Relative apical sparing in severe aortic stenosis: does it mean concomitant amyloid cardiomyopathy?

Background

Relative apical sparing (RAS) of left ventricular (LV) longitudinal strain (LS) is a red flag marker for the suspicion of amyloid cardiomyopathy. However, it has also been described in patients with severe aortic stenosis (AS).

Aim

To assess the prevalence of RAS in patients with severe symptomatic AS referred for surgical aortic valve replacement (AVR), to evaluate its clinical significance and assess its presence after surgery.

Methods

We prospectively studied 135 consecutive patients (age: 73 y [IQR 68–77 y], 49% men) with severe symptomatic AS – mean transaortic pressure gradient (AVmean): 60.9±17.7 mmHg; mean aortic valve area: 0.7±0.2 cm2, referred for surgical AVR with no previous history of ischemic cardiomyopathy or other. Beyond 12 lead-ECG and transthoracic echocardiography (TTE), all patients underwent cardiac magnetic resonance (CMR) before surgery. RAS was defined by the ratio >1 of average LS at apical segments/sum of the average basal and mid LS at speckle tracking analysis. AVR with septal myocardial biopsy, for investigational purposes, was performed in 80 patients. AS severity indexes, LV remodeling and tissue characterization parameters were compared in both groups of patients, with and without RAS. LS deformation pattern was reassessed at 3–6 months after AVR.

Results

RAS was present in 24 patients (18%). In the whole cohort there were neither pseudoinfarct pattern or low voltage ECG criteria, nor infiltration suspicion from CMR (native T1 value 1053 ms [IQR 1025–1071 ms] for institutional reference values: 972–1070 ms; ECV 24% [IQR 21–27%]). None of the patients had amyloid deposition at histopathology. Overall, mean CMR LV ejection fraction (LVEF) was 59.6±10.5% and 98 patients (74%) had non-ischemic delayed enhancement, with a median fibrosis fraction of 4.1% [IQR 1.6–7.8%]. RAS cohort had a significantly higher AVmean gradient, relative wall thickness, maximum septal thickness, peak systolic dispersion, with lower global LS at TTE, as well as higher LV mass and lower LVEF at CMR. RAS group has also higher NT-proBNP ambulatory values (Table 1). Follow-up evaluation after AVR revealed RAS disappearance in 19 patients (79.2%).

Conclusions

RAS occurs in almost one-fifth of the patients in this cohort despite the absence of signs of myocardial infiltration. This deformation pattern elapses with worse indexes of LV remodeling consistent with a more advanced stage of the disease, being reversible after AVR, which stands for the absence of concomitant myocardial infiltration.

Funding Acknowledgement

Type of funding sources: None.

Histology-verified myocardial fibrosis and quantification in severe AS patients: correlation with non-invasive LV myocardial tissue assessment

Background

Myocardial fibrosis (MF) is a common finding and a potential adverse prognostic marker in several cardiac diseases, including in severe aortic stenosis (AS). While histological analysis obtained through endomyocardial biopsy remains the gold-standard for MF assessment, non-invasive cardiac imaging may offer surrogate biomarkers for fibrosis. We tried to assess the correlation between MF quantification at histopathology and cardiac magnetic resonance (CMR)-derived tissue characterization data in patients with severe AS.

Methodology

Single-center prospective cohort enrolling 71 patients with severe symptomatic high-gradient AS undergoing surgical aortic valve replacement (SAVR) (mean age 71±9 years; 49% male, mean valvular transaortic gradient 60±20 mmHg; mean left ventricle [LV] ejection fraction 58±9%). Those with past history of myocardial infarction or cardiomyopathy were excluded. All patients underwent pre-operative CMR study with LV tissue characterization and quantification. Normal T1 mapping value was defined as >1021ms as per center protocol. Myocardial tissue was obtained during SAVR either through myocardial biopsy at basal LV septum or harvested from surgical myectomy specimens. Masson's trichrome stain was used for collagen/fibrosis assessment. Automatic quantification was obtained at QuPathTM digital pathology software after applying a dedicated artificial intelligence algorithm on ultra-high-resolution digital slide scanning images.

Results

Histology-confirmed MF was observed in all patients (median percentage of fibrotic myocardial tissue 15% [IQR 9–22%]). Median global T1 mapping and extracellular volume (ECV) percentage was 1048ms (IQR 1027–1078) and 24% (IQR 20–30%), respectively. Late gadolinium enhancement (LGE) with a non-ischemic pattern was present in 42 patients (59%) with a median LGE mass of 5.8g [IQR 1.0–10.2]; median percentage of 3.7% [IQR 0.6–10.4]. While neither T1 mapping (global or basal LV septum), ECV nor LGE had any significant correlation with histology-confirmed MF (Figure 1) the vast majority had significantly elevated global and basal LV septum T1 mapping – 81% and 92%, respectively.

Conclusion

In this single-center prospective study, microscopic MF was present in all patients with severe symptomatic high-gradient AS, was accompanied by elevated T1 mapping values but no correlation was found between myocardial fibrosis at histopathology analysis and CMR-derived LV tissue characterization parameters. This may not only stem from sampling (single point biopsy vs. whole myocardial tissue assessment) but also from distinct evaluation of different types of fibrosis by different methods.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular remodeling in aortic stenosis patients referred for surgical aortic valve replacement

Background

Left ventricular (LV) hypertrophy is a common expected finding in aortic stenosis (AS) patients. Cardiac magnetic resonance (CMR) plays an important role as a non-invasive method for determining LV mass and volume, and to characterize the LV remodeling response in AS.

Aim

To assess the prevalence, to describe the patterns and evolution of LV remodeling (by CMR) in AS patients referred for surgical aortic valve replacement (AVR).

Methods

Single-center prospective cohort of 132 consecutive patients (73 years [68–77 years], 49% men] with severe AS: mean transaortic pressure gradient (AVmean): 61±1.5 mmHg; aortic valve area (AVA): 0.7±0.1 cm2, referred for surgical AVR, with no previous history of ischemic cardiomyopathy. Before surgery, all patients underwent electrocardiogram, complete transthoracic echocardiogram (TTE) and CMR for LV assessment and tissue characterization (mean LV indexed mass [LVMi]: 80.3±26.5 g/m2; mean end-diastolic LV indexed volume [LVEDVi]: 84.4±24.5 mL/m2 and median geometric remodeling ratio [M/V]: 0.95 g/mL [IQR 0. 81–1.08 g/mL]). Patterns of LV remodeling were investigated before and after AVR by CMR measurements of LVMi, LVEDVi and M/V. Besides normal LV ventricular structure, four other patterns were considered: concentric remodeling, concentric hypertrophy, eccentric hypertrophy, and adverse remodeling (Figure 1).

Results

Overall, 43% (n=58) of the patients had concentric hypertrophy, 30% (n=40) concentric remodeling, 22% (n=29) normal ventricular geometry, 4% (n=5) eccentric hypertrophy and in two patients we observed an adverse remodeling pattern. AVR was performed in 80 patients. At the 3rd to 6th month post-AVR assessment, LV remodeling changed to: normal ventricular geometry in 46%, concentric remodeling in 31%, concentric hypertrophy in 19%, eccentric hypertrophy in 3% and adverse remodeling in only one patient (Figure 1).

Conclusions

In this group of patients with severe aortic stenosis, concentric hypertrophy was not the sole pattern of LV remodeling and two out of every five still presented a normal ventricular geometry and mass as assessed by CMR. LV response was dynamic after AVR which stands for complex and multifactorial interaction in these group of patients despite similar valvular pathophysiology and therapeutic intervention.

Funding Acknowledgement

Type of funding sources: None.

Cardiac magnetic resonance patterns of left ventricular hypertrophy in aortic stenosis patients

Background

Left ventricular (LV) hypertrophy is a known compensatory mechanism to pressure overload in aortic stenosis (AS) patients. However, by cardiac magnetic resonance (CMR) different patterns of LV adaptation are seen in this group of patients.

Aim

To describe the patterns of LV adaptation (by CMR) and to analyze its structure and function indexes in AS patients referred for surgical aortic valve replacement (AVR).

Methods

We prospectively studied 134 consecutive patients (age: 73y [IQR 68–77y], 49% men) with severe symptomatic AS - mean transaortic pressure gradient (AVmean): 61±1.5 mmHg; mean aortic valve area: AVA): 0.7±0.1 cm2, referred for surgical AVR with no previous history of ischemic cardiomyopathy or other. All patients underwent electrocardiogram, 2D transthoracic echocardiogram (TTE) and cardiac magnetic resonance (CMR) before surgery for LV assessment and tissue characterization. Five patterns of LV structure were considered: normal ventricular structure (normal LV mass/volume ratio [M/V], normal LVMi and normal indexed LV end-diastolic volume (LVEDVi); concentric remodeling: increased M/V, normal LVMi; concentric hypertrophy: increased M/V and LVMi; eccentric hypertrophy: increased LVMi and LVEDVi, normal M/V and ejection fraction; and adverse remodeling: dilated left ventricle, increased LVMi and normal M/V in the context of an impaired ejection fraction. Echocardiogram and CMR structural and functional indexes were compared between these groups.

Results

At baseline study, at CMR: mean LV indexed mass [LVMi]: 80.3±26.5 g/m2; mean end-diastolic LV indexed volume [LVEDVi]: 84.4±24.5 mL/m2 and median geometric remodeling ratio [M/V]: 0.95 g/mL [IQR 0. 81–1.08 g/mL]. Overall, 22% patients had normal LV structure, 30% concentric remodeling ventricular geometry, and two patients had an adverse remodeling pattern. LV hypertrophy was the most prevalent pattern and occurred in 48% of subjects (concentric 43%; eccentric 4%). In our cohort, the severity of AS (AVmean (p<0.001), LV function (LV ejection fraction [p<0.001] and Global longitudinal strain [p<0.001]), LV loading conditions (indexed left atrial volume [p<0.001] and E/e' ratio [p<0.001]) and NT-proBNP (p<0.001) were related to the pattern of LV structure (Table 1).

Conclusions

In our cohort, AS patients presented several distinct patterns of LV remodeling. Disease severity, functional repercussion and loading conditions are distinct between them.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular reverse remodeling in post operative aortic stenosis patients: prevalence and predictor(s)

Background

In patients with severe aortic stenosis (AS), left ventricular (LV) remodeling is believed to be a compensatory adaptive process which should reverse after aortic valve intervention. However, this is not always the rule and remodeling persistence may negatively impact post-procedural outcomes and survival.

Aim

To assess the prevalence and predictors of morphological LV reverse remodeling in severe symptomatic AS patients after surgical aortic valve replacement (AVR).

Methods

We prospectively studied 75 patients (72y [68–77y], 45% male) with severe symptomatic AS - mean gradient (AVM): 61±17mmHg; mean indexed aortic valve area (AVAi) 0.41±0.10 cm2/m2 with no previous history of ischemic cardiomyopathy, all with high gradient, 4 with low-flow, 81% with hypertension, 27% with type 2 diabetes mellitus and 35% patients with stage 3 chronic kidney disease: median MDR creat clearance: 70.4mL/min [40–102]. All patients performed pre-operative cardiac magnetic resonance (CMR) at a mean period of 3.4 months (0–17 months) before AVR and at the 3–6th months after AVR, for LV reverse remodeling assessment. It was defined as at least the occurrence of one of the following: >15% reduction in LVEDVi; >15% reduction in LVMi by CMR; >10% reduction in geometric remodeling ratio. Clinical, AV severity data, preoperative functional LV and tissue characterization data were analyzed at multivariate regression to predict the occurrence of LV reverse remodeling.

Results

Overall, at pre-operative CMR: mean LV indexed mass (LVMi): 82±28.9 g/m2; mean end-diastolic LV indexed volume (LVEDVi): 87.4±26.6 mL/m2; mean geometric remodeling (LV mass/end-diastolic volume): 0.92±0.2 g/mL. After AVR, at echocardiographic evaluation, no patient had prosthetic obstruction or prosthetic patient mismatch: median LV-Ao gradient 12mmHg [9.1–14 mmHg]; 5 of them had mild paravalvular regurgitation. LV reverse remodeling occurred in 65 patients (88%) (Figure 1A) and these were younger, had significantly smaller preoperative AVAi and higher valvular gradients (Figure 1B). At multivariate analysis, only preoperative AVAi remained an independent predictor (odds ratio 0.85, 95% CI 0.735–0.984, p=0.029).

Conclusions

In this prospective cohort of patients LV reverse remodeling after surgical AVR was highly frequent, occurring in almost nine out of every ten patients.

Funding Acknowledgement

Type of funding sources: None.

Late gadolinium enhancement patterns in severe symptomatic high-gradient aortic stenosis

Background

Left ventricular (LV) remodeling in patients with severe aortic valve stenosis (AS) is a complex process that goes beyond hypertrophic response and may involve reparative/replacement fibrosis. Currently, cardiac magnetic resonance (CMR) is the gold-standard imaging technique for detecting focal myocardial fibrosis through late gadolinium enhancement (LGE). However, myocardial fibrosis prevalence and distribution is quite variable among series. Our goal was to assess LGE prevalence and distribution pattern in severe symptomatic high-gradient AS.

Methodology

Single-center prospective cohort of 132 patients with severe symptomatic high-gradient AS (mean age 73±11 years; 48% male, mean valvular transaortic gradient 60±20 mmHg; mean aortic valve area 0.7±0.2 cm2/m2; mean LV ejection fraction by 2D echocardiogram 58±9%), all with normal flow (except one) undergoing surgical aortic valve replacement. Those with previous history of acute myocardial infarction, ischemic cardiomyopathy or other cardiomyopathy were excluded. All patients performed 1.5T CMR assessment with LV myocardium tissue characterization prior to surgery. Segmental LGE presence was assessed by two independent operators and classified according to the AHA 16 segment model, using 5-standard deviations from remote myocardium as the signal intensity cut-off for LGE identification and quantification.

Results

Overall, 96 patients (74%) had non-ischemic LGE (median LGE mass 3.2 g [IQR 0.2–8.3] g; median percentage of LGE myocardial mass 2.5% [IQR 0.1–6.1]%); 22 patients [17%] with exclusively junctional LGE); in one patient an incidental ischemic scar (subendocardial distribution) was identified. No cases of subepicardial distribution were found. Intramyocardial LGE was most frequently observed in basal and mid-anterior and inferior interventricular septum – see Figure 1. In these segments, LGE was most often junctional at right-ventricular insertion points (54%), followed by mid-wall LGE (32%) or both sites involvement (14%).

Conclusion

LGE is frequent in symptomatic high-gradient AS patients with preserved left ventricular ejection fraction, most often presenting as junctional enhancement in basal/mid-anterior and inferior interventricular septum. Future studies may address whether distinct LGE patterns may impact patient prognosis.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular myocardial work in patients with high gradient severe symptomatic aortic stenosis

Background

Left ventricular myocardial work (LVMW) is a novel method to evaluated left ventricular (LV) function using pressure-strain loops. It might correct global longitudinal strain (GLS) for afterload, being eventually useful to assess whether GLS reduction is due to reduced contractility (reflected as reduced myocardial work) or increased afterload (reflected as increased myocardial work).

Aim

To describe indices of LVMW in a group of patients with severe symptomatic aortic stenosis (AS).

Methods

We prospectively studied 104 consecutive patients (age: 71 years [IQR 66.5–75.5] years, 51% men) with severe symptomatic high gradient AS: mean transaortic pressure gradient: 56.5mmHg [IQR 46.8–67.8]; aortic valve area: 0.73cm2 [IQR 0.61–0.88]; indexed stroke volume: 47.7±1.3 mL/m2 (11 patients with low-flow AS), preserved LV ejection fraction (EV) (LVEF: 56.0% [51.0–61.3]; GLS: −14.5% [IQR −16.1 to −10.6]), with no previous coronary artery disease and no history of cardiomyopathy. Beyond complete transthoracic echocardiography, all patients underwent cardiac magnetic resonance for LV myocardium tissue characterization. As proposed for AS, LV systolic pressure was corrected adding the mean transaortic pressure gradient to non-invasive systolic blood pressure cuff measurement in the echocardiographic algorithm. Four LVMW indices were collected in 83 patients (patients excluded for atrial fibrillation, left bundle branch block or absence of non-invasive blood pressure registration) and correlated to LV function indexes, LV hypertrophy and remodeling, myocardial tissue characterization, BNP and troponin levels (Pearson or Spearman correlation). These same indexes were compared in patients with LV ejection fraction (EF) below and above 50%, normal and reduced flow and presence of replacement fibrosis.

Results

Global constructive work (GCW) (2658.6±76.4mmHg%), global myocardial work (GMW) (2218.7±74.9mmHg%) and global wasted work (GWE) (262.0mmHg% [198.8–339.5]) were high above normal with concomitant lower work efficiency (WE) (88.0% [83.2–91.8]. Weak correlations were found between LVMW indexes and parameters describing aortic valve severity, flow and LV function (table). Except for significant differences of LVMI in patients with reduced LV ejection fraction (GCW 2770.3±687.4 vs 2056.0±380.7mmHg%, p=0,014 and GMW 2362.5±657.9 vs 1621.3±319.9, p=0,021 in patients with LV EF>50% vs. LV EF<50%, respectively) work indexes were neither significantly different in low-flow patients nor in those with myocardial late gadolinium enhancement.

Conclusions

Global constructive and myocardial work are increased in these patients with severe aortic stenosis. This might reflect an increased afterload predominance rather than a LV functional impairment, particularly relevant in this group of patients with exclusive high gradient disease and preserved LVEF.

Funding Acknowledgement

Type of funding sources: None. Correlations between LVMI – LV function

Anomalous origin of the right coronary artery with interarterial course: red flag or innocent bystander?

Aims

Anomalous origin of the right coronary artery from the opposite sinus (right-ACAOS) with interarterial course (IAC) has been associated with increased risk of sudden cardiac death (SCD). Widespread use of coronary computed tomography angiography (CCTA) has led to increasing recognition of this condition, even among healthy individuals. Our study sought to examine the prevalence, anatomical characteristics and outcomes of right-ACAOS with IAC in patients undergoing CCTA for suspected coronary artery disease (CAD).

Methods and results

We conducted a retrospective analysis of consecutive patients referred for CCTA at one tertiary hospital from January 2012 to December 2020. Right-ACAOS with IAC patients were analyzed for cardiac symptoms and long-term occurrence of first MACE (SCD, non-fatal myocardial infarction (MI) or revascularization of the anomalous vessel). CCTAs were reviewed for anatomical high-risk features and concomitant CAD. Among 10928 patients referred for CCTA, 28 patients with right-ACAOS with IAC were identified. Mean age was 55±17 years, 64% were male and 11 (39.3%) presented with stable cardiac symptoms. Most patients had at least one high risk anatomical feature. During follow-up, there were no CV deaths or aborted SCD episodes and only 1 patient underwent surgical revascularization of the anomalous vessel.

Conclusion

Right-ACAOS with IAC is an uncommon finding (prevalence of 0.26%). In a contemporary population of predominantly asymptomatic patients who survived this condition well into adulthood, most patients were managed conservatively with a low event rate. Additional studies are needed to support medical follow-up as the preferred option in this setting.

Funding Acknowledgement

Type of funding sources: None.

Prevalence and determinants of right ventricular dysfunction in patients with severe symptomatic high gradient aortic stenosis

Background

Right ventricular (RV) function in aortic stenosis (AS) has been largely neglected. Recently it was demonstrated that right ventricular impairment may be influenced by left ventricular (LV) function and afterload, well before overt pulmonary hypertension development.

Aim

To describe the prevalence of RV dysfunction in a group of patients with severe symptomatic aortic stenosis (AS) and its relation to LV function parameters and afterload.

Methods

We prospectively studied 93 consecutive patients (age: 73 years [IQR 68–77] years, 55% women) with pure severe symptomatic high gradient aortic stenosis: mean transaortic pressure gradient: 57.0mmHg [IQR 46.9–71.1]; aortic valve area: 0.72cm2 [IQR 0.61–0.88]; indexed stroke volume: 48.8±1.5 mL/m2 (11 patients with low-flow AS), preserved LV ejection fraction (EV) (LVEF: 56.0% [51.0–61.3]; GLS: −14.5% [IQR −16.1 to −10.6]), with no previous coronary artery disease and no history of cardiomyopathy. Beyond complete transthoracic echocardiography, all patients underwent cardiac magnetic resonance (CMR) for LV myocardium tissue characterization (late gadolinium enhancement and extracellular volume). Normal RV function was defined according to TAPSE ≥17mm, tricuspid annular systolic velocity ≥12cm/s, mean free wall longitudinal strain ≤−20%. Patients were divided into four groups: (0) – all three RV parameters below normal (1.1%), (1) – 1 normal parameter (12.9%), (2) – 2 normal parameters (44.1%), (3) – 3 normal parameters (41.9%). Indexes of LV systolic and diastolic function, CMR derived LV geometric remodeling, hypertrophy and tissue characterization, aortic valve disease severity and afterload were compared across the 4 groups of patients. We tried to identify predictors of RV dysfunction (group 0, 1, 2 vs. group 3) at multivariate regression analysis.

Results

Left ventricular performance parameters, diastolic and myocardial work indexes were significantly different across the groups (Figure). Neither AV severity indexes nor LV tissue characterization were distinct. At multivariate analysis only global constructive work was an independent predictor of RV dysfunction.

Conclusion

RV dysfunction is common in this group of patients with severe high gradient aortic stenosis and preserved ejection fraction. RV impairment is significantly related to several LV systolic and diastolic parameters and also to LV afterload, probably accounting for RV-LV interdependence.

Funding Acknowledgement

Type of funding sources: None.

Anomalous origin of the right coronary artery with interarterial course: red flag or innocent bystander?

Funding Acknowledgements

Type of funding sources: None.

Background

Anomalous origin of the right coronary artery (right ACAOS) with interarterial course (IAC) has been associated with increased risk of sudden cardiac death (SCD). Widespread use of coronary computed tomographic angiography (CCTA) has led to increasing recognition of this condition, even among healthy individuals. This study sought to examine the prevalence, anatomical characteristics and outcomes of right ACAOS with IAC in patients undergoing CCTA for all-indications.

Methods

We conducted a retrospective analysis of consecutive patients referred for CCTA at one tertiary hospital between January 2012 and December 2020. Right ACAOS patients with IAC were analyzed for cardiac symptoms (anginal chest pain, syncope, aborted SCD) and long-term outcomes were evaluated for myocardial infarction, ischemic test results, revascularization procedures and all-cause or cardiovascular (CV) mortality. CCTAs were reviewed for proposed high-risk features (ie., take-off angle, length and severity of proximal narrowing, intramural course, interarterial length) and concomitant coronary artery disease (CAD). Association between high-risk features was analyzed. Long-term outcomes were evaluated.

Results

Among 10,928 patients referred for CCTA during the study period, we identified 28 patients (0.3% prevalence) with right ACAOS and IAC. Mean age was 55 ± 17 years, 64% were male and 11 (39.3%) presented cardiac symptoms. During a median follow-up of 44.1 ± 31.8 months, there were no CV deaths and only 1 patient (3.65%) underwent surgical revascularization. Baseline characteristics and CCTA findings are presented in figure 1.

Conclusion

Right ACAOS and IAC is an uncommon finding, with an observed prevalence of 0.3%. CCTA provides excellent anatomical characterization of anomalous vessels, including suggested high-risk features. In a population of asymptomatic patients who survived this condition well into adulthood, the risk of events was very low and medical follow up might be a reasonable option.

Longitudinal left ventricular function in a population of healthy adults: a tissue Doppler imaging study

BACKGROUND

Longitudinal left ventricular function is a major determinant of global ventricular function and is probably more sensitive than radial function in the detection of disease. Tissue Doppler imaging of the mitral annulus allows the study of longitudinal left ventricular function.

METHODS

Forty-five healthy volunteers divided into two groups (younger and older than 45 years) were studied with pulsed tissue Doppler imaging of the 4 sides of the mitral annulus (septal, lateral, inferior, anterior) in 4 and 2 apical chamber views. In each wave (systolic-s, rapid filling-e, atrial contraction-a) we analyzed velocities, time intervals and velocity-time integrals, as well as heterogeneity and asynchrony indexes. Data were compared between the different sides in each group, between groups and with conventional Doppler data.

RESULTS

In contrast to the septal side, the lateral side of the annulus shows higher velocities and velocity-time integrals of the s and e waves, with non-significantly shorter isovolumic relaxation time and shorter time to peak e. There is functional agreement between the lateral and inferior sides versus the septal and anterior sides of the annulus. Most systolic parameters remained unchanged with aging; however, aging was associated with decreased e velocity, increased a velocity and inverted e/a ratio. The relation between s and fractional shortening also did not change with aging. Annular isovolumic contraction time and isovolumic relaxation time were shorter than their respective global time intervals.

CONCLUSIONS

This study shows that there are physiological differences in velocities, time intervals and velocity-time integrals between the 4 sides of the mitral annulus, reflecting physiological heterogeneity and asynchrony, and that some of these parameters are age dependent. These data also contribute to a better understanding of longitudinal left ventricular function and may be useful in future studies as reference values in control groups.

Tissue Doppler imaging: clinical topics for the new millenium

INTRODUCTION

Tissue Doppler imaging is an echocardiographic technique that allows the selective visualization and quantification of myocardial signals. Its aim is to complement the conventional Doppler study, adding more and better information on specific topics of cardiovascular diseases. During the first seven years of the technique, much scientific work was produced and some clinical applications of the method have emerged.

CLINICAL APPLICATIONS

I--non ischemic heart disease: The technique has been widely used in diastology, in hypertrophic cardiomyopathy, in heart transplant patients and in arrhythmology. II--ischemic heart disease: The quantitative assessment of regional diastolic and systolic function makes the technique very promising during stress echocardiography and during percutaneous transluminal coronary angioplasty.

CONCLUSIONS

In 2000, tissue Doppler echocardiography is still a young, exciting and promising technique. Despite the fact that much has already been done, there is still a long way to go, implying a great amount of time and personal investment. How often do we feel that we are building a small part of the future?

[Diastolic dysfunction and left ventricular hypertrophy in familial amyloidotic polyneuropathy: a cause-effect relationship?]

TTR Met30 Familial Amyloidotic Polyneuropathy of the Portuguese type (FAP) is an incapacitating and lethal hereditary disorder that affects predominantly young adults of both genders. Portuguese type FAP patients have sensory, motor and autonomic polyneuropathy. The generalised systemic amyloid infiltration involves the heart, leading to the characteristic granular bright sparkling echocardiographic pattern. LV wall thickening occurs in the late phases of the disease. LV diastolic dysfunction has been reported in the absence of systolic dysfunction; an abnormal diastolic transmitral flow pattern assessed by pulsed wave Doppler (PW) was described. PW is very much dependent on load conditions. Tissue Doppler imaging (TDI) has been used as a more reliable method to assess long axis diastolic function.

OBJECTIVE

1--To identify the incremental value of TDI in the assessment of diastolic function in FAP. 2--To correlate diastolic pattern abnormalities and left ventricular mass index (LVMI) in FAP patients.

METHODS

We performed a prospective evaluation of 24 consecutive FAP patients and selected 14 (sinus rhythm, age < 45 years). Diastolic function was assessed by PW and classified as normal (GI-E/A > 1) or abnormal (GII-E/A < 1). TDI was performed in 4 sites of the mitral annulus (septum, lateral, inferior, anterior). Velocities of the rapid filling wave (E') and atrial contraction wave (A') were measured and E'/A' calculated. In each site we considered the TDI as normal (E'/A' > 1) or abnormal (E'/A' < 1). The LVMI was calculated by Devereux's formula.

RESULTS

Age, gender and heart rate were similar in both groups. TDI at the septal mitral annulus was normal in all of the GI patients (E'/A': 1.29 +/- 0.19) and suggestive of abnormal LV relaxation in all of the GII patients (E'/A': 0.82 +/- 0.11, p < 0.0001). TDI revealed abnormal diastolic pattern when a restricted number of sites of the mitral annulus were assessed, even in GI patients and before PW abnormalities occurred. Fractional shortening (FS) and LVMI were similar in GI and GII (FS-GI: 45.5 +/- 5.3, GII 43.5 +/- 8.1%, p: NS; LVMI--GI: 66 +/- 9.3, GII: 67 +/- 3.0 g/m2 p: NS).

CONCLUSION

The assessment of mitral annulus motion has introduced new data in the study of diastolic function of FAP patients. An abnormal LV relaxation pattern occurred early in the evolution of the disease in patients with normal LVMI and systolic function.

Tissue Doppler imaging in different locations of the mitral annulus: all different or all the same?

BACKGROUND

The assessment of the mitral annulus motion with tissue Doppler imaging is claimed to be an accurate method to quantify global left ventricular systolic and diastolic function. However, it is not yet perfectly defined which site of the annulus must be selected. Familial amyloidotic polyneuropathy of the Portuguese type (FAP) is an hereditary systemic disease in which diastolic dysfunction may occur.

AIM

1--To determine if in FAP patients the mitral annulus motion is independent of the selected site. 2--To compare pulsed wave Doppler parameters with tissue Doppler parameters in the different annular sites.

METHODS

Of 24 FAP patients studied, 14 were included. In each patient we performed conventional transmitral pulsed wave Doppler and tissue Doppler in the 4 sites of the mitral annulus and measured the velocities of the rapid filling wave e, of the atrial contraction wave a and calculated e/a ratio.

RESULTS

According to the transmitral inflow profile, patients were divided in 2 groups: Group I--normal global diastolic function and Group II--abnormal relaxation. Group I--33% of these patients showed e/a > 1 in the four sites and 67% showed e/a > 1 in at least 1, but not in all the sites. The rate of normal sites per patient was 3.1. Group II--25% of these patients showed e/a < 1 in the 4 sites of the annulus and 75% had e/a < 1 in at least 1, but not in all the sites analysed. The rate of abnormal sites/patient was 3.1. in this group. When conventional and tissue Doppler data were compared (bland and altman) the septal portion of the annulus was the one with the best correlation.

CONCLUSIONS

1--The assessment of the mitral annulus motion with tissue Doppler imaging is dependent on the site selected for study. 2--The septal site was the one that showed the highest correlation and concordance between pulsed wave Doppler and tissue Doppler. 3--The relative number of normal versus abnormal sites was determinant of the transmitral pattern. 4--Tissue Doppler imaging identified: a) among patients until now classified as normal diastolic function, a subgroup of patients with abnormal function in some sites of the annulus and b) among patients with abnormal relaxation, a subgroup with normal diastolic function in some sites of the annulus.

[Aortic peri-valvular abscess, mycotic aneurysm of Valsalva sinus, and fistula to the right ventricle in a context of acute infectious endocarditis]

Infective endocarditis continues to attract the attention of many physicians. The authors present a case report of a 64 year old man with a history of infective endocarditis of a native aortic valve complicated by a perivalvular abscess, mycotic aneurysm of a sinus of valsalva and acquired aorta-right ventricular shunt.

Regional diastolic function in hypertrophic cardiomyopathy: a tissue Doppler echocardiographic study

BACKGROUND

Tissue Doppler echocardiography (TDE) is a recent ultrasonic technique. One of its potential clinical uses is the assessment of regional diastolic function.

OBJECTIVES

To compare left ventricular global diastolic function with interventricular septum regional diastolic function in patients with hypertrophic cardiomyopathy with different levels of global diastolic dysfunction.

METHODOLOGY

10 normal subjects (group 1), eight hypertrophic cardiomyopathy patients with abnormal relaxation (group 2) and 12 patients with hypertrophic cardiomyopathy with restrictive pattern (group 3) on the mitral inflow profile (pulsed wave Doppler) were studied. Each patient performed an M-mode color; TDE of the basal septum in the four chamber view. Velocities during the rapid filling phase (RF), and during atrial contraction (AC) were measured and RF/AC ratio calculated in each patient.

RESULTS

While in normal subjects (group 1) the RF/AC ratio was always higher than 1, in patients with hypertrophic cardiomyopathy patients with different levels of global diastolic dysfunction (groups 2 and 3), the RF/AC ratio was always lower than 1 (velocities during atrial contraction always higher than during rapid filling), despite the level of global diastolic dysfunction.

CONCLUSIONS

A ratio between myocardial velocities during the rapid filling phase and during atrial contraction lower than one (RF/AC < 1) is a tissue Doppler echocardiography index of regional diastolic dysfunction, independently of the severity of global diastolic dysfunction.

[Heart disease induced by mediastinal radiotherapy in Hodgkin's disease: report of a clinical case]

As the number of adults surviving radiation therapy for Hodgkin's disease increases, the long-term clinical sequelae of such treatment is becoming increasingly more evident. Mediastinal radiation has been linked to acute and chronic pericarditis (with or without pleural effusion), coronary artery disease, myocardial fibrosis, valvular dysfunction and arrhythmias. The AA describe a case of a young patient with evidence of significant valvular disease following mediastinal irradiation, and review the radiation-induced cardiotoxicity, discussing aspects concerned with pathophysiology, diagnosis and therapy.

[The treatment of obstructive hypertrophic myocardiopathy refractory to medical therapy]

Until a few years ago, therapy of refractory Hypertrophic Obstructive cardiomyopathy was mainly surgical--Morrow's myotomy/myectomy or mitral valve replacement. Despite the good results of these techniques, they are not free of mortality and morbidity. In the last years a new and promising therapy has been developed: the Dual Chamber Pacemaker. Technically easier and less invasive than surgery, this therapy has achieved better results and lower mortality and morbidity during the follow-up.

[Tissue Doppler echocardiography: a new stage in the study of myocardial function]

Tissue Doppler echocardiography is a new technique that allows selective visualization and measurement of myocardial velocities, affording a new perspective on cardiac function. It has been showing promising and exciting preliminary results on coronary artery disease, hemodynamics, cardiomyopathies, right ventricular and aortic diseases and arrhythmias, opening a new era in the analysis of regional myocardial function.