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The aim of the study was to assess the left ventricular (LV) synchronicity in pregnant women and to identify the main determinants of LV dyssynchrony in asymptomatic pregnant women.One hundred sixty-seven pregnant women consecutively and 48 age-matched nonpregnant controls were enrolled. For the assessment of LV systolic dyssynchrony, the standard deviation of the time from QRS onset to peak systolic (Tps-LV- standard deviation [SD]) velocity and the maximal difference of the time from QRS onset to peak systolic velocity (Tps-LV) from 12 segments at the apical views. For the LV diastolic dyssynchrony, the standard deviation of the time from QRS onset to peak diastolic (Tpe-LV-SD) velocity and the maximal difference of the time from QRS onset to peak diastolic velocity (Tpe-LV) were calculated.Both systolic and diastolic dyssynchrony indexes were significantly higher in pregnant women than in the normal controls (Tps-LV; P.01, Tps-LV-SD; P.03, Tpe-LV, P.05 and Tpe-LV-SD; P.02). A total of 28 (16.8%) of the pregnant women had a dyssynchrony index above the accepted value for LV dyssynchrony (34.4 msec). There was a significant correlation between LV dyssynchrony indexes with, multiparty, multifetal pregnancies, systolic blood pressure in pregnant women with LV dyssynchrony. Additionally LV dyssynchrony was significantly associated with elevated E/e" and brain natriuretic peptide (BNP).Both systolic synchronicity and diastolic synchronicity were affected in pregnant women compared to nonpregnant women. LV dyssynchrony was significantly correlated with age, multiparity, and BNP level. Early detectable changes in systolic and diastolic synchrony may be present in pregnant women at higher risk of peripartum cardiomyopathy.

Introducción. El análisis de fase (AF) del ventrículo izquierdo es una herramienta de reciente introducción en los estudios de cardiología nuclear, que permite valorar el sincronismo mecánico de la contracción del ventrículo izquierdo con diferentes aplicaciones clínicas, si bien es poco conocida. Objetivo. Mostrar la factibilidad de la nueva herramienta AF por perfusión miocárdica (Gated-SPECT) para valorar el sincronismo mecánico del ventrículo izquierdo y verificar diferencias entre sus valores, según situaciones clínicas y condiciones técnicas. Materiales y métodos. En el estudio participaron pacientes consecutivos con Gated-SPECT. Las variables principales fueron diferentes condiciones clínicas y técnicas. La valoración del AF se realizó mediante la herramienta FASE del programa cardiodedicado (QPSQGS, Cedars-Sinai Medical Center, Los Angeles, USA). Se obtuvieron los siguientes parámetros: ancho del histograma (AH), desviación estandar de la fase (DE) y entropía (E). Se realizó análisis descriptivo y analítico de medias o medianas a través de test paramétricos o no paramétircos. El límite de significancia estadísitca fue p35% [AH (p=0.001), DE (p=0.001), E (p=0.001)], estudio normal o con necrosis [AH (p=0.001), DE (p=0.001), E (p=0.001)] y género [AH (p=0.002), DE (p=0.006), E (p=0.005)]. Conclusiones. El uso de la nueva herramienta del AF de medicina nuclear es factible. Sus parámetros no se afectaron por el tipo de estrés producido, dosis administrada o fase del estudio por la gammacámara empleada. Por su parte, sí fueron afectados por género, trastornos de conducción interventricular, necrosis y disfunción sistólica. Introduction: Phase analysis (PA) of the left ventricle is a new tool in nuclear cardiology studies used to assess left ventricular mechanical timing based on different clinical applications. However, the use of this tool is relatively unknown. Objective: To expose the feasibility of the new PA tool in myocardial perfusion (Gated-SPECT) to assess left ventricle mechanical timing, and to verify the differences between values depending on clinical and technical conditions. Materials and methods: The study included consecutive patients evaluated by Gated-SPECT. The main variables were different depending on clinical and technical conditions. PA was assessed using the PHASE tool of the QPS-QGS program (Cedars-Sinai Medical Center, Los Angeles, USA). The following parameters were obtained: histogram bandwith (HB), standard deviation (SD) and entropy (E). A descriptive and analytical analysis of means and/or medians was performed using parametric or non-parametric tests. Statistical significance was p 35% (p=0.001), E (p=0.001)] normal or necrosis study [HB (p=0.001), SD (p=0.001), E (p=0.001)], and gender [HB (p=0.002), SD (p=0.006), E (p=0.005)]. Conclusions: The new PA tool of nuclear medicine is feasible in our context. The type of stress, the administered dose, the study phase or the gamma camera used did not affect the parameters. However, gender, interventricular conduction disorders, necrosis and systolic dysfunction did have an impact on them. © 2017, Universidad Nacional de Colombia. All rights reserved.

The purpose of this review it to summarize the current literature on remodeling after myocardial infarction, inclusive of pathophysiological considerations, imaging modalities, treatment strategies, and future directions. As patients continue to live longer after myocardial infarction (MI), the prevalence of post-MI heart failure continues to rise. Changes in the left ventricle (LV) after MI involve complex interactions between cellular and extracellular components, under neurohormonal regulation. Treatments to prevent adverse LV remodeling and promote reverse remodeling in the post-MI setting include early revascularization, pharmacotherapy aimed at neurohormonal blockade, and device-based therapies that address ventricular dyssynchrony. Despite varying definitions of adverse LV remodeling examined across multiple imaging modalities, the presence of an enlarged LV cavity and/or reduced ejection fraction is consistently associated with poor clinical outcomes. Advances in our knowledge of the neurohormonal regulation of adverse cardiac remodeling have been instrumental in generating therapies aimed at arresting adverse remodeling and promoting reserve remodeling. Further investigation into other specific mechanisms of adverse LV remodeling and pathways to disrupt these mechanisms is ongoing and may provide incremental benefit to current evidence-based therapies.

Cardiac resynchronization therapy (CRT) has emerged as a valued nonpharmacologic therapy in patients with heart failure, reduced ejection fraction (EF), and ventricular dyssynchrony manifest as left bundle branch block. The mechanisms of benefit include remodeling of the left ventricle leading to decreased dimensions and increased EF, as well as a decrease in the severity of mitral regurgitation. This article reviews the rationale, effects, and indications for CRT, and discusses the patient characteristics that predict response and considerations for nonresponders.

The aim of the present study was to compare conventional right ventricular apical pacing (RVAP) with right ventricular mid-septal pacing (RVMSP) in terms of echocardiographic and clinical/biologic features. Ninety-six patients with high-degree atrioventricular block were randomly allocated to RVMSP ( n = 50) and RVAP ( n = 46). Threshold and impedance, echocardiographic left ventricular ejection fraction, ventricular dyssynchrony features, and distance during a 6-min walk test and Minnesota Living with Heart Failure Questionnaire were determined at 6 and 12 months after pacemaker implantation. Serum levels of N-terminal pro-brain natriuretic peptide were measured. At 6 months of follow-up, echocardiographic and clinical/biologic features showed no significant differences between two groups. The RVAP group had more intraventricular dyssynchrony and a trend towards a worse left ventricular ejection fraction compared with the RVMSP at 12 months of follow-up. However, no overt clinical benefits from RVMSP were found. Right ventricular mid-septal pacing was associated with decreased dyssynchrony and better left ventricular ejection fraction compared with the RVAP. Right ventricular mid-septal pacing could represent an alternative pacing site in selected patients to reduce the harmful effects of traditional RVAP.

Aims The relationship between ventricular pre-excitation and left ventricular dysfunction has been described in the absence of sustained supraventricular tachycardia in a series of case reports. There have been no systematic studies about the effect of ventricular pre-excitation with different accessory pathway locations on ventricular wall motion and left ventricular (LV) systolic function. Methods and results Thirty patients were selected for each of 4 groups, including those with right septal pathways (Group 1), right free-wall pathways (Group 2), left free-wall pathways (Group 3), and non-pre-excited patients undergoing electrophysiological evaluation for supraventricular tachycardia. We analysed the influence of the location of the accessory pathway on ventricular wall motion, systolic function, ventricular synchronism, and LV size. Right-sided accessory pathways were associated with abnormal motion of the interventricular septum, LV dyssynchrony, decreased LV systolic function, and increased LV diameter. Eighteen of 60 cases (30.0%) with right-sided accessory pathways had LV dyssynchrony, and these patients had lower LV ejection fraction and higher LV end-diastolic diameter. Conclusion Right-sided accessory pathways may impair ventricular wall motion and LV systolic function, resulting in decreased LV ejection fraction and increased LV end-diastolic diameter. These effects occurred in patients with LV dyssynchrony. These effects, including LV dyssynchrony, resolved after radiofrequency ablation. A right-sided free-wall accessory pathway may have more detrimental effects than a septal accessory pathway. Left ventricular dyssynchrony and abnormal interventricular septal motion appeared to be responsible for the pathogenesis of LV dysfunction and remodelling.

Aims: \ud \ud As patients with heart failure (HF) and concomitant diabetes carry a poor prognosis, this post-hoc subgroup analysis aimed to compare the outcomes of patients with and without diabetes randomized in the Echocardiography Guided Cardiac Resynchronization Therapy (EchoCRT) study.\ud Methods and results: \ud \ud EchoCRT randomized patients with a QRS duration

Summary– Muscular septal aneurysms are extremely rare without a ventricular septal defect and are diagnosed accidentally in most cases. Reported cases generally have rhythm disturbance or electrocardiographic findings of Wolf-Parkinson-White (WPW) syndrome. Presently described are 2 cases of ventricular septal aneurysm associated with WPW syndrome, which presented as dilated cardiomyopathy. Pre-excitation disappeared gradually in first patient. There was also concurrent decrease in degree of bulging of the interventricular septum and improvement of left ventricular systolic function. Second patient had complaints of palpitation and was referred for ablation of accessory pathway. Our findings suggest that presence of pre-excitation may lead to ventricular dyssynchrony and abnormal ventricular septal movement, resulting in appearance of aneurysm.

Objective: Left ventricular (LV) rotation and twist play an important role in LV contraction and relaxation. Left bundle branch block (LBBB) deteriorates both diastolic and systolic functions. We evaluated the LV twist in patients with LBBB and preserved ejection fraction (EF) (>50%) to determine twist as a potential marker for subtle myocardial dysfunction. Methods: This observational cross-sectional study included 34 LBBB patients with preserved EF who were free from ischemic and valvular disease (Group 1) and 36 healthy controls (Group 2). All patients underwent 2-D Doppler and 2-D speckle tracking echocardiography. LV apical, basal rotation, and twist were evaluated in both groups and compared accordingly. In addition, subjects were dichotomized considering the median twist value of the study population. Binary logistic regression analysis was performed to determine the independent variables associated with inframedian twist. Results: Baseline clinical characteristics were similar in LBBB patients and controls. Mean apical rotation (2.5°±1.9° vs. 4.4°±2.9°; p=0.002), basal rotation (-2.9°±2.3° vs. -4.1°±2.7°; p=0.05), and twist (5.4°±3° vs. 8.6°±3.3°; p

Cardiac resynchronization therapy (CRT) is an effective treatment for patients with congestive heart failure and ventricular dyssynchrony. Despite the overall efficacy of CRT, approximately 30% of patients receiving CRT do not improve. One of the main technical problems related to the CRT procedure is inadequate visualisation in X-ray fluoroscopy of the venous anatomy in relation to accurate cardiac chamber visualisation. This paper proposes a novel approach for 3D reconstruction of coronary veins from a single contrast enhanced intra-operative fluoroscopy image. For this application, the method uses back-projection geometry and a Euclidean distance/angle-based cost function. The algorithm is validated on a phantom and five patient datasets, comprising six view-angle orientations for the phantom dataset and two view-angle orientations for each of the patient datasets. Median(inter-quartile range) 3D-reconstruction accuracies of 1.41(0.55–3.00) mm and 3.28(2.10–4.89) mm were established for the phantom and patient data, respectively. The technique can facilitate careful advancement of the cannulating guide over a guidewire or a diagnostic catheter positioned in the coronary sinus, and consequently, improve the chances of response to CRT.

We present a case of pacing-induced cardiomyopathy. The patient presented with clinical symptoms of dyspnea, leg swelling, and orthopnea several months after a dual-chambered pacemaker was placed for third-degree heart block. The echocardiogram demonstrated a depressed ejection fraction. Coronary angiography was performed, which showed widely patent vessels. Single- and dual-chambered pacemakers create ventricular dyssynchrony, which in turn can cause structural, molecular changes leading to cardiomyopathy. With early intervention of biventricular pacemaker replacement, these changes can be reversible; thus, a timely diagnosis and awareness is warranted.

Survival in patients with pulmonary arterial hypertension (PAH) is determined by right ventricular (RV) function adaptation to afterload. How altered RV function impacts on exercise capacity in PAH is not exactly known.104 idiopathic PAH (IPAH) patients aged 52±14 years underwent a diagnostic right heart catheterisation, a comprehensive echocardiography including two-dimensional speckle tracking for RV dyssynchrony evaluation and a cardiopulmonary exercise test. Multivariate analyses were performed to identify independent predictors of peak oxygen uptake (peakV′O2).A first multivariate analysis of only resting haemodynamic variables identified cardiac index, right atrial (RA) pressure and pulmonary arterial compliance as independent predictors, with low predictive capacity (r2=0.31; p2=0.35; p2=0.48; pV′O2(r2=0.53; p=0.001).A comprehensive echocardiography with speckle tracking-derived assessment of the heterogeneity of RV contraction improves the prediction of aerobic exercise capacity in IPAH.

Previous studies showed different dyssynchrony patterns between ischemic and normal myocardium at early post-stress using Tl-201 gated SPECT myocardial perfusion imaging (MPI). The aim of this study was to assess the relation of stress-induced dyssynchrony and the extent of angiographic coronary artery disease (CAD). The MPI images of 144 patients were retrospectively analyzed. With ≥70% stenosis as the criteria of CAD, 57 had no CAD, 32 had 1-vessel disease, 36 had 2-vessel disease, and 19 had 3-vessel disease, respectively. LV global and territorial dyssynchrony parameters were measured by the phase analysis from stress/rest Tl-201 SPECT MPI and compared between stress and rest among the patient groups. The patients with multi-vessel CAD had significantly more global dyssynchrony than the patients without ≥70% stenosis at stress. The patients with multi-vessel CAD showed significantly more global and territorial dyssynchrony on stress images than on rest. More patients with 3-vessel CAD were correctly classified as multi-vessel disease, when combining both visual interpretation and dyssynchrony assessment. The patients with multi-vessel CAD had significantly more global and territorial dyssynchrony at early post-stress than at rest. Such quantitative measures of myocardial stunning may assist in the diagnosis of multi-vessel CAD.

Heart failure (HF) represents a serious clinical and public cause of mortality, morbidity, as well as healthcare expenditures. Guidelines for treatment of HF join in recommending multimedical regimen at targeted doses as the best medical strategy, despite that a significant percentage of patients remain symptomatic. Studies have shown that these patients might benefit from cardiac resynchronization therapy (CRT), particularly those presenting with broad QRS duration,135 msec. Trials have already shown that CRT results in improved morbidity and survival of these patients particularly those in New York Heart Association class III-IV HF, but almost 30% do not show any symptomatic or survival benefit, hence are classified as nonresponders. Exhaustive efforts have been made in using noninvasive methods of assessing left ventricle (LV) dyssynchrony in predicting nonresponders to CRT, including Doppler echocardiography, magnetic resonance imaging, and even single photon emission computed tomography analysis, but only with modest success. In this report, we aimed to review the available evidence for assessing markers of mechanical LV dyssynchrony by various echocardiographic modalities and their respective strength in predicting favorable response to CRT treatment, comparing global with segmental ones. While the accuracy of segmental markers of dyssynchrony in predicting satisfactory response to CRT remains controversial because of various technical limitations, global markers seem easier to measure, reproducible, and potentially accurate in reflecting overall cavity response and its clinical implications. More studies are needed to qualify this proposal.

The number of patients with severe aortic stenosis getting treated with transcatheter aortic valve replacement (TAVR) is rapidly growing and the outcome after the procedure is very good. However, the incidence of new persistent left bundle branch block (LBBB) following the TAVR procedure is high and the impact of this new conduction disturbance has been studied in four major studies with divergent result. This review investigates the differences between these studies that might explain the divergent results and concludes that future studies are needed to characterize whether or not new LBBB after TAVR fulfills the new strict LBBB criteria, whether these new LBBB patients develops left ventricular dyssynchrony, and which, if any, might benefit from cardiac resyncronization therapy (CRT).

Echocardiographic assessment of left ventricular mechanical dyssynchrony (LVMD) received great interest with the appearance of Cardiac resynchronization therapy ever since the first successful implants. Recent guidelines still keep QRS duration as the main selection criterion for diagnosing the presence of LVMD. However, measurement of QRS duration, which is an electrical phenomenon, seems to provide only a crude estimate on myocardial activation and is poorly correlated with the presence of LVMD. Echocardiography seems to be a more reliable tool for correctly identifying candidates for CRT and thus reducing the number of clinical non-responders. Recently LMVD was found to be associated with other cardiac and noncardiac diseases. Therefore, echocardiographic assessment of LVMD will always remain of importance. The aim of this article is to present a simplified, step-wise approach for the assessment of LVMD which can be easily followed and performed by echocardiographers to produce reliable, reproducible results for the assessment of LVMD.

Purpose. Right ventricular (RV) failure and ventricular dyssynchrony are strong determinants of prognosis in patients with adult congenital heart disease (ACHD). The aim of this study was to investigate the relationship between interventricular dyssynchrony (IVD) using cine-tagged magnetic resonance imaging (MRI) and RV dys- function in ACHD patients. Materials and Methods. Sixty-seven patients with ACHD (38 with repaired tetralogy of Fallot; 22 with atrial septal defect; seven with ventricular septal defect) underwent tagging MRI. Time curves of myocardial circumferential strains for RV and left ventricular (LV) free walls were delivered from short-axis cine-tagging images. Contraction delay between RV and LV free walls was computed by cross-correlation analysis of the two strain time curves and was defined as the IVD time (msec). Results. IVD was significantly greater for patients with RV ejection fraction (RVEF)

Ventricular dyssynchrony is associated with morbidity and mortality after palliation of a single ventricle. The authors hypothesized that resynchronization with optimized temporary multisite pacing postoperatively would be safe, feasible, and effective. Pacing was assessed in the intensive care unit within the first 24 h after surgery. Two unipolar atrial pacing leads and four bipolar ventricular pacing leads were placed at standardized sites intraoperatively. Pacing was optimized to maximize mean arterial pressure. The protocol tested 11 combinations of the 4 different ventricular lead sites, 6 atrioventricular delays (50-150 ms), and 14 intraventricular delays. Optimal pacing settings were thus determined and ultimately compared in four configurations: bipolar, unipolar, single-site atrioventricular pacing, and intrinsic rhythm. Each patient was his or her own control, and all pacing comparisons were implemented in random sequence. Single-ventricle palliation was performed for 17 children ages 0-21 years. Pacing increased mean arterial pressure (MAP) versus intrinsic rhythm, with the following configurations: bipolar multisite pacing increased MAP by 2.2 % (67.7 ± 2.4 to 69.2 ± 2.4 mmHg; p = 0.013) and unipolar multisite pacing increased MAP by 2.8 % (67.7 ± 2.4 to 69.6 ± 2.7 mmHg; p = 0.002). Atrioventricular single-site pacing increased MAP by 2.1 % (67.7 ± 2.4 to 69.1 ± 2.5 mmHg: p = 0.02, insignificant difference under Bonferroni correction). The echocardiographic fractional area change in nine patients increased significantly only with unipolar pacing (32 ± 3.1 to 36 ± 4.2 %; p = 0.02). No study-related adverse events occurred. Multisite pacing optimization is safe and feasible in the early postoperative period after single-ventricle palliation, with improvements in mean arterial pressure and fractional area shortening. Further study to evaluate clinical benefits is required.

Total isovolumic time, a marker of global left ventricular dyssynchrony, predicts response to Cardiac Resynchronization Therapy in heart failure patients

Today, quantitative analysis of three-dimensional (3D) dynamics of the left ventricle (LV) cannot be performed directly in the catheter lab using a current angiographic C-arm system, which is the workhorse imaging modality for cardiac interventions. Therefore, myocardial wall analysis is completely based on the 2D angiographic images or pre-interventional 3D/4D imaging. In this paper, we present a complete framework to study the ventricular wall motion in 4D (3D+t) directly in the catheter lab. From the acquired 2D projection images, a dynamic 3D surface model of the LV is generated, which is then used to detect ventricular dyssynchrony. Different quantitative features to evaluate LV dynamics known from other modalities (ultrasound, magnetic resonance imaging) are transferred to the C-arm CT data. We use the ejection fraction, the systolic dyssynchrony index a 3D fractional shortening and the phase to maximal contraction (ϕi, max) to determine an indicator of LV dyssynchrony and to discriminate regionally pathological from normal myocardium. The proposed analysis tool was evaluated on simulated phantom LV data with and without pathological wall dysfunctions. The LV data used is publicly available online at https://conrad.stanford.edu/data/heart. In addition, the presented framework was tested on eight clinical patient data sets. The first clinical results demonstrate promising performance of the proposed analysis tool and encourage the application of the presented framework to a larger study in clinical practice.

The present case report describes a 53-year-old man with drug-resistant heart failure. Electrocardiogram showed complete right-bundle branch block and left anterior fascicular block. A cardiac resynchronization therapy (CRT) device was implanted in him because echocardiography showed obvious left ventricular dyssynchrony between septal and lateral walls. After CRT implantation, dyssynchrony was improved and ejection fraction was increased. Evaluation of coexisting left hemiblock and left ventricular dyssynchrony may be needed in patients with atypical indications for CRT.

Purpose Functional mitral regurgitation (FMR) and myocardial dyssynchrony commonly occur in patients with dilated cardiomyopathy (DCM). The aim of this study was to elucidate changes in FMR in relation to those in left ventricular (LV) dyssynchrony as well as geometric parameters of the mitral valve (MV) in DCM patients during dobutamine infusion. Materials and methods Twenty-nine DCM patients (M:F=15:14; age: 62±15 yrs) with FMR underwent echocardiography at baseline and during peak dose (30 or 40 ug/min) of dobutamine infusion. Using 2D echocardiography, LV end-diastolic volume, end-systolic volume (LVESV), ejection fraction (EF), and effective regurgitant orifice area (ERO) were estimated. Dyssynchrony indices (DIs), defined as the standard deviation of time interval-to-peak myocardial systolic contraction of eight LV segments, were measured. Using the multi-planar reconstructive mode from commercially available 3D image analysis software, MV tenting area (MVTa) was measured. All geometrical measurements were corrected (c) by the height of each patient. Results During dobutamine infusion, EF (28±8% vs. 39±11%, p=0.001) improved along with significant decrease in cLVESV (80.1±35.2 mm³/m vs. 60.4±31.1 mm³/m, p=0.001); cMVTa (1.28±0.48 cm²/m vs. 0.79±0.33 cm²/m, p=0.001) was significantly reduced; and DI (1.31±0.51 vs. 1.58±0.68, p=0.025) showed significant increase. Despite significant deterioration of LV dyssynchrony during dobutamine infusion, ERO (0.16±0.09 cm² vs. 0.09±0.08 cm², p=0.001) significantly improved. On multivariate analysis, ΔcMVTa and ΔEF were found to be the strongest independent determinants of ΔERO (R²=0.443, p=0.001). Conclusion Rather than LV dyssynchrony, MV geometry determined by LV geometry and systolic pressure, which represents the MV closing force, may be the primary determinant of MR severity.

Aims In low-flow, low-gradient aortic stenosis (LF/LG AS), the assessment of contractile reserve (CR) by dobutamine stress echocardiography (DSE) is recommended for risk stratification and treatment strategy. However, DSE may show limitations in cases of left ventricular dyssynchrony (LVD). The impact of LVD in LF/LG AS, and the feasibility of CRT in this setting have never been evaluated. We aimed to assess: (i) the proportion of LF/LG AS patients with LVD; (ii) the influence of LVD on CR at DSE; and (iii) the effects of CRT in these patients. Methods and results Thirty consecutive patients with LF/LG AS underwent DSE with study of CR. The operative risk for aortic valve replacement (AVR) was assessed using the logistic EuroSCORE. Twenty-one of the 30 patients had LVD. They were significantly older, more symptomatic, had a higher EuroSCORE, and a lower prevalence of CR than those with a narrow QRS (47% vs. 100%, P = 0.009). A CRT pacemaker was implanted in 19 of the 21 patients with LVD. All 19 (except for one patient who died suddenly) experienced significant clinical and echocardiographic improvement. Fourteen CRT patients underwent subsequent AVR with a low event rate. Four CRT patients refused AVR; two of them worsened again 1–2 years post-CRT. Conclusion LVD is common in LF/LG AS patients and may be a major mechanism of afterload mismatch, as well as a cause of underdetection of CR. CRT in this population is feasible and may be proposed as a bridge to surgery.

Left ventricular (LV) dyssynchrony by phase analysis has been studied by myocardial perfusion imaging (MPI)-gated SPECT in patients with LV dysfunction in various clinical settings. We aimed to investigate the routine use of phase analysis with gated SPECT for predicting cardiac outcome. Patients referred to a tertiary medical center in 2010-2011 prospectively underwent a gated SPECT and phase analysis, and follow-up for cardiac events. The values of clinical variables, MPI, LV function, and LV dyssynchrony in predicting cardiac events were tested by univariate and multivariate analyses. The study group included 787 patients (66.5 ± 11 years, 81% men) followed for a mean duration of 18.3 ± 6.2 months. There were 45 (6%) cardiac events defined as composite endpoint; cardiac death occurred in 26 patients, and the rest had new-onset or worsening heart failure and life-threatening arrhythmias. In multivariate analysis, it was shown that NYHA class, diabetes mellitus, and LVEF

Cardiac resynchronization therapy (CRT) is a proven treatment adjunct for selected patients with heart failure and evidence of ventricular dyssynchrony. When applying most contemporary guidelines the accepted response rate has remained static with up to one-third of patients failing to respond. Empiric lateral/posterolateral lead positioning may not be the optimal strategy in all patients, particularly in those with extensive scar and there have been developments that suggest an approach whereby the latest mechanically activating segment is targeted for left ventricular (LV) lead placement may be of some benefit. Additionally, alternative means of delivering CRT, either by means of multi-site pacing or LV endocardial pacing, have similarly shown promise. At a time where novel predictors of response to CRT have proved disappointing in multi-center trials, a paradigm shift away from prediction towards better delivery of CRT may potentially be of most benefit to the significant minority who do not respond.

Objectives: To evaluate the effect of concomitant cardiac resynchronization therapy (CRT) on health related quality of life (QoL) in patients with heart failure (HF) and ventricular dyssynchrony undergoing cardiac surgery. Methods: Twenty-eight patients received permanent epicardial CRT in connection to coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) (CRT group). Thirty-seven HF patients without concomitant CRT served as a comparison group (non-CRT group). SF-36 was used to assess QoL in the two groups and was also compared with the general Swedish population. Results: The median follow-up time was 28 months after surgery (range 8 to 44 months). No difference in QoL could be shown between the CRT group and the comparison group. Several subscales of QoL in the CRT group were in range with the general Swedish population. Conclusion: Concomitant CRT for patients with HF and ventricular dyssynchrony undergoing CABG and/or AVR did not result in a higher estimated QoL compared to HF patients without CRT.

Objectives The association of QRS duration (QRSd) with ventricular dyssynchrony is well-known in systolic heart failure (HF). However, there are no data regarding the relationship between QRSd and atrial dyssynchrony in patients with HF. We aimed to investigate the association of QRSd with intra-atrial and inter-atrial dyssynchrony in patients with systolic HF by using color tissue Doppler imaging (TDI). Methods The study consisted of 70 systolic HF patients and 35 healthy controls. According to QRSd, HF patients were categorized into 2 subgroups as narrow QRS (n = 35) and wide QRS (n = 35) groups. Time intervals between the onset of P-wave and the onset of A-wave on color TDI from the right atrium (P-RA), inter-atrial septum (P-IAS) and left atrium (P-LA) were measured. Atrial dyssynchrony was defined as differences between P-RA and P-IAS (RA dyssynchrony), between P-LA and P-IAS (LA dyssynchrony) and between P-RA and P-LA (inter-atrial dyssynchrony). Results In patients with either HF groups, we observed significant impairment in intra-atrial and inter-atrial synchronicity compared with the controls (P

Propionic acidemia is an autosomal recessive disorder that is due to deficiency in the enzyme propionyl-CoA carboxylase. Cardiomyopathy is a well-known phenomenon in propionic acidemia that it may rapidly progress to death. Here we describe a case of propionic acidemia in a 27-year-old man who developed adult-onset secondary dilated cardiomyopathy. In early infancy he was diagnosed with propionic acidemia and was later noted to have mild mental retardation, mild renal failure, and optic nerve atrophy. Although he was in good energy status with a low-protein diet and carnitine supplementation, he was admitted to our university hospital with decompensate heart failure, which resulted in low-output cardiac syndrome with massive mitral regurgitation and left ventricular dyssynchrony. Cardiac resynchronization therapy (CRT) and continuous hemodiafiltration followed by hemodialysis (HD) dramatically improved his clinical status.

Cardiac resynchronization therapy (CRT) is an established therapy for selected heart failure (HF) patients to improve symptoms, ventricular function, and survival. Although increasingly used, left ventricular (LV) dyssynchrony assessment by echocardiography has failed to show enough predictive value to assess patient response to CRT and the current guidelines do not recommend its routine use. Furthermore, a variety of echocardiographic techniques used for the purpose, including tissue Doppler imaging (TDI), real time three-dimensional echocardiography, M-mode, and various Doppler parameters, showed limited value and poor agreement between the studies and methods, greatly influenced by interobserver variability. Speckle tracking echocardiography (STE) is a more recent approach that uses strain imaging to assess LV dyssynchrony. This article discusses the speckle tracking for LV dyssynchrony and its current clinical applications.

23633 ### The Transcription Factor Early B-cell Factor 1 is Critical for Proper Formation of the Cardiac Ventricular Conduction System Eugene Kim, Akshay Shekhar, Jie Zhang, Fang-Yu Liu, Wilson Young, Glenn I Fishman; New York Univ Sch of Medicine, New York, NY Transcriptional regulation of cardiac ventricular conduction system (VCS) development is incompletely understood. Using gene expression profiling of the VCS using the Cntn2-EGFP transgenic VCS fluorescent reporter mouse, we identified Early B-cell Factor 1, Ebf1 , as being significantly enriched in the VCS. Surface electrocardiography of the Ebf1 knockout mouse revealed ventricular conduction slowing as evidences by QRS widening; echocardiography using strain imaging revealed marked left ventricular dyssynchrony; and wholemount imaging of the Ebf1 KO heart demonstrated dramatic hypoplasia of the VCS. Gene expression profiling was performed on E13.5 embryonic hearts using deep sequencing and a number of transcription factors known to be critical for cardiogenesis were markedly reduced, including Nkx 2–5, Gata4, Hand1, Irx3 , and Irx5 . Histological analysis of embryonic hearts revealed marked cellular hyperplasia and staining for markers of cell cycle (Ki-69; phospho-histone H3) were consistent with exuberant cellular proliferation. Quantitative immunofluorescence for several markers of terminally differentiated VCS cells was performed and demonstrated reduced expression of Nkx 2–5, Scn5a , and Cx40 , particularly within the terminal Purkinje fibers of the VCS. Finally, analysis of the Nkx 2–5 promoter revealed a highly conserved Ebf1 binding site in a region previously described as critical for proper expression of Nkx 2–5 in the VCS. Using CRISPR-Cas9 mediated gene editing, a 200 bp region flanking this site was deleted and the mutant mice generated also demonstrated marked QRS widening, phenocopying the Ebf1 KO. Author Disclosures: E. Kim: None. A. Shekhar: None. J. Zhang: None. F. Liu: None. W. Young: None. G.I. Fishman: None. Key Words: Cardiac development; Biology, developmental; Cardiovascular development; Electrophysiology; Heart conduction system ### 23347 ### Intramyocardial Delivery of miR-199a Reduces Scar Size and Preserves Contractile Function In Infarcted Pig Hearts Khatia Gabisonia; Sant’Anna Sch of Advanced Studies, Pisa, Italy We have previously …

OBJECTIVE There are two distinct approaches for the assessment of left ventricular (LV) dyssynchrony by myocardial perfusion scintigraphy (MPS). The aim of this study was to compare the performance of the count-based and geometrical approach in clinical data using gated single photon emission computed tomography MPS. MATERIAL AND METHODS Group 1 consisted of 113 patients (49 men, 64 women) with normal perfusion [summed rest score (SRS)≤3], normal LV ejection fraction (≥55%), and normal QRS duration (QRSd

BACKGROUND Right atrium function and ventricular function have significant prognostic value in pulmonary arterial hypertension patients. Acute changes in right ventricular synchrony and right atrium function postiloprost inhalation have not been evaluated. METHODS Cross-sectional study. Consecutive pulmonary arterial hypertension patients (group I from Nice classification) were included. Echocardiographic right atrium and right ventricular function pre- and postiloprost inhalation, including a right ventricular dyssynchrony index and right atrium function using speckle tracking, were performed in all patients. RESULTS Twenty pulmonary arterial hypertension patients, 44±7 years and 90% females, were included. After iloprost inhalation, we observed a significant increment in right ventricular fractional area change and a significant decrease in right ventricular dyssynchrony index (21.4±5.6% vs 26.1±4.0 %, P=.007 and 79±44 vs 32±22 mseconds, P

The aim of this study was to evaluate the impact of balloon pulmonary valvuloplasty on longitudinal ventricular dysfunction and cardiac dyssynchrony in children with congenital moderately severe pulmonary stenosis (PS). Forty-eight children with congenital moderately severe valvular pulmonary stenosis and 36 age-matched normal children were included. Successful percutaneous balloon pulmonary valvuloplasty was performed for children with PS. Longitudinal Cardiac function and myocardial synchrony was assessed by echocardiography with tissue Doppler imaging (TDI). Mitral annular plane excursion (MAPSE), tricuspid annular plane excursion (TAPSE), left ventricular systolic wave (LVs), right ventricular systolic wave (RVs) and myocardial synchrony was assessed by echocardiography with TDI. TAPSE, RVs, TAPSE/MAPSE ratio and RVs/LVs ratio were significantly lower in children with PS compared to control subjects: (P

Long-standing aortic stenosis (AS) results in fibrotic changes that often persist after transcatheter aortic valve replacement (TAVR). Fibrosis in AS preferentially affects the left ventricular (LV) basal segments and can lead to ventricular dyssynchrony. We hypothesize that basal longitudinal

Introduction Increased QRS duration (QRSd) and left ventricular dyssynchrony are associated with worse outcomes in heart failure (HF). The implication of QRSd on left ventricular ejection fraction (LVEF) trajectories among patients with severe decompensated systolic HF is unclear. Methods Patients hospitalized with HF between 2014-2018 with an LVEF ≤ 35% and at least two echocardiograms with LVEF assessments were included. Patients received guideline-directed medical and device therapies. Survival was assessed for up to 4 years after the index admission. LVEF trajectory was defined as the difference between the lowest LVEF and the highest LVEF, multiplied by -1 if the lowest LVEF was more recent than the highest LVEF. Linear regression was used to evaluate the association between LVEF trajectory and QRSd, and logistic regression was used to assess survival based on QRSd and LVEF trajectory. Results Among 1,674 patients (65.3 ± 14.2 years, 35.9 % female), 39% had QRSD > 120 ms. The lowest LVEF was 26.7% ± 9.7%, the highest LVEF was 45.5% ± 14.5%, and the LVEF trajectory had a median of 5% with an interquartile range of -10% to +25%. The frequency of QRSd less than 120 ms, 120-149 ms, and greater than or equal to 150 ms were 60.5%, 20.5%, and 19.5% respectively. Increasing QRSd was associated with more negative LVEF trajectories (r = -0.24, p Conclusions Increasing QRS duration in HF is associated with worsening LVEF trajectories and increased mortality despite contemporary guideline-directed medical and device therapy. The effect of QRS duration on survival appears to be mediated both by its impact on LVEF trajectory and mechanisms independent of the LVEF trajectory.

Introduction Asymptomatic Diaphragmatic Stimulation (ADS) is a novel device-based HF therapy under investigation. Prior studies have shown that ADS transiently modulates intrathoracic pressure, thereby reducing intra-cardiac pressures and increasing stroke volume. Hypothesis Chronic ADS therapy using a novel system delivered via a trans-abdominal laparoscopic approach improves heart failure function and exercise tolerance in patients with HFrEF but without ventricular dyssynchrony. Methods Patients with moderately severe symptoms, LVEF ≤35% but no evidence of ventricular dyssynchrony underwent laparoscopic implantation of the VisONE ADS system (NCT03484780). Post implant in-clinic tests were conducted to determine the acute effects of ADS on cardiac function at stimulation levels imperceptible to the patient. At discharge, therapy was programmed to chronically deliver ADS. Patients will be followed for 12 months to assess measures of cardiac function, HF status, diaphragmatic function, and standard safety measures. Baseline and one month data are reported as median [IQR]. Results Fifteen men (60 [56, 67] years, EF 27 [23, 33] %, NYHA class II (53%)/III (47%), 100% sinus rhythm) received implants. Temporary activation of ADS post implant while conscious increased CO (4.8 [4.0, 5.4] vs. 5.7 [4.5, 5.9] l/min, p Conclusions These data suggest that the ADS system can be implanted safely with a short in-hospital stay. Acute improvements to cardiac output and key measures of heart failure after 1 month without ADS related events are encouraging. Further investigation of ADS in randomized clinical trials should be considered.

In Figure 3, sensitivity and specificity were interchanged. The corrected Figure 3 is shown below. The author names listed in reference 14 have been corrected; the correct reference reads: Nakanishi R, Gransar H, Slomka P, Arsanjani R, Shalev A, Otaki Y, et al. Predictors of high-risk coronary artery disease in subjects with normal SPECT myocardial perfusion imaging. J Nucl Cardiol 2016;23:530-41. The units of standard deviation (SD) and bandwidth (BW) in the abstract, results and in table 3 are expressed in degrees from 0 to 360°.

Background Right ventricular pacing (RVP) is the main treatment of symptomatic bradycardia. But it is well established that cardiac pacing induces electrical and mechanical left ventricular dyssynchrony. Purpose Evaluate the effect of RVP on the incidence of heart failure (HF) in patients implanted for symptomatic bradycardia. Methods The study was prospective, observational, including all consecutive patients implanted in our center between 2009 January and 2014 December for symptomatic bradycardia. HF diagnosis was based on clinical data, natriuretic peptides dosage and echocardiography. The follow up was done every 6 months. The cumulative HF rates were estimated using the Kaplan-Meier method, and variables associated with the risk of HF were identified by the Cox model. Results We included 986 patients, with a mean age of 74.6 ± 8.3 years, and 58.6% of men. A total of 675 (68.4%) had a second or third atrioventricular block and the others a sinus node dysfunction. The proportions of NYHA class I, II, III and IV at inclusion were 28.6%, 49.7%, 17.4% and 4.3% respectively. The mean left ventricular ejection fraction (LVEF) was 0.51 ± 0.10. After a median follow-up of 47.8 months, the cumulative rate of HF was 13.6% (CI 95%: 11.2%–16.0%). Predictive factors of HF occurrence were NYHA class (HR: 3.08; CI 95%: 2.45–4.41, for class II to IV versus class I); history of HF (HR: 2.10; CI 95%: 1.60–2.90); LVEF (HR: 2.13; CI 95%: 1.56–3.02, for LVEF ≤ 0.40 versus > 0.40); history of atrial fibrillation (HR: 1.48; CI 95%: 1.1–2.25); the percentage of ventricular pacing (HR: 3.26; CI 95%: 2.11–5.43; for %VP ≥ 90% versus Conclusions RVP is independently associated with the risk of HF. Using algorithms minimizing unnecessary RVP and cardiac resynchronization therapy in some cases could reduce the incidence of the “pacing induced cardiomyopathy”.

The evolving indications and uses for implantable cardiac devices have led to a significant increase in the number of implanted devices each year. Implantation of endocardial leads for permanent pacemakers and cardiac defibrillators can cause many delayed complications. Complications may be mechanical and related to the interaction of the device leads with the valves and endomyocardium, e.g., perforation, infection, and thrombosis, or due to the electrical pacing of the myocardium and conduction abnormalities, e.g., left ventricular dyssynchrony. Tricuspid regurgitation, another delayed complication in these patients, may be secondary to both mechanical and pacing effects of the device leads. Echocardiography plays an important role in the diagnosis of these device-related complications. Both two-dimensional transthoracic echocardiography and transesophageal echocardiography provide useful diagnostic information. Real time three-dimensional echocardiography is a novel technique that can further enhance the detection of lead-related complications.

Plasma BNP and high-sensitivity cardiac troponin-T (hs-TnT) are elevated by both ischaemia and LV systolic dysfunction (LVSD). As a result, it is unknown whether BNP and/or hs-TnT could be useful biomarkers to identify ischaemia in the presence of LVSD.Three separate patient populations were studied. Study A (n = 500) involved consecutive patients undergoing clinically indicated myocardial perfusion scintigraphy, study B (n = 100) included patients with vascular disease but no known cardiac disease, and study C (n = 300) recruited primary prevention patients with controlled risk factors. Levels of BNP and hs-TnT were measured prior to the stress testing to detect myocardial ischaemia. The prevalence of myocardial ischaemia was 28.2, 28, and 6.3% in study A, B, and C, respectively. For BNP, area under curve (AUC) values to identify ischaemia in the presence and absence of coincidental LVSD were: 0.73 vs. 0.63 (study A), 0.90 vs. 0.81 (study B), and 0.83 vs. 0.80 (study C). Equivalent figures for hs-TnT were: 0.64 vs. 0.60 (study A), 0.75 vs. 0.68 (study B), and 0.53 vs. 0.68 (study C). BNP and hs-cTnT, when combined together, performed better with an AUC of 0.75 vs. 0.65 (study A), 0.91 vs. 0.92 (study B), and 0.84 vs. 0.83 (study C).In three separate populations a consistent finding is that BNP is increased further by myocardial ischaemia even in the presence of LVSD. A disproportionately high BNP for the degree of LVSD might be due to (unsuspected) ischaemia, and a disproportionately low BNP could be useful as a 'rule out' test for ischaemia even in the presence of LVSD.

PURPOSE To define which circumferential strain MR-tagging metrics of left intraventricular dyssynchrony better identifies patients with systolic dysfunction against control subjects. MATERIALS AND METHODS One hundred fifty subjects were studied: (i) controls with ejection fraction (EF) > 55% (n = 84), (ii) patients with EF ≤ 55% not eligible for cardiac resynchronization therapy (CRT) (n = 52), and (iii) patients eligible for CRT according to the ESC guidelines (n = 14). Tagging cine MR-based circumferential filtered strain curves were extracted. Six dyssynchrony indices were studied: standard deviation (SD) of peak strain (SD_Ecc_ES), SD of time-to-peak (SD_TTP), strain delay index (LIM), regional variance vector (RVV), circumferential uniformity ratio estimate (CURE), and uniformity of strain TTP (US_TTP). RESULTS All metrics show significant differences between the three groups (ANOVA, P < 10(-4) ) and are correlated with EF. Significantly higher AUC values of ROC curves between patients with normal vs. decreased EF were obtained with SD_TTP (0.998) and CURE (0.995). Agreement among different methods was fair to good (kappa 0.32 to 0.89). Interobserver variability was best for CURE (1.2%) and US_TTP (0.8%) while more than 3-times larger for other metrics. CONCLUSION SD_TTP and CURE are the most discriminant dyssynchrony metrics for systolic dysfunction. However, taking into account the method's variability argues in favor of indices of uniformity of the strain, ie, CURE and US_TTP.

To analyze whether left ventricular dyssynchrony (LVD) at baseline is predictive for long-term outcome in heart failure (CHF) patients with left ventricular (LV) dysfunction and conduction disturbances treated with cardiac resynchronization therapy (CRT).In 535 consecutive individuals with CHF scheduled for implantation of a CRT device, LVD was assessed by tissue Doppler imaging (TDI), defined as an electromechanical delay (EMD) difference of ≥40 ms in 2 opposed left ventricular wall regions (septal vs. lateral, anterior vs. inferior). All-cause mortality, heart transplantation, or assist device implantation was defined as combined primary end point. Secondary end points were measures of reverse LV remodeling and of symptomatic improvement.Mean follow-up was 68 ± 36 [range: 4-150] months. LVD at baseline was present in 308 patients (61%). Of these, 24% reached the combined primary endpoint in contrast to 58% of patients without LVD (p0.001). Furthermore, patients with LVD showed pronounced improvement of all secondary end point parameters. In our cohort LVD was an independent predictor for outcome (hazard ratio [95% CI]: 0.30 [0.21-0.42], p0.001).LVD at baseline as assessed by TDI is associated with a more pronounced clinical improvement and is a predictor for transplant-free long-term survival in CRT recipients.

Background: CRT is indicated for patients with severely impaired left ventricular systolic function and ventricular dyssynchrony who remain symptomatic despite optimal medical therapy. CRT is an expensive treatment with a significant non-responder rate. Objective: To ensure appropriate use of this treatment modality, we decided to investigate whether clinical parameters can predict response to CRT in our patients. Methods: We retrospectively reviewed all CRT patients under responder based on pre-specified ECHO and clinical criteria. An ECHO response would be: relative improvement from baseline left ventricular ejection fraction (EF) of N 15%; and a decrease in End Diastolic Volume index (EDVi) or End Systolic Volume index (ESVi) of N 15%. Clinical response was defined as an improvement of at least 1 NYHA functional class. Patients who fulfil both ECHO and clinical criteria are considered responders our follow-up since 2014. We classified them as responder or non.

Myocardial perfusion imaging is a widespread technique with proven added value for CAD diagnosis, prognostication, and therapeutic monitoring. In the last decade, there have been many improvements in gammacamera hardware, software reconstructions algorithms including resolution recovery methods, and cardiac evaluation software. This has led to shortening of the acquisition time as compared to previous guidelines, going from 30 seconds down to 15 seconds per projection (the so-called ‘‘half-time’’ acquisition). Gating the acquisition with ECG has the ability to measure cardiac wall motion and thickening and left ventricular systolic and diastolic volumes, as well as ejection fraction (EF). The shortening of the acquisition time brings advantages in terms of images degradation due to patient movement, upwards heart creep in poststress period, patients throughput, as well as in patients comfort at the expense of perfusion defects detectability due to increase in image noise. A developing application of gated-SPECT MPI has been the investigation of left ventricular dyssynchrony using the phase analysis technique. This method delivers unique information about the intrinsic contractile ventricular properties, which can help deciding on which to refer patients to resynchronization therapy, as well as adding prognostication. There has not been any investigation published on examining the effect of SPECT acquisition time reduction on phase analysis. This is exactly the aim of the work by Kortelainen and co-authors published in this issue. The authors investigated the relation of left ventricular functional parameters and phase histogram to acquisition time reduction in a population of 24 patients referred for stress/rest gated-SPECT MPI. Among these patients, 20 (83%) had at least some slight perfusion abnormalities at rest and 9 (37.5%) patients had previous cardiac infarct or heart failure. Methodologically, the authors used listmode acquisitions and recording of the ECG to mimic shorter acquisition times (80%, 60%, 50%, 40%, 30%, 20%) than the initial 30 seconds per projection (100%). In a nutshell, the authors found that reducing acquisition time from 30 seconds down to 15 seconds had no clinically significant effect in left ventricular EF (Figure 1), wall motion, or wall thickening. When decreasing acquisition time further, statistically lower values were noted in end diastolic volume (EDV) and stroke volume (SV). Interestingly, end systolic volume (ESV) and EF were not affected (Figure 1). In contrary, contrast-to-noise ratio (CNR) already presented significant differences when acquisition time was reduced down to 60% (18 seconds per projection), with differences at half-time acquisition reaching -15% and -11% for systolic and diastolic CNR, respectively. Moreover, it was the same with phase analysis, where already statistically significant differences were encountered when the acquisition duration was only decreased to 80% (phase histogram bandwidth, BW), or 60% (phase histogram standard deviation, StDev and entropy, ENT), with already large errors at half-time acquisition See related article, pp. 643–651

In our study, we investigated the impact of papillary muscle systolic dyssynchrony (DYS-PAP) obtained by 2D speckle-tracking echocardiography (2D-STE) in the prediction of recurrent ischemic mitral regurgitation (MR) after restrictive annuloplasty.The study population consisted of 524 consecutive patients who survived coronary artery bypass grafting (CABG) and restrictive annuloplasty, performed between 2001 and 2010 at 3 different Institutions and who met inclusion criteria. The assessment of DYS-PAP was performed preoperatively and at follow-up (median 45.3 months [IQR 26-67]) by 2D-STE in the apical four-chamber view for the anterolateral papillary muscle (ALPM) and apical long-axis view for the posteromedial papillary muscle (PMPM).Recurrence of MR (≥ 2+ in patients with no/trivial MR at discharge) was found in 112 patients (21.3%) at follow-up. Compared to patients without recurrence of MR, these patients had higher DYS-PAP values at baseline (60.6 ± 4.4 ms vs. 47.2 ± 2.9 ms, p0.001) which significantly worsened at follow-up (74.4 ± 5.2 ms, p=0.002 vs. baseline). In contrast, in patients with no MR recurrence, DYS-PAP was significantly reduced (25.3 ± 4.4 ms, p=0.002 vs. baseline). At logistic regression analysis DYS-PAP (odds ratio [OR]: 4.8, 95% Confidence Interval [CI]: 3.4-8.2, p0.001), was the strongest predictor of recurrent MR with a cutoff ≥ 58 ms (95%CI 51-66 ms). The model showed an area under the Receiver Operating Characteristic (ROC) curve of 0.97 (CI 0.94-0.99 [optimism-corrected 0.94; CI 0.89-0.95]) with 98% sensitivity (CI 96-100% [optimism-corrected 95%; CI 91-96%]) and 90% specificity (CI 85-94% [optimism-corrected 87%; CI 82-90%]).DYS-PAP represents a reliable tool to identify patients with ischemic MR who can benefit from restrictive annuloplasty.

Left ventricular (LV) dyssynchrony reduces LV systolic function in patients with heart failure (HF). However, it remains unknown whether this relationship is independent of impaired LV myocardial perfusion.A total of 105 patients with chronic HF (age 71 ± 13 years; 71 men) were enrolled in the present study. (99m)Tc-sestamibi (MIBI) gated myocardial scintigraphy was performed at rest to assess LV myocardial perfusion as evaluated by the total defect score of perfusion Single Photon Emission Computed Tomography images (TDS-MIBI), LV systolic function as evaluated by LV ejection fraction (LVEF), and LV systolic dyssynchrony as evaluated by the maximal difference of time to end systole (MD-TES), which is the time lag between the earliest and the latest end systole among 17 LV segments analyzed with a novel program, "cardioGRAF". The mean ± SD (minimum and maximum range) of the MD-TES was 147.8 ± 117.5 (14.0-458.3)ms. The MD-TES was significantly higher in patients with LVEF45% (199.4 ± 117.6 ms) than in those with LVEF ≥ 45% (60.5 ± 41.2 ms, p0.001). In a multiple logistic regression analysis, the MD-TES showed an increased odds ratio for LVEF45% (2.46 [95% CI; 1.51-4.01] per increment in decile of MD-TES rank, p0.001), after adjusting for the TDS-MIBI, history of myocardial infarction, and other potential confounders.LV dyssynchrony is a significant determinant of LV systolic dysfunction in patients with HF, and this relationship is independent of impaired LV myocardial perfusion and history of myocardial infarction.

The relationship between accessory pathway-mediated ventricular preexcitation and left ventricular dyssynchrony-induced dysfunction has been described in patients with Wolff-Parkinson-White (WPW) syndrome in the absence of sustained supraventricular tachycardia (SVT). Supraventricular tachycardia in infants is usually successfully suppressed with antiarrhythmic medications, but catheter ablation has ultimately been required as definitive treatment in medically resistant cases. Catheter ablation has not been described in young infants for dyssynchrony-related dilated cardiomyopathy in the absence of SVT. We describe a case of an infant with WPW who did not have sustained supraventricular tachycardia, but who developed rapid progression of ventricular dysfunction after birth. Preexcitation could not be medically suppressed but was successfully ablated. This was followed by complete resolution of ventricular dysfunction within 2 months.