• Users Online: 603
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 81-97

Short-term outcome after percutaneous coronary intervention in patients with impaired left ventricular systolic function by conventional, tissue Doppler, and speckle-tracking echocardiographic study


Department of Cardiology, Al-Azhar University, Assiut, Egypt

Date of Submission14-Dec-2019
Date of Decision04-Jan-2020
Date of Acceptance20-Jan-2020
Date of Web Publication26-Mar-2020

Correspondence Address:
Mohamed M Ahmed
Assiut, 71611
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_165_19

Rights and Permissions
  Abstract 


Background Myocardial revascularization with chronic left ventricular (LV) dysfunction improved LV functional and survival. Echocardiographic (echo) remains the test for assessing cardiac function in clinical practice. Tissue Doppler imaging (TDI) and speckle-tracking echocardiography (STE) are new techniques in assessing LV functions.
Aim To assess the short-term outcome of LV functions after percutaneous coronary intervention (PCI) in impaired LV systolic function using conventional, tissue Doppler, and STE.
Patients and methods This study included 100 patients presented with ischemic cardiac chest pain, ejection fraction (EF) less than 55%, significant coronary occlusion (>70%) in a recent angiography, and were candidates for PCI. Echo study was done before and 3 months after PCI including conventional echo and TDI of both LV functions. Moreover, two-dimensional-STE: automated function imaging is used to reflect the systolic LV function by assessment of the LV global longitudinal strain (GLS).
Results Three months after PCI, there was a significant increase in LV systolic function: EF (by M-mode and modified Simpson’s methods), FS (by M-mode), and mean Sm (by TDI), GLS (by STE). Moreover, LV diastolic function significantly increased: E wave velocity and E/A ratio, with no change in A wave velocity (by PW Doppler) and E’ velocity and E/E’ ratio (by TDI). EF measured by both M-mode and with modified Simpson’s methods was significantly correlated with average Sm (by TDI) and GLS (by STE) both before and after PCI. Moreover, Sm and GLS were positively correlated both before and after PCI. There was no statistically significant correlation between E/A ratio and average E’ both before and after PCI. E/A ratio was not correlated with E/E’ ratio before PCI but significantly correlated after PCI. Average E’ and E/E’ ratio were significantly correlated before PCI but not after PCI.
Conclusion Significant improvement in the global LV systolic and diastolic functions occurs after PCI in patients with baseline impaired LV systolic function owing to coronary artery disease as assessed using conventional echo, TDI, and STE.

Keywords: coronary artery disease, left ventricular functions, echocardiography, percutaneous coronary intervention, speckle-tracking echocardiography, tissue Doppler imaging


How to cite this article:
Ahmed MM. Short-term outcome after percutaneous coronary intervention in patients with impaired left ventricular systolic function by conventional, tissue Doppler, and speckle-tracking echocardiographic study. Al-Azhar Assiut Med J 2020;18:81-97

How to cite this URL:
Ahmed MM. Short-term outcome after percutaneous coronary intervention in patients with impaired left ventricular systolic function by conventional, tissue Doppler, and speckle-tracking echocardiographic study. Al-Azhar Assiut Med J [serial online] 2020 [cited 2020 Jul 12];18:81-97. Available from: http://www.azmj.eg.net/text.asp?2020/18/1/81/281352




  Introduction Top


Left ventricular (LV) function is an important predictor of outcome in patients with coronary artery disease (CAD). Extensive myocardial ischemia can cause decreased LV contractility and function [1]. It was believed that LV dysfunction at rest was the result of ongoing ischemia or myocardial infarction. Thirty-three years ago, many studies of patients undergoing coronary artery bypass graft (CABG) surgery for angina led to the discovery of improvement or even normalization of the LV dysfunction with surgical myocardial revascularization, that is, there was viable myocardium (hibernating myocardium) in areas of LV dysfunction [2]. Percutaneous coronary intervention (PCI) is an established procedure for the treatment of CAD. Its usefulness in symptom relief is well established [3]. However, the effect of PCI on systolic and diastolic functions in patients with impaired baseline LV systolic function is a challenging issue. An accurate assessment of LV function by determining the LV volumes and the ejection fraction (EF) is important in evaluating the prognoses of patients with CAD [4]. Several methods have been developed over the years to assess both qualitatively and quantitatively different parameters of LV function. Echocardiography (echo) has been the most popular, as it is a noninvasive technique that can provide information on the structure of the heart as well as on its function. In addition, it can help assessment of the etiology of the heart condition and improve the understanding of the underlying pathophysiology, and at the same time, it can be repeated as many times as needed with no discomfort for the patient [5]. Echo remains the first-line test for assessing cardiac function in routine clinical practice, and left ventricular ejection fraction (LVEF) is the most popular index of myocardial systolic function [6]. Tissue Doppler imaging (TDI) has emerged as a sensitive and quantitative measure of both systolic and diastolic longitudinal myocardial functions [7]. Evaluation of myocardial velocity with TDI in systole and diastole is a marker of ventricular function in systole and diastole, respectively. TDI findings are not influenced significantly by the flow of blood, so they can assess systolic and diastolic functions simultaneously [8]. Speckle-tracking echocardiography (STE) is a new noninvasive imaging technique that quantitatively analyzes global and regional myocardial function. Its evaluation is based on tracking natural acoustic reflections and interference patterns within an ultrasound window [9]. A large amount of published data has described the accuracy and clinical applications of STE with the ability to elaborate the myocardial deformation in longitudinal, radial, and circumferential directions [10]. Two-dimensional (2D)-STE is superior for EF measurements because it is angle independent, less subject to artifacts, and easier to conduct than Doppler-derived tissue velocity imaging. Based on 2D-STE, automated function imaging (AFI) is used to reflect the systolic LV function by assessment of the LV global longitudinal strain (GLS) [11]. The potential of 2D-STE has been investigated in numerous experimental and clinical studies for exploration of systolic and diastolic ventricular function [12].


  Aim Top


The aim of this study is to assess the short-term echo outcome (in terms of global LV systolic and diastolic functions) after PCI in patients with impaired LV systolic function using conventional, tissue Doppler, and STE.


  Patients and methods Top


This study included 100 patients who presented with ischemic cardiac chest pain defined as characteristic substernal discomfort provoked by stress and relieved by rest or sublingual nitroglycerin (Manual of cardiovascular medicine, 4th ed. by Brian P. Griffin), LV systolic dysfunction (EF <52% for men and <54% for women [13]), significant coronary artery stenosis (>70% [14]) in recent coronary angiography (CA), and were candidates for PCI. The study is approved by the ethical committee of Al-Azhar Assiut Faculty of Medicine. The study was conducted in the Cardiology Department, Al-Hussein University Hospital, during the period from April 2015 to April 2017.

Inclusion criteria

Patients with CAD and LV systolic dysfunction (as defined above) who are candidates for PCI were included.

Exclusion criteria

The following were the exclusion criteria:

(a) Patients with any contraindication for CA and PCI, for example, hemorrhagic diathesis and contraindications to the use of aspirin and thienopyridines. (b) Patients with acute or previous STEMI. (c) Prior PCI or CABG. (d) Primary valvulopathy, myocarditis or pericarditis, pericardial effusion, and known case of cardiomyopathy (dilated, hypertrophic, or restrictive cardiomyopathy). (e) Patients with congenital heart disease. (f) Poor echo window patients. (g)Clinically or hemodynamically unstable patients. (h) Non-sinus rhythm patients.

Methods

All patients were subjected to the following: (a) informed written consent about the nature of the study. (b) Full medical history. (c) Full clinical examination. (d) Full laboratory investigation and 12-lead resting ECG. (e) Complete transthoracic echo study performed before PCI and repeated 3 months after PCI, including (a) conventional echo: all echo examinations were done with the use of Philips iE33 (Bothell, Washington, USA), equipped with a broadband S5-1 transducer (frequency transmitted: 1.7 MHz; received: 3.4 MHz). Standard views and measurements (including 2D mode, M-mode, and Doppler mode) were taken while the patient at rest in the left lateral decubitus position with synchronized ECG according to the recommendations of the American Society of Echocardiography. After measurement of LV dimensions, they are used to calculate the LVEF and FS automatically depending on the following equations: FS (%)=[LV end-diastolic dimension–LV end-systolic dimension/LV end-diastolic dimension]×100%, and LVEF (%)=[LV end-diastolic volume. −LV end-systolic volume/LV end-diastolic volume]×100%. LVEF of less than 52% for men and less than 54% for women are suggestive of abnormal LV systolic function. (b) Modified Simpson’s method: two orthogonal views − apical four-chamber and apical two-chamber − are obtained, and manual tracing of endocardial borders at end systole and end diastole is performed. Automated software divides the LV into a stack of discs oriented perpendicular to the long axis of the ventricle, and summates their individual volumes. From the end-diastolic frame, the end-diastolic volume (EDV) is calculated. From the end-systolic frame, the end-systolic volume (ESV) is calculated [13]. The stroke volume is then calculated as follows: stroke volume <td:glyph name="dbnd"/>EDV–ESV (ml). The EF is therefore, EF=[(EDV–ESV)/EDV]×100%. The LV diastolic function: the following methods were used in this study for evaluation of the LV diastolic function: (a) mitral inflow velocities, the transmitral peak early diastolic velocity (E wave), peak late diastolic velocity (A wave), and E/A ratio, where peak early diastolic velocity (E wave) corresponds to rapid filling phase measured in cm/s by drawing a perpendicular line from the summit of the wave to the baseline, peak late diastolic velocity (A wave) corresponds atrial contraction phase measured in cm/s by drawing a perpendicular line from the summit of the wave to the baseline, and E/A ratio indicated grade of diastolic dysfunction: E/A ratio less than 0.8 indicates grade I diastolic dysfunction, E/A ratio 0.8–1.5 indicates grade II diastolic dysfunction, and E/A ratio more than or equal to 2 indicates grade III diastolic dysfunction [15]. (b) TDI was performed by activating the TDI function, adjusting the spectral pulsed Doppler signal filters until a Nyquist limit of 15–20 cm/s, and using the minimal optimal gain. Spectral waveforms from pulse wave tissue Doppler are used to measure peak myocardial velocities. The apical views allow the most favorable alignment of the transducer beam to the longitudinal motion of the heart. The sample volume is typically placed in the ventricular myocardium immediately adjacent to the mitral annulus to minimize contamination from the translational and rotational motion of the heart and to maximize the longitudinal excursion of the annulus as it descends toward the apex in systole and ascends away from the apex in diastole. Thus, a cardiac cycle is represented by three waveforms: (a) systolic myocardial velocity (Sm), above the baseline; (b) early diastolic myocardial relaxation velocity (E’), below the baseline; and (c) myocardial velocity associated with atrial contraction (A’), below the baseline. To assess the global LV diastolic function by tissue Doppler, a 3-mm sample volume was placed at the septal and lateral mitral annulus to obtain early diastolic annular velocity (E’). E/E’ ratio was obtained by averaging the septal and lateral E’ velocities, as recommended in patients with wall motion abnormalities [16]. The cutoff values for abnormal E’ velocities are septal E’ less than 7 cm/s, lateral E’ less than 10 cm/s, and average E/E’ ratio more than 14. E/E’ ratio less than or equal to 8 usually indicate normal LV filling pressure; E/E’ ratio values more than or equal to 8, grade I diastolic dysfunction; values of 9–12 indicate grade II diastolic dysfunction; and values more than or equal to 13 have high specificity for increased LV filling pressures (grade III diastolic dysfunction) [15]. To assess the global LV systolic function by tissue Doppler, the mitral annular peak systolic myocardial velocities (Sm) were recorded at the septal, lateral, anterior, and inferior LV sites, and then an average value from the aforementioned four sites was used to assess global systolic function. According to previous studies, an Sm value less than 7.5 cm/s was considered as reduced longitudinal systolic function [17]. Sm averaged from six sites around the mitral annulus correlates well with LVEF, and a cutoff of more than or equal to 7.5 cm/s had a sensitivity of 79% and a specificity of 88% in predicting normal LVEF [18]. (c) STE study was performed before PCI and repeated 3 months after PCI as a follow-up. Gray-scale 2D ECG-triggered, apical 2-chamber, apical long axis, and apical 4-chamber cine-loops were recorded and digitally stored with high frame rates (more than 60 frames/s) for offline analysis. From each view, one cardiac cycle was selected for analysis of 2D strain. Based on 2D-STE, AFI is used to reflect the systolic LV function by assessment of the LV GLS. AFI method is used as follows: two points were applied on each side of the mitral valve and a third point at the apex of the LV followed by automated tracing of endocardial and epicardial borders defining region of interest (ROI). Manual readjustment of endocardial tracing and ROI were performed to achieve optimal alignment if necessary. Aortic valve closure marked end systole and was defined automatically in the apical long-axis view at the end of the T-wave of the corresponding electrocardiographic tracing and used as a reference for the four-chamber and two-chamber views. Time of aortic valve closure was also visually confirmed and adjusted if necessary. The ROI outlining the entire LV wall was divided into six segments (two basal segments, two mid segments, and two apical segments). The peak systolic strain values in a 17-segment LV model were used in the present study. Segmental LS was calculated as the percentage of lengthening or shortening, and the results for each plane were displayed. The results for all three planes were then combined in a single bull’s-eye summary. The sum of LS, averaged over the number of segments with interpretive scores, gave the GLS. A computer algorithm calculated peak systolic strain values within each segment together with global peak systolic strain from each view, and lastly, overall averaged global longitudinal peak systolic strain (a global peak systolic strain) of the apical 4-chamber, apical 2-chamber, and apical long axis views is measured. Normal values for the GLS are in the range of −18 to −22% [19]. A peak GLS in the range of −20% can be expected in a healthy person, and the lower the absolute value of strain below this value, the more likely it is to be abnormal [13]. CA and revascularization technique (elective PCI): CA was performed by the percutaneous femoral approach. CA were obtained for each coronary vessel in at least two projections. Lesion locations were assessed, and percent diameter stenosis was measured for each coronary lesion according to the American Heart Association classification. We assessed the number of affected vessels, using a cutoff of percent diameter stenosis more than or equal to 70% for three epicardial vessels and more than or equal to 50% for LM coronary artery [14]. The analysis of the CA was performed visually by an experienced operator who was blinded to the results of the echo examinations. The procedures of balloon angioplasty and coronary stenting were performed according to the standard technique. Preinterventional medications included intravenous heparin (10 000 to 15 000 IU), to keep the activated clotting time more than 300 s during the procedure, and oral clopidogrel 300 mg loading dose 24 h before the procedure. The procedure was considered successful if the residual stenosis in the target lesion was less than 30% and major complication did not occur after PCI [13].

Statistical analysis

The data were tested for normality using the Anderson–Darling test and for homogeneity variances before further statistical analysis. Continuous variables were described by mean and SD. The variables were EF and FS (by M-mode and modified Simpson’s methods); mitral inflow velocities (E and A wave velocities) and E/A ratio by conventional Doppler echo; average peak systolic myocardial velocity (Sm), average diastolic myocardial velocity (E’), and average E/E’ ratio by TDI; and GLS by STE. Comparisons between continuous data were done using Student t test. Pearson correlation coefficient (r) was used to assess the correlation between quantitative variables. A two-tailed P value of less than 0.05 was considered statistically significant. All analyses were performed with the IBM SPSS (statistical package for social science) 20.0 software (IBM SPSS Inc., Chicago, US).


  Results Top


Study population

The study included 50 patients who presented with ischemic cardiac chest pain, LV systolic dysfunction (EF <52% for men and <54% for women), significant coronary occlusion (>70%) in recent CA, and were candidates for PCI. The following patients’ demographic and clinical characteristics were assessed: (a) age: the age of the patients ranged from 44 to 68 years, with the mean age of 55.2±9.3 years. (b) Sex: the patients comprised 72 (72%) males and 28 (28%) females. (c) diabetes mellitus: the patients included 48 (48%) diabetics and 52 (52%) nondiabetics. (d) hypertension: the patients included 52 (52%) hypertensive and 48 (48%) nonhypertensive. (e) Smoking: the patients included 40 (40%) smokers and 60 (60%) nonsmokers, of which 24 were exsmokers. (f) Family history of ischemic heart disease (IHD): 38 (38%) patients had a family history of IHD and 62 (62%) with no family history of IHD. (g) Two or more clinical risk factors: 72 (72%) patients had two or more clinical risk factors and 28 (28%) with only one clinical risk factor ([Table 1]).
Table 1 Demographic and clinical characteristic of the patients

Click here to view


Systolic function: (a) EF before PCI: the mean EF was 47.8±4.1% by M-mode method and 43.5±3.9% by modified Simpson’s metho, and after PCI, the mean EF increased to 57.4±2.0% by M-mode method and to 52.8±2.2% by modified Simpson’s method. There was a highly significant statistical difference before and after PCI regarding the mean EF by M-mode and modified Simpson’s methods (P<0.001) ([Figure 1]).
Figure 1 Diagram showing the mean EF by M-mode and modified Simpson’s methods before and after PCI. EF, ejection fraction; PCI, percutaneous coronary intervention.

Click here to view


FS before PCI: the mean FS was 23.7±2.1% by M-mode method, and after PCI, the mean FS increased to 28.9±1.5% by M-mode method There was a highly significant statistical difference before and after PCI regarding the mean FS by M-mode (P<0.001) ([Figure 2]).
Figure 2 Diagram showing the mean FS by M-mode method before and after PCI. PCI, percutaneous coronary intervention.

Click here to view


Average Sm velocity by TDI: before PCI, the mean average Sm velocity was 6.4±1.7 cm/s, and after PCI, the mean average Sm velocity increased to 10.9±1.2 cm/s. There was a highly significant statistical difference before and after PCI regarding the mean average Sm velocity by TDI (P<0.001) ([Figure 3]).
Figure 3 Diagram showing the mean average Sm by TDI before and after PCI. PCI, percutaneous coronary intervention; TDI, tissue Doppler imaging.

Click here to view


GLS by STE: before PCI, the mean GLS was −7.0±2.1%, and after PCI, the mean GLS increased to −13.9±1.7%. There was a highly significant statistical difference before and after PCI regarding the mean GLS by STE (P<0.001) ([Figure 4] and [Table 2]).
Figure 4 Diagram showing the mean GLS by STE before and after PCI. GLS, global longitudinal strain; PCI, percutaneous coronary intervention; STE, speckle-tracking echocardiography.

Click here to view
Table 2 Comparison between the systolic echocardiographic parameters of the patients before and after percutaneous coronary intervention

Click here to view


Patients who regained normal LV systolic function by different methods (conventional, tissue Doppler. and STE) ([Figure 5]):
Figure 5 Diagram showing the patients who regained normal LV systolic function by different echo methods. Echo, echocardiographic; LV, left ventricular.

Click here to view


Diastolic function: (a) E wave velocity by PW Doppler: before PCI, the mean E wave velocity was 62±10.6 cm/s, and after PCI, the mean E wave velocity increased to 78±15.6 cm/s. There was a highly significant statistical difference before and after PCI regarding the mean E wave velocity by PW Doppler (P<0.001). (b) A wave velocity by PW Doppler: before PCI, the mean A wave velocity was 59.4±15.1 cm/s, and after PCI, the mean A wave velocity increased to 73±11.2 cm/s. There was a highly significant statistical difference before and after PCI regarding the mean A wave velocity by PW Doppler (P<0.001).

E/A ratio: before PCI, the mean E/A ratio was 1.1±0.4, and after PCI, the mean E/A ratio decreased to 1.1±0.3. There was no significant statistical difference before and after PCI regarding the mean E/A ratio (P=0.767).

Average E’ velocity by TDI: before PCI, the mean average E’ velocity was 5.3±1.2 cm/s, and after PCI, the mean average E’ velocity increased to 8.4±0.7 cm/s. There was a highly significant statistical difference before and after PCI regarding the mean average E’ velocity by TDI (P<0.001) ([Figure 6]).
Figure 6 Diagram showing the mean average E’ velocity by TDI before and after PCI. PCI, percutaneous coronary intervention; TDI, tissue Doppler imaging

Click here to view


E/E’ ratio: before PCI, the mean E/E’ ratio was 12.4±3.3, and after PCI, the mean E/E’ ratio wave decreased to 9.3±1.9. There was a highly significant statistical difference before and after PCI regarding the mean E/E’ ratio (P<0.001) ([Figure 7] and [Table 3]).
Figure 7 Diagram showing the mean E/E’ ratio before and after PCI. PCI, percutaneous coronary intervention.

Click here to view
Table 3 Comparison between the diastolic echocardiographic parameters of the patients before and after percutaneous coronary intervention

Click here to view


Regarding the patients who showed improvement of LV diastolic function by conventional and tissue Doppler echo, improvement was seen from GIII to II in 22 (22%) patients, and from GII to GI in 28 (28%) patients, and from GIII to GI in four (4%) patients.

Correlation between EF by M-mode method and average Sm velocity by TDI before and after PCI: there was a statistically significant positive correlation between EF and average Sm velocity before [correlation coefficient (r)=0.986 and P<0.01] and after [correlation coefficient (r)=0.957 and P<0.01] PCI ([Figure 8] and [Figure 9]).
Figure 8 Diagram showing the correlation between EF by M-mode and average Sm velocity by TDI before PCI. EF, ejection fraction; PCI, percutaneous coronary intervention; TDI, tissue Doppler imaging.

Click here to view
Figure 9 Diagram showing the correlation between EF by M-mode and average Sm velocity by TDI after PCI. EF, ejection fraction; PCI, percutaneous coronary intervention; TDI, tissue Doppler imaging.

Click here to view


Correlation between EF by M-mode method and GLS by STE before and after PCI: there was a statistically significant positive correlation between EF and GLS before [correlation coefficient (r)=0.950 and P=0.000] and after [correlation coefficient (r)=0.961 and P=0.000] PCI ([Figure 10] and [Figure 11], [Table 4]).
Figure 10 Diagram showing the correlation between EF by M-mode and GLS by STE before PCI. EF, ejection fraction; GLS, global longitudinal strain; PCI, percutaneous coronary intervention; STE, speckle-tracking echocardiography.

Click here to view
Figure 11 Diagram showing the correlation between EF by M-mode and GLS by STE after PCI. EF, ejection fraction; GLS, global longitudinal strain; PCI, percutaneous coronary intervention; STE, speckle-tracking echocardiography.

Click here to view
Table 4 Correlation between ejection fraction by M-mode method and average Sm by tissue Doppler imaging and global longitudinal strain by speckle-tracking echocardiography before and after percutaneous coronary intervention

Click here to view


Correlation between EF by modified Simpson’s method and average Sm velocity by TDI before and after PCI: there was a statistically significant positive correlation between EF and average Sm velocity before [correlation coefficient (r)=0.974 and P<0.01] and after [correlation coefficient (r)=0.912 and P<0.01] PCI ([Figure 12] and [Figure 13]).
Figure 12 Diagram showing the correlation between EF by modified Simpson’s method and average Sm velocity by TDI before PCI. EF, ejection fraction; PCI, percutaneous coronary intervention; TDI, tissue Doppler imaging.

Click here to view
Figure 13 Diagram showing the correlation between EF by modified Simpson’s method and average Sm velocity by TDI after PCI. EF, ejection fraction; PCI, percutaneous coronary intervention; TDI, tissue Doppler imaging.

Click here to view


Correlation between EF by modified Simpson’s method and GLS by STE before and after PCI: there was a statistically significant positive correlation between EF and GLS before [correlation coefficient (r)=0.939 and P<0.01] and after [correlation coefficient (r)=0.935 and P<0.01] PCI ([Figure 14] and [Figure 15], [Table 5]).
Figure 14 Diagram showing the correlation between EF by modified Simpson’s method and GLS by STE before PCI. EF, ejection fraction; GLS, global longitudinal strain; PCI, percutaneous coronary intervention; STE, speckle-tracking echocardiography.

Click here to view
Figure 15 Diagram showing the correlation between EF by modified Simpson’s method and GLS by STE after PCI. EF, ejection fraction; GLS, global longitudinal strain; PCI, percutaneous coronary intervention; STE, speckle-tracking echocardiography

Click here to view
Table 5 Correlation between ejection fraction by modified Simpson’s method and average Sm velocity by tissue Doppler imaging and global longitudinal strain by speckle-tracking echocardiography before and after percutaneous coronary intervention

Click here to view


Correlation between average Sm velocity by TDI and GLS by STE before and after PCI: There was a statistically significant positive correlation between average Sm velocity and GLS before [correlation coefficient (r)=0.965 and P=0.000] and after [correlation coefficient (r)=0.930 and P=0.000] PCI ([Figure 16] and [Figure 17], [Table 6]).
Figure 16 Diagram showing the correlation between average Sm velocity by TDI and GLS by STE before PCI. GLS, global longitudinal strain; PCI, percutaneous coronary intervention; STE, speckle-tracking echocardiography; TDI, tissue Doppler imaging.

Click here to view
Figure 17 Diagram showing the correlation between average Sm velocity by TDI and GLS by STE after PCI. GLS, global longitudinal strain; PCI, percutaneous coronary intervention; STE, speckle-tracking echocardiography; TDI, tissue Doppler imaging.

Click here to view
Table 6 Correlation between average Sm velocity by tissue Doppler imaging and global longitudinal strain by speckle-tracking echocardiography before and after percutaneous coronary intervention

Click here to view


Correlation between E/A ratio and average E’ velocity by TDI before and after PCI: there was no statistically significant correlation between E/A ratio and average E’ velocity before [correlation coefficient (r)=0.036 and P=0.802] and after [correlation coefficient (r)=0.196 and P=0.173] PCI.

Correlation between E/A ratio and E/E’ ratio before and after PCI: there was no statistically significant correlation between E/A ratio and E/E’ ratio before PCI [correlation coefficient (r)=0.011 and P=0.941], but there was statistically significant correlation after PCI [correlation coefficient (r)=0.569 and P=0.000] ([Figure 18]).
Figure 18 Diagram showing the correlation between E/A ratio and E/E’ after PCI. PCI, percutaneous coronary intervention.

Click here to view


Correlation between average E’ velocity by TDI and E/E’ ratio before and after PCI: there was a statistically significant correlation between average E’ velocity and E/E’ ratio before [correlation coefficient (r)=0.749 and P=0.000], but there was no statistically significant correlation after [correlation coefficient (r)=0.262 and P=0.066] PCI ([Figure 19] and [Table 7]).
Figure 19 Diagram showing the correlation between average E’ velocity by TDI and E/E’ before PCI. PCI, percutaneous coronary intervention; TDI, tissue Doppler imaging.

Click here to view
Table 7 Correlation between E/A ratio and average E’ velocity by tissue Doppler imaging and E/E’ ratio before and after percutaneous coronary intervention

Click here to view


So speckle tracking as a novel echo technique is considered to be better than the conventional and tissue Doppler echo parameters for more accurate and valuable information for the assessment of LV systolic function.


  Discussion Top


Myocardial revascularization using PCI is widely used and improves clinical outcome in patients with reduced LVEF [1]. Early coronary recanalization helps to survive the viable myocardium and improve global LV function. According to the studies in patients with CAD and LV dysfunction, the outcome can be improved with PCI or surgical revascularization (CABG) [20]. Routine evaluation of patients with suspected or known CAD nearly always includes echo. Because echo can provide a comprehensive assessment of cardiac structure, function, and possibly perfusion at the bedside, it is likely to be the technique of choice for years to come [21]. LV systolic function is the most commonly assessed by the LVEF using 2D echo. The visual interpretation of wall motion abnormalities (WMA) with conventional 2D echo is based on the assessment of myocardial thickening and endocardial excursion. This method is widely used for assessing LV global and segmental systolic function. However, it is observer dependent and requires experience [22]. TDI is a promising technique in the evaluation and follow-up of patients with IHD. TDI has emerged as a sensitive and quantitative measure of both systolic and diastolic longitudinal myocardial function [7]. Strain and strain rate imaging using the 2D-STE method is a novel echo technique for the evaluation of regional and global myocardial function, is relatively free from angle dependency and the frame-rate limitations of TDI, and enables calculations to be made more easily. The global LV contractile function, as assessed by 2D-STE, was shown to be superior to EF measurements by 2D echo [4]. The present study was conducted to assess the short-term echo outcome (in terms of global LV systolic and diastolic functions) after PCI in patients with impaired LV systolic function using conventional, tissue Doppler, and STE.

Regarding the effect of PCI on LV systolic function using conventional 2D echo (LVEF by M-mode and modified Simpson’s method), in our study, we found that PCI is associated with a significant improvement in LV systolic function as shown by the significant improvement in LVEF (mean EF before PCI by M-mode was 47.8±4.1%, which significantly improved after PCI to 57.4±2.0%, and mean EF before PCI by modified Simpson’s method was 43.5±3.9%, which significantly improved after PCI to 52.8±2.2%, P<0.001). Several studies showed improved LV systolic function using conventional 2D echo. Carluccio et al. [23] reported that LV volumes and contractile dysfunction as assessed by conventional echo improve 8±3 months after percutaneous revascularization in patients with impaired LV function. Mehrpooya and olleagues assessed the effects of PCI on LVEF and WMA in patients with significant coronary occlusion (70%). A total of 40 patients who presented with ischemic cardiac chest pain, EF less than 40%, and significant coronary occlusion (70%) in recent angiography underwent PCI. Overall, 29 (72.5%) of them were male and 11 (27.5%) were female. The mean age of patients was 53.9±10.87 years. PCI and stenting drug eluting stent (DES) was performed in all consecutive patients. LVEF and WMA were evaluated by echo by the same cardiologist and were confirmed by two other cardiologists (who were specialist in echo), at baseline and 1 month after procedure. The mean EF before angioplasty was 33.33±6.32 (95% confidence interval, 31.29–35.38), which significantly increased to 44.87±7.02 (95% confidence interval, 42.6–47.15) after angioplasty (P<0.0001). All of the patients (100%) had WMA at the baseline, which decreased to 65% of them after the procedure [24].

Nozari and colleagues investigated the effect of PCI on echo findings of LV systolic and diastolic function. A total of 115 patients with CAD candidate for PCI were enrolled in this study. Echo was done before PCI, the day after, and 3–6 months later. LV systolic and diastolic functions were measured and recorded. echo findings were compared with repeated measurement analysis. Mean age of the patients was 57.8±8.38 years. The mean EF percentage was 40.52±6.36 before, 41.83±7.14 the day after, and 44.0±7.89 3–6 months after PCI [25]. Dzavik and colleagues studied 244 patients and showed that the restoration of coronary potency of nonacute occluded coronary arteries is associated with a small but significant improvement in regional and global LV function, especially in patients with depressed LV function [26]. Dudek and colleagues studied patients with LVEF less than 45% undergoing PCI. They assessed duration and grade of symptoms of HF, angina class, and echo parameters of LV systolic function. After 6 months of follow-up, LVEF was obtained again. In the whole group of patients, they found a significant increase in EF (38.4±6 vs. 50.4±15%, P=0.005) at follow-up examination, suggesting an improvement in LV function in patients with ischemic cardiomyopathy after PCI [27]. Momtahen et al. [28] suggested that the restoration of coronary patency of occluded coronary arteries by successful PCI is associated with significant improvement in regional and global LV function and clinical outcome. Moreover, it was in concordance with Momtahen et al. [28], who conducted their study on 110 patients with CAD and assessed LV function by echo before and after revascularization. They found that PCI was associated with a significant improvement in global LV function (as shown by improvement in LVEF), and this improvement of LV contractility was significant 1 month after PCI. Sirnes and colleagues studied 95 patients with angina pectoris or exercise-induced ischemia with a successfully recanalyzed chronic coronary occlusion. Intracoronary stents were implanted in 71%. Left ventriculograms were obtained at baseline and after 6.7±1.4 months. LVEF and regional radial shortening were determined by a computer-assisted method. LVEF increased from 0.62±0.13 at baseline to 0.67±0.11 at follow-up (P<0.001). The change in LVEF in patients with a patent artery and in patients with reocclusion (n=8) was 0.05±0 · 06 and 0.01±0.04, respectively (P=0 · 04). They concluded that long-term patency after recanalization of old, chronic coronary occlusions in patients with angina pectoris is associated with improvement in global and regional LV function. They suggested it as a result of recovery of hibernating myocardium and support the strategy of recanalyzing chronic coronary occlusions [29]. In another study, Danchin and colleagues assessed ventriculograms before PTCA and at 6-month follow-up in 55 patients with recanalyzed chronic left anterior descending and right coronary artery occlusions. They found a high rate of reocclusion (45%) and a significant increase in LVEF only in patients without reocclusion at follow-up (0.55±0.14 before PTCA to 0.62±0.13 at follow-up) [30]. In one study by Hida and colleagues, regarding the regional analysis using gated single photon emission computed tomography (SPECT), the improvements in myocardial blood flow and function after coronary angioplasty were observed not only in revascularized territories but also in the nonrevascularized territories. They concluded that improvement in myocardial ischemia, hibernation, and LV function with coronary angioplasty can be significant. They assessed this improvement by applying gated SPECT [31]. In the present study, we were able to show improvement of EF by echo instead of SPECT. Regarding this point, applying SPECT is time wasting and expensive and is not able to determine myocardial wall thickness in contrast to echo. Our results disagreed with the results of Yousef and colleagues, in the TOAT study, which found a worse LV dilatation by echo in the PCI group in comparison with no PCI. The authors pointed out that these results could be related to the occurrence of micro-embolization to the microvasculature in the PCI group, reducing the perfusion and resulting in adverse ventricular remodeling. However, the biochemical markers of myocardial necrosis were not measured routinely, making the evidence of this possibility less obvious [32]. An alternative explanation for these negative results could be related to restenosis and reocclusion rates, which were higher than expected, with a subsequent high rate of late events, as observed in the PCI group. Our results also disagreed with the results of Diller et al. [33], who found that EF failed to reflect any improvement after PCI 1 day and after PCI 6 weeks. This may be owing to they selected patients with preserved systolic function, and may be owing to short period of follow-up of the patients (6 weeks). Sattarzadeh and colleagues evaluated the early effects of successful elective PCI on systolic and diastolic LV functions and found that Tei index and systolic indices (LVEF, WMA score, and peak systolic velocity of mitral annulus) did not change significantly. Among the diastolic indices, only flow propagation velocity (Vp) improved significantly following PCI. PW diastolic velocities, E/A ratio, deceleration time (DT), early and late diastolic velocities of mitral annulus in TDI, and pulmonary vein systolic flow did not show significant improvement [34]. Regarding the effect of PCI on LV systolic function using TDI [peak systolic myocardial velocity (Sm)] in this study, our results found that PCI is associated with a significant improvement in LV systolic function as shown by the significant improvement in Sm (mean Sm pre-PCI was 6.4±1.7 cm/s, which significantly improved after PCI to 10.9±1.2 cm/s, P<0.001). Rashid et al. [35] determined the effect of PCI on myocardial function assessed by TDI in patients with chronic stable angina and apparent normal LV function and found that systolic myocardial peak velocities improved significantly after PCI in the septal, lateral, anterior, and inferior walls (P<0.01 for each) and insignificantly at the posterior wall of LV (P>0.05). Diller et al. [33] examined 24 consecutive patients with chronic stable angina and preserved systolic LV function who underwent PCI, and patients had PW-TDI and conventional echo before PCI and 1 day and 6 weeks after PCI. The results of this study showed that the systolic peak myocardial velocity improved in the septal, lateral, inferior, and right ventricular areas (P<0.05 for each) but insignificantly in the posterior wall (P=0.06). Çaylý and colleagues studied the effect of successful elective PCI on LV functions assessed with TDI method before PCI and 24th hour and third month after PCI in 41 patients and found that no significant increase in regional myocardial systolic velocity at third month in all patients, but there was a propensity of increase in those as compared with basal values. These results were explained by them as follows: there was no routine angiographic control in our study protocol at third month. Hence, we could not evaluate the early restenosis at third month. In addition, restoring TIMI-3 flow with PCI does not always provide adequate perfusion in tissue level [36]. Strotmann et al. [37] detected a significant increase in regional myocardial peak systolic velocity at 24th hour after PCI in patients with CAD with critical stenosis. They also reported that regional myocardial systolic velocity had propensity of reduction in third month in those patients. Regarding the effect of PCI on LV systolic function using STE (GLS) in this study, our results found that PCI is associated with a significant improvement in LV systolic function as shown by the significant improvement in GLS (mean GLS before PCI was −7±2.1%, which significantly improved after PCI to −13.9±1.7%; P<0.001). Our results agree with Erdogan and colleagues, who studied a total of 129 patients with chronic coronary total occlusion who underwent percutaneous revascularization. Echo assessments with 2D-STE and real-time 3D echo were performed before the procedure and 1 month after the procedure. GLS showed a significant increase after successful revascularization (P<0.001). An increase in GLS was correlated with an increase in LVEF (r=0.27, P=0.02) [38]. Regarding the effect of PCI on LV diastolic function using conventional mitral inflow PW Doppler myocardial velocities (E wave, A wave, and E/A ratio) in this study, we found that PCI is associated with a significant improvement in LV diastolic function as shown by the significant increase of E wave velocity (mean E wave velocity before PCI was 62.5±10.6 cm/s, which significantly increased after PCI to 78±15.6 cm/s; P<0.001), leading to significant improvement in E/A ratio (mean E/A ratio before PCI was 0.9±0.1, which significantly improved after PCI to 1.2±0.3; P<0.001). Mandal and colleagues studied 100 patients scheduled for elective PCI who exhibited abnormal diastolic filling patterns before PCI characterized by prolonged mitral DT, decreased E/A peak velocity ratio, and increased atrial filling fraction (mitral A wave velocity). After PCI, mitral DT was significantly shortened. Concomitantly, E/A ratio increased significantly and mitral A wave velocity significantly decreased in all the study patients [39]. Tanaka et al. [40] studied 27 patients and showed improvement in LV early diastolic filling and regional diastolic function at 3 months after successful elective PCI. Our results disagree with Sattarzadeh et al. [34], who evaluate the early effects of successful elective PCI on diastolic LV function and found that among the diastolic indices, only flow propagation velocity (Vp) improved significantly following PCI. Diastolic velocities, E/A ratio, DT, pulmonary vein systolic, and diastolic flow velocities (PVd) did not show significant improvement. Our results also disagree with Diller et al. [33], who showed that transmitral flow Doppler parameters failed to reflect any improvement at 1 day and 6 weeks after PCI. Discrepancy between various studies may be from different follow-up periods after PCI, basic LVEF before PCI, global condition of the patients, degree of coronary artery stenosis, and the presence or absence of affection of other coronaries. Regarding the effect of PCI on LV diastolic function using TDI (average E’ velocity and E/E’ ratio) in this study, we found that PCI is associated with a significant improvement in LV diastolic function as shown by the significant improvement in average E’ velocity (mean average E’ velocity before PCI was 5.3±1.2 cm/s, which significantly improved after PCI to 8.4±0.7 cm/s, P<0.001), and the significant improvement in E/E’ ratio (mean E/E’ ratio before PCI was 12.4±3.3, which significantly improved after PCI to 9.3±1.9; P<0.001). Mandal and colleagues studied 100 patients scheduled for elective PCI who exhibited abnormal diastolic filling patterns before PCI and showed that the early diastolic mitral annular velocity (E’) was significantly improved after PCI in all patients with CAD, and the E/E’ ratio exhibited significant difference after PCI, in entire CAD group [39]. Gerhard-Paul Dille and colleagues determine the effect of PCI on LV diastolic function and stated that compared with preinterventional values, early diastolic velocities improved at all sites (P<0.05 for each). The most pronounced improvement occurred in the septal area [35]. Diller et al. [33] examined 24 consecutive patients with chronic stable angina and preserved systolic LV function who underwent PCI and found that the early and late diastolic velocities improved at all sites (P<0.05 for each). Our results disagreed with Sattarzadeh et al. [34], who evaluated the early effects of successful elective PCI on diastolic LV function and found that early and late diastolic velocities of mitral annulus in TDI did not show significant improvement following PCI. Our results also disagreed with Hueb et al. [41], who evaluate by echo the effect of PCI on LV diastolic function indices, obtained by TDI and measurement of LA volume, and observed that 3 months after PCI, the LV diastolic function did not change when assessed by echo, with the aid of tissue Doppler and LA volume measurement. Discrepancy between various studies may be from different follow-up period after PCI, basic LVEF before PCI, global condition of the patients, degree of coronary artery stenosis, and the presence or absence of affection of other coronaries.


  Conclusion Top


From the present study, we conclude the following: (a) the restoration of coronary patency of occluded coronary arteries by successful PCI is associated with significant improvement in global systolic and diastolic LV functions, and so any patient with CAD and LV dysfunction should be revascularized as early as possible to improve the LV function and improve the patient’s morbidity and mortality. (b) Improvement in some indices of LV systolic and diastolic functions after successful PCI indicates that PCI can be an effective treatment modality for impaired LV systolic and diastolic functions in patients with symptomatic CAD. (c) Tissue Doppler echo is a noninvasive and widely available diagnostic technique that allows the sensitive detection of LV systolic and diastolic dysfunction, and unlike TDI, conventional Doppler methods (as transmitral flow velocities) were not capable of detecting improvement in diastolic function after myocardial revascularization. (d) STE could provide important objective and quantitative evaluation of global LV systolic function. Using this novel echo technique, our results showed that restoring the coronary blood flow improves the LV GLS of dysfunctional myocardium.

Recommendation

We recommend the following: (a) patients with CAD and impaired LV systolic function who are candidates for PCI should be revascularized because PCI in these patients showed greater and significant improvement in the LV systolic and diastolic functions. (b) Echo should be considered in patients with CAD for the assessment of its effect on LV systolic and diastolic functions as well as for the follow-up of the effect of myocardial revascularization in these functions. (c) TDI is advised to be used as a measure of LV diastolic function to evaluate improvement of LV diastolic function after myocardial revascularization. (d) Speckle tracking as a relatively novel echo technique could be considered besides the conventional and tissue Doppler echo parameters for more accurate and valuable information for the assessment of LV systolic function.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Buszman P, Szkobka I, Tendera Z. Early and late results of percutaneous revascularization in patients with ischemic cardiomyopathy and decreased left ventricular ejection fraction. Euro Intervent 2005; 2:186–192.  Back to cited text no. 1
    
2.
Rahimtoola SH, La Canna G, Ferrari R. Hibernating myocardium: another piece of the puzzle falls into place. J Am Coll Cardiol 2006; 47:978–980.  Back to cited text no. 2
    
3.
Smith EJ, Jain AK, Rothman MT. New developments in coronary stent technology. J Interv Cardiol 2006; 19:493–499.  Back to cited text no. 3
    
4.
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; 17:1021–1029.  Back to cited text no. 4
    
5.
Sutherland GR, Di Salvo G, Claus P, D’hooge J, Bijnens B. Strain and strain rate imaging: a new clinical approach to quantifying regional myocardial function. J Am Soc Echocardiogr 2004; 17:788–802.  Back to cited text no. 5
    
6.
Yip GW, Zhang Q, Xie JM, Liang YJ, Liu YM, Yan B et al. Resting global and regional left ventricular contractility in patients with heart failure and normal ejection fraction: insights from speckle-tracking echocardiography. Heart 2011; 97:287–294.  Back to cited text no. 6
    
7.
Wang J, Abraham TP, Korinek J. Delayed onset of subendocardial diastolic thinning at rest identifies hypoperfused myocardium. Circulation 2005; 111:2943–2950.  Back to cited text no. 7
    
8.
Nikitin NP, Witte KK. Application of tissue Doppler imaging in cardiology. Cardiology 2004; 101:170–184.  Back to cited text no. 8
    
9.
Geyer H, Caracciolo G, Abe H, Wilansky S, Carerj S, Gentile F et al. Assessment of myocardial mechanics using speckle tracking echocardiography: fundamentals and clinical applications. J Am Soc Echocardiogr 2010; 23:351–369.  Back to cited text no. 9
    
10.
Mondillo S, Galderisi M, Mele D, Cameli M, Lomoriello VS, Zacà V et al. Speckle tracking echocardiography: a new technique for assessing myocardial function. J Ultrasound Med 2011; 30:71–83.  Back to cited text no. 10
    
11.
Marwick TH. Should we be evaluating the ventricle or the myocardium? Advances in tissue characterization. J Am Soc Echocardiogr 2004; 17:168–172.  Back to cited text no. 11
    
12.
Artis N, Oxborough D, Williams G, Pepper CB, Tan LB. Two-dimensional strain imaging: a new echocardiographic advance with research and clinical applications. Inter J Cardiology 2008; 123:240–248.  Back to cited text no. 12
    
13.
Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2015; 18:1440–1463.  Back to cited text no. 13
    
14.
Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B et al. ACCF/AHA/SCAI Guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation Nov 7 2011 JACC 2011; 58:e44–122.  Back to cited text no. 14
    
15.
Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr 2009; 22:107–133.  Back to cited text no. 15
    
16.
Rivas-Gotz C, Manolios M, Thohan V, Nagueh SF. Impact of left ventricular ejection fraction on estimation of left ventricular filling pressures using tissue Doppler and flow propagation velocity. Am J Cardiol 2003; 91:780–784.  Back to cited text no. 16
    
17.
Alam M, Wardell J, Andersson E. Effects of first myocardial infarction on left ventricular systolic and diastolic function with the use of mitral annular velocity determined by pulsed wave Doppler tissue imaging. J Am Soc Echocardiogr 2000; 13:343–352.  Back to cited text no. 17
    
18.
Yu CM, Sanderson JE, Marwick TH, Oh JK. Tissue Doppler imaging: a new prognosticator for cardiovascular diseases. J Am Coll Cardiol 2007; 49:1903–1914.  Back to cited text no. 18
    
19.
Marwick TH, Leano RL, Brown J, Sun JP, Hoffmann R, Lysyansky P et al. Myocardial strain measurement with 2-dimensional speckle-tracking echocardiography: definition of normal range. JACC Cardiovasc Imag 2009; 2:80–84.  Back to cited text no. 19
    
20.
Silva JC, Rochitte CE, Júnior JS, Tsutsui J, Andrade J, Martinez EE et al. Late coronary artery recanalization effects on left ventricular remodelling and contractility by magnetic resonance imaging. Eur Heart J 2005; 26:36–43.  Back to cited text no. 20
    
21.
Willerson JN, Cohn HJ, Wellens DR, Holmes DE. Echocardiographic evaluation of coronary artery disease. Textbook: Cardiovascular medicine from basic science to bedside (3rd ed.) Springe 2007; p. 811–839.  Back to cited text no. 21
    
22.
Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA et al. Recommendations for chamber quantification. Eur J Echocardiogr 2006; 7:79–108.  Back to cited text no. 22
    
23.
Carluccio E, Biagioli P, Alunni G. Patients with hibernating myocardium show altered left ventricular volumes and shape, which revert after revascularization: evidence that dyssynergy might directly induce cardiac remodeling. J Am Coll Cardiol 2006; 47:969–977.  Back to cited text no. 23
    
24.
Mehrpooya M, Ghasemi M, Shahrzad I. Improvement in left ventricular ejection fraction and wall motion abnormality after successful angioplasty and stenting in patients with chronic coronary occlusion. Heart Lung Circ 2008; 17S:S4–S53.  Back to cited text no. 24
    
25.
Nozari Y, Oskouei NJ, Khazaeipour Z. Effect of elective percutaneous coronary intervention on left ventricular function in patients with coronary artery disease. Acta Med Iran 2012; 50:26–30.  Back to cited text no. 25
    
26.
Dzavik V, Carere RG, Mancini GB, Cohen EA, Catellier D, Anderson TE et al. Total Occlusion Study of Canada Investigators. Predictors of improvement in left ventricular function after percutaneous revascularization of occluded coronary arteries: a report from the Total Occlusion Study of Canada (TOSCA). Am Heart J 2001; 142:301–308.  Back to cited text no. 26
    
27.
Dudek D, Rzeszutko L, Turek P, Sorysz D, Dubiel JS. Clinical predictors of left ventricular function improvement after percutaneous coronary interventions in patients with ejection fraction below 45% [in Polish]. Przegl Lek 2001; 58:751–754.  Back to cited text no. 27
    
28.
Momtahen M, Abdi S, Ojaghi Z. Global and regional left ventricular function improvement following successful percutaneous coronary intervention in patients with ischemic left ventricular dysfunction. Arch Iran Med 2007; 10:387–389.  Back to cited text no. 28
    
29.
Sirnes PA, Myreng Y, Mølstad P. Improvement in left ventricular ejection fraction and wall motion after successful recanalization of chronic coronary occlusions. Eur Heart J 1998; 19:273–281.  Back to cited text no. 29
    
30.
Danchin N, Angioi M, Cador R, Tricoche O, Dibon O, Juilliere Y et al. Effect of late percutaneous angioplastic recanalization of total coronary artery occlusion on left ventricular remodeling, ejection fraction, and regional wall motion. Am J Cardiol 1996; 8:729–735.  Back to cited text no. 30
    
31.
Hida S, Chikamori T, Usui Y. Effect of percutaneous coronary angioplasty on myocardial perfusion, function, and wall thickness as assessed by quantitative gated single-photon emission computed tomography. Am J Cardiol 2003; 91:591–594.  Back to cited text no. 31
    
32.
Yousef ZR, Redwood SR, Bucknall CA, Sulke AN, Marber MS. Late intervention after anterior myocardial infarction: effects on left ventricular size, function, quality of life, and exercise tolerance: results of the Open Artery Trial (TOAT Study). J Am Coll Cardiol 2002; 40:869–876.  Back to cited text no. 32
    
33.
Diller GP, Wasan BS, McG Thom SA, Foale RA, Hughes AD et al. Evidence of improved regional myocardial function in patients with chronic stable angina and apparent normal ventricular function—a tissue doppler study before and after percutaneous coronary intervention. J Am Soc Echocardiogr 2009; 22:177–182.  Back to cited text no. 33
    
34.
Sattarzadeh M, Maleki A, Jamalian A, Amirpour A, Firuzi N, Samiei M et al. Colour M-mode superiority in evaluation of improvement in myocardial performance indices following successful percutaneous coronary intervention (PCI). Cardiovasc J Afr 2011; 22:182–185.  Back to cited text no. 34
    
35.
Diller GP, Wasan BS, Thom SA, Foale RA, Hughes AD, Francis DP, Mayet J. Evidence of improved regional myocardial function in patients with chronic stable angina and apparent normal ventricular function--a tissue Doppler study before and after percutaneous coronary intervention. J Am Soc Echocardiogr 2009; 22:177–182.  Back to cited text no. 35
    
36.
Misztal M, Stopyra K, Gackowski A, Zmudka K, Piwowarska W. Assessment of left ventricle diastolic function in myocardial infarction patients treated with primary angioplasty. Cardiol J 2009; 16:440–446.  Back to cited text no. 36
    
37.
Strotmann JM, Richter A, Kukulski T. Doppler myocardial imaging in the assessment of regional myocardial function in longitudinal direction pre- and post-PTCA. Eur J Echocardiogr 2001; 2:178–186.  Back to cited text no. 37
    
38.
Erdogan E, Akkaya M, Bacaksiz A, Tasal A, Sönmez O, Ali ME et al. Echocardiographic studies in patients with CTO. Clinics 2013; 68:1333–1337.  Back to cited text no. 38
    
39.
Mandal AK, Chowdhury AHK, Choudhury AK, Monwarul Islam AKM, Guha B. Echocardiographic evaluation of left ventricular diastolic function after percutaneous coronary intervention in patients with coronary artery disease. Cardiovasc J 2012; 4:127–131.  Back to cited text no. 39
    
40.
Tanaka H, Kawai H, Tatsumi K, Kataoka T, Onishi T, Nose T et al. Improved regional myocardial diastolic function assessed by strain rate imaging in patients with coronary artery disease undergoing percutaneous coronary intervention. J Am Soc Echocardiogr 2006; 19:756–162.  Back to cited text no. 40
    
41.
Hueb JC, Adriana H, Hueb RAS, Katashi O. Percutaneous coronary intervention improves left ventricular diastolic function in patients with stable angina? Rev Bras Ecocardiogr Imagem Cardiovasc 2011; 24:29–34.  Back to cited text no. 41
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Aim
  Patients and methods
  Results
  Discussion
  Conclusion
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed264    
    Printed10    
    Emailed0    
    PDF Downloaded28    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]