Two-dimensional speckle-tracking echocardiography for atrioventricular accessory pathways persistent ventricular pre-excitation despite successful radiofrequency ablation

Echocardiographic Patterns of Abnormal Septal Motion: Beyond Myocardial Ischemia

Abnormal septal motion (ASM), which often is associated with myocardial ischemia, is also observed in other diseases. Owing to the position of the interventricular septum (IVS) in the heart, its movement not only relies on contractile properties but is also affected by the pressure gradient between the 2 ventricles and by the mode of electrical activation. Echocardiography allows the operator to focus on the motion of the IVS, analyzing its characteristics and thereby gaining information about the possible underlying pathophysiological mechanism. In this review, we focused on the main echocardiographic patterns of ASM that are not related to a failure of contractile properties of the septum (i.e., acute coronary syndrome and cardiomyopathies), showing their pathophysiological mechanisms and underlining their diagnostic usefulness in clinical practice.

Using 2D speckle-tracking echocardiography to localize the accessory pathway and evaluate cardiac function and dyssynchrony in pediatric patients with Wolf-Parkinson-White syndrome

Wolf-Parkinson-White (WPW) accessory pathway (AP) may be associated with reentry supraventricular tachycardia (SVT) in addition to ventricular dyssynchrony and cardiac dysfunction. Electrophysiological studies (EPS) are the gold standard for the localization of the AP; however, 2D speckle-tracking echocardiography (2D-STE) may help in the localization of the AP noninvasively. Our study aims to evaluate the capability of 2D-STE for AP localization and the identification of AP-related contractile abnormalities and dyssynchrony in pediatric patients with WPW syndrome. This prospective multicenter cohort study involved 18 pediatric patients with ventricular preexcitation from January 2021 to January 2023. Tissue Doppler imaging (TDI), conventional echocardiography, and 2D-STE were done. Myocardial velocities, myocardial performance index (MPI), the global and segmental longitudinal strain of the left ventricle (LV), and time-to-peak longitudinal strain (TPLS) were measured before and after ablation. The longitudinal strain of the LV segments supplied by the AP, or the nearby segments close to the AP, was significantly impaired and improved after ablation (P = 0.0001). The abnormal strain pattern in the affected segments could predict the location of the AP. The TPLS of the affected segments significantly increased after ablation (P = 0.0001), denoting improved dyssynchrony. The ejection time and the LV MPI measured at the basal septum improved significantly after ablation.

CONCLUSIONS

2D STE may be used for noninvasive localization of the AP and to evaluate cardiac function and dyssynchrony in patients with WPW. Further research on more patients is necessary to validate this method for AP localization.

WHAT IS KNOWN

• Accessory pathways (AP) associated with the Wolf-Parkinson-White (WPW) syndrome have been linked to supraventricular tachycardia (SVT). Even without SVT, WPW can cause left ventricular dyssynchrony, contractile dysfunction, and cardiomyopathy. • Electrophysiology study is the gold standard for the localization of the AP in WPW syndrome.

WHAT IS NEW

• The combination of 2D-speckle-tracking echocardiography (2D-STE) and the modified Arruda algorithm can precisely localize the AP associated with WPW syndrome. • 2D-STE can potentially assess cardiac function and dyssynchrony related to WPW syndrome. Additionally, 2D-STE can be utilized to evaluate the effectiveness of ablation in restoring cardiac function and dyssynchrony.

Evaluation of left atrial and left ventricular functions in patients with Wolff-Parkinson-White syndrome before and after radiofrequency catheter ablation using three-dimensional speckle tracking echocardiography

BACKGROUND

Wolff-Parkinson-White (WPW) syndrome is one of the most common congenital cardiac abnormalities among ventricular pre-excitation syndromes. Radiofrequency catheter ablation (RFCA) treatment of accessory pathways (APs) in WPW patients is an established curative therapy restoring normal atrioventricular conduction. We have not encountered any studies evaluating both the LA and LV functions of these patients before and after RFCA with three dimensional-speckle tracking echocardiography (3D-speckle tracking echocardiography (STE)).

AIM

The purpose of the current study was to assess the LA and LV functions in patients with WPW syndrome before and after RFCA using 3D-STE.

METHODS

A total of 21 patients with WPW syndrome who had been scheduled for RFCA were prospectively recruited for this study. 3D-STE examinations of the patients were performed 12-24 h before ablation and 1 month after ablation.

RESULTS

The LV-global longitudinal strain (LV-GLS) and LV-global circumferential strain (LV-GCS) were significantly depressed in the pre-RFCA WPW group than in the control group (-14.3 ± 2.1 vs. -21.5 ± 2.2, p < .001; -12.6 ± 1.8 vs. -20.4 ± 1.8, p < .001, respectively). The left atrial strain-reservoir (LAS-r) and LAS-active were significantly decreased in the pre-RFCA WPW group than in the control group (31.9 ± 2.4 vs. 48.8 ± 2.6, p < .001; 11.7 ± 2 vs. 26.5 ± 2.1, p < .001, respectively). The LV-GLS, LV-GCS, LAS-r, and LAS-active values improved after RFCA compared to before.

CONCLUSION

The results of our study indicated that there are subclinical impairments in LV and LA myocardial dynamics in the apparently healthy WPW patients, and these deteriorations improve after RFCA of AP.

A case of Wolff–Parkinson–White syndrome in which two-dimensional speckle-tracking echocardiography was useful for identifying the location of the accessory atrioventricular pathway

Background

In Wolff–Parkinson–White (WPW) syndrome, accessory atrioventricular pathways (AP) result in abnormal pre-excitation around the atrioventricular annuli and produce a dyssynchronous contraction of cardiac chambers. Identification of the AP affects the outcome of catheter ablation.

Case summary

We report a case of WPW syndrome and paroxysmal atrial fibrillation in a 65-year-old man. Wolff–Parkinson–White syndrome Type B was suspected from lead V1, but when two-dimensional speckle-tracking echocardiography (2D-STE) was performed, a decrease in regional strain was observed in the anterior basal wall of the left ventricle. We identified the earliest site of atrioventricular conduction, and improvement in the regional strain at the site of ablation was observed after successful AP ablation.

Discussion

Various echocardiographic techniques have been investigated as non-invasive alternatives for AP localization. Longitudinal 2D-STE accurately identified contractile abnormalities associated with the AP, allowing us to non-invasively estimate the localization of the AP in WPW syndrome.

Altered myocardial characteristics of the preexcited segment in Wolff-Parkinson-White syndrome: A pilot study with cardiac magnetic resonance imaging

Purpose

The preexcited myocardium of Wolff-Parkinson-White (WPW) syndrome would have different characteristics from normal myocardium and these findings might be related to persistent left ventricular systolic dysfunction. We evaluated myocardial tissue characteristics at the preexcited segment in adult WPW syndrome patients and their implicated findings.

Methods

For this prospective study, we enrolled 22 adult WPW syndrome patients (16 male, mean 45.4 ± 17.8 years) with echocardiographic findings of regional wall motion abnormality in our electrophysiology clinic. Of these patients, 14 underwent radiofrequency ablation before cardiac magnetic resonance imaging. All patients underwent cardiac magnetic resonance imaging including cine and late gadolinium enhancement. The ventricular morphology, function and myocardial characteristics of the preexcited segment were analyzed.

Results

A relatively high prevalence of late gadolinium enhancement (9/22, 40.9%) was observed exclusively at the basal septum. The septal accessory pathway was significantly more prevalent in patients with late gadolinium enhancement (P = 0.011). The prevalences of regional myocardial wall thinning and regional akinesia were significantly higher (P = 0.001 for both) and left ventricular function was significantly decreased in patients with late gadolinium enhancement (P < 0.001). In addition, there were no significant relationships between radiofrequency ablation and regional akinesia (P > 0.999), regional myocardial wall thinning (P > 0.999), late gadolinium enhancement (P = 0.662) and low ejection fraction (P > 0.999).

Conclusion

Myocardial fibrosis was observed at the preexcited myocardium of adult WPW syndrome patients with septal accessory pathway, which could accompany regional akinesia and regional myocardial wall thinning and might be related to persistent left ventricular systolic dysfunction even after radiofrequency ablation.

Noninvasive Localization of Accessory Pathways in Wolff-Parkinson-White Syndrome by Three-Dimensional Speckle Tracking Echocardiography

BACKGROUND

We have developed a noninvasive isochrone activation imaging (AI) system with 3-dimensional (3D) speckle tracking echocardiography (STE), which allows visualization of the wavefront image of mechanical propagation of the accessory pathway (ACP) in Wolff-Parkinson-White syndrome.

METHODS AND RESULTS

Patients with manifest Wolff-Parkinson-White syndrome were imaged in 3D-STE AI mode, which quantified the time from QRS onset to regional endocardial deformation. In 2 patients with left- and right-side ACP, we confirmed that intraoperative contact endocardial electric mapping and the 3D-STE AI system showed comparable images pre- and postablation. In normal heart assessment by 3D-echo AI, the earliest activation sites were found at the attachment of the papillary muscles in the left ventricle and midseptum in the right ventricle, and none showed earliest activation at the peri-atrioventricular valve annuli. An analyzer who was unaware of the clinical information assessed 39 ACP locations in 38 Wolff-Parkinson-White syndrome patients using 3D-STE. All showed abnormal perimitral or tricuspid annular activations, and the location of 34 ACP (87%) showed agreement with the successful ablation sites within a 2-o'clock range. Especially for left free wall ACP, 17/18 (94%) showed consistency with the ablation site within a 2 o'clock range. Among 15 ACP at the ventricular septum, 9 (60%) showed early local activation in both right and left sides of the septum.

CONCLUSIONS

Isochrone AI with 3D-STE may be a promising noninvasive imaging tool to assess cardiac synchronized activation in normal hearts and detect abnormal breakthrough of mechanical activation from both atrioventricular annuli in Wolff-Parkinson-White syndrome.

Two-dimensional speckle tracking imaging as a novel strategy for accurately identifying the accessory pathway

A 14-year-old patient was diagnosed with hypertrophic cardiomyopathy associated with Wolff-Parkinson-White syndrome. The two-dimensional speckle tracking strain method showed normal left ventricular local contraction, but the peak systolic longitudinal strain of the right ventricular (RV) anterior wall was earlier than that of the septal wall. As expected, the location of the accessory pathway was at the RV anterior wall. The patient's RV local contraction was normalized by successful radiofrequency application.

The year 2012 in the European Heart Journal-Cardiovascular Imaging. Part II

The part II of the best of the European Heart Journal - Cardiovascular Imaging in 2012 specifically focuses on studies of valvular heart diseases, heart failure, cardiomyopathies, and congenital heart diseases.