Tako-tsubo cardiomyopathy (TTC) is characterized by the presence of transient left ventricular (LV) dysfunction. Whether left atrial (LA) function is also impaired in this setting is unclear. To ...assess prospectively LA peak systolic longitudinal strain (LAS) by two-dimensional strain at the acute phase of TTC and after recovery and its association with in-hospital complications. 40 patients with typical TTC (mean age 79.5 ± 10 years) underwent transthoracic-Doppler echocardiography at the acute phase and at follow-up (32 ± 18 days later), including the measurement of the LAS (mean of maximal strain from the 4–2 chamber views). A control group of 15 patients (75 ± 7 years, 13 women) without overt cardiovascular disease served as a comparative group. In-hospital complication was a composite of death, heart failure, cardiogenic shock, LV thrombus, and sustained ventricular arrhythmia. In the TTC group, LAS improved significantly between the two examinations from 15 ± 5.5% to 27 ± 8% (p < 0.01) whereas LA volume did not change (p = NS). In the control group LAS was 30 ± 4% (p < 0.01 vs. TTC acute phase, p = NS vs. TTC follow-up). In TTC, at the acute phase LAS was independently correlated to LV global longitudinal strain (LVGLS), and after recovery to E/e′, and the change of LAS was independently correlated to the change of the LVGLS (all, p < 0.01). Furthermore LAS was independently correlated to in-hospital complications (p < 0.01). LA function (reservoir) is transiently impaired in TTC and associated to in-hospital complications. Furthermore, the improvement of LAS parallel the dynamic improvement of LVGLS suggests that TTC induces a transient global left heart dysfunction.
To test the usefulness of non-invasive coronary flow reserve (CFR) by transthoracic Doppler echocardiography by comparison to invasive fractional flow reserve (FFR) and instantaneous wave-free ratio ...(IFR), a new vasodilator-free index of coronary stenosis severity, in patients with left anterior descending artery (LAD) stenosis of intermediate severity (IS) and stable coronary artery disease. 94 consecutive patients (mean age 68 ± 10 years) with angiographic LAD stenosis of IS (50–70 % diameter stenosis), were prospectively studied. IFR was calculated as a trans-lesion pressure ratio during the wave-free period in diastole; FFR as distal pressure divided by mean aortic pressure during maximal hyperemia (using 180 μg intracoronary adenosine); and CFR as hyperemic peak LAD flow velocity divided by baseline flow velocity using intravenous adenosine (140 μg/kg/min over 2 min). The mean values of IFR, FFR, and CFR were 0.88 ± 0.07, 0.81 ± 0.09, and 2.4 ± 0.6 respectively. A significant correlation was found between CFR and FFR (r = 0. 68), FFR and IFR (r = 0.6), and between CFR and IFR (r = 0.5) (all, p < 0.01). Using a ROC curve analysis, the best cut-off to detect a significant lesion based on FFR assessment (FFR ≤ 0.8, n = 31) was IFR ≤ 0.88 with a sensitivity (Se) of 74 %, specificity (Sp) of 73 %, AUC 0.81 ± 0.04, accuracy 72 %; and CFR ≤ 2 with a Se = 77 %, Sp = 89 %, AUC 0.88 ± 0.04, accuracy 85 % (all, p < 0.001). In stable patients with LAD stenosis of IS, non-invasive CFR is a useful tool to detect a significant lesion based on FFR. Furthermore, there was a better correlation between CFR and FFR than between CFR and IFR, and a trend to a better diagnostic performance for CFR versus IFR.
Assessment of the functional significance of left anterior descending coronary artery (LAD) stenosis of intermediate severity is challenging and often based on fractional flow reserve (FFR). The ...instantaneous wave-free ratio (IFR), a new vasodilator-free index of coronary stenosis severity, and non-invasive coronary flow reserve (CFR) by transthoracic Doppler echocardiography are also potentially useful. A direct comparison of FFR, IFR, and non-invasive CFR has never been performed. Our objective was to test the usefulness of non-invasive CFR by comparison to invasive FFR and IFR in patients with LAD stenosis of angiographic intermediate severity and stable coronary artery disease.
Ninety-four stable consecutive patients (mean age, 68±10years; 19 women) with angiographic proximal or mid LAD stenosis of intermediate severity (40–70% diameter stenosis on quantitative coronary angiography), were prospectively studied. They underwent IFR that was calculated as a trans-lesion pressure ratio during a specific period of baseline diastole, FFR with intracoronary bolus adenosine (180μg), and CFR using intravenous adenosine (140μg/kg/min over 2min) in the distal part of the LAD, the same day. CFR was defined as hyperemic peak diastolic LAD flow velocity divided by baseline flow velocity and FFR as distal pressure divided by mean aortic pressure during maximal hyperemia.
The mean values of IFR, FFR, and CFR were 0.88±0.07, 0.81±0.09, and 2.4±0.6 respectively. A significant correlation was found between CFR and FFR (R=0.63, curvilinear relationship), FFR and IFR (R=0.6, linear relationship), and between CFR and IFR (R=0.5) (all, P<0.01). Using a ROC curve analysis, the best cut-off to detect a significant lesion based on FFR assessment (FFR≤0.8, N=31) was IFR≤0.88 with a sensitivity (Se) of 74%, specificity (Sp) of 73%, AUC 0.81±0.04; and CFR≤2 with a Se=77%, Sp=89%, AUC 0.88±0.04, (all, P<0.001). Based on these cut-offs, discordant results between CFR and FFR were observed in 14 cases (agreement 85%), between CFR and IFR in 26 cases (agreement 72%), and between IFR and FFR in 26 cases (agreement 72%).
In stable patients with LAD stenosis of intermediate severity, non-invasive CFR is a useful tool to detect a significant lesion based on FFR. Furthermore, there was a better correlation and agreement between CFR and FFR than with IFR.
We present a case which developed a typical tako-tsubo-like cardiomyopathy (TTC) during dobutamine stress echocardiography (DSE). Its originality is related to several findings, which have never been ...described simultaneously in the same patient. This 63-year-old woman with normal coronary angiography and no evidence of coronary vasospasm had a biphasic response to DSE, a finding which usually occurs in coronary artery disease. Moreover, the symmetric extensive wall motion abnormalities (WMA) occurred simultaneously with the development of a systolic anterior motion of the mitral valve (SAM) and left ventricular obstruction, and was clinically asymptomatic. Although in TTC the stunning usually occurs for several days, WMA and SAM resolved within few minutes after cessation of dobutamine and administration of a beta-blocker. And finally, exercise echo performed at the same target heart rate few days later did not induce neither a SAM nor WMA, which suggests that left ventricular obstruction could have played a role in the pathogenesis of this case by supply-demand mismatch. Concomitant coronary microvascular dysfunction was also demonstrated by a reduction of the non-invasive coronary flow reserve in the distal part of the left anterior descending artery.
Nous présentons le cas d’une patiente qui a développé une cardiomyopathie de tako-tsubo (TTC) au cours d’une échographie de stress à la dobutamine (ESD). Son originalité est en rapport avec plusieurs éléments n’ayant jamais été décrits simultanément chez le même patient. Cette patiente de 63ans dont la coronarographie est normale et qui n’a pas de spasme coronaire a eu une réponse biphasique à la dobutamine, phénomène qui survient habituellement dans la maladie coronaire. De plus, le trouble de cinétique étendu, symétrique est apparu en même temps qu’un mouvement systolique antérieur de la valve mitrale (SAM) et une obstruction dynamique intra-ventriculaire gauche, et était cliniquement asymptomatique. Bien qu’habituellement dans la TTC la sidération myocardique dure plusieurs jours, le trouble de cinétique et le SAM ont disparu quelques minutes après l’arrêt de la dobutamine et l’administration d’un bêtabloquant. Et enfin, une échographie d’effort réalisée avec la même fréquence cardiaque cible quelques jours plus tard n’a pas pu induire de trouble de cinétique et de SAM, ce qui suggère que l’obstruction dynamique intra-ventriculaire gauche a pu jouer un rôle dans la pathogénie de ce cas par non-congruence besoins-apports. Une dysfonction concomitante de la microcirculation coronaire a également été illustrée par la réduction de la réserve coronaire non invasive dans la partie distale de l’artère interventriculaire antérieure.
Takotsubo cardiomyopathy (TTC) is a distinct clinical entity characterized by the presence of transient left ventricular (LV) wall motion abnormalities without significant culprit obstructive ...coronary artery disease. Whether left atrial (LA) function is also transiently impaired in this setting is unclear.
To assess prospectively the LA function by two-dimensional longitudinal strain at the acute phase of TTC and after recovery.
Thirty-seven consecutive patients satisfying the criteria for typical TTC (mean age 79±9 years, 34 women) underwent transthoracic-Doppler echocardiography at the acute phase and at follow-up (on average 30 days later), including the measurement of the LA peak systolic longitudinal strain (LAS) which was measured as a mean of maximal strain from the 4–2 chamber views conducted using a dedicated software package, using R-R gating. A control group of 8 patients (76±7 years, 7 women) without overt cardiovascular disease served as a comparative group.
In the TTC group, LAS improved significantly between the two examinations from 15.5±6% to 27±9% (P<0.01) whereas LA volume did not change (from 30±13 to 29±12ml/m2, P=NS). By comparison, in the control group LAS was 30±3% (P<0.01 vs. TTC acute phase, P=NS vs. TTC follow-up) and LA volume/m2 was 28±3.5 (P=NS vs. TTC all phases). The change of LAS in the TTC group (median improvement 62%, 25th-75th percentiles: 18–129%) was significantly correlated to the change of the global LV longitudinal strain (r= −0.41, P=0.01).
Serial measurements of LAS suggests transient impairment of LA function (reservoir) at the acute phase of TTC. Furthermore, the improvement of LAS parallel the dynamic improvement of LV systolic function.
Abstract Background/Aim Left ventricular outflow tract obstruction related to systolic anterior motion (SAM) of the mitral valve is a common complication of dobutamine stress echocardiography (DSE). ...However, the mechanisms underlying SAM have not been fully characterized. The objective of the present study was to use three‐dimensional echocardiography to identify anatomic features of the mitral valve that predispose to SAM during DSE. Methods We retrospectively evaluated consecutive patients included prospectively in our database and who had undergone 3D echocardiography (including an assessment of the mitral valve) before DSE. Patients who had developed SAM during DSE (the SAM+ group) were matched 2:3 with patients who did not (the SAM− group). Results One hundred patients were included (mean age: 67 ± 10). Compared with SAM− patients ( n = 60), SAM+ patients ( n = 40) had a lower mitral annular area, a smaller perimeter, and a smaller diameter ( p < .01 for all, except the anteroposterior diameter). The SAM+ group had also a narrower mitral‐aortic angle (126 ± 12° vs. 139 ± 11° in the SAM− group; p < .01) and a higher posterior mitral leaflet length (1.4 ± .27 cm vs. 1.25 ± .29, respectively; p < .01). Furthermore, the mitral annulus was more spherical, more flexible, and more dynamic in SAM+ patients than in SAM− patients ( p < .05 for all). In a multivariate analysis of anatomic variables, the mitral‐aortic angle, the mitral annular area, and posterior leaflet length were independent predictors of SAM ( p ≤ .01 for all). In a multivariate analysis of standard echo and hemodynamic variables, the presence of wall motion abnormalities at rest ( p < .01) was an independent predictor of SAM. Conclusion SAM during DSE is multifactorial. In addition to the pharmacologic effects of dobutamine on the myocardium, 3D echocardiographic features of the mitral valve (a smaller mitral annulus, a narrower mitral‐aortic angle, and a longer posterior leaflet) appear to predispose to SAM.
Objective
To test the relationship between left atrial (LA) distensibility (LAD), LA strain (LAS), and left ventricular (LV) dysfunction and prognosis in aortic stenosis (AS).
Methods
Transthoracic ...Doppler echocardiography was performed prospectively in 102 consecutive patients with AS (77 with severe, 25 with moderate, mean age 77 years). LA volume was calculated by the area‐length method in apical four‐ and two‐chamber views, immediately before mitral valve opening (Volmax) and at mitral valve closure (Volmin). LAD was defined as (Volmax – Volmin) × 100%/Volmin. LAS (mean of maximal strain from the 4–2 chamber views) was conducted using a dedicated software package. The endpoint was hospitalization for heart failure and death from any cause.
Results
Left atrial strain, LAD, and LA vol/m² were significantly correlated with LV diastolic parameters, and PASP (all, P < 0.05). However, LAD and LAS but not LA vol/m² were significantly correlated with Charlson score, LV global longitudinal strain, and to transaortic mean gradient (all, P < 0.05). At a median follow‐up of 25 months, 53 patients had an event. LAS, LAD, LA vol/m², and Charlson index were associated with events (all, P < 0.05). In multivariate analysis, LAD, LAS, and Charlson index (all, P < 0.01) remained independently associated with events. Using a ROC curve analysis, LAD ≤ 69% and LAS ≤ 17% were the best cutoffs associated with an event.
Conclusion
In patients with moderate to severe AS, LAD and LAS are associated with LV dysfunction, AS severity, and are independently linked to events.
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