Usefulness of a Z-score of E' versus raw E' velocities to detect left ventricular dysfunction in patients with mitral or aortic regurgitation or dilated cardiomyopathy.

Despite their potential as a sensitive measure of ventricular performance, tissue Doppler velocities vary with normal aging. This is inconvenient for nonspecialists to interpret and makes it difficult to use as an entry criterion for clinical studies. The age-adjusted tissue Doppler Z-scores might avoid these disadvantages and be more discriminant for myocardial impairment than the raw velocities. We conducted a meta-regression of studies reporting age-specific normal tissue Doppler velocities to determine a consensus formula for Z-scores (8 studies, 1,867 patients) that we then tested in an independent study at our institution. We next compared the Z-scores head-to-head with the raw velocities for their ability to distinguish a fresh set of 81 healthy subjects from groups in whom subtle ventricular dysfunction might be expected, including 50 patients with dilated cardiomyopathy, 50 with aortic regurgitation, and 50 with mitral regurgitation. The discriminant capacity, assessed by the area under the receiver operating characteristic curves, was higher for the Z-scores than for the raw velocities in each patient group. At the septal angle of the mitral annulus: dilated cardiomyopathy 0.95 versus 0.92 (p = 0.03), aortic regurgitation 0.83 versus 0.78 (p = 0.02), mitral regurgitation 0.85 versus 0.81 (p = 0.04). At the lateral angle: dilated cardiomyopathy 0.94 versus 0.88 (p = 0.005), aortic regurgitation 0.92 versus 0.83 (p = 0.001), mitral regurgitation 0.87 versus 0.85 (p = 0.31). In conclusion, the Z-scores of the tissue Doppler velocities were better than the raw velocities at detecting myocardial impairment in valvular or heart muscle disease. The calculation needs only the raw velocity and patient age. Tissue Doppler Z-scores could be used to create a novel, more sensitive, definition of ventricular dysfunction and might make it easier for nonspecialists to interpret the reports.

Triple-vessel percutaneous coronary revascularization in situs inversus dextrocardia.

Dextrocardia with situs inversus occurs in approximately one in 10,000 individuals of whom 20% have primary ciliary dyskinesia inherited as an autosomal recessive trait. These patients have a high incidence of congenital cardiac disease but their risk of coronary artery disease is similar to that of the general population. We report what is, to our knowledge, the first case of total triple-vessel coronary revascularization by percutaneous stent implantation in a 79-year-old woman with situs inversus dextrocardia. We describe the successful use of standard diagnostic and interventional guide catheters with counter rotation and transversely inversed image acquisition techniques. The case also highlights that the right precordial pain may represent cardiac ischemia in this population.

Evidence of improved regional myocardial function in patients with chronic stable angina and apparent normal ventricular function--a tissue Doppler study before and after percutaneous coronary intervention.

BACKGROUND: The aim of this study was to determine the impact of percutaneous coronary intervention (PCI) on myocardial function assessed by tissue Doppler echocardiography. METHODS: Myocardial tissue peak velocities were recorded at the lateral, septal, posterior, and inferior angles of the mitral annulus as well as at the lateral tricuspid annulus by pulsed-wave tissue Doppler echocardiography before PCI, as well as 1 day and 6 weeks after intervention. RESULTS: Twenty-four consecutive patients with chronic stable angina and preserved systolic left ventricular function (20 men; mean age, 64 +/- 9 years) undergoing PCI were studied. Compared with preinterventional values, early diastolic velocities improved at all sites (P < .05 for each). The most pronounced improvement occurred in the septal area. Similarly, systolic peak velocity improved in the septal, lateral, inferior, and right ventricular areas (P < .04 for each). CONCLUSIONS: Tissue Doppler parameters of diastolic and systolic function improve early after successful PCI, and this effect persists to 6 weeks after intervention.

Effect of coronary artery bypass surgery on myocardial function as assessed by tissue Doppler echocardiography.

OBJECTIVE: Coronary artery bypass graft (CABG) surgery may induce myocardial stunning and thereby affect cardiac function. We aimed to assess whether myocardial function is affected by CABG in patients with preserved preoperative systolic function. METHODS: Myocardial tissue peak velocities were recorded at the lateral and septal angle of the mitral annulus as well as at the lateral tricuspid annulus by pulsed wave tissue Doppler echocardiography before cardiac surgery, and then at 5 days, 6 weeks and 18 months after surgery. RESULTS: Thirty-two consecutive patients with preserved systolic left ventricular function (31 male, 63+/-10 years) undergoing CABG (9 with cardiopulmonary bypass on-pump, 23 beating heart off-pump) were included. Peak systolic velocity on tissue Doppler echocardiography was unchanged after surgery. In contrast, peak early diastolic velocities (E') improved significantly 5 days and 6 weeks after surgery in the septal area (6.2+/-2.3 to 7.4+/-2.6 and 7.6+/-2.6 cm/s, respectively; p<0.05) and at the left ventricular lateral wall (9.1+/-3.0 to 10.1+/-3.0 and 11.3+/-2.9 cm/s, respectively; p<0.05), and then declined slowly to preoperative values after 18 months. In contrast, right ventricular E' decreased significantly immediately after surgery (9.8+/-2.7 preoperatively to 7.7+/-1.7 cm/s at 5 days, p=0.005) with only incomplete recovery over time. This was similar in both the conventional and the off-pump CABG cohort. CONCLUSIONS: Left ventricular function did not deteriorate after CABG in patients with preserved preoperative systolic function. On the contrary, diastolic function improved immediately after CABG. Right ventricular function, in contrast, appeared to be damaged by surgery, to similar degrees regardless of whether patients underwent off-pump or on-pump surgery. Hypothermia and immune-inflammatory activation are, therefore, not plausible explanations for this decline in right ventricular function.