest symptoms-to-balloon time, global LPSS and infarcted area LPSS were less impaired compared with groups with longer symptoms-to-balloon time (p <0.01 for the 2 comparisons). In conclusion, myocardial strain was related to peak levels of cTnT, thus reflecting damage after AMI. Early reperfusion resulted in decreased myocardial damage in the infarcted area as quantified with strain. [Copyright &y& Elsevier]

Detailed information about the absolute temporal occurrence of myocardial motion and deformation events during the cardiac cycle is still lacking. However, the normal time range of these parameters may be of great importance as a reference for detecting and interpreting mechanical dyssynchrony and for identifying a delayed contraction in case of left ventricular (LV) dysfunction. The aim of this study was to determine in young healthy subjects and for different LV segments the value of (1) time to peak systolic longitudinal velocity, displacement, strain rate, and strain using tissue Doppler imaging (TDI); (2) time to minimum systolic volume using real-time 3-dimensional echocardiography; and (3) time to maximum thickness using cardiac magnetic resonance imaging (MRI). Twenty 20 young healthy volunteers (13 men, mean age 32 ± 4 years) underwent cardiac MRI and echocardiographic examination, including TDI and real-time 3-dimensional echocardiography. To define LV ejection time and isovolumic relaxation time, aortic valve closure and opening and mitral valve opening were identified. For all LV segments, longitudinal peak systolic velocity and strain rate were early systolic events. Peak systolic longitudinal displacement and strain in turn occurred in late systole, or in 20% to 30% of LV segments, during isovolumic relaxation time, similarly to minimum systolic volume and maximum myocardial thickness. In conclusion, the present study provides a systematic report of the normal time range of measurements obtained by TDI, real-time 3-dimensional echocardiography, and cardiac MRI. Peak systolic longitudinal velocity and strain rate significantly precede peak longitudinal displacement, strain, minimum systolic volume, and maximum thickness. [Copyright &y& Elsevier]

Alcohol septal ablation (ASA) aims to decrease left ventricular outflow tract (LVOT) obstruction in patients with obstructive hypertrophic cardiomyopathy (HC). To date, no diagnostic variables at baseline are available to predict long-term success of the procedure. We hypothesized that an immediate decrease in septal longitudinal strain after ASA would be associated with sustained LVOT gradient decrease after 6 months. ASA was performed in 22 patients with HC and severe drug-refractory symptoms. Clinical evaluation and 2-dimensional echocardiography were performed before, 1 day after, and 6 months after ASA. During 6-month follow-up, New York Heart Association class improved (2.7 ± 0.5 vs 1.4 ± 0.6, p <0.01) and LVOT gradient decreased (68 ± 31 vs 21 ± 21 mm Hg, p <0.01). Strain evaluation showed considerable decreases in basal septal strain (−12 ± 3% vs −8 ± 2%, p <0.01) and midseptal strain (−13 ± 4% vs −8 ± 3%, p <0.01) 1 day after ASA. Decreases in basal septal and midseptal strain 1 day after ASA were strongly related to the decrease in LVOT gradient during 6-month follow-up (r = 0.70, p <0.01, and r = 0.65, p <0.01, respectively). In conclusion, in patients with HC and severe drug-refractory symptoms, immediate decrease in septal strain after ASA is strongly related to a decrease in LVOT gradient after 6 months and might therefore serve as an early determinant for long-term success of the ASA procedure. [Copyright &y& Elsevier]

Left ventricular (LV) twist and untwisting rate are emerging as global and thorough parameters for assessment of LV function. This study explored differences of LV twist and untwisting rate in patients with acute myocardial infarction (AMI) and patients with ischemic and nonischemic chronic heart failure (HF). Fifty patients with AMI, 49 with ischemic HF, and 38 with nonischemic HF were studied. As a control group, 28 subjects without evidence of structural heart disease were included. Speckle-tracking analysis was applied to LV short-axis images at basal and apical levels. LV twist was defined as the net difference of apical and basal rotations at isochronal time points. The first time derivative of LV untwist was defined as the LV untwisting rate. Compared with control subjects, peak LV twist was decreased in patients with AMI and extremely decreased in those with HF (p <0.001, analysis of variance). A strong correlation (r = 0.87, p <0.001) was found between peak LV twist and LV ejection fraction in the overall study population. LV untwisting rate was progressively decreased in patients with AMI and HF compared with control subjects (p <0.001, analysis of variance). A moderate correlation (r = 0.56, p <0.001) was noted between peak LV untwisting rate and grade of diastolic dysfunction in the overall study population. In conclusion, LV twist and untwisting rate are strongly related to LV systolic and diastolic functions, respectively. Impairment of LV function observed in patients with AMI and HF is associated with a decrease of LV twist and untwisting rate. [Copyright &y& Elsevier]

Heart rate (HR) at rest is an important marker of prognosis in heart failure, but has not been addressed in pulmonary arterial hypertension (PAH). To determine the prognostic value of HR at rest in patients with PAH, we retrospectively analyzed 140 consecutive patients with idiopathic PAH. Electrocardiogram (ECG)-derived HR at rest was evaluated as a potential predictor of adverse prognosis (death or lung transplantation), in addition to World Health Organization functional class, 6-minute walk distance, and hemodynamics before and approximately 1 year and 2 years after initiation of PAH treatment. During follow-up, 49 patients (35%) died, and 5 patients (4%) underwent lung transplantation. Before treatment initiation and after 1 year and 2 years of treatment, respectively, a higher HR at rest was an independent predictor of adverse prognosis (hazard ratios per 10-beats/min increase 1.76, 95% confidence interval 1.42 to 2.18, 2.31, 95% confidence interval 1.58 to 3.38, 2.1, 95% confidence interval 1.39 to 3.19, respectively, p <0.001 for all). Change in HR between the first and last ECG also independently predicted prognosis (hazard ratio per 1-beat/min increase 1.03, 95% confidence interval 1.01 to 1.06). In conclusion, a higher HR at rest and an important increase in HR at rest during follow-up signify a considerable risk of death in patients with PAH. ECG-derived HR at rest is an important marker of prognosis and should be assessed before and at frequent intervals after initiation of treatment for PAH. [Copyright &y& Elsevier]

Transcatheter aortic valve replacement (TAVR) required precise knowledge of the anatomic dimensions and physical characteristics of the aortic valve, annulus, and aortic root. Most groups currently use angiography, transthoracic echocardiography (TTE), or transesophageal echocardiography (TEE) to assess aortic annulus dimensions and anatomy. However, multislice computed tomography (MSCT) may allow more detailed 3-dimensional assessment of the aortic root. Twenty-six patients referred for TAVR underwent MSCT. Scans were also obtained for 18 patients after TAVR. All patients underwent pre- and postprocedural aortic root angiography, TTE, and TEE. Mean differences in measured aortic annular diameters were 1.1 mm (95% confidence interval 0.5, 1.8) for calibrated angiography and TTE, -0.9 mm (95% confidence interval -1.7, -0.1 mm) for TTE and TEE, -0.3 mm (95% confidence interval -1.1, 0.6 mm) for MSCT (sagittal) and TTE, and -1.2 mm (95% confidence interval -2.2, -0.2 mm) for MSCT (sagittal) and TEE. Coronal systolic measurements using MSCT, which corresponded to angiographic orientation, were 3.2 mm (1st and 3rd quartiles 2.6, 3.9) larger than sagittal systolic measurements, which were in the same anatomic plane as standard TTE and TEE views. There was no significant association between either shape of the aortic annulus or amount of aortic valve calcium and development of perivalvular aortic regurgitation. After TAVR, the prosthesis extended to or beyond the inferior border of the left main ostium in 9 of 18 patients (50%), and in 11 patients (61%), valvular calcium was <5 mm from the left main ostium. In conclusion, MSCT identified that the aortic annulus was commonly eccentric and often oval. This may in part explain the small, but clinically insignificant, differences in measured aortic annular diameters with other imaging modalities. MSCT after TAVR showed close proximity of both the prosthesis and displaced valvular calcium to the left main ostium in most patients. Neither eccentricity nor calcific deposits appeared to contribute significantly to severity of paravalvular regurgitation after TAVR. [ABSTRACT FROM AUTHOR]

In acute myocardial infarction cardiac troponin-T (cTnT) is the preferred biomarker to detect myocardial necrosis. Our aim was to investigate the prognostic value of peak plasma cTnT in patients with ST-elevation myocardial infarction treated by primary percutaneous coronary intervention (PCI). Patients were eligible if ST-elevation myocardial infarction symptoms started <9 hours before the primary PCI. During the first 48 hours after primary PCI, cTnT and creatine kinase were measured repeatedly. Main outcome measures were left ventricular ejection fraction assessed by myocardial scintigraphy at 90 days, and clinical outcomes through 1-year follow-up after primary PCI in a dedicated outpatient clinic; 168 consecutive patients (79% men) with first ST-elevation myocardial infarction were studied. Mean age ± SD was 59 ± 12 years. Peak cTnT values were reached within 24 hours after primary PCI in all patients. The enzymatic infarct size, measured by cumulative 48-hours creatine kinase release, correlated positively with peak cTnT (r = 0.73, p <0.001). Left ventricular ejection fraction at 3 months was negatively correlated with peak cTnT (r = −0.52, p <0.001). A peak plasma cTnT ≥6.5 μg/L predicted a left ventricular ejection fraction ≤40% at follow-up with 86% sensitivity and 74% specificity. Multivariable Cox regression analysis identified peak cTnT as an independent predictor of major adverse cardiac events (hazard ratio 1.07, 95% confidence limits 1.01 to 1.12) and heart failure (hazard ratio 1.12, 95% confidence limits 1.05 to 1.20) during follow-up. In conclusion, peak cTnT after primary PCI for ST-elevation myocardial infarction offers a good estimation of infarct size and is a prognostic indicator in patients with first acute myocardial infarction. [Copyright &y& Elsevier]

The time course of the effects of cardiac resynchronization therapy (CRT) on left ventricular (LV) systolic function and reverse remodeling is still unknown and was the subject of this study. In particular, whether the acute benefit of CRT translates in late response was explored. Furthermore, the time course of response was compared between ischemic and nonischemic patients. A total of 222 consecutive patients with heart failure (135 ischemic) scheduled for CRT were included. Standard echocardiography was performed before, immediately after CRT, and at 6-month follow-up to measure LV end-systolic volume (ESV), LV end-diastolic volume (EDV), and ejection fraction. Immediately after CRT, significant improvements in LV ejection fraction (from 25 ± 8% to 31 ± 9%, p <0.001) and LVESV (from 163 ± 68 to 149 ± 63 ml, p <0.001) were observed, followed by an additional improvement at 6-month follow-up (to 34 ± 9% and 132 ± 62 ml, respectively, p <0.001 for the 2 comparisons). A significant decrease in LVEDV was observed only at 6-month follow-up (from 217 ± 73 to 194 ± 72 ml, p <0.001). An acute decrease in LVESV of 6% could predict response to CRT at 6-month follow-up (defined as a decrease ≥15% in LVESV) with a sensitivity and specificity of 79% and 75%, respectively. The time course of response to CRT was similar in ischemic and nonischemic patients, but decreases in LVESV and LVEDV were significantly greater in nonischemic patients (p <0.001). In conclusion, the beneficial effect of CRT on LV systolic function occurs immediately after CRT, with additional improvement at 6-month follow-up. An acute decrease in LVESV can predict response to CRT at 6-month follow-up. Nonischemic patients show significantly greater LV reverse remodeling compared with ischemic patients. [Copyright &y& Elsevier]