[Is Tako-tsubo cardiomyopathy really reversible ?] / La Cardiomyopathie de Tako-tsubo est-elle réellement réversible ?

Tako-tsubo cardiomyopathy is characterized by a total reversibility of wall motion abnormalities of the left ventricle (LV) as well as normalization of LV ejection fraction after the acute phase. However, recent studies have shown that some patients present functional, metabolic, and morphologic abnormalities away from the acute phase suggesting an incomplete recovery of the disease. In this revue we discuss about this topic through several tools used in those studies (echocardiography, exercise test, MRI, nuclear imaging, biology, as well).

Use of ADAM-C and CHA2DS2-VASc scores to predict complex aortic atheroma after brain ischemia: A prospective observational study.

BACKGROUND AND AIMS: Complex aortic atheroma (CAA) is a common cause of acute brain ischemia (BI), including ischemic stroke (IS) and transient ischemic attack (TIA), and is associated with recurrence. The CHA2DS2-VASc score is a useful tool for predicting stroke in patients with atrial fibrillation (AF), and can also predict cardiovascular events in other populations, including non-AF populations. The ADAM-C score is a new risk score for predicting the diagnostic yield of transesophageal echocardiography (TEE) after BI. We aimed to evaluate the ability of CHA2DS2-VASc and ADAM-C scores to predict CAA after BI. METHODS: This prospective, multicenter, observational study included 1479 patients aged over 18 years who were hospitalized for BI. CAA was defined as the presence of one or more of the following criteria: thrombus, ulcerated plaque, or plaque thickening ≥ 4 mm. RESULTS: CAA was diagnosed in 216 patients (14.6%). CHA2DS2-VASc and ADAM-C scores were significantly higher in the CAA group versus the non-CAA group (P < .0001 for both). The CHA2DS2-VASc and ADAM-C scores appear to be good predictors of CAA (AUC 0.699 [0.635, 0.761] and 0.759 [0.702, 0.814], respectively). The sensitivity, specificity, predictive positive value (PPV), and negative predictive value (NPV) of the scores for detecting CAA were 94%, 22%, 17%, and 96%, respectively, for a CHA2DS2-VASc score < 2, and 90%, 46%, 22%, and 96%, respectively, for an ADAM-C score < 3 CONCLUSIONS: CHA2DS2-VASc and ADAM-C scores are able to predict CAA after BI. CHA2DS2-VASc < 2 and ADAM-C < 3 both have an interesting NPV of 96%.

Correction to: Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE).

In the original publication of the article, the first and the second authors' names should be changed as follows.

Usefulness of Noninvasive Myocardial Work to Predict Left Ventricular Recovery and Acute Complications after Acute Anterior Myocardial Infarction Treated by Percutaneous Coronary Intervention.

BACKGROUND: Predicting left ventricular recovery (LVR) after acute ST-elevation myocardial infarction (STEMI) is challenging and of prognostic importance. Our objective was to evaluate the usefulness of noninvasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LVR and in-hospital complications after STEMI. METHODS: Ninety-three patients with anterior STEMI (mean age, 59 ± 12 years) treated by percutaneous coronary intervention (PCI) were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 24-48 hours after PCI and a median of 92 days at follow-up. Myocardial work is derived from the strain-pressure relation, integrating in its calculation the noninvasive arterial pressure. Segmental LVR was defined as a normalization of wall motion abnormalities of the affected segments and global recovery as an absolute improvement of left ventricular ejection fraction (LVEF) > 5% in patients with baseline LVEF ≤ 50%. In-hospital complications were defined as a composite of death, reinfarction, heart failure, and LV apical thrombus. RESULTS: Segmental MW was impaired in infarct segments, more severely in nonrecovering versus recovering segments (P < .01). Furthermore, global constructive MW was significantly correlated with follow-up LVEF (r = 0.58) and global longitudinal strain (r = -0.67; all P < .01). Constructive MW was the best index to predict segmental (P < .01 vs MW index, MW efficiency, and wasted work) and global recovery (P < .05 vs global longitudinal strain) with an independent association (odds ratio = 1.17, 95% CI, 1.13-1.20, and odds ratio = 1.43, 95% CI, 1.18-1.68, respectively; all P < .001). Moreover, global constructive MW was more severely impaired in patients with in-hospital complications (n = 16; P < .01). CONCLUSIONS: In patients with anterior STEMI treated by PCI, constructive MW is an independent predictor of segmental and global LVR and is significantly impaired in patients with in-hospital complications.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE).

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE).

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Left atrial strain and distensibility in relation to left ventricular dysfunction and prognosis in aortic stenosis.

OBJECTIVE: To test the relationship between left atrial (LA) distensibility (LAD), LA strain (LAS), and left ventricular (LV) dysfunction and prognosis in aortic stenosis (AS). METHODS: Transthoracic Doppler echocardiography was performed prospectively in 102 consecutive patients with AS (77 with severe, 25 with moderate, mean age 77 years). LA volume was calculated by the area-length method in apical four- and two-chamber views, immediately before mitral valve opening (Volmax ) and at mitral valve closure (Volmin ). LAD was defined as (Volmax  - Volmin ) × 100%/Volmin . LAS (mean of maximal strain from the 4-2 chamber views) was conducted using a dedicated software package. The endpoint was hospitalization for heart failure and death from any cause. RESULTS: Left atrial strain, LAD, and LA vol/m² were significantly correlated with LV diastolic parameters, and PASP (all, P < 0.05). However, LAD and LAS but not LA vol/m² were significantly correlated with Charlson score, LV global longitudinal strain, and to transaortic mean gradient (all, P < 0.05). At a median follow-up of 25 months, 53 patients had an event. LAS, LAD, LA vol/m², and Charlson index were associated with events (all, P < 0.05). In multivariate analysis, LAD, LAS, and Charlson index (all, P < 0.01) remained independently associated with events. Using a ROC curve analysis, LAD ≤ 69% and LAS ≤ 17% were the best cutoffs associated with an event. CONCLUSION: In patients with moderate to severe AS, LAD and LAS are associated with LV dysfunction, AS severity, and are independently linked to events.

International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management.

The clinical expert consensus statement on takotsubo syndrome (TTS) part II focuses on the diagnostic workup, outcome, and management. The recommendations are based on interpretation of the limited clinical trial data currently available and experience of international TTS experts. It summarizes the diagnostic approach, which may facilitate correct and timely diagnosis. Furthermore, the document covers areas where controversies still exist in risk stratification and management of TTS. Based on available data the document provides recommendations on optimal care of such patients for practising physicians.

International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology.

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy.

ADAM-C score: New risk score for predicting diagnostic yield of transesophageal echocardiography after cerebral ischemia.

BACKGROUND AND AIM: The clinical utility of transesophageal echocardiography (TEE) after brain ischemia (BI) remains a matter of debate. We aimed to evaluate the clinical impact of TEE and to build a score that could help physicians to identify which patients should better benefit from TEE. METHODS: This prospective, multicenter, observational study included patients over 18 years old, hospitalized for BI. TEE findings were judged discriminant if the results showed important information leading to major changes in the management of patients. Most patients with patent foramen ovale were excluded. Variables independently associated with a discriminant TEE were used to build the prediction model. RESULTS: Of the entire population (1479 patients), 255 patients (17%) were classified in the discriminant TEE group. Five parameters were selected as predictors of a discriminant TEE. Accordingly, the ADAM-C score could be calculated as follows: Score = 4 (if age ≥60) + 2 (if diabetes) + 2 (if aortic stenosis from any degrees) + 1 (if multi-territory stroke) + 2 (if history of coronary artery disease). At a threshold lower than 3, the sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of detecting discriminant TEE were 88% (95% CI 85-90), 44% (95% CI 41-47), 21% (95% CI 19-27), and 95% (95% CI 94-97), respectively. CONCLUSION: A simple score based on clinical and transthoracic echocardiographic parameters can help physicians to identify patients who might not benefit from TEE. Indeed, a score lower than 3 has an interesting NPV of 95% (95% CI 94-97).

Noninvasive Coronary Flow Reserve Predicts Response to Exercise in Asymptomatic Severe Aortic Stenosis.

BACKGROUND: In patients with asymptomatic aortic stenosis (AS), exercise stress echocardiography (ESE) provides additional prognostic information beyond baseline. The coronary flow velocity reserve (CFVR) is impaired in AS, but its link with exertion is unknown in this setting. The aim of this study was to test the hypothesis that CFVR could predict exercise capacity and abnormal exercise test results in AS. METHODS: Noninvasive CFVR and symptom-limited semisupine ESE were prospectively performed the same day in 43 patients with asymptomatic isolated severe AS (mean age, 68.5 ± 11 years; 26% women; mean aortic valve area, 0.8 ± 0.16 cm2; mean left ventricular ejection fraction, 70 ± 7%). CFVR was performed in the distal part of the left anterior descending coronary artery using intravenous adenosine infusion (140 µg/kg/min over 2 min), and ESE was performed at an initial workload of 25 W with a 20- to 25-W increase at 2-min intervals. An abnormal result on ESE was defined as onset of symptoms at <75% of maximum predicted workload, electrocardiographic ST-segment depression ≥2 mm during exercise, increase of systolic blood pressure < 20 mm Hg or decrease in blood pressure, and complex ventricular arrhythmia. Seventeen patients with isolated severe asymptomatic AS, unable to exercise because of extracardiac conditions, served as a comparative group. RESULTS: Resting, hyperemic left anterior descending coronary artery flow velocity and CFVR (2.45 ± 0.8 vs 2.4 ± 0.8) were similar between the group unable to perform ESE and the ESE group (P = NS for all). Compared with patients with normal results on ESE, those with abnormal results on ESE (n = 22) were older, had higher E/e' ratios, had higher resting left anterior descending coronary artery flow velocities (39 ± 12 vs 31 ± 8 cm/sec), and had lower CFVR (2.01 ± 0.3 vs 2.85 ± 0.7; P < .01 for all). Furthermore, CFVR was significantly correlated with age, changes in transvalvular pressure gradient and left ventricular ejection fraction with exercise, workload (in watts), and exercise duration (P < .05 for all). After adjusting for other variables, CFVR remained independently correlated with exercise duration, workload, and abnormal results on ESE (P < .01 for all). On receiver operating characteristic curve analysis, CFVR < 2.3 was the best cutoff to predict abnormal results on ESE (area under the curve = 0.88 ± 0.06, P < .01). CONCLUSIONS: In patients with asymptomatic severe AS, noninvasive CFVR is correlated with exercise duration and workload, and low CFVR predicts abnormal results on ESE with good accuracy.

Management of Takotsubo cardiomyopathy in non-academic hospitals in France: The Observational French SyndromEs of TakoTsubo (OFSETT) study.

BACKGROUND: Takotsubo cardiomyopathy (TTC) is a rare condition characterized by a sudden temporary weakening of the heart. TTC can mimic acute myocardial infarction and is associated with a minimal release of myocardial biomarkers in the absence of obstructive coronary artery disease. AIMS: To provide an extensive description of patients admitted to hospital for TTC throughout France and to study the management and outcomes of these patients. METHODS: In 14 non-academic hospitals, we collected clinical, electrocardiographic, biological, psychological and therapeutic data in patients with a diagnosis of TTC according to the Mayo Clinic criteria. RESULTS: Of 117 patients, 91.5% were women, mean ± SD age was 71.4 ± 12.1 years and the prevalence of risk factors was high (hypertension: 57.9%, dyslipidaemia: 33.0%, diabetes: 11.5%, obesity: 11.5%). The most common initial symptoms were chest pain (80.5%) and dyspnoea (24.1%). A triggering psychological event was detected in 64.3% of patients. ST-segment elevation was found in 41.7% of patients and T-wave inversion in 71.6%. Anterior leads were most frequently associated with ST-segment elevation, whereas T-wave inversion was more commonly associated with lateral leads, and Q-waves with septal leads. The ratio of peak B-type natriuretic peptide (BNP) or N-terminal prohormone BNP (NT-proBNP) level to peak troponin level was 1.01. No deaths occurred during the hospital phase. After 1 year of follow-up, 3 of 109 (2.8%) patients with available data died, including one cardiovascular death. Rehospitalizations occurred in 17.4% of patients: 2.8% due to acute heart failure and 14.7% due to non-cardiovascular causes. There was no recurrence of TTC. CONCLUSIONS: This observational study of TTC included primarily women with atherosclerotic risk factors and mental stress. T-wave inversion was more common than ST-segment elevation. There were few adverse cardiovascular outcomes in these patients after 1-year follow-up.

Usefulness of two-dimensional longitudinal strain pattern to predict left ventricular recovery and in-hospital complications after acute anterior myocardial infarction treated successfully by primary angioplasty.

BACKGROUND: The aim of this study was to test the usefulness of two-dimensional longitudinal strain pattern in segments with wall motion abnormalities to predict left ventricular recovery and in-hospital cardiac events as well as coronary microvascular impairment (CMI) in patients with recent acute anterior myocardial infarction. METHODS: Forty-nine consecutive patients with acute myocardial infarction (mean age, 59 ± 13 years) treated successfully with primary coronary angioplasty prospectively underwent transthoracic Doppler echocardiography 24 hours after angioplasty and during follow-up (6 months). A two-dimensional strain analysis, including measurement of the duration of systolic lengthening expressed as a percentage of systolic duration (SL % duration), the lengthening-to-shortening ratio, the postsystolic shortening index in segments with wall motion abnormalities, and global longitudinal strain and left anterior descending coronary artery territory strain, was performed. Cardiac events were defined as a composite of death, reinfarction, and heart failure. CMI was assessed noninvasively by transthoracic Doppler left anterior descending coronary artery investigation <24 h after angioplasty and was defined as coronary flow velocity reserve < 1.7 and/or a no-reflow pattern (mean coronary flow velocity reserve, 1.8 ± 0.6 in the whole group). RESULTS: At the segmental level, SL % duration, lengthening-to-shortening ratio, and postsystolic shortening index were correlated with recovery (defined as normalization of wall motion abnormalities), whereas in multivariate analysis, only SL % duration independently predicted recovery (threshold level, 40%; area under the curve, 0.76; P < .01). At the patient level, in univariate analysis, SL % duration, global longitudinal strain, left anterior descending coronary artery territory strain, and troponin peak were correlated with recovery (defined as an absolute improvement of left ventricular ejection fraction of >5%). In multivariate analysis, SL % duration was independently related to recovery (area under the curve, 0.78; P < .01). Furthermore, SL % duration was independently linked to cardiac events (n = 13) and CMI (n = 24) (P < .01 for all). CONCLUSIONS: In patients with AMI treated by primary angioplasty, two-dimensional strain predicts left ventricular recovery independently of more traditional parameters and is independently linked to cardiac events and CMI.

Standard and advanced echocardiography in takotsubo (stress) cardiomyopathy: clinical and prognostic implications.

Echocardiography is frequently the initial noninvasive imaging modality used to assess patients with takotsubo cardiomyopathy (TTC). Standard transthoracic echocardiography can provide, even in the acute care setting, useful information about left ventricular (LV) morphology as well as regional and global systolic or diastolic function. It allows the differentiation of different LV morphologic patterns according to the localization of wall motion abnormalities. A "circumferential pattern" of LV myocardial dysfunction characterized by symmetric wall motion abnormalities involving the midventricular segments of the anterior, inferior, and lateral walls should be considered suggestive of TTC and included in the differential diagnosis of acute coronary syndromes. Moreover, advanced echocardiographic techniques, including speckle-tracking, myocardial contrast, and coronary flow studies, are providing mechanistic and pathophysiologic insights into this unique syndrome. Early identification of any potential complications (i.e., LV outflow tract obstruction, reversible moderate to severe mitral regurgitation, right ventricular involvement, thrombus formation, and cardiac rupture) are crucial for the management, risk stratification, and follow-up of patients with TTC. Because of the dynamic evolution of the syndrome, comprehensive serial echocardiographic examinations should be systematically performed. This review focuses on these aspects of imaging and the increasing understanding of the clinical and prognostic utility of echocardiography in TTC.

Relationship between acute strain pattern and recovery in tako-tsubo cardiomyopathy and acute anterior myocardial infarction: a comparative study using two-dimensional longitudinal strain.

After acute-anterior myocardial infarction (AMI), left ventricular (LV) viable myocardial segments show some degree of active deformation (longitudinal shortening) despite wall motion abnormalities (WMA). Tako-tsubo cardiomyopathy (TTC) is characterized by myocardial stunning; however, it is unclear whether in TTC the strain pattern mimics AMI. To compare the strain-pattern in TTC and AMI using the 2D-longitudinal strain by speckle-tracking in segments with WMA, and its relationship with recovery of function at follow-up. 21 consecutive patients with typical TTC and 21 age-matched AMI patients treated by primary angioplasty had an analysis of LV-longitudinal strain at the acute-phase and at follow-up (1 and 6 months later for TTC and AMI respectively). The recovery of a segment was defined as normal wall motion at follow-up. Among the 706 analyzable LV-segments at the acute-phase, 406 had WMA (TTC 229, AMI 177). At follow-up, total recovery was observed for 45 % segments in AMI and 100 % in TTC, (p < 0.01). At the acute phase, systolic lengthening duration (47 ± 43 vs. 18 ± 33 %) and amplitude (0.25 ± 0.29 vs. 0.09 ± 0.19) and post systolic shortening (67 ± 53 vs. 39 ± 38 %) were higher in TTC, when compared to AMI-recovery (all, p < 0.01). In AMI, systolic lengthening duration was an independent predictor of poor recovery in multivariate analysis, linked to segmental longitudinal strain at follow-up (all, p ≤ 0.01). Furthermore, among the 57 % of segments exhibiting any systolic lengthening duration in AMI, only » recovered, versus 62 % of such segments in TTC with 100 % recovery (p < 0.001). The systolic passive motion which is closely and inversely linked to recovery in AMI is paradoxically frequent and severe in TTC. This suggests that myocardial stunning in TTC and AMI is different according to longitudinal strain.

Takotsubo cardiomyopathy: an integrated multi-imaging approach.

Takotsubo cardiomyopathy (TTC) is a distinct clinical entity characterized by the presence of transient left ventricular wall dysfunction without significant culprit obstructive coronary artery disease. Invasive coronary angiography and ventriculography are the 'gold standard' for definitive diagnosis, with an integrated multi-modality imaging approach offering advantages in various clinical scenarios. Echocardiography is a widely available, first-line, non-invasive imaging technique appropriate both in emergency setting to confirm diagnosis, assess for various potential acute complications, and in serial follow-up to track myocardial recovery. Cardiac magnetic resonance (CMR) may be helpful to discriminate TTC from other acute cardiac syndromes with troponin elevation and ventricular dysfunction. Echocardiography, CMR, and nuclear imaging may also provide new insights into possible underlying pathophysiological mechanisms, and myocardial (123)I-metaiodobenzyl-guanidine imaging may have a role for retrospective diagnosis in the subacute phase of late-presenting cases. The potential diagnostic role of coronary computed tomography angiography in the emergency room requires a further study.

Stress echocardiography to assess stenosis severity and predict outcome in patients with paradoxical low-flow, low-gradient aortic stenosis and preserved LVEF.

The objective of this study was to examine the value of stress-echocardiography in patients with paradoxical low-flow, low-gradient (PLFLG) aortic stenosis (AS). The projected aortic valve area (AVAProj) at a normal flow rate was calculated in 55 patients with PLFLG AS. In the subset of patients (n = 13) who underwent an aortic valve replacement within 3 months after stress echocardiography, AVA(Proj) correlated better with the valve weight compared to traditional resting and stress echocardiographic parameters of AS severity (AVA(Proj): r = -0.78 vs. other parameters: r = 0.46 to 0.56). In the whole group (N = 55), 18 (33%) patients had an AVA(Proj) >1.0 cm(2), being consistent with the presence of pseudo severe AS. The AVA(Proj) was also superior to traditional parameters of stenosis severity for predicting outcomes (hazard ratio: 1.32/0.1 cm(2) decrease in AVA(Proj)). In patients with PLFLG AS, the measurement of AVA(proj) derived from stress echocardiography is helpful to determine the actual severity of the stenosis and predict risk of adverse events.

Non-invasive detection of tako-tsubo cardiomyopathy vs. acute anterior myocardial infarction by transthoracic Doppler echocardiography.

AIMS: Typical tako-tsubo cardiomyopathy (TTC) mimics acute anterior myocardial infarction (AMI) and the differential diagnosis is challenging before coronary angiography (CA) is performed; it demonstrates reduced or absent antegrade flow in the left anterior descending artery (LAD) in AMI, whereas there is no such flow limiting in TTC. At the acute phase, we tested the usefulness of the distal LAD flow visualization by transthoracic Doppler echocardiography (TDE) to distinguish between these two diseases. For this purpose, we prospectively enrolled 28 consecutive patients with TTC (75 ± 10 years, 93% females) who were compared with 28 consecutive patients with AMI treated successfully by primary angioplasty (66 ± 12 years, 79% females). All the patients underwent the assessment of the distal LAD flow just before CA, using colour and pulsed-wave TDE. In addition, the symmetric involvement of wall motion abnormalities (WMAs) based on the extent of the disease far beyond one coronary territory in TTC was searched by TDE. Non-invasive coronary flow reserve (CFR) by TDE, in the distal LAD, was also performed within 1 day after admission. RESULTS: Before CA, the distal LAD flow was visible in 38 of 56 cases (68%) in the whole population, in all cases with TTC and in 10 cases with AMI (36%). The sensitivity (Se) and specificity (Sp) of the LAD flow visualization for the diagnosis of TTC were 100 and 64%, respectively, with a diagnostic accuracy of 82%. In comparison, the pattern of WMA yielded a Se of 75% and Sp of 86%, and a diagnostic accuracy of 80%. With the combination of both tools, the Se and Sp to detect TTC were 75 and 96% respectively, with a diagnostic accuracy of 86%. After CA, the acute CFR was less severely impaired in the TTC group when compared with the AMI group (2.2 ± 0.5 vs. 1.7 ± 0.6, P < 0.01) despite a worse LV systolic dysfunction. CONCLUSION: Non-invasive evaluation of the distal LAD flow could be helpful to differentiate TTC from AMI, and its combination with the pattern of WMA improved slightly its diagnostic accuracy. Furthermore, the acute CFR is less severely impaired in TTC compared with AMI despite poorer LV systolic dysfunction, suggesting that other mechanisms than direct microcirculatory damage are also involved in the pathogenesis of WMAs in TTC.

Echocardiographic prediction of postoperative atrial fibrillation after aortic valve replacement for aortic stenosis: a two-dimensional speckle tracking left ventricular longitudinal strain multicentre pilot study.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery, with increased risk of embolic events, haemodynamic instability, haemorrhagic complications and prolonged hospital stay. AIMS: We sought to assess the value of preoperative left ventricular global longitudinal strain (GLS) for the prediction of POAF in a series of patients with severe symptomatic aortic stenosis who underwent aortic valve replacement (AVR). METHODS: Fifty-eight consecutive patients (52% men) aged 73±9 years, with severe symptomatic aortic stenosis (aortic valve area<1cm(2) or<0.5cm(2)/m(2)), in sinus rhythm, who underwent AVR were prospectively included in three centres between 2009 and 2010. Complete preoperative echocardiography was performed in all patients, including global and segmental longitudinal strain using two-dimensional speckle tracking. RESULTS: The POAF incidence was 28/58 (48%). On univariate analysis, aortic valve area (P=0.04), preoperative E/e' ratio (P=0.04) and GLS (P=0.005) were associated with the occurrence of POAF. Chronic obstructive pulmonary disease (P=0.05), preoperative statin treatment (P=0.09), age≥80 years (P=0.09), left ventricular ejection fraction (P=0.09) and systolic pulmonary artery pressure (P=0.06) tended to increase the risk of POAF. The best GLS cut-off value for the prediction of POAF was -15% (82% sensitivity, 53% specificity, area under the curve 0.72). On multivariable analysis, GLS>-15% was the only independent predictor of POAF (odds ratio 7.74, 95% confidence interval [1.15-52.03]; P=0.035). CONCLUSIONS: Incidence of POAF is high after AVR for severe aortic stenosis. Our results suggest an additive value of the study of left ventricular myocardial deformation to classical clinical and echocardiographic variables for the prediction of POAF in this setting.