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Aims Left ventricular (LV) mechanical dispersion (MD) may result from heterogeneous electrical conduction and is associated with adverse events. The present study investigated (i) the association between LV MD and the extent of LV scar as assessed with contrast-enhanced cardiac magnetic resonance (CMR) and (ii) the prognostic implications of LV MD in patients after ST-segment elevation myocardial infarction. Methods and results LV MD was calculated by echocardiography and myocardial scar was analysed on CMR data retrospectively. Infarct core and border zone were defined as ≥50% and 35–50% of maximal signal intensity, respectively. Patients were followed for the occurrence of the combined endpoint (all-cause mortality and appropriate implantable cardioverter-defibrillator therapy). In total, 96 patients (87% male, 57 ± 10 years) were included. Median LV MD was 53.5 ms [interquartile range (IQR) 43.4–62.8]. On CMR, total scar burden was 11.4% (IQR 3.8–17.1%), infarct core tissue 6.2% (IQR 2.0–12.7%), and border zone was 3.5% (IQR 1.5–5.7%). Correlations were observed between LV MD and infarct core (r  = 0.517, P  < 0.001), total scar burden (r  = 0.497, P  < 0.001), and border zone (r  = 0.298, P  = 0.003). In total, 14 patients (15%) reached the combined endpoint. Patients with LV MD >53.5 ms showed higher event rates as compared to their counterparts. Finally, LV MD showed the highest area under the curve for the prediction of the combined endpoint. Conclusion LV MD is correlated with LV scar burden. In addition, patients with prolonged LV MD showed higher event rates. Finally, LV MD provided the highest predictive value for the combined endpoint when compared with other parameters. [ABSTRACT FROM AUTHOR]

Aims  We aimed to evaluate the associations of body fat distribution with cardiovascular function and geometry in the middle-aged general population. Methods and results  Four thousand five hundred and ninety participants of the UK Biobank (54% female, mean age 61.1 ± 7.2 years) underwent cardiac magnetic resonance for assessment of left ventricular (LV) parameters [end-diastolic volume (EDV), ejection fraction (EF), cardiac output (CO), and index (CI)] and magnetic resonance imaging for body composition analysis [subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT)]. Body fat percentage (BF%) was assessed by bioelectrical impedance. Linear regressions were performed to assess the impact of visceral (VAT) and general (SAT and BF%) obesity on cardiac function and geometry. Visceral obesity was associated with a smaller EDV [VAT: β −1.74 (−1.15 to −2.33)], lower EF [VAT: β −0.24 (−0.12 to −0.35), SAT: β 0.02 (−0.04 to 0.08), and BF%: β 0.02 (−0.02 to 0.06)] and the strongest negative association with CI [VAT: β −0.05 (−0.06 to −0.04), SAT: β −0.02 (−0.03 to −0.01), and BF% β −0.01 (−0.013 to −0.007)]. In contrast, general obesity was associated with a larger EDV [SAT: β 1.01 (0.72–1.30), BF%: β 0.37 (0.23–0.51)] and a higher CO [SAT: β 0.06 (0.05–0.07), BF%: β 0.02 (0.01–0.03)]. In the gender-specific analysis, only men had a significant association between VAT and EF [β −0.35 (−0.19 to −0.51)]. Conclusion  Visceral obesity was associated with a smaller LV EDV and subclinical lower LV systolic function in men, suggesting that visceral obesity might play a more important role compared to general obesity in LV remodelling. [ABSTRACT FROM AUTHOR]

Background: High idiopathic premature ventricular contractions (PVC) burden has been associated with PVC-induced cardiomyopathy. Patients may be symptomatic before left ventricular (LV) dysfunction develops. N-terminal pro-B-type natriuretic peptide (NT-proBNP) and circumferential end-systolic wall stress (cESS) on echocardiography are markers for increased ventricular wall stress. This study aimed to evaluate the relation between presenting symptoms, PVC burden, and increased ventricular wall stress in patients with frequent PVCs and preserved LV function.Methods and Results: Eighty-three patients (41 men; 49±15 years) with idiopathic PVCs and normal LV function referred for PVC ablation were included. Type of symptoms (palpitations, fatigue, and [near-]syncope), PVC burden on 24-hour Holter, NT-proBNP levels, and cESS on echocardiography were assessed before and 3 months after ablation. Sustained successful ablation was defined as ≥80% PVC burden reduction during follow-up. Patients were symptomatic for 24 months (Q1-Q3, 16-60); 73% reported palpitations, 47% fatigue, and 30% (near-)syncope. Baseline PVC burden was 23±13%, median NT-proBNP 92 pg/mL (Q1-Q3 50-156), and cESS 143±35 kdyne/cm(2). Fatigue was associated with higher baseline NT-proBNP and cESS (P<0.001, P=0.011, respectively). After sustained successful ablation, achieved in 81%, NT-proBNP and cESS decreased significantly (P<0.001 and P=0.036, respectively). Fatigue was independently associated with a significantly larger reduction in NT-proBNP. In patients with nonsuccessful ablation, NT-proBNP and cESS remained unchanged.Conclusions: In patients with frequent PVCs and preserved LV function, fatigue was associated with higher baseline NT-proBNP and cESS, and with a significantly larger reduction in NT-proBNP after sustained successful ablation. These findings support a link between fatigue and PVC-induced increased ventricular wall stress, despite preserved LV function. [ABSTRACT FROM AUTHOR]

Background: Serum troponin assays, widely used to detect acute cardiac ischemia, might be useful biomarkers to detect chronic cardiovascular disease (CVD). Cardiac-specific troponin-I (cTnI) and troponin-T (cTnT) generally detect myocardial necrosis equally well. In dialysis patients however, serum cTnT levels are often elevated, unlike cTnI levels. The present study aims to elucidate the associations of cTnI and cTnT with CVD in clinically stable dialysis patients. Methods: Troponin levels were measured using 5th generation hs-cTnT assays (Roche) and STAT hs-cTnI assays (Abbott) in a cohort of dialysis patients. Serum troponin levels were divided into tertiles with the lowest tertile as a reference value. Serum troponins were associated with indicators of CVD such as left ventricular mass index (LVMI), left ventricular ejection fraction (LVEF) and the presence of coronary artery disease (CAD). Associations were explored using regression analysis. Results: We included 154 consecutive patients, 68±7 years old, 77% male, 70% hemodialysis. Median serum cTnT was 51ng/L (exceeding the 99th percentile of the healthy population in 98%) and median serum cTnI was 13ng/L (elevated in 20%). A high cTnI (T3) was significantly associated with a higher LVMI (Beta 31.60; p=0.001) and LVEF (Beta -4.78; p=0.005) after adjusting for confounders whereas a high serum cTnT was not. CAD was significantly associated with a high cTnT (OR 4.70 p=0.02) but not with a high cTnI. Unlike cTnI, cTnT was associated with residual renal function (Beta:-0.09; p=0.006). Conclusion: In the present cohort, serum cTnI levels showed a stronger association with LVMI and LVEF than cTnT. However, cTnT was significantly associated with CAD and residual renal function, unlike cTnI. Therefore, cTnI seems to be superior to cTnT as a marker of left ventricular dysfunction in asymptomatic dialysis patients, while cTnT might be better suited to detect CAD in these patients. [ABSTRACT FROM AUTHOR]

Aims Mortality and ventricular arrhythmias are reduced in patients responding to cardiac resynchronization therapy (CRT). This response is accompanied by improvement in LVEF, and some patients even outgrow original eligibility criteria for implantable cardioverter-defibrillator ( ICD) implantation. It is however unclear if these patients still benefit from ICD treatment. The current study aimed to evaluate if the incidence of ICD therapy is related to the extent of CRT response. Methods and results All patients who underwent primary prevention CRT-defibrillator implantation were included. They were divided into subgroups according to the reduction in LV end-systolic volume ( LVESV) 6 months after implantation. Pre-defined subgroups were: negative responders (increased LVESV), non-responders (decreased LVESV 0-14%), responders (decreased LVESV 15-29%), and super-responders (decreased LVESV ≥30%). During a median follow-up of 57 months (25th-75th percentile 39-84), 512 patients were studied [101 (20%) negative responders, 101 (20%) non-responders, 149 (29%) responders, and 161 (31%) super-responders]. In the first year of follow-up super-responders received significantly less appropriate ICD therapy (3% vs. 12%; P < 0.001). The 5-year cumulative incidence of appropriate ICD therapy was 31% [95% confidence interval ( CI) 19-43] in negative responders, 39% (95% CI 25-53) in non-responders, 34% (95% CI 25-43) in responders, and 27% (95% CI 18-35) in super-responders, respectively ( p = 0.13). Conclusions The extent of CRT response was associated with a parallel reduction of appropriate device therapy during the first year of follow-up. Thereafter, no association was observed. Furthermore, 23% of super-responders were treated for potentially life-threatening arrhythmias and benefit from ICD treatment. [ABSTRACT FROM AUTHOR]

Dyssynchrony and Right Ventricular Apical Pacing Background Right ventricular apical (RVA) pacing may induce left ventricular (LV) dyssynchrony. The long-term prognostic implications of induction of LV dyssynchrony were retrospectively evaluated in a cohort of patients who underwent RVA pacing. Methods A total of 169 patients (62 ± 13 years, 69% male) with high RVA pacing burden were included. Echocardiographic evaluation of LV volumes, ejection fraction, and dyssynchrony were performed before and after device implantation. LV dyssynchrony was assessed by 2-dimensional radial strain speckle tracking echocardiography. Based on the median LV dyssynchrony value after RVA pacing, the patient population was dichotomized (induced and noninduced LV dyssynchrony groups) and was followed up for the occurrence of all-cause mortality and heart failure (HF) hospitalization. Results Baseline mean LV ejection fraction was 51 ± 11%. Median LV dyssynchrony value was 40 ms (12-85 ms) before RVA pacing and increased to 91 ms (81-138 ms) after a median of 13 months (3-26 months) after RVA pacing. Median follow-up duration was 70 months (interquartile range 42-96 months). Patients with induced LV dyssynchrony, defined as LV dyssynchrony value superior to the median at follow-up (≥91 ms), showed higher mortality rates (5% and 27% vs. 1% and 3% at 3 and 5 years follow-up; log-rank P = 0.003) and HF hospitalization rates (18% and 24% vs. 3% and 4% at 3 and 5 years follow-up; log-rank P < 0.001) than patients with LV dyssynchrony <91 ms after RVA pacing. A multivariate model was developed to identify independent associates of a combined endpoint of all-cause mortality or HF hospitalization. Induction of LV dyssynchrony was independently associated with increased risk of combined endpoint (HR [95% CI]: 3.369 [1.732-6.553], P < 0.001). Conclusion Induction of LV dyssynchrony by RVA pacing is associated with worse long-term mortality and increased HF hospitalization rates. [ABSTRACT FROM AUTHOR]

Aims Mitral valve repair in patients with functional mitral regurgitation (FMR) has been associated with beneficial left ventricular (LV) reverse remodelling. Recently, galectin-3 emerged as a marker of myocardial inflammation and fibrosis which may influence LV remodelling after surgery. The aim of the current study was to evaluate the association between pre-operative galectin-3 levels and LV reverse remodelling in heart failure patients with significant FMR who underwent mitral valve repair. Methods and results In total, 42 heart failure patients (66 ± 10 years, 69% male) were evaluated. Plasma galectin-3 levels were assessed pre-operatively. Two-dimensional echocardiographic parameters were measured at baseline, and at 6 and 12 months after surgery. LV reverse remodelling was defined as a decrease in LV end-systolic volume ≥15% at 6 months follow-up. In total, 57% of the patients showed LV reverse remodelling. Patients with LV reverse remodelling showed significantly lower pre-operative galectin-3 levels (17.5 ± 5.6 vs. 23.7 ± 9.9 ng/mL, P = 0.009) compared with patients without LV reverse remodelling. In addition, patients with galectin-3 ≤18.2 ng/mL had a six-fold higher probability of showing LV reverse remodelling after surgery as compared with patients with levels >18.2 ng/mL (odds ratio 6.58, 95% confidence interval 1.32–33.33, P = 0.02). Conclusion High pre-operative plasma galectin-3 is independently associated with the absence of LV reverse remodelling after mitral valve repair. Galectin-3 may be useful to identify heart failure patients who will need additional treatment to obtain beneficial LV reverse remodelling. [ABSTRACT FROM AUTHOR]

OBJECTIVE--The influence of diabetes on cardiac resynchronization therapy (CRT) remains unclear. The aims of the current study were to 1) assess the changes in left ventricular (LV) systolic and diastolic function and 2) evaluate long-term prognosis in CRT recipients with diabetes. RESEARCH DESIGN AND METHODS--A total of 710 CRT recipients (171 with diabetes) were included from an ongoing registry. Echocardiographic evaluation, including LV systolic and diastolic function assessment, was performed at baseline and 6-month follow-up. Response to CRT was defined as a reduction of ≥15% in LV end-systolic volume (LVESV) at the 6-month follow-up. During long-term follow-up (median = 38 months), all-cause mortality (primary end point) and cardiac death or heart failure hospitalization (secondary end point) were recorded. RESULTS--At the 6-month follow-up, significant LV reverse remodeling was observed both in diabetic and non-diabetic patients. However, the response to CRT occurred more frequently in non-diabetic patients than in diabetic patients (57 vs. 45%, P<0.05). Furthermore, a significant improvement in LV diastolic function was observed both in diabetic and non-diabetic patients, but was more pronounced in non-diabetic patients. The determinants of the response to CRT among diabetic patients were LV dyssynchrony, ischemic cardiomyopathy, and insulin use. Both primary and secondary end points were more frequent in diabetic patients (P < 0.001). Particularly, diabetes was independently associated with all-cause mortality together with ischemic cardiomyopathy, renal function, LVESV, LV dyssynchrony, and LV diastolic dysfunction. CONCLUSIONS--Heart failure patients with diabetes exhibit significant improvements in LV systolic and diastolic function after CRT, although they are less pronounced than in non-diabetic patients. Diabetes was independently associated with all-cause mortality. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to evaluate the feasibility and accuracy of real-time integration of multidetector computed tomography (MDCT) derived coronary anatomy and epicardial fat distribution and its impact on electroanatomical mapping and ablation. Background: Epicardial catheter ablation for ventricular arrhythmias (VA) is an important therapeutic option in patients after endocardial ablation failure. However, epicardial mapping and ablation are limited by the presence of coronary arteries and epicardial fat. Methods: Twenty-eight patients (21 male, age 59 ± 16 years) underwent combined endo-epicardial electroanatomical mapping. Prior to the procedure, MDCT derived coronary anatomy and epicardial fat meshes were loaded into the mapping system (CARTO XP, Biosense Webster Inc, Diamond Bar, California). Real-time registration of MDCT data was performed after endocardial mapping. The distance between epicardial ablation sites and coronary arteries was assessed by registered MDCT and angiography. After the procedure, mapping and ablation points were superimposed on the MDCT using a reversed registration matrix for head-to-head comparison of mapping data and corresponding fat thickness. Results: Image registration was successful and accurate in all patients (position error 2.8 ± 1.3 mm). At sites without evidence for scar, epicardial bipolar voltage decreased significantly (p < 0.001) with increasing fat thickness. Forty-six VA were targeted; 25 (54%) were abolished by catheter ablation, in 21 (46%) ablation failed. In 5 VA no target site was identified and in 3 VA adhesions prevented mapping. In 2 VA ablation was withheld due to His-bundle vicinity and in 7 VA due to proximity of coronary arteries. In 4 VA catheter ablation was ineffective. At ineffective ablation sites epicardial fat was significantly thicker compared to successful sites (16.9 ± 6.8 mm [range 7.3 to 22.2 mm] and 1.5 ± 2.1 mm [range 0.0 to 6.1 mm], p = 0.002). Conclusions: Real-time image integration of pre-acquired MDCT information is feasible and accurate. Epicardial fat >7 mm and the presence of coronary arteries are important reasons for epicardial ablation failure. Visualization of fat thickness during the procedure may facilitate interpretation of bipolar electrograms and identification of ineffective ablation sites. [Copyright &y& Elsevier]

Aims Despite a successful surgical procedure and adherence to current recommendations, postoperative left ventricular (LV) dysfunction after mitral valve repair (MVr) for organic mitral regurgitation (MR) may still occur. New approaches are therefore needed to detect subclinical preoperative LV dysfunction. LV global longitudinal strain (GLS), assessed with speckle-tracking echocardiographic analysis, has been proposed as a novel measure to better depict latent LV dysfunction. The aim of this study was to investigate the value of GLS to predict long-term LV dysfunction after MVr. Methods and results A total of 233 patients (61% men, 61 ± 12 years) with moderate–severe organic MR who underwent successful MVr between 2000 and 2009 were included. Echocardiography was performed at baseline and long-term follow-up (34 ± 20 months) after MVr. LV dysfunction at follow-up was defined as LV ejection fraction (EF) <50% and was present in 29 (12%) patients. A cut-off value of −19.9% of GLS showed a sensitivity and specificity of 90 and 79% to predict long-term LV dysfunction. By univariate logistic regression analysis, baseline LVEF ≤60%, LV end-systolic diameter (ESD) ≥40 mm, atrial fibrillation, presence of symptoms, and GLS >−19.9% were predictors of long-term LV dysfunction. By multivariate analysis, GLS remained an independent predictor of LV dysfunction (odds ratio 23.16, 95% confidence interval: 6.53–82.10, P < 0.001), together with LVESD. Conclusion In a large series of patients operated within the last decade, MVr resulted in a low incidence of long-term LV dysfunction. A GLS of >−19.9% demonstrated to be a major independent predictor of long-term LV dysfunction after adjustment for parameters currently implemented into guidelines. [ABSTRACT FROM PUBLISHER]

Aims The relationship between temporal changes in left ventricular (LV) dyssynchrony and LV functional recovery after acute myocardial infarction (MI) remains unclear. Accordingly, the aim of the present study was to evaluate the temporal evolution of LV synchronicity after acute MI, and to explore the relationship between changes in LV systolic function and LV synchronicity. Methods and results In 193 patients with a first acute MI, LV dyssynchrony (SDI) and global systolic function were evaluated with real-time three-dimensional echocardiography 48 h after percutaneous coronary intervention and at 6 months follow-up. Changes in LV systolic function and synchronicity were evaluated at the follow-up and the relationship between these changes was explored. A total of 59 (40%) patients had an anterior acute MI. Median peak value of troponin T was 2.97 µg/L (1.41–6.06 µg/L). Mean LVEF was 47 ± 8% and mean SDI was 5.01 ± 2.10%, respectively. At 6 months follow-up, a significant improvement in LVEF (50 ± 9 vs. 47 ± 8%; P < 0.001) and SDI (4.52 ± 1.97 vs. 5.01 ± 2.10%; P = 0.003) was noted. A strong correlation was found between LVEF change and SDI change (β = −0.63; P < 0.001). At multivariate analysis, SDI change was an independent factor associated with changes in LVEF. Importantly, an addition of SDI change to the multivariate model significantly increased the R2 from 0.41 to 0.57 (F change 49.0, P < 0.001). Conclusion A temporal evolution of LV synchronicity was observed after a first, mechanically reperfused, acute MI. The reduction in LV dyssynchrony independently influenced LV functional recovery in these patients. [ABSTRACT FROM PUBLISHER]

The article evaluates the prognostic value of left ventricular (LV) global longitudinal strain (GLS) as a new index of LV systolic function in chronic ischemic cardiomyopathy and to determine the incremental value of GLS in predicting long term outcomes in patients. The study involved 1,060 patients who underwent transthoracic echocardiography. Results indicated that LV GLS assessment is significantly related to long term outcomes in ischemic cardiomyopathy patients.

Background. Diastolic dysfunction is common among dialysis patients and is associated with increased morbidity and mortality. Novel echocardiographic speckle tracking strain analysis permits accurate assessment of left ventricular diastolic function, independent of loading conditions and taking all myocardial segments into account. The aim of the study was to evaluate the prevalence of diastolic dysfunction in chronic dialysis patients using this novel technique, and to identify its determinants among clinical and echocardiographic variables. Methods. Patients currently enrolled in the ICD2 study protocol were included for this analysis. Next to conventional echo measurements diastolic function was also assessed by global diastolic strain rate during isovolumic relaxation (SRIVR). Results. A total of 77 patients were included (age 67±8 years, 74% male).When defined as E/SRIVR ⩾ 236, the prevalence of diastolic dysfunction was higher compared to more conventional measurements (48% versus 39%). Left ventricular mass (OR 1.02, 95% CI 1.00-1.04, P = 0.014) and pulse wave velocity (OR 1.34, 95% CI 1.07-1.68, P = 0.01) were independent determinants of diastolic dysfunction. Conclusion. Diastolic dysfunction is highly prevalent among dialysis patients and might be underestimated using conventional measurements. Left ventricular mass and pulse wave velocity were the only determinants of diastolic dysfunction in these patients. [ABSTRACT FROM AUTHOR]

Background Left atrial (LA) dilatation is an important risk factor for recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA). However, the clinical applications to select patients eligible for RFCA according to LA size is limited. Additional pre-procedural assessment of LA fibrosis might improve patient selection for RFCA. Objective To investigate the impact of LA size and LA fibrosis on the outcome of RFCA for AF. Methods One hundred and seventy consecutive patients undergoing RFCA for AF were studied. LA size was assessed by measuring maximum LA volume index on echocardiography. LA wall ultrasound reflectivity was assessed by measuring echocardiography-derived calibrated integrated backscatter (IBS) as a surrogate of LA fibrosis. Results After 12±3 months' follow-up, 103 patients (61%) had maintained sinus rhythm and 67 patients (39%) had recurrence of AF. Univariate Cox analyses identified LA wall ultrasound reflectivity, as well as LA size and type of AF, as predictors of AF recurrence after RFCA. Importantly, multivariate analyses showed that LA wall ultrasound reflectivity remained a strong predictor after correction for LA size and type of AF. Moreover, LA wall ultrasound reflectivity provided an incremental value in predicting outcome of RFCA over LA size and type of AF (increment in global &khgr;2=61.6, p<0.001). Conclusion Assessment of LA fibrosis using twodimensional echocardiography-derived calibrated IBS can be useful to predict AF recurrence after RFCA. Combined assessment of LA wall ultrasound reflectivity and LA size improves the identification of patients with a high likelihood for a successful ablation [ABSTRACT FROM AUTHOR]

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Aims Changes in left ventricular (LV) diastolic function after cardiac resynchronization therapy (CRT) in relation to LV reverse remodelling and heart failure aetiology have not been extensively characterized. The aims of the study were to evaluate changes in LV diastolic function with speckle-tracking echocardiography in relation to: (i) cardiac resynchronization therapy response (LV remodelling) and (ii) heart failure aetiology. Methods and results A total of 192 heart failure patients undergoing CRT implantation were evaluated. Speckle-tracking echocardiography was performed before and 6 months after implantation and reliable analysis was obtained in 188 patients. Left ventricular diastolic function was assessed by measuring diastolic strain rate during the isovolumic relaxation period (SRIVR) and by calculating the ratio of peak transmitral E-wave to SRIVR (E/SRIVR). Changes in LV diastolic parameters were evaluated in responders and non-responders and in patients with ischaemic and non-ischaemic cardiomyopathy. Response to CRT was defined as ≥15% reduction in LV end-systolic volume at 6 months follow-up. One-hundred and nine patients (58%) were defined as responders. Significant improvements in LV diastolic performance were observed in responders with improvement in SRIVR (from 0.14 ± 0.08 to 0.18 ± 0.12 s−1, P= 0.001) and E/SRIVR (from 834 ± 840 to 641 ± 612, P= 0.04). In addition, LV relaxation improved in patients with non-ischaemic aetiology (SRIVR: from 0.15 ± 0.08 to 0.19 ± 0.13 s−1, P= 0.004). In contrast, LV relaxation did not improve in non-responders and in patients with ischaemic heart disease. Conclusions Novel diastolic strain rate indices are useful for evaluating changes in LV diastolic function after CRT. Improvement in diastolic function was only observed in responders to CRT and patients with non-ischaemic aetiology. [ABSTRACT FROM AUTHOR]

Objectives: Previous studies demonstrated beneficial short-term effects of surgical ventricular restoration on mechanical dyssynchrony and left ventricular function and improved midterm and long-term clinical parameters. However, long-term effects on systolic and diastolic left ventricular function are still largely unknown. Methods: We studied 9 patients with ischemic dilated cardiomyopathy who underwent surgical ventricular restoration with additional restrictive mitral annuloplasty and/or coronary artery bypass grafting. Invasive hemodynamic measurements by conductance catheter (pressure–volume loops) were obtained before and 6 months after surgery. In addition, New York Heart Association classification, quality-of-life score, and 6-minute hall-walk test were assessed. Results: At 6 months'' follow-up, all patients were alive and clinically in improved condition: New York Heart Association class from 3.3 ± 0.5 to 1.4 ± 0.7, quality-of-life score from 46 ± 22 to 15 ± 15, and 6-minute hall-walk test from 302 ± 123 to 444 ± 78 m (all P < .01). Hemodynamic data showed improved cardiac output (4.8 ± 1.4 to 5.6 ± 1.1 L/min), stroke work (6.5 ± 1.9 to 7.1 ± 1.4 mm Hg · L; P = .05), and left ventricular ejection fraction (36% ± 10% to 46% ± 10%; P < .001). Left ventricular surgical remodeling was sustained at 6 months: end-diastolic volume decreased from 246 ± 70 to 180 ± 48 mL and end-systolic volume from 173 ± 77 to 103 ± 40 mL (both P < .001). Left ventricular dyssynchrony decreased from 29% ± 6% to 26% ± 3% (P < .001) and ineffective internal flow fraction decreased from 58% ± 30% to 42% ± 18% (P < .005). Early relaxation (Tau, minimal rate of pressure change) was unchanged, but diastolic stiffness constant increased from 0.012 ± 0.003 to 0.023 ± 0.007 mL−1 (P < .001). Conclusions: Surgical ventricular restoration with additional restrictive mitral annuloplasty and/or coronary artery bypass grafting leads to sustained left ventricular volume reduction at 6 months'' follow-up. We observed improved systolic function and unchanged early diastolic function but impaired passive diastolic properties. Clinical improvement, supported by decreased New York Heart Association class, improved quality-of-life score, and improved 6-minute hall-walk test may be related to improved systolic function, reduced mechanical dyssynchrony, and reduced wall stress. [Copyright &y& Elsevier]

Background Improvement of left ventricular ejection fraction (LVEF) after radiofrequency catheter ablation (RFCA) of frequent premature ventricular contractions (PVCs) has been reported. However, most patients with frequent PVCs have a normal LVEF. In these patients subtle and early forms of PVC-induced left and right ventricular (RV) impairment may not be detected by standard echocardiographic techniques. Objective To assess the effect of frequent PVCs on ventricular function in patients with preserved LVEF. Methods 49 patients (30 male, 49±16 years) with recent-onset (median 1.2 years), frequent PVCs (burden 26±13%) and 25 healthy controls were studied. Thirty-four patients with PVCs underwent successful RFCA. Two-dimensional echocardiography was performed at baseline and follow-up. LV volumes and LVEF were calculated by Simpson's rule. Tricuspid annulus plane systolic excursion and fractional area change were calculated to assess RV function. Multidirectional LV strain (radial, circumferential, longitudinal) and RV free-wall longitudinal strain were calculated by two-dimensional speckle tracking imaging. At baseline LVEF, volumes and RV dimensions were normal in patients and controls. Results Speckle tracking imaging demonstrated reduced LV and RV strain in patients with PVC as compared with controls. At follow-up there were no changes in LVEF, LV volumes and RV dimensions and function in patients successfully treated by RFCA and untreated patients. However, radial, circumferential and longitudinal strain improved significantly in patients after RFCA but remained unchanged in untreated patients. Conclusions Frequent PVCs can induce subtle cardiac dysfunction detected by speckle tracking imaging analysis in patients without apparent cardiomyopathy. RFCA can successfully eliminate PVCs and improve cardiac function. [ABSTRACT FROM AUTHOR]

The article presents a study on the role of global left ventricular (LV) strain that has been evaluated with automated function imaging (AFI) to predict recovery after acute myocardial infarction. It states that 147 individuals who have been admitted for acute myocardial infarction have undergone two-dimensional (2D) echocardiography within 48 hours of admission. Results show that early AFI global LV strain following acute myocardial infarction predicts LV function recovery at 1-year follow-up.

The authors discuss an incremental value of assessing left ventricular (LV) twist mechanics in patients with heart failure (HF) and its potential usefulness in characterizing response to cardiac resynchronization therapy (CRT) and reversal of LV remodeling at 6 months follow-up. They also underscore a critical relationship between LV lead position and changes in LV twist after CRT, and suggest that the reversal of LV remodeling in HF patients following CRT primarily results from restoration of the global sequence of LV twist mechanics. [Copyright &y& Elsevier]

Background: Besides implantation of an implantable cardioverter-defibrillator (ICD), a proportion of patients with left ventricular (LV) dysfunction due to ischemic cardiomyopathy are potential candidates for surgical LV reconstruction (Dor procedure), which changes LV ejection fraction (LVEF) considerably. In these patients, LVEF as selection criterium for ICD implantation may be difficult. This study aimed to determine the value of LVEF as criterium for ICD implantation in heart failure patients undergoing surgical LV reconstruction. Methods: Consecutive patients with end-stage heart failure who underwent ICD implantation and LV reconstruction were evaluated. During admission, two-dimensional (2D) echocardiography (LV volumes and LVEF) was performed before surgery and was repeated at 3 months after surgery. Over a median follow-up of 18 months, the incidence of ICD therapy was evaluated. Results: The study population consisted of 37 patients (59 ± 11 years). At baseline, mean LVEF was 23 ± 5%. Mean left ventricular end-systolic volume (LVESV) and left ventricular end-diastolic volume (LVEDV) were 175 ± 73 mL and 225 ± 88 mL, respectively. At 3-month follow-up, mean LVEF was 41 ± 9% (P < 0.0001 vs. baseline), and mean LVESV and LVEDV were 108 ± 65 mL and 176 ± 73 mL, respectively (P < 0.0001 vs. baseline). During 18-month follow-up, 12 (32%) patients had ventricular arrhythmias, resulting in appropriate ICD therapy. No significant relations existed between baseline LVEF (P = 0.77), LVEF at 3-month follow-up (P = 0.34), change in LVEF from baseline to 3-month follow-up (P = 0.28), and the occurrence of ICD therapy during 18-month follow-up. Conclusion: LVEF before and after surgical LV reconstruction is of limited use as criterium for ICD implantation in patients with end-stage heart failure. [ABSTRACT FROM AUTHOR]

The article reports on the results of research which was conducted in an effort to investigate the effect of intramyocardial bone marrow cell injection on myocardial perfusion and left ventricular function in patients with chronic myocardial ischemia. Researchers used a randomized, double-blind, placebo-controlled trial at a Netherlands university hospital to examine 50 patients with chronic myocardial ischemia. They found that in their short term study of patients with chronic myocardial ischemia, intramyocardial bone marrow cell injection resulted in a statistically significant but modest improvement in myocardial perfusion compared with placebo.

Cardiac resynchronization therapy (CRT) is an established therapy for patients with advanced heart failure, depressed left ventricular function, and wide QRS complex. However, individual response varies, and a substantial amount of patients do not respond to CRT. Recent studies observed that assessment of inter- and particularly intraventricular dyssynchrony may allow identification of potential responders to CRT. In addition, presence of scar tissue and venous anatomy may play a role in the selection of candidates. In this review, an extensive overview of the available dyssynchrony measurements is provided using echocardiography as well as magnetic resonance imaging (MRI) and nuclear imaging. Furthermore, other information derived from MRI, nuclear imaging, and computed tomography useful for the selection of potential candidates for CRT will be discussed. [ABSTRACT FROM AUTHOR]

Background: Myocardial contractile reserve has been shown to provide important prognostic information in patients with heart failure. We hypothesized that myocardial contractile reserve would predict left ventricular (LV) reverse remodeling after cardiac resynchronization therapy (CRT). Methods: Thirty-one consecutive patients with heart failure (LV ejection fraction [LVEF] 26% ± 7%, 35% nonischemic cardiomyopathy) underwent echocardiography during low-dose dobutamine infusion before CRT implantation to assess global contractile reserve (improvement in LVEF) and local contractile reserve in the region of the LV pacing lead (assessed by radial strain using speckle tracking analysis). Responders were defined by a decrease in LV end-systolic volume ≥15% after 6 months of CRT. Results: During low-dose dobutamine infusion, responders showed a greater increase in LVEF compared with nonresponders (Δ 13% ± 8% vs 3% ± 4%, P < .001). Furthermore, contractile reserve was directly related to improvement in LVEF after 6 months of CRT (r = 0.80, P < .001). Moreover, a cutoff value of >7.5% increase in dobutamine-induced LVEF exhibited a sensitivity of 76% and a specificity of 86% to predict response after 6 months of CRT (area under the curve 0.87). Lastly, contractile reserve in the region in the LV pacing lead was present only in responders (Δ strain during low-dose dobutamine 6% ± 5% in responders vs −1% ± 4% in nonresponders, P = .002). Conclusions: The current study demonstrates that myocardial contractile reserve (>7.5% increase in LVEF during low-dose dobutamine infusion) predicts LV reverse remodeling after CRT. [Copyright &y& Elsevier]

Background: Reverse remodeling of the left ventricle (LV) is one of the advantageous mechanisms of cardiac resynchronization therapy (CRT). Substantial LV dyssynchrony seems mandatory for echocardiographic response to CRT. Conversely, LV dyssynchrony early after acute myocardial infarction may result in LV dilatation during follow-up.Objective: The purpose of this study was to evaluate the relation between LV dyssynchrony early after acute myocardial infarction and the occurrence of long-term LV dilatation.Methods: A total of 124 consecutive patients presenting with acute myocardial infarction who underwent primary percutaneous coronary intervention were included. Within 48 hours of intervention, two-dimensional echocardiography was performed to assess LV volumes, LV ejection fraction (LVEF), and wall motion score index (WMSI). LV dyssynchrony was quantified using color-coded tissue Doppler imaging (TDI). At 6-month follow-up, LV volumes and LVEF were reassessed.Results: Patients with substantial LV dyssynchrony (> or =65 ms) at baseline (18%) had comparable baseline characteristics to patients without substantial LV dyssynchrony (82%), except for a higher prevalence of multivessel coronary artery disease (P = .019), higher WMSI (P = .042), and higher peak levels of creatine phosphokinase (P = .021). During 6 months of follow-up, 91% of the patients with substantial LV dyssynchrony at baseline developed LV remodeling, compared with 2% in the patients without substantial LV dyssynchrony. LV dyssynchrony at baseline was strongly related to the extent of long-term LV dilatation at 6 months of follow-up.Conclusion: Most patients with substantial LV dyssynchrony immediately after acute myocardial infarction develop LV dilatation during 6 months of follow-up. [ABSTRACT FROM AUTHOR]

Background: Tissue synchronisation imaging (TSI) is a new technique to assess left ventricular (LV) dyssynchrony. Objectives: The value of using TSI to automatically assess LV dyssynchrony compared with manual assessment of LV dyssynchrony from colour-coded tissue Doppler imaging (TDI), and to evaluate the value of TSP to predict response to cardiac resynchronisation therapy (CRT). Methods: 60 symptomatic patients with heart failure with depressed LV ejection fraction (LVEF) and QRS >120 ms were evaluated clinically and echocardiographically at baseline and after 6 months of CRT. LV dyssynchrony was measured manually using velocity tracings from the colour-coded TDI and automatically using TSI. LV volumes and LVEF were assessed from two-dimensional echocardiography. Clinical responders had to exhibit an improvement in New York Heart Association functional class by ⩾1 score and an improvement by ⩾25% in 6 min walking distance after 6 months. Reverse LV remodelling was defined as a reduction of ⩾15% LV end-systolic volume. Results: An excellent correlation was observed between LV dyssynchrony measured manually and automatically derived by TSI (r=0.95, p<0.001). 34 patients showed clinical response after 6 months of CRT and 32 patients showed reverse remodelling. Baseline characteristics were comparable between responders and non-responders, except for more extensive LV dyssynchrony in the responders: 78 (26) vs 29 (29) ms (p<0.001) as assessed manually, and 79 (29) vs 28 (27) ms (p<0.001) as assessed with TSI. Using a cut-off value of 65 ms to define extensive LV dyssynchrony, TSI had a sensitivity of 81% with a specificity of 89% to predict reverse LV remodelling. Conclusion: TSI allows automatic and reliable assessment of LV dyssynchrony and predicts reverse LV remodelling after CRT. [ABSTRACT FROM AUTHOR]

Objectives: This study was designed to assess the effects of long-term right ventricular (RV) pacing on left ventricular (LV) dyssynchrony, LV function, and heart failure symptoms. Background: Atrioventricular (AV) node ablation and subsequent long-term RV pacing is a well-established treatment option in patients with atrial fibrillation (AF). Methods: In 55 patients with drug-refractory AF, AV node ablation and implantation of a pacemaker was performed. At baseline and after a mean of 3.8 ± 1.7 years, LV dyssynchrony (by M-mode echocardiography and tissue Doppler imaging), LV function, and volumes and functional status were assessed. Results: After long-term RV pacing, 27 patients (49%) had developed LV dyssynchrony. Concomitantly, these patients worsened in heart failure symptoms (New York Heart Association functional class increased from 1.8 ± 0.6 to 2.2 ± 0.7, p < 0.05), with a decrease in LV ejection fraction (from 48 ± 7% to 43 ± 7%, p < 0.05) and an increase in LV end-diastolic volume (from 116 ± 39 ml to 130 ± 52 ml, p < 0.05). Conversely, patients without LV dyssynchrony did not deteriorate in heart failure symptoms, LV function, or LV volumes. Conclusions: Long-term RV pacing can induce LV dyssynchrony in almost 50% of patients treated with AV node ablation for chronic AF. The development of LV dyssynchrony was associated with deterioration in heart failure symptoms, systolic LV function, and LV dilatation. [Copyright &y& Elsevier]

Noncompaction cardiomyopathy is a recently described rare congenital cardiomyopathy; patients can be asymptomatic or develop diastolic and/or systolic left ventricular dysfunction with heart failure, systemic emboli or ventricular arrhythmias. Long-term prognosis is poor. Currently, diagnosis is based on findings on 2D echocardiography; in the current case report we demonstrate the use of MRI to diagnose noncompaction cardiomyopathy. [ABSTRACT FROM AUTHOR]

In large cardiac resynchronization therapy (CRT) trials, approximately 20–30% of patients did not respond to CRT. Recent studies indicated that left ventricular (LV) dyssynchrony is needed for response to CRT. However, the presence of LV dyssynchrony may not be the only determinant of response, because some patients with LV dyssynchrony do not benefit from CRT. In the current case report, we present a patient with ischemic cardiomyopathy, NYHA class III heart failure symptoms, and substantial LV dyssynchrony on tissue Doppler imaging who underwent CRT implantation but did not respond. Following CRT, LV dyssynchrony was not reduced and the patient did not improve in clinical symptoms or LV function. The lack of LV resynchronization was explained by the presence of extensive scar tissue in the region of the tip of the LV pacing lead resulting in ineffective LV pacing. In patients with ischemic cardiomyopathy and history of previous infarction, assessment of scar tissue should be considered before CRT implantation. [ABSTRACT FROM AUTHOR]

This report describes the mid-term beneficial hemodynamic effect of biventricular pacing in an infant with congestive heart failure after congenital heart surgery, due to resynchronization of the left and right ventricle, optimization of the AV delay, and (partial) correction of the LV dyssynchrony. (PACE 2003; 26:2042–2044) [ABSTRACT FROM AUTHOR]

Objective: Nonischemic dilated cardiomyopathy with functional mitral regurgitation carries a poor prognosis. Mitral valve surgery with implantation of a cardiac support device can treat mitral regurgitation and promote left ventricular reverse remodeling. This observational study evaluates clinical and echocardiographic outcomes of an individualized medico–surgical approach, focusing on mitral regurgitation recurrence and left ventricular reverse remodeling. Methods: Sixty-nine consecutive patients with heart failure (New York Heart Association class III/IV) with functional mitral regurgitation (grade 3+/4+) and left ventricular remodeling (end-diastolic volume 227 ± 73 mL, ejection fraction 26% ± 8%) underwent restrictive mitral annuloplasty (median ring size 26), with (n = 41) or without (n = 28) a cardiac support device and optimal postoperative medical treatment. Patients were clinically and echocardiographically evaluated at up to 3.1 years’ median follow-up. Results: Early mortality was 5.8%. Actuarial survival at 1, 2, and 5 years was 86% ± 4%, 79% ± 5%, and 63% ± 7%. New York Heart Association class improved from 3.1 ± 0.4 to 2.0 ± 0.5 (P < .01). Cardiac support device implantation in addition to mitral valve surgery, applied in patients with more advanced left ventricular remodeling, resulted in similar clinical outcome, greater left ventricular end-diastolic volume decrease (33% vs 18%; P = .007), and in a trend toward less recurrent mitral regurgitation of grade 2+ or more (actuarial freedom at 3 years 89% ± 8% vs 63% ± 11%; P = .067). Conclusions: An individualized medico–surgical approach to nonischemic cardiomyopathy combining restrictive mitral annuloplasty, cardiac support device implantation, and optimal medical management leads to favorable survival and improved functional status, low incidence of significant recurrent mitral regurgitation, and sustained left ventricular reverse remodeling. [Copyright &y& Elsevier]

Cardiac resynchronization therapy (CRT) is an effective treatment for patients with drug-refractory, chronic heart failure. Multiple single-center and multicenter studies have shown significant reductions in left ventricular (LV) volumes and an increase in LV systolic function. More importantly, CRT reduces mortality and morbidity during long-term follow-up. Current guidelines consider CRT as a Class I indication for heart failure patients in New York Heart Association (NYHA) functional class III to IV with depressed LV ejection fraction ≤35% and a wide QRS complex (≥120 ms). However, the benefits of this therapy could possibly be extended to selected subgroups of patients who do not fulfill these criteria. These subgroups include patients with mildly symptomatic heart failure and patients with a narrow QRS complex (<120 ms). Results from recent multicenter controlled clinical trials including heart failure patients in NYHA functional class I to II or with a narrow QRS complex are equivocal. Although expanding CRT to patients with a narrow QRS complex seems currently not likely, the benefits of CRT in mildly symptomatic patients are more evident. Perhaps attenuation of disease progression will prove to be a successful new treatment strategy in heart failure patients in the future. In addition, multimodality cardiac imaging will allow optimizing responder rate in patients undergoing CRT according to current guidelines. [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]

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]

Objectives: The purpose of this study was to evaluate the impact of upgrading implantable cardioverter-defibrillator (ICD) therapy to cardiac resynchronization therapy (CRT) combined with defibrillator (CRT-D) on the occurrence of ventricular arrhythmia (VA) and appropriate ICD therapies. Background: CRT has been shown to improve left ventricular (LV) systolic function and induce reverse LV remodeling. In addition, it has been hypothesized that CRT may reduce the incidence of VA. Methods: Heart failure patients receiving an upgrade from ICD to CRT-D were evaluated. Patients were considered responders to CRT if LV end-systolic volume reduced ≥15% at 6 months of follow-up. Episodes of VA, triggering device therapy (anti-tachycardia pacing and shocks) were recorded before and after upgrade for the overall population. In addition, these outcomes were compared between CRT responders and nonresponders during the follow-up period after CRT response was assessed. Results: One hundred fifteen patients (93 males [81%], age 65 ± 12 years) were evaluated during a mean follow-up of 54 ± 34 months before CRT-D upgrade and 37 ± 27 months after upgrade. In CRT responders (n = 70), the frequency of VA requiring appropriate device therapy demonstrated a trend toward a decrease from 0.51 ± 0.79 to 0.30 ± 0.59 per patient per year after CRT-D upgrade (p = 0.052). In CRT nonresponders (n = 45), the frequency of VA requiring appropriate device therapy significantly increased from 0.40 ± 0.69 to 1.21 ± 2.53 per patient per year after CRT-D upgrade (p = 0.014). Conclusions: After upgrade from ICD to CRT-D, nonresponders to CRT showed a significant increase in VA burden requiring appropriate device therapy. [ABSTRACT FROM AUTHOR]

Objectives: This study examined the mid-term hemodynamic and clinical impact of prosthesis–patient mismatch (PPM) in patients undergoing transcatheter aortic valve implantation (TAVI) with balloon-expandable valves. Background: PPM can be observed after aortic valve surgery. However, little is known about the incidence of PPM in patients undergoing TAVI. Methods: Echocardiography and clinical assessment were performed in 165 patients at baseline, before hospital discharge, and at 6 months after TAVI. PPM was defined as an indexed effective orifice area ≤0.85 cm2/m2. Results: Thirty patients (18.2%) showed PPM before hospital discharge. At baseline, patients with PPM had a larger body surface area (1.84 ± 0.18 m2 vs. 1.73 ± 0.18 m2, p = 0.003) and a greater severity of aortic stenosis (indexed valve area 0.35 ± 0.09 cm2/m2 vs. 0.40 ± 0.10 cm2/m2, p = 0.005) than patients without PPM. Patients with PPM demonstrated a slower and smaller reduction in mean transaortic gradient, limited left ventricular (LV) mass regression, and left atrial volume reduction over 6 months compared with patients without PPM. LV filling pressure, measured by E/e′, tended to remain elevated in patients with PPM. Importantly, a higher proportion of patients with PPM did not improve in New York Heart Association functional class compared with patients without PPM (36.7% vs. 1.5%, p < 0.001), although major adverse valve-related and cardiovascular events did not differ between the 2 groups. Conclusions: PPM may be observed after TAVI and when present may be accompanied by less favorable changes in transvalvular hemodynamics, limited LV mass regression, persistent elevated LV filling pressure, and less improvement in clinical functional status. [Copyright &y& Elsevier]

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]

Objectives: Aims of this study were to investigate the effect of renal function on left ventricular (LV) reverse remodeling and long-term outcome after cardiac resynchronization therapy (CRT), and to explore the relation between LV reverse remodeling and changes in renal function at 6-month follow-up. Background: Renal insufficiency is highly prevalent in heart failure patients, including patients eligible for CRT, and is associated with poor prognosis. Methods: The study comprised 490 patients undergoing CRT. Response to CRT was defined as a decrease in LV end-systolic volume ≥15% at 6-month follow-up. Primary end point during long-term follow-up was all-cause mortality. Results: At baseline, mean estimated glomerular filtration rate (eGFR) was 70 ± 28 ml/min/1.73 m2. At 6-month follow-up, 263 patients (54%) demonstrated response to CRT. Responders had an eGFR of 74 ± 26 ml/min/1.73 m2 versus 64 ± 28 ml/min/1.73 m2 in nonresponders (p < 0.001). During long-term follow-up, patients with an eGFR <60 ml/min/1.73 m2 had higher mortality than patients with an eGFR of 60 to 90 ml/min/1.73 m2 or an eGFR >90 ml/min/1.73 m2 (p < 0.001). Finally, responders to CRT had preservation of renal function (ΔeGFR −0.6), whereas nonresponders had a slight worsening in renal function (ΔeGFR −4.7, p < 0.05). Conclusions: Impaired renal function in CRT candidates is associated with nonresponse during 6-month follow-up. Additionally, patients with impaired renal function have worse long-term survival after CRT. Response to CRT results in preservation of renal function. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to assess left atrial (LA) strain during long-term follow-up after catheter ablation for atrial fibrillation and to find predictors for LA reverse remodeling. Background: The association between LA reverse remodeling and improvement in LA strain after catheter ablation has not been investigated thus far. Methods: In 148 patients undergoing catheter ablation for atrial fibrillation, LA volumes and LA strain were assessed with echocardiography at baseline and after a mean of 13.2 ± 6.7 months of follow-up. The study population was divided according to LA reverse remodeling at follow-up: responders were defined as patients who exhibited 15% or more reduction in maximum LA volume at long-term follow-up. Left atrial systolic (LAs) strain was assessed with tissue Doppler imaging. Results: At follow-up, 93 patients (63%) were classified as responders, whereas 55 patients (37%) were nonresponders. At baseline, LAs strain was significantly higher in the responders as compared with the nonresponders (19 ± 8% vs. 14 ± 6%; p = 0.001). Among the responders, a significant increase in LAs strain was noted from baseline to follow-up (from 19 ± 8% to 22 ± 9%; p < 0.05), whereas no change was noted among the nonresponders. LAs strain at baseline was an independent predictor of LA reverse remodeling (odds ratio: 1.813; 95% confidence interval: 1.102 to 2.982; p = 0.019). Conclusions: In the present study, 63% of the patients exhibited LA reverse remodeling after catheter ablation for atrial fibrillation, with a concomitant improvement in LA strain. LA strain at baseline was an independent predictor of LA reverse remodeling. [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]

Objectives: This study sought to examine the changes in diastolic dyssynchrony with cardiac resynchronization therapy (CRT). Background: Little is known about the effect of CRT on diastolic dyssynchrony. Methods: Consecutive heart failure patients (n = 266, age 65.7 ± 10.0 years) underwent color-coded tissue Doppler imaging at baseline, 48 h, and 6 months after CRT. Systolic and diastolic dyssynchrony were defined as maximal time delay in peak systolic and early diastolic velocities, respectively, in 4 basal LV segments. CRT responders were defined as those with ≥15% decrease in LV end-systolic volume at 6 months. Results: Baseline LVEF was 25.2 ± 8.1%; 63.5% patients were CRT responders. Baseline incidence of systolic and diastolic dyssynchrony, and a combination of both was 46.2%, 51.9%, and 28.6%, respectively. Compared to nonresponders, responders had longer baseline systolic (79.2 ± 43.4 ms vs. 45.4 ± 30.4 ms; p < 0.001) and diastolic (78.5 ± 52.0 ms vs. 50.1 ± 38.2 ms; p < 0.001) delays. In follow-up, systolic delays (45.4 ± 31.6 ms at 48 h; 38.9 ± 26.2 ms at 6 months; p < 0.001) and diastolic delays (49.4 ± 36.3 ms at 48 h; 37.7 ± 26.0 ms at 6 months; p < 0.001) improved only in responders. Conclusions: At baseline: 1) diastolic dyssynchrony was more common than systolic dyssynchrony in HF patients; 2) nonresponders had less baseline diastolic dyssynchrony compared to responders. After CRT: 1) diastolic dyssynchrony improved only in responders. Further insight into the pathophysiology of diastolic dyssynchrony and its changes with CRT may provide incremental information on patient-specific treatments. [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]

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]

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]

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]

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]

Objectives: This study explored the effects of cardiac resynchronization therapy (CRT) on left ventricular (LV) twist, particularly in relation to LV lead position. Background: LV twist is emerging as a comprehensive index of LV function. Methods: Eighty heart failure patients were included. Two-dimensional echocardiography was performed at baseline, immediately after CRT, and at 6-month follow-up. Speckle-tracking analysis was applied to assess LV twist. The LV lead was placed preferably in a (postero)lateral vein, and at fluoroscopy, the position was classified as basal, midventricular, or apical. Response to CRT was defined as reduction of LV end-systolic volume ≥15% at 6-month follow-up. A control group comprised 30 normal subjects. Results: Peak LV twist in heart failure patients was 4.8 ± 2.6° compared with 15.0 ± 3.6° in the control subjects (p < 0.001). At 6-month follow-up, peak LV twist significantly improved only in responders (56%), from 4.3 ± 2.4° to 8.5 ± 3.2° (p < 0.001). The strongest predictor of response to CRT was the improvement of peak LV twist immediately after CRT (odds ratio: 1.899, 95% confidence interval: 1.334 to 2.703, p < 0.001). Furthermore, LV twist significantly improved in patients with an apical (from 4.3 ± 3.1° to 8.6 ± 3.0°, p = 0.001) and midventricular (from 4.8 ± 2.2° to 6.4 ± 3.9°, p = 0.038) but not with a basal (5.0 ± 3.3° vs. 4.1 ± 3.2°, p = 0.28) LV lead position. Similarly, LV ejection fraction significantly increased in patients with an apical (from 26 ± 7% to 37 ± 7%, p < 0.001) and midventricular (from 26 ± 6% to 33 ± 8%, p < 0.001) but not with a basal (26 ± 5% vs. 28 ± 8%, p = 0.30) LV lead position. Conclusions: An immediate improvement of LV twist after CRT predicts LV reverse remodeling at 6-month follow-up. [Copyright &y& Elsevier]