Echocardiographic features of congestive cardiomyopathy compared with normal subjects and patients with coronary artery disease

Identifying the etiology: a systematic approach using delayed-enhancement cardiovascular magnetic resonance

In patients who have heart failure, treatment and survival are directly related to the cause. Clinically, as a practical first step, patients are classified as having either ischemic or non-ischemic cardiomyopathy, a delineation usually based on the presence or absence of epicardial coronary artery disease. However, this approach does not account for patients with non-ischemic cardiomyopathy who also have coronary artery disease, which may be either incidental or partly contributing to myocardial dysfunction (mixed cardiomyopathy). By allowing direct assessment of the myocardium, delayed-enhancement cardiovascular magnetic resonance (DE-CMR) may aid in addressing these conundrums. This article explores the use of DE-CMR in identifying ischemic and non-ischemic myopathic processes and details a systematic approach to determine the cause of cardiomyopathy.

Comparison of echocardiography and electron beam tomography in differentiating the etiology of heart failure

BACKGROUND

The clinical manifestations in patients with ischemic cardiomyopathy are often indistinguishable from those in patients with primary dilated cardiomyopathy (DCM). Clinicians often base work-up of patients with heart failure on echocardiographic wall motion abnormalities; however misclassification can lead to unnecessary coronary angiography.

HYPOTHESIS

The study was undertaken to evaluate the diagnostic ability of echocardiography and electron beam tomography (EBT) to differentiate between ischemic and nonischemic cardiomyopathy.

METHODS

The accuracy of EBT and echocardiography was compared in 111 patients undergoing coronary angiography for the evaluation of heart failure. The presence of coronary calcification (CC) by EBT or segmental wall motion abnormalities by echocardiography was used as evidence of coronary-induced cardiomyopathy.

RESULTS

Of 63 patients, 61 (97%) with obstructive coronary artery disease had CC by EBT. This sensitivity was significantly higher compared with 43 of 63 patients (68%) with segmental wall motion abnormalities by echocardiography (p < 0.001). Of 48 patients without obstructive coronary artery disease by angiography, 39 (81%) had no CC by EBT and 35 (73%) had no segmental wall motion (global hypokinesis) by echocardiography (p = 0.33). The overall accuracy of EBT to differentiate ischemic from nonischemic cardiomyopathy was 90%, significantly higher than echocardiography (70%, p < 0.001).

CONCLUSION

This double-blind study demonstrates that the presence of CC by EBT is superior to that of segmental wall motion abnormalities by echocardiography to distinguish ischemic from nonischemic cardiomyopathy. This modality may prove to be an important diagnostic tool when the etiology of the cardiomyopathy is not clinically evident.

Assessment of Mitral Annulus Size and Function by Real-time 3-Dimensional Echocardiography in Cardiomyopathy: Comparison with Magnetic Resonance Imaging

OBJECTIVE

We sought to assess mitral annular (MA) size and function in hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM) using real-time 3-dimensional (3D) echocardiography (RT3DE).

METHODS

The study included 30 patients with HCM, 20 patients with DCM, and 30 control subjects. RT3DE measurements included end-systolic and end-diastolic MA area (MAA) (MAA(3D)), MA diameter(3D), MA fractional area change (MAFAC), and MA fractional shortening. In subgroup of 50 patients, magnetic resonance imaging (MRI) was used for MAA(MRI) and MA diameter(MRI) measurement.

RESULTS

End-diastolic MAA(3D) was larger in HCM than in control group (P < .0001). Higher MAFAC and MA fractional shortening were present in HCM than in control group (P = .001 and P = .006, respectively). End-systolic and end-diastolic MAA(3D) in DCM were higher than in HCM and control groups (P < .0001). Lower MAFAC and MA fractional shortening were present in DCM than in HCM and control groups (P < .0001). MAFAC correlated well with left ventricular function in control subjects (r = 0.94, P < .0001), whereas correlation was less in DCM (r = 0.53, P = .02) and HCM (r = 0.42, P < .01). RT3DE and MRI measurements were comparable.

CONCLUSION

RT3DE assessment of MA size and function in control subjects and patients with cardiomyopathy is accurate and well correlated with MRI.

Should Patients Be Submitted to Coronary Arteriography After Echocardiographic Diagnosis of Idiopathic Dilated Cardiomyopathy?

OBJECTIVES: The present study was designed to determine if patients with an echocardiographic diagnosis of idiopathic dilated cardiomyopathy should be submitted to coronary arteriography. BACKGROUND: Whether echocardiography allows distinction of idiopathic dilated cardiomyopathy from severe coronary heart disease remains controversial. METHODS: A questionnaire was sent out to the members of the Swiss Society of Cardiology. In the first study 78 patients with an echocardiographic diagnosis of idiopathic dilated cardiomyopathy who had undergone coronary arteriography or had been followed-up for >5 years were investigated. In a second study, the echocardiograms of 50 patients with either idiopathic cardiomyopathy or severe coronary heart disease, all of whom had also undergone coronary arteriography, were reviewed by two independent echocardiographers without access to any complementary information. RESULT: The questionnaire revealed that one half of the Swiss cardiologists generally refer such patients for coronary arteriography. The first study showed that the diagnosis of idiopathic dilated cardiomyopathy was confirmed in all cases, in which the echocardiographer had been certain of the diagnosis (64/78 [82%]). In the uncertain cases (14 [18%]) coronary arteriography revealed 9 idiopathic cardiomyopathies, 3 coronary heart diseases, and 2 mixed etiologies. The second study showed that a correct diagnosis was achieved in 85% of cases. Furthermore, the echocardiographers were able to specify those patients with an uncertain diagnosis who would therefore require coronary arteriography. CONCLUSIONS: In the overwhelming majority of cases, echocardiography can distinguish idiopathic dilated cardiomyopathy from severe coronary heart disease. Coronary arteriography is only indicated when the echocardiographer is uncertain of the diagnosis. The routine and costly practice of coronary arteriography of these patients does not appear to be justified.

Assessment of right ventricular diastolic and systolic function in patients with dilated cardiomyopathy using cine magnetic resonance imaging

Cine magnetic resonance imaging (MRI) can provide clear endocardial margins of the entire right ventricle, and Simpson's algorithm can be applied to obtain the volumes at multiple phases of the cardiac cycle. Time-volume curves of the right ventricle were obtained by using cine MRI in 10 patients with dilated cardiomyopathy (DCM) and eight normal volunteers to assess right ventricular function. There were no significant differences in volumes and ejection fraction of the right ventricle between the group with DCM and the normal group. In the group with DCM the time to peak filling rate was increased (p less than 0.05) and the filling fraction was decreased (p less than 0.01). In the patients with DCM cine MRI demonstrated normal volumes and ejection fraction of the right ventricle in contradistinction to the marked increase in volumes and the decrease in ejection fraction of the left ventricle; with the use of time-volume curves of the right ventricle, impairment of diastolic function of the right ventricle was demonstrated.

Hemodynamic effect of physiological dual chamber pacing in a patient with end-stage dilated cardiomyopathy: a case report

I report a case of end-stage dilated cardiomyopathy with first-degree atrioventricular (AV) block, which had been resistant to intensive medical therapy and was eventually treated by DDD pacemaker. The optimal AV interval setting was decided using invasive right-heart catheterization and Doppler echocardiography. At a pacing rate of 92/minute, an AV interval setting of between 200 and 100 msec increased left ventricular filling and enhanced myocardial contractility. An AV interval setting of 50 msec increased the left ventricular filling further. However, this resulted in deteriorated left ventricular function. Based on these findings, the pacemaker was programmed at an optimal AV delay of 100 msec, a rate of 82-150 beats/min and a DDD mode, resulting in a good clinical course for 4 months after the therapy. Thus, it is suggested that in patients with end-stage dilated cardiomyopathy and first-degree AV block, an optimal AV delay setting using a DDD pacemaker can improve deteriorated myocardial function probably by increasing the left ventricular filling, and thus promote utility of the Frank-Starling mechanism.

Differentiating cardiomyopathy of coronary artery disease from nonischemic dilated cardiomyopathy utilizing positron emission tomography

To determine if imaging of blood flow (using N-13 ammonia) and glucose metabolism (using F-18 2-deoxyglucose) with positron emission tomography can distinguish cardiomyopathy of coronary artery disease from nonischemic dilated cardiomyopathy, 21 patients with severe left ventricular dysfunction who were evaluated for cardiac transplantation were studied. The origin of left ventricular dysfunction had been previously determined by coronary angiography to be ischemic (11 patients) or nonischemic (10 patients). Images were visually analyzed by three observers on a graded scale in seven left ventricular segments and revealed fewer defects in dilated cardiomyopathy compared with ischemic cardiomyopathy for N-13 ammonia (2.7 +/- 1.6 versus 5 +/- 0.6; p less than 0.03) and F-18 deoxyglucose (2.8 +/- 2.1 versus 4.6 +/- 1.1; p less than 0.03). An index incorporating extent and severity of defects revealed more homogeneity with fewer and less severe defects in subjects with nonischemic than in those with ischemic cardiomyopathy as assessed by imaging of flow (2.8 +/- 1.8 versus 9.2 +/- 3; p less than 0.001) and metabolism (3.8 +/- 3.3 versus 8.5 +/- 3.6; p less than 0.005). Diagnostic accuracy for distinguishing the two subgroups by visual image analysis was 85%. Using previously published circumferential count profile criteria, patients with dilated cardiomyopathy had fewer ischemic segments (0.4 +/- 0.8 versus 2.5 +/- 2 per patient; p less than 0.01) and infarcted segments (0.1 +/- 0.3 versus 2.4 +/- 1.4 per patient; p less than 0.001) than did patients with cardiomyopathy of coronary artery disease. The sensitivity for differentiating the two clinical subgroups using circumferential profile analysis was 100% and the specificity 80%. An index incorporating both number and severity of defects derived from circumferential profile analysis was significantly lower in subjects with dilated cardiomyopathy than in ischemic cardiomyopathy (0.3 +/- 0.8 versus 2.7 +/- 2.4; p less than 0.005). Thus, noninvasive positron emission tomographic imaging with N-13 ammonia and F-18 deoxyglucose is helpful in distinguishing patients with severe left ventricular dysfunction secondary to coronary artery disease from those with nonischemic cardiomyopathy, and a semiquantitative index such as circumferential profile analysis is superior to that of visual analysis alone.

Interstudy reproducibility of dimensional and functional measurements between cine magnetic resonance studies in the morphologically abnormal left ventricle

The validity of geometric formulas to derive mass and volumes in the morphologically abnormal left ventricle is problematic. Imaging techniques that are tomographic and therefore inherently three-dimensional should be more reliable and reproducible between studies in such ventricles. Determination of reproducibility between studies is essential to define the limits of an imaging technique for evaluating the response to therapy. Sequential cine magnetic resonance (MR) studies were performed on patients with dilated cardiomyopathy (n = 11) and left ventricular hypertrophy (n = 8) within a short interval in order to assess interstudy reproducibility. Left ventricular mass, volumes, ejection fraction, and end-systolic wall stress were determined by two independent observers. Between studies, left ventricular mass was highly reproducible for hypertrophied and dilated ventricles, with percent variability less than 6%. Ejection fraction and end-diastolic volume showed close reproducibility between studies, with percent variability less than 5% End-systolic volume varied by 4.3% and 4.5% in dilated cardiomyopathy and 8.4% and 7.2% in left ventricular hypertrophy for the two observers. End-systolic wall stress, which is derived from multiple measurements, varied the greatest, with percent variability of 17.2% and 15.7% in dilated cardiomyopathy and 14.8% and 13% in left ventricular hypertrophy, respectively. The results of this study demonstrate that mass, volume, and functional measurements are reproducible in morphologically abnormal ventricles.

Determinants of the occurrence of vortex rings in the left ventricle during diastole

This study employs classical inviscid fluid dynamics theory to investigate whether LV diastolic inflow volume and the size of the LV play a role in vortex ring formation. Fluid injection across an orifice into a large container results in the generation of a vortex ring having a constant size and speed. Relations between the vortex size and speed and the injection were obtained by applying conservation laws regarding kinetic energy, impulse and vorticity; the initial state was computed using a bolus injection model, and the final state by using the Kelvin vortex model. An important parameter in the equations is the relative injection length, i.e., the ratio of the length of the injected bolus and the radius of the orifice (L/R). Its estimated highest value in man, L/R = 15, produces a rather thick vortex ring (relative thickness 0.77). Comparable results following from the Hill vortex model convinced us that the Kelvin vortex model can be applied in the whole range of injection lengths in the human left ventricle. In an in vitro model it is shown experimentally that vortex rings can be generated for L/R in the range from 2 to 16. The measured traveling speed of the vortex ring is in fair agreement with the theory, as well as the ring radius for large injections. A vortex ring located in a narrow channel cannot reach its proper traveling speed. The method of images is used to estimate the speed reduction of vortex rings within a cylinder. It turns out that propagation of vortex rings is possible when the ratio of orifice to cylinder radius is less than about 0.5.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiography in congestive or dilated cardiomyopathy

Echocardiography plays an important role in the evaluation of patients with congestive or dilated cardiomyopathy. Its role in diagnosis consists of demonstration of ventricular and atrial chamber dilation and assessment of left ventricular systolic function. A subgroup of patients with depressed function but with no significant left ventricular dilation are described. Echocardiographic detection of intracavitary thrombi in the left ventricular cavity has a high predictive accuracy in excess of 90%. The pathophysiology of mitral and tricuspid regurgitation in relation to annular size, valve dysfunction, and chamber dilation is readily assessed by two-dimensional echocardiography. The Doppler methods are useful to measure cardiac output, to quantify pulmonary hypertension, and to assess left ventricular systolic and diastolic functional abnormalities. An important role of echocardiography in prognosis relates to predictive value of M-mode parameters of left ventricular size, wall thickness, and function in long-term survival, as observed in a prospective multicenter study.

Dilated cardiomyopathy and myocarditis: natural history, etiology, clinical manifestations, and management

This monograph begins and ends with a statement of uncertainty regarding many aspects of dilated cardiomyopathy. Natural history studies identify patients with widely differing outcomes. A host of prognostic factors have emerged, yet it would appear that the major determinants of survival are as yet unrecognized. The diagnosis remains primarily one of exclusion, and management is largely nonspecific and supportive. The frequency of sudden cardiac death is well documented, but the ability to accurately identify patients at risk and the efficacy of antiarrhythmic therapy is unestablished. The emerging success of cardiac transplantation is a source of encouragement. The causes of dilated cardiomyopathy remain a source of intense investigation. Accumulating evidence (much of it circumstantial) does, however, implicate a viral etiology and perhaps altered function of the immunoregulatory system. However, the disparity between the severity of functional disturbance with the relative lack of histologic markers of cellular necrosis implies a disturbance at a cellular level. The etiology or etiologies remain elusive. Future investigation directed at fundamental aspects of cardiac cellular biology may provide the answers.

Clinical significance of early diastolic time intervals for the differentiation of idiopathic dilative cardiomyopathy from ischemic cardiomyopathy

In order to differentiate idiopathic dilative cardiomyopathy from ischemic cardiomyopathy noninvasively, systolic time intervals (STIs) and early diastolic time intervals were investigated in patients with idiopathic dilative cardiomyopathy (n = 11), patients with ischemic cardiomyopathy (n = 8), and normal controls (n = 17). Minimal left ventricular pressure and pulmonary capillary wedge pressure (PCWP) were also measured to clarify the relationship between early diastolic time intervals and early diastolic hemodynamics. Cardiac function estimated by STIs was markedly depressed both in idiopathic dilative cardiomyopathy and ischemic cardiomyopathy, and there was no difference between the two diseases. In early diastolic time intervals, IIA-O time (the interval from the aortic component of the second heart sound to the O point of apexcardiogram) was significantly prolonged both in idiopathic dilative cardiomyopathy (144 +/- 31 (SD); p less than 0.01) and ischemic cardiomyopathy (153 +/- 15; p less than 0.01) compared to normal controls (126 +/- 11). IIA-MVO time (the interval from IIA to the mitral valve opening) in idiopathic dilative cardiomyopathy (49 +/- 23) was significantly shorter than that in normal controls (70 +/- 8; p less than 0.05). On the contrary, IIA-MVO time in ischemic cardiomyopathy (126 +/- 11) was markedly prolonged compared with normal controls (p less than 0.01) and idiopathic dilative cardiomyopathy (p less than 0.01). MVO-O time was significantly prolonged in idiopathic dilative cardiomyopathy (94 +/- 18; p less than 0.01). However, it was conversely shortened in ischemic cardiomyopathy (25 +/- 15) compared with normal controls (54 +/- 7; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Regional left ventricular wall thickening by magnetic resonance imaging: evaluation in normal persons and patients with global and regional dysfunction

Gated magnetic resonance imaging (MRI) provides excellent anatomic evaluation of the heart, but its capability for assessing cardiac physiology is less clear. Accordingly, regional left ventricular (LV) wall thickening was evaluated by multiphasic transverse images in 37 patients with a variety of myocardial diseases and in 9 normal subjects. Angiography and 2-dimensional echocardiography (2-D echo) were used for comparison. End-diastolic and end-systolic wall thickness, absolute systolic wall thickening and percent systolic wall thickening were determined in 7 regions. Mean systolic wall thickening in normal subjects was not significantly different among the regions. However, there was considerable individual variation in wall thickening, ranging from 18 to 100%. Patients with LV hypertrophy (n = 4), amyloid cardiomyopathy (n = 1), constrictive pericarditis (n = 5), and hypertrophic cardiomyopathy (n = 3) had absolute and percent systolic wall thickening within normal limits. Infarcted segments in patients with ischemic heart disease (n = 17) had reduced absolute and percent systolic wall thickening, often combined with diastolic wall thinning, whereas mean percent systolic wall thickening in adjacent normal myocardial regions was higher than in normal volunteers (p less than 0.001). In patients with coronary artery disease, MRI had a sensitivity and specificity of 93% in detecting regional wall motion abnormalities. Because sagittal images were not acquired, inferior wall motion abnormalities were not assessed by MRI due to parallel wall sectioning in transverse images.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of alcohol on the heart: current views

Chronic and heavy alcohol consumption has deleterious effects upon the cardiovascular system and may cause congestive cardiomyopathy. Evidence of cardiac malfunction has been found in chronic alcoholics without overt heart failure by invasive and noninvasive methods. Ethanol is the incriminated factor having a direct cardiotoxic effect. Electron microscopy and cardiac muscle biopsies show that ethanol may cause changes on plasmalemmal, mitochondrial, and sarcoplasmic membranes. The clinical picture and general management of alcoholic cardiomyopathy do not differ substantially from those of congestive cardiomyopathies of any type. It has, however, been demonstrated that cessation of alcohol consumption may lead to an improved prognosis, even to restoration of normal cardiac function, in individuals with preclinical and mild manifestations of cardiac dysfunction. The literature on the possible association of coronary heart disease with alcohol seems to be ambiguous. It has, however, been postulated recently that moderate alcohol intake may have a protective role against coronary heart disease, in contrast to alcoholic intemperance, which may be a factor favoring coronary heart disease.

Pulsed Doppler echocardiographic study of left ventricular filling in dilated cardiomyopathy

Patients with dilated cardiomyopathy (DC) have been reported to have abnormal left ventricular (LV) diastolic properties. To evaluate LV diastolic filling characteristics in patients with DC, pulsed Doppler echocardiography was used to study mitral flow velocity in 21 patients with DC and mitral regurgitation (MR), 12 patients with DC but no MR and 19 age-matched normal subjects. Diagnosis of MR was based on the Doppler echocardiographic finding of holosystolic turbulent flow in the left atrium. Peak mitral flow velocity in early diastole (PFVE) and during atrial systole (PFVA), PFVA/PFVE and deceleration half-time of early diastolic flow were measured from Doppler mitral flow velocity recordings. In 21 patients with DC and MR, PFVE (61 +/- 13 cm/s), PFVA (37 +/- 19 cm/s) and PFVA/PFVE (0.6 +/- 0.4) were not significantly different from PFVE (53 +/- 10 cm/s), PFVA (47 +/- 12 cm/s) and PFVA/PFVE (1.0 +/- 0.4) in normal subjects (p greater than 0.05). Deceleration half-time in DC patients with MR (62 +/- 32 ms) was shorter than normal (87 +/- 25 ms) (p less than 0.05). In contrast, PFVE (31 +/- 11 cm/s) was lower and PFVA/PFVE (1.7 +/- 0.8) was higher in the 12 DC patients without MR than in normal subjects and DC patients with MR (p less than 0.005). PFVA (46 +/- 8 cm/s) and deceleration half-time (88 +/- 33 ms) in patients without MR were not significantly different from normal mean values. Thus, abnormalities of peak diastolic mitral flow velocity were detected in DC patients without MR but not in DC patients with MR, suggesting that MR masks LV filling abnormalities in patients with DC.

Treadmill exercise test in children with cardiomyopathy and postmyocarditic myocardial hypertrophy

The treadmill exercise test with the Bruce protocol was performed in three patients with post-myocarditic myocardial hypertrophy (PMH) and ten patients with cardiomyopathy, including three with dilated cardiomyopathy (DCM), five with hypertrophic obstructive cardiomyopathy (HOCM), and two with hypertrophic and nonobstructive cardiomyopathy (HCM). The endurance time was below the normal level in all but one case and was normal or near normal in the three cases with PMH. ST depression was observed in five cases, none of which were of HCM. A marked increase in amplitude of the negative phase of the P wave in V1 was observed in one patient with DCM. The response of blood pressure during the exercise was abnormal in patients with DCM and HCM but was normal in PMH.

Cardiac function in alcohol-associated systemic hypertension

The pathogenesis of alcohol cardiomyopathy is obscure. Because systemic hypertension is observed in one-third of alcoholics, the relation of this finding to left ventricular (LV) function was analyzed in 66 alcoholics (26 with a blood pressure of 160/95 mm Hg or higher) 4 to 5 days after alcohol withdrawal. Hypertensive alcoholics had a more abnormal ratio of preejection period/LV ejection time (PEP/ET) (0.398 +/- 0.01 vs 0.35 +/- 0.01, p less than 0.02) than normotensive alcoholics (matched normal 0.290 +/- 0.01). Hypertensive alcoholics (transitory hypertension) with blood pressures of 120/80 mm Hg or less at time of study also had more abnormal PEP/LVET than matched normotensive alcoholics (0.415 +/- 0.03 vs 0.331 +/- 0.01, p less than 0.05). In both hypertensive (77 +/- 6 dynes/cm2 X 10(3)) and normotensive alcoholics (67 +/- 4 dynes/cm2 X 10(3) LV stress was elevated (normal 46 +/- 3 dynes/cm2 X 10(3), both p less than 0.02). However, LV mass was not increased (hypertensive 96 +/- 4 g/m2; vs normotensive 100 +/- 4 g/m2; (normal 92 +/- 5 g/m2), resulting in a markedly increased stress to mass ratio (hypertensive 0.8 +/- 0.06; Normal 0.05 +/- 0.05, p less than 0.02). Hypertensive alcoholics also had LV "hyperfunction," with an increased stress/LV end-systolic volume ratio (1.7 +/- 0.1 vs 1.3 +/- 0.1 dynes/cm2 X 10(3)/ml, p less than 0.02). Thus, hypertensive alcoholics, even those with transitory hypertension, have more abnormal cardiac function than normotensive alcoholics. Presence of hypertension with hyperdynamic LV features may be a prelude to heart failure.

The value of echocardiographic regional wall motion abnormalities in detecting coronary artery disease in patients with or without a dilated left ventricle

To evaluate the usefulness of echocardiographic regional wall motion abnormalities (RWMA) in detecting coronary artery disease (CAD) in patients with left ventricular (LV) dysfunction and a normal-sized or dilated left ventricle, 103 patients were studied by two-dimensional echocardiography (2DE) and cardiac catheterization. In 60 patients (group I) who had LV dysfunction and a dilated left ventricle by echo (patients with dilated cardiomyopathy), RWMA were detected in 44 patients and 38 (86%) of them had significant CAD, usually two- or three-vessel obstruction; of the 16 patients with dilated cardiomyopathy (DCM) and diffuse LV hypokinesis, eight (50%) had evidence of CAD. Thus the presence of RWMA by 2DE had an 83% sensitivity, a 57% specificity, and a 77% predictive accuracy in detecting CAD in patients with DCM and thus in distinguishing ischemic from idiopathic DCM. In 43 patients with LV dysfunction but normal LV size (group II), the sensitivity, specificity, and predictive accuracy of RWMA in detecting significant CAD was 95%, 100%, and 95%, respectively. We conclude that the detection of RWMA by 2DE is highly suggestive of significant CAD in patients with LV dysfunction and normal-sized or dilated left ventricle; the finding, however, of diffuse LV hypokinesis does not exclude CAD in these patients, especially when the left ventricle is dilated.

Multiple aortic root echoes: clinical, radiographic, and angiographic correlations

Multiple diastolic echoes in the aortic root on M-mode echocardiography may represent fibrosis or calcification of the aortic wall, aortic leaflets, or proximal portions of the coronary arteries. In this study, 83 patients with multiple diastolic echoes were evaluated by cardiac fluoroscopy and the incidence of valvular, coronary, and aortic wall calcification was determined. In patients with multiple diastolic echoes who have no evidence of significant aortic stenosis (aortic valve opening less than or equal to 1.0 cm) or aortic insufficiency (fine fluttering of the anterior leaflet of the mitral valve), the presence of multiple diastolic echoes was highly associated with significant coronary artery calcification (64%) with over two-thirds having multivessel involvement. Patients referred for echocardiography who are free of significant aortic stenosis or aortic insufficiency by echocardiographic criteria who are found to have multiple diastolic echoes in the aortic root should be evaluated further for the possible presence of significant multivessel coronary artery disease.

Echographic early systolic partial closure (notching) of the aortic valve in congestive cardiomyopathy

We investigated the prevalence and significance of aortic valve early systolic partial closure (notching) in congestive cardiomyopathy by reviewing clinical and M-mode echocardiographic findings in 33 patients. We also compared their echocardiographic aortic root and valve findings to those in 17 aortic regurgitation patients and 24 normal subjects. Thirteen cardiomyopathy patients (39%) exhibited aortic valve partial closure--similar to the prevalence in the aortic regurgitation (41%) and normal (33%) groups. However, patients with dilated cardiomyopathy and aortic valve notching exhibited a higher mean percentage of partial closure (18% +/- 10) than those with notching in either the aortic regurgitation (8% +/- 9) or normal (5% +/- 2) group. There was no significant difference in age, body surface area, left ventricular dimension, systolic function, or presence of mitral regurgitation between cardiomyopathy patients with and without aortic valve notching, but the former had slightly greater aortic root dimensions and maximal aortic leaflet separation. Although the reason for this difference is unknown, a wider aortic root may result in low-pressure areas bordering the aortic flow stream during early systole, which may favor partial aortic valve closure.

Long-term echocardiographic assessment of dilated cardiomyopathy in children

Left ventricular (LV) dimensions and function were assessed by echocardiography in 22 children with dilated cardiomyopathy. They had survived an initial episode of congestive heart failure in infancy for greater than or equal to 2 years. At the time of echocardiography, when they were 3 to 16 years old, 8 patients (Group 1) still had signs of dilated cardiomyopathy and 14 (Group 2) had lost all roentgenographic and electrocardiographic evidence of heart disease. All 8 patients in Group 1 (average follow-up 4.5 years) had significantly increased LV dimensions. The end-diastolic dimension averaged 144 +/- 18% of the normal value. Fractional LV shortening with systole was significantly reduced and averaged 23 +/- 3%. The E point-septal separation ranged from 7 to 17 mm (mean 12 +/- 4) and was far above the normal limit in all. Of the 14 patients in Group 2, seven (average follow-up 7 years) had normal ventricular dimensions and 7 (average follow-up 10 years) had LV dimensions larger than the upper range of the 95% prediction limit. In 6 of the latter patients the fractional LV shortening with systole was less than or equal to 31% and the E point-septal separation in excess of the upper limit of normal. These findings indicate that about half of the patients who had apparently recovered still had residual lesions as judged from the echocardiogram. In 6 patients in group 1, two-dimensional echo-cardiography allowed the visualization of a thickened endocardium. One of these 6 patients died. The echocardiographic image correlated well with the process of LV endocardial fibroelastosis found at necropsy.

Evaluation of dilated cardiomyopathy by pulsed Doppler echocardiography

The ability of pulsed Doppler echocardiography to identify patients with left ventricular systolic dysfunction was evaluated in 12 patients with dilated (congestive) cardiomyopathy. A range-gated, spectrum analyzer-based Doppler velocimeter was used to record blood flow velocity in the ascending aorta and main pulmonary artery. The following blood flow velocity parameters were measured or derived: peak flow velocity, acceleration time, average acceleration, deceleration time, average deceleration, ejection time, and aortic flow velocity integral. Doppler blood flow velocity data in the cardiomyopathy patients were compared to data from 20 normal subjects. Measurements from the ascending aorta revealed that peak aortic flow velocity discriminated between cardiomyopathy patients (mean 47 cm/sec, range 35 to 62) and normal subjects (mean 92 cm/sec, range 72 to 120) with no overlap in data (p less than 0.001). Aortic flow velocity integral was also able to separate the patients with dilated cardiomyopathy (mean 6.7 cm, range 3.5 to 9.1) from normal subjects (mean 15.7 cm, range 12.6 to 22.5) with no overlap in data (p less than 0.001). Although mean values for average aortic acceleration and aortic ejection time were also significantly different (both p less than 0.005), there was some overlap between the two groups. Pulmonary artery blood flow studies demonstrated significantly increased average acceleration, as well as decreased ejection time (both p less than 0.05), but no difference in average deceleration or peak flow velocity in cardiomyopathy patients compared to normals. Compared to pulmonary flow measurements, aortic Doppler flow velocity measurements allowed better separation of cardiomyopathy and normal groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of left ventricular function by synchronous echocardiography and apex cardiography

The relationship between left ventricular dimension measured using M-mode echocardiography and simultaneous apex cardiography has been studied in 69 normal subjects (2 groups) and 159 patients with heart disease (6 groups). A loop was formed by plotting the apex cardiogram, which is related to ventricular wall stress, against ventricular dimension. Abnormalities in ventricular function due to shape or volume changes in the isovolumic phases of the cardiac cycle produced characteristic alterations in the loop pattern. These changes were measured and the results for different groups compared. Normal subjects were divided into two age groups (13-38, 40-78) and no significant differences were found between them. In the heart-disease, patients, 25% had an abnormal decrease in dimension during isovolumic contraction and 25% had an abnormal increase during isovolumic relaxation. When the downstroke of the apex cardiogram was differentially analysed, it was possible to show that 60% of heart-disease patients lay outside the normal range. By using these techniques it is possible (a) to show abnormal ventricular response to pressure changes during the isovolumic periods, (b) to quantify the abnormality and, (c) to detect early abnormal muscle behaviour before it becomes visible on conventional ultrasound recordings.

Value of positive myocardial technetium-99m-pyrophosphate scintigraphy in the noninvasive diagnosis of cardiac amyloidosis

Ten consecutive patients with tissue-proven amyloidosis, seven of whom presented with congestive heart failure, were found to exhibit intense diffuse uptake of technetium-99m-pyrophosphate (Tc-99m-PYP) on cardiac radionuclide imaging. The patients exhibited echocardiographic and systolic time interval abnormalities suggesting combined restrictive and congestive cardiomyopathic changes. On M-mode echocardiograms, there was symmetrically increased thickness of the interventricular septum and left ventricular (LV) posterior wall in diastole (10 of 10), decreased fractional shortening of the LV minor axis diameter in systole (eight of nine), and decreased percent thickening of the LV minor axis diameter in systole (eight of nine) and LV posterior wall (10 of 10) in systole. Three patients demonstrated enlarged LV end-diastolic diameter. All 10 patients had abnormal PEP/LVET and eight had shortened LVETI. When combined with noninvasive tests of LV performance, positive myocardial pyrophosphate (PYP) scanning provides a new and useful adjunct in the diagnosis of amyloid heart disease.

High predictive accuracy for detection of left main coronary artery disease by antilog signal processing of two-dimensional echocardiographic images

Two-dimensional echocardiography has been used to image the left main coronary artery. We have successfully imaged the left main coronary artery in 16 of 19 patients with left main coronary artery disease (LMCAD) and in 14 of 18 control patients using a dynamically focused 3-1/2 MHz experimental phased array sector scanner. Images were displayed with standard logarithmic compression grey scale allocation and with a modified antilog curve which enhances high intensity echoes. All of the 16 patients with LMCAD were identified from the antilog processed image. Only 1 of the 18 control patients had a false positive study. Modified antilog processed images provide high sensitivity (100%) and specificity (93%) for detecting LMCAD. This noninvasive technique could be used to screen patients for the presence or absence of LMCAD.

Comparative study of the echocardiographic findings in hypertensive and nonhypertensive cardiomyopathy

Thirty adult male patients with advanced myocardial disease were evaluated by echocardiography. Fourteen were hypertensive; 16 were normotensive. In the former group, 7 subjects had hypertension alone; 7 had combined hypertension and alcoholism or ischemia. The latter group included 4 patients with ischemia, 6 patients with alcoholism, and 6 with idiopathic cardiomyopathy. Nine of the 14 hypertensives and 3 of 6 subjects with ischemic disease had diabetes. Compared to the normotensives, the hypertensive subjects had greater posterior wall thickness (10.4 ± 1.3 mm versus 8.3 ±1.1 mm) (p < 0.001), a larger left ventricular mass (expressed as cross-sectional area) (26.8 ± 6.6 cm2 versus 19.6 ± 3.3 cm 2) (p < 0.001) and a larger aortic root dimension (34.9 ± 2.8 mm versus 30.3 ± 5.5 mm) (p < 0.01). Aortic root size was >32 mm in 12 of 16 hypertensive and in only 3 of 16 without hypertension.

Reduction in the percentage of systolic thickening of the septum was more pronounced than that of the posterior wall in all types of cardiomyopathy (1.30 ± 4.0% versus 24.6 ± 16.0%, respectively) (p < 0.001) and excursion of interventricular septum and posterior wall was uniformly depressed. Ischemic heart disease could therefore not be differentiated from other forms of cardiomyopathy by analysis of segmental function.

When cardiomyopathy was associated with mitral insufficiency, the posterior aortic root motion was greater (6.6 ± 1.7 mm) than in its absence (3.4 ± 1.0 mm) (p < 0.001), and the septal excursion was more pronounced with mitral incompetence. Additional echocardiographic features of cardiomyopathy included the uniform presence of multiple systolic echoes and "hammock" appearance of the mitral valve and AC notching of the tricuspid valve.

We conclude that hypertensive cardiomyopathy can be distinguished from nonhypertensive types of advanced heart disease but that ischemic, alcoholic, and idiopathic cardiomyopathies cannot be differentiated by echocardiography.

The natural history of idiopathic dilated cardiomyopathy

Between 1960 and 1973, a total of 104 patients at the Mayo Clinic had a diagnosis of idiopathic dilated cardiomyopathy on the basis of clinical and angiographic criteria; these patients were followed up for 6 to 20 years. Twenty-one percent of the patients had a history of excessive consumption of alcohol, 20 percent had had a severe influenza-like syndrome within 60 days before the appearance of cardiac manifestations and 8 percent had had rheumatic fever without involvement of cardiac valves several years before; thus, possible etiologic risk factors of infectious-immunologic type may be important. Eighty patients (77 percent) had an accelerated course to death, with two thirds of the deaths occurring within the first 2 years. Twenty-four patients (23 percent) survived, and 18 of them had clinical improvement and a normal or reduced heart size. Univariate analysis at the time of diagnosis revealed three factors that were highly predictive (p less than 0.01) of the clinical course: age, cardiothoracic ratio on chest roentgenography and cardiac index. Systemic emboli occurred in 18 percent of the patients who did not receive anticoagulant therapy and in none of those who did; thus, anticoagulant agents should probably be prescribed unless their use is contraindicated.

Echocardiographic abnormalities in chronic alcoholics with and without overt congestive heart failure

To assess the type and prevalence of cardiac abnormalities in heavy drinkers with and without overt congestive heart failure, M mode echocardiography was performed in 11 symptomatic chronic alcoholics with dilated (congestive) cardiomyopathy and in 22 asymptomatic chronic alcoholics. Echocardiographic data in both groups were adjusted for age and body surface area using previously derived regression equations. All 11 symptomatic patients had a significantly decreased left ventricular percent fractional shortening (mean 14 percent, normal range 28 to 44) along with significant increases in left ventricular systolic and diastolic dimensions (mean increases of 105 and 48 percent above normal, respectively), left atrial dimension (mean increase 21 percent) and estimated left ventricular mass (mean increase 105 percent). Among the 22 asymptomatic patients, 15 (68 percent) demonstrated significant increases in at least one of the following echocardiographic variables: left ventricular mass, left ventricular dimensions, septal and left ventricular wall thicknesses, and left atrial dimension. Asymptomatic patients could be classified into two subgroups: (1) those with a left ventricular diastolic dimension less than 10 percent above the normal predicted value and an increased left ventricular wall thickness to radius ratio (mean increase 16 percent above normal) and upper normal percent fractional shortening, and (2) those with a left ventricular diastolic dimension 10 to 24 percent above normal and a slightly subnormal thickness to radius ratio and lower normal percent fractional shortening. Echocardiographic abnormalities in asymptomatic chronic alcoholics did not correlate with the presence or absence of auscultatory abnormalities on physical examination and appear to reflect an earlier stage in the spectrum of alcoholic disease before the development of dilated cardiomyopathy.

Value of radionuclide imaging techniques in assessing cardiomyopathy

Radionuclide imaging techniques add an important dimension to the diagnosis, classification and management of myocardial disease. The gated blood pool scan provides information allowing determination of the functional type of cardiomyopathy (congestive, restrictive or hypertrophic) as well as evaluation of ventricular performance. Myocardial perfusion imaging with thallium-201 is useful in distinguishing congestive cardiomyopathy from severe coronary artery disease and also in depicting septal abnormalities in hypertrophic cardiomyopathy. Radionuclide techniques also prove useful in following progression of disease and in evaluating the efficacy of therapeutic interventions.

Echocardiographic detection of coronary artery disease. Detection of effects of ischemia on regional myocardial wall motion and visualization of left main coronary artery disease

M mode and cross-sectional echocardiographic studies at rest have been used to detect regional left ventricular wall motion abnormalities as a sign of hemodynamically significant coronary artery disease. These techniques have proved to be fairly specific but not highly sensitive. Detection of new regional wall motion abnormalities with cross-sectional echocardiography during exercise appeared practical in 80 percent of patients in preliminary studies; the finding of such abnormalities is highly specific for the presence of coronary artery disease and, with this approach, the sensitivity of echocardiography is improved. Thus, patients with anatomically severe coronary artery disease on angiography may not manifest an echocardiographic abnormality in regional wall motion even during exercise. The direct noninvasive detection of the left main coronary artery in up to 90 percent of patients studied with cross-sectional echocardiography using the short axis or apical approach, or both, has been well defined. A high sensitivity and specificity of detecting anatomically severe left main coronary artery disease using the criteria of both luminal impingement and the presence of high intensity echoes have been confirmed. Further advances in imaging techniques may allow for better definition of the coronary arterial tree.

Value and limitations of two dimensional echocardiography in assessment of cardiomyopathy

Primary myocardial diseases have traditionally been classified into congestive, hypertrophic and restrictive varieties. M mode echocardiography has proved extremely valuable in distinguishing congestive cardiomyopathy with major ventricular dilation and poor contractile performance from hypertrophic cardiomyopathy with predominant left ventricular hypertrophy (septum greater than posterior wall) and normal pump performance, and restrictive disorders with symmetric ventricular wall thickening and normal or diminished contractile function. The contributions of two dimensional echocardiography to the evaluation of patients with congestive or restrictive cardiomyopathy have been limited to certain specific situations, such as the recognition of left ventricular mural thrombi. Twenty-five patients with hypertrophic cardiomyopathy were studied to assess two dimensional echocardiography in the evaluation of patients with this disorder. Two dimensional echocardiography indicated that hypertrophy of the interventricular septum is not uniform from apex to base in all patients but may be greatest in the apical, mid or basal third. In addition, the anterior free wall of the left ventricle was involved in the hypertrophic process in approximately 50 percent of patients. Two dimensional echocardiography documented that the location of systolic anterior motion of the mitral valve in patients with hypertrophic cardiomyopathy is most often at the junction of the mitral valve leaflets and chordae tendineae, although the chordae themselves and even th papillary muscles may be involved in this movement. The heterogeneity of these characteristics may enable patients with hypertrophic cardiomyopathy to be classified into subsets of patients in whom meaningful therapeutic and prognostic implications may be derived. Finally, data derived from two dimensional echocardiography have shown that, although the left ventricle in hypertrophic cardiomyopathy conforms in some degree to the configuration of a catenoid, this geometric conformation is unlikely to account for the genesis of this order.

Echocardiographic determination of septal and left ventricular wall motion in the early hours of acute myocardial infarction

Interventricular septal and left ventricular posterior wall excursions and velocities were determined by M-mode echocardiography in the early hours of acute myocardial infarction in 43 patients. In the group with anterior infarction, including 24 patients, the systolic septal excursion (SSE), systolic septal velocity (SSV), diastolic septal excursion (DSE), and diastolic septal velocity(DSV) were decreased (P less than 0.001). The posterior wall excursion during isovolumetric contraction (B-C) and the mean systolic posterior wall velocity (PWVmean) were also decreased (P less than 0.02). The posterior wall excursion during ejection (PWE) was not affected significantly. In the group with inferior infarction, including 19 patients, the B-C excursion was not significantly affected, but the PWE and PWVmean were diminished (P less than 0.001). The opposing healthy interventricular septum showed an increased movement-compensatory hyperactivity. These findings indicate that the acute myocardial ischemia which grossly affects the mobility of the myocardium can be detected and determined in the early hours by M-mode echocardiography.

Echocardiographic evaluation of left ventricular function in children with congestive cardiomyopathy

Echocardiography was used to study left ventricular function in 37 children with congestive cardiomyopathy. Left atrial and left ventricular diameters were approximately 1.5 times that predicted by body weight, whereas systolic decrease in left ventricular diameter (shortening fraction) and increase in posterior wall thickness were half that of normal children. The ratio of left ventricular preejection period to ejection time was increased in 25 patients and normal in 10. The mean velocity of circumferential fiber shortening was decreased in 30 of 34 patients and averaged 52 percent of that predicted by heart rate. The shortening fraction was higher in the 12 patients who were asympatomatic at the time of study than in the 25 who had symptoms of congestive heart failure (19.6 +/- 2.4 standard error of the mean versus 14.6 +/- 1.2) (P less than 0.05). In 11 patients whose condition improved after therapy with digoxin and diuretic drugs, serial echocardiograms showed significant increases in shortening fraction and posterior wall thickening and decreases in left atrial diameter and the ratio of preejection period to ejection time. However, one or more indexes of left ventricular function remained abnormal, despite the resolution of symptoms and a return of heart size to normal as judged from the chest roentgenogram.

Echocardiography and valve replacement in the critically ill patient with acute rheumatic carditis

In 4 critically ill patients with acute rheumatic carditis, valve incompetence, and severe life-threatening cardiac failure, medical treatment consisting of bedrest, oxygen, digitalis, diuretics, and steroids produced little or no clinical improvement. Echocardiography showed that in each patient myocardial function was relatively well preserved despite active rheumatic carditis and the critical clinical state. Emergency valve replacement was performed, and a good clinical result was achieved in all 4 patients.

The noninvasive assessment of anomalous origin of the left coronary artery from the pulmonary artery

We present a patient with anomalous origin of the left main coronary artery from the pulmonary artery. We correlate the findings of echocardiography and myocardial imaging with angiography, and discuss the value of the noninvasive techniques in the diagnosis and in the followup of such patients.

Noninvasive diagnosis of ischemic cardiomyopathy by fluoroscopic detection of coronary artery calcification

Twenty-four patients with severe congestive heart failure and cardiomegaly in whom the presence or absence of significant coronary disease could not be ascertained clinically underwent fluoroscopy for coronary artery calcification prior to cardiac catheterization. Ten of the patients were found to have significant coronary artery disease, and 14 had normal coronary arteriograms. Coronary artery calcification was found in all ten patients with significant coronary disease, and was absent in all of those patients with normal coronary arteriograms. We conclude that fluoroscopy for coronary artery calcification provides a reliable noninvasive method for differentiating ischemic from nonischemic cardiomyopathy.

Pitfalls and limitations of M-mode echocardiography

Newer diagnostic applications as well as the ability of obtaining physiologic information has resulted in a greater interest in echocardiography. As with any new technique, certain classical criteria have not been found to be as specific and diagnostic as was originally believed. This review has focused on the more important clinical applications in echocardiography. We have not attampted to discuss every single clinical entity. A critical evaluation as to the sensitivity and specificity of echocardiography in each clinical application is necessary. A thorough knowledge of the basic principles of ultrasound, a familiarity with recording devices, and a realization of the pitfalls and limitations of the technique in each cardiac disorder is essential. Hazards of echocardiographic interpretation may actually hamper its development as a diagnostic tool. Before embarking on complex and sophisticated two-dimensional echocardiography, problems with regard to technique and interpretation of M-mode echocardiography must be overcome.

Echocardiographic diagnosis of left anterior descending coronary artery disease

To determine the usefulness of the standard echocardiogram in the diagnosis of left anterior descending coronary artery disease proximal or distal to the first septal branch, coronary arteriograms and echocardiograms were performed in 77 patients with a chest pain syndrome. Seventy-nine percent of patients with proximal disease (15 of 19) had an abnormal septal motion measured as a posterior wall/interventricular septal (PW/IVS) excursion ratio greater than or equal to 2.5 compared with 10% of patients with distal disease (2 of 20) who had abnormal septal motion. Only 5% of patients without obstructive disease of the left anterior descending coronary artery (2 of 38) had abnormal septal motion. Proximal disease was found in 79% with abnormal septal motion in the echocardiogram (15 of 19) but in only 7% of patients with normal septal motion (4 of 58). Therefore, abnormal septal motion as measured by the PW/IVS excursion ratio in the echocardiogram is a useful index for the diagnosis of disease of the left anterior descending coronary artery when that disease is proximal to the first septal branch.

Echocardiography in ischemic heart disease

Echocardiographic findings in patients with ischemic heart disease are described; their correlations with clinical, hemodynamic and angiographic data are presented and discussed. Regional abnormalities of left ventricular wall motion and/or thickening during systole are detected in 84 per cent of patients with acute myocardial infarction and in a high percentage of patients with larger than or equal to 75 per cent narrowing of a major coronary artery. These abnormalities may occur with stress and may be reversible. Left ventricular wall thinning during systole indicates acute ischemia or infarction and thin, dense myocardial echoes indicate scar. Echocardiographic evidence of left ventricular dysfunction is useful in predicting heart failure and mortality in patients with acute myocardial infarction and in predicting surgical mortality for patients undergoing aneurysmectomy and/or coronary artery bypass surgery. Echocardiography has not proved useful in determining graft patency following coronary artery bypass surgery. Technical difficulties and limitations of echocardiography in patients with coronary artery disease are discussed.