Intravenous myocardial contrast echocardiography; recent advances

Until quite recently, contrast echocardiography for myocardial perfusion imaging has required the invasive direct injection of contrast agent into the coronary artery. Recent advances in ultrasonic technology and contrast agents have enabled myocardial contrast echocardiography with intra-venous injection of contrast agent in the clinical setting. This noninvasive technique has made the following clinical applications; left ventricular opacification, determination of the endocardium, enhancement of the Doppler flow signals, and detection of myocardial perfusion. Furthermore, in the near future, local drug delivery and pathology-specific targeted adherence of contrast agent may be added to the applications for the treatment. Intravenous myocardial contrast echocardiography is expected to have wide-ranging clinical potential.     

多普勒组织成像技术对冠心病室壁运动的价值探讨

目的探讨多普勒组织成像技术（DTI）对冠心病室壁运动评分中的应用价值。方法55例临床确诊的冠心病患者和31例健康体检的正常对照者左室壁节段长轴及短轴方向运动速度进行检测,并与常规二维超声心动图（2DE）检查结果对照分析。结果冠心病组前间隔与左室后壁运动异常节段短轴方向运动速度与正常组相应节段波群比较,除心尖水平、后壁二尖瓣口水平和低位乳头肌水平的A波无显著差异外,其余各指标均有明显的减低（P〈0．01）;冠心病室壁运动异常节段长轴方向的收缩速度（S）及舒张速度（E和A）也明显低于正常组相应节段的速度（P〈0．01）。结论DTI将M型超声与多普勒超声技术结合起来,不仅可以评价心脏整体功能,而且还能够对局部室壁的运动速度进行分析,是一有价值的显像技术,值得进一步研究。     

Prevalence of myocardial ischemia as depicted by regional wall motion abnormality in blacks.

Coronary artery disease with subsequent myocardial ischemia is a common cause of morbidity and mortality in the United States, and data are scarce on the prevalence of the disease in blacks. Regional wall motion abnormality correlates either directly or indirectly with myocardial ischemia. This study examines the two-dimensional (2-D) echocardiography of patients > or = 45 years for men and > or = 55 years at Metropolitan Nashville General Hospital, Nashville, Tennessee. A total of 601 2-D echocardiographic studies were performed on patients who presented with symptoms and signs of cardiovascular disease. Of these, 377 (62.7%) met the age criteria and formed the study group; 92 were excluded for various reasons, leaving 285 (75%) in the analysis group. A total of 80 (28.1%) patients had regional wall motion abnormality while 205 (71.9%) did not. On analysis of the 80 patients with regional wall motion abnormality, the segment of the heart commonly affected was the septal area, although more than one segment of the myocardium was affected in all of the patients. A total of 36 (45%) patients had normal left ventricular size. In relation to race, blacks had a higher prevalence of regional wall motion abnormality compared with whites (29.2% versus 26.2%, respectively), but the difference was not statistically significant. These prevalence rates indicate the importance of looking for this abnormality during echocardiographic evaluation of a patient. The presence of regional wall motion abnormality on 2-D echocardiography in the presence of other cardiovascular risk factors necessitates further investigation and management to minimize later complications of coronary artery disease.     

Wertigkeit der 2-D-Echokardiographie zur Erkennung belastungsinduzierter Wandbewegungsstörungen bei koronarer Herzerkrankung — Ein Vergleich mit der biplanen Cineventrikulographie

Summary To determine the accuracy of echocardiography in assessment of exercise-induced wall motion abnormalities, the results of stress-echocardiography were compared with exercise-cineventriculography.In 56 consecutive patients biplane cineventriculography at rest and immediately after supine bicycle exercise was performed. Cross-sectional echocardiography was obtained using the apical 2- and 4-chamber view for LV imaging under identical exercise conditions.In 6 of the 56 patients 2-D echo, in 8 patients LV-angio, and in 2 patients both methods were of inadequate quality during exercise.Thus, in 40 patients (34 patients had coronary artery disease) local wall motion of 360 wall segments was analysed. 49 segments (14%) of 24 patients showed exercise-induced ischemic wall motion abnormalities during cineventriculography. Only 24 of these 49 asynergics (49%) were also detected by 2-D-echo. Using cross-sectional echocardiography, ischemia related wall motion abnormalities were best detected lateraly and septaly, whereas apical asynergies were identified in 3 of 12 segments only.Thus, the clinical value of exercise 2-D echo as a screening method in patients suspected to have coronary artery disease is limited and restricted to patients with excellent visualization of the left ventricular endocardium.

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Abkürzungen 2-D-Echokardiographie zweidimensionale Echokardiographie - EKG Elektrokardiogramm - KHK koronare Herzerkrankung     

多普勒组织成像定量评价左室心肌运动异常的价值

目的 运用多普勒组织成像（DTI）技术对急性心肌缺血的检测,探讨其在左室心功能方面的应用价值。方法 对10头开胸的猪结扎左冠状动脉前降支,采用二维超声及DTI对照检测缺血部心肌的运动状况。结果 DTI显示心肌缺血在15s内收缩期、舒张早期运动速度显著降低,心肌色彩暗淡或缺失。而传统超声在结扎1min后才出现显著差异。结论 DTI技术既能通过色彩反映室壁缺血的范围,又能量化其运动速度,可为临床早期评价局部心肌缺血及功能异常提供充分证据。     

超声心动图对冠心病诊断的特异性、敏感性和ROC曲线分析

目的: 对超声心动图诊断冠心病的特异性、敏感性和ROC曲线进行分析,评价其诊断价值。方法: 对114例临床诊断标准为冠心病的患者进行超声心动图检查,观察有无室壁运动异常及其部位,并测量左室射血分数、左室舒张末期内径、左室收缩末期内径、二尖瓣舒张早期峰值流速(E)和舒张晚期峰值流速(A),计算E/A比值。上述患者进行冠脉造影检查,观察3支冠状动脉有无病变、狭窄及狭窄程度,狭窄≥50%诊断为冠心病。结果: 114例中经冠脉造影明确为冠心病患者96例。冠心病超声心动图表现为:节段性室壁运动减弱、消失或矛盾运动。超声心动图诊断冠心病的敏感性为79.2%,定位准确率为75.0%。以左室室壁运动评分≥4为截点,诊断冠心病的敏感性为82.2%,特异性为100%,ROC曲线下面积为0.95(0.89-0.98)。结论: 超声心动图是诊断冠心病首选的无创性诊断方法。利用室壁节段性运动评分诊断冠心病具有较高的特异性和敏感性。     

实时三维超声心动图评价左心室下壁节段收缩功能与运动心电图的相关性研究

应用实时三维超声心动图技术评价冠心病患者左心室壁节段功能及其与运动心电图试验的相关性。应用实时三维超声心动图分别测量30例健康者和30冠心病患者的左室壁节段节段每搏量（regionalstroke volume,rSV）、舒张末容积（rEDV）、节段射率（rPEF）,对所有受测者进行运动平板试验检查。60例受测者均获得了具有清晰内膜边界的实时三维图像和17节段容积-时间曲线;两组间17节段rSVr、EDVr、EF测值间差异有统计学意义（P〈0.05）,冠心病患者的节段功能与运动平板试验阳性的ST段改变高度相关（P〈0.05）。冠心病患者与正常人左室壁节段收缩功能存在差异,实时三维超声心动图定量评价左室壁节段收缩功能异常与运动平板试验阳性对冠心病的检测高度相关。     

Quantitative Three-Dimensional Wall Motion Analysis Predicts Ischemic Region Size and Location

Stress echocardiography is an important screening test for coronary artery disease. Currently, cardiologists rely on visual analysis of left ventricular (LV) wall motion abnormalities, which is subjective and qualitative. We previously used finite-element models of the regionally ischemic left ventricle to develop a wall motion measure, 3DFS, for predicting ischemic region size and location from real-time 3D echocardiography (RT3DE). The purpose of this study was to validate these methods against regional blood flow measurements during regional ischemia and to compare the accuracy of our methods to the current state of the art, visual scoring by trained cardiologists. We acquired RT3DE images during 20 brief (<2 min) coronary occlusions in dogs and determined ischemic region size and location by microsphere-based measurement of regional perfusion. We identified regions of abnormal wall motion using 3DFS and by blinded visual scoring. 3DFS predicted ischemic region size well (correlation r ² = 0.64 against microspheres, p < 0.0001), reducing error by more than half compared to visual scoring (8 ± 9% vs. 19 ± 14%, p < 0.05), while localizing the ischemic region with equal accuracy. We conclude that 3DFS is an objective, quantitative measure of wall motion that localizes acutely ischemic regions as accurately as wall motion scoring while providing superior quantification of ischemic region size.     

干细胞移植治疗缺血性心脏病：临床应用的可行性与安全性

背景：干细胞移植到受损的心脏组织,可以大量分化为心肌细胞,这项研究为缺血性心脏病治疗带来新的希望。 目的：探讨干细胞移植治疗缺血性心脏病的可行性与安全性。 方法：分析干细胞移植治疗缺血性心脏病安全性和可行性的多种试验方法。REPAIR-AMI试验是一项分析急性心肌梗死后即刻冠脉内移植骨髓祖细胞治疗效果的随机双盲、安慰剂对照的多中心研究;MAGIC Cell-3-DES试验是评价粒细胞集落刺激因子动员的干细胞疗法的安全性和冠脉内注射动员的外周血干细胞对急性心肌梗死和陈旧性心肌梗死的效果;BOOST试验是心肌梗死后经冠脉移植自体骨髓细胞的随机对照研究。PROTECT-CAD试验是一项随机、对照的直接将干细胞注入心肌治疗慢性缺血性心肌病的临床试验。 结果与结论：干细胞移植可以改善左心室的收缩功能和舒张功能以及冠脉血流储备,相关研究也得到验证。对于干细胞移植治疗缺血性心脏病,可以增加左室射血分数,临床事件较少,在药物洗脱支架治疗的基础上,干细胞治疗并不增加再狭窄风险。干细胞移植治疗缺血性心脏病安全可行,未来还需要进行大样本、长时间的大规模多中心的随机对照研究,来进一步评价其疗效和风险。     

Chemokine receptor (CCR2) genotype is associated with myocardial infarction and heart failure in patients under 65 years of age

Inflammation is associated with atherosclerosis of coronary arteries. Chemokines have an important role in inflammation. The CCR2 chemokine receptor mediates leukocyte chemoattraction, which is involved in the pathogenesis of coronary heart disease. We prospectively studied 1960 consecutive patients aged under 65 years and referred for a first-time left ventricular catheter. Left heart catheters were analyzed by two independent cardiologists for the presence of myocardial infarction (regional wall motion abnormality) and moderate or severely reduced left ventricular function on cineventriculography and presence of coronary atherosclerosis on angiography. Genotyping for CCR2 V64I polymorphism was performed. The presence of the rare allele of the CCR2 gene was significantly associated with a higher prevalence of myocardial infarction on cinventriculography (32.0% vs. 24.2%, moderately or severely reduced left ventricular function (14.0% vs. 9.5%) and NYHA class III or IV (16.7% vs. 12.2%). The association of the CCR2 genotype with heart failure was not independent of the presence of myocardial infarction in multivariate analysis. There was no association of the CCR2 genotype with coronary atherosclerosis. The CCR2 genotype seems to predispose patients for myocardial infarction before the age of 65 years. The higher prevalence of heart failure in gene carriers with the rare alle might be a consequence of myocardial infarction. If the CCR2 genotype is associated with higher mortality in the general population must be investigated in further studies.     

超声心动图曲线M型应变率成像研究冠心病心肌缺血

目的应用曲线M型应变率成像（CMM-SRI）技术研究冠心病缺血心肌的图像特点，重点探讨收缩-舒张转换时间（Tcec）的改变。方法冠心病组和正常对照组各60例，观察左心室CMM-SRI图像特点，定量检测各节段Tcec，冠状动脉造影确定缺血节段，比较冠心病组左心室壁各节段与对照组之间Tcec的差异。结果无缺血节段的室壁，CMM-SRI图像红、蓝颜色转换的交界线基本呈直线，有缺血节段的室壁，交界线呈不规则曲线；缺血节段Tcec延长，与对照组比较绝大多数缺血节段差异有统计学意义。结论CMM-SRI可定量分析缺血心肌Tcec的改变，提示CMM-SRI技术可用于检测缺血心肌。     

Chronic hibernating myocardium in sheep can occur without degenerating events and is reversed after revascularization

IntroductionOur goal was to show that blunting of myocardial flow reserve is mainly involved in adaptive chronic myocardial hibernation without apparent cardiomyocyte degeneration.Methods and resultsSheep chronically instrumented with critical multivessel stenosis and/or percutaneous transluminal coronary angioplasty (PTCA)-induced revascularization were allowed to run and feed in the open for 2 and 5 months, respectively. Regional myocardial blood flow (MBF) with colored microspheres, regional and global left ventricular function and dimensions (2D echocardiography), and myocardial structure were studied. In sheep with a critical stenosis, a progressive increase in left ventricular end-diastolic and end-systolic cavity area and a decrease in fractional area change were found. Fraction of wall thickness decreased in all left ventricular wall segments. MBF was slightly but not significantly decreased at rest at 2 months. Morphological quantification revealed a rather small but significant increase in diffusely distributed connective tissue, cardiomyocyte hypertrophy, and presence of viable myocardium of which almost 30 % of the myocytes showed depletion of sarcomeres and accumulation of glycogen. The extent of myolysis in the transmural layer correlated with the degree of left ventricular dilation. Structural degeneration of cardiomyocytes was not observed. Balloon dilatation (PTCA) of one of the coronary artery stenoses at 10 weeks revealed recovery of fraction of wall thickness and near normalization of global subcellular structure at 20 weeks.ConclusionThese data indicate that chronic reduction of coronary reserve by itself can induce ischemic cardiomyopathy characterized by left ventricular dilatation, depressed regional and global function, adaptive chronic myocardial hibernation, reactive fibrosis and cardiomyocyte hypertrophy in the absence of obvious degenerative phenomena.SummaryReduction of myocardial flow reserve due to chronic coronary artery stenosis in sheep induces adaptive myocardial hibernation without involvement of degenerative phenomena.     

Cardiovascular reactivity and mental stress-induced myocardial ischemia in patients with coronary artery disease

This report evaluates the relationships of hemodynamic reactivity and determinants of myocardial oxygen demand to myocardial ischemia during mental stress in coronary artery disease patients. Thirty-nine patients and 12 controls were studied by radionuclide ventriculography during three mental tasks (arithmetic, Stroop task, and simulated public speaking). Patients were subdivided into three groups based on the severity of ischemic wall motion responses to the mental stressors. Results revealed that systolic blood pressure (SBP) levels during the mental tasks and SBP reactivity (increases) to stress were highest for the severely ischemic group, lowest for controls, with the mild-moderate ischemic and nonischemic patients in between. Severely ischemic patients started out with lower double product (heart rate x SBP) levels, and reached higher levels during the Stroop and speech tasks. There were no reliable group effects for diastolic blood pressure, heart rate, or left ventricular end-diastolic volumes. Among severely ischemic patients, the most potent task in eliciting ischemia (the speech) was associated with higher cardiovascular levels and elicited greater heart rate, double product, and ventricular volume responses. The present data indicate a relationship between cardiovascular levels and reactivity and the magnitude of ischemia induced by mental stress.     

冠状动脉造影和三磷酸腺苷负荷超声心动图对川崎病冠状动脉损害远期追踪的价值

目的探讨选择性冠状动脉造影及三磷酸腺苷负荷超声心动图对川崎病（KD）冠状动脉损害远期追踪的价值。方法选取1999至2007年广州市儿童医院KD急性期超声心动图检查发现合并冠状动脉损害的患儿,同时采用三磷酸腺苷负荷超声心动图及选择性冠状动脉造影于恢复期进行远期随访。结果依据纳入标准和排除标准逐层筛选,确定9例KD患儿为本研究的样本。男8例,女1例,急性期发病年龄为1-10岁,平均（4.44±3.09）岁。检查时年龄4-12岁,平均（7.89±2.62）岁。追踪时间1.5~7年,平均（3.44±1.67）年。急性期超声心动图示9例患儿中冠状动脉巨瘤5例,冠状动脉瘤3例,冠状动脉扩张1例。三磷酸腺苷负荷超声心动图示：节段性室壁运动异常6/9例;冠状动脉血流储备下降5/9例。冠状动脉造影示：双侧主干冠状动脉瘤4例,同时伴远端动脉瘤3处,冠状动脉左前降支狭窄1处,并冠状动脉扭曲,狭窄或充盈缺损3处,附近侧支血管形成1处;左前降支动脉瘤、右冠状动脉闭塞伴侧支循环形成1例,冠状动脉扩张4例。与同期超声心动图检查比较,冠状动脉造影新发现冠状动脉远端瘤3处,右冠状动脉远端狭窄2处,左前降支狭窄1处,右冠状动脉闭塞伴侧支血管形成1例。5例三磷酸腺苷负荷超声心动图检查结果阳性者与冠状动脉造影比较：均发现相应冠状动脉支狭窄或充盈缺损表现;1例三磷酸腺苷负荷超声心动图检查结果阳性,冠状动脉造影仅见轻度冠状动脉扩张。结论KD合并冠状动脉损害特别是动脉瘤造成的心脏损害可长期存在。对于远期追踪观察KD患儿冠状动脉病变,三磷酸腺苷负荷超声心动图具无创、安全可靠的优点,是判断心肌缺血的重要方法;选择性冠状动脉造影可明确显示冠状动脉病变的位置、形态、数目及严重程度,特别对冠状动脉狭窄、闭塞及远端病变能做出准确的评估。两种方?     

Microvascular integrity as a predictor of left ventricular remodeling after acute anterior wall myocardial infarction.

The purpose of this study was to investigate the relation of microvascular integrity and ventricular remodeling after acute myocardial infarction. Twenty-six patients with first acute anterior myocardial infarction were studied before discharge with myocardial contrast echocardiography (MCE). Opacification index (OI) and wall motion index were calculated in the left anterior descending artery territory and left ventricular diastolic volume was measured at baseline and during a 9-month follow-up. In total 26 patients, the regional wall motion improved but the left ventricular volume and global function was not changed significantly at follow-up. When the patients were divided into 3 groups according to opacification index (> or = 0.75, 0.5 approximately 0.75, < or = 0.5) at baseline, functional recovery was not observed and significant left ventricular dilatation was developed in patients with < or = 0.5 OI. Among the baseline echo-parameters such as ejection fraction, wall motion score, left ventricular volume and opacification index, the best predictor for long term left ventricular dilatation was the opacification index by multivariate analysis. In patients with acute anterior wall infarction the assessment of microvascular integrity by MCE at acute stage provides useful information regarding recovery of dysfunctional regional wall motion and ventricular remodeling.     

心肌声学造影在冠状动脉微血管疾病中的临床应用进展

冠状动脉微血管疾病是心肌微循环异常的临床综合征,其出现打破了以往对心脏疾病认识的局限,正引起越来越多的关注。心肌声学造影是评估心肌微循环灌注情况的新技术,有望成为该病的重要检查方法。本文简要综述心肌声学造影的作用机制、冠状动脉微血管疾病的相关概念以及心肌声学造影在冠状动脉微血管疾病的临床诊断、治疗及预后评估方面的作用。     

The relation between viable segments and left ventricular ejection fraction improvement

For patients with coronary artery disease and left ventricular dysfunction who undergo revascularization, it is important to estimate the left ventricular ejection fraction (LVEF) improvement after revascularization, as this is a strong indicator of the long-term outcome. Identification of viable segments from echocardiography has been considered a predictive sign of LVEF improvement. However, a quantitative relation between segmental function recovery and global ejection fraction improvement has not been established. There is a clinical need to determine parameters that are predictive to LVEF improvement. A cylindrical left ventricular model is proposed to establish the relation between segmental myocardial function and LVEF based on a 12-segment echocardiograph model. Model results show that LVEF improvement is directly related to the contraction ratio in normal segments and a weighted sum of the number of viable segments that recover to normal or hypokinetic, which is equal to a weighted sum of the change in wall motion scores. This new combined parameter is a better predictor of the amount of LVEF improvement than the total number of viable segments or preoperative ejection fraction. The predictive value of the model was illustrated in a group of four patients with coronary artery disease who underwent revascularization.     

Verdachtsdiagnose akuter Myokardinfarkt bei akuter regionaler Myokarditis

Summary We report on 4 patients in whom acute myocardial infarction was suspected due to acute onset of chest pain and elevation of the ST-segment. Furthermore in 2 patients the echocardiography revealed regional abnormal wall motion on admission, the others later. Coronary angiography showed normal coronary arteries in all cases. The left ventricular angiogram namely demonstrated regional abnormal wall motion. 2 patients developed a slight increase of the creatine phosphokinase including the CK-MB. Only one patient mentioned a grippal infectious disease 6 weeks before. During the hospital time all patients presented one of the inflammatory signs. A demonstration of the infectious agent was not possible in any of the cases. The endomyocardial biopsy was positive in two cases, and slightly positive in one case.Sometimes regional myocarditis might imitate an acute myocardial infarction. Both, the exact anamnesis and coronary angiography are necessary. The performance of an endomyocardial biopsy is desirable.

     

Ischemic myocardial necrosis and papillary muscle dysfunction in infants and children

Ischemic myocardial and papillary muscle dysfunction has considerable implication in newborn infants and children with normal or malformed hearts. Papillary muscle dysfunction in adults primarily involves coronary artery occlusion and ischemic necrosis in the left ventricle and papillary muscles. Infants and children rarely develop coronary artery occlusion. Their myocardial dysfunction and injury occurs with nearly equal frequency in both ventricles as a result of underperfusion from a wide range of causes, including severe birth asphyxia, congenital heart disease, and complications of premature delivery. A history of cardiogenic shock, acute congestive heart failure with cyanosis and atrioventricular murmur, or persistent fetal circulation in a newborn without congenital heart disease should alert the pathologist to the possibility of ischemic myocardial necrosis (IMN). Older infants with ventricular hypertrophy, persistent pulmonary hypertension (PPHN), bronchopulmonary dysplasia (BPD), and those with malformed hearts involving severe ventricular hypertension due to outflow obstruction or pulmonary hypertension may have IMN, fibrosis, or dystrophic calcification alone or in combination. Animal models of adult ischemic cardiac injury may not be suitable for study of the newborn.     

超声心动图观察急性心肌梗塞开通相关冠状动脉对左室重构及心功能的影响

目的动态观察急性心肌梗塞1～4周对梗塞相关冠状动脉(IRCA)开通后对左室重构及心功能的影响。方法对首发急性心肌梗塞患者通过多普勒超声心动图对照观察冠状动脉开通前、后左室重构及左室功能指标。结果术前组与术后组相比,1年后左室舒张容积(EDA)、左室收缩末容积(ESV)、左室舒张末弧长(EDC)及节段性室壁运动异常(RWMA)范围均减小,(P<0.01),左室射血分数(EF)升高,而RWMA程度改善。结论急性心肌梗塞均有不同程度左室形态及功能改变,对IRCA开通能有效地防止左室重构,保护左室功能。