Björn Goebel

Risk Assessment of Ventricular Arrhythmias in Patients with Nonischemic Dilated Cardiomyopathy by Strain Echocardiography

BACKGROUND Indications for prophylactic implantable cardioverter-defibrillator implantation in patients with nonischemic dilated cardiomyopathy (DCM) are based on left ventricular (LV) ejection fraction (LVEF), although LVEF has limited ability to predict arrhythmias. It has recently been shown that strain echocardiography can predict ventricular arrhythmias in patients after myocardial infarction. The aim of this study was to evaluate whether strain echocardiography may help in the risk stratification of ventricular arrhythmias in patients with DCM. METHODS Ninety-four patients with nonischemic DCM were prospectively included. By speckle-tracking strain echocardiography, global longitudinal strain was calculated as the average of peak longitudinal strain from a 16-segment LV model. The time interval from electrocardiographic peak R to peak negative strain was assessed in each LV segment. Mechanical dispersion was defined as the standard deviation of time to peak negative strain from 16 LV segments. RESULTS After a median of 22 months of follow-up (range, 1-46 months), 12 patients (13%) had experienced arrhythmic events, defined as sustained ventricular tachycardia or cardiac arrest. LVEF and global longitudinal strain were reduced in patients with DCM with arrhythmic events compared with those without (28 ± 10% vs 38 ± 13%, P = .01, and -6.4 ± 3.3% vs -12.3 ± 5.2%, P < .001, respectively). Global longitudinal strain showed greater area under the curve than LVEF to identify arrhythmic events in receiver operating characteristic curve analyses (P = .05). Patients with arrhythmic events had increased mechanical dispersion (98 ± 43 vs 56 ± 18 ms, P < .001). Mechanical dispersion predicted arrhythmias independently of LVEF (hazard ratio, 1.28; 95% confidence interval, 1.11-1.49; P = .001). CONCLUSIONS Global longitudinal strain is a promising marker of arrhythmias. Mechanical dispersion predicted arrhythmic events in patients with DCM independently of LVEF. Strain echocardiography may help in the risk stratification of patients with DCM not fulfilling current implantable cardioverter-defibrillator indications.

Detection of a pseudonormal mitral inflow pattern: an echocardiographic and tissue Doppler study.

Objective: The aim of this study was to assess the ability of several echocardiographic and tissue Doppler imaging (TDI) derived parameters to improve the noninvasive diagnosis of a pseudonormal mitral inflow pattern. Methods: Ninety‐eight consecutive patients with age‐related normal transmitral Doppler profile underwent echocardiography including TDI and measurement of left ventricular end‐diastolic pressure (LVEDP) using fluid‐filled catheters. Peak transmitral velocities were determined at rest (E, A) and during the strain phase of a Valsalva maneuver. The difference in duration between the pulmonary venous retrograde velocity and the transmitral A‐velocity (PVR–A) was calculated from pulsed Doppler recordings. Propagation velocity of the early mitral inflow (VP) was determined by color M‐mode. Early diastolic peak mitral annulus velocities (E′) and the early diastolic transmyocardial velocity gradient of the posterior basal wall (MVG) were obtained by TDI. Results: Fifty‐two patients presented with normal diastolic function (group I: LVEDP 9.5 ± 3 mm Hg , E/A 1.1 ± 0.19 ), while pseudonormalization, defined as LVEDP 15 mm Hg and E/A > 0.9, was found in 46 patients (group II: LVEDP 23 ± 7 mm Hg , E/A 1.43 ± 0.83 ). The coefficient of linear correlation (r) and the area under ROC – curve (AUC) to predict LVEDP values 15 mm Hg were maximal for the index PVR–A ( AUC = 0.92, r = 0.77 ), followed by E/E′ (AUC = 0.80, r = 0.46), MVG (AUC = 0.65, r = 0.33) and E/VP (AUC = 0.69, r = 0.30), P < 0.01 , whereas the decrease in E/A ratio during Valsalva maneuver failed to reach significance. Similar results were observed when echocardiographic parameters were used to estimate the left ventricular diastolic pressure before atrial contraction. Conclusions: PVR–A enabled the most accurate estimation of LVEDP. TDI‐derived indices E/E′ and MVG are also reliable alternatives superior to the classical Valsalva maneuver to detect a pseudonormal transmitral Doppler profile. (ECHOCARDIOGRAPHY, Volume 20, May 2003)

Detection of irregular patterns of myocardial contraction in patients with hypertensive heart disease: a two-dimensional ultrasound speckle tracking study.

Objective To evaluate the effect of myocardial hypertrophy in patients with arterial hypertension on regional myocardial function and left ventricular twist. Methods Eighty patients with normal coronary angiograms and ejection fraction higher than 55% were divided according to left ventricular mass indexed to body height (LVMH) into a group with and without left ventricular hypertrophy (LVH). The absolute values and time-to-peak values of overall strain (S), systolic (SRS) and early diastolic strain rate (SRE) were measured in longitudinal, circumferential and radial directions using two-dimensional speckle tracking echocardiography. Left ventricular twist and twist rate curves were calculated from rotation curves obtained from apical and basal parasternal short-axis planes. Results In the patient group with LVH, SRS and SRE, quantified in longitudinal and circumferential direction, were lower compared with the group without LVH. In addition, systolic twist rate and diastolic untwist rate were significantly lower in this patient group, too. No differences between patients groups were found for peak overall S measured in any direction or left ventricular twist. LVMH correlated significantly with longitudinal SRS (r = 0.48, P < 0.001), longitudinal SRE (r = −0.48, P < 0.001), systolic twist rate (r = 0.37, P = 0.006) and diastolic untwist rate (r = −0.27, P = 0.046). Conclusion In conclusion, LVH in patients with arterial hypertension predominantly affected longitudinal and circumferential deformation rate. Moreover, LVH resulted in a significant reduction of systolic twist rate and diastolic untwist rate, whereas overall left ventricular twist angle was not influenced by LVMH.

An exercise tissue Doppler and strain rate imaging study of diastolic myocardial dysfunction after Kawasaki syndrome in childhood.

OBJECTIVE Myocardial dysfunction due to coronary arterial lesions is an important complication after Kawasaki syndrome in childhood. Tissue Doppler echocardiography, and strain rate imaging, have shown their value in detecting regional myocardial dysfunction in coronary arterial disease. We aimed to examine the diagnostic value of these methods in patients with coronary arterial lesions after Kawasaki syndrome. METHODS We assessed regional myocardial function in 17 asymptomatic patients with coronary arterial lesions. Follow-up coronary angiographies were available in all cases. Tissue Doppler echocardiography, and strain rate imaging, were performed at rest and during bicycle exercise. Examination included peak systolic and diastolic velocities, peak systolic strain and strain rate. We enrolled 17 age- and gender-matched persons to serve as a control group. RESULTS Segmental left ventricular longitudinal function did not significantly differ between the groups with respect to peak systolic velocity, strain, and strain rate. Diastolic abnormalities were identified in segments supplied by coronary arteries with stenotic lesions. Peak diastolic velocity decreased significantly during exercise in those areas, from 77 plus or minus 34 to 59 plus or minus 56 millimetres per second, p smaller than 0.05. Under exercise, a peak diastolic velocity value under 90 millimetres per second enabled us to identify coronary arterial stenosis with a sensitivity of 75 percent and specificity of 64 percent. CONCLUSIONS After Kawasaki syndrome, diastolic impairment develops in segments supplied by stenotic coronary arteries before systolic dysfunction is detectable. Exercise tissue Doppler echocardiography has the potential to detect these subtle abnormalities, and help monitor progression of the disease.

Stent Coverage and Neointimal Proliferation in Bare Metal Stents Postdilated With a Paclitaxel-Eluting Balloon Versus Everolimus-Eluting Stents Prospective Randomized Study Using Optical Coherence Tomography at 6-Month Follow-Up

Background—In this randomized trial, strut coverage and neointimal proliferation of a therapy of bare metal stents (BMSs) postdilated with the paclitaxel drug-eluting balloon (DEB) was compared with everolimus drug-eluting stents (DESs) at 6-month follow-up using optical coherence tomography. We hypothesized sufficient stent coverage at follow-up. Methods and Results—A total of 105 lesions in 90 patients were treated with either XIENCE V DES (n=51) or BMS postdilated with the SeQuent Please DEB (n=54). At follow-up, comparable results on the primary optical coherence tomography end point (percentage uncovered struts 5.64±9.65% in BMS+DEB versus 4.93±9.29% in DES; P=0.366) were found. Thus, BMS+DEB achieved the prespecified noninferiority margin of 5% uncovered struts versus DES (difference between treatment means, 0.71%; one-sided upper 95% confidence interval, 4.14%; noninferiority P=0.04). Optical coherence tomography analysis showed significantly more global neointimal proliferation in the BMS+DEB group (15.7±7.8 versus 11.0±5.2 mm3 proliferation volume/cm stent length; P=0.002). No significant focal in-stent stenosis analyzed with angiography (percentage diameter stenosis at follow-up, 22.8±11.9 versus 16.9±10.4; P=0.014) and optical coherence tomography (peak local area stenosis, 39.5±13.8% versus 36.8±15.6%; P=0.409) was found. Conclusions—Good stent strut coverage of >94% was found in both therapy groups. Despite greater suppression of global neointimal growth in DES, both DES and BMS+DEB effectively prevented clinically relevant focal restenosis at 6-month follow-up. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01056744.

Outcome After Mechanical Aortic Valve Replacement in Children and Young Adults

BACKGROUND We asked whether aortic valve replacement using a mechanical prosthesis would allow normalization of left ventricular function and structure in children and young adults. METHODS We performed a clinical follow-up examination in 30 patients with aortic valve replacement at 25 years of age or younger, including conventional and tissue Doppler echocardiography and magnetic resonance imaging. RESULTS Aortic valve replacement was performed at the median age of 14.3 years (range, 7.6 to 24.3 years) using a mechanical prosthesis (St. Jude Medical; median diameter, 23 mm; range, 17 to 27 mm). Indications were severe aortic stenosis in 6 of 30 patients, aortic regurgitation in 20 of 30 patients, or a combination of aortic stenosis and regurgitation (4 of 30 patients). Aortic valve replacement was a reoperation in 12 of 30 patients who primarily underwent aortic valvotomy at a median of 7.1 years (range, 1.0 to 11.3 years). In-hospital mortality was 0%. Follow-up was a median of 6 years (range, 1.2 to 14.5 years). Twenty-nine of 30 patients were in New York Heart Association functional class I without thromboembolic complications, cerebrovascular accidents, or major bleeding on oral anticoagulation. Left ventricular dilatation before aortic valve replacement was present in 20 of 30 patients but normalized in all but 4 patients on follow-up. Most patients showed a normal end-diastolic volume on magnetic resonance imaging, and 23 of 26 patients showed a normal left ventricular ejection fraction (median, 0.53; range, 0.33 to 0.75). Peak systolic strain of the left ventricular myocardium was a median of -13.3% (range, -0.5% to -31%), and was normal in 28 of 30 patients. CONCLUSIONS Aortic valve replacement in children and young adults offers a good treatment option and may lead to normalization of left ventricular size and function in most patients.

Churg-Strauss Syndrome Presenting with Cardiac Mass and Right Ventricular Obstruction

A 57‐year‐old woman presenting with asthma, hypereosinophilia, and generalized unspecific symptoms was diagnosed with Churg‐Strauss syndrome. Echocardiography revealed a cardiac mass obliterating the right ventricle and severely impaired left ventricular function, which were caused by endomyocardial fibrosis. Cortisone and cyclophosphamide therapy resulted in amelioration of left ventricular function and significant size reduction of the right ventricular mass. Copyright

Decrease in circulating plasmacytoid dendritic cells during short‐term systemic normobaric hypoxia

During exposure to high altitude, the immune system is altered. During hypoxia, an increase in interleukin (IL)‐6 and high sensitivity C‐reactive protein (hs‐CRP), and an increase in natural killer cells and decrease in T cells in blood was shown. However, the impact of hypoxia on dendritic cells has not been investigated yet.

A way to improve the reproducibility of measurements of myocardial velocity gradients

Background: A peak negative myocardial velocity gradient (MVG) across the left ventricular wall is an important indicator of diastolic performance. The reproducibility of MVG measurements by color M-Mode tissue Doppler imaging (TDI) is still unsatisfactory, restraining its use in clinical practice. Aim of the study was to improve the reproducibility of measurements of MVG. Methods: The peak diastolic MVG of left ventricular posterior wall was determined in 50 consecutive patients by two investigators in two ways:(1) using directly standard anatomic color M-Mode TDI and (2) by the same technique, but guided by a preliminary MVG estimation with pulsed TDI using four measurement sets within the ventricular wall. Results: The interobserver agreement limits of the combined method [−0.78 s−1(95% CI:−0.95 to −0.6 s−1) to 0.57 s−1(95% CI: 0.4–0.75 s−1)] were clearly superior to those shown by color M-Mode TDI without B-Mode pre-assessment [−1.35 s−1(95% CI:−1.72 to −0.98 s−1) to 1.5 s−1(95% CI: 1.13–1.87 s−1)]. Conclusions: An initial estimation by pulsed TDI is useful to achieve a clinically acceptable reproducibility of MVG measurements.

Effect of a weight loss program in obese adolescents; a long-term follow-up

OBJECTIVES Obesity during adolescence is an increasing health problem in industrial countries. The co-morbidities associated with obesity include important metabolic diseases. METHODS To analyze the effect of a weight-loss program, we recruited 12 obese, male adolescents before entering this program. We determined body weight measures at baseline, 6-week and 36-month follow-up. Also, the long-term changes of blood pressure, HbA1c, and CRP were evaluated. Twenty healthy age-matched adolescents served as controls. RESULTS Within the intervention group ((body mass index [BMI, kg/m2] > 95th percentile for age and sex, age 13-17 years) the BMI and BMI-standard deviation score [SDS] were significantly reduced in the 6-week follow-up after completing the weight loss program. However, the significant weight-reduction effect was not persistent until the 36-month follow-up. CONCLUSION The 6-week weight-loss program had beneficial short-term effects on body weight, BMI, and BMI-SDS in obese adolescents, but these effects could not be maintained until the 36-month follow-up.