Relação entre capacidade funcional e função diastólica no infarto recente

O infarto do miocárdio (IM) altera a função diastólica (FD) do ventrículo esquerdo (VE) em diferentes graus, o que pode refletir na capacidade funcional (CF). O objetivo deste estudo foi avaliar, após IM recente, a relação entre a FD do VE por meio de ecocardiografia Doppler e a CF estimada por meio da distância percorrida no teste de caminhada de seis minutos (DP6). Cinquenta e seis pacientes com IM não complicado foram selecionados após a alta da unidade coronariana e submetidos aos testes. Foi realizada análise de correlação considerando todos os pacientes e de comparação entre grupos definidos de acordo com a classificação da FD do VE. Foi observada correlação entre a onda a' lateral (referente à diástole tardia) e a DP6 (r=-0,320; p=0,023) e não houve diferença entre a CF dos grupos classificados conforme a FD do VE. As respostas de pressão arterial e frequência cardíaca ao teste foram fisiológicas. A correlação encontrada indica que o comprometimento da diástole precoce amplia o papel da contração atrial na CF, reforçando a necessidade de avaliação desses pacientes ainda no hospital. A resposta fisiológica ao TC6 reforça a viabilidade de sua utilização após IM recente.

Review of epidemiology and management of atrial fibrillation in developing countries

BACKGROUND

Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia. In developing countries, AF is a growing public health problem with the epidemiologic transition from communicable to non-communicable diseases. However, relatively little is known about AF in the developing world. The aim of this review is to examine in developing countries the prevalence, associated medical conditions and management of AF.

METHODS

A literature search was conducted via MEDLINE and EMBASE (1990-2012).

RESULTS

Seventy studies were included in the review. The prevalence of AF in the general population ranged from 0.03% to 1.25%, while the prevalence of AF in hospital-based studies varied from 0.7% to 55.7%. Prevalence of AF in Africa was lower than in other regions. The most common conditions associated with AF were hypertension (10.3%-71.9%) and valvular heart disease (5.6%-66.3%). The prevalence of stroke in patients with AF ranged from 6.7% to 27%. The utilization of anticoagulants was highly variable (2.7%-72.7%). Approximately half of the patients with AF using warfarin had therapeutic International Normalized Ratios (INR). There was a high prevalence of use of rate control therapies (55.3%-87.3%).

CONCLUSIONS

The limited studies available suggest that in the developing world there is a significant prevalence of AF, which is predominantly associated with hypertension and valvular heart disease, and carries a risk of stroke. Highly variable use of anticoagulants may be related to different health care and socioeconomic settings. More studies are needed to improve understanding of the epidemiology and management of AF in developing countries.

Incremental value of the preoperative echocardiogram to predict mortality and major morbidity in coronary artery bypass surgery

BACKGROUND

Although echocardiography is commonly performed before coronary artery bypass surgery, there has yet to be a study examining the incremental prognostic value of a complete echocardiogram.

METHODS AND RESULTS

Patients undergoing isolated coronary artery bypass surgery at 2 hospitals were divided into derivation and validation cohorts. A panel of quantitative echocardiographic parameters was measured. Clinical variables were extracted from the Society of Thoracic Surgeons database. The primary outcome was in-hospital mortality or major morbidity, and the secondary outcome was long-term all-cause mortality. The derivation cohort consisted of 667 patients with a mean age of 67.2±11.1 years and 22.8% females. The following echocardiographic parameters were found to be optimal predictors of mortality or major morbidity: severe diastolic dysfunction, as evidenced by restrictive filling (odds ratio, 2.96; 95% confidence interval, 1.59-5.49), right ventricular dysfunction, as evidenced by fractional area change <35% (odds ratio, 3.03; 95% confidence interval, 1.28-7.20), or myocardial performance index >0.40 (odds ratio, 1.89; 95% confidence interval, 1.13-3.15). These results were confirmed in the validation cohort of 187 patients. When added to the Society of Thoracic Surgeons risk score, the echocardiographic parameters resulted in a net improvement in model discrimination and reclassification with a change in c-statistic from 0.68 to 0.73 and an integrated discrimination improvement of 5.9% (95% confidence interval, 2.8%-8.9%). In the Cox proportional hazards model, right ventricular dysfunction and pulmonary hypertension were independently predictive of mortality over 3.2 years of follow-up.

CONCLUSIONS

Preoperative echocardiography, in particular right ventricular dysfunction and restrictive left ventricular filling, provides incremental prognostic value in identifying patients at higher risk of mortality or major morbidity after coronary artery bypass surgery.

Impact of Preoperative Left Ventricular Ejection Fraction on Long-Term Survival After Aortic Valve Replacement for Aortic Stenosis

Background—

The survival of patients who undergo aortic valve replacement (AVR) for severe aortic stenosis with reduced preoperative ejection fractions (EFs) is not well described in the literature.

Methods and Results—

Patients undergoing AVR for severe aortic stenosis were analyzed using the Northern New England Cardiovascular Disease Study Group surgical registry. Patients were stratified by preoperative EF (≥50%, 40%–49%, and <40%) and concomitant coronary artery bypass grafting. Crude and adjusted survival across strata of EF was estimated for patients up to 8 years beyond their index admission. A total of 5277 patients underwent AVR for severe aortic stenosis between 1992 and 2008. There were 727 (14%) patients with preoperative EF <40%. Preoperative EF had minimal effect on postoperative morbidity. There was no difference in 30-day mortality across EF strata among the isolated AVR cohort. Preserved EF conferred 30-day survival benefit among the AVR+coronary artery bypass grafting population (EF≥50%, 96%; EF<40%, 91%; P =0.003). Patients with preserved EF had significantly improved 6-month and 8-year survival compared with their reduced EF counterparts.

Conclusions—

Survival after AVR or AVR+coronary artery bypass grafting was most favorable among patients with preoperative preserved EF. However, patients with mild to moderately depressed EF experienced a substantial survival benefit compared with the natural history of medically treated patients. Furthermore, minor reductions of EF carried equivalent increased risk to those with more compromised function suggesting patients are best served when an AVR is performed before even minor reductions in myocardial function.

Evaluation of serum 25-hydroxyvitamin d as a predictor of carotid intima-media thickness and carotid total plaque area in nonsmokers: the tromsø study

Objective. Altered calcium homeostasis has been linked to increased intima-media thickness (IMT) and plaques. We aimed to investigate whether serum 25-hydroxyvitamin D (25(OH)D) and serum calcium are associated with IMT and plaques in nonsmoking population. Methods. Ultrasound of the right carotid artery with the measurements of IMT and plaques was performed in 4194 nonsmoking subjects with available measurements of serum 25(OH)D and total calcium. Linear regression was applied to study the linear relationships between variables. Multinomial logistic regression was used to evaluate predictors of increased IMT and total plaque area (TPA), adjusted for age, body mass index, systolic blood pressure, and total cholesterol. Results. There was no significant linear relationship between mean IMT, TPA, and either serum 25(OH)D or total serum calcium. One SD increase in serum 25(OH)D was independently associated with increased odds of being in the highest quartile of IMT in men (OR 1.30, 95% CI 1.12, 1.51). In women, 1 SD increase in serum 25(OH)D was independently associated with increased risk of being in the upper tertile of TPA (OR 1.15, 95% CI 1.01, 1.33). Conclusions. Impaired calcium homeostasis has no consistent association with mean IMT and TPA; however, increased serum 25(OH)D may predict subclinical atherosclerosis in nonsmokers.

Speckle tracking echocardiography derived 2-dimensional myocardial strain predicts left ventricular function and mass regression in aortic stenosis patients undergoing aortic valve replacement

Regression of left ventricular (LV) mass in severe aortic stenosis (AS) following aortic valve replacement (AVR) reduces the potential risk of sudden death and congestive heart failure associated with LV hypertrophy. We investigated whether abnormalities of resting LV deformation in severe AS can predict the lack of regression of LV mass following AVR. Two-dimensional speckle tracking echocardiography (STE) was performed in a total of 100 subjects including 60 consecutive patients with severe AS having normal LV ejection fraction (EF > 50 %) and 40 controls. STE was performed preoperatively and at 4 months following AVR, including longitudinal strain assessed from the apical 4-chamber and 2-chamber views and the circumferential and rotational mechanics measured from the apical short axis view. In comparison with controls, the patients with AS showed a significantly lower LV longitudinal (p < 0.001) and circumferential strain (p < 0.05) and higher apical rotation (p < 0.001). Following AVR, a significant improvement was seen in both strains (p < 0.001 for each respectively), however, apical rotation remained unchanged (p = 0.14). On multivariate analysis, baseline LV mass (odds ratio 1.02; p = 0.011), left atrial volume (odds ratio 0.81; p = 0.048) and circumferential strain (odds ratio 0.84; p = 0.02) independently predicted LV mass regression (>10 %) following AVR. In conclusion, STE can quantify the burden of myocardial dysfunction in patients with severe AS despite the presence of normal LV ejection fraction. Furthermore, resting abnormalities in circumferential strain at LV apex is related with a hemodynamic milieu associated with the lack of LV mass regression during short-term follow up after AVR.

Differential association of proinflammatory cytokines with left ventricular diastolic dysfunction in subjects with and without continuous ambulatory peritoneal dialysis

BACKGROUND AND AIMS

The association between inflammation and left ventricular (LV) diastolic dysfunction in continuous ambulatory peritoneal dialysis (CAPD) and non-CAPD patients is not established. The objective of this study was to test the above association and whether inflammation interacts with CAPD to increase LV diastolic dysfunction risks.

METHODS AND RESULTS

120 subjects with normal creatinine levels and 101 CAPD patients were recruited. Echocardiographic parameters were assessed in all patients. The participants were classified as having LV diastolic dysfunction by echocardiographic findings including mitral inflow E/A ratio < 1, deceleration time > 220 cm/s, or decreased peak annular early diastolic velocity in tissue Doppler imaging. Blood was sampled at the baseline for measurement of inflammation markers, including tissue necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6). Subjects with LV diastolic dysfunction had higher proinflammation cytokines levels in both groups. Inflamed markers correlated significantly with echocardiography parameters for LV diastolic dysfunction in patients receiving CAPD. In a multivariate regression analysis adjusting for all the factors associated with LV diastolic dysfunction, inflammation is still significantly associated with left ventricular diastolic dysfunction (TNF-alpha, OR: 2.6, 95% CI: 2.0-3.35, p < 0.001; IL-6, OR: 1.26, 95% CI: 1.25-1.26, p = 0.01). In addition, the interaction of CAPD and inflammation significantly contributed to the development of LV diastolic dysfunction (CAPD∗ TNF-α: OR: 1.45, 95% CI: 1.13-1.79, P = 0.004).

CONCLUSION

We found inflammation plays a vital role for LV diastolic dysfunction especially in CAPD patients. A synergistic effect between CAPD and inflammation, especially TNF-α, would further aggravate LV diastolic dysfunction.

Cellular cross-talk between epicardial adipose tissue and myocardium in relation to the pathogenesis of cardiovascular disease

Epicardial and perivascular fat depot size is considered an index of cardiac and visceral obesity. The functional and anatomic proximity of epicardial adipose tissue (EAT) to myocardium has drawn increasing attention in recent years among researchers attempting to elucidate its putative role as an endocrine organ. This includes the role of EAT as a lipid storing depot and as an inflammatory tissue secreting cytokines and chemokines under pathogenic conditions such as cardiovascular diseases. In this review, we discuss the current state of knowledge regarding the potential EAT mediators of inflammation and the paracrine cross-talk between EAT and the underlying myocardium. We also highlight the most recent findings on the causes and correlates of myocardial steatosis/cardiac lipotoxicity and its association with cardiac dysfunction.

The impairment of endocardial radial strain is related to aortic stenosis severity in patients with aortic stenosis and preserved LV ejection fraction using two-dimensional speckle tracking echocardiography

BACKGROUND

Myocardial function is heterogeneous in different myocardial layers. Recently, two-dimensional speckle tracking echocardiography has been used to define myocardial deformation parameters of the left ventricular (LV) segment. This study aimed to investigate strain in subendocardial and subepicardial layers in patients with aortic stenosis (AS) and preserved LV ejection fraction (LVEF) using speckle tracking echocardiography.

METHODS

Parasternal short-axis and apical long-axis views of the left ventricle were acquired at the mid-papillary level in 35 control subjects and 32 patients with AS and preserved LVEF. Radial, circumferential, and longitudinal strain in subendocardial and subepicardial layers at the posterior and anteroseptal segments were calculated.

RESULTS

There was no significant difference in circumferential strain in subendocardial and subepicardial layers between the control subjects and the patients with AS. Similarly, there was no significant difference in epicardial radial strain at the posterior and anteroseptal segments between the control subjects and the patients with AS. Longitudinal strain at both the posterior and anteroseptal segments was significantly decreased in the AS group compared with that in the control group. AS patients had significantly decreased values of endocardial radial strain compared with those in controls (anteroseptal: 18.2 ± 11.2 vs. 34.5 ± 14.8, P < 0.005; posterior: 25.2 ± 14.8 vs. 32.6 ± 12.6, P < 0.05). In the AS group, endocardial radial strain in the posterior and anteroseptal segments was significantly correlated with the aortic valve area (posterior: r = 0.41, P < 0.05; anteroseptal: r = 0.33, P < 0.05).

CONCLUSION

Patients with AS and preserved LVEF have impaired longitudinal strain and endocardial radial strain, although circumferential strain and epicardial radial strain are preserved. Despite preserved LVEF, endocardial radial strain was associated with AS severity.

Left ventricular markers of global dyssynchrony predict limited exercise capacity in heart failure, but not in patients with preserved ejection fraction

BACKGROUND

The aim of this study was to prospectively examine echocardiographic parameters that correlate and predict functional capacity assessed by 6 min walk test (6-MWT) in patients with heart failure (HF), irrespective of ejection fraction (EF).

METHODS

In 147 HF patients (mean age 61 ± 11 years, 50.3% male), a 6-MWT and an echo-Doppler study were performed in the same day. Global LV dyssynchrony was indirectly assessed by total isovolumic time - t-IVT [in s/min; calculated as: 60 - (total ejection time + total filling time)], and Tei index (t-IVT/ejection time). Patients were divided into two groups based on the 6-MWT distance (Group I: ≤ 300 m and Group II: >300 m), and also in two groups according to EF (Group A: LVEF ≥ 45% and Group B: LVEF < 45%).

RESULTS

In the cohort of patients as a whole, the 6-MWT correlated with t-IVT (r = -0.49, p < 0.001) and Tei index (r = -0.43, p < 0.001) but not with any of the other clinical or echocardiographic parameters. Group I had lower hemoglobin level (p = 0.02), lower EF (p = 0.003), larger left atrium (p = 0.02), thicker interventricular septum (p = 0.02), lower A wave (p = 0.01) and lateral wall late diastolic myocardial velocity a' (p = 0.047), longer isovolumic relaxation time (r = 0.003) and longer t-IVT (p = 0.03), compared with Group II. In the patients cohort as a whole, only t-IVT ratio [1.257 (1.071-1.476), p = 0.005], LV EF [0.947 (0.903-0.993), p = 0.02], and E/A ratio [0.553 (0.315-0.972), p = 0.04] independently predicted poor 6-MWT performance (<300 m) in multivariate analysis. None of the echocardiographic measurements predicted exercise tolerance in HFpEF.

CONCLUSION

In patients with HF, the limited exercise capacity, assessed by 6-MWT, is related mostly to severity of global LV dyssynchrony, more than EF or raised filling pressures. The lack of exercise predictors in HFpEF reflects its multifactorial pathophysiology.

Prolonged total isovolumic time is related to reduced long-axis functional recovery following valve replacement surgery for severe aortic stenosis

BACKGROUND

The left ventricular (LV) long axis (Lax) function is very sensitive in documenting myocardial abnormalities in aortic stenosis (AS). We hypothesized that Lax recovery after aortic valve replacement (AVR) is related to the extent of cavity dyssynchrony measured by total isovolumic time (t-IVT).

METHODS

A consecutive 107 patients (aged 70 ± 7 years, 70 male) with severe AS and Lax impairment were studied. T-IVT was measured before and after AVR. Reduced Lax function and its post-operative recovery were defined as mitral annular plane systolic excursion (MAPSE) ≦10 mm and an increase of MAPSE >10%, respectively.

RESULTS

LV function improved (EF: 43 ± 8 to 48 ± 10%; MAPSE: 7.9 ± 1.0 to 11.0 ± 2.4 mm) and t-IVT shortened (9.7 ± 3.7 to 7.0 ± 2.8s/min, p<0.01 for all) after AVR. Sixty-five (61%) patients had Lax recovery after a median of 32-month follow-up. Univariate predictors were LV size, LA dimensions, the presence of restrictive LV filling and prolonged t-IVT. Only LV end-systolic dimension, restrictive filling and t-IVT (OR 0.61, 95% CI 0.47-0.79, p<0.01) were independent predictors. A pre-operative t-IVT ≦ 9.3s/min was 81% sensitive and 63% specific in predicting Lax recovery (AUC 0.81, p<0.001). The prevalence of CAD or concomitant CABG were similar in 2 patient groups with different t-IVT.

CONCLUSIONS

Lax recovery was evident in the majority of AS patients after AVR. The lower prevalence of Lax recovery seen in patients with prolonged t-IVT suggests that dyssynchrony may play an important role in the process of adverse LV remodeling.

Low glial angiotensinogen improves body habitus, diastolic function, and exercise tolerance in aging male rats

OBJECTIVES

Long-term systemic blockade of the renin-angiotensin system (RAS) with either an angiotensin (Ang) II type 1 receptor antagonist or an angiotensin-converting enzyme inhibitor attenuates age-related cardiac remodeling and oxidative damage, and improves myocardial relaxation. However, the role of the brain RAS in mediating the development of diastolic dysfunction during aging is not known. We hypothesized that low brain RAS protects against the development of age-related diastolic dysfunction and left ventricular remodeling.

METHODS

Sixty-week-old transgenic male ASrAOGEN rats (n =9), with normal circulating Ang II and functionally low brain Ang II, because of a GFAP promoter-linked angiotensinogen antisense targeted to glia, and age-matched and sex-matched Hannover Sprague-Dawley (SD; n= 9) rats, with normal levels of both circulating and brain Ang II, underwent echocardiograms to evaluate cardiac structure and function. Postmortem hearts were further compared for histological, molecular, and biochemical changes consistent with cardiac aging.

RESULTS

ASrAOGEN rats showed preserved systolic and diastolic function at mid-life and this was associated with a lower, more favorable ratio of the phospholamban-SERCA2 ratio, reduced incidence of histological changes in the left ventricle, and increased cardiac Ang-(1-7) when compared with the in-vivo functional, and ex-vivo structural and biochemical indices from age-matched SD rats. Moreover, ASrAOGEN rats had lower percent body fat and a superior exercise tolerance when compared with SD rats of the same age.

CONCLUSION

Our data indicate that the central RAS plays a role in the maintenance of diastolic function and exercise tolerance in mid-life and this may be related to effects on body habitus.

Left atrial myxoma mimicking mitral stenosis

Cardiac myxoma is a benign (non-malignant) neoplasm that represents the most common primary tumour of the heart. We present the case of a 36 year old woman with background hypertension who presented with features of left ventricular failure and seizures, and was found during transthoracic echocardiography to have left atrial myxoma protruding through the mitral valve orifice. She subsequently had excision of the atrial myxoma. The usefulness of early transthoracic echocardiography in any patient presenting with features of heart failure even when the aetiology seems obvious cannot be over-emphasised.

Longitudinal left ventricular 2D strain is superior to ejection fraction in predicting myocardial recovery and symptomatic improvement after aortic valve implantation

BACKGROUND

Predicting improvement of myocardial function after transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) remains a challenge. As ejection fraction (EF) may be of limited value in detecting early myocardial dysfunction and predicting outcome, we assessed the potential of echocardiographic longitudinal function in this setting.

MATERIALS AND METHODS

Left ventricular (LV) function was assessed using EF, mitral annular plane systolic excursion (MAPSE), peak longitudinal 2D strain (LS) and strain rate (SR) in101consecutive patients with severe symptomatic AS (age 81 ± 11 years) undergoing TAVI. Echocardiography and assessment of clinical status including NYHA functional class were performed prior and after intervention (median 70 days).

RESULTS

Pre-interventional EF was 57 ± 17% and 32 patients (32%) had an EF<50% while 58 patients (57%) were found to have an impaired LS. After TAVI there was no significant change in EF. In contrast, LS, SR and MAPSE improved significantly (-14.0 ± 4.4 vs. -15.5 ± 4.0%; p=0.007, 0.68 ± 0.24 vs. 0.78 ± 0.23/s, p=0.002; and 9.1 ± 3.2 vs. 10.2 ± 3.3mm, p=0.006, respectively). Receiver Operating Curve characteristic analysis identified a pre-TAVI LS>-13.3% as the optimal cut-off value for predicting lack of LS recovery post TAVI. There was a marked improvement in NYHA FC after intervention (p=0.0002). Among the studied echocardiographic parameters LS change correlated closest with NYHA class improvement (r=0.42, p=0.0008).

CONCLUSION

Overall, LS appears to be more sensitive for detecting early myocardial damage in patients with AS compared to conventional echocardiographic parameters. More importantly, pre-interventional LS may identify irreversible myocardial dysfunction and LS improvement correlates with symptomatic improvement after intervention.

Independent and incremental value of severely enlarged left atrium in risk stratification of very elderly patients with chronic systolic heart failure

The authors sought to assess the impact on survival of demographic, clinical, and echo-Doppler parameters in patients with chronic heart failure due to left ventricular systolic dysfunction divided according to age groups. This study included 734 patients (age 69±11 years) who were classified into tertiles of age: I (22-66 years), II (67-76 years), and III (77-94 years). Severely enlarged left atrial size was defined as ≥52 mm in men and ≥47 mm in women. Multivariable analysis identified male sex (P=.018) and severely enlarged left atrium (P=.024) as significant correlates of all-cause mortality in the very elderly cohort, while restrictive filling pattern (RFP) (P=.004) and New York Heart Association class III or IV (P=.005) among patients of the first tertile and RFP (P=.028) among patients in the second tertile were independently associated with mortality after 30±21 months of follow-up. At the interactive stepwise model in the very elderly population, a severely enlarged left atrium, added to the model after clinical parameters and ejection fraction, moved the chi-square value from 20.7 to 25.8 (P=.048). RFP emerged as the single best predictor of all-cause mortality in the younger and intermediate ranges, whereas severely enlarged left atrium was the best predictor in the very elderly.

Left ventricular long-axis function: reference values of the mitral annular plane systolic excursion in 558 healthy children and calculation of z-score values

BACKGROUND

Longitudinal myocardial function has gained more interest in the last years. The mitral annular plane systolic excursion (MAPSE) is an echocardiographic measurement to assess left ventricular (LV) long-axis function in adults. The aim of this study was to evaluate MAPSE values in a healthy pediatric population and to propose reference values.

METHODS

A prospective study was conducted in a group of 558 healthy children and adolescents (age day 1 to 18 years) (body surface area [BSA] 0.18-2.21 m(2)). We determined the effects of age and BSA on MAPSE values and a possible correlation of MAPSE values with LV ejection fraction values.

RESULTS

The MAPSE ranged from a mean of 0.57 cm (z-score ±2: 0.38-0.76 cm) in neonates to 1.63 cm (z-score ±2: 1.31-1.95 cm) in 18-year-old adolescents. The MAPSE values showed a positive correlation with age (r = 0.87, P < .001) and BSA (r = 0.89, P < .001) with a nonlinear course. There was no significant difference in MAPSE values between females or males. A positive correlation was found between MAPSE values and LV ejection fraction values (r = 0.28, P < .001).

CONCLUSIONS

Z-scores of MAPSE values were calculated, and percentile charts were established to serve as reference data in patients with congenital heart disease or heart failure in the future.

Coxiella burnetii infection of a bovine jugular vein conduit in a child

We report a case of an 11-year-old girl with Coxiella burnetii infection of a bovine jugular vein conduit which is an extremely rare manifestation of Q fever. The role of surgery in the management of C. burnetii endovascular infection and the use of serology are discussed.

Acute regional improvement of myocardial function after interventional transfemoral aortic valve replacement in aortic stenosis: a speckle tracking echocardiography study

Background

Transcatheter aortic valve implantation (TAVI) is a promising therapy for patients with severe aortic stenosis (AS) and high perioperative risk. New echocardiographic methods, including 2D Strain analysis, allow the more accurate measurement of left ventricular (LV) systolic function. The goal of this study was to describe the course of LV reverse remodelling immediately after TAVI in a broad spectrum of patients with symptomatic severe aortic valve stenosis.

Methods

Thirty consecutive patients with symptomatic aortic valve stenosis and preserved LVEF underwent transfemoral aortic valve implantation. We performed echocardiography at baseline and one week after TAVI. Echocardiography included standard 2D and Doppler analysis of global systolic and diastolic function as well as 2D Strain measurements of longitudinal, radial and circumferential LV motion and Tissue Doppler echocardiography.

Results

The baseline biplane LVEF was 57 ± 8.2%, the mean pressure gradient was 46.8 ± 17.2 mmHg and the mean valve area was 0.73 ± 0.27 cm². The average global longitudinal 2D strain of the left ventricle improved significantly from -15.1 (± 3.0) to -17.5 (± 2.4) % (p < .001). This was reflected mainly in improvement in the basal and medial segments while strain in the apex did not change significantly [-11.6 (± 5.2) % to -15.1 (± 5.5) % (p < .001), -13.9 (± 5.1) % to -16.8 (± 5.6) % (p < .001) and -19.2 (± 7.0) % to -20.0 (± 7.2) % (p = .481) respectively]. While circumferential strain [-18.1 (± 5.1) % vs. -18.9 (± 4.2) %, p = .607], radial strain [36.5 (± 13.7) % vs. 39.7 (± 17.2) %, p = .458] and the LVEF remained unchanged after one week [57.0 (± 8.2) % vs. 59.1 (± 8.1) %, p = .116].

Conclusion

There is an acute improvement of myocardial longitudinal systolic function of the basal and medial segments measured by 2D Strain analysis immediately after TAVI. The radial, circumferential strain and LVEF does not change significantly in all patients acutely after TAVI. These data suggest that sensitive new echo methods can reliably detect early regional changes of myocardial function after TAVI before benefits in LVEF are detectable.

Residual compromised myocardial contractile reserve after valve replacement for aortic stenosis

OBJECTIVE

Despite recovery of left ventricular (LV) function and morphology after aortic valve replacement (AVR) for aortic stenosis (AS), its relationship with exercise capacity remains unknown. Twenty-one AVR patients (age 61 ± 12 years, 14 male) with normal ejection fraction (EF, 64 ± 7%) and 21 age- and sex-matched controls (57 ± 9 years, 10 male, EF 68 ± 8%) were studied.

METHODS AND RESULTS

All subjects performed semi-supine bicycle exercise and speckle tracking echocardiography (STE) study. Peak oxygen consumption (pVO(2)) was collected during semi-supine bicycle exercise. Systolic (GLSRs) and early diastolic (GLSRe) longitudinal strain rate using STE and Doppler echocardiographic parameters were measured at rest, submaximal, peak exercise, and 4 min after exercise. The two groups had comparable resting echocardiographic measurements. At peak exercise, pVO(2) was lower in patients than controls (18.5 ± 4.5 vs. 22.1 ± 4.3 L/min/kg, P < 0.05). GLSRs (0.98 ± 0.28 vs. 1.55 ± 0.30 1/s, P < 0.001), septal Sm (7.9 ± 1.4 vs. 11.1 ± 2.3 cm/s, P < 0.001) and their changes between rest and peak exercise (ΔGLSRs: 0.16 ± 0.33 vs. 0.68 ± 0.27 1/s, P < 0.001; ΔSm 2.29 ± 2.23 vs. 4.63 ± 2.29 cm/s, P < 0.01) were significantly lower in patients than controls. There was no correlation between pVO(2) and any echocardiographic measurements in controls. In patients, pVO(2) correlated with peak exercise GLSRs (r = 0.60, P = 0.0007), septal Sm (r = 0.65, P = 0.002), and Em (r = 0.57, P = 0.009). In a multivariate model, peak exercise GLSRs (β = 7.18, P = 0.03) was the only independent predictor of pVO(2) in the patients group.

CONCLUSION

Exercise capacity is subnormal after AVR for AS, irrespective of normal LVEF suggesting residual compromised myocardial functional reserve.

[Assessment of left ventricular twist mechanics by two-dimensional strain in severe aortic stenosis with preserved ejection fraction]

Left ventricular (LV) twist is increased in aortic stenosis (AS) and the hypothesis of a compensatory mechanism is suggested but not established. Our aim was to assess LV twist mechanics in severe AS (<1cm(2) or 0.6cm(2)/m(2)) with preserved LV ejection fraction (LVEF>50%), and to analyze its relationship with LV systolic longitudinal function, early impaired in this setting, LV diastolic function, and symptomatic status.

METHODS

Forty-five consecutive patients with severe AS and preserved LVEF (mean age 73±11 years, 47% female, LVEF 68±11%, 67% symptomatic) underwent a transthoracic echocardiography including a bidimensional strain analysis by speckle tracking method, and were compared to a control group matched for age and sex (n=15). Global longitudinal strain (GLS) was measured using the four, two, and three apical views, and LV twist mechanics from the basal and apical short axis views. LV twist was defined as the net difference between apical and basal rotation, and LV twisting and untwisting rate (in°/s) were derived from twist curves.

RESULTS

Peak apical rotation, LV twist (25±8° vs 20±6), as well as peak systolic and diastolic apical rotation rate, and peak LV twisting rate were significantly higher in patients with AS when compared to controls (all, P<0.05), whereas, the other parameters of LV twist mechanics including basal rotation, were not significantly different between groups. By contrast, the GLS was significantly lower in patients with AS when compared to controls (-17.9±4 vs -20.5±2%, P<0.01). In addition, the GLS was significantly correlated to LV torsion (r=-0.42, P<0.01). Moreover, LV twist progressively impaired with the worsening of diastolic dysfunction and with symptoms onset.

CONCLUSION

LV twist is increased in severe AS with preserved LVEF, compensating the impairment of systolic longitudinal function. However, above a certain threshold LV twist deteriorates, attesting the failure of the compensatory mechanisms, leading to advanced diastolic dysfunction and symptom onset.

Giant asymptomatic left atrial myxoma

The classic triad of myxoma clinical presentation is characterized by intracardiac obstruction, embolisms, and constitutional symptoms with fever, weight loss, or symptoms resembling connective tissue disease. Giant myxoma without symptoms are very rare. We present a case of a 30-year-old female with a giant asymptomatic myxoma in the left atrium, discovered by echocardiography. The patient was asymptomatic.

Insulin resistance is not associated with myocardial steatosis in women

AIMS/HYPOTHESIS

Insulin resistance, an independent risk-factor for cardiovascular disease, precedes type 2 diabetes and is associated with ectopic lipid accumulation in skeletal muscle and liver. Recent evidence indicates that cardiac steatosis plays a central role in the development of diabetic cardiomyopathy. However, it is not known whether insulin resistance as such in the absence of type 2 diabetes is associated with heart steatosis and/or impaired function. We therefore assessed myocardial steatosis and myocardial function in a sample of women with normal insulin sensitivity, insulin resistance, impaired glucose tolerance (IGT) and type 2 diabetes.

METHODS

Magnetic resonance imaging and localised spectroscopy were used to measure left ventricular dynamic variables and myocardial lipid accumulation in interventricular septum of non-diabetic, age- and BMI-matched insulin-sensitive (n = 11, 47 ± 6 years, BMI 25 ± 2 kg/m(2); clamp-like index [CLIX] = 9.7 ± 0.7) and insulin-resistant (n = 10, 48 ± 5 years, 27 ± 4 kg/m(2); CLIX = 4.5 ± 0.4) women with normal glucose tolerance as well as of women with IGT (n = 6, 45 ± 5 years, 28 ± 6 kg/m(2); CLIX = 3.6 ± 1.1) and type 2 diabetes (n = 7, 52 ± 10 years, 27 ± 3 kg/m(2)).

RESULTS

Myocardial lipid content was increased in type 2 diabetic women only (insulin-sensitive 0.4 ± 0.2% [means ± SD]; insulin-resistant 0.4 ± 0.1%; IGT 0.5 ± 0.2%; type 2 diabetes 0.7 ± 0.3%; p < 0.05). In insulin-resistant and type 2 diabetic women, stroke volume was lower (-15% and -27%, respectively, vs insulin-sensitive) and heart rate was higher (11% and 14%, respectively, vs insulin-sensitive, p < 0.05). No other differences in systolic and diastolic function were observed between study groups.

CONCLUSIONS/INTERPRETATION

In contrast to liver and skeletal muscle, insulin resistance as such is not associated with increased myocardial lipid accumulation.

The effect of intravenous ferric carboxymaltose on health-related quality of life in iron-deficient patients with acute heart failure: the results of the AFFIRM-AHF study

AIMS

Patients with heart failure (HF) and iron deficiency experience poor health-related quality of life (HRQoL). We evaluated the impact of intravenous (IV) ferric carboxymaltose (FCM) vs. placebo on HRQoL for the AFFIRM-AHF population.

METHODS AND RESULTS

The baseline 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12), which was completed for 1058 (535 and 523) patients in the FCM and placebo groups, respectively, was administered prior to randomization and at Weeks 2, 4, 6, 12, 24, 36, and 52. The baseline KCCQ-12 overall summary score (OSS) mean ± standard error was 38.7 ± 0.9 (FCM group) and 37.1 ± 0.8 (placebo group); corresponding values for the clinical summary score (CSS) were 40.9 ± 0.9 and 40.1 ± 0.9. At Week 2, changes in OSS and CSS were similar for FCM and placebo. From Week 4 to Week 24, patients assigned to FCM had significantly greater improvements in OSS and CSS scores vs. placebo [adjusted mean difference (95% confidence interval, CI) at Week 4: 2.9 (0.5-5.3, P = 0.018) for OSS and 2.8 (0.3-5.3, P = 0.029) for CSS; adjusted mean difference (95% CI) at Week 24: 3.0 (0.3-5.6, P = 0.028) for OSS and 2.9 (0.2-5.6, P = 0.035) for CSS]. At Week 52, the treatment effect had attenuated but remained in favour of FCM.

CONCLUSION

In iron-deficient patients with HF and left ventricular ejection fraction <50% who had stabilized after an episode of acute HF, treatment with IV FCM, compared with placebo, results in clinically meaningful beneficial effects on HRQoL as early as 4 weeks after treatment initiation, lasting up to Week 24.

Independent and incremental prognostic value of Doppler-derived left ventricular total isovolumic time in patients with systolic heart failure

BACKGROUND

A prolonged total isovolumic time (T-IVT) has been shown to be associated with worsening survival in patients submitted to coronary artery surgery. However, it is not known whether it has prognostic significance in patients with chronic systolic heart failure (HF).

AIM

To determine the prognostic value of T-IVT in comparison with other clinical, biochemical and echocardiographic variables in patients with chronic systolic HF.

METHODS

Patients (n=107; age 68±12 years, 25% women) with chronic systolic HF, left ventricular ejection fraction (EF)<45%, and sinus rhythm, underwent a complete Doppler echocardiographic study, that included tissue Doppler long axis velocities and total isovolumic time (T-IVT), determined as [60-(total ejection time+total filling time)]. Plasma N-terminal pro-B natriuretic peptide (NT-pro-BNP) was also measured. The associations of dichotomous variables selected according to the Receiver Operator Characteristic analysis were assessed using the Cox proportional hazard model.

RESULTS

Follow-up period was 37±18 months. Multivariate predictors of events were T-IVT≥12.3% s/min, mean E/Em ratio≥10, log NT-pro-BNP levels≥2.47 pg/ml and LV EF≤32.5%. On Kaplan-Meier analysis, patients with prolonged T-IVT, high mean E/Em ratio, increased NT-pro-BNP levels and decreased LV EF had a worse outcome compared with those without. The addition of T-IVT and NT-pro-BNP to conventional clinical and echocardiographic variables significantly improved the chi-square for the prediction of the outcome from 33.1 to 38.0, (P<0.001).

CONCLUSIONS

Prolonged T-IVT added to the prognostic stratification of patients with systolic HF.

Aortic valve replacement normalizes left ventricular twist function

The aim of this study was to assess the effect of aortic valve replacement (AVR) on left ventricular (LV) twist function. We studied 28 severe aortic stenosis (AS) patients with normal LV ejection fraction (EF) before and six months after AVR. LV long axis function was assessed using M-mode and tissue Doppler and twist function using speckle tracking echocardiography. The data were compared with 28 age and sex-matched normal controls. In patients, LVEF remained unchanged after AVR. LV long axis function was reduced before surgery but normalized after AVR. LV twist was increased before (19.7 ± 5.7° vs. 12.9 ± 3.2°, P<0.001) and normalized after AVR (14.4 ± 5.2 °, P < 0.001). In normals, LV twist correlated with LV fractional shortening (r = 0.81, P<0.001) but not with EF. This relationship was reversed in patients before ( r= 0.52, P < 0.01) and after AVR (r = 0.34, P = ns). In patients with severe AS and normal EF, LV twist is exaggerated suggesting potential compensation for the reduced long axis function. These disturbances normalize within six months of AVR but lose their relationship with basal LV function.

Type 2 diabetes and cardiovascular disease in South Asians

Type 2 diabetes (T2DM) is growing at a pandemic scale and is associated with a rapid increase in its complications such as cardiovascular diseases (CVD). This problem is even worse in South Asian population with South Asian people having a much higher prevalence of T2DM and CVD, occurring at an earlier age and being associated with premature and high mortality. This review looks in detail at the current knowledge on epidemiology and characteristic pathophysiology of T2DM and CVD (coronary heart disease, heart failure, stroke and peripheral vascular disease) in South Asian migrant population. Specific attention is also drawn to the role of novel risk factors and cultural and socioeconomic factors on occurrence and outcomes of these chronic diseases in this population. Finally the review makes recommendations on various measures including need for further research to tackle this serious health challenge facing the South Asian community.

Metabolic syndrome and insulin resistance are associated with abnormal left ventricular diastolic function and structure independent of blood pressure and fasting plasma glucose level

BACKGROUND

Abnormal left ventricular (LV) structure and diastolic function are frequently detected in a variety of heart diseases, and insulin resistance has been suggested to be associated with LV diastolic dysfunction (LVDD). The aims of this study were to determine the association between LVDD or LV structure and metabolic syndrome (MetS) or insulin resistance, and whether or not the associations are independent of age, blood pressure, and plasma glucose level.

METHODS

A total of 1599 subjects (1161 men and 398 women), 25-83 years of age, who underwent medical health check-ups at two institutions, were enrolled. LV diastolic function and structure were assessed by echocardiographic evaluation, including tissue Doppler imaging (TDI).

RESULTS

The subjects with MetS had significant differences in the level of parameters reflecting cardiac structure and LV diastolic function compared to those without MetS, even after adjustment for age, gender, blood pressure, and fasting plasma glucose level (P<0.001). MetS was independently associated with an increased risk for LVDD (OR, 1.67; 95% CI, 1.18-2.37; P = 0.004). In addition, as the HOMA-IR value increased, the level of parameters reflecting cardiac structure and LVDD significantly increased and the E/A ratio significantly decreased (P<0.001). Furthermore, the LV mass, E/A ratio, and E/E' ratio were significantly different across the HOMA-IR quartiles, even after adjustment for other confounders.

CONCLUSIONS

MetS and insulin resistance are associated with abnormal LV diastolic function and structure independent of age, gender, blood pressure, and fasting plasma glucose level.

Left ventricular asynchrony and raised filling pressure predict limited exercise performance assessed by 6 minute walk test

BACKGROUND

Six minute walking test (6-MWT) may serve as a reproducible test for assessing exercise capacity in heart failure (HF) patients and can be clinically predicted. We aimed in this study to ascertain if global markers of ventricular asynchrony can predict 6MWT distance in a group of patients with HF and left ventricular (LV) ejection fraction (EF) <45%.

METHODS AND RESULTS

This study included 77 consecutive patients (60 ± 12 years) with stable HF. LV end-diastolic and end-systolic dimensions, shortening fraction (SF), EF, myocardial velocities, t-IVT, and Tei index were measured, as well as 6-MWT distance. Patients with limited exercise performance (≤ 300 m) had lower SF (p = 0.02) and EF (p = 0.017), longer t-IVT (p = 0.001), higher Tei index (p = 0.002) and higher E/E' ratio (p < 0.001) compared with good performance patients. In multivariate analysis, only E/E' ratio [0.800 (0.665-0.961), p = 0.017], and t-IVT [0.769 (0.619-0.955), p = 0.018] independently predicted poor exercise performance.

CONCLUSIONS

In heart failure patients, the higher the filling pressures and the more asynchronous the left ventricle, the poorer is the patient's exercise capacity. These findings highlight specific LV functional disturbances that should be targeted for better optimization of medical and/or electrical therapy.

Plasma amino-terminal propeptide of procollagen type III is associated with subclinical left ventricular systolic dysfunction in aortic stenosis

OBJECTIVE

The aim of the study was to investigate the association of plasma amino-terminal propeptide of procollagen type III (PIIINP) with subclinical left ventricular (LV) systolic dysfunction in patients with aortic stenosis (AS) and normal LV ejection fraction.

METHODS

The study was performed in 57 AS patients with normal LV ejection fraction and in 30 control subjects with normal aortic valve and normal LV ejection fraction. Tissue Doppler and speckle tracking image were performed to assess LV diastolic and systolic function. Plasma PIIINP level was measured by specific radioimmunoassay.

RESULTS

In AS patients, LV systolic longitudinal strain was significantly reduced (-17.1 ± 2.1 vs. -18.8 ± 1.4%, P<0.001) and plasma PIIINP was increased compared with controls (2.5 ± 0.6 vs. 2.1 ± 0.4 μg/l, P<0.001). A significant correlation was found between LV systolic longitudinal strain and PIIINP (r=-0.67, P<0.001). In patients with abnormal LV diastolic function, LV systolic longitudinal strain was reduced compared with patients with normal LV diastolic function (-16.3 ± 1.5 vs. -18.8 ± 2.1%, P<0.001) and plasma PIIINP was increased (2.8 ± 0.5 vs. 2.0 ± 0.3 μg/l, P<0.001). A stepwise multivariate regression analysis revealed that LV systolic longitudinal strain and diastolic blood pressure were independent predictors of plasma PIIINP (multiple r=0.71, P<0.001).

CONCLUSIONS

Plasma PIIINP is associated with subclinical LV systolic dysfunction (the impaired LV systolic long axis function) in patients with AS and normal LV ejection fraction. In addition, the impaired LV systolic long axis function and increased plasma PIIINP concentration are most marked in patients with abnormal LV diastolic function.

Effects of a localized high-flow anastomosis between the aorta and left lower lobe pulmonary artery on great vessel flow and pulmonary arterial reactivity in the contralateral lung

OBJECTIVES

We sought to assess the effects of a localized anastomosis between the aorta and left lower lobe pulmonary artery on flows through central vessels and on the vascular reactivity of small pulmonary arteries distal or contralateral to the shunt.

METHODS

Flow rates in major vessels and tensions from small pulmonary arteries from the left and right lower lobes were determined 48 hours after creation of an end-to-side anastomosis of the left lower lobe pulmonary artery to the aorta.

RESULTS

Anastomoses increased flow through the left lower lobe pulmonary artery from 194±6 to 452±18 mL/min immediately after anastomosis to 756±19 mL/min by the time of harvest (n=88, P<.05). Flow rates in main pulmonary arteries from hosts with anastomoses were lower (557±26 vs 1033±244 mL/min), whereas aortic root flows were not different from control values (1370±53 vs 1120±111 mL/min; P=.07). Wet/dry weights of both lungs and aortic flow rates were proportional to shunt flow rates. Pulmonary artery rings harvested from the right (unshunted) lobes of high-flow hosts exhibited increased reactivity to the thromboxane agonist U46619 and phenylephrine relative to those of left pulmonary arteries from the same animal or those of control hosts.

CONCLUSIONS

Our studies are the first to identify enhanced reactivity of pulmonary arteries in a lung contralateral to a localized high-output shunt between an aorta and pulmonary artery. These observations suggest that patients with localized systemic-to-pulmonary shunt could exhibit modified vascular tone in remote pulmonary arteries.

Role of cardiovascular imaging in systemic autoimmune diseases

Systemic autoimmune diseases are characterized by an excess of cardiovascular (CV) morbidity and mortality compared to the general population, mainly due to chronic inflammation that promotes the development of endothelial dysfunction and enhanced atherosclerosis. Early diagnosis of silent CV involvement is mandatory to improve the long term prognosis of these patients and CV imaging provides valuable information as a reliable diagnostic tool. Transthoracic echocardiography, with several applications (e.g. coronary flow reserve evaluation, tissue Doppler imaging, speckle tracking and the transesophageal approach), represents a first line evaluation, in association with biomarkers of endothelial dysfunction, such as asymmetric dimethylarginine. Nuclear medicine provides useful information on myocardial perfusion. The aim of this editorial is to provide a brief but complete review of the diagnostic tools available for screening and follow up of CV involvement in systemic autoimmune diseases.

Increased prevalence of diastolic dysfunction in rheumatoid arthritis

OBJECTIVE

To compare the prevalence of left ventricular (LV) diastolic dysfunction in subjects with and without rheumatoid arthritis (RA), among those with no history of heart failure (HF), and to determine risk factors for diastolic dysfunction in RA.

METHODS

A cross-sectional, community-based study comparing cohorts of adults with and without RA and without a history of HF was carried out. Standard two-dimensional/Doppler echocardiography was performed in all participants. Diastolic dysfunction was defined as impaired relaxation (with or without increased filling pressures) or advanced reduction in compliance or reversible or fixed restrictive filling.

RESULTS

The study included 244 subjects with RA and 1448 non-RA subjects. Mean age was 60.5 years in the RA cohort (71% female) and 64.9 years (50% female) in the non-RA cohort. The vast majority (>98%) of both cohorts had preserved ejection fraction (EF> or =50%). Diastolic dysfunction was more common in subjects with RA at 31% compared with 26% (age and sex adjusted) in non-RA subjects (OR=1.6; 95% CI 1.2 to 2.4). Patients with RA had significantly lower LV mass, higher pulmonary arterial pressure and higher left atrial volume index than non-RA subjects. RA duration and interleukin 6 (IL-6) level were independently associated with diastolic dysfunction in RA even after adjustment for cardiovascular risk factors.

CONCLUSION

Subjects with RA have a higher prevalence of diastolic dysfunction than those without RA. RA duration and IL-6 are independently associated with diastolic dysfunction, suggesting the impact of chronic autoimmune inflammation on myocardial function in RA. Clinical implications of these findings require further investigation.

A review of cardiopulmonary research in Brazilian medical journals: clinical, surgical and epidemiological data

Research in the field of cardiopulmonary disease in Brazil has been very active in recent decades. The combination of PUBMED, SCieLO, open access and online searching has provided a significant increase in the visibility of Brazilian journals. This newly acquired international visibility has in turn resulted in the appearance of more original research reports in the Brazilian scientific press. This review is intended to highlight part of this work for the benefit of the readers of "Clinics." We searched through PUBMED for noteworthy articles published in Brazilian medical journals included in the Journal of Citation Reports of the Institute of Scientific Information to better expose them to our readership. The following journals were examined: "Arquivos Brasileiros de Cardiologia," "Arquivos Brasileiros de Endocrinologia e Metabologia," "Brazilian Journal of Medical and Biological Reviews," "Jornal Brasileiro de Pneumologia," "Jornal de Pediatria," "Revista Brasileira de Cirurgia Cardiovascular," "Revista da Associação Médica Brasileira," Revista da Escola de Enfermagem U.S.P." and "São Paulo Medical Journal." These journals publish original investigations in the field of cardiopulmonary disease. The search produced 71 references, which are briefly examined.

Persistent ventricular asynchrony after coronary artery bypass surgery predicts cardiac events

AIM

The aim of this study was to identify echocardiographic LV systolic and diastolic measurements that predict clinical events post-coronary artery bypass graft (CABG) surgery.

METHODS

We collected data from 27 patients (age 70 +/- 7 years) who underwent elective CABG, before and within 6 weeks after surgery. LV systolic function was assessed by conventional echocardiographic parameters. A number of LV filling measurements were also made, which included total isovolumic time (t-IVT), Tei index, and restrictive filling pattern. Postoperative cardiac events were death or hospitalization for chest pain, breathlessness, or arrhythmia.

RESULTS

Patient's follow-up period was 17 +/- 10 months. Of the 27 patients (age 70 +/- 7 years, 22 male), 10 had postoperative cardiac events. LV ejection fraction (EF) and fractional shortening (FS) were lower (P = 0.01, and P = 0.007, respectively), t-IVT longer (P < 0.001), and Tei index was higher (P < 0.001) preoperatively in patients with events compared to those without. The same differences between groups remained after surgery; EF (P = 0.002), FS (P = 0.002), t-IVT (P < 0.001), and Tei index (P < 0.001). T-IVT was the only preoperative predictor of events (P = 0.038) but its postoperative value as well as that of FS predicted events (P = 0.034, and P = 0.042, respectively). T-IVT of 12.2 s/min and FS of 26% were 80% sensitive and 88% specific for predicting postoperative events.

CONCLUSION

Despite successful surgical revascularization residual impairment of LV systolic function and persistent asynchrony in the form of prolonged t-IVT are associated with postoperative events. Since these abnormalities remained despite full medical therapy, they may thus suggest a need for electrical resynchronization therapy.