Pulsed wave tissue Doppler imaging for the quantification of contractile reserve in stunned, hibernating, and scarred myocardium

Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023

Central Illustration : Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023 Proposal for including strain in the integrated diastolic function assessment algorithm, adapted from Nagueh et al.67 Am: mitral A-wave duration; Ap: reverse pulmonary A-wave duration; DD: diastolic dysfunction; LA: left atrium; LASr: LA strain reserve; LVGLS: left ventricular global longitudinal strain; TI: tricuspid insufficiency. Confirm concentric remodeling with LVGLS. In LVEF, mitral E wave deceleration time < 160 ms and pulmonary S-wave < D-wave are also parameters of increased filling pressure. This algorithm does not apply to patients with atrial fibrillation (AF), mitral annulus calcification, > mild mitral valve disease, left bundle branch block, paced rhythm, prosthetic valves, or severe primary pulmonary hypertension.

Updated knowledge and practical implementations of stress echocardiography in ischemic and non-ischemic cardiac diseases: an expert consensus of the Working Group of Echocardiography of the Hellenic Society of Cardiology

Stress echocardiography (SE) is a well-established and valid technique, widely-used for the diagnostic evaluation of patients with ischemic and non-ischemic cardiac diseases. This statement of the Echocardiography Working Group of the Hellenic Society of Cardiology summarizes the consensus of the writing group regarding the applications of SE, based on the expertise of their members and on a critical review of current medical literature. The main objectives of the consensus document include a comprehensive review of SE methodology and training, focusing on the preparation, the protocols used and the analysis of the SE images and an updated, evidence-based knowledge about SE applications on ischemic and non-ischemic heart diseases, such as in cardiomyopathies, heart failure and valvular heart disease.

Taxonomy of segmental myocardial systolic dysfunction

The terms used to describe different states of myocardial health and disease are poorly defined. Imprecision and inconsistency in nomenclature can lead to difficulty in interpreting and applying trial outcomes to clinical practice. In particular, the terms ‘viable’ and ‘hibernating’ are commonly applied interchangeably and incorrectly to myocardium that exhibits chronic contractile dysfunction in patients with ischaemic heart disease. The range of inherent differences amongst imaging modalities used to define myocardial health and disease add further challenges to consistent definitions. The results of several large trials have led to renewed discussion about the classification of dysfunctional myocardial segments. This article aims to describe the diverse myocardial pathologies that may affect the myocardium in ischaemic heart disease and cardiomyopathy, and how they may be assessed with non-invasive imaging techniques in order to provide a taxonomy of myocardial dysfunction.

Mitochondrial-Targeted Molecular Imaging in Cardiac Disease

The present study aimed to discuss the role of mitochondrion in cardiac function and disease. The mitochondrion plays a fundamental role in cellular processes ranging from metabolism to apoptosis. The mitochondrial-targeted molecular imaging could potentially illustrate changes in global and regional cardiac dysfunction. The collective changes that occur in mitochondrial-targeted molecular imaging probes have been widely explored and developed. As probes currently used in the preclinical setting still have a lot of shortcomings, the development of myocardial metabolic activity, viability, perfusion, and blood flow molecular imaging probes holds great potential for accurately evaluating the myocardial viability and functional reserve. The advantages of molecular imaging provide a perspective on investigating the mitochondrial function of the myocardium in vivo noninvasively and quantitatively. The molecular imaging tracers of single-photon emission computed tomography and positron emission tomography could give more detailed information on myocardial metabolism and restoration. In this study, series mitochondrial-targeted ^99mTc-, ¹²³I-, and ¹⁸F-labeled tracers displayed broad applications because they could provide a direct link between mitochondrial dysfunction and cardiac disease.

Myocardial viability: what we knew and what is new

Some patients with chronic ischemic left ventricular dysfunction have shown significant improvements of contractility with favorable long-term prognosis after revascularization. Several imaging techniques are available for the assessment of viable myocardium, based on the detection of preserved perfusion, preserved glucose metabolism, intact cell membrane and mitochondria, and presence of contractile reserve. Nuclear cardiology techniques, dobutamine echocardiography and positron emission tomography are used to assess myocardial viability. In recent years, new advances have improved methods of detecting myocardial viability. This paper summarizes the pathophysiology, methods, and impact of detection of myocardial viability, concentrating on recent advances in such methods. We reviewed the literature using search engines MIDLINE, SCOUPS, and EMBASE from 1988 to February 2012. We used key words: myocardial viability, hibernation, stunning, and ischemic cardiomyopathy. Recent studies showed that the presence of viable myocardium was associated with a greater likelihood of survival in patients with coronary artery disease and LV dysfunction, but the assessment of myocardial viability did not identify patients with survival benefit from revascularization, as compared with medical therapy alone. This topic is still debatable and needs more evidence.

Determinants of contractile reserve in viable, chronically dysfunctional myocardium

There is considerable variability in the sensitivity of inotropic reserve to identify viability in chronically dysfunctional myocardium. This is partially related to the underlying pathophysiology, with more frequent contractile reserve in chronically stunned (with normal resting perfusion) than hibernating myocardium (with reduced flow). This study was undertaken to determine the physiological responses to transient and graded stimulation in chronically stunned and hibernating myocardium to define the relative roles of acute catecholamine desensitization and biphasic responses. Pigs were chronically instrumented with a fixed left anterior descending artery stenosis that resulted in chronically stunned myocardium after 2 mo. One month later, hibernating myocardium was confirmed by regional dysfunction (wall thickening, 3.2 +/- 0.3 vs. 5.5 +/- 5 mm in remote, P=0.01) with reduced resting flow (0.70 +/- 0.07 vs. 0.92 +/- 0.09 ml x min(-1) x g(-1) in remote, P=0.01) without infarction. Wall thickening in dysfunctional regions significantly increased during both graded and transient epinephrine stimulation in chronically stunned (from 3.6 +/- 0.3 to 5.6 +/- 0.5 and 4.9 +/- 0.5 mm, respectively) and hibernating myocardium (from 3.3 +/- 0.3 to 5.4 +/- 0.6 and 5.0 +/- 0.7 mm, respectively) and returned to baseline within 15 min. Although a biphasic response during graded stimulation was common, the subsequent decrement in function was small and similar in both groups (stunned, 0.7 +/- 0.2 mm; hibernating, 1.1 +/- 0.3 mm, P=0.25). We conclude that 1) the extent of contractile reserve during beta-adrenergic stimulation is similar in chronically stunned and hibernating myocardium, 2) there are no significant differences between the responses to transient compared with graded catecholamine stimulation, and 3) submaximal catecholamine stimulation does not induce additional stunning in either chronically stunned or hibernating myocardium.

Predictive accuracy of tissue Doppler imaging for assessment of noninfarct myocardial region in patients with acute myocardial infarction

OBJECTIVES

To investigate the value of pulsed tissue Doppler imaging (TDI) in order to predict significant coronary artery stenosis supplying the noninfarct region in patients after acute anterior myocardial infarction.

SUBJECTS AND METHODS

Transthoracic echocardiography and coronary angiography were performed on 220 patients with acute anterior myocardial infarction. The TDI-derived variables of the mitral valve annulus in the noninfarct region, systolic velocity (Sm), early diastolic velocity (Em) and late diastolic velocity (Am), were estimated in centimeters per second, and the Em/Am ratio was calculated.

RESULTS

Predictive indices revealed that the impaired TDI-derived variables, Sm, Em, Am and the Em/Am ratio, were an indicator for predicting significant coronary stenosis in the noninfarct region. Multivariate analysis revealed that the impaired Sm and Em velocities were significantly associated with age of the patients, coronary collaterals and infarct-related artery stenosis (p < 0.05). Receiver-operating characteristic curve data of TDI-derived variables for prediction of significant coronary stenosis revealed that the cut-off values of Sm, Em, Am and Em/Am ratio were 7.2 cm/s, 6.4 cm/s, 12.1 cm/s and 0.56, respectively. The kappa coefficient value indicated that there was an agreement between coronary angiography and the TDI-derived variables Sm, Em, Am and Em/Am ratio in noninfarct regions (kappa = 0.770, 0.731, 0.693 and 0.679, respectively). There was a significant correlation between the severity of coronary artery stenosis (independent variable) and impaired Sm and Em/Am ratio (dependent variables), y = 11.5 - 0.05x, r = -0.902, (p < 0.05), and y = - 0.14x + 1.87, r = -0.754, (p < 0.05), respectively.

CONCLUSION

TDI can be used to identify patients with significant stenosis of the coronary arteries supplying the noninfarct region and consequently may be helpful in considering patients for coronary angiography in the early postinfarction period.

Mechanisms leading to reversible mechanical dysfunction in severe CAD: alternatives to myocardial stunning

Patients with severe chronic coronary artery disease (CAD) exhibit a highly altered myocardial pattern of perfusion, metabolism, and mechanical performance. In this context, the diagnosis of stunning remains elusive not only because of methodological and logistic considerations, but also because of the pathophysiological characteristics of the myocardium of these patients. In addition, a number of alternative pathophysiological mechanisms may act by mimicking the functional manifestations usually attributed to stunning. The present review describes three mechanisms that could theoretically lead to reversible mechanical dysfunction in these patients: myocardial wall stress, the tethering effect, and myocardial expression and release of auto- and paracrine agents. Attention is focused on the role of these mechanisms in scintigraphically “normal” regions (i.e., regions usually showing normal perfusion, glucose metabolism, and cellular integrity as assessed by nuclear imaging techniques), in which stunning is usually considered, but these mechanisms could also operate throughout the viable myocardium. We hypothesize that reversion of these three mechanisms could partially explain the unexpected functional benefit after reperfusion recently highlighted by high-spatial-resolution imaging techniques.

Strain Rate Dobutamine Echocardiography for Prediction of Recovery After Revascularization in Patients With Ischemic Left Ventricular Dysfunction

BACKGROUND

The purpose of the present study was to assess the accuracy of quantitative segmental analysis by strain rate imaging (SRI) technique during dobutamine test for detecting myocardial recovery after revascularization in patients with chronic ischemic regional left ventricular (LV) dysfunction and compare results with those of 2-dimensional echocardiography (2D) and tissue Doppler imaging (TDI) as well as rest-4 hours-24 hours redistribution thallium SPECT (Tl SPECT).

METHODS AND RESULTS

Forty-one patients with chronic ischemic regional LV dysfunction (EF 29 +/- 8%) underwent dobutamine 2D/TDI/SRI and Tl SPECT before and after myocardial revascularization. The sensitivity, specificity, and accuracy for the recovery of regional LV function were 73%, 81%, and 77% for dobutamine 2D; 77%, 82%, and 80% for dobutamine TDI; 86%, 88%, and 85% for dobutamine SRI; and 94%, 76%, and 84% for Tl tomography. The area under the ROC curve (AUC), which reflects the overall performance for the prediction of recovery, was 0.79 for systolic-SR, 0.81 for Tl SPECT, 0.83 for postsystolic strain, and 0.87 for isovolumic-SR. If both systolic and postsystolic SRI indexes were combined with Tl SPECT, the AUC was improved to 0.94.

CONCLUSIONS

Dobutamine SRI is more accurate than TDI in identifying hibernating myocardium. Systo-diastolic values obtained using dobutamine SRI echocardiography and values derived from nuclear perfusion techniques may be complementary in assessing myocardial viability.

Stress echocardiography for the diagnosis of coronary artery disease: progress towards quantification

PURPOSE OF REVIEW

This review highlights recent progress in the quantitative approach to the interpretation of stress echocardiograms. Recent literature regarding the application of tissue Doppler and strain rate imaging for the diagnosis of coronary artery disease is summarized.

RECENT FINDINGS

The high temporal and spatial resolution of tissue Doppler and strain rate imaging permit recognition of regional myocardial dysfunction. These techniques have been performed during low- and high-dose dobutamine stress echocardiography and have been applied to exercise echocardiography. During stress, the peak systolic velocity and early diastolic velocity increased to a greater degree in normal segments compared to ischemic segments. With tissue Doppler imaging, viable segments show increases in systolic velocities in contrast to infarcted segments. Presently, the feasibility of strain rate imaging is slightly less than that of conventional wall motion assessment. However, in preliminary studies, tissue Doppler parameters and especially strain rate parameters appear to offer advantages in accuracy compared to conventional wall motion assessment.

SUMMARY

Tissue Doppler and strain rate imaging offer great promise for the accurate, reproducible quantification of regional myocardial function. Further studies are indicated to prove their accuracy, efficiency, and superiority over existing methods.

Pulsed tissue Doppler imaging for the detection of myocardial ischaemia, a comparison with myocardial perfusion SPECT

In order to compare the diagnostic ability of pulsed tissue Doppler and myocardial perfusion Single Photon Emission Computed Tomography (SPECT) in patients with a history of unstable coronary artery disease, CAD, 26 patients, 22 men and four women, age 47-76 years, were investigated in a prospective study, 5-10 day after an episode of unstable angina. Tissue Doppler and two-dimensional echocardiography were performed during dobutamine stress testing and myocardial scintigraphy after bicycle exercise and at rest. Patients with a normal SPECT had higher peak systolic velocity during dobutamine infusion, 18.9 +/- 4.1 cm s(-1), than patients with ischaemia, 12.2 +/- 3.8 cm s(-1) (P<0.001) or scar, 8.8 +/- 3.0 cm s(-1) (P<0.01). In a territorial analysis the difference in peak systolic velocity between areas with a normal and abnormal SPECT was less apparent. Failure to achieve >/=13 cm s(-1) in mean-peak systolic velocity was the most accurate criterion for detection of significant CAD on SPECT. We conclude that pulsed tissue Doppler can be used for objective quantification of left ventricular wall motion during dobutamine stress testing and for identification of patients with CAD on SPECT but not for identification of regional ischaemia.