Tricuspid annular plane systolic excursion for the assessment of ventricular function in adults operated on with mustard procedure for complete transposition of the great arteries.

BACKGROUND: In adult patients with d-transposition of the great arteries after atrial switch operation, dysfunction of the systemic right ventricle (RV) is a well-known complication. Echocardiographic variables may provide adequate estimation of subpulmonary RV function, but their applicability to the subaortic RV is not straightforward. We evaluate the concordance between tricuspid annular plane systolic excursion (TAPSE) and magnetic resonance imaging-derived ejection fraction of the RV (MRI-RVEF) in these patients. METHODS: Patients were recruited from those evaluated at the adult congenital clinic of our department between 2010 and 2012. All patients who had an echocardiographic assessment within 6 months of their MRI examination were selected. Patients clinically unstable, not in sinus rhythm, with a prosthetic systemic atrioventricular valve, permanent pacemaker, or more than moderate systemic atrioventricular valve regurgitation were excluded. RESULTS: Eighteen Mustard-operated patients aged 22 ± 3.7 years were studied. The mean values of TAPSE and RVEF were 13.22 ± 1.7 mm and 49.7 ± 6%, respectively. TAPSE and RVEF were normal in 1 (5.5%) and 10 (55.5%) patients, respectively. Seventeen (94.4%) patients showed reduced TAPSE (12.9 ± 1.3 mm): RVEF was reduced in eight (47%) of these subjects, and normal in nine (53%). In patients with normal RVEF, both the MRI-RV end-diastolic and the MRI-RV end-systolic volumes were significantly lower than in patients with reduced RVEF. There were no other statistically significant differences between these patients. No correlation was found between TAPSE and both the MRI-RV end-diastolic and the end-systolic volumes. Globally, agreement between TAPSE and RVEF was slight (K = 0.09 ± 0.089). CONCLUSIONS: Our results indicate that in these patients TAPSE is not a useful measure of RV function.

Resynchronization of the left ventricular contraction by tailored programming of right and left ventricular pacing.

AIMS: The prerequisite and the rationale for the benefit of cardiac resynchronization therapy (CRT) is that it is able to resynchronize left ventricular (LV) walls that have a delayed activation. METHODS AND RESULTS: In 69 consecutive patients who underwent biventricular (BIV) pacemaker implantation, we assessed the magnitude of intraventricular resynchronization achieved by means of simultaneous (BIV 0) and sequential BIV pacing (with an individually optimized VV interval value among +80 ms and -80 ms) using pulsed-wave tissue Doppler imaging techniques and in particular the measurement of the intra-LV electromechanical delay. The intra-LV delay was defined as the difference between the longest and the shortest activation time in the six basal segments of the LV. An abnormal intra-LV delay was defined as a value >41 ms. The intra-LV delay was 63 +/- 28 ms baseline, decreased to 44 +/- 26 ms with BIV 0 and to 26 +/- 15 ms with optimized BIV (P = 0.001). BIV 0 determined the shortest delay in 28 (41%) patients (23 +/- 12 ms). In 41 (59%) patients, a better resynchronization was achieved with optimized VV intervals (LV first in 32 and RV first in 5) or single-chamber pacing (LV in 3 and RV in 1). With BIV 0, the intra-LV delay remained abnormal in 41% and was longer than baseline in 30% of patients compared with 9 and 12% with optimized BIV, respectively (P = 0.001). CONCLUSION: A sub-optimal resynchronization is achieved with simultaneous BIV pacing in most patients. A tailored programming of the relative contribution of RV and LV pacing forms the prerequisite for improving CRT results.

Transient left ventricular apical ballooning syndrome: all that glitters is not apical.

Transient left ventricular apical ballooning syndrome is a new entity in the field of acute coronary syndromes and percutaneous coronary intervention. A 92-year-old patient presented with an intriguing, previously undescribed finding: the 'migrant' nature of the wall motion abnormalities, first involving the inferior wall and, subsequently, the apical region of the left ventricle. We add a small piece to the complicated puzzle represented by this syndrome.

Left ventricular electromechanical delay in patients with heart failure and normal QRS duration and in patients with right and left bundle branch block.

AIMS: We sought to define the reference values of intra-left ventricular (LV) electromechanical delay (EMD), and to assess the prevalence (and pattern) of intra-LV dyssynchrony in patients with heart failure (HF) and normal QRS and in patients with right and left bundle branch block. METHODS AND RESULTS: We used tissue Doppler imaging echocardiography and a six-LV wall model to study LV EMD in 103 patients [41 with HF and normal QRS, 22 with right bundle branch block (RBBB), and 40 with left bundle branch block (LBBB)], and in 59 controls. In controls, the median intra-LV EMD was 17 ms, (inter-quartile range 13-30); 95% of controls had a value < or =41 ms. Patients showed a longer intra-LV EMD than controls: 33 ms (20-57) in patients with normal QRS, 32 ms (23-50) in RBBB patients, and 50 ms (30-94) in LBBB patients. Intra-LV dyssynchrony (defined as intra-LV EMD >41 ms) was present in 39, 36, and 60% of the patients, respectively. On average, HF patients showed the same pattern of activation as controls, from the septum to the posterior wall, but activation times were significantly prolonged. In RBBB patients the activation sequence was directed from inferior to anterior and in LBBB from anterior to inferior wall. CONCLUSIONS: Left ventricular dyssynchrony was present in several patients with HF and normal QRS, and in patients with RBBB; conversely, 40% of LBBB patients showed values of LV EMD within the normal range. Left ventricular activation sequence was different between groups. Assessment of LV synchronicity by means of imaging techniques may be more important than QRS duration or morphology in selecting patients for cardiac resynchronization treatment.

Effects of right ventricular pacing on intra-left ventricular electromechanical activation in patients with native narrow QRS.

Some patients with right ventricular (RV) apical pacing show contractile asynchrony of the left ventricle. Whether the asynchrony is due to RV pacing or was a preexistimg condition remains unknown. The aim of this study was to evaluate how much pacing from the RV apex affects left ventricular (LV) electromechanical activation and to assess whether the extent of LV asynchrony during RV pacing can be predicted by clinical, electrocardiographic, or echocardiographic findings obtained during spontaneous rhythm. We evaluated 56 patients with narrow QRS and preserved atrioventricular conduction who received permanent backup RV pacing. Intra-LV electromechanical activation was assessed during spontaneous rhythm and during pacing using tissue Doppler echocardiography. An abnormal intra-LV electromechanical delay (EMD) (defined as a >41-ms difference between the faster and slower activated LV wall) was found in 15 patients (27%) during spontaneous rhythm and 28 patients (50%) during RV pacing (p<0.001). Of the 9 baseline variables (age, gender, history of heart failure, QRS duration in spontaneous rhythm and during pacing, LV end-diastolic and end-systolic diameters, LV ejection fraction, and intra-LV EMD in spontaneous rhythm), an abnormal baseline intra-LV EMD and QRS duration of >85 ms were independent predictors of an abnormal intra-LV delay during RV pacing. RV apical pacing induces asynchrony of LV contractions in a substantial percentage of patients but not in all. Although normal baseline intra-LV electromechanical activation cannot exclude the development of significant asynchrony during RV pacing, the presence of preimplant LV asynchrony predicts for a worsening of this detrimental effect.

Transient ballooning of the left ventricle: a case report.

A 67-year-old woman was admitted to the coronary care unit for chest pain with ECG modifications suggestive of acute myocardial infarction. The clinical course of the disease and the absence of abnormalities of the epicardial vessels with reversible asynergy of the apical segments of the left ventricle were suggestive of the syndrome of transient apical ballooning of the left ventricle. To my knowledge, this is the first case of the disease described in the Italian population.