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Purpose: Vasopressin, used as a catecholamine adjunct, is a vasoconstrictor that may be detrimental in some hemodynamic profiles, particularly left ventricular (LV) systolic dysfunction. This study tested the hypothesis that echocardiographic parameters differ between patients with a hemodynamic response after vasopressin initiation and those without a response., Methods: This retrospective, single-center, cross-sectional study included adults with septic shock receiving catecholamines and vasopressin with an echocardiogram performed after shock onset but before vasopressin initiation. Patients were grouped by hemodynamic response, defined as decreased catecholamine dosage with mean arterial pressure ≥ 65 mmHg six hours after vasopressin initiation, with echocardiographic parameters compared. LV systolic dysfunction was defined as LV ejection fraction (LVEF) <45%., Results: Of 129 included patients, 72 (56%) were hemodynamic responders. Hemodynamic responders, versus non-responders, had higher LVEF (61% [55%,68%] vs. 55% [40%,65%]; p = 0.02) and less-frequent LV systolic dysfunction (absolute difference  -16%; 95% CI -30%,-2%). Higher LVEF was associated with higher odds of hemodynamic response (for each LVEF 10%, response OR 1.32; 95% CI 1.04-1.68). Patients with LV systolic dysfunction, versus without LV systolic dysfunction, had higher mortality risk (HR(t) = e [0.81-0.1*t] ; at t = 0, HR 2.24; 95% CI 1.08-4.64)., Conclusions: Pre-drug echocardiographic profiles differed in hemodynamic responders after vasopressin initiation versus non-responders., Competing Interests: Declaration of Competing Interest PC disclosed he received consulting and speaking fees from Philips. All other authors have disclosed that they do not have any conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The implications of left ventricular remodeling and dysfunction before and after aortic valve replacement (AVR) for mixed aortic valve disease (MAVD) are not well understood. This study aims to evaluate the impact of AVR on left ventricular (LV) systolic function in MAVD, and determine the prognostic value of postoperative LV global longitudinal strain (LV-GLS) and LV ejection fraction (LVEF)., Methods: We retrospectively assessed 489 consecutive patients with MAVD (defined as at least moderate aortic stenosis and at least moderate aortic regurgitation) and baseline LVEF ≥50%, who underwent AVR between February 2003 and August 2018. All patients had baseline echocardiography, whereas 192 patients underwent postoperative echocardiography between 3 and 18 months after AVR. The primary endpoint was all-cause mortality., Results: Mean age was 65 ± 15 years, and 65% were male. AVR in MAVD patients has a neutral effect on LV systolic function quantitated by LVEF and LV-GLS. During a median follow-up period of 5.8 years, 65 patients (34%) of 192 patients with follow-up echocardiography died. The patients with postoperative LVEF ≥50% had better survival than those with postoperative LVEF <50% (P < .001). Furthermore, among patients with postoperative LVEF ≥50%, mortality differed between patients with postoperative LV-GLS worse than -15% and those with postoperative LV-GLS better than -15% (P < .001)., Conclusions: In patients with MAVD who underwent AVR, the mean postoperative LV-GLS and LVEF remain at a similar value to baseline. However, worse postoperative LV-GLS and LVEF were both independently associated with higher mortality in this population., (© 2023 Wiley Periodicals LLC.)

Background: Post-systolic shortening index (PSI) is defined as myocardial shortening that occurs after aortic valve closure, and is an emerging measure of regional LV contractile dysfunction. PSI measurement variability amongst software vendor and its relationship with mechanical dyssynchrony and mechanical dispersion index (MDI) remains unknown. We evaluated PSI by speckle-tracking echocardiography from several vendors in patients with increased left ventricular wall thickness, and associations with MDI., Methods: This is a prospective cross-sectional study of 70 patients (36 hypertrophic cardiomyopathy [HCM], 18 cardiac amyloidosis and 16 healthy controls) undergoing clinically indicated echocardiography. PSI was measured using QLAB/aCMQ (Philips), QLAB/LV auto-trace (Philips), EchoPAC (GE), Velocity Vector Imaging (Siemens), and EchoInsight (EPSILON) software packages, and calculated as 100%×(post systolic strain-end-systole strain)/post systolic strain., Results: There was a significant difference in mean PSI among controls 2.1±0.6%, HCM 6.1±2.6% and cardiac amyloidosis 6.8±2.7% (p <0.001). Variations between software vendors were significant in patients with pathologic increases in LV wall thickness (for HCM p = 0.03, for amyloidosis p = 0.008), but not in controls (p = 0.11). Furthermore, there were moderate correlations between PSI and both MDI (r = 0.77) and left ventricular global longitudinal strain (r = 0.69)., Conclusion: PSI was greater in HCM and cardiac amyloidosis patients than controls, and a valuable tool for dyssynchrony evaluation, with moderate correlations to MDI and strain. However, there were significant variations in PSI measurements by software vendor especially in patients with pathological increase in LV wall thickness, suggesting that separate vendor-specific thresholds for abnormal PSI are required., Competing Interests: The authors have declared that no competing interests exist.

Aims: We sought to assess the relationship between left atrial (LA) strain mechanics and exercise intolerance, and to evaluate the prognostic impact of LA strain mechanics on clinical deterioration necessitating septal reduction therapy in hypertrophic cardiomyopathy (HCM)., Methods and Results: Consecutive HCM patients who underwent exercise stress echocardiography and cardiopulmonary exercise testing on the same day between October 2015 and April 2019 were enrolled prospectively. LA strain mechanics were analysed using speckle tracking echocardiography. LA stiffness was calculated as the ratio of E/e' ratio to LA reservoir strain. The study cohort was divided into four groups based on the quartile of percent-predicted peak VO2, and exercise intolerance was defined as the lowest quartile (≤51%). Of 532 patients studied (mean age: 51 ± 15 years, 42% female), 138 patients demonstrated exercise intolerance. As exercise capacity worsened, LA strain mechanics worsened along a continuum (P < 0.001). LA contractile strain with a cut-off of -13.9% was optimal at identifying exercise intolerance. On multivariable analysis, worse LA contractile strain was an independent predictor for exercise intolerance (P = 0.002). Of patients with left ventricular outflow tract obstruction, patients with LA stiffness worse than the median value (≥0.41) were significantly more likely to require septal reduction therapy than those with better LA stiffness (P = 0.026)., Conclusion: Worse LA contractile strain was an independent predictor for exercise intolerance in HCM. Patients with worse LA stiffness had a higher probability of clinical deterioration necessitating septal reduction therapy., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Background: Reversibility of left ventricular (LV) dysfunction in high-risk aortic stenosis patient and its impact on survival after transcatheter aortic valve replacement (TAVR) are unclear. We aimed to evaluate longitudinal changes of LV structure and function after TAVR and their impact on survival., Methods and Results: We studied 209 patients with aortic stenosis who underwent TAVR from May 2006 to December 2012. Echocardiograms were used to calculate LV end-diastolic volume index (LVEDVi), LV ejection fraction, LV mass index (LVMi), and global longitudinal strain before, immediately (<10 days), late (1-3 months), and yearly after TAVR. During a median follow-up of 1345 days, 118 patients died, with 26 dying within 1 year. Global longitudinal strain, LVEDVi, LV ejection fraction, and LVMi improved during follow-up. In patients who died during the first year, death was preceded by LVEDVi and LVMi increase. Multivariable longitudinal data analysis showed that aortic regurgitation at baseline, aortic regurgitation at 30 days, and initial LVEDVi were independent predictors of subsequent LVEDVi. In a joint analysis of longitudinal and survival data, baseline Society of Thoracic Surgeons score was predictive of survival, with no additive effect of longitudinal changes in LVEDVi, LVMi, global longitudinal strain, or LV ejection fraction. Presence of aortic regurgitation at 1 month after TAVR was the only predictor of 1-year survival., Conclusions: LV reverse remodeling was observed after TAVR, whereas lack of LVEDVi and LVMi improvement was observed in patients who died during the first year after TAVR. Post-TAVR, aortic regurgitation blocks reverse remodeling and is associated with poor 1-year survival after TAVR., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

An updated 2016 echocardiographic algorithm for diagnosing left ventricular (LV) diastolic dysfunction (DD) was recently proposed. We aimed to assess the reliability of the 2016 echocardiographic LVDD grading algorithm in predicting elevated LV filling pressure and clinical outcomes compared to the 2009 version., Methods: We retrospectively identified 460 consecutive patients without atrial fibrillation or significant mitral valve disease who underwent transthoracic echocardiography within 24 hours of elective heart catheterization. LV end-diastolic pressure (LVEDP) and the time constant of isovolumic pressure decay (Tau) were determined. The association between DD grading by 2009 LVDD Recommendations and 2016 Recommendations with hemodynamic parameters and all-cause mortality were compared., Results: The 2009 LVDD Recommendations classified 55 patients (12%) as having normal, 132 (29%) as grade 1, 156 (34%) as grade 2, and 117 (25%) as grade 3 DD. Based on 2016 Recommendations, 177 patients (38%) were normal, 50 (11%) were indeterminate, 124 (27%) patients were grade 1, 75 (16%) were grade 2, 26 (6%) were grade 3 DD, and 8 (2%) were cannot determine. The 2016 Recommendations had superior discriminatory accuracy in predicting LVEDP (P<.001) but were not superior in predicting Tau. During median follow-up of 416 days (interquartile range: 5 to 2004 days), 54 patients (12%) died. Significant DD by 2016 Recommendations was associated with higher risk of mortality (P=.039, subdistribution HR1.85 [95% CI, 1.03-3.33]) in multivariable competing risk regression., Conclusions: The grading algorithm proposed by the 2016 LV diastolic dysfunction Recommendations detects elevated LVEDP and poor prognosis better than the 2009 Recommendations., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: With improved survival of patients undergoing primary bioprosthetic aortic valve replacement (AVR), reoperation to relieve severe prosthetic aortic stenosis (PAS) is increasing. Timing of redo surgery in asymptomatic/minimally symptomatic patients remains controversial. Left ventricular (LV) global longitudinal strain (GLS) is a marker of subclinical LV dysfunction. In asymptomatic/minimally symptomatic patients with severe PAS undergoing redo AVR, we sought to determine whether LV-GLS provides incremental prognostic use., Methods and Results: We studied 191 patients with severe bioprosthetic PAS (63±16 years, 58% men) who underwent redo AVR between 2000 and 2012 (excluding mechanical PAS, severe other valve disease transcatheter AVR, and LV ejection fraction <50%). Society of Thoracic Surgeons score was calculated. Standard echocardiography data were obtained. LV-GLS was measured on 2-, 3-, and 4-chamber views using velocity vector imaging. Severe PAS was defined as aortic valve area <0.8 cm 2 , mean aortic valve gradient ≥40 mm Hg, and dimensionless index <0.25. A composite outcome of death and congestive heart failure admission was recorded. At baseline, mean Society of Thoracic Surgeons score, LV ejection fraction, mean aortic valve gradients, and right ventricular systolic pressure were 7±6, 58±6%, 54±10 mm Hg and 40±14 mm Hg, whereas 50% had >2+ aortic regurgitation. Median LV-GLS was -14.2% (-11.4, -17.1%). At 4.2±3 years, 41 (22%) patients met the composite end point (2.5% deaths and 1% strokes at 30 days postoperatively). On multivariable Cox survival analysis, LV-GLS was independently associated with longer-term composite events (hazard ratio, 1.21; 95% confidence interval, 1.10-1.33), P <0.01. The C statistic for the clinical model (Society of Thoracic Surgeons score, degree of aortic regurgitation, and right ventricular systolic pressure) was 0.64 (95% confidence interval 0.54-0.79), P <0.001. Addition of LV-GLS to the clinical model increased the C statistic significantly to 0.71 (95% confidence interval 0.58-0.81), P <0.001., Conclusions: In asymptomatic/minimally symptomatic patients with severe bioprosthetic PAS undergoing redo AVR, baseline LV-GLS provides incremental prognostic use over established predictors and could potentially aid in surgical timing and risk stratification., (© 2017 American Heart Association, Inc.)

Background: Although improvement in left ventricular (LV) function has been shown to portend superior short-term outcomes in patients with heart failure undergoing cardiac resynchronization therapy (CRT), the durability of this effect at 5 years has not been established., Objective: To determine the long-term outcomes of patients undergoing CRT on the basis of the degree of echocardiographic response., Methods: We extracted clinical data on a cohort of 880 consecutive patients undergoing the new implantation of a CRT device between September 30, 2003, and August 6, 2007. Patients with an ejection fraction (EF) ≤35% undergoing initial CRT implantation, with an available pre-CRT and follow-up echocardiogram, were included in the final cohort. On the basis of changes in LVEF, patients were categorized into "nonresponders" (change in EF ≤4%), "responders" (EF change 5%-20%), and "super-responders" (change in EF >20%). A Cox multivariate model was performed to determine the effect of response on long-term survival free of LV assist device or heart transplant., Results: A total of 526 patients met inclusion criteria, of whom 196 (37.3%) were classified as nonresponders, 236 (44.9%) as "responders," and 94 (17.9%) as "super-responders." In multivariate analysis, "super-responders" had the best survival and nonresponders the worst over a mean of follow-up of 5.3 ± 2.4 years. At 5 years, survival free of LV assist device or heart transplant among super-responders was 82%; responders, 70%; and nonresponders, 48%., Conclusions: In patients with heart failure undergoing CRT, survival benefit is durable at 5 years of follow-up and its degree intimately tied to the level of improvement in ventricular function. The prognosis of nonresponders is exceptionally poor., (Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Although not recommended in isolation, visual estimation of echocardiographic ejection fraction (EF) is widely applied to confirm quantitative EF. However, interobserver variability for EF estimation has been reported to be as high as 14%. The aim of this study was to determine whether self-directed education could improve the accuracy and interobserver variability of visual estimation of EF and whether a multireader estimate improves measurement precision., Methods: Thirty-one participants provided single-point EF estimates for 30 echocardiograms with a spectrum of EFs, image quality, and clinical contexts in patients undergoing cardiac magnetic resonance (CMR) within 48 hours. Participants received their own case-by-case variance from CMR EF, and the 10 cases with the largest reader variability were discussed along with corresponding CMR images. Self-directed learning was undertaken by side-by-side review of echocardiographic and CMR images. Two months later, 20 new cases were shown to the same 31 participants, using the same methodology., Results: The baseline interobserver variability of ±0.120 improved to ±0.097 after the intervention. EF misclassification (defined as ±0.05 of CMR EF) was reduced from 56% to 47% (P < .001), and the intervention also resulted in a decrease in the absolute difference between CMR and echocardiography for all cases and all readers (from 0.07 ± 0.01 to 0.06 ± 0.01, P = .0001). This improvement was most prominent for the readers with lower baseline accuracy. A combined physician-sonographer EF estimate improved the precision of EF determination by 25% compared with individual reads., Conclusions: In readers with varying levels of experience, a simple, mostly self-directed intervention modestly decreased interobserver variability and improved the accuracy of EF measurements. Combined physician-sonographer EF reporting improved the precision of EF estimates., (Copyright © 2013 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

We sought to assess the prognostic value of diastolic dysfunction (DD) in low-risk adults beyond Framingham risk score (FRS). Consecutive patients without cardiovascular risk factors or co-morbidities were identified from a retrospective cohort. Multivariate binary logistic regression was performed to identify factors associated with DD, and Cox proportional hazard model to evaluate the association of DD with all-cause death. Analysis was repeated by stratifying by the year of the echocardiogram to account for possible time-related shift in measurement techniques. Net reclassification improvement (NRI) was performed to assess incremental prognostic value of DD. The study cohort consisted on 1,039 patients with a mean age (SD) 47.9 (15.7) years. Overall, 346 patients (33.3 %) had DD, among whom 327 were grade 1. Age was the only independent predictor of DD with odds ratio 3.2 (2.8; 3.7) for every 10 years increase (p < 0.0001). After a mean follow-up time (SD) of 7.3 (1.7) years, 71 (6.8 %) patients died. Adjusting for age, gender, and race, DD remained an independent predictor of all-cause mortality with hazard ratio (95 % CI) 2.03 (p = 0.029), and similarly after adjusting for FRS (HR 2.73, p = 0.002) which resulted in IDI gain of 1.4 % (p = 0.0037) and NRI of 15 % (p = 0.029). In 463 age and gender matched subgroups, DD was still an independent predictor of mortality (HR 2.6 [1.25; 5.55], p = 0.01). In low-risk adult outpatients undergoing echocardiography, DD was associated with 2-3 fold increase in risk of death and had incremental prognostic value beyond FRS.

Measurement of left ventricular (LV) mechanical dyssynchrony from single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) allows optimization of cardiac resynchronization therapy in heart failure patients. We compared the discriminatory ability and reproducibility of a new software method, Corridor 4DM (4DM) to the established method, Emory Cardiac Toolbox (ECTb) in normals and heart failure patients. LV dyssynchrony was measured in 100 control (Group 1) and 100 patients with LVEF <35% (Group 2) using time to peak thickening with first harmonic, fourth harmonic, and volume curve methods with the 4DM software, and compared to ECTb. Of the 3 4DM methods, first harmonic had the best correlation with the ECTb (R = 0.88, slope = 1.00, P < 0.0001, bias = -0.18° [95% CI: -20°; 16°] for phase standard deviation; and similarly for histogram bandwidth, while volume curve analysis had the greatest variation. The intra and inter-observer reproducibility for 4DM time to peak thickening with first harmonic was very good (R = 0.99, P < 0.0001 and coefficient of variability 10% [95% CI 9.2-12%] for intra-observer, and R = 0.97, P < 0.0001, coefficient of variability 16% [15-17%] for inter-observer, respectively). Finally, in patients with LVEF <35%, the area under the curve on receiver operator characteristic analysis was 0.93 [95% CI: 0.89-0.97] to detect significant mechanical dyssynchrony (i.e. standard deviation ≥43°) using 4DM versus ECTb. The 4DM-software provides an accurate and reproducible alternative method of dyssynchrony analysis of SPECT MPI for evaluation and management of heart failure.

Background: Echocardiographic measures of left ventricular (LV) dyssynchrony in pediatric patients with heart failure (HF) have not been adequately evaluated. The aim of this study was to evaluate LV systolic dyssynchrony in pediatric patients with HF and normal children., Methods: Among a total of 68 patients, 22 had HF and 46 were normal. Doppler tissue imaging, M-mode echocardiography, and pulsed-wave Doppler echocardiography were performed. Intraventricular dyssynchrony using the maximal difference in time to peak myocardial systolic contraction (Ts), the standard deviation of Ts of 12 LV segments, septal-to-posterior wall motion delay, and interventricular dyssynchrony by measuring aortic and pulmonary pre-ejection delays were obtained., Results: The maximal difference in Ts (patients with HF, 91.27 ± 31.18 msec; controls, 45.93 ± 21.29 msec; P < .001), the standard deviation of Ts (patients with HF, 31.05 ± 10.68 msec; controls, 15.60 ± 7.70 msec; P < .001), septal-to-posterior wall motion delay (patients with HF, 117.14 ± 45.18 msec; controls, 48.69 ± 16.63 msec; P < .001) and interventricular dyssynchrony (patients with HF, 21.60 ± 16.27 msec; controls, 11.56 ± 9.38 msec; P = .03) were significantly prolonged in the HF group. Defining systolic dyssynchrony as a standard deviation of Ts > 31 msec (+2 standard deviations of normal controls) and a maximal difference in Ts > 89 msec in normal controls and 18 patients with HF due to dilated cardiomyopathy was included for analysis of systolic dyssynchrony; it was present in three (6.5%) and two (4.3%) controls and in nine (50%) and 10 (55%) patients with HF due to dilated cardiomyopathy, respectively. Low ejection fraction, elevated LV end-diastolic volume, and elevated LV end-systolic volume had significant correlations with systolic dyssynchrony. QRS duration was not significantly correlated with measures of dyssynchrony., Conclusions: Systolic mechanical dyssynchrony is common in pediatric patients with HF. QRS duration is not a determinant of systolic dyssynchrony in pediatric patients. Echocardiographic measurements of systolic dyssynchrony are feasible in pediatric patients., (Published by Mosby, Inc.)

Aims: Strain delay index (SDI) allows quantification of the wasted contraction or gain of myocardial contractility expected after cardiac resynchronization therapy (CRT). The present multicentre prospective study aimed to assess the accuracy of the SDI in predicting responses to CRT in real-life patients with wide and narrow (<130 ms) QRS complexes., Methods and Results: Implantation of a CRT device was performed in 235 heart failure patients and echocardiography data were analysable in 80% (n= 189) of patients (age 65 ± 12 years, left ventricular ejection fraction = 26 ± 8%, 63 ischaemic, 51 with narrow QRS complexes). Mechanical dyssynchrony before CRT was quantified by the 12-segment standard deviation of peak longitudinal strain by speckle tracking (12SD-ε, 12 standard deviation of time to peak strain by speckle tracking), and SDI, defined as the sum of difference between end-systolic and peak-ε across the 16 segments. Response to CRT was defined as an end-systolic volume reduction (ESVR) at 6 months >15%. After CRT, ESVR>15% was observed in 60% (n= 114/189) of patients, and was greater in non-ischaemic (68 vs. 44%, P= 0.003) and wide QRS patients (65 vs. 49%, P= 0.04). Correlation between 12SD-ε and ESVR was poor (r = 0.18, P= 0.01). In contrast, SDI correlated with reverse remodelling (r = 0.61, P< 0.0001 for all) in both wide and narrow QRS patients and ischaemic and non-ischaemic patients. Decrease in SDI after CRT was greater in responders and correlated with ESVR. Finally, SDI > 25% identified responders to CRT (positive and negative predictive value of 80 and 84%, respectively) with 6% inter-observer variability., Conclusion: The present multicentre study suggests that SDI may identify responders to CRT in ischaemic and non-ischaemic patients.

Aims: Electrical stimulation [coupled pacing (CP)] applied near the end of the T-wave is able to create a retrograde activation of the atrioventricular (AV) node in turn to prevent rapid ventricular conduction during atrial fibrillation (AF). The impact of this pacing modality associated with cardiac resynchronization therapy (CRT) has been evaluated in the present experimental study., Methods and Results: After inducing AF by rapid pacing in six dogs, we applied the following pacing modalities: rapid right ventricular (RV) pacing, rapid CRT, CRT with an additional RV paced beat (CP) at a specific delay (CRT + CP), and CRT with vagal stimulation (CRT-VS). Left ventricular (LV) pressure recordings and echocardiography for 2D strain analysis were performed. CRT + CP reduced the ventricular response rate and increased the LV systolic pressure and cardiac output compared with CRT alone (136 +/- 6 vs. 86 +/- 13 mmHg, P < 0.05 and 2.0 +/- 0.4 vs.1.2 +/- 0.1, P < 0.05 L/m, respectively). Compared with CRT-VS, CRT + CP increased the LV ejection fraction (LVEF = 51 +/- 10 vs. 28 +/- 4%, P < 0.05), peak global circumferential strain (-17 +/- 2 vs. -11 +/- 3%), and diastolic filling time (49 +/- 6 vs. 28 +/- 3%, P < 0.02) suggesting beneficial effects of CP beyond rate control. CRT + CP did not result in increased dyssynchrony [CRT (8.3 +/- 2%) vs. CRTCP (8.4 +/- 3%, P = NS)]., Conclusion: CRT + CP effectively reduces ventricular contractile rate and leads to an increase in systolic and diastolic performance without inducing mechanical dyssynchrony.

Aims: To elucidate the usefulness of the early diastolic mitral flow propagation velocity (V(p)) obtained from colour M-mode Doppler for non-invasively assessing left-ventricular (LV) relaxation during atrial fibrillation (AF)., Methods and Results: Ten healthy adult dogs were studied to correlate V(p) with the invasive minimum value of the first derivative of LV pressure decay (dP/dt(min)) and the time constant of isovolumic LV pressure decay (tau) at baseline, during rapid and slow AF, and during AF after inducing myocardial infarction. There were significant positive and negative curvilinear relationships between V(p) and dP/dt(min) and tau, respectively, during rapid AF. After slowing the ventricular rate, the average value of V(p) increased, while dP/dt(min) increased and tau decreased. After inducing myocardial infarction, the average value of V(p) decreased, while dP/dt(min) decreased and tau increased., Conclusion: The non-invasively obtained V(p) evaluates LV relaxation even during AF regardless of ventricular rhythm or the presence of pathological changes.

Background: Myocardial dysfunction and left ventricular (LV) geometry deformation may reduce the accuracy of tissue Doppler imaging (TDI) in assessing myocardial contractility., Methods: In 92 patients with heart failure who underwent cardiac resynchronization therapy (CRT), we assessed the impact of LV end-diastolic volume on the accuracy of peak longitudinal velocity (TDI) and strain (epsilon(L) by speckle tracking) to assess regional wall motion and LV dyssynchrony., Results: Peak-epsilon correlated to normal (-13% +/- 6%, n = 259), hypokinetic (-10% +/- 5%, n = 347), and akinetic (-7% +/- 5%, n = 498, P < .0001) wall motion independent of LV size. In contrast, velocity failed to distinguish normal from dysfunctional segments in patients with severe LV dilatation (end-diastolic volume > 250 mL). The 12 standard deviation of time to peak systolic velocity and the opposing septal-lateral wall delay by strain and TDI failed to predict response to CRT, whereas the 12 segment standard deviation of time to peak epsilon correlated to end-systolic volume reduction (r = -0.39, P < .001)., Conclusion: Accuracy of TDI in assessing LV wall regional motion is limited in severely dilated ventricles and probably affects LV dyssynchrony measurement.

Background: Although atrial ventricular (AV) intervals are often optimized at rest in patients receiving cardiac resynchronization therapy (CRT), there are limited data on the impact of exercise on optimal AV interval., Methods: In 15 patients with CRT, AV intervals were serially programmed while patients were supine and at rest, and during exercise with heart rates that averaged 20 and 40 beats per minute above their resting rates. Echocardiographic Doppler images were acquired at each programmed AV interval and each rate. Three independent echocardiographic criteria were retrospectively used to determine each patient's optimal AV interval as a function of exercise-induced increased heart rates: the duration of left ventricular filling, stroke volume, and a clinical assessment of left ventricular function., Results: A negative correlation between the optimal AV interval and heart rate was observed across all patients using all three independent criterion: the maximum left ventricular filling time (slope =-0.77, intercept = 151.9, r = 0.55, P < 0.001), maximum stroke volume (slope =-0.93, intercept = 183.3, r = 0.50, P = 0.002), or the subjective clinical assessment (slope =-1.06, intercept = 182.0, r = 0.72, P < 0.001). Consistent trends were observed between all three parameters for 12 out of the 15 patients., Conclusions: These results suggest that in patients indicated for CRT, rate-adaptive functions may be useful to shorten AV intervals with increased rate, in order to maximize left ventricular filling, stroke volume, and clinical left ventricular function. Further studies are necessary to determine the clinical impact of these rate-adaptive algorithms.

Aims: The aim of this study is to describe the relationship between ventricular mechanical dyssynchrony (VMD) and echocardiographic indices of cardiac remodelling., Methods and Results: We evaluated 219 ambulatory patients with chronic systolic heart failure [left ventricular ejection fraction (LVEF) 40 ms and/or inter-VMD > 38 ms). In our study cohort, 59% of patients had evidence of dyssynchrony (including 44% with intra-VMD and 38% with inter-VMD, and 20% with both). Inter-VMD correlated with QRS width (r = 0.48, P < 0.0001) better than intra-VMD (r = 0.24, P < 0.001). Higher inter-VMD was associated with less restrictive filling patterns (rank sums P = 0.012) and larger left ventricular end-diastolic dimension (LVEDD, rank sums P = 0.020), but intra-VMD values were similar across diastolic stages and LVEDD tertiles., Conclusion: In chronic systolic heart failure, evidence of mechanical dyssynchrony is prevalent but the underlying cardiac structure and performance may influence the degree of inter-VMD more so than intra-VMD. Our data suggest that the extent of inter-VMD is directly related to the degree of dilatation of the heart but inversely to diastolic dysfunction.

Background: In heart failure patients with left ventricular dyssynchrony, contractility in delayed segments does not fully contribute to end-systolic function. We quantified this reserve of contraction related to mechanical dyssynchrony to predict response to cardiac resynchronization therapy by the strain delay index, which was defined as the sum of the difference between peak and end-systolic strain across 16 segments., Methods and Results: In 100 heart failure patients (ejection fraction=26+/-9%, QRS=154+/-29 ms, 94% in New York Heart Association class III), we studied left ventricular dyssynchrony before cardiac resynchronization therapy by the strain delay index using longitudinal strain by 2D speckle tracking and by the SD of time to peak myocardial velocity in 12 segments. The optimal cutoff value of the strain delay index to predict response to cardiac resynchronization therapy was determined in a retrospective group (n=65) and then confirmed in a validation group (n=35). Left ventricular end-systolic volume reduction at 3 months >15% (responder) occurred in 64 of 100 patients. In the retrospective group, the strain delay index but not the SD of time to peak myocardial velocity was greater in responders (n=42/65) than nonresponders (35+/-8% versus 19+/-7%, P<0.0001), and the optimal cutoff value to identify response to cardiac resynchronization therapy was 25%. In the validation group, strain delay index > or =25% identified 82% (18/22) of responders and 92% (12/13) of nonresponders. Among the entire population (n=100), strain delay index correlated with reverse remodeling in both the ischemic (r=-0.68, P<0.0001) and nonischemic (r=-0.68, P<0.0001) population., Conclusions: Use of the strain delay index with longitudinal strain by speckle tracking has a strong predictive value for predicting response to cardiac resynchronization therapy in both ischemic and nonischemic patients.

Echocardiography plays an evolving and important role in the care of heart failure patients treated with biventricular pacing, or cardiac resynchronization therapy (CRT). Numerous recent published reports have utilized echocardiographic techniques to potentially aide in patient selection for CRT prior to implantation and to optimized device settings afterwards. However, no ideal approach has yet been found. This consensus report evaluates the contemporary applications of echocardiography for CRT including relative strengths and technical limitations of several techniques and proposes guidelines regarding current and possible future clinical applications. Principal methods advised to qualify abnormalities in regional ventricular activation, known as dyssynchrony, include longitudinal velocities by color-coded tissue Doppler and the difference in left ventricular to right ventricular ejection using routine pulsed Doppler, or interventricular mechanical delay. Supplemental measures of radial dynamics which may be of additive value include septal-to-posterior wall delay using M-mode in patients with non-ischemic disease with technically high quality data, or using speckle tracking radial strain. A simplified post-CRT screening for atrioventricular optimization using Doppler mitral inflow velocities is also proposed. Since this is rapidly changing field with new information being added frequently, future modification and refinements in approach are anticipated to continue.

Objective: To identify subgroups of heart failure patients who might benefit from biventricular pacing., Background: Cardiac resynchronization therapy (CRT) improves the quality of life, New York Heart Association (NYHA) functional class, and exercise capacity and decreases hospitalizations for heart failure for patients who have severe heart failure and a wide QRS. It is unclear if other populations of heart failure patients would benefit from CRT., Methods: One hundred forty-four consecutive heart failure patients who underwent CRT and completed 3 months of follow-up were reviewed. Demographic, echocardiographic, electrocardiographic, and clinical outcome data were analyzed to assess the relationship of functional class and QRS duration before device implantation to postimplant outcomes., Results: There were 20, 88, and 36 patients in NYHA functional class II, III, and IV, respectively. Thirty-four patients had right ventricular pacing and another 29 patients had a QRS duration < or = 150 ms. Patients who were in NYHA functional class II at baseline had significant improvement in left ventricular ejection fraction and indices of left ventricular remodeling after CRT. Similar significant findings were seen in the subgroup with right ventricular pacing at baseline after CRT. However, in the subgroup with a narrow QRS duration, there were no significant changes in the indices of left ventricular remodeling or in the NYHA functional class and there was a significant increase in the QRS duration. For the study cohort as a whole, an improvement in NYHA functional class after CRT correlated with a significant decrease in adverse clinical outcomes., Conclusions: Heart failure patients who were in NYHA functional class II and those with right ventricular pacing appeared to benefit from CRT.

Background: Mitral regurgitation (MR) is a common complication of ischemic heart disease, and its presence portends adverse outcomes. As the exact mechanisms of ischemic MR are not well defined, we characterized left ventricular global geometry, regional function, and regional myocardial scarring, in addition to mitral valve apparatus geometry, using magnetic resonance imaging (MRI) of ischemic heart disease patients with left ventricular dysfunction and varying degrees of ischemic MR., Methods: Sixty patients with varying degrees of MR (none, mild, moderate, and severe) determined by echocardiography and referred for MRI assessment of ischemic heart disease were included. Left ventricular geometric, functional, and scar measurements in addition to mitral valve geometric measurements were evaluated., Results: Clinical characteristics found to be significant predictors of degree of MR included severity of coronary artery disease (p < 0.05), completeness of myocardial perfusion (p < 0.005), and average systolic blood pressure (p < 0.05). Mitral systolic tenting area (p < 0.0001) in a statistical model with scarring of the anterior-lateral region (p < 0.05) proved to be the most powerful predictor of MR severity (r2 = 0.31). Mitral annular dilatation in the anterior-posterior direction (p < 0.0001) and diminished LV systolic function (p < 0.005) were important determinants of mitral systolic tenting area (r2 = 0.57)., Conclusions: Mitral tenting in combination with regional left ventricular myocardial scarring are important mechanisms to the development of ischemic MR. Surgical annuloplasty addresses mitral tenting, but has little impact on the effect of regional scarring. Moderate-to-severe ischemic MR develops in patients with regional scarring of the anterior-lateral and inferior-posterior regions, and new surgical developments should take this into account.

Cardiac resynchronization therapy improves hemodynamics in selected patients with heart failure. Mechanic asynchrony parameters that may guide patient selection or therapy optimization are still being investigated. A biventricular (BiV) pacemaker was implanted in 34 patients with dilated ischemic, idiopathic, or valvular cardiomyopathy, and a QRS duration of > or =130 milliseconds. Two-dimensional standard and Doppler tissue echocardiography was performed during right ventricular (RV), left ventricular (LV), BiV, and no pacing in a random and blinded manner. LV and BiV pacing increased stroke volume (P <.02 for both) and ejection fraction (P <.001 for both). Regional contractility assessed by displacement, strain rate, and peak systolic strain was improved in some segments (P <.05) during LV and BiV pacing. A homogenization of segmental contractions was observed during LV and BiV pacing as evaluated by net systolic displacement and segmental myocardial performance index. LV and BiV pacing provides benefits that can be quantified by echocardiography.

Background: The extent of myocardial scarring of the left ventricle (LV) is important in patients with chronic ischemic heart disease (CIHD). With delayed-enhancement magnetic resonance imaging (DE-MRI), scarred myocardium (hyper-enhanced) is easily distinguishable from viable (dark) myocardium. This investigation assessed the use of DE-MRI for predicting functional improvement after coronary artery bypass grafting (CABG) in patients with CIHD and significant LV dysfunction., Methods: The patient population (n = 29) with CIHD and LV dysfunction (ejection fraction 28% +/- 10%) underwent both DE-MRI, to delineate scarred regions before revascularization, and echocardiography (Echo), to assess segmental function before and after CABG (interval 188 +/- 57 days). Using a 16-segment model, LV myocardium was semiquantitatively analyzed for scarring based on DE-MRI and for improvements in resting function by pre- and post-CABG Echo., Results: Before CABG, 82% of targeted myocardial segments had abnormal contraction; 78% showed scarring, including 38% with greater than mild amounts (25%-100%). Normal contraction was found in 18% of segments before revascularization; scarred areas were identified in 42%, 84% of which had, at most, minimal amounts (0%-24%). Of segments with pre-CABG dysfunction, 82% with no evidence of scar recovered, compared to only 18% with > or =50% scarring. Amount of hyper-enhancement was a very good indicator of improvement of function, especially at the > or =50%/segment threshold; overall accuracy was 0.74 (95% CI 0.66-0.82, P <.001)., Conclusions: In patients with CIHD and significant LV dysfunction, DE-MRI can predict likelihood of functional improvement after revascularization.

In this study, we sought evidence for an underlying atrial or ventricular myopathy in patients with paroxysmal lone atrial fibrillation using standard echocardiographic parameters in addition to Doppler tissue imaging of mitral annular motion. No impairment in atrial contractile function was found, but there was evidence for impaired diastolic function in these patients.