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Background Relationships between right ventricular (RV) and left ventricular (LV) shape and function may be useful in determining optimal timing for pulmonary valve replacement in patients with repaired tetralogy of Fallot (rTOF). However, these are multivariate and difficult to quantify. We aimed to quantify variations in biventricular shape associated with pulmonary regurgitant volume (PRV) in rTOF using a biventricular atlas. Methods In this cross-sectional retrospective study, a biventricular shape model was customized to cardiovascular magnetic resonance (CMR) images from 88 rTOF patients (median age 16, inter-quartile range 11.8–24.3 years). Morphometric scores quantifying biventricular shape at end-diastole and end-systole were computed using principal component analysis. Multivariate linear regression was used to quantify biventricular shape associations with PRV, corrected for age, sex, height, and weight. Regional associations were confirmed by univariate correlations with distances and angles computed from the models, as well as global systolic strains computed from changes in arc length from end-diastole to end-systole. Results PRV was significantly associated with 5 biventricular morphometric scores, independent of covariates, and accounted for 12.3% of total shape variation (p Conclusion A biventricular atlas of rTOF patients quantified multivariate relationships between left–right ventricular morphometry and wall motion with pulmonary regurgitation. Regional RV dilation, LV reduction, LV septal-lateral flattening and increased RV strain were all associated with increased pulmonary regurgitant volume. Morphometric scores provide simple metrics linking mechanisms for structural and functional alteration with important clinical indices.

Acute coronary syndrome is one of the most common causes of chest pain in adults. We report a case of 61-year-old female, who presented to her primary care physician with chest pain. Despite temporary character of symptoms, normal standard 12-lead resting ECG, lack of rising serum levels of myocardial necrosis biomarkers and no regional wall motion abnormalities in transthoracic echocardiography, on the basis of proper history taking, including risk factors of coronary artery disease, coronary angiography was done, which showed high-grade narrowing of left anterior descending artery, resulting in prompt qualification for coronary artery bypass graft procedure. It should be stressed that proper history taking, which includes risk factors of coronary artery disease, is of utmost importance for correctly diagnosing acute coronary syndrome in primary care, which allows rapid initiation of treatment.

BACKGROUND: This feasibility study aimed to detect respiratory waveforms from thoracic movements and evaluate if postoperative complications could be predicted using a carbon nanotube sensor. METHODS: Fifty patients who underwent lung resection for lung tumors were enrolled. The lung monitoring system of the carbon nanotube sensor was placed on bilateral chest walls across the 6(th)–9(th) ribs to measure chest wall motion. We examined the respiratory waveform in relation to surgical findings, postoperative course, and complications using Hilbert transform and Fast Fourier Transform (FFT). RESULTS: Of 50 patients (37 males, 13 females), 22 were included in the normal lung function group and 28 were included in the low lung function group. The respiratory rate and waveform indicated a regular pattern in the normal lung function group and the respiratory rate could be detected. Conversely, irregular respiratory pattern was detected in 70% of patients in the low lung function group. There was no significant different overall envelope peak value between operated side and non-operated side (0.195±0.05 and 0.18±0.06). In contrast, there was significantly high peak value in the presence of postoperative complications (P

We present an extremely rare case of mitral Ebstein's anomaly that resulted in severe mitral regurgitation (MR). A 41-year-old woman with a history of tuberous sclerosis underwent surgery. Preoperatively, it was assumed that MR had occurred due to leaflet tethering related to left ventricular posterior wall motion asynergy due to a scarred rhabdomyoma. However, surgical inspection revealed a dysplastic posterior leaflet adhering to the ventricular wall, which was completely covered by the endocardium. Both congenital mitral Ebstein's anomaly and acquired wall motion abnormality due to a scarred rhabdomyoma may have contributed to the development of severe MR in this case.

Sensitivity and specificity of ESE to determine hemodynamically significant coronary artery disease (CAD) is limited by subjective qualitative interpretation resulting in false-positive results. The objective of this study was to determine whether resting myocardial work estimated from non-invasive left ventricular pressure-strain loops can help improve the interpretation of exercise stress echocardiography (ESE). Resting global myocardial work was performed on 288 patients referred for clinically indicated ESE with no resting regional wall motion abnormalities and normal ejection fraction (≥ 55%). Coronary angiography was used to validate the presence of significant CAD in those with a positive ESE. Resting global myocardial work index (GWI) was significantly reduced (p

PURPOSE The echocardiographic measurement of left ventricular (LV) ejection fraction (EF) is dependent on professional experience and adequate visualization. Tissue motion of mitral annular displacement (TMAD) can be easily assessed using speckle-tracking echocardiography (STE), even in patients with poor acoustic windows. Therefore, this study aimed to assess whether left ventricular ejection fraction (LVEF) can be estimated using STE-derived TMAD when LVEF is not available. METHODS Four-hundred fifty-six outpatients were enrolled after excluding the patients whose LVEF measurements remained challenging or TMAD value could be confounded. An optimized regression model for LVEF-TMAD was developed in the derivation set (n = 287), and its reliability was verified in the validation set (n = 123) and regional wall motion abnormalities (RWMA) set (n = 46). RESULTS In the derivation set, the power models had the highest F-value. Therefore, the power equations were chosen to estimate LVEF by TMAD in the validation set. There was a near-zero bias and a narrow range between the observed and estimated LVEF. The highest intra-class correlation coefficient was found between the observed and the estimated LVEF by normalized TMAD at the midpoint of mitral annular (nTMADmid). Moreover, there were no significant differences between the observed and the estimated LVEF in the RWMA set. CONCLUSION The LVEF can be estimated with STE-derived TMAD, even for patients with RWMA, and nTMADmid may be the optimal parameter.

Purpose of review The review summarizes the key parameters that can aid in determining the optimal treatment of ischemic mitral regurgitation (IMR). Recent findings Left ventricular (LV) and mitral valve (MV) parameters are important for surgical planning and risk stratification in IMR. Although LV dimensions is one of the main parameters used in the guidelines, volumes more accurately depict LV remodelling. Furthermore, wall motion abnormalities and wall motion score index can also be useful for surgical planning in treatment of IMR. Viability is best measured with cardiac magnetic resonance, but it is not feasible in certain centres. In contrast, measurement of strain with echocardiography is an emerging and feasible tool for estimating viability. MV leaflet tethering and pattern measured with echocardiography are also useful for MV surgery. Anterior leaflet excursion angle can identify patients in whom undersized ring annuloplasty is potentially unsuitable. Summary Treatment of IMR relies on accurate parameters that can determine the optimal surgical approach. In some patients, lack of viable myocardium suggests inadequacy of revascularization and thus, an adjunctive left ventricular reconstruction may be necessary. Degree and pattern of MV leaflet tethering can indicate whether ring annuloplasty, which is the most common repair technique, is sufficient or an adjunctive sub-valvular intervention is beneficial.

Transcatheter device closure is a common treatment option of atrial septal defect. Mitral regurgitation has been reported with comorbid mitral valve prolapse and atrial septal defect. However there is no consensus regarding the pathogenesis of mitral regurgitation after closure. We are reporting a patient with functional mitral regurgitation associated with both an oversize closure device and wall motion abnormality after inferior myocardial infarction.

Myocardial infarction (MI), or commonly known as heart attack, is a life-threatening health problem worldwide from which 32.4 million people suffer each year. Early diagnosis and treatment of MI are crucial to prevent further heart tissue damages or death. The earliest and most reliable sign of ischemia is regional wall motion abnormality (RWMA) of the affected part of the ventricular muscle. Echocardiography can easily, inexpensively, and non-invasively exhibit the RWMA. In this article, we introduce a three-phase approach for early MI detection in low-quality echocardiography: 1) segmentation of the entire left ventricle (LV) wall using a state-of-the-art deep learning model, 2) analysis of the segmented LV wall by feature engineering, and 3) early MI detection. The main contributions of this study are highly accurate segmentation of the LV wall from low-quality echocardiography, pseudo labeling approach for ground-truth formation of the unannotated LV wall, and the first public echocardiographic dataset (HMC-QU)a MI detection. Furthermore, the outputs of the proposed approach can significantly help cardiologists for a better assessment of the LV wall characteristics. The proposed approach has achieved 95.72% sensitivity and 99.58% specificity for the LV wall segmentation, and 85.97% sensitivity, 74.03% specificity, and 86.85% precision for MI detection on the HMC-QU dataset.aThe benchmark HMC-QU dataset is publicly shared at the repository https://www.kaggle.com/aysendegerli/hmcqu-dataset.for publishedVersion

For more than 30 years, echocardiography, through the measurement of ejection fraction and wall motion assessment, has played a crucial role in the diagnosis and management of patients with acute and chronic ischemic heart disease. The introduction of myocardial strain, measured by speckle tracking echocardiography, is shifting this paradigm. Strain imaging catches something pathophysiologically deeper into myocardial function, facing a wide range of clinical applications. This review summarizes the basic concepts of strain imaging and its applicability in clinical practice for the evaluation of the ventricular and the left atrial function in ischemic cardiomyopathy.

International audience; Motion extracted from the carotid artery wall provides unique information for vascular health evaluation. Carotid artery longitudinal wall motion corresponds to the multiphasic arterial wall excursion in the direction parallel to blood flow during the cardiac cycle. While this motion phenomenon has been well characterized, there is a general lack of awareness regarding its implications for vascular health assessment or even basic vascular physiology. In the last decade, novel estimation strategies and clinical investigations have greatly advanced our understanding of the bi-axial behavior of the carotid artery, necessitating an up-to-date review to summarize and classify the published literature in collaboration with technical and clinical experts in the field. Within this review, the state-of-the-art methodologies for carotid wall motion estimation are described, and the observed relationships between longitudinal motion-derived indices and vascular health are reported. The vast number of studies describing the longitudinal motion pattern in plaque-free arteries, with its putative application to cardiovascular disease prediction, point to the need for characterizing the added value and applicability of longitudinal motion beyond established biomarkers. To this aim, the main purpose of this review was to provide a strong base of theoretical knowledge, together with a curated set of practical guidelines and recommendations for longitudinal motion estimation in patients, to foster future discoveries in the field, toward the integration of longitudinal motion in basic science as well as clinical practice.

Aims Speckle-tracking imaging is a novel method for assessing left ventricular (LV) function and ischemic changes. The aim of this prospective study was to assess the diagnostic accuracy of global longitudinal strain (GLS) and regional longitudinal strain (RLS) parameters at rest in comparison to stress echocardiography findings for detecting significant coronary artery disease (CAD) in patients with diabetes mellitus (DM). Methods We prospectively studied echocardiographic characteristics at rest with Speckle tracking echocardiography (2D STE) measures; then stress echocardiography and coronary angiography data in 34 diabetic patients without regional wall motion abnormality (RWMA) at rest. Patients were grouped according to coronary angiography and stress echocardiography results into two groups CAD (+) vs control group CAD (-). Results GLS at rest was lower in the CAD (+) group ((-14.2 % ± 3.1 vs -17.8 % ± 3.1 in the control group CAD (-), P=0.004). GLS at rest had the highest area under the ROC curve (AUC) (AUC 0.78, sensitivity 61%, specificity 91%,P=0.009) with the cut-off of -14.5% which is equal to predictive power of wall motion scoring index (WMSI) at peak stress to detect significant CAD (AUC=0.76 (95% CI 0.58-0.94, P= 0.016) with the cut-off value of 1.21). Conclusions Global longitudinal strain at rest by STE showed excellent specificity (>90%) and good sensitivity (60%) for the diagnosis of severe CAD among the diabetic population with unknown CAD. This is the first study showing that GLS at rest with cutoff value at -14.5% had good and equal diagnostic accuracy as WMSI at peak stress to detect significant CAD among the diabetic population.

We try to investigate whether the values of three-dimensional principal longitudinal strain present differently between the left and right ventricles in patients with long-time follow-ups after heart transplantation (HTx).Transthoracic echocardiography with three-dimensional speckle tracking was performed at one-, five- and ten-year follow-ups in 62 "healthy" HTx patients together with routine echocardiographic evaluation in 32 control group (CG) individuals. Longitudinal strain was applied in all subjects assessing without myocardium wall motion abnormality. Firstly, left ventricular ejection fraction preserved in HTx and had no significant difference in comparison with the controls (p .05). 3D measurement showed obvious reduction in global (%: CG: -20.5 ± 3.5 vs. HT1y: -13.7 ± 4.6, HT5y: -14.4 ± 4.5, HT10y: -14.6 ± 4.7. p .01) and horizontal segmental (basal, mid, apical, CG vs. HTx: all p .01) strain values of the left compared HTx with control subjects. Secondly, tissue Doppler imaging s' velocity and tricuspid annular plane systolic excursion reduced in HTx as compared to the controls in right ventricle (p .01). Longitudinal strain presented a more distinctive reduction in global (%: CG: -24.5 ± 4.6 vs. HT1y:-14.8 ± 7.5, HT5y: -15.5 ± 6.4, HT10y: -15.9 ± 6.8. p .01) and horizontal segmental (basal, mid, apical, CG vs. HTx: all p .01) average values of the right compared HTx with control subjects. Thirdly, there weren't any significant changes between one-, five- and ten-year of all the values with HTx inter-group comparison in both the left and right ventricles (p .05). Fourthly, the global and segmental strain of the right ventricle decreased more than that of the left ventricle in all HTx groups, with the global decreased differentiation rates of 7%, 7%, 6%, respectively.Compared HTx with control subjects in both ventricles, conventional evaluation showed preserved or decreased functions in the left and right separately. Myocardial function evaluating by 3D longitudinal strain reduced after HTx, but the deformation of the right ventricle reduced more than those of the left ventricle. Additionally, 3D strain values almost remained with stable decreased differentiation rates during the long-time follow-ups.

Visual Abstract, Highlights • Surgical myectomy is morbid and transcoronary alcohol septal ablation can result in geographic miss or occasional nontarget injury. • We developed a transvenous intraseptal radiofrequency ablation technique (cerclage ablation method) to overcome the shortcomings of surgical myectomy and alcohol septal ablation. • We delivered dedicated intraseptal radiofrequency ablation catheter into the ventricular septum through the coronary sinus and a septal vein. The ablated volume of myocardium was larger at higher electrode temperatures and using an irrigated-ablation mode in vitro. Cerclage ablation was successful in all in vivo attempts and induced a focal regional wall motion abnormality at later follow-up. • This study presents in vivo evidence of the feasibility, effectiveness, and safety of cerclage ablation method to debulk interventricular septal myocardium., Summary Debulking of left ventricular septal mass is typically accomplished using surgical myectomy, which is morbid, or using transcoronary alcohol septal ablation, which can result in geographic miss and occasional catastrophic nontarget coronary injury. The authors developed and tested operational parameters in vitro and vivo for a device to accomplish transvenous intraseptal radiofrequency ablation to reduce ventricular septal mass using a technique derived from mitral cerclage, which the authors call cerclage ablation. Cerclage ablation appeared feasible in vitro and safe and effective in vivo. Cerclage ablation is an attractive new approach to debulk the interventricular septum in obstructive hypertrophic cardiomyopathy. These data support clinical investigation.

A 53-year-old man was referred to our centre with palpitations. There was no significant medical history and he took no regular medication. Twenty-four hours Holter monitoring revealed sinus rhythm with frequent ventricular ectopy. Echocardiography identified a wall motion abnormality at the apex, raising the possibility of ischaemic heart disease. Coronary angiography was subsequently performed, and this demonstrated normal coronary arteries. Cardiac magnetic resonance (CMR) imaging was arranged to further investigate the regional wall motion abnormality detected on echocardiography (see figure 1). Figure 1 (A) …

Takotsubo syndrome (TS) is an acute cardiac condition characterized by transient wall motion abnormalities mostly of the left ventricle. First described in 1990, TS has gained substantial attention during the past 15 years. However, the disease is still underdiagnosed. Prospective studies on TS are largely lacking, and the condition remains incompletely understood. In addition, significant misconceptions and misunderstandings are evident, contributing to potentially severe underestimation. Here, we review important aspects of TS with a focus on pitfalls, misinterpretations, and knowledge gaps considered important during diagnosis and management of the disease. Electronic supplementary material The online version of this article (10.1007/s00059-020-04906-2) contains the references to the tables. The article and additional material are available in the electronic full text archive at http://www.springermedizin.de/herz. You will find the additional material at the end of the article under “Supplementary Material”.

Background. It is unknown how much precociously the cigarette smoking (CS) may compromise the integrity of the cardiovascular (CV) system. Myocardial function can be routinely assessed by conventional echocardiography, but abnormalities are only detected when somewhat a remodelling has already occurred. These limitations could be overcome by strain imaging. Methods. We evaluated whether young smokers with normal left ventricular (LV) geometry, wall motion and ejection fraction may present abnormalities in myocardial deformation, both at rest and during physical effort. We selected 50 young smokers with no additional CV risk factors, and 60 non-smokers to undergo a standardized exercise-test. Consistently, we evaluated the CV adaptation to exercise by both conventional echocardiography and speckle-tracking analysis (2D-STE). Results. We found no difference between smokers and controls regarding baseline characteristics; as expected, smokers presented with lower HDL-cholesterol (p

BACKGROUND Strain imaging by speckle tracking is a well-established method to assess left ventricular function. The objective of this study was to define the utility of strain imaging in predicting obstructive coronary artery disease (CAD) in a subset of patients who do not have regional wall motion abnormality (RWMA) on routine 2D echocardiography. METHODS This is a prospective study. Consecutive patients with no RWMA scheduled to undergo coronary angiography (CAG) for clinical indications were included in the study. Longitudinal strain imaging by speckle tracking using automated functional imaging (AFI) was done by a single investigator prior to CAG. All angiograms were reported by a second investigator who was blinded to the strain imaging findings. Obstructive CAD was defined as ≥ 70% luminal stenosis of epicardial coronary arteries and/or ≥ 50% luminal stenosis of LMCA. RESULTS 129 patients were enrolled over a 7 month period (mean age 56.07±10.7, males 69%, females 31%). For detecting obstructive CAD, strain imaging had a sensitivity of 97% for LAD, 90.69% for RCA, 91.6% for LCX, a negative predictive value of 81.81% for LAD, 91.3% for RCA, 92.3% for LCX, a specificity of 15.2% for LAD, 13.9% for RCA, 22.8% for LCX and a positive predictive value of 57.6% for LAD, 34.5% for RCA and 21.3% for LCX territories. Patients with obstructive CAD had a lower global strain value of -18.37 ± 4.13 as compared to -21.18 ± 3.81 in patients who did not have obstructive CAD (p value

Background Neurogenic stunned myocardium (NSM) is a condition in a group of stress cardiomyopathies with evolving nomenclature that includes Takotsubo cardiomyopathy. It manifests through electrocardiogram changes, cardiac enzyme elevation, and regional or global kinetic wall motion abnormalities. Case Report We present a 43-year-old female with a subarachnoid hemorrhage who developed persistent hypotension and tachycardia secondary to neurogenic stress cardiomyopathy. Why Should an Emergency Physician Be Aware of This? It is important to consider NSM in any patient with neurologic pathology and undifferentiated shock. Early recognition in the emergency department setting can yield valuable data to guide the treatment and improve clinical outcomes in these patients.

El síndrome de Takotsubo (STT), es una miocardiopatía de estrés que afecta más frecuentemente a mujeres postmenopaúsicas tras un estímulo físico o emocional. Se caracteriza por presentar una clínica similar al síndrome coronario agudo, con elevación de enzimas cardiacas y alteraciones en el electrocardiograma. El diagnóstico se basa en los “InterTAK Diagnostic Criteria” establecidos en 2018, siendo fundamental el hallazgo de una anormalidad en la contracción del ventrículo izquierdo, sin patología coronaria (aunque su aparición no excluye el diagnóstico), con reversibilidad del cuadro precoz. El tratamiento no está claramente establecido, incluyendo medidas de soporte y la prevención de complicaciones. En los últimos años, ha habido un aumento de su descripción en los entornos sanitarios, lo que sugiere un probable infradiagnóstico. El entorno perioperatorio puede ser un escenario ideal para su aparición, por la implicación del estrés quirúrgico, siendo el anestesiólogo el principal implicado en su diagnóstico y manejo.

Background: Despite the risk for complications, allograft surveillance after orthotopic heart transplantation (OHT) is performed by cardiac catheterization and biopsies. We investigated the diagnostic and prognostic value of a TDI-derived systolic wall motion analysis of the posterobasal wall of the left ventricle (Sm) as a screening modality in OHT aftercare. Methods: We examined data of 210 eligible patients who underwent OHT between 2010 and 2020. Forty-four patients who had died within the initial hospital stay were excluded. For 166 patients, baseline and follow-up data were analyzed. The mean age at OHT was 46.2 (±11.4) years, 76.5% were male. Results: Within the observational period, 22 (13.3%) patients died. In total, 170 episodes of acute cellular or humoral rejections occurred (84 ISHLT1R, 13 ISHLT2R, 8 ISHLT3R, 65 AMR), and 29 catheterizations revealed cardiac allograft vasculopathy (5 CAV1, 4 CAV2, 20 CAV3). Individual Sm radial/longitudinal remained stable within the follow-up period (11.5 ± 2.2 cm/s, 10.9 ± 2.1 cm/s). Patients with acute rejections and CAV3 showed significant Sm radial/longitudinal reductions (AMR1: 1.6 ± 1.9 cm/s, confidence interval (CI) 0.77–0.243, p &lt, 0.001, 1.8 ± 2.0 cm/s, CI 0.92–0.267, p &lt, 0.001. ISHLT1R: 1.7 ± 1.8 cm/s, CI 1.32–2.08, p &lt, 2.0 ± 1.6 cm/s, CI 1.66–2.34, p &lt, 0.001. CAV3: 1.3 ± 2.5 cm/s, CI 0.23–2.43, p &lt, 0.017, 1.4 ± 2.8 cm/s, CI 0.21–2.66, p &lt, 0.021). Lower Sm was associated with a threefold increase in all-cause mortality (hazard ratio (HR) 3.24, CI 1.2–8.76, p = 0.020, HR 2.92, CI 1.19–7.18, p = 0.019). Overall, Sm-triggered surveillance led to 0.75 invasive diagnostics per patient post-OHT year. Conclusions: Sm remained stable in the post-OHT course. Reductions indicated ISHLT1R, AMR1 and CAV3 and were associated with higher all-cause mortality. Sm-triggered surveillance may be referred to as a safe, high-yield screening modality in OHT aftercare.

PurposeThis study aimed to investigate global myocardial work (GMW), derived from non-invasive left ventricular (LV) pressure-strain loops (PSLs) in coronary artery disease (CAD) patients without regional wall motion abnormality (RWMA), and explored the relationship between GMW and severity of CAD using Gensini score (GS) . Methods120 patients prepared for coronary angiography (CAG) who had left ventricular ejection fraction≥55%, no resting RWMA in two-dimensional echocardiography were enrolled. Global longitudinal strain (GLS), GMW parameters (including global myocardial work index (GWI), global constructive work (GCW), global wasted work (GWW) and global myocardial work efficiency (GWE)) were quantified. The severity of coronary lesions was evaluated by GS system based on CAG findings. We divided CAG-confirmed CAD patients into three subgroups according to the tertiles of GS: low 038. ResultsCAD patients showed a significantly reduced GLS and GWE, but an increased GWW. GLS, GWE, GWI and GCW were significantly decreased in the high-GS group while GWW was increased. GLS, GWE, GWI and GCW was negatively correlated with the GS, GWW was positively correlated with GS. Multivariate regression analysis showed that GWE was the independent factor of predicting coronary stenosis. ROC analysis demonstrated that GWE was the most powerful predictor of high-GS and was superior to GLS. GWE under 91% had the optimal sensitivity and specificity for identifying high-GS. ConclusionThe proposed GWE, which outperformed the GLS, showed the optimal performance and could be considered as a potential predictive indicator to detect severe coronary disease in non-RWMA CAD patients.

This study emphasizes that VSD should not be immediately diagnosed as a congenital disorder; instead, regional wall motion abnormalities in the left ventricle should also be taken into account since it may result from mechanical complications of neglected myocardial infarction.

Background Current ESC guidelines for non-ST-segment elevation myocardial infarction suggest the utilization of echocardiography in patients with inconclusive initial electrocardiography and cardiac enzymes. Besides detection of alternative pathologies associated with chest pain, echocardiography can screen for wall motion abnormalities (WMA) as sign of myocardial necrosis. Purpose We evaluated the ability of the assessment of regional WMA, detected via transthoracic echocardiography, to predict the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Methods In this prospective single-centre observational cohort study, we included consecutive patients presenting to the emergency department of our University Hospital with acute chest pain, suggestive of an acute coronary syndrome, between December 2018 and August 2020. Patients with ST-elevation myocardial infarction, hemodynamic instability, or known coronary artery disease were excluded. As part of initial workup, patients received bedside echocardiography for the assessment of regional WMA by a dedicated study physician, blinded to all patients' characteristics. The primary endpoint was defined as the presence of culprit lesions as detected in subsequent invasive coronary angiography, requiring coronary revascularization therapy. Logistic regression analysis was performed in different models adjusted for traditional cardiovascular risk factors, cardiac biomarkers as well as established risk scores. Area under the receiver operating characteristics curve (AUC) was calculated to assess a potential improvement in the prediction of culprit lesions. Results Overall, 657 patients (age 58.06±18.04 years, 53% male) were included in our study. WMA were detected in 76 patients (11.6%). Patients with WMA were older (66.92±13.85 vs. 56.90±18.21 years, p Conclusion WMA strongly and independently predict the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Our results suggest that routine bedside echocardiography for assessment of WMA in emergency department may improve diagnostic algorithms in suspected acute coronary syndrome. Funding Acknowledgement Type of funding sources: None.

We report a rare and complex case of cardiac sarcoidosis in a patient presenting with ventricular tachycardia. Multimodality imaging, along with clinical and histological examination, was essential in establishing the diagnosis of cardiac sarcoidosis. (Level of Difficulty: Beginner.).

Background: The potential of global and regional myocardial work (MW) parameters for detecting moderate, clinically unapparent coronary artery disease (CAD) remains unclear. This study aimed to evaluate the diagnostic power of global and regional MW to detect CAD in patients with normal left ventricular ejection fraction and wall motion. Methods: One hundred and seventy-six consecutive patients with clinically suspected CAD were prospectively included. All subjects underwent comprehensive echocardiographic evaluation and coronary angiography. Noninvasive MW indices include global work index (GWI), global work efficiency (GWE), global constructive work (GCW), global wasted work (GWW) and regional MW parameters. Results: GWI, GWE and GCW were significantly impaired in patients with CAD (stenosis ≥50%) compared with patients without CAD (all P＜0.01). An optimal GWI cutoff value of 1855.5 mmHg % (sensitivity, 71.7%; specificity, 78.0%) has been defined for predicting CAD [area under the curve (AUC) value, 0.76; P = 0.000]. GWI provided incremental value over all other echocardiographic parameters in detecting CAD, including global longitudinal strain (GLS) (P＜0.05). MW parameters in left anterior descending (LAD) segments had higher diagnostic value (AUC = 0.67-0.74, all P = 0.000) than parameters in left circumflex (LCX) (AUC = 0.64, P＜0.01) or right coronary artery (RCA) territories (AUC = 0.65-0.71, all P＜0.01).Conclusions: Global and regional MW parameters assessed at rest are of good diagnostic value for detecting CAD. GWI provides incremental value over all other echocardiographic parameters in predicting CAD, including GLS. Besides, regional MW may be a useful tool to localize and detect relevant coronary artery stenosis.

Background: The cardiomyopathies are defined as “hetrogenous group of diseases of the myocardium associated with mechanical or electrical dysfunction that usually (but not invariably) exhibit inappropriate ventricular hypertrophy or dilatation and are due to variety of causes that frequently are genetic. They usually present clinically with heart failure. Methods: The cross sectional hospital based study was conducted in the Department of Radiodiagnosis in patients with heart failure with LVEF (Left Ventricular Ejection Fraction) of

Aims: To determine the agreement between two-dimensional transthoracic echocardiography (2DTTE) and cardiovascular magnetic resonance (CMR) in left ventricular (LV) function [including end-systolic volume (LVESV), end-diastolic volume (LVEDV), and ejection fraction (LVEF)] in chronic total occlusion (CTO) patients.Methods: Eighty-eight CTO patients were enrolled in this study. All patients underwent 2DTTE and CMR within 1 week. The correlation and agreement of LVEF, LVESV, and LVEDV as measured by 2DTTE and CMR were assessed using Pearson correlation, Kappa analysis, and Bland–Altman method.Results: The mean age of patients enrolled was 57 ± 10 years. There was a strong correlation (r = 0.71, 0.90, and 0.80, respectively, all P < 0.001) and a moderately strong agreement (Kappa = 0.62, P < 0.001) between the two modalities in measurement of LV function. The agreement in patients with EF ≧50% was better than in those with an EF r = 0.84, 0.96, and 0.87, respectively) and smaller biases in LV function measurement.Conclusions: The difference in measurement between 2DTTE and CMR should be noticed in CTO patients with EF

Aims The purpose of the study was to compare the accuracy of cardiac magnetic resonance (CMR) with echocardiography for the evaluation of ventricular dysfunction in patients of dilated cardiomyopathy (DCM). Further, we evaluated the potential of CMR for myocardial tissue characterization. Design Prospective observational. Materials and Methods A total of 30 patients with suspected DCM prospectively underwent cardiac magnetic resonance (MR) using a 1.5 Tesla MR scanner, with appropriate phased-array body coils. Dynamic sequences after injection of 0.1 mmol/kg of body weight of gadolinium-based intravenous contrast (Magnevist) were acquired for each patient, after which delayed images were obtained at an interval of 12 to 15 minutes. Myocardial tagging was performed in all patients for assessment of wall motion abnormalities. Each MR examination was interpreted with two radiologists for chamber dimensions and ventricular dysfunction as well as morphologic characteristics with disagreement resolved by consensus. All patients included in the study were taken up for MR evaluation after cardiological evaluation through echocardiography and the results for both the studies were compared. Data were analyzed through standard statistical methods. Conclusion CMR is a comprehensive diagnostic tool, which can estimate the ventricular function more precisely than echocardiography. CMR reliably differentiates between ischemic and nonischemic etiologies of DCM based on patterns of late gadolinium enhancement (LGE) and based on the presence or absence of LGE, which helps to estimate the degree of myocardial fibrosis. Thereby it can be a useful tool in establishing risk stratification, predicting prognosis, and thus instituting appropriate therapy in DCM patients.

The diagnosis of coronary artery disease (CAD) with nonstress echocardiography remains challenging. Although the assessment of either early systolic lengthening (ESL) or postsystolic shortening (PSS) allows the sensitive detection of CAD, it is unclear whether the integrated analysis of ESL and PSS in addition to the peak systolic strain can improve the diagnostic accuracy. We investigated the incremental value of ESL and PSS in detecting left anterior descending artery (LAD) stenosis using nonstress speckle-tracking echocardiography. Fifty-nine patients with significant LAD stenosis but without visual wall motion abnormalities on echocardiography at rest (30 single-vessel stenosis, 29 multivessel stenosis) and 43 patients without significant stenosis of any vessel were enrolled. The peak systolic strain, the time to ESL (TESL), and the time to PSS (TPSS) were analyzed in all LAD segments, and the incremental values of the TESL and TPSS in detecting LAD stenosis and the diagnostic accuracy were evaluated. In the apical anterior segment, the peak systolic strain was significantly lower and TESL and TPSS were significantly longer in the single-vessel group than in the no stenosis group. In the single-vessel group, the addition of TESL and TPSS to the peak systolic strain significantly increased the model power in detecting stenosis, and the integrated analysis improved diagnostic accuracy compared with the peak systolic strain alone. In contrast, this incremental value was not demonstrated in the multivessel group. The integrated analysis of the peak systolic strain, ESL, and PSS may allow better screening of single-vessel LAD stenosis using nonstress speckle-tracking echocardiography.

Highlights • Takotsubo syndrome (TTS) has become a globally recognized disease and its spectrum has been widened based on the observations using multimodality images. • Despite the long-standing clinical experience and efforts in basic research, its pathophysiology and specific treatments have not been well established. • We should always remember possible cardiovascular complications such as coronary artery disease, thromboembolism, myocarditis, and TTS in patients with COVID-19., Takotsubo cardiomyopathy or takotsubo syndrome (TTS) has become a well-known disease not only in Japan but also in the rest of the world. Early reports suggested that TTS is a self-limiting disease with better prognosis than acute coronary syndrome. However, recent data showed that TTS is not a benign disease as compared with acute coronary syndrome. In addition to the apical ballooning, several other types of wall motion abnormalities have been classified as variants of TTS. In particular, right ventricular involvement, or biventricular TTS, is not uncommon and is associated with poor in-hospital as well as long-term outcomes. With respect to the pathophysiology, modulation (desensitization) of the beta-adrenergic receptor is suspected as a possible mechanism for transiently depressed myocardial contraction. Although specific treatments to improve prognosis of TTS are still uncertain, observational data suggest favorable impact of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Finally, in the era of COVID-19, we should pay attention to a variety of cardiovascular conditions related to COVID-19. TTS is one of these conditions that can be triggered by both emotional and physical impact of the COVID-19 pandemic.

Hypocalcemia usually causes heart failure and rarely causes acute coronary syndrome. This is a case where hypoparathyroidism and hypocalcemia presented as acute coronary syndrome. A 37 year old gentleman presented with angina having ST/T changes, elevated troponin levels and wall motion abnormality on echocardiography. He had non-obstructive coronaries. After correction of the calcium his chest pain subsided. This is a case where hypocalcemia presented as coronary artery spasm and very few cases have been reported due to it.

Ventricular diverticulum is a rare congenital heart defect that is usually found incidentally upon imaging, such as 2-dimensional transthoracic echocardiogram. We report a case in which an isolated right-ventricular diverticulum and a left-ventricular aneurysm were both found on transthoracic echocardiogram in the setting of a pulmonary embolism. This case highlights how to distinguish between an aneurysm and a diverticulum based on wall motion on echocardiogram, as well as potential complications that may arise from either anomaly.

The application of myocardial strain by two-dimensional speckle-tracking to quantify right ventricular (RV) function has recently been endorsed by the American Society of Echocardiography/European Association of Cardiovascular Imaging Joint Industry Task Force, with emphasis on the need for standardization and quality control.1 However, there are no specific recommendations to date for the level of training required for accurate RV strain analysis for independent reporting. Our group has previously demonstrated the existence of a learning curve for left ventricular global longitudinal strain analysis,2 while others have demonstrated similar learning curves for wall motion analysis during stress echocardiography3 and visual estimation of left ventricular ejection fraction.4 The aim of this study was to determine whether there is a learning curve for RV longitudinal strain analysis for novice readers to achieve independent competency in consistency and reproducibility.

New onset regional wall motion abnormality (RWMA) following coronary artery bypass grafting adversely affects the patient outcome. Early detection and addressing the cause of RWMA improves overall morbidity and mortality of the patient. We report a rare case of early myocardial ischemia detected by intraoperative transesophageal echocardiography due to mechanical compression of a vein graft by a pericardial drain tube.

Stress cardiomyopathy, or Takotsubo syndrome, is similar to that of an acute coronary syndrome, with electrocardiographic changes and an increase in troponin levels; however, coronary arteriography typically shows no obstructive lesions. One of the characteristic patterns are regional wall motion abnormalities identified by echocardiography. It has been described in association with thyroid disorders, although the causal mechanism is not clearly established. We present the case of a woman with acute chest pain and electrical and analytical changes. A severe ventricular dysfunction was observed but the coronary tree was free of lesions, all of which was compatible with a stress cardiomyopathy. Hyperthyroidism due to Graves' disease was observed as a trigger. The identification and management of clinical factors that might predispose patients to Takotsubo syndrome or impact on subsequent clinical outcome is mandatory.

Reverse takotsubo cardiomyopathy (rTTC) is a less frequent variant of takotsubo cardiomyopathy (TTC) with several differences about epidemiology and clinical aspects. While left ventricular outflow tract (LVOT) obstruction is relatively frequent in TTC patients, this complication has not been reported in the setting of rTTC yet. We describe the case of a female patient with rTTC complicated by LVOT obstruction and systolic anterior motion of mitral valve: the onset of these findings coincided with the regression of wall motion abnormalities. This dangerous “relay race” seems to be not casual but related to the characteristics of rTTC and should be always expected and prevented.

We report a case of a 64-year-old man suspected of myocardial infarction two months previously. Coronary angiography revealed total occlusion of the left anterior descending (LAD), and left ventriculography (LVG) showed remarkably reduced cardiac function and anterior dyskinesis. Electrocardiogram-gated thallium-201 Single Photon Emission Tomography (TL-SPECT) and (18)F fluorodeoxyglucose positron emission tomography (FDG) were performed separately, and revealed large anterior myocardial infarction with markedly reduced tracer uptake, suggestive of non-viable myocardium. Percutaneous coronary intervention (PCI) was performed and stent was implanted successfully. Six months after PCI, LVG showed remarkable recovery in global function. Significant wall motion improvement and recovered glucose metabolism were observed in the infarcted myocardium despite having previously been diagnosed as lacking viability.

To use adenosine-induced stress CT myocardial perfusion imaging (CT-MPI) to determine normal reference values for left ventricle (LV) wall thickness (WT) and motion parameters.This study included 106 Korean subjects (52 men and 54 women) who underwent CT-MPI due to chest pain, but were not found to have any detectable mild or severe coronary artery disease or myocardial perfusion defect. The following quantitative parameters were assessed on the CT-MPI according to a 17-segment model: LV myocardial thickness at end-systolic (WTSeptal wall (7.2 mm) and basal-level (7.7 mm) LV myocardium demonstrated significantly higher WT (p 0.001). SWT was highest in lateral (77.8%, p 0.014) and apical (78.9%, p = 0.009) myocardium, while lateral (7.7 mm) and basal (6.7 mm) myocardium exhibited the greatest WM (p 0.001). WT was significantly higher in men and younger (60 years) subjects (all, p 0.001). Hypertensive individuals presented with significantly higher SWT (79.9%, p = 0.024). LV WT exhibited statistically significant correlations (all positive, except for age) with age, height, weight, body surface area, body mass index, and systolic blood pressure (all, p 0.010).The present study provides CT-MPI reference values for LV myocardial WT, SWT, and WM measured on an adult Korean population. Knowledge of such normal reference measurements would be beneficial for the efficient interpretation of CT-MPI examinations in populations of Asian ethnicity.

Takotsubo syndrome is a disease of great clinical importance that remains underdiagnosed. It is a form of acute heart failure characterized by a transient wall motion abnormality of the left ventricular apex typically triggered by emotional or physical stress. Takotsubo syndrome is commonly associated with cancer and results in poor outcomes. Therefore, early recognition and prompt therapy are essential to improve prognosis. The aim of this manuscript is to review the consequences of the association between cancer and Takotsubo to summarize the available evidence to guide physicians to improve the management of these patients.

Post myocardial infarction (MI) short and long term clinical outcome is largely determined by the size of the infarcted area. It is generally assumed that as the lead involvement in the 12 lead electrocardiography (ECG) is less in anteroseptal ST segment elevation myocardial infarction (AS-STEMI), where ST segment elevation (STE) is limited to leads V1 to V3, myocardial damage is likely to be less. This study was intended to assess regional wall motion abnormality (RWMA) in acute anteroseptal STEMI patients. 90 patients with AS-STEMI admitted in between October 2012 and September 2013, were included. For each patient, a transthoracic echocardiogram (TTE) was performed within 24-48 hours of MI and was interpreted by an independent investigator blinded to the patient’s ECG data.The mean (± SD) age of the patients was 51.57 (± 12.02) years with mean (± SD) age of the patients was 52.58 (± 12.02) years with a range of 23 - 80 years. There were 91.1% male and 8.9% female. The mean (± SD) EF% was 38.80 %( ± 5.78). All the segments of left ventricle, except basal and mid inferolateral segments, were affected in anteroseptal STEMI. So, the term AS-STEMI may be a misnomer, as it implies that only the anteroseptal segments of the left ventricle are involved. This study shows that regional dysfunction in patients with AS-STEMI extends beyond the anteroseptal region and may be it is as much extensive as extensive anterior myocardial infarction. So, any patients with anterior wall involvement should be treated with utmost importance. University Heart Journal Vol. 15, No. 1, Jan 2019; 28-33

We investigated the influence of the extent of viability using low dose dobutamine wall motion score index (WMS) on the survival benefit of surgical revascularization (CABG) versus medical therapy. In the STICH trial, viability assessment was not helpful in determining the benefit of CABG. However, the extent of viable myocardium with contractile function was not assessed in the trial. Dobutamine echocardiography was performed in 250 patients with ischemic left ventricular dysfunction (125-medically treated, 125-CABG). The mean ejection fraction (EF) was 32% in both groups. WMS during low dose dobutamine infusion was used to classify patients into groups with extensive (WMS

Takotsubo cardiomyopathy is a common disease, but Takotsubo cardiomyopathy complicated by ventricular septal perforation is very rare. We describe the case of a 92-year-old male who had Takotsubo cardiomyopathy complicated by ventricular septal perforation. We treated the patient medically without surgical or catheter interventions. In three weeks, his abnormal wall motion recovered completely, whereas the ventricular septal perforation remained open. He was ambulatory, subsequently discharged, and had been uneventful for one year. In this manuscript, we discuss the importance of non-invasive management for Takotsubo cardiomyopathy complicated by ventricular septal perforation.

Regional wall motion abnormalities (RWMA) are usually described with Ischemic Heart Disease. But many other conditions also show RWMA. What are those conditions, how to recognize RWMA in them and what is it's importance is discussed.

Background and Objective: Coronary artery disease is a significant global health problem and is a leading cause of disability and death. In this study, the effect of coronary artery bypass graft (CABG) surgery on left ventricular (LV) systolic functions and regional wall motion abnormalities in the 1st week and 3rd month after surgery was evaluated through echocardiographic techniques. Patients and Methods: Fifty patients who underwent elective isolated CABG at Azadi Heart Center were included and studied prospectively from November 2018 to May 2019. Transthoracic two-dimensional echocardiography was used to assess the LV-systolic function (LV ejection fraction [LVEF]) and wall motion score index (WMSI) and abnormalities. Results: Almost all patients had chest pain preoperatively, and 32% and 38% of them were in Canadian Cardiovascular Society (CCS) Class III and IV, respectively. Ninety percent had multivessel disease, and the left anterior descending was the most common vessel affected (86%), complete revascularization was done in all patients using 3–6 grafts, and left internal mammary artery was used in 48 patients (96%). There was no significant improvement in LVEF in the early postoperative period (P = 0.28). On the contrary, there was a highly significant improvement of LVEF lately postoperatively, which was improved from (49.62%–56.92%) at (P ≤ 0.001). As well, there was a substantial improvement of WMSI at lately postoperative (P = 0.026) that changed from (1.204 to 1.12). Conclusions: The present study suggests that CABG has a positive effect on LV systolic functions and regional wall motion abnormalities 3-month post-operatively as confirmed through echocardiographic techniques.

Takotsubo cardiomyopathy (TTC) is a syndrome of acute left ventricular dysfunction with a clinical presentation often mimicking acute coronary syndrome. Without a high index of suspicion, this clinical entity often goes unrecognized. Although initially categorized as a benign completely reversible condition, it is no longer considered to be so. Recurrence of this condition, though rare, has been reported in a non-Indian population. We present a case of recurrent TTC in a postmenopausal Indian lady who had a similar clinical presentation both at the index event and at recurrence.

Subarachnoid hemorrhage due to rupture of a pre-existing intracranial aneurysm has quite a poor outcome in spite of intensive medical care. Hemodynamic stress loaded on intracranial arterial walls is considered as a trigger and a regulator of formation and progression of the disease, but how intracranial arterial walls or intracranial aneurysm walls behave under hemodynamic stress loading remains unclear. The purpose of this study was to visualize and analyze the wall motion of intracranial aneurysms to detect a pathological flow condition. We subjected a transgenic rat line, in which endothelial cells are specifically visualized by expression of a green fluorescent protein, to an intracranial aneurysm model and observed a real-time motion of intracranial arterial walls or intracranial aneurysm walls by a multiphoton laser confocal microscopy. The anterior cerebral artery–olfactory artery bifurcation was surgically exposed for the monitoring. First, we observed the proper flow-dependent physiological dilatation of a contralateral intracranial artery in response to increase of blood flow by one side of carotid ligation. Next, we observed intracranial aneurysm lesions induced in a rat model and confirmed that a wall motion of the dome was static, whereas that of the neck was more dynamic in response to pulsation of blood flow. We successfully monitored a real-time motion of intracranial aneurysm walls. Findings obtained from such a real-time imaging will provide us many insights especially about the correlation of mechanical force and the pathogenesis of the disease and greatly promote our understanding of the disease.

Takotsubo cardiomyopathy (TCM) is characterized by transient ventricular dysfunction in the absence of obstructive coronary artery disease that may be triggered by an acute medical illness or intense physical or emotional stress. TCM is often confused with acute myocardial infarction given the similar electrocardiographic changes, cardiac enzymes, hemodynamic perturbations, and myocardial wall motion abnormalities. In the perioperative setting, the clinical picture may be more confusing because of the effect of anesthesia as well as hemodynamic changes related to the surgery itself. However, awareness of various other diagnostic modalities may enable clinicians to distinguish between the two, more systematically and with greater certainty. Despite the large body of literature, there still seems to be an overall paucity in our understanding of the etiopathogenesis, clinical characteristics, natural history, and management of this syndrome, especially in the perioperative setting. This narrative review seeks to present and synthesize the most recent literature on TCM and to identify gaps in current knowledge which can become the basis for future research.