Left Ventricular Motion and Shape Analysis Using Multiple Imaging Modalities

Left ventricular (LV) pseudoaneurysm is a rare complication that occurs shortly after myocardial infarction or previous cardiac surgery. We present here a case of an elderly patient with an LV pseudoaneurysm that developed over a long period of time after Dor operation. An 83-year-old man with rapid LV enlargement 18 years after Dor operation presented with dyspnea. We diagnosed his mass as an LV pseudoaneurysm using multiple non-invasive imaging modalities. The suture between the patch and the LV myocardium became fragile and detached over time. However, due to adhesion in the thorax and slow blood flow, the enlargement stopped. Surgery was considered, but due to his age and renal dysfunction, he did not undergo surgery. Conservative treatment with antihypertensive and heart failure therapy was continued. Clinical manifestations of LV pseudoaneurysm vary from asymptomatic to signs of heart failure and even sudden death. Surgery is recommended for LV pseudoaneurysm because of the high risk of rupture, but conservative treatment may be an option that has been developed long after surgery in the era of an increasing number of elderly OMI or post-cardiac surgery patients. Proper diagnosis using multiple imaging modalities may lead to the avoidance of this devastating complication.

Hypertrophic cardiomyopathy (HCM) is a common monogenetic cardiac disease with a prevalence of 0.2%1 that usually is inherited as an autosomal dominant trait with variable penetrance and expression. Clinically, HCM is defined by the presence of left ventricular (LV) hypertrophy (LVH) unexplained by abnormal loading conditions.1 The natural history varies from an asymptomatic course to drug-refractory angina/dyspnea, sudden cardiac death (SCD), and end-stage heart failure. The incidence of HCM-related SCD is approximately 1% to 2% in children and adolescents and 0.5% to 1% in adults.2,3 In this review, we examine the impact of advanced diagnostic imaging technologies on HCM, with particular emphasis on the detection of particular genetic subtypes. In ≈60% of cases, HCM is inherited as an autosomal dominant trait caused by mutations in genes coding for cardiac sarcomere proteins (Figure 1).4–7 Mutations in genes encoding Z-disc proteins and proteins involved in calcium regulation account for <5% of cases. The absence of sarcomeric gene mutations can be explained by limitations of current mutation detection techniques or mutations in as yet unidentified genes, but in some cases, hypertrophy is caused by other diseases that mimic the phenotype of sarcomeric protein disease. Table 1 lists genetic disorders associated with HCM. Figure 1. A schematic illustration of a cardiac sarcomere. View this table: Table 1. Currently Known Genes Implicated in HCM More than 600 different sarcomeric gene mutations are reported in patients with HCM.8–16 The majority are missense mutations, but nonsense, frameshift, and in-frame insertion/deletion mutations also occur. Most mutations are characterized by incomplete penetrance and variable clinical expression likely due to locus heterogeneity and the effect of mutations at different locations within the same gene. Most mutations probably have a dominant negative effect on sarcomere function, but in some cases, haploinsufficiency (ie, only a single functional …

While partial left ventriculectomy (PLV) may improve functional status, the duration and determinants of this improvement are poorly known. This study sought to assess the relationship between left ventricular (LV) shape and function and functional status in late survivors after PLV for non-ischemic dilated cardiomyopathy (DCM). We assessed the relations between LV shape and function and functional status in 17 consecutive patients who survived >12 months after PLV for non-ischemic DCM. Invasive diagnostic studies were performed before, early after, at mid-term after, and late after PLV. According to their functional status after >12 months of follow-up, patients were divided into responders (n=10) or non-responders (n=7). After PLV, the LV systolic major-to-minor axis ratio was higher in responders at early, mid-, and late follow-up (P=0.003, P=0.008 and P=0.04, respectively). LV circumferential end-diastolic stress decreased early after PLV, but increased afterwards in non-responders only (P=0.049). LV ejection fraction was similar in the two groups at baseline, and at early and mid-follow-up, but was lower in non-responders at late follow-up (P=0.006). However, LV end-diastolic and end-systolic volumes, and LV end-systolic circumferential stress showed no difference between the two groups. It appears that poor functional capacity in late post-PLV survivors is related to postoperative LV geometry.

We mapped the three dimensional (3D) regional right ventricular (RV) motion using Cine-CT in 9 normal subjects and compared it to data from 10 patients with left ventricular (LV) aneurysm. The endocardial borders were traced and the RV's reconstructed in 3D. Regional perpendicular RV systolic motion was evaluated by our 3D stroke-volume-element approach, and the circumferential and longitudinal variations determined. The normal RV is characterized by higher endocardial motion in the posterior relative to the anterior regions (p < 0.0001), and no longitudinal (apex-to-base) gradient. In hearts with LV aneurysms, similar circumferential variations in wall motion are accompanied with a longitudinal increase in systolic motion, from apex to the base (p < 0.0001). Therefore, a 3D method for measurement of RV regional motion was developed and applied to normal and LV aneurysm patients, showing that LV aneurysm causes RV motion abnormality at the apex, compensated by an increased basal motion.

Anticoagulation in Ischemic Left Ventricular Aneurysm

See article on page 1376

Chronic aortic regurgitation (AR) is associated with a unique pattern of left ventricular (LV) volume and pressure overload, leading to LV remodelling. LV torsional motion, a key component of LV performance, can be altered in this setting. We aimed to assess the impact of LV remodelling on LV torsional dynamics parameters using speckle-tracking echocardiography (STE) in asymptomatic AR patients. We prospectively enrolled 60 patients with chronic AR and LVEF > 50% and 55 healthy controls. LV rotation, twisting and untwisting were assessed using STE. Patients with AR had higher LV diameters, volumes and mass, a more spherical LV shape than controls, but similar LVEF. In AR patients we found reduced peak LV apical rotation and decreased (2.1 ± 0.8 vs 2.9 ± 0.9°/cm, p < 0.001) and delayed (time to peak LV twist: 0.94 ± 0.12 vs 0.99 ± 0.09, p = 0.004) peak LV torsion. Also, peak LV untwisting velocity was decreased (-123.5 ± 41.5 vs -152.3 ± 55.0°/s, p = 0.002) due to lower peak LV apical diastolic rotation rate. LV shape influenced LV torsional dynamics, a more spherical LV displaying reduced peak LV apical rotation and diastolic rotation rate and decreased LV twist. A more hypertrophied LV had a lower peak LV torsion, peak LV apical diastolic rotation rate and peak LV untwisting velocity. LV apical rotation and torsion are decreased and LV twist is delayed in patients with chronic AR and normal LVEF, detecting early subclinical LV dysfunction before LVEF declines. Also, LV untwisting is reduced in these patients. LV remodelling impairs LV torsional dynamics parameters in this setting.

We report three young patients presenting with life-threatening ventricular tachycardia (VT) or ventricular fibrillation (VF) and/or survived sudden cardiac arrest, who were admitted to our institution for further diagnostic evaluation. In all patients, idiopathic left ventricular (LV) aneurysms were identified after a detailed non-invasive and invasive evaluation. Sustained VT/VF was inducible during programmed ventricular stimulation in two of the three patients. Left ventricular aneurysms were depicted and characterized by various imaging modalities (echocardiography, magnetic resonance imaging, LV angiography). To elucidate the pathogenesis further, both myocardial viability and regional sympathetic innervation were assessed by radionuclide imaging techniques. Defects of innervation and metabolism were documented in the area of the aneurysm but distal to the aneurysm there were no signs of downstream denervation. Life-threatening arrhythmias may be the first manifestation of an idiopathic LV aneurysm, which can be reliably diagnosed with modern imaging techniques. Radionuclide imaging may yield additional information as to the involvement of the autonomic nervous system potentially associated with arrhythmogenesis. Management strategies in patients with an idiopathic LV aneurysm range from antiarrhythmic drug treatment, implantation of an automatic cardioverter-defibrillator to surgical aneurysmectomy.

Seventy-eight consecutive survivors of a first acute anterior Q wave myocardial infarction (AMI) underwent two-dimensional echocardiography (2D echo), colour Doppler echo and radionuclide angiography (RNA) for the diagnosis of left ventricular (LV) anteroapical aneurysm, in order to study the relationship of this complication to precordial ST segment elevation in these patients. The ST elevation (mm) in lead V2, the maximum ST elevation in V1-V6 and the sum of ST elevation in V1 to V6 were calculated. LV aneurysm was present in 19 patients by 2D echo, of whom 12 had a paradoxical systolic flow pattern (red and outward towards the transducer) at the apex. There was no difference between the mean ST elevation in V2 or the maximum ST elevation in V1-V6 in patients with and without an aneurysm, although the sum of ST elevations in V1 to V6 was higher in the former group (P < 0.01). ST elevation of patients with and without paradoxical systolic flow also did not differ significantly. Wall motion abnormality (akinesis and dyskinesis) by 2D echo in the anterior wall was seen in 74% of patients with and 36% of patients without an aneurysm (P < 0.005), and in the septal region in 63% and 47% of respective patients (P-NS). There was no difference between the magnitude of ST elevation in subgroups of patients with ejection fraction (EF) < or = 30% to > or = 40%, but the mean EF of patients with (23 +/- 2.1%) and without a LV aneurysm (34 +/- 1.3%) differed (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Endoaneurysmorrhaphy (EAR) has become an important therapeutic option in the treatment of patients with left ventricular (LV) aneurysm and congestive heart failure. Today, more and more patients are referred for EAR with a dilated akinetic LV rather than a classic dyskinetic LV aneurysm. Little is known about the contribution of the extent of akinesis to perioperative mortality. We reviewed the data of 147 patients with anterior left ventricular aneurysms undergoing EAR. Seventy percent of the patients were male; mean age was 62+/-9 years. Demographic, hemodynamic, angiographic and surgical variables were analyzed using univariate statistic tests in order to determine risk factors for in-hospital mortality.Eighty-two percent of the LV aneurysms had at least some dyskinesia, but 70% were mainly akinetic. 133 patients had additional bypass surgery, one had additional mitral valve replacement. In-hospital mortality was 4.1% (n=6). Risk factors for in-hospital mortality were the total extent of akinetic myocardium (p=0.027) in the 30 degrees RAO view and the duration of cardiopulmonary bypass (CPB, p=0.0068) which was itself dependent on the LV ejection fraction (p=0.001), the number of stenosed coronary arteries (p=0.004), and the extent of akinesis (p=0.023). The extent of dyskinesia was not associated with either perioperative mortality (p=0.36) or CPB duration. EAR can be performed with acceptable perioperative results. Because akinesis increases in many patients with time, and because the duration of ECC was dependent on variables reflecting the severity of the underlying heart disease, our findings underscore the importance of optimal timing for the surgical intervention.

Background The functional implications of left ventricular (LV) morphological characterization in congenital heart disease (CHD) are not widely explored. Purpose This study qualitatively and quantitatively assessed LV shape associations with a) LV function and b) thoracic aortic morphology in patients with aortic coarctation (CoA) with/without bicuspid aortic valve (BAV). Methods A statistical shape modelling (SSM) framework was employed to analyse three-dimensional (3D) LV shapes from cardiac magnetic resonance (CMR) imaging data in n=110 cases including: isolated CoA (n=25), CoA+BAV (n=30), isolated BAV (n=30), and age-matched healthy controls (n=25). Average 3D templates (Picture 1) and deformations were computed. Correlations between shape data and CMR-derived morphometric parameters (i.e. sphericity, conicity) as well as CMR-derived global and apical strain values were assessed to elucidate possible functional implications. The relationship between LV shape features and arch architecture (i.e. gothicity, tortuosity) was also explored by means of regression analysis. Results The LV template was shorter and more spherical in CoA patient (Picture 1), as also confirmed by statistical analysis of the SSM-derived shape modes. LV sphericity, which was higher in CoA, was associated (p≤0.04) with lower global longitudinal, radial and circumferential strain, irrespective of the presence of aortic stenosis and/or regurgitation. Conversely, neither LV morphology nor LV strain was not associated with arch architecture. Conclusions Differences in LV morphology were observed between CoA and BAV patients. Increasing LV sphericity was associated with reduced strain, independent of aortic arch architecture and functional aortic valve disease. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): British Heart Foundation and NIHR BRC

Early and Late Effects of Passive Epicardial Constraint on Left Ventricular Geometry: Ellipsoidal Re-shaping Confirmed by Electron-beam Computed Tomography

To evaluate the influence of left ventricular (LV) aneurysm on non-infarcted ventricular wall, the shape of the left ventricular wall was assessed by thallium-201 single photon emission computed tomography (SPECT). From the morphology of the ventricular wall close to the apex, the rest images along the transaxis, horizontal long axis and vertical long axis were classified into 4 types: convergent, parallel, divergent and completely defective. LV aneurysm was detected by 2-dimensional echocardiography and/or contrast left ventriculography in 39 of 80 patients with previous myocardial infarction. Although convergence in the normal configuration of ventricular walls close to the apex, 4 of 39 patients with LV aneurysm showed this pattern. The divergent type was very specific (100%) and the most sensitive (56.4%) of the 4 for identifying LV aneurysm. Moreover, the parallel configuration indicated aneurysm in cases of inferoposterior infarction and all the completely defective cases exhibited this abnormality. Thus, thallium-201 SPECT is suitable for observing the morphology of the ventricular wall and can provide highly reliable information for detecting postinfarction ventricular aneurysm with a sensitivity of 89.7%, a specificity of 87.8% and a diagnostic accuracy of 88.8%.

X-ray computed tomography (CT) imaging plays an essential role in disease diagnosis due to its noninvasive, painless mode and superior penetration depth. However, the resolution of the soft tissue ...

INTRODUCTION: Giant ventricular aneurysm is a rare but highly relevant clinical entity due to its impact on cardiac function and its high morbidity and mortality. A giant ventricular aneurysm is considered when the diameter of the aneurysmal sac exceeds 5 cm. Left ventricular (LV) aneurysms are generally a consequence of mechanical complications caused by severe ischemic injury of the myocardium secondary to myocardial infarction (MI) and are associated with heart failure, arrhythmias and rupture. They are generally located apically and anteriorly, with significant mortality. The incidence is low, and the diagnosis is usually made late through suggestive findings on chest x-ray or transthoracic echocardiogram . CASE PRESENTATION: We present the case of an 85-year-old male who was admitted to the emergency room with severe chest pain 48 hours prior to arrival. An electrocardiogram diagnosed STEMI, with a finding of subendocardial lesion and inferior wall necrosis, angina intensity 8/10. Since there was no catheterization laboratory available, he was thrombolyzed with alteplase and presented criteria for reperfusion . A chest x-ray showed dilation in the middle and apical third of the left ventricle. An echocardiogram showed a biplane left ventricular systolic function of 28% with an image suggestive of a left ventricular aneurysm. A chest CT scan showed a finding compatible with a giant left ventricular aneurysm measuring 65 mm x 85 mm (2.5 x 3.3 in) and the presence of a laminar thrombus. CONCLUSION: Establishing an early diagnosis is vital to avoid complications. Treatment may be medical in patients with mild symptoms, but in those with severe heart failure or complex arrhythmias, surgery (such as surgical resection or aneurysm repair) may be necessary. A thorough evaluation and a multidisciplinary approach are recommended for the management of these patients, tailoring treatment to the individual characteristics of each case. Article Details