Combined flow-based imaging assessment of optimal cardiac resynchronization therapy pacing vector: a case report.

BACKGROUND: There are still many pendent issues about the effective evaluation of cardiac resynchronization therapy impact on functional mitral regurgitation. In order to reduce the intrinsic difficulties of quantification of functional mitral regurgitation itself, an automatic quantification of real-time three-dimensional full-volume color Doppler transthoracic echocardiography was proposed as a new, rapid, and accurate method for the assessment of functional mitral regurgitation severity. Recent studies suggested that images of left ventricle flow by echo-particle imaging velocimetry could be a useful marker of synchrony. Echo-particle imaging velocimetry has shown that regional anomalies of synchrony/synergy of the left ventricle are related to the alteration, reduction, or suppression of the physiological intracavitary pressure gradients. We describe a case in which the two technologies are used in combination during acute echocardiographic optimization of left pacing vector in a 63-year-old man, Caucasian, who showed worsening heart failure symptoms a few days after an implant, and the effect of the device's optimization at 6-month follow-up. DISCUSSION: The degree of realignment of hemodynamic forces, with quantitative analysis of the orientation of blood flow momentum (φ), can represent improvement of fluid dynamics synchrony of the left ventricle, and explain, with a new deterministic parameter, the effects of cardiac resynchronization therapy on functional mitral regurgitation. Real-time three-dimensional color flow Doppler quantification is feasible and accurate for measurement of mitral inflow, left ventricular outflow stroke volumes, and functional mitral regurgitation severity. CONCLUSION: This clinical case offers an innovative and accurate approach for acute echocardiographic optimization of left pacing vector. It shows clinical utility of combined three-dimensional full-volume color Doppler transthoracic echocardiography/echo-particle imaging velocimetry assessment to increase response to cardiac resynchronization therapy, in terms of reduction of functional mitral regurgitation, improving fluid dynamics synchrony of the left ventricle.

STRAIN ANALYSIS OF MASSETER MUSCLE BY ULTRASOUND.

The masseter muscle represents an area of important functional interest. The present study aims to verify the feasibility of ultrasound imaging for quantifying the muscular deformation pattern in the masseter. Fifteen consecutive subjects were enrolled and underwent masseter ultrasound according to a repeatable protocol. Ultrasound was carried out during teeth clenching in natural conditions and after the insertion of a medical device that alters the distance between the dental arches, and was repeated on 3 different days. Results showed that masseter deformation is not uniform within the muscle. The same strain patterns were repeated in the different ultrasounds of the same patient and were modified after the introduction of a medical device. This was supported by quantitative comparisons in the deep portion of the muscle (standard deviation on the three measures: 3% normal conditions, 2% with medical device) showing a systematic reduction with the prosthesis (30% on average). This study demonstrated that masseter strain analysis is a repeatable and sensitive tool for the study of functional analysis of the masticatory organ. This opens new technical perspectives for the diagnosis and therapy of dysfunctional pathologies of the masticatory organ.

Quantitative analysis of intraventricular blood flow dynamics by echocardiographic particle image velocimetry in patients with acute myocardial infarction at different stages of left ventricular dysfunction.

AIMS: Left ventricular (LV) diastolic filling is characterized by the formation of a vortex that supports an efficient transit into systolic ejection. Aim of this study was to assess the intraventricular (IV) blood flow dynamics among patients with ST elevated myocardial infarction (STEMI) at different degrees of LV dysfunction, in the attempt to find novel indicators of LV pump efficiency. METHODS AND RESULTS: Sixty-four subjects, 34 consecutive STEMI patients and 30 healthy controls, underwent before hospital discharge 2D speckle tracking echocardiography to assess global longitudinal strain (GLS), and echo-particle image velocimetry analysis to assess flow energetic parameters. Left ventricular volumes ejection fraction (LVEF) and global wall motion score index (GWMSI) were evaluated by 3D echocardiography. ST elevated myocardial infarction patients were subdivided into three groups according to LVEF. Energy dissipation, vorticity fluctuation, and kinetic energy fluctuation indexes, which characterize the degree of disturbance in the flow, exhibit a biphasic behaviour in STEMI patients when compared with controls, with the highest values in patients with still preserved LV function and progressive lower values with LV function worsening. Significant linear correlations were found between energy dissipation index and both LVEF and GLS (r = 0.57, P < 0.001 and r = -0.61, P = 0.001, respectively). Kinetic energy fluctuation index significantly correlates with both LVEF (r = 0.75, P < 0.001) and GLS (-0.58, P = 0.002). Finally, a significant correlation was observed between GWMSI and energy dissipation index (-0.56, P = 0.008). CONCLUSIONS: The present study describes, for the first time, the progression of IV flow energetic properties in patients with acute myocardial infarction at different stages of LV dysfunction when compared with healthy controls. Further data are needed to assess the role of these parameters in the development and maintenance of LV dysfunction.

Describing the highly three dimensional Right Ventricle flow.

Visualization of the three-dimensional flow within the Right Ventricle (RV) is a challenging issue due to the fully three-dimensional geometry of the ventricular cavity. To date proper characterization and quantification of the RV flow still remains incomplete, and techniques that can be easily applied to current medical imaging are scarce. A method for simulating the highly complex, multi directional flow within the RV is presented by coupling 4D echocardiography imaging with numerical simulations based on the Immersed Boundaries Method (IBM). A novel formulation for accurately computing the space-time distribution of the blood residence time inside the cavity is introduced. Results showed an initial compact vortex forming past the tricuspid orifice at early diastole that quickly breaks into a weakly turbulent flow pattern and rearranges, during systole, into a peculiar stream-wise vortex spinning out towards the pulmonary orifice. This arrangement is maintained when the Ejection Fraction (EF) is reduced from 58 to 32%. The average blood transit time is found to scale almost inversely proportional to the EF. A careful analysis of the residence time permitted to assess the relative significance of the different flow components (from the direct flow, with a residence time less than one heartbeat, to the residual volume, that stagnates in the ventricle) and their distribution in space.

Combined experimental and numerical analysis of the flow structure into the left ventricle.

Fluid dynamics is used for diagnosis in cardiology only to a partial extent. Indeed several aspects of cardiac flows and their relation with pathophysiology are unknown. The flow that develops into the left ventricle is here studied by using a combination of numerical and experimental models. The former allows a detailed three-dimensional analysis, the latter can be used in conditions, like in presence of turbulence, that are out of reach of the current computational power. The three-dimensional flow dynamics is analyzed in terms of its vortical structure. The study, within its limitations, provides further physical understanding about the intraventricular flow structure. This could eventually support the development of cardiac diagnostic indicators based on fluid dynamics.

Relationship between preclinical abnormalities of global and regional left ventricular function and insulin resistance in severe obesity: a Color Doppler Imaging Study.

BACKGROUND: The aim of this study was to evaluate the relationship between insulin resistance and preclinical abnormalities of the left ventricular structure and function detected in severe obesity by Color Doppler Myocardial Imaging (CDMI). Forty-eight consecutive severely obese patients (Group O) (11 males, 37 females, mean age 32.8+/-7 years) were enrolled. Forty-eight sex- and age-matched non-obese healthy subjects were also recruited as controls (Group C). All subjects underwent conventional 2D-Color Doppler echocardiography and CDMI. The homeostasis model assessment insulin resistance index (HOMA-IR) was used to assess insulin resistance results. Obese subjects had a greater left ventricular mass index (by height) (58.8+/-14 g/m(2.7)) than controls (37+/-8 g/m(2.7)) (P<0.0001), owing to compensation response to volume overload caused by a greater cardiac output (P<0.02). Preload reserve was increased in obese subjects, as demonstrated by a significant increase in left atrial dimension (P<0.0001). Obese patients had a slightly reduced LV diastolic function (transmitral E/A ratio: Group O, 1.1+/-0.8 vs Group C, 1.5 +/-0.5; P<0.002). Cardiac deformation assessed by regional myocardial systolic strain and strain rate (SR) values was significantly lower (abnormal) in obese patients than in controls, both at the septum and lateral wall level. These strain and SR abnormalities were significantly related to body mass index. In addition, the early phase of diastolic function, evaluated using SR, was compromised in obese patients (P<0.001). The HOMA-IR values in obese patients were significantly higher (3.09+/-1.6) than those determined in the control group (0.92+/-0.5) (P<0.0001). The HOMA-IR values, in the obese group, were significantly related to systolic strain and SR values sampled at the septum level (P<0.0001). CONCLUSION: In conclusion, this study has demonstrated that obese patients pointed out systolic structural and functional abnormalities at a preclinical stage, in particular through strain and SR analysis; on the other hand, those altered CDMI parameters well distinguish obese subjects as compared with the control group. Furthermore, another main finding of the study was that myocardial deformation (systolic strain) could have a correlation with insulin resistance level.

Flow on the symmetry plane of a total cavo-pulmonary connection.

The flow inside a total cavo-pulmonary connection, a bypass operation of the right heart adopted in the presence of congenital malformation, is here studied for a specific geometry which has been recently introduced in clinics. The analysis has been performed by preliminary experimental observation and a novel Navier-Stokes formulation on the symmetry plane. This method, once some basic hypotheses are verified, allows to reproduce the flow on the symmetry plane of a three-dimensional field by using an extension of the two-dimensional approach. The analysis has confirmed the existence of a central vortex showing that it is not a real vortex (i.e. a place with accumulation of vorticity) but, rather, a weakly dissipative recirculating zone. It is surrounded by a shear layer that becomes spontaneously unsteady at moderately high Reynolds number. The topological changes and energy dissipation have been analysed in both cases of unbalanced and of balanced pulmonary artery and caval flows.