Andrea Grohmann

Head-to-Head Comparison of Left Ventricular Function Assessment with 64-Row Computed Tomography, Biplane Left Cineventriculography, and Both 2- and 3-Dimensional Transthoracic Echocardiography Comparison With Magnetic Resonance Imaging as the Reference Standard

OBJECTIVES This study was designed to compare the accuracy of 64-row contrast computed tomography (CT), invasive cineventriculography (CVG), 2-dimensional echocardiography (2D Echo), and 3-dimensional echocardiography (3D Echo) for left ventricular (LV) function assessment with magnetic resonance imaging (MRI). BACKGROUND Cardiac function is an important determinant of therapy and is a major predictor for long-term survival in patients with coronary artery disease. A number of methods are available for assessment of function, but there are limited data on the comparison between these multiple methods in the same patients. METHODS A total of 36 patients prospectively underwent 64-row CT, CVG, 2D Echo, 3D Echo, and MRI (as the reference standard). Global and regional LV wall motion and ejection fraction (EF) were measured. In addition, assessment of interobserver agreement was performed. RESULTS For the global EF, Bland-Altman analysis showed significantly higher agreement between CT and MRI (p < 0.005, 95% confidence interval: ±14.2%) than for CVG (±20.2%) and 3D Echo (±21.2%). Only CVG (59.5 ± 13.9%, p = 0.03) significantly overestimated EF in comparison with MRI (55.6 ± 16.0%). CT showed significantly better agreement for stroke volume than 2D Echo, 3D Echo, and CVG. In comparison with MRI, CVG-but not CT-significantly overestimated the end-diastolic volume (p < 0.001), whereas 2D Echo and 3D Echo significantly underestimated the EDV (p < 0.05). There was no significant difference in diagnostic accuracy (range: 76% to 88%) for regional LV function assessment between the 4 methods when compared with MRI. Interobserver agreement for EF showed high intraclass correlation for 64-row CT, MRI, 2D Echo, and 3D Echo (intraclass correlation coefficient >0.8), whereas agreement was lower for CVG (intraclass correlation coefficient = 0.58). CONCLUSIONS 64-row CT may be more accurate than CVG, 2D Echo, and 3D Echo in comparison with MRI as the reference standard for assessment of global LV function.

Early right ventricular systolic dysfunction in patients with systemic sclerosis without pulmonary hypertension: a Doppler Tissue and Speckle Tracking echocardiography study

BackgroundIsovolumetric acceleration (IVA) is a novel tissue Doppler parameter for the assessment of systolic function. The aim of this study was to evaluate IVA as an early parameter for the detection of right ventricular (RV) systolic dysfunction in patients with systemic sclerosis (SSc) without pulmonary hypertension.Methods22 patients and 22 gender- and age-matched healthy subjects underwent standard echocardiography with tissue Doppler imaging (TDI) and speckle tracking strain to assess RV function.ResultsTricuspid annular plane systolic excursion (TAPSE) (23.2 ± 4.1 mm vs. 26.5 ± 2.9 mm, p < 0.006), peak myocardial systolic velocity (Sm) (11.6 ± 2.3 cm/s vs. 13.9 ± 2.7 cm/s, p = 0.005), isovolumetric contraction velocity (IVV) (10.3 ± 3 cm/s vs. 14.8 ± 3 cm/s, p < 0.001) and IVA (2.3 ± 0.4 m/s2 vs. 4.1 ± 0.8 m/s2, p < 0.001) were significant lower in the patient group. IVA was the best parameter to predict early systolic dysfunction with an area under the curve of 0.988.ConclusionIVA is a useful tool with high-predictive power to detect early right ventricular systolic impairment in patients with SSc and without pulmonary hypertension.

Is antiarrhythmia device implantation safe under dual antiplatelet therapy

Background: Device implantations in patients on dual antiplatelet‐therapy (DA‐therapy) continue to rise. The aim of our study was to compile and analyze data on complications of antiarrhythmia device implantation under DA‐therapy.

Circumferential 2D-strain imaging for the prediction of long term response to cardiac resynchronization therapy

BackgroundCardiac Resynchronization Therapy (CRT) leads to hemodynamic and clinical improvement in heart failure patients. The established methods to evaluate myocardial asynchrony analyze longitudinal and radial myocardial function. This study evaluates the new method of circumferential 2D-strain imaging in the prediction of the long-term response to CRT.Methods and results38 heart failure patients (NYHA II-III, QRS > 120 ms, LVEF < 0.35) received CRT and echocardiographic evaluation with a mean follow-up of 9.4 months. 18 (47.4%) of the patients were hemodynamic responders to long-term CRT. In the responder group, the maximum delay in the circumferential 2D-strain in the basal segments decreased (246 ± 94 to 123 ± 92 ms, p < 0.001). In the non-responder group there was no significant change (pre CRT: 195 ± 86, post CRT 135 ± 136 ms, p = 0.84). This was paralleled by a reduction of the maximum delay in the radial and longitudinal 2D strain in the basal segments. In ROC analysis, the baseline delay of circumferential 2D strain (AUC 0.66 (± 0.14)) does not predict a long-term response to CRT (p = 0.37).ConclusionThere is a significant decrease in the circumferential 2D-strain derived delays after CRT, indicating that resynchronization induces improvement in all three dimensions of myocardial contraction. However, the resulting predictive values of 2D strain delays are not superior to longitudinal and radial 2D-strain or TDI delays.

Implementation of seven echocardiographic parameters of myocardial asynchrony to improve the long-term response rate of cardiac resynchronization therapy (CRT)

BackgroundCardiac resynchronization Therapy (CRT) is an effective therapy for chronic heart failure with beneficial hemodynamic effects leading to a reduction of morbidity and mortality. The responder rates, however, are low. There are various and contentious echocardiographic parameters of myocardial asynchrony. Patient selection by echocardiographic assessment of asynchrony is thought to improve responder rates.MethodsIn this small single-center pilot-study, seven established parameters of myocardial asynchrony were used to select patients for CRT: (1) interventricular electromechanical delay (IMD, cut-off ≥ 40 ms), (2) Septal-to-posterior wall motion delay (SPWMD, ≥ 130 ms), (3) maximal difference in time-to-peak velocities between any two of twelve LV segments (Ts-12 ≥ 104 ms), (4) standard deviation of time to peak myocardial velocities (Ts-12-SD, ≥ 34.4 ms), (5) difference between the septal and basal time-to-peak velocity (TDId, ≥ 60 ms), (6) left ventricular electromechanical delay (LVEMD, > 140 ms) and (7) delayed longitudinal contraction (DLC, > 2 segments).16 chronic heart failure patients (NYHA III–IV, LVEF < 0.35, QRS ≥ 120 ms) at least two out of seven parameters of myocardial asynchrony received cardiac resynchronization therapy (CRT-ICD). Follow-up echo examination was after 6 months. The control group was a historic group of CRT patients (n = 38) who had not been screened for echocardiographic signs of myocardial asynchrony prior to device implantation.ResultsBased on reverse remodeling (relative reduction of LVESV > 15%, relative increase of LVEF > 25%), the responder rate to CRT was 81.2% in patients selected for CRT according to our protocol as compared to 47.4% in the control group (p = 0.04). At baseline, there were on average 4.1 ± 1.6 positive parameters of asynchrony (follow-up: 3.7 [± 1.6] parameters positive, p = 0.52). Only the LVEMD decreased significantly after CRT (p = 0.027). The remaining parameters showed a non-significant trend towards reduction of myocardial asynchrony.ConclusionThe implementation of different markers of asynchrony in the selection process for CRT improves the hemodynamic response rate to CRT.

Interventricular septum hematoma during cineventriculography

BackgroundIntraseptal hematoma and subsequent myocardial infarction due to accidental contrast agent deposition complicating diagnostic cineventriculography is a previously undescribed complication of angiography.Case presentationA 61 year old man was admitted at intensive care unit because of unstable angina pectoris 1 hour after coronary angiography. Transthoracic contrast echocardiography showed a non-perfused area in the middle of interventricular septum with an increase of thickening up to 26 mm. Review of cineventriculography revealed contrast enhancement in the interventricular septum after contrast medium injection and a dislocation of the pigtail catheter tip. Follow up by echocardiography and MRI showed, that intramural hematoma has resolved after 6 weeks. After 8 weeks successful stent implantation in LAD was performed and after 6 month the patient had a normal LV-function without ischemic signs or septal thickening demonstrated by stressechocardiography.ConclusionA safe and mobile position of the pigtail catheter during ventriculography in the middle of the LV cavity should be ensured to avoid this potentially life-threatening complication. For assessment and absolute measurement of intramural hematoma contrast-enhanced echocardiography is more feasible than MRI and makes interchangeable results.

Wie aufgeklärt ist der deutsche Bürger bezüglich kardiovaskulärer Notfälle

SummaryA survey was conducted among 2,000 Germans at the mainline platforms of the two largest train stations in Berlin: Bahnhof Zoo and Ostbahnhof. These German citizens were surveyed concerning coronary risk factors, symptom complexes, angina pectoris, and acute myocardial infarction. An additional 400 Germans were questioned for gender-specific differences in cardiovascular disease. Our findings revealed a balanced relationship between male and female survey participants, and between the two German areas of origin (i. e., former West and East Germany). The share of those with college or university degrees was 37%, and 10% of the participants came from medical professions. Those surveyed indicated that 21% had, either themselves or among family members, directly experienced symptoms of angina pectoris or suffered myocardial infarction. The survey disclosed considerable deficiencies of information: only 2% of those surveyed were able to answer all questions posed correctly. There was no difference in this respect between the genders, or between Germans from former West and East Germany. Young Germans (<25) are significantly less well informed than are older (> 60).The results of this survey are alarming. They clearly reveal that the great majority of the population is unable, in the event of cardiac emergency, to take advantage of the unique possibilities in Germany that are offered by its infrastructure of cardiac medical centers and its tightly meshed network of facilities for left-ventricular catheterization and cardiac surgery. This ignorance exists despite the fact that German taxpayers, with their billions of investments, have created some of the best facilities for such treatment in the world. Ongoing programs of public education are therefore urgently necessary to ensure satisfactory post-infarction utilization of already existing medical capacities. A total of 77% of those surveyed expressed the need and a desire for more information, and 70% placed the blame for these deficiencies on publichealth politicians and their lack of commitment.ZusammenfassungEs wurden 2 000 Bundesbürger auf den Fernbahngleisen der zwei größten Berliner Bahnhöfe (Bahnhof Zoo und Ostbahnhof) zu koronaren Risikofaktoren, Symptomatik und Angina pectoris des akuten Herzinfarktes sowie 400 Bundesbürger zusätzlich zu geschlechtsspezifischen Unterschieden bei kardiovaskulären Erkrankungen befragt. Es fand sich ein ausgeglichenes Verhältnis zwischen männlichen und weiblichen Befragten, ebenso zwischen ihrer Herkunft (alte vs. neue Bundesländer). Der Anteil an Akademikern betrug 37%, aus medizinischen Berufen kamen 10% der Teilnehmer. Von den Befragten hatten 21% entweder selbst oder bei einem Familienangehörigen bereits Symptome von Angina pectoris oder einem Herzinfarkt aus eigener Anschauung erlebt. Die Befragung erwies ein beträchtliches Aufklärungsdefizit, nur 2% der Befragten konnten sämtliche Fragen richtig beantworten. Dabei fand sich kein Unterschied zwischen Männern und Frauen, ebenso zwischen Bürgern aus den alten vs. neuen Bundesländern. Junge Bundesbürger (< 25 Jahre) sind signifikant schlechter informiert als ältere (> 60 Jahre).Das Umfrageergebnis ist alarmierend und zeigt klar, dass die überwiegende Mehrzahl der Bevölkerung die einzigartigen Möglichkeiten in der BRD, was die Infrastruktur mit Herzzentren, deren flächendeckenden Linksherzkatheterplätzen und Herzchirurgien anbetrifft, im Ernstfall überhaupt nicht nutzen kann, obwohl der Steuerzahler mit milliardenschweren Investitionen die besten Voraussetzungen weltweit geschaffen hat. Eine kontinuierliche Aufklärungsaktion zur Nutzung der bereits vorhandenen Kapazitäten ist dringend erforderlich. Hier ist nach der Meinung von 77% der Befragten der Wunsch und das Bedürfnis nach mehr Aufklärung vorhanden, 70% werfen den Gesundheitspolitikern diesbezüglich fehlendes Engagement vor.