Shih-Hung Hsiao

Right Heart Function and Scleroderma: Insights from Tricuspid Annular Plane Systolic Excursion

Objective: The purpose of this study was to evaluate the use of echocardiographic parameters as predictors of rehospitalization in scleroderma patients. Methods: Echocardiographic studies were conducted in 38 patients with systolic scleroderma (SSc) to assess cardiopulmonary function. Forty‐five age‐matched volunteers without any sign of heart failure served as the control group. Transmitral flow pattern, tricuspid annular plane systolic excursion (TAPSE), left ventricular ejection fraction (LVEF), and right ventricular ejection fraction (RVEF) were evaluated. All patients were subsequently followed for one year. Results: Peak transmitral early‐diastolic velocity (mitral E) and TAPSE measurements were significantly different between SSc and control patients (mitral E: 74.1 ± 16.3 vs. 83.5 ± 17.0 cm/s with P = 0.012; TAPSE: 2.4 ± 0.43 vs. 1.9 ± 0.39 cm with P < 0.0001). LVEF was similar, but RVEF was lower in the SSc group (LVEF: 61.7 ± 9.7 vs. 61.7 ± 5.8% with P = 0.962; RVEF: 49.6 ± 6.8 vs. 39.2 ± 6.7% with P < 0.0001). A strong correlation was found between TAPSE and RVEF. A TAPSE less than 1.96 cm indicted a RVEF less than 40% with a sensitivity of 81% and specificity of 78%. Contrary to expectation, pulmonary artery systolic pressure (PASP) did not correlate well with RV function (r = 0.261, r2= 0.068, P = 0.016). Finally, the frequency of rehospitalization was inversely correlated with RVEF and TAPSE in SSc patients. Conclusions: We can predict the rehospitalization rate of SSc patients by TAPSE and RVEF, suggesting the involvement of heart, skin, lung, and other organs in scleroderma patients.

Pulmonary hypertension and left heart function: insights from tissue Doppler imaging and myocardial performance index.

Background: As a consequence of a leftward shift of the interventricular septum and of pericardial restraint, related to the degree RV dilatation, left heart function would be influenced after pulmonary hypertension and right heart failure. Methods and Results: We enrolled 70 patients with pulmonary artery systolic pressure (PASP) more than 30 mmHg: 40 patients with PASP between 30 and 60 mmHg (Group 2), 30 patients with PASP more than 60 mmHg (Group 3). Another 70 patients with normal heart performance and PASP less than 30 mmHg served as the control group (Group 1). Myocardial performance index (MPI), isovolumic contraction time (IVCT), and isovolumic relaxation time (IVRT) were obtained by tissue Doppler imaging (TDI). PASP correlated negatively to peak systolic velocity of lateral tricuspid annulus (RV‐Sm) and RVEF. The MPI of RV and LV in patients with severe pulmonary hypertension (Group 3) became higher as the result of the prolongation of IVRT. The higher E/Em (peak early‐diastolic mitral‐inflow velocity divided by early‐diastolic velocity of mitral annulus) in pulmonary hypertension indicated diastolic dysfunction of LV. The decline of left ventricular ejection fraction, and also right ventricular ejection fraction, suggested LV systolic dysfunction after pulmonary hypertension. The LV‐MPI truly reflected LV systolic and diastolic dysfunction in patients with pulmonary hypertension. In multiple linear regression analysis, LV‐MPI was independently associated only with RV‐MPI (Beta 0.47, P < 0.0001). Conclusion: The result infers that the systolic and diastolic function of LV declined, following pulmonary hypertension.

Identification and viability assessment of infarcted myocardium with late enhancement multidetector computed tomography: Comparison with thallium single photon emission computed tomography and echocardiography

BACKGROUND Recent studies revealed that multidetector computed tomography late enhancement (MDCT-LE) is a reliable technique for detecting necrotic and scarred myocardial tissue. The aims of the study were to identify infarcted myocardium using MDCT-LE protocol in patients after myocardial infarction (MI) and assess viability in resting wall motion abnormalities. METHODS One hundred one patients with previous MI (62 +/- 13 years, 1-6 months after MI) underwent MDCT-LE (15 minutes after contrast medium administration), rest-redistribution thallium single photon emission computed tomography (Tl-SPECT), and dobutamine echocardiography (DbE). In a 17-segment model, infarcted myocardium detected by MDCT-LE was categorized as none, 1%-25%, 26%-50%, 51%-75%, or >75% segmental extent and was compared with decreased uptake of Tl-SPECT and contractile function by DbE on per patient and segmental basis in a blinded fashion. RESULTS By per patient analysis, MDCT-LE identified the presence of infarcted myocardium in 97 patients (96%), and Tl-SPECT decreased uptake in 88 patients (87%), (P = .02). By per segment analysis, the concordance for detecting infarcted myocardium was good (kappa value = 0.792). In segments with resting wall motion abnormalities (N = 486), there was moderate concordance in assessing viability (kappa value between MDCT and Tl-SPECT = 0.555, MDCT and DbE = 0.498, Tl-SPECT and DbE = 0.478) with predefined MDCT-LE threshold of 50% segmental extent. Among segments with MDCT-LE >75% segmental extent, the proportion designated nonviable by Tl-SPECT and DbE reached 87.8% and 92.2%, respectively. CONCLUSIONS Multidetector computed tomography late enhancement is accurate in identifying the presence and extent of infarcted myocardium. Its segmental extent has good correlation with the magnitude of thallium decreased uptake and can predict contractile reserve. Multidetector computed tomography late enhancement can be an alternative to assess viability.

Comparison of left atrial volume parameters in detecting left ventricular diastolic dysfunction versus tissue Doppler recordings.

Because of diastolic coupling between the left atrium and left ventricle, we hypothesized that left atrial (LA) function mirrors the diastolic function of left ventricle. The aims of this study were to assess whether LA volume parameters can be good indexes of left ventricular diastolic dysfunction. Six hundred fifty-nine patients underwent cardiac catheterization and measurements of left ventricular filling pressure (LVFP). Echocardiographic examinations including tissue Doppler and LA volumes were also assessed. Ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity and LVFP tended to increase after progression of diastolic dysfunction. The inverse phenomenon existed in LA ejection and LA distensibility. LA distensibility was superior to LA ejection fraction and early diastolic mitral inflow velocity/early diastolic mitral annular velocity for identifying LVFP >15 mm Hg (areas under receiver operating characteristic curve 0.868, 0.834, and 0.759, respectively) and for differentiating pseudonormal from normal diastolic filling (areas under receiver operating characteristic curve 0.962, 0.907, and 0.741, respectively). Multivariate logistic regression showed that LA ejection fraction and LA distensibility were associated significantly with the presence of pseudonormal/restrictive ventricular filling. In conclusion, LA volume parameters can identify LVFP >15 mm Hg and differentiate among patterns of ventricular diastolic dysfunction. For assessing diastolic function LA parameters offer better performance than even tissue Doppler.

Left Atrial Expansion Index for Predicting Atrial Fibrillation and In-Hospital Mortality After Coronary Artery Bypass Graft Surgery

BACKGROUND Atrial fibrillation (AF), a common complication after coronary artery bypass graft surgery (CABG), is associated with prolonged hospital stay. This prospective study assessed the accuracy of left atrial parameters and additional preoperative characteristics for predicting post-CABG AF and in-hospital mortality. METHODS A total of 197 patients without hemodynamic-significant valvular problems, who received isolated CABG, were enrolled. Echocardiography was performed before CABG. RESULTS Compared with patients without post-CABG AF, those with post-CABG AF were older (71 vs 64 years, p<0.0001), had a higher incidence of CABG during index hospitalization of acute myocardial infarction and preoperative respiratory failure requiring ventilator support, lower left ventricular ejection fraction (0.41 vs 0.48, p<0.0001), lower left atrial expansion index (52.2% vs 93.3%, p<0.0001), and higher left ventricular filling pressure (24.2 vs 19.1 mm Hg, p<0.0001). Multivariate analysis of preoperative variables showed that independent predictors of AF included age (odds ratio [OR], 1.064; 95% confidence interval [CI], 1.022 to 1.107 per 1-year increase; p 0.002), maximal indexed left atrial volume (OR, 1.026; 95% CI, 1.002 to 1.051 per 1 mL/m2 increase; p 0.037) and left atrial expansion index (OR, 0.981; 95% CI, 0.962 to 0.998 per 1% increase; p 0.029). The left atrial expansion index was also significantly associated with in-hospital mortality (OR, 0.982; 95% CI, 0.951 to 0.996 per 1% increase; p 0.042). Incidence of post-CABG AF in patients with left atrial expansion index less than 120% progressively increased as left atrial expansion index decreased. CONCLUSIONS Left atrial expansion index independently predicts post-CABG AF and in-hospital mortality.

Myocardial Tissue Doppler-Based Indexes to Distinguish Right Ventricular Volume Overload from Right Ventricular Pressure Overload

The objective of this study was to develop tissue Doppler parameters that could be used to differentiate right ventricular (RV) volume overload from RV pressure overload. The RV-pressure-overload group consisted of 40 patients with severe pulmonary hypertension, and the RV-volume-overload group consisted of 40 patients who had an atrial septal defect without evidence of right-to-left shunt, significant pulmonary hypertension, or Eisenmengers complex. Another 40 healthy subjects were enrolled and served as a control group. Routine echocardiography and tissue Doppler imaging were performed. RV myocardial performance index was determined based on data collected during tissue Doppler imaging over the lateral tricuspid annulus. In patients with RV pressure overload, tissue Doppler parameters showed characteristically lower systolic velocity over the tricuspid annulus (RV myocardial systolic wave [Sm]) and longer isovolumic relaxation time (RV-IVRT). Nevertheless, in patients with RV volume overload, RV-Sm increased significantly, but early-diastolic velocity over tricuspid annulus was relatively low. In conclusion, RV-MPI, RV-Sm/early-diastolic velocity over tricuspid annulus, and RV-IVRT/RV-Sm were all useful to differentiate RV pressure overload from volume overload, although RV-IVRT/RV-Sm was the best parameter, with excellent sensitivity and specificity.

Comparing culprit lesions in ST-segment elevation and non-ST-segment elevation acute coronary syndrome with 64-slice multidetector computed tomography

BACKGROUND Classifying acute coronary syndrome (ACS) as ST elevation ACS (STE-ACS) or non-ST elevation ACS (NSTE-ACS) is critical for clinical prognosis and therapeutic decision-making. Assessing the differences in composition and configuration of culprit lesions between STE-ACS and NSTE-ACS can clarify their pathophysiologic differences. OBJECTIVE This study focused on evaluating the ability of 64-slice multidetector computed tomography (MDCT) to investigate these differences in culprit lesions in patients with STE-ACS and NSTE-ACS. METHODS Of 161 ACS cases admitted, 120 who fit study criteria underwent MDCT and conventional coronary angiography. The following MDCT data were analyzed: calcium volume, Agatston calcium scores, plaque area, plaque burden, remodeling index, and plaque density. RESULTS The MDCT angiography had a good correlation with conventional coronary angiography regarding the stenotic severity of culprit lesions (r=0.86, p<0.001). The STE-ACS culprit lesions (n=54) had significantly higher luminal area stenosis (78.6+/-21.2% vs. 66.7+/-23.9%, p=0.006), larger plaque burden (0.91+/-0.10 vs. 0.84+/-0.12, p=0.007) and remodeling index (1.28+/-0.34 vs. 1.16+/-0.22, p=0.021) than those with NSTE-ACS (n=66). The percentage of expanding remodeling index (remodeling index >1.05) was significantly higher in the STE-ACS group (81.5% vs. 63.6%, p=0.031). The patients with STE-ACS had significantly lower MDCT density of culprit lesions than patients with NSTE-ACS (25.8+/-13.9HU vs. 43.5+/-19.1HU, p<0.001). CONCLUSIONS Sixty-four-slice MDCT can accurately evaluate the stenotic severity and composition of culprit lesions in selected patients with either STE-ACS or NSTE-ACS. Culprit lesions in NSTE-ACS patients had significantly lower luminal area stenosis, plaque burden, remodeling index and higher MDCT density, which possibly reflect differences in the composition of vulnerable culprit plaques and thrombi.

Dual-phase multi-detector computed tomography assesses jeopardised and infarcted myocardium subtending infarct-related artery early after acute myocardial infarction

Objectives: To investigate dual-phase multi-detector computed tomography (MDCT) for assessing extent and severity of jeopardised and infarcted myocardium subtended by infarct-related artery (IRA), and its indication for revascularisation after acute myocardial infarction (AMI). Designs, setting and patients: Prospective, single-centre study included 107 patients with uncomplicated post-AMI 3–7 days, who met criteria and underwent dual-phase 64-slice MDCT. IRA, culprit lesion and extent of jeopardised/infarcted myocardium were assessed by three-dimensional (3D) volume-rendered images with myocardium maps and computed tomography angiography (CTA), compared with stress-redistribution thallium-201 single-photon emission computed tomography (SPECT) plus conventional coronary angiography (CCA). MDCT-jeopardised score (severity of jeopardised myocardium) was defined as extent of jeopardised myocardium multiplied by the weighted factor dependent on culprit lesion severity compared with SPECT-SRS (summation of segmental reversible score). The IRA indication for revascularisation was evaluated by MDCT-jeopardised score plus CTA. SPECT-SRS ⩾2 plus CCA-culprit lesion ⩾50% was the standard reference. Results: The presence of MDCT-delayed enhancement was found in 101 (94.4%) patients. The IRA and culprit lesion were identified in 99 (92.5%) patients by MDCT-myocardium maps plus CTA. The concordance between MDCT and SPECT for detecting infarcted myocardium was good (kappa = 0.702). The correlation between MDCT-jeopardised score and SPECT-SRS was 0.741. The correlation between CTA and CCA for culprit lesion severity was 0.85. The sensitivity, specificity, negative and positive predictive values of MDCT-jeopardised score ⩾2.5 plus CTA for indicating revascularisation were 90.2%, 80.4%, 86.0% and 85.9%, respectively. Conclusions: Dual-phase MDCT has good accuracy for identifying IRA, and assessing infarcted and jeopardised myocardium for clinical relevance. It provides an alternative for triage and therapeutic planning in post-AMI.

Major Events in Uremic Patients: Insight from Parameters Derived by Flow Propagation Velocity

BACKGROUND The parameters derived by flow propagation velocity (FPV) of early-diastolic mitral inflow have been proved to be associated with cardiovascular risk. This study was undertaken to analyze the prognosis of uremic patients by FPV. METHODS A total of 100 uremic patients were enrolled. All patients underwent conventional echocardiographic examination and FPV measurement. Those examinations were performed before and after hemodialysis (within 30 minutes). Patients were followed for 4 years. Major events were recorded and defined as any-cause mortality and nonfatal cardiovascular events with hospitalization. Patients were separated into two groups according to a post-dialytic E/FPV of <1.5 or > or =1.5 (early-diastolic velocity of mitral inflow divided by FPV). RESULTS Twenty-six major events were recorded, including 13 cases with mortality and 13 cases with nonfatal cardiovascular events. The patients with a post-dialytic E/FPV of > or =1.5 had a higher prevalence of underlying coronary arterial disease (30% vs. 17%), left ventricular systolic dysfunction (left ventricular ejection fraction: 46% +/- 10% vs. 52% +/- 8%), and a major event. By Cox regression analysis, a post-dialytic E/FPV of > or =1.5 (hazard ratio 2.358, 95% confidence interval 1.118-4.62, P = .008) was the strongest independent factor to predict the major events, after adjustment of other covariates. CONCLUSION A post-dialytic E/FPV of > or =1.5 predicts higher adverse events in uremic patients.

Left Atrial Expansion Index Predicts Left Ventricular Filling Pressure and Adverse Events in Acute Heart Failure With Severe Left Ventricular Dysfunction

BACKGROUND The power of left atrial (LA) parameters for predicting left ventricular (LV) filling pressure and adverse events in acute heart failure (HF) with severe LV dysfunction, either sinus rhythm or atrial fibrillation (AF), is not fully understood. METHODS AND RESULTS Echocardiography was performed in 141 patients with acute decompensated congestive HF and LV ejection fraction <35%, including 42 with permanent AF. The LA expansion index was calculated as (Volmax - Volmin) × 100%/Volmin, where Volmax was defined as maximal and Volmin as minimal LA volume. Of 141 patients, invasive LV filling pressures within 12 hours of LA expansion index measurement were available in 109. The end points were 3-year frequencies of HF hospitalization and all-cause mortality. Over a median follow-up of 3.1 years, 74 participants (52.5%) reached the end points (sinus vs AF group: 48.5% vs 61.9%, respectively; P = .047). Multivariate analysis revealed that adverse events of both groups were only independently associated with age and LA expansion index. Rates of adverse events were proportional to LA expansion index. There was a good logarithmic relationship between LA expansion index and LV filling pressure, regardless of presence or absence of AF. CONCLUSIONS LV filling pressure can be estimated well by LA expansion index, with or without AF. The LA expansion index predicts adverse events in HF patients with severe systolic dysfunction. (ClinicalTrials.gov number: NCT01307722).