Hsin Yueh Liang

Role of Tissue Doppler and Strain Echocardiography in Current Clinical Practice

The motion of a muscle, is performed only by the Carnous fibers, and each Carnous fiber has a power of contracting itself…. The force of the whole Muscle is but an aggregate of the contractions of each particular fiber. — —William Croone in De ratione motus musculorum (On the Reason of the Movement of the Muscles), 1664 Visual or semiautomated tracking of the endocardial border provide estimates of cardiac volume, which are used to derive ejection fraction, a quantitative indicator of ventricular function. However, the heart is a complex mechanical organ that undergoes cyclic changes in multiple dimensions that ultimately effect a change in chamber volume that results in ejection of blood. Regardless of imaging technique, ejection fraction is unable to provide information on the underlying myocardial mechanical activity. Also, ejection fraction reflects the sum contribution of several regions and does not provide information on regional function. Regional function assessed visually is subjective and prone to error.1 Quantification of regional myocardial activity (deformation) was feasible only in experimental studies by use of markers attached directly to the myocardium, a technique not practicable in the clinical realm.2 Myocardial tagging with cardiac magnetic resonance (CMR) introduced the opportunity to noninvasively track regional myocardial mechanics.3,4 Modifications to the filter settings on pulsed Doppler to image low-velocity, high-intensity myocardial signal rather than the high-velocity, low-intensity signal from blood flow allows similar assessment by ultrasound. This technique is commonly referred to as tissue Doppler imaging (TDI) or Doppler myocardial imaging.5 The TDI method depicts myocardial motion (measured as tissue velocity) at specific locations in the heart. Tissue velocity indicates the rate at which a particular point in the myocardium moves toward or away from the transducer. Integration of velocity over time yields displacement or the absolute distance moved by that point …

Myostatin Does not Regulate Cardiac Hypertrophy or Fibrosis

Myostatin is a negative regulator of muscle growth. Loss of myostatin has been shown to cause increase in skeletal muscle size and improve skeletal muscle function and fibrosis in the dystrophin-deficient mdx muscular dystrophy mouse model. We evaluated whether lack of myostatin has an impact on cardiac muscle growth and fibrosis in vivo. Using genetically modified mice we assessed whether myostatin absence induces similar beneficial effects on cardiac function and fibrosis. Cardiac mass and ejection fraction were measured in wild-type, myostatin-null, mdx and double mutant mdx/myostatin-null mice by high resolution echocardiography. Heart mass, myocyte area and extent of cardiac fibrosis were determined post mortem. Myostatin-null mice do not demonstrate ventricular hypertrophy when compared to wild-type mice as shown by echocardiography (ventricular mass 0.69+/-0.01 vs. 0.69+/-0.018 g) and morphometric analyses including heart/body weight ratio (5.39+/-0.45 vs. 5.62+/-0.58 mg/g) and cardiomyocyte area 113.67+/-1.5, 116.85+/-1.9 microm(2)). Moreover, absence of myostatin does not attenuate cardiac fibrosis in the dystrophin-deficient mdx mouse (12.2% vs. 12%). The physiological role of myostatin in cardiac muscle appears significantly different than that in skeletal muscle as it does not induce cardiac hypertrophy and does not modulate cardiac fibrosis in mdx mice.

Diastolic Dysfunction in Familial Hypertrophic Cardiomyopathy Transgenic Model Mice

AIMS Several mutations in the ventricular myosin regulatory light chain (RLC) were identified to cause familial hypertrophic cardiomyopathy (FHC). Based on our previous cellular findings showing delayed calcium transients in electrically stimulated intact papillary muscle fibres from transgenic Tg-R58Q and Tg-N47K mice and, in addition, prolonged force transients in Tg-R58Q fibres, we hypothesized that the malignant FHC phenotype associated with the R58Q mutation is most likely related to diastolic dysfunction. METHODS AND RESULTS Cardiac morphology and in vivo haemodynamics by echocardiography as well as cardiac function in isolated perfused working hearts were assessed in transgenic (Tg) mutant mice. The ATPase-pCa relationship was determined in myofibrils isolated from Tg mouse hearts. In addition, the effect of both mutations on RLC phosphorylation was examined in rapidly frozen ventricular samples from Tg mice. Significantly, decreased cardiac function was observed in isolated perfused working hearts from both Tg-R58Q and Tg-N47K mice. However, echocardiographic examination showed significant alterations in diastolic transmitral velocities and deceleration time only in Tg-R58Q myocardium. Likewise, changes in Ca(2+) sensitivity, cooperativity, and an elevated level of ATPase activity at low [Ca(2+)] were only observed in myofibrils from Tg-R58Q mice. In addition, the R58Q mutation and not the N47K led to reduced RLC phosphorylation in Tg ventricles. CONCLUSION Our results suggest that the N47K and R58Q mutations may act through similar mechanisms, leading to compensatory hypertrophy of the functionally compromised myocardium, but the malignant R58Q phenotype is most likely associated with more severe alterations in cardiac performance manifested as impaired relaxation and global diastolic dysfunction. At the molecular level, we suggest that by reducing the phosphorylation of RLC, the R58Q mutation decreases the kinetics of myosin cross-bridges, leading to an increased myofilament calcium sensitivity and to overall changes in intracellular Ca(2+) homeostasis.

Influence of Atrial Function and Mechanical Synchrony on LV Hemodynamic Status in Heart Failure Patients on Resynchronization Therapy

OBJECTIVES The aim of this study was to evaluate atrial and ventricular function in patients undergoing cardiac resynchronization therapy (CRT). BACKGROUND Right atrial pacing (AP) in CRT induces delays in electrical and mechanical activation of the left atrium. The influence of atrial sensing (AS) versus AP on ventricular performance in CRT and the mechanisms underlying the differences between AS and AP in CRT have not been fully elucidated. METHODS Fifty-five patients with heart failure undergoing CRT for 9 ± 12.5 months and 22 control subjects without heart failure were enrolled. Conventional and tissue Doppler echocardiography was performed to examine atrial and ventricular mechanics and hemodynamic status. RESULTS The optimal atrioventricular interval was shorter in AS compared with AP mode (126 ± 19 ms vs. 155 ± 20 ms, p < 0.0001). Left ventricular (LV) outflow tract time-velocity integral (22 ± 7 cm vs. 20 ± 7 cm, p < 0.001), diastolic filling period (468 ± 124 ms vs. 380 ± 93 ms, p < 0.001), and global strain (-32 ± 24% vs. -27 ± 22%, p = 0.001) were greater in AS compared with AP mode. Atrial strain was higher in AS compared with AP mode in the right atrium (-28.2 ± 8.6% vs. -22.6 ± 7.6%, p = 0.0007), interatrial septum (-17.1 ± 6.5% vs. -13.2 ± 5.4%, p = 0.002), and left atrium (-16.4 ± 11.0% vs. -13.6 ± 8.5%, p = 0.02). There was no difference in intraventricular dyssynchrony but significantly lower atrial dyssynchrony in AS compared with AP mode (31 ± 19 ms vs. 42 ± 24 ms, p = 0.0002). CONCLUSIONS AS is associated with preserved atrial contractility and atrial synchrony, resulting in optimal LV diastolic filling, stroke volume, and LV systolic mechanics. This pacing mode maximizes LV performance and the hemodynamic benefit of CRT in patients with heart failure.

Electromechanical Relationship in Hypertrophic Cardiomyopathy

We examined whether there is a relationship between repolarization abnormalities on electrocardiography (EKG) and deformation abnormalities by echocardiography. Analysis of baseline EKGs and mechanical (echo-based deformation) changes was performed in 128 patients with a clinical diagnosis of hypertrophic cardiomyopathy (HCM). Patients with left ventricular hypertrophy (LVH) or repolarization abnormalities had higher septal thickness when compared to patients with normal EKG. Patients with EKG evidence of LVH or QTc prolongation had lower systolic velocity, systolic strain, systolic strain rate, late diastolic velocity, and late diastolic strain rate than patients with a normal EKG. Patients with strain pattern or ST depression/T-wave inversion had lower systolic velocity, systolic strain, systolic strain rate, early diastolic velocity, and late diastolic velocity when compared to patients with normal EKGs. LVH and repolarization abnormalities on surface EKG are markers of impaired systolic and diastolic mechanics in HCM.

Stress Echocardiography: Diastole to the rescue

Assessment of myocardial ischemia by echocardiography rests on the detection of systolic wall motion abnormalities, namely, reduced wall thickening. Traditionally, this assessment is performed visually and is therefore subjective and variable ([1][1]). Tissue Doppler and strain echocardiography that

Safety profile and utility of treadmill exercise in patients with high-gradient hypertrophic cardiomyopathy

Background Exercise echocardiography in the evaluation of hypertrophic cardiomyopathy (HCM) provides valuable information for risk stratification, selection of optimal treatment, and prognostication. However, HCM patients with left ventricular outflow tract gradients ≥30 mm Hg are often excluded from exercise testing because of safety considerations. We examined the safety and utility of exercise testing in patients with high‐gradient HCM. Methods We evaluated clinical characteristics, hemodynamics, and imaging variables in 499 consecutive patients with HCM who performed 959 exercise tests. Patients were divided based on peak left ventricular outflow tract gradients using a 30‐mm Hg threshold into the following: obstructive (n = 152), labile‐obstructive (n = 178), and nonobstructive (n = 169) groups. Results There were no deaths during exercise testing. We noted 20 complications (2.1% of tests) including 3 serious ventricular arrhythmias (0.3% of tests). There was no difference in complication rate between groups. Patients with obstructive HCM had a higher frequency of abnormal blood pressure response (obstructive: 53% vs labile: obstructive: 41% and nonobstructive: 37%; P = .008). Obstructive patients also displayed a lower work capacity (obstructive: 8.4 ± 3.4 vs labile obstructive: 10.9 ± 4.2 and nonobstructive: 10.2 ± 4.0, metabolic equivalent; P < .001). Exercise testing provided incremental information regarding sudden cardiac death risk in 19% of patients with high‐gradient HCM, and we found a poor correlation between patient‐reported functional class and work capacity. Conclusion Our results suggest that exercise testing in HCM is safe, and serious adverse events are rare. Although numbers are limited, exercise testing in high‐gradient HCM appears to confer no significant additional safety hazard in our selected cohort and could potentially provide valuable information.