Copyright © 2005, The European Society of Cardiology
Significant improvement of myocardial function following cardiac support device implantation: Illustration by two-dimensional strain
Cardiologic Hospital, Pessac, Bordeaux 2 University, France
Received 8 July 2005; received in revised form 22 September 2005; accepted after revision 30 September 2005.
* Corresponding author. Hopital Cardiologique du Haut-Leveque, Service Pr Roudaut, Avenue de Magellan, 33604 Pessac, France. Tel.: +33 5576 56565/56485; fax: +33 5576 56012. karimserri{at}hotmail.com
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Cardiac support devices (CSD) offer a new therapeutic alternative to patients with end-stage refractory heart failure and severe left ventricle (LV) dilatation. Passive mechanical constraint has been shown to reduce LV dilatation as well as to improve LV function and patient symptoms. Using a new echocardiographic technique to evaluate myocardial strain from bidimensional acquisitions, we describe the case of a patient with significant improvement in global and regional LV functions, as well as LV dyssynchrony following CSD implantation.
Keywords: Echocardiography; Myocardial strain; Heart failure
A 53-year old woman was operated for end-stage ischemic cardiomyopathy with implantation of a CorCapTM cardiac support device (Acorn Cardiovascular) without mitral annuloplasty or coronary-artery bypass grafting (Fig. 1). One-year follow-up showed a significant overall improvement with increased left-ventricular (LV) ejection fraction (from 20% to 30%), decreased LV end-diastolic and end-systolic volumes (137 to 125ml and 109 to 86ml, respectively), complete regression of mitral regurgitation, and significantly improved functional class.
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Using a new software (EchoPac PC, GE), longitudinal and transverse strains were measured from bidimensional acquisitions. By tracing the endocardial contour on an end-diastolic frame, the software automatically tracks endocardial motion on subsequent frames by a technique of speckle tracking.1 Strain is then calculated as an average value between the subendocardial and epicardial layers. This method has advantages over traditional Doppler-based strain measurements, such as the absence of angle dependency, better reproducibility, and simple and rapid application.
This example demonstrates decreased myocardial deformation preoperatively (light-shaded colors, Fig. 2) corresponding to longitudinal strain values between 0 and –5% and for transverse strain between 0 and 14%. Significant improvement can be appreciated at one-year follow-up (darker coloring of the lateral wall and basal segments, Fig. 3), with values for longitudinal strain between –9 and –12% and for transverse strain between 17% and 41%.
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The software also allows determination of different timing intervals, such as the time to peak longitudinal or transverse strain. Alternatively, these data can be color-coded, allowing for rapid visual assessment of dyssynchrony. In this case, LV synchrony was significantly improved postoperatively, with simultaneous activation of septal and lateral walls (homogeneous green color, Fig. 3) as opposed to late activation of the lateral wall preoperatively (red color, Fig. 2). This finding was confirmed by other indices of LV dyssynchrony using Tissue Doppler Imaging (TDI). Using reconstructed TDI analysis, comparison of times to peak systolic velocity for the septal and lateral walls confirmed the presence of intraventricular dyssynchrony preoperatively, with postoperative restoration of normal LV synchrony (Fig. 4).
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The CorCapTM cardiac support device (CSD) is a mesh-like polyester fabric, which is placed around the heart during surgery. The procedure can be performed either alone, or with concomitant coronary-artery bypass grafting or mitral valve surgery. As opposed to ventricular assist devices, CSDs are passive mechanical devices, whose primary role is to decrease wall stress and myocyte stretch by providing end-diastolic circumferential myocardial support. Clinical and experimental studies have shown reduced LV dilatation, improved sphericity index, reverse remodelling as well as improved LV function and symptoms.2–4 Although the effects of CSDs on LV synchrony have never been investigated, it appears plausible that the various beneficial effects (decreased LV dilatation, reverse remodelling, improved ejection fraction) be accompanied by improvements in LV dyssynchrony. However, this will need to be studied before definitive conclusions can be drawn.
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- Leitman M., Lysyansky P., Sidenko S., Shir V., Peleg E., Binenbaum M., et al. Two-dimensional strain—a novel software for real-time quantitative echocardiographic assessment of myocardial function. J Am Soc Echocardiogr (2004) 17(10):1021–1029.[CrossRef][Web of Science][Medline]
- Oz M.C., Konertz W.F., Kleber F.X., Mohr F.W., Gummert J.F., Ostermeyer J., et al. Global surgical experience with the Acorn cardiac support device. J Thorac Cardiovasc Surg (2003) 126(4):983–991.
[Abstract/Free Full Text] - Blom A.S., Mukherjee R., Pilla J.J., Lowry A.S., Yarbrough W.M., Mingoia J.T., et al. Cardiac support device modifies left ventricular geometry and myocardial structure after myocardial infarction. Circulation (2005) 112(9):1274–1283.
[Abstract/Free Full Text] - Starling R.C., Jessup M. Worldwide clinical experience with the CorCap Cardiac Support Device. J Card Fail (2004) 10(Suppl. 6):S225–S233.[CrossRef][Web of Science][Medline]
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