Search

Nowadays, multiple studies involving over several thousands of patients have established that CT angiography is a highly accurate noninvasive approach for delineation of the presence and severity of coronary atherosclerosis [1–35]. With its high negative predictive value cardiac CT is optimally suited for the evaluation of patients with a low or intermediate risk of coronary disease, allowing the non-invasive exclusion of coronary disease at relatively low cost and risk [36–48]. However, the appropriate radiation dose remains an important issue in cardiac CT. On one hand, a too low radiation dose may result in a high level of image noise and therefore in non-evaluable images. On the other hand, using higher radiation exposure levels may put patients at unnecessary risk of radiation damage [49–58]. Effective strategies to reduce radiation dose, such as prospective gating, ECG-correlated modulation of the tube current, and tube voltage below 100 kV, are becoming more and more available [59–65]. Leschka et al. [61] showed that adjustment of the scan length of CT coronary angiography using the images from calcium scoring instead of the scout was associated with a 16% reduction in radiation dose of dual-source CT coronary angiography. In a large multicenter study of coronary CT angiography in patients with excellent heart rate control, Labounty et al. [62] reported that the use of minimal padding (i.e. additional surrounding X-ray beam on time), was associated with a substantial reduction in radiation dose (from mean 5.7 mSv to mean 2.0 mSv) together with preserved image interpretability. Rogalla et al. [63] showed that the anterior-posterior diameter adapted tube current in dynamic volume CT coronary angiography provided a new simple and practical approach to keep image quality constant by accounting for differences in patient size. Maintaining a constant image quality in CT, independent of patient body habitus, significantly contributed to a substantially improved diagnostic image quality together with a reduced radiation dose for the patient. Blankstein et al. [64] investigated the effective radiation dose and image quality of 100 kV versus 120 kV tube voltage among patients referred for cardiac dual source CT imaging in 294 consecutive patients. They convincingly demonstrated that use of low kV resulted in a substantial reduction of radiation dose without compromising image quality. The effective radiation dose for the 100 and 120 kV scans was 8.5 and 15.4 mSv, respectively. In the recently published PROTECTION II trial, Hausleiter et al. [65] studied 400 non-obese patients undergoing CT angiography with either 100 or 120 kV CT angiography. The study specifically examined the impact of a reduction in tube voltage to 100 kV using 64-slice CT angiography systems from three different manufacturers. It was demonstrated that a further 31% reduction in radiation exposure could be obtained with 100 kV tube voltage settings while image quality was preserved. In the current issue of the International Journal of Cardiovascular Imaging, Zhang et al. [66] prospectively evaluated image quality parameters, contrast volume and radiation dose at the 100 kV tube voltage setting during CT coronary angiography. Interestingly, the authors used a 320-row CT scanner. The authors studied 107 consecutive patients with a heart rate

Assessment of myocardial viability and ischemia continues to be an important issue in patients with coronary artery disease and left ventricular dysfunction [1–10]. In particular in patients following a myocardial infarction and in the evaluation of patients eligible for interventional procedures such as coronary artery bypass grafting (CABG), accurate assessment of myocardial viability remains pivotal [11–14]. To assess myocardial viability, different diagnostic methods are currently performed, such as FDG/PET, MRI, SPECT, and echocardiography [15–28]. In the clinical arena, detection of myocardial viability is predominantly based on the use of nuclear techniques, which show preserved tracer uptake and metabolism in viable myocardium. FDG/PET is considered the reference standard due to its ability to differentiate dysfunctional but viable myocardium from scar formation and normal myocardium [29–38]. In patients with ischemic cardiomyopathy, CABG offers an important therapeutic option but this operative procedure is still associated with a high perioperative mortality. Although previous studies suggest a benefit from revascularization for patients with defined viability by a non-invasive technique [39–44], the role of viability assessment to determine suitability for revascularization in patients with ischemic cardiomyopathy has not yet been defined. In the current issue of the International Journal of Cardiovascular Imaging, Boehm et al. [45] evaluated the hypothesis that the use of PET imaging in the decision-making process for CABG will improve postoperative patient survival. The authors studied 476 patients with ischemic cardiomyopathy (left ventricular ejection fraction

Over the past years, echocardiography has been shown to play a pivotal role in the accurate evaluation of left ventricular function particularly in patients with ischemic heart disease and various manifestations of cardiomyopathy [1]. The ability to rapidly perform bedside echocardiography with Echo-Doppler imaging places this modality in the heart of clinical research to understand cardiac function and to quantify various associated abnormalities. Echocardiography has found a major niche in visualizing left ventricular function in diverse manifestions of cardiomyopathies. For instance, widespread use of echocardiography has contributed to more frequent recognition of takotsubo stress cardiomyopathy [1–3]. Takotsubo cardiomyopathy has recently been recognized in patients with typical signs of acute myocardial infarction mostly due to emotional stress [4]. The disease may mimic an acute coronary syndrome and the acute course can be complicated by heart failure, arrhythmias, dynamic left ventricular outflow tract obstruction, hypotension and death [5]. In these patients the coronary arteries appear normal but they show reversible wall motion abnormalities [6, 7]. In the current issue of the International Journal of Cardiovascular Imaging, Chockaligam et al. [8] nicely reviewed the clinical presentation of takotsubo stress cardiomyopathy and proposed a unified diagnostic algorithm for cardiologists acutely managing this cardiac emergency. Also the pivotal role of echocardiography was emphasized and the nuances of this peculiar acute cardiomyopathy from an echocardiographers’ perspective were put forward. Accurate evaluation by echocardiography may assist in refining the diagnosis of takotsubo cardiomyopathy and to unravel its pathophysiological mechanism. The diagnosis of stress cardiomyopathy appears appropriate when angiography reveals no culprit lesions and left ventricular apical ballooning is typically seen. For example, at first sight, stress cardiomyopathy appears like an evolving left anterior descending infarction with akinesia of the apex, apical anterior wall and septum. At a closer view of the two-dimensional images from the apical four- and two chamber views, typical stress cardiomyopathy manifests as symmetrical regional wall motion abnormalities extending equally into the apical inferior and lateral walls. However, the definitive diagnosis of stress cardiomyopathy is confirmed when echocardiography repeated after few days to weeks shows complete normalization of regional wall motion abnormalities and left ventricular ejection fraction. Interestingly, the authors also revealed that about 25% of patients with stress cardiomyopathy very likely manifest left ventricular outflow tract obstruction. Loading conditions may significantly alter the severity of left ventricular outflow tract obstruction which may be a transient phenomenon. Left ventricular outflow tract obstruction can be precipitated when a small left ventricle develops hypercontractility, especially in the basal segments. This may lead to acute systolic subendocardial wall stress. This left ventricular strain consisting of both the systolic blood pressure and increased wall stress may result in myocardial stunning and cause the acute ballooning syndrome. Also advanced echocardiographic techniques such as tissue Doppler imaging, regional strain imaging and time-volume curves from three-dimensional echo image modeling may offer visually better demonstration of the regional wall motion abnormalities of stress cardiomyopathy with higher diagnostic sensitivity. Lastly, transesophageal echocardiography may provide anatomic details that may direct repair or replacement of the mitral apparatus when significant MR persists after stress cardiomyopathy and left ventricular outflow tract obstruction have resolved. As also mentioned by the authors, magnetic resonance imaging (MRI) has become an important imaging modality in patients with a broad spectrum of cardiomyopathies [2, 9–56], in particular in patients with takotsubo cardiomyopathy [57–61]. In a recent study, the value of MRI has been shown by using its capability of myocardial tissue characterization [57]. At coronary angiography all patients showed normal coronary arteries; four patients had apical ballooning and four patients had midwall- or basal ballooning. MRI was performed at hospital admission and the images were analyzed with commercially available software (QMASS MR Version 6.2.1, Medis, Leiden, the Netherlands). A T2-weighted imaging technique was used and it was found that T2-signal intensity was significantly higher in the dysfunctional segments, potentially indicating the presence of myocardial edema in the affected areas that showed ballooning. In the five patients who had a 2–3 week follow-up MRI scan, there was normalization of the wall motion abnormalities associated with a significant reduction in T2 signal intensity. As a result, it might be of great interest to know the pathophysiological condition of the affected myocardial tissue in the setting of the acute myocardial infarction in patients with stress cardiomyopathy. Both echocardiography- and MRI-derived parameters may therefore be of great significance in the follow-up of these patients as they may show spontaneous recovery of the cardiac abnormalities. To summarize, both echocardiography and MRI have their own specific value in the evaluation of patients with takotsubo cardiomyopathy. Of course, echocardiography, by virtue of its versatility and accessibility, wlll remain the first imaging modality of choice in routine clinical practice.

Cardiac magnetic resonance imaging (CMR) has long been recognized as an accurate and reliable means of evaluating cardiac anatomy and ventricular function. Considerable progress has been made in the field of CMR, providing accurate evaluation of left ventricular function parameters in coronary artery disease, heart failure, hypertrophic cardiomyopathy, and many other cardiac diseases [1–12]. Stress first-pass contrast-enhanced myocardial perfusion CMR can be used to detect subendocardial ischemia and recent studies have demonstrated the high diagnostic accuracy of stress myocardial perfusion CMR for detecting significant coronary artery disease [13–16]. Magnetic resonance angiography has been introduced as a method that can provide visualization of all three major coronary arteries, coronary anomalies, coronary bypasses and the aorta within a single three-dimensional acquisition [17–19]. CMR has become the first choice imaging modality in complex congenital heart disease [20–26], imaging great vessels, and evaluation of therapy such as cardiac resynchronization therapy [27–38]. Over the past years, contrast-enhanced CMR has been used to visualize the transmural extent of myocardial infarction with high spatial resolution [39–45]. Infarcted myocardium appears hyperenhanced compared with normal myocardium when imaged by a late enhancement MRI technique with the use of T1-weighted sequence after injection of gadolinium chelates. Late gadolinium-enhanced CMR can clearly delineate subendocardial infarction and the transmural extent of delayed enhancement potentially predicts functional outcome after revascularization in acute myocardial infarction and chronic ischemic heart disease [46–49]. In the current issue of the International Journal of Cardiovascular Imaging, Husser et al. [50] compared quantitative assessment of contrast CMR with visual analysis in patients with ST-segment elevation myocardial infarction (STEMI) for predicting reduced ejection fraction and major adverse cardiac events such as death, re-infarction, and re-admission for heart failure. The authors studied 192 patients who underwent CMR at 1 week and 6 months after a sustained STEMI. Three quantitative indices (initial slope, maximal signal intensity and contrast delay in first-pass imaging) and two visual perfusion indices (hypo-enhancement in first-pass and microvascular obstruction in late enhancement imaging) were evaluated. Quantification of infarct mass and visual assessment of the extent of transmural necrosis was also performed on the basis of the standard 17-segment model. At 6 months, 69 patients showed reduced ejection fraction; during follow-up of mean 655 days, 20 major adverse cardiac events occurred. Quantification of the perfusion images was very time-consuming and proved not superior to visual perfusion analysis to predict reduced ejection fraction and/or major adverse cardiac events. Similarly, quantification of infarct size was not superior to visual assessment of the extent of transmural necrosis. In multivariate analysis, only visual assessment of extent of transmural necrosis predicted reduced ejection fraction and major adverse cardiac events. The authors concluded that visual analysis of CMR in patients with STEMI is not time-consuming and predicts reduced ejection fraction and major adverse cardiac events comparable to quantitative analysis. The extent of transmural necrosis turned out to be the strongest parameter. The present study is the first to investigate whether a complete quantitative analysis of a post-infarct-CMR study would be more accurate than a complete visual analysis of microvascular perfusion and myocardial necrosis to predict late ejection fraction and major adverse cardiac events in a large group of patients with STEMI. The data confirm previous findings from the same group showing that neither qualitative nor quantitative myocardial perfusion nor time-consuming quantification of infarct mass provides incremental predictive value over visual assessment of transmural necrosis [51–53]. Despite these interesting findings, it should be realized that quantification of perfusion and infarct size offers the potential advantages of being less operator-dependent, more objective, and more accurate. At present, CMR offers several acquisition techniques for precise and highly reproducible assessment of global and regional ventricular function, flow, and perfusion at rest and under pharmacological or physical stress conditions [54–56]. Moreover, CMR allows quantification of blood flow over the valves, and automatic vessel wall contour detection and quantification of wall thickness of in-vivo MR images of the human aorta [57–59]. Recent advances in hardware and software have resulted in strong improvement of image quality and in a significant decrease in the required imaging time for each of these acquisitions. However, quantitative image analysis often still relies on manual tracing of contours in the images, being indeed time-consuming thereby limiting the clinical applicability of CMR for routine analysis. Methods for automated and robust assessment of the parameters of cardiac function, blood flow and morphology, are still being developed to overcome the limitations associated with manual image processing [60]. Until these issues are fully solved, the present study clearly indicates that, for prediction of late cardiac events in patients with STEMI, a comprehensive visual approach may suffice in routine clinical practice.

Cardiac resynchronization therapy (CRT) has shown to be an effective treatment for patients with advanced heart failure (HF) (NYHA Class III or IV), reduced left ventricular ejection fraction (LVEF 120 ms) [1, 2]. The beneficial effects include improvement in heart failure symptoms, exercise capacity, and left ventricular function, as well as less heart failure hospitalizations and lower mortality rates. Despite these remarkable results, 30–40% of patients show no benefit after CRT, the so-called ‘non-responders’ [3–5]. It remains, however, difficult to distinguish responders from non-responders in the early period after CRT. The presence of LV dyssynchrony prior to implantation and its subsequent reduction after implantation are proposed as the key mechanisms for response to CRT [5, 6]. A variety of imaging modalities has already been applied to identify dyssynchrony and to evaluate the effects of CRT [7–10]. The use of echocardiography [11–17], magnetic resonance imaging (MRI) [18–29], and multislice computed tomography (MSCT) [30–43] has recently been proven for patients eligible for CRT. In addition, nuclear imaging techniques have become suited for the evaluation of LV dyssynchrony [44–51]. Until now, scintigraphic studies in CRT mainly concerned radionuclide angiography with phase image analysis [52–55]. In recent years positron emission tomography (PET) has emerged as a suitable modality to study the metabolic mechanisms of left ventricular dyssynchrony and the effects of CRT [56]. It has been reported that dyssynchrony influences regional myocardial workload, cardiac efficiency and oxygen metabolism as measured by carbon-11 (11C)-acetate PET. Several studies did already report that 11C-acetate PET performed in the chronic phase after CRT showed improvement of oxygen metabolism and cardiac efficiency by CRT [57, 58]. However, there are no data regarding the value of 11C-acetate PET to predict responses to CRT in the acute phase after treatment. In the current issue in the International Journal of Cardiovascular Imaging, Kitaizumi et al. [59] examined the usefulness of 11C-acetate PET for assessing the early efficacy of CRT in 20 patients with severe heart failure. All patients underwent 11C-acetate PET imaging within 1 week after CRT. Oxygen consumption was measured by the mono-exponential clearance rate of 11C-acetate for both the patient’s own beats (CRT off) and biventricular pacing (CRT-on). Plasma brain natriuretic peptide (BNP) levels were measured at 1, 3 and 12 months after installment of CRT. Oxygen consumption was measured by the mono-exponential clearance rate of 11C-acetate (Kmono) for both CRT-off and CRT-on. Cardiac efficiency was determined using the work metabolic index (WMI), which was calculated as WMI = (stroke volume index) × (systolic blood pressure) × (heart rate)/Kmono. Two groups of patients were discerned: 14 patients with improved cardiac efficiency and six patients with deteriorated cardiac efficiency by CRT-on. The mono-exponential clearance rate of 11C-acetate decreased significantly by CRT-on in the improved cardiac efficiency group, but increased in the deteriorated- cardiac efficiency group. At 1-year follow-up, there were significantly higher rates of major cardiac adverse events in the deteriorated cardiac efficiency group than in the improved-cardiac efficiency group. Consequently, the decrease in oxygen consumption in the early period after CRT is a useful marker for predicting a good clinical outcome after CRT. The most impressive result of the study was that the patients with improved cardiac efficiency showed decreased oxygen consumption indicating improved oxidative metabolism with no changes in hemodynamic parameters in the early period after CRT. The authors concluded that improvement of cardiac efficiency, as assessed by 11C-acetate PET in the early period after CRT, was produced by the decrease in oxygen consumption in patients showing good responses to CRT. There are several caveats to the study, already recognized by the authors. Because of the relatively small population studied (20 patients), the authors were not able to address differences between non-ischemic (NICM) and ischemic (ICM) patients. These differences might be of importance, since Lindner et al. [60] showed that in patients with NICM CRT induces changes of myocardial oxygen consumption and myocardial blood flow on a regional level with a more uniform distribution between the myocardial walls and improved ventricular efficiency than in patients with ICM. Therefore, CRT might to be more effective in NICM than in ICM patients. Marsan et al. [61] questioned whether sequential biventricular pacing provides substantial benefits over conventional simultaneous stimulation, particularly regarding the differences between ICM and NICM patients. It was found that optimized sequential biventricular pacing further increased left ventricular systolic performance as compared to simultaneous stimulation; this finding held in particular for ICM patients where the presence of a large scar was correlated with a larger left ventricular pre-activation. So, ICIM and NICM patients should be separately considered in the evaluation of the effects of CRT therapy. Next, the PET studies were performed only once in the early period after CRT and not in the chronic phase. Comparison of PET data between acute and chronic phases may have more clearly shown the clinical use of PET to predict patient responses to CRT. However, the present results provide new information by showing that improved cardiac efficiency due to decreased oxygen metabolism may predict the improvement of cardiac function assessed by plasma BNP levels as well as predicting major adverse cardiac events after CRT. To summarize, the study by Kitaizumi et al. [59] clearly shows that improvement of cardiac efficiency assessed by 11C-acetate PET in the early period after CRT is caused by a decrease in oxygen consumption in patients who showed an adequate response to CRT. The decrease in oxygen consumption assessed by PET in the early period after CRT is therefore a potential marker to predict improvement of cardiac function and major cardiac events during the first year of follow-up. More metabolic cardiac studies are needed to unravel the basic mechanisms of left ventricular dyssynchrony in order to install the most appropriate therapy [62, 63].

Cardiac magnetic resonance imaging (CMR) is an accurate and reliable means of evaluating cardiac morphology, ventricular function, and myocardial perfusion, both for the left and the right ventricle thereby covering a whole spectrum of cardiac diseases. 1 CMR is therefore very well suited for identifying and characterising patients with various manifestations of left ventricular hypertrophy (LVH).

Amongst the advanced cardiac imaging modalities, computed tomography (CT) angiography has emerged as a reliable non-invasive method for the assessment of coronary artery disease (CAD), coronary anatomy and cardiac function [1–17]. Multiple studies involving over several thousands of patients have established that CT angiography is highly accurate for delineation of the presence and severity of coronary atherosclerosis [18–23]. CT angiography may also reveal the total plaque burden, i.e. both calcified and non-calcified components, for individual patients with coronary atherosclerosis [24–35]. Coronary calcification is a marker of atherosclerosis that can be quantified with the use of cardiac CT and it is proportional to the extent and severity of atherosclerotic disease. Several large clinical trials found true incremental predictive value of coronary artery calcium over the Framingham risk score (FRS) when used in asymptomatic patients [36–40]. This relevant prognostic information may be used to initiate or intensify appropriate treatment strategies to slow the progression of atherosclerotic vascular disease. Current data suggests intermediate risk patients may benefit most from further risk stratification with cardiac CT, as coronary artery calcium testing is effective at identifying increased risk. Consequently, there is nowadays sufficient evidence that coronary artery calcium may be considered as useful predictor of coronary artery disease in certain at risk populations such as patients with diabetes, hypertension and in elderly patients [41–43]. Vascular dysfunction is generally considered a key initial event in the atherosclerotic process which is a systemic disorder local manifestation. Functional changes in arteries precede the development of structural changes and also reverse more quickly in response to therapies [44]. Fingertip digital thermal monitoring (DTM) of vascular reactivity is a new non-invasive, operator-independent approach based on changes in fingertip temperature during and after arm cuff occlusion. DTM of vascular function during cuff-occlusive reactive hyperemia relies on the premise that changes in fingertip temperature during and after an ischemic stimulus reflect changes in blood flow. Vascular dysfunction measured by DTM has been shown to strongly correlate with FRS and coronary artery calcium independent of age, sex, and traditional cardiac risk factors and was superior to FRS for the prediction of significant coronary artery calcium [45]. In a previous issue of the International Journal of Cardiovascular Imaging Ahmadi et al. [46] evaluated the correlation between DTM and CAD measured by CT angiography in 129 symptomatic patients. The authors investigated the correlation between CT angiography and neurovascular reactivity measured by DTM. All DTM indices of vascular and neurovascular reactivity significantly decreased from normal to non-obstructive to obstructive CAD. Coronary artery calcium increased in each FRS category as vascular dysfunction increased. The most extensive CAD was observed in the group with maximum calcium score and vascular dysfunction, independent of age, gender and traditional cardiovascular risk factors. The authors concluded that vascular dysfunction measured by DTM provided incremental value over FRS for the detection of obstructive and non-obstructive CAD at CT angiography. Previous studies from the same group had already shown strong correlations between low fingertip temperature rebound measured by DTM during a 5-minute arm-cuff induced reactive hyperemia and both the FRS, and coronary artery calcification in asymptomatic populations [47]. In another study, Amahdi et al. [48] did already demonstrate that vascular dysfunction measured by DTM was associated with the extent of myocardial perfusion defect independent of age, gender, and cardiac risk factors. Although large prospective trials are needed to establish the true clinical value of fingertip DTM, the clinical implications are very promising. Patients at risk for CAD, such as patients with hypertension, metabolic syndrome and diabetes mellitus can be easily and noninvasively investigated with the patient-friendly fingertip DTM [49]. In these patients it is of paramount importance to measure and know the status of their vascular function. Fingertip DTM will also allow the evaluation of the effects of pharmacological drugs that influence vascular function. The current study by Ahmadi et al. [46] extends therefore previous findings that fingertip DTM is potentially valuable in the evaluation of at risk individuals in addition to risk factor measurement.

Background To assess the relationship between improved regional and global myocardial function in patients with ischemic cardiomyopathy in response to β-blocker therapy or revascularization. Materials and methods Cardiovascular Magnetic Resonance (CMR) was performed in 32 patients with ischemic cardiomyopathy before and 8 ± 2 months after therapy. Patients were assigned clinically to β-blocker therapy (n = 20) or revascularization (n = 12). CMR at baseline was performed to assess regional and global LV function at rest and under low-dose dobutamine. Wall thickening was analyzed in dysfunctional, adjacent, and remote segments. Follow-up CMR included rest function evaluation. Results Augmentation of wall thickening during dobutamine at baseline was similar in dysfunctional, adjacent and remote segments in both patient groups. Therefore, baseline characteristics were similar for both patient groups. In both patient groups resting LV ejection fraction and end-systolic volume improved significantly (p < 0.05) at follow-up. Stepwise multivariate analysis revealed that improvement in global LV ejection fraction in the β-blocker treated patients was significantly related to improved function of remote myocardium (p < 0.05), whereas in the revascularized patients improved function in dysfunctional and adjacent segments was more pronounced (p < 0.05). Conclusion In patients with chronic ischemic LV dysfunction, β-Blocker therapy or revascularization resulted in a similar improvement of global systolic LV function. However, after β-blocker therapy, improved global systolic function was mainly related to improved contraction of remote myocardium, whereas after revascularization the dysfunctional and adjacent regions contributed predominantly to the improved global systolic function.

Over the past years, myocardial perfusion imaging has been established as the reference standard for prognosis and clinical decision making of patients with coronary artery disease (CAD). Myocardial perfusion has predominantly been assessed by single photon emission tomography (SPECT) [1–7] and, more recently, by positron emission tomography (PET) and magnetic resonance imaging (MRI) [8–16]. Amongst the advanced cardiac imaging modalities, multi detector computed tomography (CT) angiography has emerged as a reliable non-invasive method for the assessment of coronary anatomy, CAD, and cardiac function [17–22]. Multiple studies involving over several thousands of patients have established that CT angiography is highly accurate for delineation of the presence and severity of coronary atherosclerosis [23–30]. CT angiography may also reveal the total plaque burden, i.e. both calcified and non-calcified components, for individual patients with coronary atherosclerosis [31–40]. The advent of prospectively gated acquisition techniques for 64-slice CT angiography has allowed a significant reduction in dose exposure. Consequently, a combined approach of CT coronary angiography and myocardial perfusion imaging with CT angiography might potentially become feasible at a total radiation dose of less than 10 mSv, particularly for the assessment of patients with established CAD, who are likely to have diffuse calcification [40–47]. Since myocardial perfusion by CT angiography is based on myocardial signal density, it is crucial to determine the normal values of myocardial signal density and to identify potential mechanisms of misinterpretation of perfusion defects. In routine CT angiography acquisitions, there might be a considerable signal density drop at the posterobasal wall resembling perfusion defects possibly being attributed to beam hardening artifacts. In the current issue of the International Journal of Cardiovascular Imaging Rodriguez-Granillo et al. [48] investigated normal myocardial signal density levels during CT angiography and evaluated the impact of artifacts due to beam hardening. A group of 36 consecutive asymptomatic patients with a low probability of CAD were referred for CT angiography because of inconclusive or discordant functional tests. Perfusion defects were defined as a myocardial segment having a signal density two standard deviations below the average myocardial signal density for the 16 left ventricular American Heart Association (AHA) segments. Signal density was evaluated in 576 American Heart Association (AHA) segments and 36 posterobasal segments. The mean myocardial signal density at the posterobasal segment was 53.5 ± 35.1 Hounsfield Units, whereas the mean myocardial signal density at the basal, mid and apical myocardium was 97.4 ± 17.3 Hounsfield Units, with significant differences between posterobasal and all AHA segments. Posterobasal perfusion defects were identified in 26 (72%) patients. The only variable associated to the presence of posterobasal perfusion defect was heart rate, whereas body mass index, blood signal density of the left and right ventricles, contrast-to-noise ratio, and the extent of atherosclerosis were not related to the presence of perfusion defects. The main findings of the study were that (1) beam hardening artifacts are a common finding at CT angiography of asymptomatic patients affecting predominantly the posterobasal wall, (2) perfusion defects at the short axis plane including the mitral valve and the left ventricular outflow tract are not related to technical issues whereas heart rate may be associated with this finding, (3) perfusion defects can be also identified at the inferior and anteroapical segments but this occurs less often. Occurrence of attenuation artifacts during radionuclide SPECT perfusion imaging has been considered an important limitation of the technique [49–51]. Apical thinning due to the overlying diaphragm and the occurrence of anteroseptal defects as a result of breast attenuation are very common causes for unwanted perfusion deficits, leading to image misinterpretation and potentially a wrong diagnosis. The present study [48] indicates that perfusion artifacts also occur at CT perfusion angiography and could therefore be a reason for misinterpretation. These perfusion defects can largely be ascribed to beam hardening artifacts most likely from the spine for posterobasal segments and from the sternum for anteroapical segments. In radionuclide myocardial perfusion SPECT imaging, successful attenuation correction programs have been developed in order to discriminate between true and false perfusion defects [52–55]. Similarly, correction algorithms are currently being designed for CT angiography with the same purpose. Recently, So et al. [56] designed phantoms to simulate the beam hardening artifacts encountered in cardiac CT perfusion studies of humans and animals. These phantoms were used to investigate whether beam hardening artifacts could be reduced with this approach and to determine the optimal settings of the correction algorithm for patient and animal studies, which depend upon the anatomy of the scanned subject. The correction algorithm was also applied to correct beam hardening in a clinical study to further demonstrate the effectiveness of this technique. To summarize, the study by Rodriguez-Granillo et al. [48] convincingly shows that in an asymptomatic population with no history of CAD, who undergo CT perfusion angiography, artifacts in the posterobasal wall are a common finding in more than two-thirds of patients. This phenomenon of pseudo-perfusion defects may considerably affect proper image interpretation and should be taken into account in the judgment of CT perfusion images. In the near future, correction algorithms for CT perfusion angiography will assist in identifying the true nature of the defects in order to establish the correct diagnosis.

To assess whether multislice computed tomography coronary angiography (MSCTA) may be useful for risk stratification of patients with suspected coronary artery disease (CAD) at intermediate pretest likelihood according to Diamond and Forrester.MSCTA images were evaluated for the presence of significant CAD in 316 patients with suspected CAD (60% male, average (SD) age 57 (11) years) and an intermediate pretest likelihood according to Diamond and Forrester. Patients were followed up to determine the occurrence of an event.A combined end point of all-cause mortality, non-fatal infarction and unstable angina requiring revascularisation.Significant CAD was seen in 89 patients (28%), whereas normal MSCTA or non-significant CAD was seen in the remaining 227 (72%) patients. During follow-up (median 621 days (25-75th centile 408-835) an event occurred in 13 patients (4.8%). The annualised event rate was 0.8% in patients with normal MSCT, 2.2% in patients with non-significant CAD and 6.5% in patients with significant CAD. Moreover, MSCTA remained a significant predictor (p0.05) of events after multivariate correction (hazard ratio = 3.460 (95% CI 1.142 to 10.480).The results suggest that in patients with an intermediate pretest likelihood, MSCTA is highly effective in re-stratifying patients into either a low or high post-test risk group. These results further emphasise the usefulness of non-invasive imaging with MSCTA in this patient population.

In recent years, multi-slice computed tomography (MSCT) technology has developed rapidly, allowing high-resolution non-invasive imaging of the coronary arteries and surrounding structures. Since the introduction of MSCT, acquisition time, detector number, spatial and temporal resolution have continuously improved with each new scanner generation, resulting in excellent image quality and diagnostic accuracy in the detection of coronary artery disease (CAD). At the same time, developments in MSCT technology have focused on reduction of the radiation dose. In particular, the availability of dose modulation and prospective ECG gating have drastically reduced patient radiation dose. Moreover, with the introduction of 320-slice MSCT, volumetric scanning of the entire heart has become possible in a single heart beat or gantry rotation, thereby eliminating oversampling and stair-step artifact. The present article provides an overview of state of the art clinical applications of cardiac MSCT, including the diagnosis of CAD, evaluation of plaque morphology and composition, prognostification, and the evaluation of left ventricular function and aortic and mitral valve anatomy. (Heart, Lung and Circulation 2010;19:107-116) (C) 2009 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.

A 43-year-old man with type 2 diabetes mellitus was referred for cardiovascular risk assessment 2 years ago. Other risk factors for coronary artery disease included hypercholesterolemia, smoking, and a family history of coronary artery disease. The patient was asymptomatic. Physical examination was unremarkable; his body mass index was 22 kg/m2 and his blood pressure was 125/80 mm Hg. Hypercholesterolemia was well regulated with statin administration (total cholesterol 3.52 mmol/L, low-density lipoprotein cholesterol 2.23 mmol/L, high-density lipoprotein cholesterol 0.94 mmol/L). ECG showed normal sinus rhythm and no additional abnormalities (Figure 1). Figure 1. ECG showing sinus rhythm and no abnormalities. Myocardial perfusion imaging was performed with gated single-photon emission computed tomography (SPECT) using technetium-99m sestamibi (500 MBq). Pharmacological stress was induced with adenosine; the stress ECG showed no abnormalities. On gated SPECT, left ventricular ejection fraction was 68% during stress as well as at rest; myocardial perfusion imaging revealed no perfusion abnormalities during stress or at rest (Figure 2). Figure 2. SPECT myocardial perfusion imaging reveals normal perfusion at stress …

This position statement was prepared by the European Council of Nuclear Cardiology and summarises the current and future potential of PET as a clinical cardiovascular diagnostic imaging tool. The first section describes how methodological developments have positively influenced the transition of PET from a research tool towards a clinical diagnostic test. In the second section, evidence in support of its superior diagnostic accuracy, its value to guide decision making and to predict outcome and its cost effectiveness is summarised. The third section finally outlines new PET-based approaches and concepts, which will likely influence clinical cardiovascular medicine in the future. The notion that integration of cardiac PET into healthcare systems and disease management algorithms will advance quality of care is increasingly supported by the literature highlighted in this statement.

Tissue Doppler imaging is a recently introduced echocardiographic tool for measuring myocardial velocities. In this article the physical principles and different myocardial velocity imaging modalities are discussed. Examples of practical applications and clinical use of this non-invasive imaging technique are provided.

To evaluate the effect of bone marrow cell injection on global strain and left ventricular (LV) dyssynchrony.In 14 patients with severe postinfarction heart failure, 93 (14) x 10(6) autologous bone marrow cells were percutaneously injected in the infarction border zone. LV ejection fraction (LVEF), LV dyssynchrony and echocardiographic global strain were assessed at baseline and 3 months in patients and in a non-randomised control group of 10 patients with a history of infarction who developed heart failure and were treated medically.No periprocedural complications occurred during bone marrow cell injection. At 3 months mean (SD) LVEF increased from 23 (8)% to 27 (9)% (p = 0.02) and global strain improved from -7.7 (4.7)% to -8.5 (4.9)% (p = 0.04). In patients withor =5% improvement in LVEF after bone marrow cell injection, global strain improved from -8.7 (4.6)% to -10.6 (4.5)% (p0.01). Global strain remained unchanged in patients with5% improvement in LVEF (-6.6 (4.9)% vs -6.4 (4.5)%, p = NS). The relation between the increase in LVEF and improvement in global strain was significant (r = 0.84, p0.01). In patients withor =5% improvement in LVEF, LV dyssynchrony decreased from 173 (64) ms to 116 (64) ms (p = 0.01). In patients with5% improvement in LVEF, LV dyssynchrony remained unchanged (155 (67) ms vs 177 (81) ms, p = NS). The correlation between improvement in LVEF and reduction in LV dyssynchrony was good (r = -0.77, p0.01). In the control group, LVEF, global strain and LV dyssynchrony did not improve.Bone marrow cell injection improves LVEF in patients with severe postinfarction heart failure. The improvement in LVEF was related to reduced LV dyssynchrony and increased global strain.

Radionuclide imaging of cardiac function represents a number of well-validated techniques for accurate determination of right (RV) and left ventricular (LV) ejection fraction (EF) and LV volumes. These first European guidelines give recommendations for how and when to use first-pass and equilibrium radionuclide ventriculography, gated myocardial perfusion scintigraphy, gated PET, and studies with non-imaging devices for the evaluation of cardiac function. The items covered are presented in 11 sections: clinical indications, radiopharmaceuticals and dosimetry, study acquisition, RV EF, LV EF, LV volumes, LV regional function, LV diastolic function, reports and image display and reference values from the literature of RVEF, LVEF and LV volumes. If specific recommendations given cannot be based on evidence from original, scientific studies, referral is given to "prevailing or general consensus". The guidelines are designed to assist in the practice of referral to, performance, interpretation and reporting of nuclear cardiology studies for the evaluation of cardiac performance.

Aims Cardiac morbidity and mortality is high in patients undergoing high-risk surgery. This study investigated whether impaired glucose regulation and elevated glycated haemoglobin (HbA(1c)) levels are associated with increased cardiac ischaemic events in vascular surgery patients. Methods Baseline glucose and HbA(1c) were measured in 401 vascular surgery patients. Glucose < 5.6 mmol/l was defined as normal. Fasting glucose 5.6-7.0 mmol/l or random glucose 5.6-11.1 mmol/l was defined as impaired glucose regulation. Fasting glucose >= 7.0 or random glucose >= 11.1 mmol/l was defined as diabetes. Perioperative ischaemia was identified by 72-h Holter monitoring. Troponin T was measured on days 1, 3 and 7 and before discharge. Cardiac death or Q-wave myocardial infarction was noted at 30-day and longer-term follow-up (mean 2.5 years). Results Mean (+/- SD) level for glucose was 6.3 +/- 2.3 mmol/l and for HbA(1c) 6.2 +/- 1.3%. Ischaemia, troponin release, 30-day and long-term cardiac events occurred in 27, 22, 6 and 17%, respectively. Using subjects with normal glucose levels as the reference category, multivariate analysis revealed that patients with impaired glucose regulation and diabetes were at 2.2- and 2.6-fold increased risk of ischaemia, 3.8- and 3.9-fold for troponin release, 4.3- and 4.8-fold for 30-day cardiac events and 1.9- and 3.1-fold for long-term cardiac events. Patients with HbA(1c) > 7.0% (n = 63, 16%) were at 2.8-fold, 2.1-fold, 5.3-fold and 5.6-fold increased risk for ischaemia, troponin release, 30-day and long-term cardiac events, respectively. Conclusions Impaired glucose regulation and elevated HbA(1c) are risk factors for cardiac ischaemic events in vascular surgery patients.

Several two-dimensional (2-D) tissue Doppler imaging (TDI) echocardiographic techniques have proved useful to identify responders to cardiac resynchronisation therapy (CRT). Recently a 3-D probe allowing simultaneous acquisition of TDI data in three imaging planes became available.To evaluate the value of triplane TDI to predict reverse left ventricular (LV) remodelling after CRT.Sixty patients with heart failure, scheduled for CRT, underwent triplane echocardiography with simultaneous TDI acquisition before and 6 months after implantation. From the triplane dataset a 3-D LV volume was generated and LV volumes and ejection fraction were calculated. Intraventricular dyssynchrony was quantitatively analysed by evaluating time from onset of the QRS complex to peak myocardial systolic velocity in 12 LV segments from the triplane dataset and calculation of the standard deviation (Ts-SD-12). Clinical response was defined as an improvement of at least one New York Heart Association class. Reverse LV remodelling was defined as/=15% decrease of LV end-systolic volume at 6 months' follow-up.Responders to CRT had significantly more LV dyssynchrony at baseline than non-responders (mean (SD) Ts-SD-12: 42 (14) vs 22 (12), p0.001). A cut-off value of 33 ms for baseline Ts-SD-12, acquired from the triplane TDI dataset, yielded a sensitivity of 89% with a specificity of 82% to predict clinical response to CRT; sensitivity and specificity to predict reverse LV remodelling were 90% and 83%, respectively.Triplane TDI echocardiography predicts clinical response and reverse LV remodelling 6 months after CRT implantation.

Accurate and early detection of coronary artery disease (CAD) is essential, as the disease remains one of the leading causes of death in the industrialised world. For this purpose, several invasive as well as noninvasive modalities are available. The current gold standard to detect significant narrowing of the coronary arteries is invasive coronary angiography, which allows direct visualisation of the coronary arteries with high spatial and temporal resolution. In addition, if abnormalities are demonstrated, direct intervention is possible. However, it is also an invasive technique that is associated with substantial patient discomfort, costs and a small but distinct risk of potentially life-threatening complications.

OBJECTIVE. The objective of our study was to validate using MDCT for the assessment of right ventricular (RV) function. MDCT with retrospective ECG gating was performed in 15 patients being evaluated for suspected cardiovascular disease. Echocardiography was performed for comparison. The MDCT images were reconstructed at 20 phase points over the cardiac cycle. The end-diastolic and end-systolic volumes of both ventricles were measured. Stroke volumes and ejection fractions were calculated from these data.CONCLUSION. RV volumes can be accurately assessed using MDCT.

In recent years, multi-slice computed tomography (MSCT) has emerged as a rapidly expanding modality for non-invasive assessment of coronary artery disease. Simultaneously, left ventricular (LV) function can be evaluated although this is not yet a routine component of an MSCT examination. Accordingly, the purpose of the present study was to validate assessment of LV function with MSCT using 2D-echocardiography in a large cohort of patients.In 70 patients (57 male, 13 female), 16-slice MSCT was performed (Toshiba Aquilion 16, Japan) followed by retrospective analysis of global LV function. For these measurements, 2D-echocardiography served as the standard of reference.For LV volumes, excellent correlations for both end-diastolic volume (EDV) (r=0.97) and end-systolic volume (ESV) (r=0.98) were obtained by linear regression analysis. At Bland-Altman analysis, mean differences (+/-standard deviations) of -1.4 ml+/-11.3 ml and -3.0 ml+/-7.7 ml were observed between MSCT and 2D-echocardiography for LV EDV and LV ESV respectively. As a result, LV EF was slightly overestimated with MSCT (1.7%+/-4.9%, P0.05). Correlation between the two techniques was excellent (r=0.91).In a large cohort of patients, an excellent correlation was observed between 16-slice MSCT and 2D-echocardiography in the evaluation of LV volumes and EF. The addition of LV function analysis to the anatomical MSCT data may potentially enhance the diagnostic and prognostic value of the technique.

Heart failure has become a major problem in clinical cardiology, with recent estimations showing that 4.9 million patients in the USA have chronic heart failure, with 550 000 new patients diagnosed annually, resulting in 970 000 hospitalisations.1 It appears that coronary artery disease is the underlying cause of heart failure in > 70% of patients.1 The available therapeutic options include optimised medical treatment, heart transplantation, revascularisation (with optional left ventricular (LV) restoration and/or mitral valve repair) and cardiac resynchronisation therapy. Currently, substantial effort is invested in the development of gene and cell therapy for treatment of heart failure. In daily clinical practice, the choice is frequently between medical treatment and revascularisation. From this perspective, assessment of viability is important to guide management of patients with ischaemic LV dysfunction; patients with viable myocardium may improve in LV function after revascularisation, whereas patients with only scar tissue will not improve. In view of the increased risk for (peri-) operative complications, a pre-operative evaluation for myocardial viability is thus warranted, to select the patients who may benefit from surgery. Currently, many techniques are available for identification of dysfunctional but viable myocardium.w1 The most frequently used techniques in the clinical setting include nuclear imaging with positron emission tomography (PET) and single photon emission computed tomography (SPECT) to assess myocardial metabolism, perfusion, cell membrane and mitochondrial intactness; and echocardiographic imaging using dobutamine stress to assess contractile reserve/ischaemia or contrast agents to assess myocardial perfusion. More recently cardiac magnetic resonance (CMR) has become popular for the assessment of myocardial viability. This technique has an excellent spatial resolution and is currently the only imaging modality that allows distinction between transmural and subendocardial processes. Various techniques with CMR provide information on myocardial viability; these will be discussed extensively in this article. Besides assessment of viability, …

Accurate knowledge of the anatomy of intracardiac structures is essential for the efficiency and safety of performing interventional procedures. Although fluoroscopy is an important aid while advancing catheters in the heart, it is not sufficient to supply accurate anatomical information on the position of veins, ridges, and septa in the heart. Furthermore radiation exposure forms a risk to both the patient and the operator. Intracardiac echocardiography (ICE) is a promising technique for imaging of intracardiac structures, and may serve as an alternative for the transoesophageal approach,1 which is semi-invasive and requires anaesthesiology. The introduction of ICE catheters with low frequencies allows accurate visualisation of intracardiac anatomical structures with an ultrasound catheter placed exclusively in the right side of the heart. This report focuses on the use of ICE in guiding percutaneous interventional procedures. ### History of two dimensional intracardiac ultrasound systems The first application of ICE was done using mechanical ultrasound systems, which were introduced in the 1980s. These systems provided high resolution imaging, but because of the high frequency of the transducers (20–40 MHz), tissue penetration was only limited and anatomic intracardiac overviews could not be obtained. The subsequent development of lower frequency transducers allowed imaging of intracardiac structures, but these systems were still limited by the low steerability and over-the-wire design of the catheters.2 The clinical use was improved by the development of flexible lower frequency transducers (9 MHz), but depth control of these catheters still was not sufficient to allow visualisation of the whole heart from the right side of the heart. In the 1990s, systems modified after transoesophageal echocardiographic probes were introduced. In these systems depth was improved by the use of lower frequencies (5 MHz). However, the large size of these transducers limited the clinical use. In recent years the development of steerable phased array ultrasound catheter systems with low frequency …

Introduction: This study was designed to evaluate potential reversibility of left-ventricular (LV) dysfunction in patients with acromegaly following long-term control of disease. It is unknown whether the cardiac changes induced by acromegaly can be reversed completely by long-term strict control of growth hormone excess by octreotide. Patients and methods: We compared LV systolic and diastolic function in inactive patients with acromegaly (n = 22), who were divided into patients with long-term control by octreotide (n = 14) and patients with long-term cure by surgery/radiotherapy (n = 8). We also assessed these parameters in patients with active acromegaly (n = 17). Results: In patients with active acromegaly, systolic function at rest was decreased by 18% (P < 0.01), LV mass index increased by 40% (P < 0.04) and isovolumetric relaxation time increased by 19% (P < 0.01), compared with patients with inactive acromegaly. These parameters were not different between well-controlled and cured patients. Using tissue Doppler imaging, the ratio between early and late diastolic velocity (E′/A′ ratio) was decreased in active, compared with inactive acromegaly (0.75±0.07 versus 1.24±0.15; P < 0.01). This E′/A′ ratio was considerably higher in cured, compared with octreotide-treated, patients (1.75±0.41 versus 1.05±0.1; P < 0.01). Conclusion: Diastolic function is persistently and significantly more impaired in acromegalic patients with long-term control by octreotide than in surgically cured patients, which points to biological effects of subtle abnormalities in growth hormone secretion. Criteria for strict biochemical control of acromegaly should thus be reconsidered.

The current report describes a rare case of a pseudotumor in the left ventricle. Transthoracic and transesophageal echocardiography demonstrated a round, echodense, mobile mass attached to the posterior mitral leaflet and annulus. At surgical exploration caseous annular calcification of the posterior mitral leaflet was diagnosed. After resection of the mass, successful mitral valvular plasty was performed. Review of the literature indicated that mitral annular calcification is associated with an increased risk of stroke. Optimal treatment may be surgery, especially when valve plasty can be performed, although randomized trials are currently lacking.

OBJECTIVE: To assess the prognostic value of dobutamine stress echocardiography (DSE) in patients with previous myocardial revascularisation. DESIGN: Prospective study. SETTING: Tertiary referral centre in Rotterdam, the Netherlands. PATIENTS: 332 consecutive patients with previous percutaneous or surgical coronary revascularisation underwent DSE. Follow up was successful for 331 (99.7%) patients. Thirty eight patients who underwent early revascularisation (

Over the past decade the number of patients presenting with heart failure has increased exponentially.1 It has been estimated that 4.7 million patients in the USA have chronic heart failure, with 400 000 new cases per year, resulting in one million hospitalisations.1 The diagnostic and therapeutic costs involved with heart failure are estimated to be more than $11 billion per year.1 Gheorghiade and Bonow emphasised that the aetiology of heart failure may be coronary artery disease in > 70% of patients.2 Currently, three routine courses of action are available: medical treatment, heart transplantation, and revascularisation. Newer therapeutic modalities include laser therapy, advanced surgery, assist devices, artificial hearts,3 and transplantation of different (progenitor) cells.4 These options should currently be considered experimental but may offer alternative treatments in the future. Medical treatment has improved substantially over the past years, with the introduction of angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, and spironolactone. Four recent trials have demonstrated the value of β adrenergic blocking agents in the treatment of patients with heart failure.5 Finally, amiodarone has been demonstrated to reduce sudden death in patients with heart failure.6 Despite all of these new drugs, mortality of patients with severe heart failure remains high; Cowie and colleagues7 reported 12 month mortality to be 38% and extrapolation of these results demonstrated five year mortality to be > 70%. The second option, heart transplantation, has fairly good long term prognosis but the limited number of donor hearts is largely exceeded by demand.8 In addition, many patients with heart failure have significant co-morbidities, excluding them as candidates for heart transplantation. Revascularisation is the third option in patients with heart failure. The major drawback to performing revascularisation in these patients is the high periprocedural morbidity and mortality. …

OBJECTIVES: To assess whether quantification of myocardial systolic velocities by pulsed wave tissue Doppler imaging can differentiate between stunned, hibernating, and scarred myocardium. DESIGN: Observational study. SETTING: Tertiary referral centre. PATIENTS: 70 patients with reduced left ventricular function caused by chronic coronary artery disease. METHODS: Pulsed wave tissue Doppler imaging was done close to the mitral annulus at rest and during low dose dobutamine; systolic ejection velocity (Vs) and the difference in Vs between low dose dobutamine and the resting value (DeltaVs) were assessed using a six segment model. Assessment of perfusion (with Tc-99m-tetrofosmin SPECT) and glucose utilisation (by 18F-fluorodeoxyglucose SPECT) was used to classify dysfunctional regions (by resting cross sectional echocardiography) as stunned, hibernating, or scarred. RESULTS: 253 of 420 regions (60%) were dysfunctional. Of these, 132 (52%) were classified as stunned, 25 (10%) as hibernating, and 96 (38%) as scarred. At rest, Vs in stunned, hibernating, and scar tissue was, respectively, 6.3 (1.8), 6.6 (2.2), and 5.5 (1.5) cm/s (p = 0.001 by ANOVA). There was a gradual decline in Vs during low dose dobutamine infusion between stunned, hibernating, and scar tissue (8.3 (2.6) v 7.8 (1.5) v 6.8 (1.9) cm/s, p < 0.001 by ANOVA). DeltaVs was higher in stunned (2.1 (1.9) cm/s) than in hibernating (1.2 (1.4) cm/s, p < 0.05) or scarred regions (1.3 (1.2) cm/s, p = 0.001). CONCLUSIONS: Quantitative tissue Doppler imaging showed a gradual reduction in regional velocities between stunned, hibernating, and scarred myocardium. Dobutamine induced contractile reserve was higher in stunned regions than in hibernating and scarred myocardium, reflecting different severities of myocardial damage

Two-dimensional echocardiography is a valuable tool in visualizing and monitoring aortic valve and root abnormalities. We present a rare case of a patient with massive aortic regurgitation due to cusp aneurysm, which was accurately diagnosed by echocardiography and treated by valve replacement. A complicated course with recurrent aneurysms of the aortic wall after aortic valve replacement was remarkable in this case. Although different possible etiologies could not be determined, endocarditis and/or aortitis may be the most likely explanation of the complicated and finally fatal course of this patient.

ObjectiveTo investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA).BackgroundPatients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers.MethodsWe studied 570 patients (mean age 69±9 years, 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative mortality and MI within 30 days of surgery.ResultsPerioperative mortality or MI occurred in 51 (8.9%) patients. The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13–0.74; p=0.01). After correcting for other covariates, the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR: 0.24, 95% CI: 0.10–0.70; p=0.01). Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11–0.54). Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events.ConclusionsA combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk.

66 3D speckle-tracking echocardiography in acute myocardial infarction: relationship between contrast-enhanced magnetic resonance imaging and myocardial deformation {#article-title-2} Speckle analysis of 3D echocardiography improves information on left ventricle (LV) segmental and global deformation by avoiding loss of speckles as it is the case in monoplane 2D analysis. Our goal was to evaluate the accuracy of 3D deformation parameters to detect myocardial delayed enhancement (MDE) transmural extent by cardiac magnetic resonance imaging (CMR) in myocardial infarction (MI). Methods: We included 72 patients (57.3±12.4yo) with first acute MI who underwent within 3 days following revascularization both CMR (GE 3T) and echocardiography (GE Vivid E9) including a 3D acquisition of full LV volume. Furthermore, 31 normal subjects (56.5±8.2yo) underwent a complete echocardiography. Automated analysis of 3D allowed the calculation of 3D global LV area (3DGAS), longitudinal (3DGLS), circumferential (3DGCS) and radial (3DGRS) strains (S%). Peak systolic 2D and 3D S values from the 17 LV myocardial segments were recorded. For each segment MDE was defined as transmural (MDE>66%), intermediate (33–66%) and subendocardial (

Objective: To quantify regional left ventricular (LV) function and contractile reserve in Q wave and non-Q wave regions in patients with previous myocardial infarction. Design: An observational study. Setting: Tertiary care centre. Patients: 81 patients with previous myocardial infarction and depressed LV function. Interventions: All patients underwent surface ECG at rest and pulsed wave tissue Doppler imaging at rest and during low dose dobutamine infusion. The left ventricle was divided into four major regions (anterior, inferoposterior, septal, and lateral). Severely hypokinetic, akinetic, and dyskinetic regions on two dimensional echocardiography at rest were considered dysfunctional. Main outcome measures: Regional myocardial systolic velocity (Vs) at rest and the change in Vs during low dose dobutamine infusion (ΔVs) in dysfunctional regions with and without Q waves on surface ECG. Results: 220 (69%) regions were dysfunctional; 60 of these regions corresponded to Q waves and 160 were not related to Q waves. Vs and ΔVs were lower in dysfunctional than in non-dysfunctional regions (mean (SD) Vs 6.2 (1.9) cm/s v 7.1 (1.7) cm/s (p v 2.6 (2.5) cm/s (p = 0.009), respectively). There were no significant differences in Vs and ΔVs among dysfunctional regions with and without Q waves (Q wave regions: Vs 6.2 (1.8) cm/s, ΔVs 1.6 (2.2) cm/s; non-Q wave regions: Vs 6.3 (1.9) cm/s, ΔVs 2.0 (2.0) cm/s). Conclusions: Quantitative pulsed wave tissue Doppler demonstrated that, among dysfunctional regions, Q waves on the ECG do not indicate more severe dysfunction, and myocardial contractile reserve is comparable in Q wave and non-Q wave dysfunctional myocardium.

Intact perfusion, preserved metabolism of free fatty acids and glucose, and the presence of contractile reserve have been used as markers of viable myocardium. However, not all viable myocardium may exhibit all these characteristics. Accordingly, these features were evaluated in patients with chronic coronary artery disease and left ventricular dysfunction. Fourteen patients with chronic ischaemic heart disease and depressed left ventricular function (LVEF 34+/-10%) perfusion was evaluated by early resting Tl-201 single photon emission computed tomography (SPECT), fatty acid utilization by 15-p-[I-123]iodophenyl-3-(R,S)-methylpentadecanoic acid SPECT, glucose utilization by 2-[F-18]fluoro-2-deoxy-D-glucose SPECT and contractile reserve (CR) by dobutamine echocardiography. The comparison of the different modalities was restricted to akinetic or dyskinetic myocardium as assessed by resting 2-dimensional echocardiography. For all techniques a 13-segment model was used. Sixty-four of 182 segments (35%) showed akinesia or dyskinesia. Intact perfusion was found in 33/64 (52%) segments. Fatty acid utilization was maintained in 38/64 (59%) segments and glucose utilization was maintained in 38/64 (59%) segments. CR was present in significantly fewer segments: 21 of 64 (33%) (P

Aims To determine the degree of inter-institutional agreement in the assessment of dobutamine stress echocardiograms using modern stress echocardiographic technology in combination with standardized data acquisition and assessment criteria. Method and Results Among six experienced institutions, 150 dobutamine stress echocardiograms (dobutamine up to 40μg.kg−1 min−1 and atropine up to 1mg) were performed on patients with suspected coronary artery disease using fundamental and harmonic imaging following a consistent digital acquisition protocol. Each dobutamine stress echocardiogram was assessed at every institution regarding endocardial visibility and left ventricular wall motion without knowledge of any other data using standardized reading criteria. No patients were excluded due to poor image quality or inadequate stress level. Coronary angiography was performed within 4 weeks. Coronary angiography demonstrated significant coronary artery disease (≥50% diameter stenosis) in 87 patients. Using harmonic imaging an average of 5·2±0·9 institutions agreed on dobutamine stress echocardiogram results as being normal or abnormal (mean kappa 0·55; 95% CI 0·50–0·60). Agreement was higher in patients with no (equal assessment of dobutamine stress echocardiogram results by 5·5±0·8 institutions) or three-vessel coronary artery disease (5·4± 0·8 institutions) and lower in one- or two- vessel disease (5·0±0·9 and 5·2±1·0 institutions, respectively; P =0·041). Disagreement on test results was greater in only minor wall motion abnormalities. Agreement on dobutamine stress echocardiogram results was lower using fundamental imaging (mean kappa 0·49; 95% CI 0·44–0·54; P

Expression of concern relating to: D. Poldermans, E. Boersma, J. J. Bax, I. R. Thomson, B. Paelinck, L. L. M. van de Ven, M. G. Scheffer, G. Trocino, C. Vigna, H. F. Baars, H. van Urk, J. R. T. C. Roelandt, for the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. ‘Bisoprolol reduces cardiac death and myocardial infarction in high-risk …

AIM—To evaluate the angiographic, myocardial perfusion, and wall motion abnormalities in patients with severe compared with mild worsening of regional function during dobutamine stress echocardiography (DSE) for evaluation of myocardial ischaemia. METHODS—147 patients with significant coronary artery disease and new or worsening wall motion abnormalities during DSE were enrolled. Left ventricular function was evaluated using a 16 segment/4 grade score model where 1 = normal and 4 = dyskinesis. Simultaneous sestamibi SPECT myocardial perfusion imaging was performed in all patients. RESULTS—Severe worsening of regional function (an increase in wall motion score of two grades or more in ⩾ 1 segment) was detected in 37 patients, while 110 patients had mild worsening (an increase in wall motion score of no more than one grade in ⩾ 1 segment). Patients with severe worsening of regional function had more stenotic coronary arteries (2.31 (0.8) v 1.97 (0.8) (mean (SD)) (p

Background Both nuclear imaging with F18-fluorodeoxyglucose and dobutamine stress echocardiography have been used to identify viable myocardium, although dobutamine–stress echocardiography has been demonstrated to be the less sensitive of the two. Aim To compare the accuracy of pulsed-wave Doppler tissue sampling with dobutamine–stress echocardiography for the detection of viable myocardium, using F18-fluorodeoxyglucose imaging as a reference. Methods Forty patients with chronic coronary artery disease and left ventricular dysfunction (mean ejection fraction 33±11%), underwent F18-fluorodeoxyglucose imaging, dobutamine–stress echocardiography and pulsed-wave Doppler tissue sampling. Evaluation was performed using a six-segment model. Results Visual assessment by resting echo was feasible in 230 out of 240 segments (96%); 177 (77%) segments showed severe dyssynergy at rest. F18-fluorodeoxyglucose imaging showed viability in 95 (54%) segments while 82 (46%) were non-viable. Ejection phase velocity at rest was not significantly different; ejection velocities during low-dose and peak-dose dobutamine, however, were significantly higher in viable myocardium (8·6±2·9 vs 6·0±1·8 and 9·3±31 vs 6·2±2·1cm.s−1). Using receiver operating characteristic curves the optimal cut-off value for viability assessment was an increase in the ejection phase velocity low-dose of 1±0·5cm.s−1, while 0±0·5cm.s−1predicted non-viability. The sensitivity and specificity (95%CI) of pulsed-wave Doppler tissue sampling and dobutamine–stress echocardiography for the prediction of viability was respectively 87% (82–92) vs 75% (67–81) ( P

In 32 patients undergoing revascularization, viability assessment by FDG SPECT was related to improvement in LVEF and heart failure (HF) symptoms (graded according to the NYHA criteria). In 18 patients with substantial viability, the LVEF improved from 27±8% to 34±9% (P

Cell transplantation is currently being explored as a novel therapeutic option for patients with chronic myocardial ischaemia. The main goal of bone marrow cell transplantation is to augment blood flow in ischaemic myocardium through induction of angiogenesis. Improved collateral perfusion and enhanced left ventricular function have already been documented in animal models with chronic myocardial ischemia.1 Until now, most clinical studies were carried out in patients with acute myocardial infarction. Only two studies containing ⩽10 patients assessed the safety and feasibility of autologous bone marrow cell transplantation in patients with angina and ischaemia.2,3 Further studies are needed to confirm the safety, feasibility and effectiveness reported in these pilot trials. The present phase I/II study tested the feasibility, safety and clinical effects of trans-endocardial transplantation of autologous bone marrow-derived mononuclear cells in patients with drug-refractory angina and myocardial ischaemia. Moreover, we aimed to determine whether cell transplantation is associated with improved myocardial function and perfusion by means of technetium-99m tetrofosmin gated single photon emission computed tomography (SPECT). Patients with ischaemia on technetium-99m tetrofosmin SPECT and with Canadian Cardiovascular Society (CCS) class III or IV angina pectoris (despite maximal tolerated medical treatment) without options for conventional revascularisation were included in the study. An independent expert panel that reviewed the angiograms determined the ineligibility for surgical or percutaneous revascularisation. Seventeen patients fulfilled the inclusion criteria and were considered for inclusion. Exclusion criteria were acute myocardial infarction

Radioiodinated fatty acid analogues modified by methyl-substitution are used for single photon emission tomography (SPET) imaging of the heart. The effect of mono- and dimethyl-substitution on heart-to-organ ratios was investigated in humans to evaluate their relative merits for SPET image quality. Planar total body scans were performed in fasting patients with coronary artery disease, but without heart failure, 1 h after administration of 111 MBq 15-(p-[I-123]-iodophenyl)-3-(R,S)-methylpentadecanoic acid (BMIPP, n = 7) or 111 MBq 15-(p-[I-123]-iodophenyl)-3,3-dimethylpentadecanoic acid (DMIPP, n = 4). Because these branched fatty acids are used for cardiac imaging, we focused on heart-to-organ (heart/organ) ratios by comparing small regions of interest in heart, liver, lung, muscle and bladder. Both tracers showed good visualization of the heart. DMIPP showed a relatively high liver uptake: the heart/liver ratios for DMIPP and BMIPP were 0.39 +/- 0.05 and 1.00 +/- 0.12, respectively (P < 0.0001). Increased lung activity was found for BMIPP, with a heart/lung ratio of 1.63 +/- 0.17 versus 2.32 +/- 0.28 for DMIPP (P < 0.001). In contrast to DMIPP, BMIPP also showed increased activity in the bladder. In conclusion, BMIPP and DMIPP show different distribution patterns. Despite the more favourable heart/lung ratios for DMIPP, the high liver uptake affects cardiac SPET image quality and therefore BMIPP appears to provide superior cardiac SPET image quality in humans.