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Diastolic Dysfunction during Acute Myocardial Infarction—A Quantitative Tissue Doppler Assessment
S50
Abstracts
Heart, Lung and Circulation 2008;17S:S1–S209
ABSTRACTS
following PCI for AMI. Evidence for diastolic remodelling is seen to accompany the systolic remodelling seen in this population. Diastolic as well as systolic function should be considered in the treatment of patients following AMI.
115 Magnetic Resonance Imaging Pulmonary Flows Versus Nuclear Medicine Perfusion Scanning: Are Both Necessary?
doi:10.1016/j.hlc.2008.05.114
T. Glenie 1,∗ , B. Cowan 2 , M. Rutland 3 , T. Hornung 4 , C. Occleshaw 1
114 Assessment of Long-Term Consequences of Composite Bentall and Aortic Valve Replacement using Dual-source 64-slice Multi-detector Computed Tomography Austin Chin Chwan Ng 1,∗ , Lloyd Ridley 1 , Andy Sze Chiang Yong 1 , Paul Bannon 2 , Leonard Kritharides 1 , John Yiannikas 1 1 Concord
RG Hospital, Concord, NSW, Australia; Prince Alfred Hospital, Sydney, NSW, Australia
2 Royal
Background: During composite aortic root and valve replacement (Bentall operation), the ‘button’ technique is commonly performed whereby a cuff of native aorta is implanted, together with the coronary ostium, into the aortic graft. The coronary-aortic and aorto-aortic graft anastomoses features years post-surgery are not welldescribed. We have studied the multi-detector (64-slice, dual-source) computed tomography (MDCT) appearance of these anastomoses. Methods and results: Sixteen patients (mean age 68 ± 11 years) with previous Bentall operation underwent MDCT scan, median 71 months post-surgery (range: 33–257 months). Two patients had asymptomatic aortic dissection, and six had aortic dilation ≥40 mm distal to the graft. Of the 32 coronary ostia, 31 were >5 mm in diameter and 22 were ≥10 mm. 14/16 patients had at least an ostium ≥10 mm; 8/16 had both ostia ≥10 mm. Mean increase in diameter of the left coronary ostial-graft anastomosis was 167%, relative to distal left main coronary artery. The mean increase was 127% for the right ostial-graft anastomosis relative to the distal segment of proximal right coronary artery. Majority of ostia (19/32) were conical in shape, with varying loss of angle between native aortic ‘button’ and native coronary ostium. The remainder (13/32) had an ‘aneurysmal’ appearance. Morphological discordance between left and right coronary ostia was observed in seven patients. Conclusion: All native aorto-coronary segments adjacent to the aortic graft had increased size calibre of varying grade, with morphological variations noted. The residual native ‘button’ aortic tissue appears to carry a risk of aneurysm formation and MDCT provides an ideal technique for monitoring these patients. doi:10.1016/j.hlc.2008.05.115
1 Cardiology
Department, Auckland City Hospital, Auckland, New Zealand; 2 Centre for Advanced MR, Auckland University, Auckland, New Zealand; 3 Nuclear Medicine Department, Auckland City Hospital, Auckland, New Zealand; 4 Starship Children’s Hospital, Auckland, New Zealand Background: Asymmetric pulmonary perfusion due to pulmonary artery pathology is a feature of many congenital cardiac conditions and requires repeated surgical and transcatheter interventions. Pulmonary perfusion depends on more distal resistance, RV pressure, as well as the size, angulation and distortion of the central arteries by abnormal cardiac and vascular anatomy. Instantaneous pulmonary perfusion may be assessed by nuclear imaging, and both perfusion and absolute flow can be assessed by MRI, but not instantaneously. There are important differences between these techniques that may lead to discrepant results however, and validation of the MR perfusion is required. Methods: All patients who underwent both pulmonary flow measurement (Siemens Avanto 1.5 T) at Auckland University between July 2004 and September 2007, and nuclear pulmonary perfusion imaging, were retrospectively identified. MR scans were supervised by experienced radiologists or cardiologists, blinded to the nuclear perfusion results. Twelve subjects were identified but one was excluded because of inadequate MR flow imaging, and another because of pulmonary artery surgery between the investigations. Results: The remaining 10 subjects included D-TGA, tetralogy, truncus and DORV. The mean difference in relative pulmonary perfusion between the two methods was 3.2% (S.D. 5.7%), p = 0.11. Eight out ten patients were within 7% of a perfect correlation. Conclusion: The data indicate that when MR imaging is performed correctly, there is no significant difference between with nuclear imaging. Technical factors may impact on the accuracy of MR flow measurements and more data is required to ascertain its suitability for general application. doi:10.1016/j.hlc.2008.05.116 116 Diastolic Dysfunction during Acute Myocardial Infarction—A Quantitative Tissue Doppler Assessment Sandhir Prasad ∗ , Valerie See, Paula Brown, Tanya McKay, Karen Byth, Pramesh Kovoor, Liza Thomas Westmead Hospital, Sydney, Australia Background: Ischaemia causes systolic dysfunction, but diastolic function in acute ST elevation myocardial infarction (STEMI) has not been evaluated. Transmitral peak
E velocity, deceleration time (DT), IVRT, Doppler tissue imaging derived E velocity are markers of ventricular relaxation. E/E correlates with LV filling pressures, but it is unknown if this relationship exists during ischaemia/infarction. Aim: To determine the impact of myocardial ischaemia and revascularisation on diastolic properties in subjects with STEMI. Methods: Twenty-eight consecutive patients presenting with their first STEMI, who underwent primary angioplasty during office hours were prospectively studied with a rapid transthoracic echo protocol performed prior to primary angioplasty. A comprehensive echocardiogram was performed at 3 days. LVEDP was measured prior to and following revascularization in a subset of patients. Results: The mean age of pts was 62 ± 11 years, 71% were males and anterior infarction was present in 11 patients (65%). LVEF improved following revascularisation (47 ± 8% vs. 52 ± 8%; p = 0.002). Significant changes were noted in diastolic parameters following revascularization: Peak E-velocity decreased (77 ± 21 vs. 67 ± 15, p = 0.03) as did E velocity (7 ± 2 vs. 6 ± 2, p = 0.002) while E/E ratio (11 ± 2 vs. 12 ± 2, p = 0.02) and DT (168 ± 26 vs. 195 ± 47, p = 0.005) increased. No significant improvement was noted in the LVEDP immediately post-reperfusion (25.0 ± 8.1 vs. 21.3 ± 5.0 mmHg, p = 0.10). No correlation was noted between LVEDP and E/E ratio during ischaemia (r = 0, p = 1.0). Conclusion: In this study, acute changes in diastolic indices were noted alongside improvement in systolic function with revascularization. E/E may not correlate with LVEDP in the setting of acute ischaemia. doi:10.1016/j.hlc.2008.05.117 117 Optimal Reconstruction Phase For Demonstration of Maximal Coronary Sinus Area by Cardiac Computed Tomography Rohan Poulter ∗ , Camilla Wainwright, John F. Younger, Melanie Fuentes Royal Brisbane & Women’s Hospital, Brisbane, Australia Background: The cardiac venous system can be visualised with computed tomography (CT) prior to left ventricular lead placement for cardiac resynchronisation therapy. The choice of reconstruction phase for CT coronary artery imaging relies on selecting the period of minimum cardiac motion, typically at end-diastole (70% of the cardiac cycle). The use of dose modulation, while limiting radiation dose, requires the prediction of the ideal reconstruction phase prior to scanning. However the diastolic phase may not be optimal for venous imaging due to changes in venous luminal diameter during the cardiac cycle. Aims: To establish the optimal CT reconstruction phase to demonstrate maximal cardiac venous area. Methods: 16 patients (11 male, 5 female; mean age 61.3 years) with complete data sets for 10 phases of the cardiac cycle were retrospectively analysed to establish a cross
Abstracts
S51 ABSTRACTS
Heart, Lung and Circulation 2008;17S:S1–S209
Figure 1. Mean CS Area.
section of the coronary sinus (CS) and 159 interpretable images were available. The CS area was calculated from diameter measured in two orthogonal dimensions. Results: There was marked inter-individual variation in CS area (mean 81.5 mm2 , S.D. 37.3 mm2 ). There was a significant difference between maximal and minimal mean area (p = 0.0046) (Fig. 1). The interval between 30% and 50% of the cardiac cycle represented maximal CS area in 11 patients (69%). The maximal mean area occurred at 40% of the cardiac cycle (92.3 mm2 , S.D. 41.6 mm2 ). Conclusions: Maximal mean CS area occurs in the systolic phases of the cardiac cycle. Reconstruction at 40% may be preferable to typical diastolic (70%) reconstructions for venous imaging. doi:10.1016/j.hlc.2008.05.118 118 Increase in Left Atrial Volume in Mitral Regurgitation is mediated by an Increase in Passive Emptying with no Increase in Conduit or Active Emptying Volumes Jane Vidaic ∗ , Ee-May Chia, Anita Boyd, Liza Thomas, Dominic Y. Leung Liverpool Hospital, Sydney, NSW, Australia Background: Left atrial (LA) enlargement is well described in mitral regurgitation (MR) and is presumably due to the increased regurgitant volume. We sought to examine the phasic changes in LA volumes in varying grades of MR severity. Methods: Patients in sinus rhythm, with varying grades of MR, determined semi-quantitatively, were identified from the departmental database. Thirty patients in each of the categories of severe, moderate and mild MR were compared with ninety age-matched normal subjects. Maximal/minimal left atrial volumes (LAV) and pre-p LAV were measured using Simpson’s bi-plane method. Passive emptying, conduit, and active emptying volumes were calculated. Results: Maximal, minimal and pre-p LAV increased with increasing severity of MR that resulted in increased passive LA emptying but no increase in passive emptying fraction. Conduit volume was reduced as a % of maximal LAV. There was no increase in active atrial emptying volume with a resultant reduction in active emptying fraction. Subgroup analysis based on ischaemic versus valvular MR, demonstrated no significant difference in phasic atrial
Abstracts
Heart, Lung and Circulation 2008;17S:S1–S209
ABSTRACTS
following PCI for AMI. Evidence for diastolic remodelling is seen to accompany the systolic remodelling seen in this population. Diastolic as well as systolic function should be considered in the treatment of patients following AMI.
115 Magnetic Resonance Imaging Pulmonary Flows Versus Nuclear Medicine Perfusion Scanning: Are Both Necessary?
doi:10.1016/j.hlc.2008.05.114
T. Glenie 1,∗ , B. Cowan 2 , M. Rutland 3 , T. Hornung 4 , C. Occleshaw 1
114 Assessment of Long-Term Consequences of Composite Bentall and Aortic Valve Replacement using Dual-source 64-slice Multi-detector Computed Tomography Austin Chin Chwan Ng 1,∗ , Lloyd Ridley 1 , Andy Sze Chiang Yong 1 , Paul Bannon 2 , Leonard Kritharides 1 , John Yiannikas 1 1 Concord
RG Hospital, Concord, NSW, Australia; Prince Alfred Hospital, Sydney, NSW, Australia
2 Royal
Background: During composite aortic root and valve replacement (Bentall operation), the ‘button’ technique is commonly performed whereby a cuff of native aorta is implanted, together with the coronary ostium, into the aortic graft. The coronary-aortic and aorto-aortic graft anastomoses features years post-surgery are not welldescribed. We have studied the multi-detector (64-slice, dual-source) computed tomography (MDCT) appearance of these anastomoses. Methods and results: Sixteen patients (mean age 68 ± 11 years) with previous Bentall operation underwent MDCT scan, median 71 months post-surgery (range: 33–257 months). Two patients had asymptomatic aortic dissection, and six had aortic dilation ≥40 mm distal to the graft. Of the 32 coronary ostia, 31 were >5 mm in diameter and 22 were ≥10 mm. 14/16 patients had at least an ostium ≥10 mm; 8/16 had both ostia ≥10 mm. Mean increase in diameter of the left coronary ostial-graft anastomosis was 167%, relative to distal left main coronary artery. The mean increase was 127% for the right ostial-graft anastomosis relative to the distal segment of proximal right coronary artery. Majority of ostia (19/32) were conical in shape, with varying loss of angle between native aortic ‘button’ and native coronary ostium. The remainder (13/32) had an ‘aneurysmal’ appearance. Morphological discordance between left and right coronary ostia was observed in seven patients. Conclusion: All native aorto-coronary segments adjacent to the aortic graft had increased size calibre of varying grade, with morphological variations noted. The residual native ‘button’ aortic tissue appears to carry a risk of aneurysm formation and MDCT provides an ideal technique for monitoring these patients. doi:10.1016/j.hlc.2008.05.115
1 Cardiology
Department, Auckland City Hospital, Auckland, New Zealand; 2 Centre for Advanced MR, Auckland University, Auckland, New Zealand; 3 Nuclear Medicine Department, Auckland City Hospital, Auckland, New Zealand; 4 Starship Children’s Hospital, Auckland, New Zealand Background: Asymmetric pulmonary perfusion due to pulmonary artery pathology is a feature of many congenital cardiac conditions and requires repeated surgical and transcatheter interventions. Pulmonary perfusion depends on more distal resistance, RV pressure, as well as the size, angulation and distortion of the central arteries by abnormal cardiac and vascular anatomy. Instantaneous pulmonary perfusion may be assessed by nuclear imaging, and both perfusion and absolute flow can be assessed by MRI, but not instantaneously. There are important differences between these techniques that may lead to discrepant results however, and validation of the MR perfusion is required. Methods: All patients who underwent both pulmonary flow measurement (Siemens Avanto 1.5 T) at Auckland University between July 2004 and September 2007, and nuclear pulmonary perfusion imaging, were retrospectively identified. MR scans were supervised by experienced radiologists or cardiologists, blinded to the nuclear perfusion results. Twelve subjects were identified but one was excluded because of inadequate MR flow imaging, and another because of pulmonary artery surgery between the investigations. Results: The remaining 10 subjects included D-TGA, tetralogy, truncus and DORV. The mean difference in relative pulmonary perfusion between the two methods was 3.2% (S.D. 5.7%), p = 0.11. Eight out ten patients were within 7% of a perfect correlation. Conclusion: The data indicate that when MR imaging is performed correctly, there is no significant difference between with nuclear imaging. Technical factors may impact on the accuracy of MR flow measurements and more data is required to ascertain its suitability for general application. doi:10.1016/j.hlc.2008.05.116 116 Diastolic Dysfunction during Acute Myocardial Infarction—A Quantitative Tissue Doppler Assessment Sandhir Prasad ∗ , Valerie See, Paula Brown, Tanya McKay, Karen Byth, Pramesh Kovoor, Liza Thomas Westmead Hospital, Sydney, Australia Background: Ischaemia causes systolic dysfunction, but diastolic function in acute ST elevation myocardial infarction (STEMI) has not been evaluated. Transmitral peak
E velocity, deceleration time (DT), IVRT, Doppler tissue imaging derived E velocity are markers of ventricular relaxation. E/E correlates with LV filling pressures, but it is unknown if this relationship exists during ischaemia/infarction. Aim: To determine the impact of myocardial ischaemia and revascularisation on diastolic properties in subjects with STEMI. Methods: Twenty-eight consecutive patients presenting with their first STEMI, who underwent primary angioplasty during office hours were prospectively studied with a rapid transthoracic echo protocol performed prior to primary angioplasty. A comprehensive echocardiogram was performed at 3 days. LVEDP was measured prior to and following revascularization in a subset of patients. Results: The mean age of pts was 62 ± 11 years, 71% were males and anterior infarction was present in 11 patients (65%). LVEF improved following revascularisation (47 ± 8% vs. 52 ± 8%; p = 0.002). Significant changes were noted in diastolic parameters following revascularization: Peak E-velocity decreased (77 ± 21 vs. 67 ± 15, p = 0.03) as did E velocity (7 ± 2 vs. 6 ± 2, p = 0.002) while E/E ratio (11 ± 2 vs. 12 ± 2, p = 0.02) and DT (168 ± 26 vs. 195 ± 47, p = 0.005) increased. No significant improvement was noted in the LVEDP immediately post-reperfusion (25.0 ± 8.1 vs. 21.3 ± 5.0 mmHg, p = 0.10). No correlation was noted between LVEDP and E/E ratio during ischaemia (r = 0, p = 1.0). Conclusion: In this study, acute changes in diastolic indices were noted alongside improvement in systolic function with revascularization. E/E may not correlate with LVEDP in the setting of acute ischaemia. doi:10.1016/j.hlc.2008.05.117 117 Optimal Reconstruction Phase For Demonstration of Maximal Coronary Sinus Area by Cardiac Computed Tomography Rohan Poulter ∗ , Camilla Wainwright, John F. Younger, Melanie Fuentes Royal Brisbane & Women’s Hospital, Brisbane, Australia Background: The cardiac venous system can be visualised with computed tomography (CT) prior to left ventricular lead placement for cardiac resynchronisation therapy. The choice of reconstruction phase for CT coronary artery imaging relies on selecting the period of minimum cardiac motion, typically at end-diastole (70% of the cardiac cycle). The use of dose modulation, while limiting radiation dose, requires the prediction of the ideal reconstruction phase prior to scanning. However the diastolic phase may not be optimal for venous imaging due to changes in venous luminal diameter during the cardiac cycle. Aims: To establish the optimal CT reconstruction phase to demonstrate maximal cardiac venous area. Methods: 16 patients (11 male, 5 female; mean age 61.3 years) with complete data sets for 10 phases of the cardiac cycle were retrospectively analysed to establish a cross
Abstracts
S51 ABSTRACTS
Heart, Lung and Circulation 2008;17S:S1–S209
Figure 1. Mean CS Area.
section of the coronary sinus (CS) and 159 interpretable images were available. The CS area was calculated from diameter measured in two orthogonal dimensions. Results: There was marked inter-individual variation in CS area (mean 81.5 mm2 , S.D. 37.3 mm2 ). There was a significant difference between maximal and minimal mean area (p = 0.0046) (Fig. 1). The interval between 30% and 50% of the cardiac cycle represented maximal CS area in 11 patients (69%). The maximal mean area occurred at 40% of the cardiac cycle (92.3 mm2 , S.D. 41.6 mm2 ). Conclusions: Maximal mean CS area occurs in the systolic phases of the cardiac cycle. Reconstruction at 40% may be preferable to typical diastolic (70%) reconstructions for venous imaging. doi:10.1016/j.hlc.2008.05.118 118 Increase in Left Atrial Volume in Mitral Regurgitation is mediated by an Increase in Passive Emptying with no Increase in Conduit or Active Emptying Volumes Jane Vidaic ∗ , Ee-May Chia, Anita Boyd, Liza Thomas, Dominic Y. Leung Liverpool Hospital, Sydney, NSW, Australia Background: Left atrial (LA) enlargement is well described in mitral regurgitation (MR) and is presumably due to the increased regurgitant volume. We sought to examine the phasic changes in LA volumes in varying grades of MR severity. Methods: Patients in sinus rhythm, with varying grades of MR, determined semi-quantitatively, were identified from the departmental database. Thirty patients in each of the categories of severe, moderate and mild MR were compared with ninety age-matched normal subjects. Maximal/minimal left atrial volumes (LAV) and pre-p LAV were measured using Simpson’s bi-plane method. Passive emptying, conduit, and active emptying volumes were calculated. Results: Maximal, minimal and pre-p LAV increased with increasing severity of MR that resulted in increased passive LA emptying but no increase in passive emptying fraction. Conduit volume was reduced as a % of maximal LAV. There was no increase in active atrial emptying volume with a resultant reduction in active emptying fraction. Subgroup analysis based on ischaemic versus valvular MR, demonstrated no significant difference in phasic atrial