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The value of pixel per pixel multiharmonic Fourier analysis to assess left ventricular function.

Left ventricular systolic and diastolic function can be assessed by peak ejection and filling rates and their time of occurrence. These parameters can be calculated using two different methods: from the global left ventricular time-activity curve analysed with a four harmonic Fourier fit and from each pixel time-activity curve analysed with two and three harmonics (the values being averaged over the left ventricular region of interest). In both cases, values were normalized for heart rate and end diastolic counts. A study was conducted in a series of 11 patients (six without and five with a previous myocardial infarction but a normal left ventricular function) examined at baseline and during an i.v. dobutamine infusion, at a dose known to increase both peak ejection and filling rates. During dobutamine infusion, analysis of global left ventricular time-activity curve demonstrated a statistically significant increase in both peak ejection and filling rates, but the local analysis showed a more significant increase of these parameters. To assess ventricular function, a local harmonic analysis can be used and appears to be a more sensitive approach than analysis of the global left ventricular time-activity curve. The local analysis provides spatial mapping and a histogram of the parameters which can be used as parametric images to describe systolic and diastolic function.

Dobutamine↗

Effects of different antihypertensive drugs on left ventricular function.

Left ventricular hypertrophy (LVH) is a response by the heart to haemodynamic overload. It is frequently observed in hypertension as a consequence of work overload secondary to an increased systemic resistance. This increase is not the only cause of LVH; there are other factors which can have a significant effect on its incidence. LVH in arterial hypertension acts initially as a useful compensatory mechanism against increased peripheral resistance. However after a certain amount of time it produces changes of variable intensity which have important consequences for the heart and some of them impair cardiac performance: 1. It affects both systolic and diastolic ventricular function; 2. It reduces coronary reserve; 3. It increases the incidence of angina and heart failure; 4. It increases the incidence of ventricular arrhythmias and sudden death. It therefore seems reasonable to include the reduction of LVH among the basic aims of antihypertensive treatment. Antisympathetic drugs (methyldopa, prazosin, urapidil), adrenergic beta-blockers, calcium antagonists and the converting enzyme inhibitors have proven to have a variable degree of efficacy in effecting a regression of LVH.

Antihypertensive Agents↗

[Measurement of right systolic time intervals in complete transposition of the great vessels. Value in the surveillance of ventricular function].

Right ventricular function was regularly assessed pre- and postoperatively by measuring right systolic time intervals at the aortic valve in 21 children with complete transposition of the great arteries. Twenty children underwent "physiological" surgical correction (Senning procedure) and one child with right ventricular hypokinesia underwent detransposition of the arteries. The mean value of the right ventricular pre ejection/ejection period ratio was 0.40 +/- 0.05; this was independent of age and no significant difference was observed between the pre- and postoperative periods (0.41 +/- 0.06 vs 0.39 +/- 0.04) at least with a maximum follow-up of 5 years. This index allows early diagnosis of right ventricular dysfunction and therefore helps to orientate the choice between "physiological" or "anatomical" surgical correction.

Child, Preschool↗

End-systolic volume and long-term survival after coronary artery bypass graft surgery in patients with impaired left ventricular function.

BACKGROUND: Left ventricular function is the main predictor of long-term survival in patients with coronary artery disease. In patients with impaired left ventricular function after myocardial infarction, end-systolic volume is a better predictor than the global ejection fraction. We analyzed long-term follow-up of patients with impaired left ventricular function undergoing coronary artery bypass graft surgery to evaluate preoperative predictors of survival. METHODS AND RESULTS: Consecutive patients with ejection fractions < or = 40% (n = 193) who had undergone surgical revascularization were followed to assess the predictive value of preoperative baseline characteristics and catheterization findings for long-term survival. Patients were followed for 133 +/- 30.7 months. At the time of surgery, patient age was 56 +/- 7.9 years and 169 patients (87.6%) had a history of previous myocardial infarction. Thirty-one patients (16%) were female. The ejection fraction was 32 +/- 7%, and the end-systolic volume was 147.4 +/- 52.6 mL. One hundred sixty-four patients (84.9%) had three-vessel disease, and 44 (22.8%) had a left main stenosis with > 50% diameter loss. Follow-up was complete in 99%. Fourteen patients died (7.3%) within the first 30 days after surgery. Twelve-month actuarial survival was 86%, 4-year survival was 80%, and 10-year survival was 40%. Predictors of poor long-term survival on multivariate analysis were end-systolic volume index (chi 2 = 14.02, P = .002), number of previous myocardial infarctions (chi 2 = 6.47, P = .001), preoperative stenosis score (chi 2 = 4.97, P = .02), and age at the time of surgery (chi 2 = 4.45, P = .03). CONCLUSIONS: End-systolic volume index is the major predictor of survival after coronary artery bypass graft surgery in patients with impaired left ventricular function. Strategies to prevent ventricular dilatation, such as angiotensin-converting enzyme inhibitors, may improve the long-term outcome in these patients.

Adult↗

Quantitative planar rest-redistribution 201Tl imaging in detection of myocardial viability and prediction of improvement in left ventricular function after coronary bypass surgery in patients with severely depressed left ventricular function.

BACKGROUND: Although many patients with multivessel coronary artery disease (CAD) and severely depressed left ventricular (LV) function will benefit from coronary artery bypass graft surgery (CABG), surgeons may be reluctant to perform CABG on these patients without evidence of myocardial viability in regions of severe asynergy. We hypothesized that quantitative planar rest-redistribution 201Tl imaging would identify viable myocardium and predict improved regional and global function after revascularization in patients with depressed LV function and CAD. METHODS AND RESULTS: Twenty-one patients (mean LV ejection fraction, 0.27 +/- 0.05) were studied. Regional and global LV functions were evaluated before and 8 weeks after CABG with radionuclide ventriculography. Segments were prospectively classified as showing normal, mildly reduced, or severely reduced viability on the basis of quantitative analysis of defect severity and redistribution on planar resting 201Tl imaging. By 201Tl criteria, 90% of hypokinetic segments were classified with normal or mildly reduced viability. Among akinetic or dyskinetic segments, 20% had normal 201Tl uptake, 53% had mildly reduced viability, and only 27% had severely reduced viability. 201Tl viability criteria identified segments that improved function after CABG. Sixty-two percent of severely asynergic segments with normal viability and 54% with mildly reduced viability improved function after surgery, but only 23% with severely reduced viability improved function (p = 0.002). When only adequately revascularized segments were considered, the predictive value of a positive preoperative viability scan for functional improvement was 73%. The greatest improvement in global LV function after CABG occurred in patients with the greatest number of asynergic segments classified as viable before surgery (p < 0.01). In 10 patients with more than seven viable, asynergic segments, mean LV ejection fraction increased significantly after CABG (0.29 +/- 0.07 to 0.41 +/- 0.11, p = 0.002). In 11 patients with seven or fewer viable, asynergic segments, mean LV ejection fraction remained unchanged after revascularization (0.27 +/- 0.05 to 0.30 +/- 0.08, p = NS). CONCLUSIONS: In patients with CAD and severely depressed LV function, preoperative quantitative planar rest-redistribution. 201Tl imaging identifies viability in many asynergic myocardial segments, and these segments frequently improve function after CABG. The presence of numerous asynergic but viable myocardial segments before surgery correlated significantly with improvement in global LV function after bypass surgery.

Aged↗

Left ventricular endomyocardial biopsy. III: ultrastructural characteristics of cardiomyopathy and cardiac hypertrophy with good or poor ventricular function.

Left ventricular endomyocardial biopsies have been obtained from patients with cardiomyopathy and hypertrophy due to aortic valve disease. These biopsies have been examined by electron microscopy and the ultrastructural abnormalities compared. In congestive cardiomyopathy no specific abnormalities were found although myofibrillary degeneration and membrane-bound vacuoles were more commonly present. Crossing of whole groups of sarcomeres was found only in asymmetric septal hypertrophy, but was not present in all cases. Amyloid deposits were demonstrated easily by electron microscopy in patients with restrictive cardiomyopathy. In the patients with hypertrophy due to aortic valve disease, no specific features were found and ultrastructural abnormalities did not differentiate between normal and impaired left ventricular functions.

Aortic Stenosis, Subvalvular↗

Heart rate variability profiles in symptomatic coronary artery disease and preserved left ventricular function: relation to ventricular tachycardia and transient myocardial ischemia. Regression Growth Evaluation Statin Study (REGRESS).

We studied heart rate variability in ambulatory electrocardiographic recordings from 312 patients with significant coronary artery disease and a left ventricular ejection fraction of > or = 30%. Only those patients who had both episodes of ischemia and nonsustained ventricular arrhythmias showed diminished values for parasympathetic nonspectral and spectral heart rate (HR) variability parameters. The root mean square of difference of successive R-R intervals (RMSSD) and high-frequency (HF) power in this group were 28 +/- 3 msec and 9 +/- 1 msec, respectively. The highest values of these HR variability parameters were found in patients with nonsustained ventricular tachycardia and no ischemia (81 +/- 21 msec and 14 +/- 1 msec, respectively, p < or = 0.05). A relation was seen between transient myocardial ischemia and low-frequency power and between transient ischemia and ventricular tachycardia. These data suggest that the autonomic nervous system may play a role in ischemia and in ischemia-related ventricular arrhythmias.

Autonomic Nervous System↗

Left ventricular function during asynchronous ventricular pacing: a radionuclide study.

This study was undertaken to assess ventricular volumes and function by radionuclide angiography during asynchronous ventricular pacing in a group of 22 patients who needed an artificial pacemaker. 14 had ischaemic heart disease and 8 had primary disturbances of conduction of the impulse-forming system. The transition from sinus to a paced rhythm or increasing the pacing rate had little effect on patients with primary conduction disturbances. In contrast, in patients with ischaemic heart disease, the transition to a paced rhythm decreased significantly left ventricular end-diastolic (15.3 +/- 4.7%) and stroke (26.3 +/- 4%) volumes, ejection fraction (9.0 +/- 4.4%), and cardiac output (21.0 +/- 3.9%). Pacing at a progressively increasing heart rate showed that each patient had an optimal rate of pacing.

Aged↗

Long-term follow-up of Thoratec ventricular assist device bridge-to-recovery patients successfully removed from support after recovery of ventricular function.

BACKGROUND: In certain forms of severe heart failure there is sufficient improvement in cardiac function during ventricular assist device (VAD) support to allow removal of the device. However, it is critical to know whether there is sustained recovery of the heart and long-term patient survival if VAD bridging to recovery is to be considered over the option of transplantation. METHODS: To determine long-term outcome of survivors of VAD bridge-to-recovery procedures, we retrospectively evaluated 22 patients with non-ischemic heart failure successfully weaned from the Thoratec left ventricular assist device (LVAD) or biventricular assist device (BVAD) after recovery of ventricular function at 14 medical centers. All patients were in imminent risk of dying and were selected for VAD support using standard bridge-to-transplant requirements. There were 12 females and 10 males with an average age of 32 (range, 12-49). The etiologies were 12 with myocarditis, 7 with cardiomyopathies (4 post-partum [PPCM], 1 viral [VCM], and 2 idiopathic [IDCM]), and 3 with a combination of myocarditis and cardiomyopathy. BVADs were used in 13 patients and isolated LVADs in 9 patients, for an average duration of 57 days (range, 11-190 days), before return of ventricular function and successful weaning from the device. Post-VAD survival was compared with 43 VAD bridge-to-transplant patients with the same etiologies who underwent cardiac transplantation instead of device weaning. RESULTS: Nineteen of the 22 patients are currently alive. Three patients required heart transplantation, 1 within 1 day, 2 at 12 and 13 months post-weaning, and 2 died at 2.5 and 6 months. The remaining 17 patients are alive with their native hearts after an average of 3.2 years (range, 1.2-10 years). The actuarial survival of native hearts (transplant-free survival) post-VAD support is 86% at 1 year and 77% at 5 years, which was not significantly different (p = 0.94) from that of post-VAD transplanted patients, also at 86% and 77%, respectively. CONCLUSIONS: Long-term survival for bridge-to-recovery with VADs for acute cardiomyopathies and myocarditis is equivalent to that for cardiac transplantation. Recovery of the native heart, which can take weeks to months of VAD support, is the most desirable clinical outcome and should be actively sought, with transplantation used only after recovery of ventricular function has been ruled out.

Adolescent↗

Influence of right ventricular stimulation site on left ventricular function in atrial synchronous ventricular pacing.

OBJECTIVES: The study investigates the correlation between left ventricular function and QRS duration obtained by alternate right ventricular pacing sites. BACKGROUND: 1. Right ventricular apical pacing is associated with alterations of left ventricular contraction sequence. 2. A stimulation producing narrow QRS complexes is supposed to provide for better left ventricular contraction patterns. METHODS: Fourteen patients with third degree AV block received one ventricular pacing lead in apical position. The alternate lead was attached to that site on the septum that produced the smallest QRS complex as measured from the earliest to the last deflection in any of the orthogonal Frank leads (xyz). During atrial synchronous ventricular pacing, the AV delay was optimized individually and for each stimulation site using mitral valve doppler or impedance cardiography. By radionuclide ventriculography, the phase distribution histogram of left ventricular contraction was evaluated as area under the curve (AuC); systolic function was determined as ejection fraction (EF) and as absolute ejected counts (EC) in random order. The difference (delta) in QRS duration between apical and septal stimulation (deltaxyz) was correlated with the difference in phase distribution (deltaAuC) and ejection parameters (deltaEF, deltaEC). RESULTS: QRS duration was shorter with septal than with apical pacing in 9 out of 14 patients (64%); it was longer in 4 (29%), and no difference was seen in 1 patient. There was a significant positive correlation between the change in QRS duration (deltaxvz) and phase distribution (deltaAuC: r = 0.66393, p = 0.010) and a significant negative correlation to systolic function (deltaEF: r = 0.70931, p = 0.004; deltaEC: r = 0.74368, p = 0.002). CONCLUSIONS: In atrial synchronous right ventricular pacing, if the AV delay is adapted individually, decreased QRS duration obtained by alternate pacing sites is significantly correlated with homogenization of left ventricular contraction and with increased systolic function in acute tests.

Aged↗

Improved left ventricular function after chronic left ventricular unloading.

BACKGROUND: This study assessed the effect of prolonged left ventricular unloading on native ventricular function. METHODS: We reviewed data from 31 patients (30 men, 1 woman) supported more than 30 days (mean, 137 days; range, 31 to 505 days) with the HeartMate left ventricular assist system. The patients' mean age was 46 years (range, 22 to 64 years); 17 had idiopathic and 14 had ischemic cardiomyopathy. Data (anatomic, physiologic, hemodynamic, histologic, and biochemical) were collected at the time of HeartMate implantation, during support with the device temporarily off, and at the time of device explantation. RESULTS: Routine chest roentgenogram showed improvement in cardiothoracic ratio (0.62 +/- 0.04 to 0.55 +/- 0.03; p < 0.0001). Echocardiography performed with the pump off showed a significant decrease in left ventricular end-diastolic dimension (6.81 +/- 0.87 cm to 5.39 +/- 1.08 cm; p < 0.0005) and a significant improvement in ejection fraction (0.11 +/- 0.05 to 0.22 +/- 0.17; p < 0.02). Cardiac index increased (1.96 +/- 0.52 L.min-1.m-2 to 2.93 +/- 0.73 L.min-1.m-2; p < 0.0001), mean aortic pressure increased (71.40 +/- 10.63 mm Hg to 76.33 +/- 16.84 mm Hg; p = 0.48), pulmonary capillary wedge pressure decreased (24.18 +/- 6.27 mm Hg to 14.48 +/- 3.01 mm Hg; p < 0.0001), and pulmonary vascular resistance decreased (3.34 +/- 2.00 Wood units to 2.51 +/- 0.88 Wood units; p < 0.05). Comparisons of tissue samples taken at the time of implantation and at the time of transplantation showed a marked reduction in myocytolysis. Calcium uptake, calcium-binding rates, and lipid levels normalized in patients studied. Plasma norepinephrine levels decreased to near normal levels. CONCLUSION: Prospective studies are now indicated to determine whether device removal without transplantation may be beneficial in selected patients.

Adult↗

Rest and exercise ventricular function in adults with congenital ventricular septal defects.

Rest and exercise right and left ventricular function were compared using equilibrium gated radionuclide angiography in 19 normal sedentary control subjects (mean age 28 years, range 22 to 34) and 34 patients with hemodynamically documented congenital ventricular septal defect (VSD) (mean age 27 years, range 20 to 40). The 34 patients with VSD were divided into 3 groups: those in Group 1 (17 patients) had pulmonary to systemic blood flow ratios of less than 2 to 1; those in Group 2 (12 patients) had prior surgical closure of VSD (mean interval from surgery 17 years, range 9 to 22), and those in Group 3 (5 patients) had Eisenmenger's complex. Gated radionuclide angiography was performed at rest and during each level of graded supine bicycle exercise to fatigue. Heart rate, blood pressure, maximal work load achieved, and right and left ventricular ejection fractions were assessed. The control subjects demonstrated an increase in both the left and right ventricular ejection fractions with exercise (0.70 +/- 0.07 to 0.79 +/- 0.05 and 0.46 +/- 0.06 to 0.57 +/- 0.04; p less than 0.001 for left and right ventricles, respectively). All study groups failed to demonstrate an increase in ejection fraction in either ventricle with exercise. Furthermore, resting left ventricular ejection fraction in Groups 2 and 3 was lower than that in the control subjects (0.59 +/- 0.09 and 0.54 +/- 0.06 versus 0.70 +/- 0.07; p less than 0.001) and resting right ventricular ejection fraction was lower in Group 3 versus control subjects (0.30 +/- 0.07 versus 0.46 +/- 0.06; p less than 0.001). Thus (1) left and right ventricular function on exercise were abnormal in patients with residual VSD as compared with control subjects; (2) rest and exercise left ventricular ejection fractions remained abnormal despite surgical closure of VSD in the remote past; (3) resting left and right ventricular function was abnormal in patients with Eisenmenger's complex; (4) lifelong volume overload may be detrimental to myocardial function.

Adult↗

[Left ventricular function in right ventricular overload: asymmetry of the left ventricular ejection].

This study clarified regional and global functions of the distorted left ventricle due to right ventricular overload by means of gated radionuclide ventriculography (RNV). Cardiac catheterization and RNV were performed in 13 cases of atrial septal defect (ASD), 13 of pure mitral stenosis (MS), 10 of primary pulmonary hypertension (PPH), and 10 of normal subjects (NL). Right ventricular systolic pressure (RVSP) was 32.9 +/- 13.9, 45.0 +/- 12.2, 88.3 +/- 17.1, and 21.2 +/- 4.5 mmHg, respectively. RNV was performed with a 99mTc-red blood cell in a vivo labeling technique. The end-systolic LAO view of the left ventricle was halved into septal and free-wall sides. The end-diastolic halves were determined in the same plane. Ejection fractions of the global left ventricle (LVEF), global right ventricle (RVEF), the septal half of the left ventricle (SEPEF), and the free-wall half of the left ventricle (FWEF) were obtained. LVEF was 56.8 +/- 9.8% in NL, 52.8 +/- 10.5% in ASD, and 49.5 +/- 12.9% in PPH. In MS, LVEF (47.0 +/- 13.0%) was smaller than those in the other groups. RVEF was 37.0 +/- 5.2% in NL, 43.7 +/- 15.5% in ASD, and 32.8 +/- 11.5% in MS. In PPH, RVEF (25.0 +/- 10.6%) was smaller than those in the other groups. SEPEF was smaller in AS D (42.5 +/- 13.2%), MS (40.4 +/- 13.1%), PPH (40.5 +/- 12.5%) than in NL (53.5 +/- 8.5%). Systolic function of the septal half of the left ventricle was disturbed by right ventricular overload. RVEF (r = -0.35, p less than 0.05) and SEPEF (r = -0.51, p less than 0.01) had negative correlations with RVSP. As RVSP rose, systolic function of the septal half of the left ventricle was more severely disturbed. FWEF was the same among the four groups; NL (57.0 +/- 12.6%), ASD (48.6 +/- 15.2%), MS (50.5 +/- 12.0%), and PPH (51.1 +/- 12.3%). Right ventricular overload does not affect systolic function of FWLV. There was a good correlation between SEPEF and LVEF in NL (r = 0.81), though in PPH this correlation was poor (r = 0.64). In patients with PPH the septal side of the left ventricle does not act as a part of the global left ventricle. Systolic function of the septal side of the left ventricle is disturbed due to the distortion of the ventricular septum, but systolic function of the free-wall side is maintained within a normal range, when the left ventricular myocardium is kept normal.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗

Outcomes after aortic valve replacement in patients with severe aortic regurgitation and markedly reduced left ventricular function.

BACKGROUND: Left ventricular dysfunction is an indication for aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR). However, the postoperative outcome of patients with severe AR and a markedly low ejection fraction (EF) is not known. METHODS AND RESULTS: The study group consisted of a total of 450 patients who had AVR for isolated AR between 1980 and 1995. Patients with markedly reduced left ventricular function (EF <35%, LoEF, n=43) were compared with those with moderate reduction in left ventricular function (EF 35% to 50%, MedEF, n=134) and those with normal left ventricular function (EF > or =50%, Nl EF, n=273). The operative mortality rate was higher with LoEF (14%) than with MedEF and Nl EF (6.7% and 3.7%, respectively, P=0.02). At 10 years, 41%+/-9% of LoEF patients had survived compared with 56%+/-5% and 70%+/-3% of MedEF and Nl EF patients, respectively (P<0.0001). Congestive heart failure occurred at 10 years in 25%+/-9% with LoEF compared with 17%+/-4% and 9%+/-2% with MedEF and NL EF, respectively (P<0.003). Postoperative EF improved by 4.9%+/-13.8% in the LoEF group and by 4%+/-11.9% in the MedEF group compared with -2.3%+/-10.9% in the Nl EF group (P<0.002 and P<0.0001, respectively). CONCLUSIONS: Patients with severe AR and markedly low EF incur excess operative mortality rates, postoperative mortality rates, and congestive heart failure after AVR. However, postoperative EF improves markedly, and most patients enjoy a long postoperative survival without recurrence of heart failure after AVR; thus they should not be denied the benefits of AVR.

Angiography↗

[Signal-averaged ECG and left-ventricular function in patients with severe ventricular arrhythmia in ischemic heart disease].

In 35 patients with ischemic heart disease we evaluated the incidence of ventricular late potentials and left ventricular function. The patients were divided into two groups: group A consisting of 15 patients (14 men, 1 woman) aged from 40 to 71 years (mean age 56) with previously documented ventricular tachycardia or fibrillation, and into group B comprising 20 subject (16 men, 4 women) aged from 35 to 62 years (mean age 50) with ischemic heart disease without the above-mentioned arrhythmias. Time from the development of ventricular tachycardia or fibrillation was 3 weeks to 4 years. The incidence of arterial hypertension and previous myocardial infarction was similar in both groups. Body surface late potentials were recorded by signal averaging technique according to Simson using Frank's orthogonal XYZ lead system. In addition, in all the patients 24-hour ECG monitoring was performed to reveal any ventricular rhythm disturbances and echocardiography was used to evaluate left ventricular function. The presence of the ventricular late potentials meeting at least two of the Simson's--Dene's criteria was found in 13 (87%) patients in group A and in 2 (10%) patients from group B. In the patients after ventricular tachycardia or fibrillation the mean values of th total QRS duration (QRS-D) and the low amplitude signal duration (LAS40) were higher whereas the root mean square voltage of the last 40 ms of th vector magnitude QRS (RMS) was lower (154 ms, 56 ms, 15 muV, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Action Potentials↗

Left ventricular function and regression of left ventricular hypertrophy in essential hypertension.

Although left ventricular hypertrophy (LVH) is an adaptive response to the increased load imposed on the heart in patients with hypertension, it ultimately is itself a major risk factor for cardiovascular disease. The influence of LVH on left ventricular function and on the coronary circulation, and the occurrence of serious ventricular arrhythmias are the major mechanisms of this increased risk. There is no doubt that regression of LVH occurs, but there are clear differences in this respect among antihypertensive drugs: angiotensin-converting enzyme (ACE) inhibitors and calcium antagonists produce the best response. Whether regression of LVH also causes an improvement in left ventricular function is unclear; various studies using the same drugs have yielded contradictory results. Furthermore, it has yet to be determined whether regression of LVH has a positive influence on the long-term prognosis in such patients; the results of the European Multicenter Study OvA will help in shedding more light on this important question.

Antihypertensive Agents↗