Regional and global left ventricular function. Thor Edvardsen, MD, PhD Professor, Dept. of Cardiology, Rikshospitalet

Transcription

1 Regional and global left ventricular function Thor Edvardsen, MD, PhD Professor, Dept. of Cardiology, Rikshospitalet

2 Systolic function Echocardiography Fractional shortening Visual assessment WMSI (Wall motion score index) Ejection fraction (EF) Stroke volume / Cardiac output Tissue velocities Mitral annulus displacement Regional strain / Global strain

3 Repeated VTs Left main coronary artery occlusion 24 year old female

4 EF

5 Tissue Doppler velocities

6 Displacement

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9 Global strain = -4.5% Global strain = average of segmental strain

10 Speckle tracking echocardiography Is there really a need for speckle tracking? Time consuming Useful in clinical practice?

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12 Cardiac MRI Late enhancement contrast MRI Cine MRI Ola Gjesdal et al, Circ CV Imag 2008

13 Chronic Myocardial Infarct Contrast MRI ANT_SEPT ANT SEPT INF LAT POST Global strain = average of segmental strain

14 Gjesdal et al Circ CV Imag 2008

15 Sensitivity Sensitivity Global ROC 30g Infarct 50g Infarct 1 1 0,8 0,8 0,6 0,6 0,4 0,4 0,2 0, ,2 0,4 0,6 0,8 1 1-Specificity 0 0 0,2 0,4 0,6 0,8 1 1-Specificity Longitudinal Strain Circumferential Strain Radial Strain Strain by TDI Strain Rate by TDI PSSI LVEF WMSI Twist Global strain by speckle tracking was the best parameter to identify small and medium sized MIs Gjesdal et al, Circ CV Imag 2008

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17 Prognosis after mycoardial infarction Acute MI Scar development

18 Post MI Who needs ICD? Secondary prevention: Survived heart arrest VT with hemodynamic consequences > hours after onset (AVID, CIDS, CASH) Primary prevention: EF < 35% and NYHA 2-3 EF < 40% and Non sustained VT (Holter) VT during an EP test (MADIT2, SCDHeFT) > 40 days after myocardial infarct ACC/AHA/ESC 2006 Guidelines

19 Selection of post-mi patients for ICD 1. ICD never in use (15%) 2. Many patients who not fulfill ICD indications experience arrhythmia

20 EF 20%, no arrhythmia

21 EF 50%, arrhythmia ICD

22 Strain Amplitudes or time intervals? Global strain average strain from 16 LV segments Delta systolic time difference between longest and shortest regional duration of systole

23 Myocardial mechanical dispersion 85 patients after mycoardial infarction with ICD ( ) years follow up

24 Myocardial mechanical dispersion 85 patients after mycoardial infarction with ICD N=23 N=47 N= ( ) years follow up K Haugaa et al, JACC CV Imag 2010

25 K Haugaa et al, JACC CV Imag 2010

26 Predictors of arrhythmias that required appropriate ICD therapy Cox multivariate analysis (n=85) HR (95% CI) P Age (per 5 years increase) 1.23( ) 0.14 Gender (man vs. woman) 3.80( ) 0.20 EF (per 5% increase) 1.10( ) 0.51 Global strain (per 1% increase) 0.92( ) 0.37 Mechanical dispersion (per 10ms increase) 1.31 ( ) <0.01 K Haugaa et al, JACC CV Imag 2010

27 Summary Cardiac contraction heterogeneity seems to be a marker of increased arrhythmogenecity in patients after myocardial infarction Mechanical dispersion by echocardiography a promising parameter for predicting malignant arrhythmias time consuming more studies should be done

28 Patient 25 year woman 1. heart transplant 1996 DCMP after myocarditis Coxachi virus 2. heart transplant month post surgery Nausea / cough / dyspnea

29 LV function

30 Tissue Doppler Imaging

31 Circumferential strain

32 Reduced longitudinal LV function

33 Endomyocardial biopsy Acute antibody mediated cardiac transplant rejection C4D positive Cortisone treatment (i.v.) Plasmaferesis Anti-thymocyte globulin (ATG)

34 After 2 years

35 Summary Speckle tracking strain Accurate global and regional function Global strain predicts outcome Mechanical dispersion is a promising parameter for predicting malignant arrhythmias

36 Myocardial function Otto A Smiseth Espen Remme Helge Skulstad Svend Aakhus Stig Urheim Trond Vartdal Thomas Helle-Valle Anders Opdahl Ola Gjesdal Marit Kristine Smedsrud Kristina H Haugaa Kristoffer Russel Espen Bøe Andreas Espinoza Siv Hestenes Sebastian Sarvari Lillian Lundeby Thor Edvardsen Transplant / Heart Failure EP lab Cath. Lab. Inst. for surg. Research Inst. for medical research Dept of Radiology Intervention centre NTNU, Trondheim Sørlandet Hospital, Arendal Stavanger Univ Hosp Johns Hopkins University, Baltimore, US Katholieke Universitet, Leuven, Belgium