Niels Thue Olsen

Cardiac Dysfunction Assessed by Echocardiographic Tissue Doppler Imaging Is an Independent Predictor of Mortality in the General Population

Background— Tissue Doppler imaging (TDI) detects left ventricular dysfunction in patients with heart failure and normal ejection fraction, but the prognostic significance of left ventricular dysfunction by TDI in the general population is unknown. Methods and Results— Within the Copenhagen City Heart Study, a large community-based population study, cardiac function was evaluated in 1036 participants by both conventional echocardiography and TDI. Averages of peak systolic (s′), early diastolic (e′), and late diastolic (a′) velocities from 6 mitral annular sites were used. TDI was furthermore quantified by a combined index (eas index) of diastolic and systolic performance: e′/(a′×s′). During follow-up (median, 5.3 years), 90 participants died. Left ventricular dysfunction by TDI, in terms of low s′ (hazard ratio, 1.23 per 1-cm/s decrease; P<0.05) and a′ (hazard ratio, 1.20 per 1-cm/s decrease; P=0.001), were significant predictors of death in Cox proportional-hazards models adjusted for clinical variables (age, sex, body mass index, heart rate, hypertension, diabetes mellitus, and ischemic heart disease) and conventional echocardiography. The adjusted hazard ratio for death in the third tertile compared with the first tertile of the combined index of systolic and diastolic performance by TDI was 2.5 (P<0.005). Conclusions— In the general population, in which most are free of left ventricular systolic dysfunction and restrictive diastolic filling using conventional echocardiographic parameters, left ventricular dysfunction by TDI is a powerful and independent predictor of death, especially when systolic performance and diastolic performance are considered together, recognizing their interdependency and their complex relation to deteriorating cardiac function.

Speckle-tracking echocardiography for predicting outcome in chronic aortic regurgitation during conservative management and after surgery.

OBJECTIVES The aim of this study was to test myocardial deformation imaging using speckle-tracking echocardiography for predicting outcomes in chronic aortic regurgitation. BACKGROUND In chronic aortic regurgitation, left ventricular (LV) dysfunction must be detected early to allow timely surgery. Speckle-tracking echocardiography has been proposed for this purpose, but the clinical value of this method in aortic regurgitation has not been established. METHODS A longitudinal study was performed in 64 patients with moderate to severe aortic regurgitation. Thirty-five patients were managed conservatively with frequent clinical visits and sequential echocardiography and followed for an average of 19 ± 8 months, while 29 patients underwent surgery for the valve lesion and were followed for 6 months post-operatively. Baseline LV function by speckle-tracking and conventional echocardiography was compared with impaired outcome after surgery (defined as persisting symptoms or persisting LV dilation [LV end-diastolic volume index ≥ 87 ml/m(2)] or dysfunction [LV ejection fraction <50%]) and with disease progression during conservative management (defined as development of symptoms, increase in LV volume >15%, or decrease in LV ejection fraction >10%). RESULTS Reduced myocardial systolic strain, systolic strain rate, and early diastolic strain rate by speckle-tracking echocardiography was associated with disease progression during conservative management (-16.3% vs. -19.0%, p = 0.02; -1.04 vs. -1.19 s(-1), p = 0.02; and 1.20 vs. 1.60 s(-1), p = 0.002, respectively) and with impaired outcome after surgery (-11.5% vs. -15.6%, p = 0.01; -0.88 vs. -1.01 s(-1), p = 0.04; and 0.98 vs. 1.33 s(-1), p = 0.01, respectively). Conventional parameters of LV function and size (LV ejection fraction and LV end-diastolic volume index) were associated with outcome after surgery (p = 0.04 and p = 0.01, respectively) but not with outcome during conservative management (p = 0.57 and p = 0.39, respectively). CONCLUSIONS Speckle-tracking echocardiography is useful for the early detection of LV systolic and diastolic dysfunction in chronic aortic regurgitation.

Mechanical dyssynchrony evaluated by tissue Doppler cross-correlation analysis is associated with long-term survival in patients after cardiac resynchronization therapy

AIMS Pre-implant assessment of longitudinal mechanical dyssynchrony using cross-correlation analysis (XCA) was tested for association with long-term survival and compared with other tissue Doppler imaging (TDI)-derived indices. METHODS AND RESULTS In 131 patients referred for cardiac resynchronization therapy (CRT) from two international centres, mechanical dyssynchrony was assessed from TDI velocity curves using time-to-peak opposing wall delay (OWD) ≥80 ms, Yu index ≥32 ms, and the maximal activation delay (AD-max) >35 ms. AD-max was calculated by XCA of the TDI-derived myocardial acceleration curves. Outcome was a composite of all-cause mortality, cardiac transplantation, or implantation of a ventricular assist device (left ventricular assist device) and modelled using the Cox proportional hazards regression. Follow-up was truncated at 1460 days. Dyssynchrony by AD-max was independently associated with improved survival when adjusted for QRS > 150 ms and aetiology {hazard ratio (HR) 0.35 [95% confidence interval (CI) 0.16-0.77], P = 0.01}. Maximal activation delay performed significantly better than Yu index, OWD, and the presence of left bundle branch block (P < 0.05, all, for difference between parameters). In subgroup analysis, patients without dyssynchrony and QRS between 120 and 150 ms showed a particularly poor survival [HR 4.3 (95% CI 1.46-12.59), P < 0.01, compared with the group with dyssynchrony and QRS between 120 and 150 ms]. CONCLUSION Mechanical dyssynchrony assessed by AD-max was associated with long-term survival after CRT and was significantly better associated compared with other TDI-derived indices. Patients without dyssynchrony and QRS between 120 and 150 ms had a particularly poor prognosis. These results indicate a valuable role for XCA in selection of CRT candidates.

Diastolic dysfunction predicts new-onset atrial fibrillation and cardiovascular events in patients with acute myocardial infarction and depressed left ventricular systolic function: a CARISMA substudy

AIMS The aim of this study was to investigate the association between diastolic dysfunction and long-term occurrence of new-onset atrial fibrillation (AF) and cardiac events in patients with acute myocardial infarction (AMI) and left ventricular (LV) systolic dysfunction. METHODS AND RESULTS The study was performed as a substudy on the CARISMA study population. The CARISMA study enrolled 312 patients with an AMI and LV ejection fraction <or=40%. Patients were implanted with an implantable loop recorder and followed for 2 years. Sixty-two patients had a full echocardiographic assessment of the diastolic function using tissue Doppler analysis performed 6 weeks after the AMI. The endpoints were: (i) new-onset AF and (ii) major cardiovascular events (MACE) defined as re-infarction, stroke, or cardiovascular death. Twenty-four patients had diastolic dysfunction, whereas 38 patients had normal diastolic function. Diastolic dysfunction was associated with an increased risk of new-onset AF [HR = 5.30 (1.68-16.75), P = 0.005] and MACE [HR = 4.70 (1.25-17.75), P = 0.022] after adjustment for age, sex, NYHA class, and hypertension. CONCLUSION Diastolic dysfunction in post-MI patients with LV systolic dysfunction predisposes to new-onset AF and MACE.

The incidence and prognostic significance of new-onset atrial fibrillation in patients with acute myocardial infarction and left ventricular systolic dysfunction: A CARISMA substudy

BACKGROUND The incidence and risk associated with new-onset atrial fibrillation (AF) occurring after discharge in patients with acute myocardial infarction (MI) remains unknown. OBJECTIVE This study sought to describe the incidence and clinical risk associated with postdischarge new-onset AF in post-MI patients with left ventricular systolic dysfunction. METHODS The population included 271 post-MI patients with left ventricular ejection fraction ≤ 40% and no history of previous AF from the Cardiac Arrhythmias and Risk Stratification after Acute Myocardial Infarction (CARISMA) study. All patients were implanted with an implantable cardiac monitor and followed up every 3 months for 2 years. Major cardiovascular events were defined as reinfarction, stroke, hospitalization for heart failure, or death. RESULTS The risk of new-onset AF is highest during the first 2 months after the acute MI (16% event rate) and decreases until month 12 post-MI, after which the risk for new-onset AF is stable. The risk of major cardiovascular events was increased in patients with AF events ≥ 30 seconds (hazard ratio [95% CI] = 2.73 [1.35 to 5.50], P = .005), but not in patients with AF events lasting <30 seconds (hazard ratio [95% CI] = 1.17 [0.35 to 3.92], P = .80). More than 90% of all recorded AF events were asymptomatic. CONCLUSION Using an implantable cardiac monitor, the incidence of new-onset AF was found to be 4-fold higher than earlier reported. In the study population, in which treatment with beta-blockers was optimized, the vast majority of AF events were asymptomatic, emphasizing the importance of using continuous monitoring for studies concerning AF in heart failure patients. A duration of 30 seconds or more identified clinically important AF episodes documented by an implantable cardiac monitor.

Mechanical Dyssynchrony by Tissue Doppler Cross-Correlation is Associated with Risk for Complex Ventricular Arrhythmias after Cardiac Resynchronization Therapy.

BACKGROUND Tissue Doppler cross-correlation analysis has been shown to be associated with long-term survival after cardiac resynchronization defibrillator therapy (CRT-D). Its association with ventricular arrhythmia (VA) is unknown. METHODS From two centers 151 CRT-D patients (New York Heart Association functional classes II-IV, ejection fraction ≤ 35%, and QRS duration ≥ 120 msec) were prospectively included. Tissue Doppler cross-correlation analysis of myocardial acceleration curves from the basal segments in the apical views both at baseline and 6 months after CRT-D implantation was performed. Patients were divided into four subgroups on the basis of dyssynchrony at baseline and follow-up after CRT-D. Outcome events were predefined as appropriate antitachycardia pacing, shock, or death over 2 years. RESULTS Mechanical dyssynchrony was present in 97 patients (64%) at baseline. At follow-up, 42 of these 97 patients (43%) had persistent dyssynchrony. Furthermore, among 54 patients with no dyssynchrony at baseline, 15 (28%) had onset of new dyssynchrony after CRT-D. In comparison with the group with reduced dyssynchrony, patients with persistent dyssynchrony after CRT-D were associated with a substantially increased risk for VA (hazard ratio [HR], 4.4; 95% CI, 1.2-16.3; P = .03) and VA or death (HR, 4.0; 95% CI, 1.7-9.6; P = .002) after adjusting for other covariates. Similarly, patients with new dyssynchrony had increased risk for VA (HR, 10.6; 95% CI, 2.8-40.4; P = .001) and VA or death (HR, 5.0; 95% CI, 1.8-13.5; P = .002). CONCLUSIONS Persistent and new mechanical dyssynchrony after CRT-D was associated with subsequent complex VA. Dyssynchrony after CRT-D is a marker of poor prognosis.

Comparison of Dyssynchrony Parameters for VV-Optimization in CRT Patients

Optimization of the interventricular delay (VV‐optimization) in cardiac resynchronization therapy (CRT) patients can be performed by evaluation of mechanical dyssynchrony. However, there is no consensus on which method to use. In this study, three conceptually different methods were evaluated.

Pulsed-Wave Tissue Doppler and Color Tissue Doppler Echocardiography: Calibration with M-Mode, Agreement, and Reproducibility in a Clinical Setting

Background: Myocardial velocities can be measured with both pulsed‐wave tissue Doppler (PWTD) and color tissue Doppler (CTD) echocardiography. We aimed to (A) to explore which of the two methods better approximates true tissue motion and (B) to examine the agreement and the reproducibility of the two methods in a routine clinical setting. Methods: For Study A, the displacements of 63 basal myocardial segments from 13 patients were examined with M‐mode and compared with the velocity‐time integral of PWTD and CTD velocities. For Study B, the basal lateral segments from 58 patients were examined with PWTD and CTD, and the peak myocardial velocities during systole (Sm), early diastole (Em), and late diastole (Am) were measured. Results: Study A: CTD‐based measurements of displacement were 12% lower than M‐mode measurements (95% CI: −18%; −6%). PWTD velocity‐time integrals measured at the outer edge of the spectral band were 40% higher (33%; 46%) than M‐mode measurements. Study B: PWTD measurements of myocardial velocity were systematically higher than CTD measurements: Sm 7.51 versus 5.54, difference 1.97 ± 1.41 cm/sec; Em 8.74 versus 6.86, difference 1.88 ± 1.70 cm/sec; Am 7.46 versus 5.17, difference 2.29 ± 1.82 cm/sec; P < 0.001 for all. Intraobserver coefficient of variation for Sm, Em, and Am were 6%, 12%, and 12% for PWTD, 14%, 13%, and 20% for CTD. Conclusions: CTD measures numerically smaller tissue velocities than PWTD, mostly due to an overestimation of true tissue motion by PWTD. The methods have good agreement and comparable reproducibility. (ECHOCARDIOGRAPHY, Volume 26, July 2009)

Intracardiac echocardiography unveils large thrombus on a restenotic TAVR prosthesis more than 6 years after implantation

An 84-year-old female with a history of chronic lymphocytic leukaemia and type 2 diabetes presented more than 6 years after transcatheter aortic valve replacement (TAVR, CoreValve 29 mm) with dyspnoea NYHA III–IV. Transoesophageal echocardiography showed aortic restenosis ( V max 4.1 m/s, mean gradient 37 mmHg) with thickened, rigid leaflets ( Panels A and B and Supplementary …

QRS Width and Mechanical Dyssynchrony for Selection of Patients for Cardiac Resynchronization Therapy. One Can't Do Without the Other

Cardiac resynchronization therapy (CRT) in patients with therapy-resistant, symptomatic heart failure in the setting of reduced left ventricular (LV) ejection fraction and wide QRS complex provides symptom relief, induces reverse remodeling, and improves survival ([1–3][1]). Because approximately