|Year : 2019 | Volume
| Issue : 1 | Page : 7-11
Non-ischemic regional wall motion abnormality
ST Yavagal1, Vivek Bantwal Baliga2
1 Department of Cardiology, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
2 Baliga Diagnostics, Bengaluru, Karnataka, India
|Date of Web Publication||15-Mar-2019|
S T Yavagal
1782, 34th Cross, 14th Main, Banashankari 2nd Stage, Bengaluru - 560 070, Karnataka
Source of Support: None, Conflict of Interest: None
Regional wall motion abnormalities (RWMA) are usually described with Ischemic Heart Disease. But many other conditions also show RWMA. What are those conditions, how to recognize RWMA in them and what is it's importance is discussed.
Keywords: Coronary artery disease, nonischemic, regional wall motion abnormality
|How to cite this article:|
Yavagal S T, Baliga VB. Non-ischemic regional wall motion abnormality. J Indian Acad Echocardiogr Cardiovasc Imaging 2019;3:7-11
|How to cite this URL:|
Yavagal S T, Baliga VB. Non-ischemic regional wall motion abnormality. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2019 [cited 2019 Mar 19];3:7-11. Available from: http://www.jiaecho.org/text.asp?2019/3/1/7/254260
| Introduction|| |
Regional wall motion abnormalities on echocardiography are often tied to the presence of underlying ischemic heart disease. A detailed 17 segment analysis of each aspect of the cardia allows for the determination of the presence of hypokinesis, akinesis, dyskinesis, and other cardiac structural abnormalities. When evaluating regional wall motion abnormalities, one often relies on their experience in determining its presence. This “visual” estimate is commonly utilized and is subjective, though there are scoring systems that allow for a more structured qualitative assessment. For example, assessing delayed cardiac contraction in the ejection phase (tardokinesis) can be difficult to perform through visual assessment. Ischemic wall motion abnormalities are restricted to some particular segments such as inferior or anterior and show typical akinesia, hypokinesia, or dyskinesia.
Once a regional wall motion abnormality is detected, it is not uncommon for a multitude of investigations to follow. However, it is often forgotten that regional wall motion abnormalities are not exclusive to ischemia, and can be encountered in multiple clinical conditions. Newer imaging modalities allow for a more detailed assessment, though results must be taken in the context of clinical presentation.
This article details the common nonischemic etiologies of regional wall motion abnormalities and the unique echocardiographic presentations that might be encountered.
| Left Bundle Branch Block|| |
The presence of the left bundle branch block (LBBB) [Figure 1] is well known to cause regional wall motion abnormality on echocardiography. Clinical studies have demonstrated that its presence may be an anticipatory sign of underlying cardiovascular disease.
The cardiac conduction system is a complex functioning pathway that includes the impulse generating sinoatrial node, the slowly conducting atrioventricular node, and the rapidly conducting ventricular conduction system. After electrical impulses are generated in the sino-atrial node, it travels rapidly through the atrial myocardium, reaching the atrioventricular node, where it slows down. The slowing down of electrical impulses at this node allows sufficient time for the ventricles to fill. Following this, there is once again rapid conduction of electricity through the His–Purkinje system, also called the ventricular conduction system. Electrical conduction through this system allows for contraction from the apex to the base, synchrony between the left and right ventricle and intraventricular synchrony.
When viewed on echocardiography, such electrical conduction will be visible as a normal, synchronous contraction of both the right and left ventricle. However, in LBBB, there is preferential electrical conduction through the right bundle, leading to electrical activation of the right half of the septum and the right ventricle first. Delayed activation of the left ventricle leads to early right to left movement of the septum (perceived as dyskinesis), with delayed activation of the posterolateral wall region.
Typically described as a “jerky” septum, a wide QRS duration of more than 150 ms will lead to paradoxical movement of the septum. More detailed analyses have found asynchrony in not only contraction, but also in ejection, end systole, and end diastole. This translates into a decrease in the overall left ventricular (LV) function and efficiency.
Speckle tracking echocardiography is recently being utilized to determine cardiac dyssynchrony in the setting of LBBB, with a view to performing cardiac resynchronization therapy. Longitudinal strain curves determined from the 4-chamber view have shown early shortening of at least 1 basal or mid-ventricular segment in the septal wall and early stretching in at least 1 basal or midventricular segment in the lateral wall, early septal peak shortening (within the first 70% of the ejection phase) and lateral wall peak shortening following aortic valve closure.
| Paced Hearts|| |
The right ventricular pacing [Figure 2] can produce regional wall motion abnormalities at the site of pacing wire insertion. In one study, 64% of individuals who had right ventricular pacing showed apical regional wall motion changes. Chronic right ventricular pacing has also been linked to asymmetrical septal hypertrophy, dilatation of the left ventricle, and a deterioration in LV systolic function over a period of time. In fact, the right ventricular outflow pacing produces lesser regional wall motion change compared to the right ventricular apical pacing.
|Figure 2: Paced heart showing pacemaker lead in right ventricle with abnormal septal motion|
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| Nonischemic Cardiomyopathy|| |
Most patients with nonischemic cardiomyopathy [Table 1] have global LV dysfunction. However, segmental wall motion abnormalities, i.e., wall motion changes in at least two echocardiographic segments, have been found to present, secondary to myocardial scar formation. These segmental changes have a direct bearing on arrhythmic events but not on mortality.
|Table 1: Causes of nonischemic regional wall motion abnormality on echocardiography|
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| Takotsubo Cardiomyopathy|| |
Stress cardiomyopathy [Figure 3], often called Takotsubo (meaning “octopus pot”) cardiomyopathy, is a well-recognized clinical condition and etiology of cardiac failure. The clinical history of the patient plays a pivotal role in diagnosis, and the condition is usually seen in postmenopausal women who experience great emotional or physical stress. Patients can present with chest pain, and electrocardiography demonstrates ST-segment elevation. This mimics acute myocardial ischemia, which can be discombobulating at times. However, coronary angiography demonstrates normal epicardial coronary arteries.
|Figure 3: Stress cardiomyopathy with apical ballooning, affecting mid and apical segments of left ventricle|
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Echocardiography classically shows apical ballooning that involves all the LV walls in a symmetrical manner, associated with hyperdynamic contraction of the bases. Correlation with coronary artery distribution territories is poor. In 25% of the cases, there is involvement of the right ventricular apex as well, and is associated with a poor prognosis. A circumferential, mid-ventricular pattern of involvement (with or without apical involvement) may be noted in the acute phase, involving the mid-ventricular aspect of the inferior, lateral, and anterior walls (which corresponds to segments 7–12 in the ASE guidelines).
There are three additional types of echocardiographic findings reported in Takotsubo cardiomyopathy. The inverted type presents with basal and mid-ventricular akinesis (or hypokinesis) with apical normokinesis or hyperkinesis. The mid-ventricular type is described earlier and is seen in the early part of the disease. The localized type shows altered myocardial contraction in the distribution of a coronary artery. Such a localized cardiomyopathy has been reported to be seen in pheochromocytoma. The apical form is the classic finding at diagnosis.
In the early stages of Takotsubo cardiomyopathy, the myocardial stunning of the LV apex accompanied by hyperdynamic contraction of the basal segments can lead to mitral systolic anterior motion and septal bulge. This may result in a significant LV outflow tract gradient obstruction (LVOTO), with values up to 140 mmHg reported. Mitral regurgitation is a frequent co-finding, with up to 25% of patients presenting with acute mitral regurgitation. Other than the LVOTO as an etiology, apical tethering of the mitral valve leaflets may be a cause. Mitral valve surgery is recommended in the current guidelines for such a scenario, though some bodies advise maximal medical therapy given the reversible nature of Takotsubo.
Besides, systolic dysfunction, echocardiography may also demonstrate diastolic dysfunction. Clinical studies have utilized E/e' ratio as an easy to use and reproducible parameter to determine LV filling pressures.
| Hypertension|| |
Regional wall motion in patients with hypertension [Figure 4] has been reported with co-existent LV hypertrophy. Often, wall motion abnormalities seen in hypertension are associated with underlying myocardial ischemia. In one particular study, 7% of patients with hypertension and LV hypertrophy demonstrated regional wall motion changes affecting the ventricular septum and the posterior wall.
|Figure 4: Hypertensive left ventricular hypertrophy showing variable thickening|
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| Myopericarditis|| |
Myopericarditis [Figure 5] is often a result of a viral infection. Patients may present with chest pain that is worse when supine and better when sitting and leaning forward, fever and associated elevation in cardiac enzymes.
|Figure 5: Myopericarditis showing variable thickening of the left ventricle|
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Regional wall motion abnormalities are not uncommon in myopericarditis. Global hypokinesis may be seen, but the commonly affected areas as the inferoposterolateral LV wall. Strain imaging has found lower longitudinal and circumferential strain.
Other causes such as right ventricular pressure or volume overload [Figure 6] and constrictive pericarditis [Figure 7] can also be considered as nonischemic wall motion abnormalities
|Figure 6: Right ventricular dilatation due to pressure overload with abnormal septal motion|
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| Perioperative Regional Wall Motion Abnormalities|| |
The perioperative period can be marred by numerous cardiac complications in patients at a high risk. While underlying ischemia can produce regional wall motion changes in areas corresponding to coronary artery distribution, hypovolemia, and arrhythmias can also lead to similar changes in the absence of ischemia. Stress-induced cardiomyopathy may also be noticed, with changes described earlier in this article. Aortic cross-clamping can increase systemic afterload, leading to regional wall motion changes. The presence of a pacemaker can also lead to wall motion changes as described previously. In aortic dissection surgery, regional wall motion changes may be noted due to occlusion of the left coronary artery from a suture placed at the sinotubular junction. However, preexisting coronary artery disease is the likely cause, making the wall motion changes ischemic in nature.
Regional wall motion abnormalities in the perioperative period are rarely given any importance, as most treating physicians wish to know the cardiac ejection fraction.
Regional wall motion abnormalities in normal individuals
Interestingly, a study of the data from the Strong Heart Study found that individuals who had no previous or underlying cardiac disease and had wall motion abnormalities on echocardiography had a 2.5-fold increase in cardiovascular death. However, specific wall motion changes were not described.
Why is nonischemic regional wall motion change important?
Patients who demonstrate regional wall motion abnormalities from a nonischemic etiologies have a higher risk of arrhythmia, stroke, and even death. Such patients can be carefully evaluated for implantable cardioverter defibrillator therapy.
| Conclusion|| |
Regional wall motion changes on echocardiography are often assumed to be ischemic in origin. However, nonischemic regional wall motion changes are common and must be taken in the context of cardiovascular morbidity and mortality.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Park DS, Fishman GI. Development and function of the cardiac conduction system in health and disease. J Cardiovasc Dev Dis 2017;4. pii: 7.
Grines CL, Bashore TM, Boudoulas H, Olson S, Shafer P, Wooley CF, et al.
Functional abnormalities in isolated left bundle branch block. The effect of interventricular asynchrony. Circulation 1989;79:845-53.
Risum N, Tayal B, Hansen TF, Bruun NE, Jensen MT, Lauridsen TK, et al.
Identification of typical left bundle branch block contraction by strain echocardiography is additive to electrocardiography in prediction of long-term outcome after cardiac resynchronization therapy. J Am Coll Cardiol 2015;66:631-41.
Sato-Iino T, Watanabe H, Koyama T, Iino K, Kosaka T, Ito H, et al.
The prevalence of apical wall motion abnormalities in patients with long-term right ventricular apical pacing. J Am Soc Echocardiogr 2011;24:556-640.
Steinberg JS, Fischer A, Wang P, Schuger C, Daubert J, McNitt S, et al.
The clinical implications of cumulative right ventricular pacing in the multicenter automatic defibrillator trial II. J Cardiovasc Electrophysiol 2005;16:359-65.
Thambo JB, Bordachar P, Garrigue S, Lafitte S, Sanders P, Reuter S, et al.
Detrimental ventricular remodeling in patients with congenital complete heart block and chronic right ventricular apical pacing. Circulation 2004;110:3766-72.
Wang F, Shi H, Sun Y, Wang J, Yan Q, Jin W, et al.
Right ventricular outflow pacing induces less regional wall motion abnormalities in the left ventricle compared with apical pacing. Europace 2012;14:351-7.
Gaitonde RS, Subbarao R, Michael MA, Dandamudi G, Bhakta D, Mahenthiran J, et al.
Segmental wall-motion abnormalities of the left ventricle predict arrhythmic events in patients with nonischemic cardiomyopathy. Heart Rhythm 2010;7:1390-5.
Movahed MR. Important echocardiographic features of takotsubo or stress-induced cardiomyopathy that can aid early diagnosis. JACC Cardiovasc Imaging 2010;3:1200-1.
Elesber AA, Prasad A, Bybee KA, Valeti U, Motiei A, Lerman A, et al.
Transient cardiac apical ballooning syndrome: Prevalence and clinical implications of right ventricular involvement. J Am Coll Cardiol 2006;47:1082-3.
Zheng XY, Peng DQ, Zhao SP, Duan S. Asymmetric blood pressure caused by extremely rapid cyclic fluctuations and reversible cardiomyopathy in pheochromocytoma. Hypertens Res 2012;35:1201-2.
El Mahmoud R, Mansencal N, Pilliére R, Leyer F, Abbou N, Michaud P, et al.
Prevalence and characteristics of left ventricular outflow tract obstruction in tako-tsubo syndrome. Am Heart J 2008;156:543-8.
Izumo M, Nalawadi S, Shiota M, Das J, Dohad S, Kuwahara E, et al.
Mechanisms of acute mitral regurgitation in patients with takotsubo cardiomyopathy: An echocardiographic study. Circ Cardiovasc Imaging 2011;4:392-8.
Citro R, Lyon AR, Meimoun P, Omerovic E, Redfors B, Buck T, et al.
Standard and advanced echocardiography in takotsubo (stress) cardiomyopathy: Clinical and prognostic implications. J Am Soc Echocardiogr 2015;28:57-74.
Palmieri V, Okin PM, Bella JN, Gerdts E, Wachtell K, Gardin J, et al.
Echocardiographic wall motion abnormalities in hypertensive patients with electrocardiographic left ventricular hypertrophy: The LIFE study. Hypertension 2003;41:75-82.
Leitman M, Tyomkin V, Peleg E, Copel L, Vered Z. Left ventricular function in acute inflammatory peri-myocardial diseases – New insights and long-term follow-up. Cardiovasc Ultrasound 2012;10:42.
Leitman M, Bachner-Hinenzon N, Adam D, Fuchs T, Theodorovich N, Peleg E, et al.
Speckle tracking imaging in acute inflammatory pericardial diseases. Echocardiography 2011;28:548-55.
Boisen ML, McHugh SM, Boretsky RH, Phillips DP, Meng L, Caldwell MW, et al
. Perioperative echocardiographic diagnosis of regional wall motion abnormalities: Not all of them are ischemic. J Perioper Echocardiogr 2016;4:70-3.
Gregory SH, Zoller JK, Lakshminarasimhachar A. A new regional wall motion abnormality after aortic dissection repair: What is the next step? J Cardiothorac Vasc Anesth 2017;31:2131-3.
Cicala S, de Simone G, Roman MJ, Best LG, Lee ET, Wang W, et al.
Prevalence and prognostic significance of wall-motion abnormalities in adults without clinically recognized cardiovascular disease: The strong heart study. Circulation 2007;116:143-50.
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