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Interaction Between Duration of Ischaemia, Infarct Size and Left Ventricular Diastolic Function in Patients with Acute ST-elevation Myocardial Infarction
S186
Heart, Lung and Circulation 2010;19S:S1–S268
Abstracts
ABSTRACTS
441 Watchman®
Initial Experience with Left Atrial Appendage Occluder Device Implantation—Lessons from Transoesophageal Echocardiographic Guidance J. Humphries ∗ , K. Phillips Heart Care Partners, Greenslopes, QLD, Australia Background: Left atrial appendage (LAA) occluder device implantation is a new therapy for patients with non-valvular atrial fibrillation that reduces or removes the need for warfarin therapy. The Watchman® LAA occluder device is the only device approved for this use in Australia. This series represents the largest clinical implantation experience to date in a single Australian centre. Results: The occluder size and device deployment is guided by continuous transoesophageal echo (TOE). Views are obtained in 0◦ , 45◦ , 90◦ and 140◦ midtransoesophageal position. The largest dimension from all views determines occluder size, with the largest diameter most often recorded from the 140◦ view. Accurate imaging of the LAA is often technically challenging in all views, and we found biplane 2D TOE (Philips) offers the best imaging modality for accurate assessment of LAA anatomy. Accurate determination of lobe size and number, and orifice dimensions are essential for device selection and deployment. The deployment of the device requires 2D and colour flow Doppler imaging in all 4 views to establish correct device placement, in conjunction with fluoroscopic imaging. Multiple devices and multiple attempts at repositioning have been required in most cases in the initial experience, due to technically challenging LAA anatomy. Device deployment and position is reliant on many anatomical factors, none of which appear to predict ease of implantation. Implantation time has initially varied between 90 and 180 min (mean procedural time was 121 ± 22). Correct trans-septal puncture in the most posterior aspect of the fossa membrane also appears to be crucial for device deployment. This is best guided by biplane 2D TOE. Conclusion: Biplane 2D TOE provides the best imaging modality for accurate trans-septal puncture, device selection and deployment in Watchman® LAA device closure.
through the aortic valve. Studies have shown an improvement in LV strain 24hrs post procedure with persistent improvement at 1 month follow up. Using intraprocedural transoesophageal echocardiography (TOE) we propose to measure the immediate changes in LV function using circumferential and radial strain. Methods: We performed intraoperative TOE during percutaneous aortic valve implantation for 32 patients (mean age 84 ± 7 years). In a subgroup of 10 patients, 2D images in the trans-gastric view were acquired at the level of the papillary muscle. These were taken prior to valvuloplasty and within 3 minutes of prosthetic valve deployment. This allowed the patients to be their own controls using the same settings, machine and operator with similar haemodynamic conditions. Circumferential and radial strain was measured using Philips Qlab 7.0 software. Results: There was no significant difference noted in either circumferential or radial strain immediately post procedure (p = 0.53 and p = 0.44, respectively), despite the significant decrease in both peak and mean gradients (peak gradient pre PAVI 73 ± 11 mm Hg, post 20 ± 8 mm Hg, p < 0.001; and mean gradient pre PAVI 44 ± 9 mm Hg and post 11 ± 4 mm Hg, p < 0.001). Conclusions: The expected instant improvement in LV systolic strain after PAVI was not seen in our study. The effects of sudden afterload reduction may have been obviated by myocardial stunning caused by rapid RV pacing and balloon inflation. In addition our numbers were small and a trend towards a significant result may be more apparent in larger numbers. More likely is that LV strain and systolic function take time to improve after reduction in chronic afterload. doi:10.1016/j.hlc.2010.06.451 443 Interaction Between Duration of Ischaemia, Infarct Size and Left Ventricular Diastolic Function in Patients with Acute ST-elevation Myocardial Infarction S. Prasad 1,2,∗ , V. See 2 , P. Brown 2 , T. Narayan 2 , P. Kovoor 2 , L. Thomas 2,3
McKay 2 , A.
1 Royal
Brisbane and Women’s Hospital, Australia Hospital, Sydney, Australia 3 Liverpool Hospital, Sydney, Australia 2 Westmead
doi:10.1016/j.hlc.2010.06.450 442 Instantaneous Decrease in Left Ventricular Afterload during Percutaneous Aortic Valve Implantation does not Result in Immediate Changes in Left Ventricular Strain A. Penhall ∗ , R. Perry, M. Altman, A. Sinhal, J. Bennetts, D. Chew, M. Joseph Flinders Medical Centre, Adelaide Background: Severe aortic stenosis causes chronic afterload on the left ventricle (LV). Percutaneous aortic valve implantation (PAVI) immediately decreases the afterload on the LV by reducing the pressure gradient
Background: The duration of ischaemia is an important determinant of survival following acute myocardial infarction (AMI). The impact of the duration of ischaemia on left ventricular (LV) diastolic properties following AMI has not been previously studied. We determined the correlation between the symptom-to-reperfusion time and severe diastolic dysfunction (restrictive filling patternRFP) in patients undergoing primary angioplasty (PAMI) for AMI. Methods: A total of 95 consecutive patients with a firstever AMI had transthoracic echocardiography performed 3 days following PAMI. RFP was defined as an E/A ratio of >2.0 and/or mitral E-wave deceleration time of <140 ms. Composite major adverse cardiovascular events (MACE)
(death, reinfarction, heart failure or revascularization) was determined at 12 months. Results: A total of 20 patients (21%) had RFP on day 3. The symptom-to-reperfusion time in the RFP group was 413 ± 287 compared to 252 ± 138 minutes in the non-RFP group (p = 0.014). Logistic regression identified symptom-to-reperfusion time (HR 1.008, 95%CI 1.002–1.014, p = 0.045) and infarct size by peak Troponin-T levels (HR 1.537, 95%CI 1.130–2.089, p = 0.006) as independent predictors of RFP. MACE occurred in 10 patients (50%) in the RFP group compared to 6 patients (8%) in the non-RFP group (univariate Cox HR 8.389, 95%CI 3.036–23.178, p < 0.001). On multivariate Cox analysis, RFP was the only independent predictor of MACE at 12 months (HR 3.8, 95%CI 1.7–7.2, p < 0.001). Conclusions: Delayed reperfusion following acute myocardial infarction was associated with severe diastolic dysfunction, which in turn was strongly correlated with adverse long-term outcomes. Diastolic dysfunction represents a pathophysiologic link between duration of ischaemia and outcomes. doi:10.1016/j.hlc.2010.06.452 444 Interpretability of the Parasternal Long Axis Window Following Administration of Definity Echocardiography Contrast A. Lamanna ∗ , E. Savill, A. Lo, J. Younger Royal Brisbane and Women’s Hospital, Australia Background: Definity (perfluren lipid microsphere) echo contrast is effective in improving left ventricular chamber enhancement and endocardial border definition in the apical views. However, the parasternal window is thought to be uninterpretable post-contrast particularly the posterolateral segments and acquisition is not recommended. We sought to assess the effect of Definity contrast on parasternal long axis (PLAX) window interpretability in technically challenging echocardiograms. Method: One hundred and eighty myocardial-segments were identified through retrospective review of 45 echocardiograms requiring echo-contrast. The 4 myocardial segments visible on the PLAX view were assessed (basal and mid anteroseptal, basal and mid posterolateral) and given a score of 1 if visible and 0 if not. Results: The PLAX view was uninterpretable (no segments visualized) in 3 (7%) pre-contrast and 9 (20%) post-contrast studies. All PLAX segments were visualized in 28 (62%) pre-contrast and 17 (38%) post-contrast images. Two or more segments were seen in 40 (89%) pre and post 30 (66%) contrast studies. The mean number of segments visualized pre and post-contrast was 3.2 ± 1.2 and 2.3 ± 1.6, respectively. The mean difference of number of segments visualized between post- and pre-contrast images is −0.9 ± 0.4 (p < 0.001). Post-contrast, 47% and 38% of basal and mid posterolateral segments respectively are visible.
S187
Abstracts
Conclusion: The PLAX view provided some interpretable images post-contrast in two thirds of patients studied. In almost 40% of studies all 4 PLAX myocardial segments could be visualized. The PLAX view is not uninterpertable post-contrast. doi:10.1016/j.hlc.2010.06.453 445 Left Atrial Changes with Varying Grades of Valvular Mitral Regurgitation E. Chia 1,2,∗ , J. Thomas 1,2 1 Liverpool
Vidaic 1 , A.
Boyd 2 , D.
Leung 1,2 , L.
Hospital, Australia of New South Wales, Australia
2 University
Background: Left atrial (LA) enlargement occurs in valvular mitral regurgitation (MR). We sought to examine changes in LA volumes and phasic function with increasing severity of valvular MR. Methods: Patients with valvular MR determined semiquantitatively were identified from the departmental database; 65 patients with varying grades of MR in sinus rhythm (severe = 27, moderate = 20, mild = 18) were compared to 54 age-matched normal subjects. Maximal, minimal and pre-p LA volumes (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. Passive and active emptying volumes, but not their respective fractions, increased with increasing MR severity while conduit volume decreased. Conclusions: Maximal LA volume increases with increasing grades of MR with an increase in passive and active emptying volume but not their respective emptying fractions. These suggest preserved atrial contractile function despite atrial enlargement from volume overload when patients remain in sinus rhythm. Normal’s LAV max (ml) Pass emptying (ml) Conduit vol (ml) Act emptying (ml)
41.8 12.1 30.1 9.7
± ± ± ±
9.2 4.5 11.2 3.5
Mild MR 58.4 17.2 31.7 9.3
± ± ± ±
17.9* 7.6 15.8 5.8
Moderate MR 92.2 22.4 16.5 17.7
± ± ± ±
25.2*† 10.7* 15.5*† 11.9*†
Severe MR 91.2 26.5 19.1 14.9
± ± ± ±
34.4*† 10.8*† 19*† 7.4*†
*p < 0.05 compared to Normal’s, †p < 0.05 compared to Mild MR, ‡p < 0.05 compared to Moderate MR. doi:10.1016/j.hlc.2010.06.454
ABSTRACTS
Heart, Lung and Circulation 2010;19S:S1–S268
Heart, Lung and Circulation 2010;19S:S1–S268
Abstracts
ABSTRACTS
441 Watchman®
Initial Experience with Left Atrial Appendage Occluder Device Implantation—Lessons from Transoesophageal Echocardiographic Guidance J. Humphries ∗ , K. Phillips Heart Care Partners, Greenslopes, QLD, Australia Background: Left atrial appendage (LAA) occluder device implantation is a new therapy for patients with non-valvular atrial fibrillation that reduces or removes the need for warfarin therapy. The Watchman® LAA occluder device is the only device approved for this use in Australia. This series represents the largest clinical implantation experience to date in a single Australian centre. Results: The occluder size and device deployment is guided by continuous transoesophageal echo (TOE). Views are obtained in 0◦ , 45◦ , 90◦ and 140◦ midtransoesophageal position. The largest dimension from all views determines occluder size, with the largest diameter most often recorded from the 140◦ view. Accurate imaging of the LAA is often technically challenging in all views, and we found biplane 2D TOE (Philips) offers the best imaging modality for accurate assessment of LAA anatomy. Accurate determination of lobe size and number, and orifice dimensions are essential for device selection and deployment. The deployment of the device requires 2D and colour flow Doppler imaging in all 4 views to establish correct device placement, in conjunction with fluoroscopic imaging. Multiple devices and multiple attempts at repositioning have been required in most cases in the initial experience, due to technically challenging LAA anatomy. Device deployment and position is reliant on many anatomical factors, none of which appear to predict ease of implantation. Implantation time has initially varied between 90 and 180 min (mean procedural time was 121 ± 22). Correct trans-septal puncture in the most posterior aspect of the fossa membrane also appears to be crucial for device deployment. This is best guided by biplane 2D TOE. Conclusion: Biplane 2D TOE provides the best imaging modality for accurate trans-septal puncture, device selection and deployment in Watchman® LAA device closure.
through the aortic valve. Studies have shown an improvement in LV strain 24hrs post procedure with persistent improvement at 1 month follow up. Using intraprocedural transoesophageal echocardiography (TOE) we propose to measure the immediate changes in LV function using circumferential and radial strain. Methods: We performed intraoperative TOE during percutaneous aortic valve implantation for 32 patients (mean age 84 ± 7 years). In a subgroup of 10 patients, 2D images in the trans-gastric view were acquired at the level of the papillary muscle. These were taken prior to valvuloplasty and within 3 minutes of prosthetic valve deployment. This allowed the patients to be their own controls using the same settings, machine and operator with similar haemodynamic conditions. Circumferential and radial strain was measured using Philips Qlab 7.0 software. Results: There was no significant difference noted in either circumferential or radial strain immediately post procedure (p = 0.53 and p = 0.44, respectively), despite the significant decrease in both peak and mean gradients (peak gradient pre PAVI 73 ± 11 mm Hg, post 20 ± 8 mm Hg, p < 0.001; and mean gradient pre PAVI 44 ± 9 mm Hg and post 11 ± 4 mm Hg, p < 0.001). Conclusions: The expected instant improvement in LV systolic strain after PAVI was not seen in our study. The effects of sudden afterload reduction may have been obviated by myocardial stunning caused by rapid RV pacing and balloon inflation. In addition our numbers were small and a trend towards a significant result may be more apparent in larger numbers. More likely is that LV strain and systolic function take time to improve after reduction in chronic afterload. doi:10.1016/j.hlc.2010.06.451 443 Interaction Between Duration of Ischaemia, Infarct Size and Left Ventricular Diastolic Function in Patients with Acute ST-elevation Myocardial Infarction S. Prasad 1,2,∗ , V. See 2 , P. Brown 2 , T. Narayan 2 , P. Kovoor 2 , L. Thomas 2,3
McKay 2 , A.
1 Royal
Brisbane and Women’s Hospital, Australia Hospital, Sydney, Australia 3 Liverpool Hospital, Sydney, Australia 2 Westmead
doi:10.1016/j.hlc.2010.06.450 442 Instantaneous Decrease in Left Ventricular Afterload during Percutaneous Aortic Valve Implantation does not Result in Immediate Changes in Left Ventricular Strain A. Penhall ∗ , R. Perry, M. Altman, A. Sinhal, J. Bennetts, D. Chew, M. Joseph Flinders Medical Centre, Adelaide Background: Severe aortic stenosis causes chronic afterload on the left ventricle (LV). Percutaneous aortic valve implantation (PAVI) immediately decreases the afterload on the LV by reducing the pressure gradient
Background: The duration of ischaemia is an important determinant of survival following acute myocardial infarction (AMI). The impact of the duration of ischaemia on left ventricular (LV) diastolic properties following AMI has not been previously studied. We determined the correlation between the symptom-to-reperfusion time and severe diastolic dysfunction (restrictive filling patternRFP) in patients undergoing primary angioplasty (PAMI) for AMI. Methods: A total of 95 consecutive patients with a firstever AMI had transthoracic echocardiography performed 3 days following PAMI. RFP was defined as an E/A ratio of >2.0 and/or mitral E-wave deceleration time of <140 ms. Composite major adverse cardiovascular events (MACE)
(death, reinfarction, heart failure or revascularization) was determined at 12 months. Results: A total of 20 patients (21%) had RFP on day 3. The symptom-to-reperfusion time in the RFP group was 413 ± 287 compared to 252 ± 138 minutes in the non-RFP group (p = 0.014). Logistic regression identified symptom-to-reperfusion time (HR 1.008, 95%CI 1.002–1.014, p = 0.045) and infarct size by peak Troponin-T levels (HR 1.537, 95%CI 1.130–2.089, p = 0.006) as independent predictors of RFP. MACE occurred in 10 patients (50%) in the RFP group compared to 6 patients (8%) in the non-RFP group (univariate Cox HR 8.389, 95%CI 3.036–23.178, p < 0.001). On multivariate Cox analysis, RFP was the only independent predictor of MACE at 12 months (HR 3.8, 95%CI 1.7–7.2, p < 0.001). Conclusions: Delayed reperfusion following acute myocardial infarction was associated with severe diastolic dysfunction, which in turn was strongly correlated with adverse long-term outcomes. Diastolic dysfunction represents a pathophysiologic link between duration of ischaemia and outcomes. doi:10.1016/j.hlc.2010.06.452 444 Interpretability of the Parasternal Long Axis Window Following Administration of Definity Echocardiography Contrast A. Lamanna ∗ , E. Savill, A. Lo, J. Younger Royal Brisbane and Women’s Hospital, Australia Background: Definity (perfluren lipid microsphere) echo contrast is effective in improving left ventricular chamber enhancement and endocardial border definition in the apical views. However, the parasternal window is thought to be uninterpretable post-contrast particularly the posterolateral segments and acquisition is not recommended. We sought to assess the effect of Definity contrast on parasternal long axis (PLAX) window interpretability in technically challenging echocardiograms. Method: One hundred and eighty myocardial-segments were identified through retrospective review of 45 echocardiograms requiring echo-contrast. The 4 myocardial segments visible on the PLAX view were assessed (basal and mid anteroseptal, basal and mid posterolateral) and given a score of 1 if visible and 0 if not. Results: The PLAX view was uninterpretable (no segments visualized) in 3 (7%) pre-contrast and 9 (20%) post-contrast studies. All PLAX segments were visualized in 28 (62%) pre-contrast and 17 (38%) post-contrast images. Two or more segments were seen in 40 (89%) pre and post 30 (66%) contrast studies. The mean number of segments visualized pre and post-contrast was 3.2 ± 1.2 and 2.3 ± 1.6, respectively. The mean difference of number of segments visualized between post- and pre-contrast images is −0.9 ± 0.4 (p < 0.001). Post-contrast, 47% and 38% of basal and mid posterolateral segments respectively are visible.
S187
Abstracts
Conclusion: The PLAX view provided some interpretable images post-contrast in two thirds of patients studied. In almost 40% of studies all 4 PLAX myocardial segments could be visualized. The PLAX view is not uninterpertable post-contrast. doi:10.1016/j.hlc.2010.06.453 445 Left Atrial Changes with Varying Grades of Valvular Mitral Regurgitation E. Chia 1,2,∗ , J. Thomas 1,2 1 Liverpool
Vidaic 1 , A.
Boyd 2 , D.
Leung 1,2 , L.
Hospital, Australia of New South Wales, Australia
2 University
Background: Left atrial (LA) enlargement occurs in valvular mitral regurgitation (MR). We sought to examine changes in LA volumes and phasic function with increasing severity of valvular MR. Methods: Patients with valvular MR determined semiquantitatively were identified from the departmental database; 65 patients with varying grades of MR in sinus rhythm (severe = 27, moderate = 20, mild = 18) were compared to 54 age-matched normal subjects. Maximal, minimal and pre-p LA volumes (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. Passive and active emptying volumes, but not their respective fractions, increased with increasing MR severity while conduit volume decreased. Conclusions: Maximal LA volume increases with increasing grades of MR with an increase in passive and active emptying volume but not their respective emptying fractions. These suggest preserved atrial contractile function despite atrial enlargement from volume overload when patients remain in sinus rhythm. Normal’s LAV max (ml) Pass emptying (ml) Conduit vol (ml) Act emptying (ml)
41.8 12.1 30.1 9.7
± ± ± ±
9.2 4.5 11.2 3.5
Mild MR 58.4 17.2 31.7 9.3
± ± ± ±
17.9* 7.6 15.8 5.8
Moderate MR 92.2 22.4 16.5 17.7
± ± ± ±
25.2*† 10.7* 15.5*† 11.9*†
Severe MR 91.2 26.5 19.1 14.9
± ± ± ±
34.4*† 10.8*† 19*† 7.4*†
*p < 0.05 compared to Normal’s, †p < 0.05 compared to Mild MR, ‡p < 0.05 compared to Moderate MR. doi:10.1016/j.hlc.2010.06.454
ABSTRACTS
Heart, Lung and Circulation 2010;19S:S1–S268