Multimodality Imaging in Restrictive Cardiomyopathies: An EACVI expert consensus document In collaboration with the "Working Group on myocardial and pericardial diseases" of the European Society of Cardiology Endorsed by The Indian Academy of Echocardiography.

Restrictive cardiomyopathies (RCMs) are a diverse group of myocardial diseases with a wide range of aetiologies, including familial, genetic and acquired diseases and ranging from very rare to relatively frequent cardiac disorders. In all these diseases, imaging techniques play a central role. Advanced imaging techniques provide important novel data on the diagnostic and prognostic assessment of RCMs. This EACVI consensus document provides comprehensive information for the appropriateness of all non-invasive imaging techniques for the diagnosis, prognostic evaluation, and management of patients with RCM.

Assessment of myocardial mechanics in patients with end-stage renal disease and renal transplant recipients using speckle tracking echocardiography.

OBJECTIVES: Velocity vector imaging allows quantitation of myocardial strain and strain rate from 2-dimensional images based on speckle tracking echocardiography. The aim of this study was to analyze the changes in myocardial strain and strain rate patterns in patients with end-stage renal disease and renal transplant recipients. MATERIALS AND METHODS: We studied 33 patients with end-stage renal disease on hemodialysis (19 men; mean age, 36 ± 8 y), 24 renal transplant recipients with functional grafts (21 men; mean age, 36 ± 7 y) and 26 age- and sex-matched control subjects. Longitudinal peak systolic strain and strain rate for basal, mid, and apical segments of the left ventricular wall were determined by velocity vector imaging from apical 4- and 2-chamber views. The average longitudinal strain and strain rate for the left ventricle were noted. From short-axis views at the level of papillary muscles, average circumferential, and radial strain, and strain rate were assessed. RESULTS: Mean heart rate and systolic and diastolic blood pressure during imaging were similar between the groups. Longitudinal peak systolic strain and strain rate at basal and mid-segments of the lateral wall were significantly higher in renal transplant recipients and control groups than endstage renal disease patients. Average longitudinal systolic strain from the 4-chamber view was highest in control subjects (-14.5% ± 2.9%) and was higher in renal transplant recipients (-12.5% ± 3.0%) than end-stage renal disease patients (-10.2% ± 1.6%; P ≤ .001). Radial and circumferential strain and strain rate at the level of the papillary muscle were lower in patients with end-stage renal disease than other groups. CONCLUSIONS: Differences in myocardial function in patients with end-stage renal disease, renal transplant recipients, and normal controls can be quantified by strain imaging. Myocardial function is improved in renal transplant recipients compared with end-stage renal disease patients.

Impaired coronary flow reserve in patients with metabolic syndrome.

BACKGROUND: Metabolic syndrome (MetS) is a strong predictor of cardiovascular events. Coronary flow reserve (CFR), as determined by transthoracic echocardiography, is an indicator of microvascular function. In this study, we sought to determine whether CFR is impaired in patients with MetS without clinical coronary heart disease. METHODS: Thirty-three patients with MetS (mean age, 67+/-8 years) and 35 age- and sex-matched controls were studied prospectively. Transthoracic two-dimensional and Doppler echocardiography was performed on all patients. Baseline and hyperemic (after dipyridamole infusion) coronary flow rates were measured using pulsed Doppler echocardiography. CFR was calculated as the ratio of hyperemic to baseline diastolic peak velocities. RESULTS: There was no difference with regard to baseline systolic and diastolic coronary flow rates in patients with MetS compared with control subjects (19.9+/-3.1cm/s vs. 19.7+/-2.9cm/s, P>.05; and 27.7+/-4.2cm/s vs. 27.1+/-3.6cm/s, P>.05, respectively). Hyperemic diastolic flow and CFR were significantly lower in patients with MetS than in controls (61.7+/-9.4cm/s vs. 70.2+/-9.2cm/s, P<.0001; and 2.2+/-0.5 vs. 2.6+/-0.4, P=.001, respectively). In a logistic regression analysis that included age, sex, body mass index, hypertension, and dyslipidemia and MetS, MetS was the only predictor of a CFR<2.5 (P=.007, OR=6.1, 95% CI: 1.6-23.3). CONCLUSION: In conclusion, CFR is impaired in patients with MetS suggesting that coronary microvascular dysfunction, an early finding of atherosclerosis, is present in this patient population. Metabolic syndrome is associated with a CFR<2.5.

Dobutamine stress echocardiography in the assessment of cardiac allograft vasculopathy in asymptomatic recipients.

PURPOSE: Cardiac allograft vasculopathy (CAV) is the most important cause of late mortality among cardiac allograft recipients. Dobutamine stress echocardiography (DSE) is considered a safe and cost-effective method to screen these patients who remain free of angina most of the time. We evaluated DSE results in a series of cardiac allograft recipients. METHODS: The DSE was performed on a yearly basis. From 2004 to 2006, twelve DSEs were performed on 8 patients, including 7 men, and overall mean age of 36 +/- 12 years. Dobutamine infusion begun at 5 microg/kg/min was titrated at 3-minute stages to 10, 20, 40, and 50 microg/kg/min to achieve the target heart rate. In addition, at every stage, we performed a 12-lead EKG, heart rate, and blood pressure recording. The DSE results were compared with coronary angiograms and endomyocardial biopsies. RESULTS: Two patients displayed mildly and 1 patient a severely abnormal DSE test. The severely abnormal DSE test was associated with severe coronary artery stenosis, including inexperiment of the left main coronary artery. The second patient with an abnormal DSE had contour irregularities and distal cut-off of the right coronary artery as well as 2R cellular rejection. The third patient had a normal angiogram and no rejection. None of the patients with normal DSE experienced a cardiac event, coronary lesions, or rejection. CONCLUSION: Use of DSE appears to be a sensitive method to detect CAV in asymptomatic recipients. However, mild wall motion abnormalities can be detected in patients without stenosing coronary lesions. The value of DSE in predicting CAV must be examined in larger series with long-terms of follow-up.

Detection of subclinical cardiac involvement in systemic sclerosis by echocardiographic strain imaging.

BACKGROUND: Cardiac involvement is one of the major problems in systemic sclerosis (SSc). Subclinical cardiac involvement has a higher frequency than thought previously. In this study we investigated whether subclinical cardiac involvement can be detected by using echocardiographic strain imaging in SSc patients without pulmonary hypertension. METHODS: Echocardiographic examinations were performed to 27 SSc patients and 26 healthy controls. Left ventricular strain parameters were obtained from apical views and average strain value was calculated from these measurements. RESULTS: There were no significant differences between patients and controls regarding two-dimensional (2D), conventional Doppler and tissue Doppler velocity measurements. Strain was reduced in 6 of 12 segments of the left ventricle (LV) and in 1 of 2 segments of the right ventricle (RV). Strain rate (SR) was reduced in 2 of 12 segments of the LV and 1 of 2 segments of the RV in SSc patients as compared to controls (P < 0.05 for all). These involvements did not match any particular coronary artery distribution. More important differences were detected by average strain and SR values of the LV between patients and controls (19.78 +/- 3.00% vs 23.41 +/- 2.73%, P < 0.001; 2.01 +/- 0.41 vs 2.23 +/- 0.27/sec, P = 0.026, respectively). Furthermore, carbon monoxide diffusion capacity (DLCO) in scleroderma patients significantly correlated with LV average strain (r = 0.59; P = 0.001). CONCLUSION: Evaluation of ventricular function by using echocardiographic strain imaging appears to be useful to detect subclinical cardiac involvement in SSc patients with normal standard echocardiographic and tissue Doppler velocity findings.

Serum gamma-glutamyl transferase activity: a new marker for stent restenosis?

Stent restenosis remains the main limitation of percutaneous coronary intervention. Elevated serum gamma-glutamyl transferase (GGT) level is associated with an inflammatory response. We aimed to determine the correlation of stent restenosis with the serums level of GGT. One hundred and twenty patients (age 58.56+/-10.46 years, 66% male) with a history of coronary stent implantation and had undergone control coronary angiography (60 with restenosis and 60 without) were included. All had baseline serum GGT activity and were free of systemic and hepatobiliary disease. Median baseline serum GGT activity was significantly higher in patients with restenosis (34.00 U/L (24.00-47.75)) than in those without restenosis (21.00 U/L (17.25-26.7500)) (P<0.0001). Stent restenosis was identified in 38% of the patients with a serum GGT value >40 U/L and in 5% of patients with a serum GGT value

Usefulness of angle corrected tissue Doppler to assess segmental left ventricular function during dobutamine stress echocardiography in patients with and without coronary artery disease.

The application of angle correction to tissue Doppler (TD) during dobutamine stress echocardiography (DSE) extends the application of TD to all left ventricular segments, improves the differentiation of abnormal from normal segmental responses to stress, and has promise to improve its clinical utility for objectively evaluating wall motion during DSE.

A mechanism for immediate reduction in mitral regurgitation after cardiac resynchronization therapy: insights from mechanical activation strain mapping.

OBJECTIVES: We tested the hypothesis that an immediate reduction in mitral regurgitation (MR) after cardiac resynchronization therapy (CRT) results from improved coordinated timing of the papillary muscle insertion sites, using the novel approach of mechanical activation strain mapping. BACKGROUND: Heart failure patients with left bundle branch block often benefit acutely from CRT; however, the role and mechanism of reduction of MR are unclear. METHODS: Twenty-six consecutive patients undergoing CRT with at least mild MR were studied (ejection fraction 24 +/- 6%; QRS duration 168 +/- 30 ms). Echocardiographic Doppler and strain imaging was performed immediately before and the day after CRT, as well as in 10 normal control subjects. Mechanical activation sequence maps were constructed using longitudinal strain from 12 basal and mid-LV sites, with color coding of time-to-peak strain. RESULTS: Mitral regurgitation by the volumetric method consistently decreased after CRT: regurgitant volume from 40 +/- 20 ml to 24 +/- 17 ml and regurgitant fraction from 40 +/- 12% to 25 +/- 14% (both: p < 0.001 vs. baseline). Normal controls had uniform segmental time-to-peak strain, with a difference of only 12 +/- 8 ms between all segments. In contrast, CRT patients at baseline had a 106 +/- 74 ms time delay between papillary muscle insertion sites (p < 0.001 vs. normal). This interpapillary muscle time delay shortened after CRT to 39 +/- 43 ms (p < 0.001 vs. baseline) and was significantly correlated with reductions in mitral regurgitant fraction (r = 0.77, p < 0.001). CONCLUSIONS: Cardiac resynchronization therapy significantly and immediately reduced MR. Improved coordinated timing of mechanical activation of papillary muscle insertion sites appears to be a mechanistic contributor to immediate MR reduction by CRT.

Quantification of radial mechanical dyssynchrony in patients with left bundle branch block and idiopathic dilated cardiomyopathy without conduction delay by tissue displacement imaging.

Cardiac resynchronization therapy has made assessment of cardiac dyssynchrony clinically important. To test the hypothesis that echocardiographic displacement imaging can quantify dyssynchrony, 22 patients with left bundle branch block (LBBB), 14 with idiopathic dilated cardiomyopathy (IDC) without electrical conduction delay, and 22 normal controls were studied using radial angle-corrected displacement imaging. Control subjects had coordinated wall movement, whereas patients with LBBB had dyssynchrony characterized by early inward anteroseptal movement and markedly delayed posterior, lateral, or inferior regions (157 +/- 99 ms; p <0.001 vs normal). An interesting subset of patients with IDC without conduction delay (36%) had dyssynchrony with anteroseptal to posterior wall delays of 169 +/- 56 ms (p <0.001 vs normal), similar to patients with LBBB.

Influence of hand-carried ultrasound on bedside patient treatment decisions for consultative cardiology.

To test the hypothesis that hand-carried ultrasound (HCU) may influence patient treatment on consultative cardiology rounds, 235 patients who were hospitalized (aged 65 +/- 10 years) were studied. First, routine treatment decisions regarding diagnostic workup and therapy were made from patient history, physical examination, 12-lead electrocardiogram, and chart data. Second, a goal-directed HCU study was performed in <10 minutes focusing on left ventricular global and regional function, wall thickness, and presence of pericardial effusion, followed by a reassessment of treatment decisions. HCU data influenced treatment decisions in 149 patients (63%); 50% had a change in medical therapy and 22% had a change in their diagnostic workup (most with changes in both). In all, 12 patients (5%) had an immediate change in the decision for cardiac catheterization or pericardiocentesis. Overall agreement for the above findings with subsequent full-size system echocardiography ranged from 92% to 100% (kappa 0.91-0.96). Goal-directed HCU has the potential to influence bedside patient treatment decisions and expedite health care.

Regional correlation by color-coded tissue Doppler to quantify improvements in mechanical left ventricular synchrony after biventricular pacing therapy.

Cardiac resynchronization therapy (CRT) can improve cardiac function in patients with heart failure and left bundle branch block. To test a new synchrony index derived from mitral annular velocity by color tissue Doppler, 19 subjects were studied: 9 patients with heart failure and left bundle branch block at baseline and at 1, 3 and 6 months after CRT and 10 normal controls. The synchrony index in patients with heart failure was less than that in controls at baseline (r = 0.60 +/- 0.13 vs 0.94 +/- 0.02; p <0.01), but improved at 6 months after CRT (r = 0.77 +/- 0.09; p <0.05 vs baseline).