Letter to the Editor Ross procedure valve function, clinical outcomes and predictors after 25 years follow up.

The following letter presents an answer of a comment of our work titled "Ross procedure: valve function, clinical outcomes and predictors after 25 years' follow-up," recently published in your journal by Rangwala et al.1 As our colleagues point out, the Ross procedure has excellent survival rates but a significant risk of valve dysfunction and therefore reintervention at follow-up. Although the survival advantage with the Ross procedure appears to be consistent compared with mechanical valve substitutes, this benefit is not as clear compared with biological valve substitutes. However, biological valve substitutes also have significant reintervention rates during follow-up. The different surgical modifications of the Ross procedure have not clearly demonstrated better results in follow-up in terms of autograft reintervention. This procedure can be performed in a medium-volume center with good results as long as adequate patient selection and adequate surgical training are carried out.

Bifurcation lesions involved in the recanalization process of coronary chronic total occlusions: Incidence, treatment and clinical implications.

BACKGROUND: The presence of a bifurcation (BL) in the context of a coronary chronic total occlusion (CTO) represents an additional difficulty. This study analyzes the incidence of BLs in CTO recanalization, the treatment, predictors of bifurcation technical success and their clinical impact. METHODS AND RESULTS: BLs with a side branch (SB) ≥2.0mm located proximally, distally or within the occluded segment were observed in 130 (33%) of 391 CTO. Provisional stenting was the strategy more frequently used (94%). Bifurcation success (stenosis <30% in main vessel and TIMI flow III in both branches) was achieved in 105 patients (81%). In the remaining 25 (19%), the TIMI flow at the SB was

Treatment and clinical outcomes of transcatheter heart valve thrombosis.

BACKGROUND: Valve thrombosis has yet to be fully evaluated after transcatheter aortic valve implantation. This study aimed to report the prevalence, timing, and treatment of transcatheter heart valve (THV) thrombosis. METHODS AND RESULTS: THV thrombosis was defined as follows (1) THV dysfunction secondary to thrombosis diagnosed based on response to anticoagulation therapy, imaging modality or histopathology findings, or (2) mobile mass detected on THV suspicious of thrombus, irrespective of dysfunction and in absence of infection. Between January 2008 and September 2013, 26 (0.61%) THV thromboses were reported out of 4266 patients undergoing transcatheter aortic valve implantation in 12 centers. Of the 26 cases detected, 20 were detected in the Edwards Sapien/Sapien XT cohort and 6 in the Medtronic CoreValve cohort. In patients diagnosed with THV thrombosis, the median time to THV thrombosis post-transcatheter aortic valve implantation was 181 days (interquartile range, 45-313). The most common clinical presentation was exertional dyspnea (n=17; 65%), whereas 8 (31%) patients had no worsening symptoms. Echocardiographic findings included a markedly elevated mean aortic valve pressure gradient (40.5±14.0 mm Hg), presence of thickened leaflets or thrombotic apposition of leaflets in 20 (77%) and a thrombotic mass on the leaflets in the remaining 6 (23%) patients. In 23 (88%) patients, anticoagulation resulted in a significant decrease of the aortic valve pressure gradient within 2 months. CONCLUSIONS: THV thrombosis is a rare phenomenon that was detected within the first 2 years after transcatheter aortic valve implantation and usually presented with dyspnea and increased gradients. Anticoagulation seems to have been effective and should be considered even in patients without visible thrombus on echocardiography.

Impact of asymptomatic acute cellular rejection on left ventricle myocardial function evaluated by means of two-dimensional speckle tracking echocardiography in heart transplant recipients.

BACKGROUND: Our objective was to evaluate the impact of asymptomatic acute cellular rejection (ACR) in left ventricular myocardial strain in heart transplant (HT) recipients by means of two-dimensional speckle tracking echocardiography (2DSTE). METHODS: From September 1, 2009 to December 15, 2010 a conventional echocardiography and 2DSTE exam was performed on all consecutive HT recipients in their first year posttransplantation within 3 hours of the surveillance endomyocardial biopsies, as well as on 14 healthy controls. The association of strain echocardiographic variables with different grades of ACR was investigated. RESULTS: Of the 78 studies performed 4 ± 3 months after HT in 20 patients, 32 studies were coincident with grade 0R rejection, 41 with grade 1R, and 5 with grade 2R. Significantly lower values of average radial strain were found with higher grades of ACR (29.1 ± 7.7%, 23.2 ± 8.5%, and 14.3 ± 8.8% for grades 0R, 1R, and 2R of ACR, P = 0.001). Average deformation was similar for controls versus transplanted patients, in the absence of acute rejection: radial 29.1 ± 10.0% versus 29.1 ± 7.7%, P = 0.98; circumferential -19.3 ± 3.2% versus -20.2 ± 5.9%, P = 0.62; and longitudinal -20.7 ± 4.1% versus -18.5 ± 5.4%, P = 0.19. An average radial strain <25% presented 100% sensitivity, 48% specificity, 6% positive predictive value, and 100% negative predictive value for the presence of 2R rejection (area under the curve 0.80, IC 95% 0.60-0.99, P = 0.048). CONCLUSION: In this study, HT recipients showed significantly lower values of average radial left ventricle strain, evaluated by means of 2DSTE, with the presence of ACR.

Prognostic impact of baseline low blood pressure in hypertensive patients with stable coronary artery disease of daily clinical practice.

The authors' aim was to investigate the prognostic value of first-visit systolic and diastolic blood pressure (SBP/DBP) in hypertensive patients with stable coronary artery disease (sCAD) in conditions of contemporary daily clinical practice. From February 1, 2000, to January 31, 2004, 690 consecutive hypertensive patients with sCAD (mean age 68 ± 10 years, 65% male) were prospectively followed in the outpatient cardiology clinic for major events (acute coronary syndrome, revascularization, stroke, heart failure, or death) and associations with baseline SBP/DBP were investigated. At first visit, median SBP/SDP were 130/75 mm Hg (interquartile range, 25-75; 120-140/70-80 mm Hg). After 25 months of follow-up (median), 19 patients died (2.8%); 10 from cardiovascular causes (1.5%), 87 patients experienced a coronary event (13%), and 130 patients (19%) a major event. After adjusting for baseline variables, DBP <75 mm Hg or SBP <130 mm Hg resulted in independent predictors of major events (hazard ratio [HR], 1.52; 95% confidence interval [CI], 1.07-2.16, P=.02; HR, 1.68; 95% CI, 1.18-2.40, P=.004, respectively), coronary events (HR, 1.78; 95% CI, 1.15-2.75, P=.009; HR, 1.84; 95% CI, 1.20-2.83, P=.005, respectively), and cardiovascular mortality (HR, 7.02; 95% CI, 1.26-39.04, P=.03; HR, 9.26; 95% CI, 1.33-64.32, P=.02, respectively). In this study, a low first-visit SBP or DBP was associated with an adverse prognosis in hypertensive patients with sCAD of contemporary daily clinical practice.

An electrocardiographic sign of tumor invasion of the myocardium.

Lung cancer is one of the most common neoplasms associated with cardiac metastasis, and the pericardium is often affected. However, isolated myocardial involvement in these patients is very uncommon. Most tumor invasions into the heart are nonspecific and clinically silent. Myocardial metastasis rarely mimics an acute myocardial infarction. We report a case of a 59-year-old man with a metastatic lung cancer into the myocardium mimicking an acute myocardial infarction.

Long-term outcome of patients with isolated thin discrete subaortic stenosis treated by balloon dilation: a 25-year study.

BACKGROUND: Transluminal balloon tearing of the membrane in a thin discrete subaortic stenosis is an alternative to membrane surgical resection. However, the long-term outcome of patients with isolated thin discrete subaortic stenosis treated by transluminal balloon tearing remains unknown. METHODS AND RESULTS: This 25-year study describes findings from 76 patients with isolated thin discrete subaortic stenosis who underwent percutaneous transluminal balloon tearing of the membrane and were followed up for a mean period of 16±6 years. The age at presentation had a wide range (2-67 years). The mean age at treatment was 19±16 years. Immediately after treatment, the subvalvular gradient decreased from 70±27 to 18±12 mm Hg (P<0.001). No significant postprocedural aortic regurgitation was observed. After a mean follow-up time of 16±6 years, 11 patients (15%) developed restenosis, 3 patients (4%) progressed to muscular obstructive disease, and 1 patient (1.3%) developed a new distant obstructive membrane. Twelve patients (16%) were redilated at a mean of 5±3 years after their first treatment, and 4 patients (5%) underwent surgery at a mean of 3±2 years after their first treatment. Fifty-eight patients (77%) remained alive and free of redilation or surgery at follow-up. Larger annulus diameter and thinner membranes were independent factors associated with better long-term results. CONCLUSIONS: Most patients (77%) with isolated thin discrete subaortic stenosis treated with transluminal balloon tearing of the membrane had sustained relief at subsequent follow-ups without restenosis, the need for surgery, progression to muscular obstructive disease, or an increase in the degree of aortic regurgitation.

Combined percutaneous revascularization and cell therapy after failed repair of anomalous origin of left coronary artery from pulmonary artery.

This report shows the course of an infant with an abnormal left coronary artery origin arising from the pulmonary artery who underwent failed surgical reimplantation. Treatment entailed combined stent revascularization followed by intracoronary infusion of bone marrow-derived mononuclear cells. The patient was admitted with an acute coronary syndrome and low cardiac output; he was endotracheally intubated under respiratory assistance. Fourteen months after intracoronary infusion of autologous bone marrow-derived mononuclear cells, the infant remains symptom-free with significant recovery of the left ventricular function. These findings suggest that the combination of percutaneous revascularization and cell therapy should be considered in those infants or children in whom salvage therapy for ischemic heart disease is required.

Drug eluting and bare metal stents in people with and without diabetes: collaborative network meta-analysis.

OBJECTIVE: To compare the effectiveness and safety of three types of stents (sirolimus eluting, paclitaxel eluting, and bare metal) in people with and without diabetes mellitus. DESIGN: Collaborative network meta-analysis. DATA SOURCES: Electronic databases (Medline, Embase, the Cochrane Central Register of Controlled Trials), relevant websites, reference lists, conference abstracts, reviews, book chapters, and proceedings of advisory panels for the US Food and Drug Administration. Manufacturers and trialists provided additional data. REVIEW METHODS: Network meta-analysis with a mixed treatment comparison method to combine direct within trial comparisons between stents with indirect evidence from other trials while maintaining randomisation. Overall mortality was the primary safety end point, target lesion revascularisation the effectiveness end point. RESULTS: 35 trials in 3852 people with diabetes and 10,947 people without diabetes contributed to the analyses. Inconsistency of the network was substantial for overall mortality in people with diabetes and seemed to be related to the duration of dual antiplatelet therapy (P value for interaction 0.02). Restricting the analysis to trials with a duration of dual antiplatelet therapy of six months or more, inconsistency was reduced considerably and hazard ratios for overall mortality were near one for all comparisons in people with diabetes: sirolimus eluting stents compared with bare metal stents 0.88 (95% credibility interval 0.55 to 1.30), paclitaxel eluting stents compared with bare metal stents 0.91 (0.60 to 1.38), and sirolimus eluting stents compared with paclitaxel eluting stents 0.95 (0.63 to 1.43). In people without diabetes, hazard ratios were unaffected by the restriction. Both drug eluting stents were associated with a decrease in revascularisation rates compared with bare metal stents in people both with and without diabetes. CONCLUSION: In trials that specified a duration of dual antiplatelet therapy of six months or more after stent implantation, drug eluting stents seemed safe and effective in people both with and without diabetes.

Ultrasound findings during percutaneous treatment of bifurcated coronary lesions.

INTRODUCTION AND OBJECTIVES: Provisional stenting has been shown to be effective in the treatment of bifurcated coronary lesions. The aim of this study was to evaluate changes in the geometry of the main vessel stent following side branch (SB) dilatation and kissing balloon (KB) inflation. METHODS: The study involved 23 patients with a bifurcated coronary lesion. A first intravascular ultrasound (IVUS) study was performed after drug-eluting stent implantation in the main vessel. Subsequently, angioplasty of the SB was carried out, and a second IVUS was performed to evaluate its effect. Finally, KB inflation was carried out, followed by a third IVUS study of the main vessel. The cross-sectional area of the implanted stent at different points was compared in the three IVUS studies. RESULTS: The cross-sectional area of the proximal segment of the recently implanted stent was 7.3+/-1.9 mm2 and increased to 9.6+/-2.9 mm2 after KB inflation (P< .05). Dilatation of the SB resulted in a reduction in the cross-sectional area under the SB origin from 5.9+/-1.2 mm2 initially to 5.2+/-1.2 mm2 (P< .05). After KB inflation, the cross-sectional area partially recovered (to 5.6+/-1.2 mm2). CONCLUSIONS: After angioplasty of the SB, a reduction was observed in the cross-sectional area of the stent immediately distal to the SB origin. The area did not return to its initial value after KB inflation. However, KB inflation increased the cross-sectional area of the proximal segment of the stent and changed stent geometry.

Outcomes associated with drug-eluting and bare-metal stents: a collaborative network meta-analysis.

BACKGROUND: Whether the two drug-eluting stents approved by the US Food and Drug Administration-a sirolimus-eluting stent and a paclitaxel-eluting stent-are associated with increased risks of death, myocardial infarction, or stent thrombosis compared with bare-metal stents is uncertain. Our aim was to compare the safety and effectiveness of these stents. METHODS: We searched relevant sources from inception to March, 2007, and contacted investigators and manufacturers to identify randomised controlled trials in patients with coronary artery disease that compared drug-eluting with bare-metal stents, or that compared sirolimus-eluting stents head-to-head with paclitaxel-eluting stents. Safety outcomes included mortality, myocardial infarction, and definite stent thrombosis; the effectiveness outcome was target lesion revascularisation. We included 38 trials (18,023 patients) with a follow-up of up to 4 years. Trialists and manufacturers provided additional data on clinical outcomes for 29 trials. We did a network meta-analysis with a mixed-treatment comparison method to combine direct within-trial comparisons between stents with indirect evidence from other trials while maintaining randomisation. FINDINGS: Mortality was similar in the three groups: hazard ratios (HR) were 1.00 (95% credibility interval 0.82-1.25) for sirolimus-eluting versus bare-metal stents, 1.03 (0.84-1.22) for paclitaxel-eluting versus bare-metal stents, and 0.96 (0.83-1.24) for sirolimus-eluting versus paclitaxel-eluting stents. Sirolimus-eluting stents were associated with the lowest risk of myocardial infarction (HR 0.81, 95% credibility interval 0.66-0.97, p=0.030 vs bare-metal stents; 0.83, 0.71-1.00, p=0.045 vs paclitaxel-eluting stents). There were no significant differences in the risk of definite stent thrombosis (0 days to 4 years). However, the risk of late definite stent thrombosis (>30 days) was increased with paclitaxel-eluting stents (HR 2.11, 95% credibility interval 1.19-4.23, p=0.017 vs bare-metal stents; 1.85, 1.02-3.85, p=0.041 vs sirolimus-eluting stents). The reduction in target lesion revascularisation seen with drug-eluting stents compared with bare-metal stents was more pronounced with sirolimus-eluting stents than with paclitaxel-eluting stents (0.70, 0.56-0.84; p=0.0021). INTERPRETATION: The risks of mortality associated with drug-eluting and bare-metal stents are similar. Sirolimus-eluting stents seem to be clinically better than bare-metal and paclitaxel-eluting stents.

Transcatheter closure of perimembranous ventricular septal defects using the amplatzer membranous VSD occluder: immediate and midterm results of an international registry.

OBJECTIVE: To report the immediate and midterm results of transcatheter closure of perimembranous ventricular septal defect (PmVSD) using the Amplatzer membranous VSD occluder (AMVSD). METHODS: Between April 2002 and August 2004, 100 patients underwent an attempt of percutaneous device closure of PmVSD using the AMVSD in 24 international centers. The median age was 9.0 years (0.7-58 years) and the median weight was 27.5 kg (7-121 kg). RESULTS: A device was successfully deployed in 93/100 (93%) patients. Reasons for procedural failure were an increased gradient across the left ventricle outflow tract in one patient, aortic regurgitation in 2 patients, and inability to securely position the device in 4 patients. The median VSD size by TEE was 7.0 mm (1.5-13 mm), median device size 10 mm (4-16 mm) and median fluoroscopy time 22.1 min (8.9-96.0 min). Weight below 10 kg (P = 0.0392), inlet extension of the VSD (P = 0.0139) and aortic cusp prolapse into the VSD (P = 0.0084) were significantly associated with a lower procedural success. Patients have been followed up for a median of 182 days (1-763 days). There were no procedure-related deaths. Complications were encountered in 29/100 (29%) patients, including rhythm or conduction anomalies in 13 patients (two with complete heart block requiring permanent pacemaker implantation), new or increased aortic (9 patients) or tricuspid (9 patients) regurgitation, most of which were classified as trivial or mild. Patients with a weight below 10 kg had a significantly higher incidence of adverse events than patients with a weight above 10 kg (58.3% versus 25.0%, P = 0.0285). Immediately after device release complete closure of the defect was present in 54/93 (58.1%) patients, increasing to 46/55 (83.6%) patients at 6-months follow-up (P = 0.0012). Left ventricle end-diastolic diameter decreased from a median of 44 mm prior to device closure to a median of 39 mm at 6-months postprocedure (P = 0.0015). CONCLUSION: Closure of PmVSDs using the AMVSD occluder is safe and effective. However, longer follow-up period is warranted prior to the wide spread use of this device.

Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: a randomized comparison of a simple versus complex strategy.

BACKGROUND: Rapamycin-eluting stents (RES) have been shown to reduce restenosis in many types of lesions. However, the ideal strategy for the treatment of coronary bifurcated lesions has not been established to date. This randomized study compares 2 strategies for the RES treatment of bifurcation lesions: a simple approach (stenting the main vessel and balloon dilatation for the side branch [SB]) versus a complex approach (stents for both vessels). METHODS: To compare both strategies, a randomized study was conducted in 91 patients with true coronary bifurcation lesions. All patients received an RES at the main vessel, covering the SB. Patients from group A (n = 47) were assigned to balloon dilation of the involved SB (simple strategy); patients in group B (n = 44) were randomized to receive a second stent at the SB origin (complex strategy). There were no differences between groups regarding baseline clinical and angiographic data. RESULTS: Major adverse cardiac events occurred in 3 patients from group A (2 non-Q-wave myocardial infarctions and 1 target lesion revascularization). Six-month angiographic reevaluation was obtained in 80 patients (88%). Restenosis of the main vessel was observed in 1 (2%) patient from group A and in 4 (10%) from group B. Restenosis of the SB appeared in 2 (5%) patients from group A and in 6 (15%) from group B. CONCLUSIONS: Both strategies are effective in reducing the restenosis rate, with no differences in terms of clinical outcome. Elective SB stenting seems to provide no advantages over the simpler stent jail followed by SB balloon dilation.

Rapamycin-eluting stents for the treatment of unprotected left main coronary disease.

BACKGROUND: Conventional bare stents have been used to treat unprotected left main (LM) coronary artery stenosis. However, restenosis remains the main limitation. Since rapamycin-eluting stents (RES) appear to inhibit neointimal proliferation, their application to this specific site seems promising. METHODS: Since May 2002, we have studied a series of 52 patients with LM lesions treated with RES. Forty-seven patients presented with de novo stenoses, and 5 had in-stent restenosis; 19 patients required combined stent treatment for other remote lesions in the coronary tree, 6 of them at the level of proximal right coronary artery. The RES was implanted directly at the LM in 39 patients; 13 others needed predilation. Once deployed, the RES was overexpanded with short balloons adjusted to the LM length in 44 patients. Quantitative coronary angiograms were analyzed in the same view before and immediately after treatment and at follow-up. Patients were followed-up closely and new cardiac catheterization was scheduled at 6-month evaluation or earlier in the presence of symptoms. At follow-up study, quantitative coronary angiography and motorized intravascular ultrasound analyses were performed in 35 (67%) patients. RESULTS: Primary success was obtained in 50 patients (96%). Two patients (4%) developed a non-Q-wave myocardial infarction. All patients were symptom-free at discharge. After a mean follow-up of 12 +/- 4 months, 50 patients (96%) remain asymptomatic. No late death or acute thrombosis have been recorded. Two patients became symptomatic 2 and 4 months after treatment, respectively. One had restenosis at a remote site, while the other had in-segment restenosis. None of the remaining 33 angiographically evaluated patients developed restenosis at any site. Target lesion revascularization was 1/52 (2%). CONCLUSIONS: Although longer-term follow-up studies are needed, the tailored treatment of coronary lesions located at the LM by overexpanded RES is feasible and safe. Midterm results seem promising, which might help to shift the orientation of patient management from surgical to percutaneous revascularization.

Acute aortic insufficiency complicating stent treatment of supravalvular aortic stenosis: successful release of trapped leaflets by wiring the stent.

This report shows the findings observed in a 7-year-old boy patient having severe supravalvular aortic stenosis who was treated by stent implantation. Immediately after deployment, a severe acute aortic insufficiency developed due to leaflets trapped by the stent. Release was attempted percutaneously. After wiring the proximal stent, snaring the wire and pulling smoothly, the leaflets came free and valve competence was completely restored. The procedure was then successfully completed, with no residual gradient or aortic insufficiency.

Successful stent ablation with rotational atherectomy.

We describe the findings from two patients with coronary artery disease treated with stents who had unexpandable rings after deployment. These covered rings were successfully ablated with rotational atherectomy. The treated segment was then scaffolded with a new stent. Our observations confirm the efficacy of rotational atherectomy for stent ablation.

Effectiveness of percutaneous device occlusion for atrial septal defect in adult patients with pulmonary hypertension.

BACKGROUND: Adult patients with atrial septal defect (ASD) and pulmonary hypertension have a more advanced degree of disease, frequently having functional class deterioration and atrial arrhythmias when they are aged >40 years. Surgery at this age prolongs life expectancy and limits functional deterioration. Although percutaneous ASD device occlusion is an accepted alternative to surgery, there is limited information on the immediate and long-term effects of device occlusion in middle-aged and elderly patients with ASD and pulmonary hypertension. METHODS: From a total of 101 patients with secundum ASD who were receiving treatment with percutaneous device occlusion, we selected for analysis 29 adult patients (mean age 56 +/- 14 years) with a baseline peak pulmonary pressure of >40 mm Hg (mean 65 +/- 23 mm Hg). Three of the patients had suprasystemic pulmonary pressure and a bidirectional shunt. Six patients were asymptomatic at treatment. The remaining 23 had different degrees of dyspnea; 14 of them had an advanced New York Heart Association functional class (III-IV). Twelve patients had chronic atrial fibrillation. At cardiac catheterization, the mean ratio of pulmonary to systemic flow was 1.8 +/- 0.5, and the pulmonary-to-systemic pressure ratio was 0.66 +/- 0.22. The mean diameter of the defect, as evaluated by the stretching balloon method, was 26 +/- 7 mm. All patients received an Amplatzer septal occluder (Golden Valley, Minn). Seven patients had combined therapeutic procedures for associated anomalies before the implant: mitral balloon valvuloplasty (n = 1), stent coronary revascularization (n = 1), stent in pulmonary vein stenosis (n = 1), and internal catheter defibrillation (n = 4). After treatment, patients were followed up by clinical and echocardiographic Doppler studies every 6 months. RESULTS: Immediately after the implantation, the peak systolic pulmonary pressure significantly decreased to 54 +/- 21 mm Hg (P <.001). A clear improvement in functional status was observed after the treatment in all symptomatic patients, especially in those with refractory heart failure. There were no major complications. Six patients who had atrial fibrillation at baseline study recovered to a stable sinus rhythm after treatment, and it was maintained at discharge. Complete ASD occlusion by echocardiographic Doppler at discharge was observed in 28 patients (97%). After a mean follow up of 21 +/- 14 months, clinical improvement persisted in all previously symptomatic patients, and the peak systolic pulmonary pressure, obtained by echocardiographic Doppler, further decreased to 31 +/- 11 mm Hg (P <.001) compared with baseline and immediately after hemodynamic measurements. CONCLUSIONS: Our findings suggest that percutaneous device occlusion of ASD in adult patients with pulmonary hypertension is safe and effective and provides significant and prolonged relief.

QUANTITATIVE ASSESSMENT OF LEFT VENTRICULAR ASYNERGY.

Myocardial performance in the intact human heart can be assessed from the analysis of ejection phase indices. Accordingly, among 20 consecutive patients who were studied by means of biplane left ventricular cineangio-cardiography, 18 were selected solely on the basis of high quality angiograms. The characteristics of left ventricular contraction were expressed quantitatively by the systolic ejection fraction, the mean velocity of circumferential fiber shortening at the left ventriculalr equator, and at several chords, the mean velocity of shortening of the hemichords and the mean normalized systolic ejection rate. All 18 patients had abnormalities of contraction based on the velocity of the hemichords. Both ejection fraction and mean normalized systolic ejection rate showed a low sensitivity in detecting depressed myocardial function in patients with segmental asynergy. Equatorial V(CF) provided additional information only when the affected areas were adjacent to the left ventricular minor axis. The sensitivity of this index was markedly increased by construction of several chords perpendicular to the left ventricular long axis (segmental V(CF)). However, when only one wall was affected, measurement of the velocity of shortening of the hemichords provided a better definition of the regional performance.