Assessment of subclinical left ventricular dysfunction in patients with chronic mitral regurgitation using torsional parameters described by tissue doppler imaging

Left ventricular [LV] twist is due to oppositely directed apical and basal rotation and has been proposed as a sensitive marker of LV function. We sought to assess the impact of chronic pure mitral regurgitation [MR] on the torsional mechanics of the left human ventricle using tissue Doppler imaging. Nineteen severe MR patients with a normal LV ejection fraction and 16 non-MR controls underwent conventional echocardiography and apical and basal short-axis color Doppler myocardial imaging [CDMI]. LV rotation at the apical and basal short-axis levels was calculated from the averaged tangential velocities of the septal and lateral regions, corrected for the LV radius over time. LV twist was defined as the difference in LV rotation between the two levels, and the LV twist and twisting/untwisting rate profiles were analyzed throughout the cardiac cycle. LV twist and LV torsion were significantly lower in the MR group than in the non-MR group [10.38° +/- 4.04° vs. 13.95° +/- 4.27°; p value = 0.020; and 1.29 +/- 0.54 °/cm vs. 1.76 +/- 0.56 °/cm; p value = 0.021, respectively], both suggesting incipient LV dysfunction in the MR group. Similarly, the untwisting rate was lower in the MR group [-79.74 +/- 35.97 °/s vs.-110.96 +/- 34.65 °/s; p value = 0.020], but there was statistically no significant difference in the LV twist rate. The evaluation of LV torsional parameters in MR patients with a normal LV ejection fraction suggests the potential role of these sensitive variables in assessing the early signs of ventricular dysfunction in asymptomatic patients

Patient controlled analgesia versus conventional analgesia for postoperative pain

Patients may control postoperative pain by self-administration of intravenous opioids using devices designed for this purpose [patient controlled analgesia or PCA]. This study set out to determine whether any of the two opioid administrations [i.e. PCA or conventional analgesia] would provide superior pain relief among patients undergoing laparoscopic cholecystectomy or not. In a clinical trial the PCA group received self-administered intermittent intravenous morphine via PCA and the conventional group received intravenous Pethidine every 6 hours per day. The patients were assessed on an hourly basis for the first 4 hours after surgery, every 2 hours for the next 8 hours and every 4 hours for next 12 hours. Two methods were used in order to evaluate the degree of pain relief in patients: [1] facial pain scale; pain assessment based on the patient's appearance and [2] numerical rating scale; based on patient ratings of their pain. Forty eight patients [79.1% female, 20.1% male] with a mean age of 45.7 +/- 10.7 years old were enrolled into the study. During the first 24 hours after laparoscopic cholecystectomy, pain intensity based on facial pain scale was lower in the PCA group. However, the difference was significant only in the second hour [mean pain score in PCA group: 2.9, mean pain score in conventional group: 3.7, P = .007]. Also, the mean pain scores based on numerical rating scale were significantly lower in PCA group except for the first hour. Although it was not significantly lower than conventional group [mean pain score in PCA group: 4.2, mean pain score in conventional group: 4.6, P = .45]. Intravenous PCA resulted in better postoperative pain reduction compared to intermittent bolus opioid delivery in laparoscopic cholecystectomy.

Noninvasive localization of accessory pathways in patients with Wolff-Parkinson-White syndrome: a strain imaging study

Noninvasive techniques for the localization of the accessory pathways [APs] might help guide mapping procedures and ablation techniques. We sought to examine the diagnostic accuracy of strain imaging for the localization of the APs in Wolff-Parkinson-White syndrome. We prospectively studied 25 patients [mean age = 32 +/- 17 years, 58.3% men] with evidence of pre-excitation on electrocardiography [ECG]. Electromechanical interval was defined as the time difference between the onset of delta wave and the onset of regional myocardial contraction. Time differences between the onset of delta wave [delta] and the onset of regional myocardial contraction [delta-So], peak systolic motion [delta-Sm], regional strain [delta-epsilon], peak strain [delta-epsilonp], and peak strain rate [delta-SRp] were measured. There was a significant difference between time to onset of delta wave to onset of peak systolic motion [mean +/- SD] in the AP location [A] and normal segments [B] versus that in the normal volunteers [C] [A: [57.08 +/- 23.88 msec] vs. B: [75.20 +/- 14.75] vs. C: [72.9 0 +/- 11.16]; p value [A vs. B] = 0.004 and p value [A vs. C] = 0.18] and [A: [49.17 +/- 35.79] vs. B: [67.60 +/- 14.51] vs. C: [67.40 +/- 6.06 msec]; p value [A vs. B] < 0.001 and p value [A vs. C] = 0.12, respectively]. Our study showed that strain imaging parameters [[delta-So] and [delta-Strain]] are superior to the ECG in the localization of the APs [84% vs. 76%]

Tissue doppler imaging and doppler studies in patients with transmural and non-transmural myocardial infarction

Myocardial longitudinal shortening play an important role in cardiac contraction [1,2]. Tissue velocity imaging [TVI] is an ultrasonographic technique that measure myocardial motion and providing a quantitative agreement of left ventricular regional myocardial function in different modalities [3]. The present review discusses the most recent development in the application of TDI in coronary artery disease. Seventy patients with myocardial infarction [transmural and nontransmural] were included in the study. These subjects were diagnosed with recent myocardial infarction wall [septal side of mitral annulus] and basal segment of base of RV free wall were examined for tissue Doppler study with complete transthoracic echocardiography study. Mean age in group of inferior MI, anterior MI and non Q wave MI are as follows: 61.87 +/- 10.7, 57.04 +/- 10.7, 58.45 +/- 9.2. Sm was significantly reduced in anterior MI groups than non Q wave MI [PV=0.01]. In patients with inferior myocardial infarction 88% of patients had left ventricular ejection fraction [LVEF]>45% and in patients with anterior MI 18.2% patients had EF>45%. In non Q wave MI groups 60% patients had LVEF>45%. Except for Sm, other TDI parameters had no significant difference between two groups [transmural and nontransmural infarction] but it has significant changes in reduced left ventricle function and could be of determinants for prognosis

assessment of left ventricular time-varying radius using tissue doppler imaging

Left ventricular twist/torsion is believed to be a sensitive indicator of systolic and diastolic performance. To obtain circumferential rotation using tissue Doppler imaging, we need to estimate the time-varying radius of the left ventricle throughout the cardiac cycle to convert the tangential velocity into angular velocity. The aim of this study was to investigate accuracy of measured LV radius using tissue Doppler imaging throughout the cardiac cycle compared to two-dimensional [2D] imaging. A total of 35 subjects [47 +/- 12 years old] underwent transthoracic echocardiographic standard examinations. Left ventricular radius during complete cardiac cycle measured using tissue Doppler and 2D-imaging at basal and apical short axis / levels. For this reason, the 2D-images and velocity-time data derived and transferred to a personal computer for off-line analysis. 2D image frames analyzed via a program written in the MATLAB software. Velocity-time data from anteroseptal at basal level [or anterior wall at apical level] and posterior walls transferred to a spreadsheet Excel program for the radius calculations. Linear correlation and Bland-Altman analysis were calculated to assess the relationships and agreements between the tissue Doppler and 2D-measured radii throughout the cardiac cycle. There was significant correlation between tissue Doppler and 2D-measured radii and the Pearson correlation coefficients were 0.84 to 0.97 [P<0.05]. Bland-Altman analysis by constructing the 95% limits of agreement showed that the good agreements existed between the two methods. It can be concluded from our experience that the tissue Doppler imaging can reasonably estimate radius of the left ventricle throughout the cardiac cycle

Assessment of statistical relationship of ejection time and acceleration time with the severity of valvular aortic stenosis

Valvular aortic stenosis is a relatively common disease among valvular heart diseases and can be rheumatic, degenerative or congenital. Evaluation of the severity of the disease is sometimes challenging and problematic. Besides, the use of more parameters of non-invasive methods for the assessment of valvular disease and its severity seems attractive and helpful. Transthoracic echocardiography [TTE] is an appropriate modality for the evaluation of the aortic valve. In this study, TTE was performed for 80 patients with valvular aortic stenosis. The goals were to assess the statistical relationships between ejection time [ET] and acceleration time [AT] and their ratio [AT/ET] with the four traditional parameters of the echocardiographic severity of aortic valvular stenosis [aortic jet velocity, aortic valve area, mean pressure gradient and LVOT VTI/aortic VTI ratio]. There was a meaningful relationship between adjusted ET with the four above-mentioned parameters, d. ET [ET-adjusted ET according to heart rate and stroke volume] was inversely related with the aortic valve area [calculated with continuity equation]. AT/ET was significantly correlated with the four mentioned parameters. The regression equations were calculated. The cut-off value of AT/ET for the echocardiographic diagnosis of severe valvular stenosis was 0.36 [with 95% level of confidence]

Percutaneous mitral balloon valvotomy; single center experience: a review of outcome

Percutaneous balloon mitral valvotomy [BMV] has been accepted as an alternative to surgical mitral commissurotomy in the treatment of patients with symptomatic rheumatic mitral stenosis. Despite the worldwide use of the BMV technique, no studies have been hitherto designed to assess the outcome of the patients undergoing BMV in Iran. The present study reports the outcome of 3138 BMV procedures at Shaheed Rajaei Cardiovascular, Medical and Research Center during a 15-year time period. A total of 2531 patients underwent 3138 BMV procedures at Shaheed Rajaei Cardiovascular, Medical and Research Center between 1992 and 2006. Seventy-three percent [2278] of the cases were followed for 48 +/- 41 months. Recurrent stenosis in 802 [25.8%], mitral valve replacement [MVR] in 213 [6.9%], immediate good result in 3110 [99.1%], and successful outcome in 2000 [72.9%] cases were the outcome of the BMV procedures in the current study. Concordant to the similar studies, we concluded that BMV produces a good clinical outcome in a high percentage of patients. The recent study demonstrated that the successful outcome of BMV was multi factorial and the selection of patients with rheumatic mitral stenosis is recommended to be based on both anatomic and clinical characteristics of the individuals. The procedure-related variables must also be considered in order to predict the outcome

comparison between methods used to extract maximum and minimum myocardial velocities by spectral pulsed-TDI

Tissue Doppler imaging is an echocardiographic useful method in the assessment of left ventricular myocardial function in the clinical condition. Pulsed Doppler interrogation measures the instantaneous velocities of the myocardium which passes through the sample volume during the cardiac cycle. The present study attempts to verify a computerized method to determine myocardial maximum and minimum velocities throughout the cardiac cycles using spectral pulsed-tissue Doppler imaging. The data of curves might be used to calculate myocardial physical and mechanical parameters throughout the cardiac cycle. Spectral pulsed-TDI was performed to evaluate longitudinal function in 23 healthy volunteers by using a sample volume placed in 170 left ventricular segments. The velocities were extracted automatically based on four common edge detection algorithms using Matlab software. Labeling of connected components in boundary of spectrum allowed comparing the methods. In addition to analysis of variance and t-test, linear correlation and Bland-Altman analysis were calculated to assess the relationships and agreements between the systolic and diastolic results of measurements before and after using the computed program. Comparison of the means of the four edge detection methods showed that there are statistically significant differences between methods [number of labels were 12 3 for Canny, 20 4 for Roberts, 31 4 for Sobel and 39 5 for Prewitt respectively, P<0.05]. There were not significant differences between measured velocities in the segments; before and after application of the Canny method. There was significant correlations [r=0.99 and r=0.96, P=0.01] at the base and mid segments, respectively with Bland-Altman analysis significant agreements between the measurements. It is concluded that the proposed method automatically extracts myocardial velocities using spectral pulsed images. Canny method showed relatively favorable results and seems to be a preferable option to extract velocities from the spectral images. Correlation study and Bland-Altman analysis confirmed a good agreement between the measurements

Right ventricular strain predicts functional capacity in patients with repaired tetralogy of Fallot

Echocardiography-derived strain rate and strain may provide new insights into right ventricular [RV] function in repaired tetralogy of Fallot [rTOF] patients in whom evaluation of RV function and functional capacity has an important role in further management. In 45 rTOF patients with severe pulmonary regurgitation. the routine echocardiography-derived indices for evaluation of RV function [TAPSE. RVOT Excursion and eyeball method] and longitudinal strain rate and strain were acquired from basal, mid and apical segments of RV free wall [RVFW] and interventricular septum; functional capacity was measured by standard Bruce protocol exercise testing. All patients had some degrees of RV dysfunction with no correlations between results of routine indices and functional capacity. Reduced RVFW average systolic strain was correlated directly with reduced functional capacity [r = 0.86[P <0.001], this was also true for peak systolic strain of basal and mid segments of RVFW. Derivation of ROC curves showed that a cut-off value of 15.8% for average RVFW systolic strain predicts good exercise capacity [>/= 10 METs] with a sensitivity of 91.2% and a specificity of 100%. Although routine echocardiography indices are not accurate tools in rTOF patients, systolic strain of RVFW seems to be reliable in estimation of RV function and functional capacity

Accessory mitral valve tissue in mirror-image dextrocardia

A 20-year-old man was referred to us for further evaluation due to infective endocarditis. He had mirror-image dextrocardia with visceral situs inversus. He had a history of dyspnea on exertion [NYHA class II] of several years' duration with no new onset symptoms. On physical examination, he had no peripheral stigmata of infective endocarditis. Laboratory examination showed a normal erythrocyte sedimentation rate with normal hemoglobin. Three separate sets of blood cultures obtained over a 24-hour period and cultures were negative in aerobic and anaerobic media. Transthoracic and transesophageal echocardiographic studies showed mirror-image dextrocardia with total situs inversus as well as accessory mitral valve tissue with chordal attachment to the posteromedial papillary muscle with no significant LVOT obstruction [Figs. 1,2] but resulting in mild to moderate aortic insufficiency [Fig.3]. There was also aneurysmal dilation of the membranous part of the interventricular septum with a residual pouch and no residual ventricular septal defect according to computational fluid dynamics and contrast studies [Fig 4]. There was no other concomitant abnormality. The patient was discharged in good physical condition

Non-invasive assessment of coronary artery stenosis with estimation of myocardial wall stress

More diagnostic techniques require a better understanding of the forces and stresses developed in the wall of the left ventricle. The aim of this study was to differentiate significant coronary artery disease [CAD] patients using a non-invasive quantification of myocardial wall stress in the diastole phase. Sixty male subjects with sinus rhythm [30 patients with significant and 30 with moderate left anterior descending coronary artery stenosis in the proximal portion] as well as 35 healthy subjects as the control group were recruited into the present study. By two-dimensional, pulsed wave, and tissue Doppler echocardiography, the average end-diastolic wall stress was calculated at the left ventricle anterior and interventricular septum wall segments using regional wall thickness, meridional and circumferential radii, and non-invasive left ventricular end-diastolic pressure. A comparison of the calculated end-diastolic myocardial wall stress between the patients with significant and moderate coronary stenosis on the one hand and the healthy subjects on the other showed statistically significant differences in the anterior and septum wall segments [p value < 0.05]. The patients with significant left anterior descending coronary artery stenosis had higher end-diastolic myocardial wall stress than did those with moderate stenosis and the healthy group in all the anterior and septum wall segments. It is concluded that non-invasive end-diastolic myocardial wall stress in coronary artery disease patients is an important index in evaluating myocardial performance

Presentation of anomalous origin of the left coronary artery from the pulmonary artery with left sided coronary ostium in an adult patient

An anomalous origin of the left coronary artery from the pulmonary artery [ALCAPA] is a rare congenital coronary anomaly. It usually presents in infancy with intractable left sided heart failure. Most patients die in infancy, but survival into adulthood is possible. Patients may complain of dyspnea, syncope or effort angina. They may remain asymptomatic; or experience sudden death after exercise. A 56-year-old woman presented with a twomonth history of exertional chest discomfort. Echocardiography showed a coronary anomaly with preserved systolic function and no resting regional wall motion abnormality. The coronary and CT [computed tomography] angiography studies revealed the anomalous origin of the left coronary artery. A review of ALCAPA studies is presented along with images from the echocardiogram, coronary angiogram and CT scan performed for this case

Prevalence of left ventricular diastolic asynchrony in patient with systolic heart failure

To study the occurence of left ventricular [LV] diastolic asynchrony in patients with systolic heart failure [HP] and its relationship to diastolic function regardless of QRS duration. Recent work has demonstrated that intraventricular asynchrony is a common finding in patients with systolic heart failure. Little attention has been paid to diastolic asynchrony in patients with systolic heart failure. We have therefore decided to determine the extent to whuch patients with systolic heart failure have evidence of diastolic asynchrony and wheather or not diastolic asynchrony is correlated with diastolic dycfunction. Tissue Doppler echocardiography was performed in 50 HF patients [LV EF=23 +/- 8%]. Diastolic and systolic asynchrony was determined by tissue synchronization imaging using a 6 basal, 6 mid-segmental model. Systolic and diastolic asynchrony were assessed by the maximal difference in time to peak systolic and early diastolic velocities between any two of 12 LV segments, and the standard deviation of time to peak systolic and early diastolic velocities of the 12 LV segments. The mean +/- SD maximal difference in time to peak systolic velocity [controls: 17.2 +/- 9.6 ms versus narrow QRS: 66.7 +/- 38.0 ms versus wide QRS: 76.5 +/- 34.6 ms, both P<0.05 versus controls] and in standard deviation of time to peak systolic velocity of 12 LV segments [controls: 15 +/- 6.1 ms versus narrow QRS: 25.9 +/- 15.3 ms versus wide QRS: 28.6 +/- 14.4ms, both P<0.05 versus controls] was prolonged in both the narrow and wide QRS groups compared with normal controls. Similarly, the maximal difference in time to peak diastolic velocity [controls: 39 +/- 16.8 ms versus narrow QRS: 73.1 +/- 58ms versus wide QRS: 108.5 +/- 168 ms, both P<0.05 versus controls] and in standard deviation of time to peak early diastolic velocity of 12 LV segments [controls: 15.3 +/- 5.8ms versus narrow QRS: 25.1 +/- .13.8ms versus wide QRS: 25.5 +/- 14.9ms, both P<0.05 versus controls] was prolonged in both the narrow and wide QRS groups. The respective prevalence of systolic and diastolic asynchrony was 31.4% and 20%, in the narrow QRS group, and 40% and 28.6%, in the wide QRS group respectively.Stepwise multiple regression analysis showed that low ejection fraction and low mitral annular early diastolic velocity were independent predictors of both systolic and diastolic asynchrony. QRS complex duration was found to correlate only with diastolic asynchrony. LV systolic and diastolic mechanical asynchrony is common in patients with HF regardless of QRS duration. Selection for cardiac resynchronization treatment should also be based on information about systolic and diastolic synchronicity

Estimation of septal wall thickness by processing sequential echocardiographic images

Non-invasive quantitative analysis of the heart wall thickness is a fundamental step in diagnosis and discrimination of heart disease. Thickness measurements in 2D echocardiographic images have many applications in research and clinic for assessment of wall stress, wall thickening and viability parameters. The measurement of interventricular septum wall thickness by conventional manual method is more dependent on sonographer's experiment.This encouraged researchers to develop a semi-automatic computer algorithm to access interventricular septum segments thickness. We proposed and developed a computerized algorithm for wall thickness measurements in 2D echocardiographic image frames. In this program, wall thickness measurement is based on intensity profile function and adaptive bilateral thresholding operation. For validation, thicknesses of septum base and mid segments were estimated in constituent image frames using proposed technique followed by comparing them with conventional manual results from same images of the cardiac cycle by statistical methods. In our sample image frames [240 corresponding segments; with different range of image quality], a bias of 0.10 mm and 0.12 mm with SD differences of +/- 0.81 mm and +/- 0.72 mm and correlation coefficients of 0.87 and 0.89 were found in base and mid segments, respectively. Interobserver variability using the computer-assisted method [CAM] and conventional manual technique [CMM] were 4.0% and 4.7% for the basal and 2.8% and 3.9% for the middle segments. The method introduced in the present study permits precise thickness assessment of base and mid segments of the interventricular septum wall with high concordance with CMM

Approach to the patient with combined coarctation of aorta and Wolf-Parkinson-White syndrome

At the present time the treatment of choice for postductal coarctation of aorta is percutaneous angioplasty and stenting. One crucial step for successful stenting of coarctation is accurate positioning of the stent across the lesion, which is difficult due to high pressure blood flow at the site of the coarct. To solve this problem, rapid pacing has been used to decrease cardiac output and blood pressure for a few seconds and prevent excessive motion of the stent during deployment. However, if coarctation is combined with pre-excitation syndrome, rapid atrial/ventricular pacing could cause life-threatening tachyarrhythmias. In this paper, we report a 28-year-old women with combined coarctation of aorta and Wolf-Parkinson-White syndrome who underwent radio frequency catheter ablation of the accessory pathway and then stenting angioplasty of the coarctation was performed without any complication

Assessment of regional myocardial displacement via spectral tissue doppler compared with color tissue tracking

The recent developments in tissue Doppler imaging [TDI] now more than ever permit the quantification of the myocardial function. In the current systems, tissue tracking or displacement curves are generated from color tissue Doppler data through the instantaneous temporal integral of velocity-time curves. The purpose of the present study was to assess regional myocardial displacement via spectral TDI. Maximum myocardial velocities were extracted from spectral pulsed tissue Doppler images using a developed computer program and were integrated throughout the cardiac cycle. Spectral tissue Doppler echocardiography was performed to evaluate longitudinal and radial functions in 20 healthy men, and the calculated end-systolic displacements were subsequently compared with the displacements measured from the same areas via color tissue tracking. According to the Bland-Altman analysis between spectral tissue tracking and color tissue tracking, the significant arithmetic mean was 7.34 mm with SD mean differences of +/- 2.24 mm in all of the evaluated segments. Despite significant differences [p < 0.001], there was a good significant correlation between the two methods [r=0.79, p < 0.001]. A verification study showed that the proposed approach had the ability to assess regional myocardial displacement using spectral TDI, which can be used in a wider range of equipment than is currently possible