Correlation between Stroke and Spontaneous Echo Contrast by Tissue Harmonic Imaging in Patients with Dilated Cardiomyopathy

  • Kim, Min-Kwan (Division of Cardiology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine) ;
  • Park, Dae-Gyun (Division of Cardiology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine)
  • Published : 2009.03.27

Abstract

Background: Spontaneous echo contrast (SEC) has been considered as a predisposition to thromboembolism and cerebrovascular accident. However, there have been few reports on the prevalence and role of SEC in dilated cardiomyopathy (DCM). The aim of this study was to investigate the prognostic usefulness of SEC in predicting a stroke in patients with DCM. Methods: Between October 2001 and January 2008, transthoracic echocardiography with tissue harmonic imaging (THI) was performed for recognition of SEC in patients with DCM. Patients were divided into 2 groups according to the presence of SEC. Clinical characteristic data, echocardiographic parameters were compared between two groups. Results: In this retrospective study, 220 patients (136 men, age 62.8${\pm}$15.4 years) with DCM (left ventricular ejection fraction 27.8${\pm}$7.8%) were included. SEC in the left ventricle (LV) was observed in 24 patients (10.9%). Stroke occurred in 4 (16.7%) of patients with SEC and in 9 (4.6%) of patients without SEC. There were no differences in LA dimension (p=0.24) and LV end-diastolic dimension (p=0.88) between both groups. On univariate analysis, SEC and coronary heart disease at presentation had statistical significance of risk factors for stroke in these groups (p<0.05). On multivariate analysis, only SEC was an independent predictor for stroke (OR 4.393, 95% CI 1.116-17.290, p=0.03). Conclusion: These results suggest that SEC by THI through transthoracic echocardiography has a strong association with stroke in patients with DCM. Therefore, this study may help in the risk stratification of cardiac embolism in patients with DCM.

Keywords

References

  1. Chimowitz MI, DeGeorgia MA, Poole RM, Hepner A, Armstrong WM. Left atrial spontaneous echo contrast is highly associated with previous stroke in patients with atrial fibrillation or mitral stenosis. Stroke 1993;24:1015-9. https://doi.org/10.1161/01.STR.24.7.1015
  2. Fatkin D, Kelly RP, Feneley MP. Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol 1994;23:961-9. https://doi.org/10.1016/0735-1097(94)90644-0
  3. Zotz RJ, Müller M, Genth-Zotz S, Darius H. Spontaneous echo contrast caused by platelet and leukocyte aggregates? Stroke 2001;32:1127-33. https://doi.org/10.1161/01.STR.32.5.1127
  4. Feigenbaum H. Coronary artery disease. In: Echocardiography. 2nd ed. Philadelphia: Lea and Febiger;1975. p.341-80.
  5. Castello R, Pearson AC, Labovitz AJ. Prevalence and clinical implications of atrial spontaneous contrast in patients undergoing transesophageal echocardiography. Am J Cardiol 1990;65:1149-53. https://doi.org/10.1016/0002-9149(90)90330-4
  6. Fatkin D, Herbert E, Feneley MP. Hematologic correlates of spontaneous echo contrast in patients with atrial fibrillation and implications for thromboembolic risk. Am J Cardiol 1994;73:672-6. https://doi.org/10.1016/0002-9149(94)90932-6
  7. Song WH, Lim HE, Shin SH, Lee EM, Hwang KS, Ahn JC, Lim DS, Park CG, Shim WJ, Oh DJ, Ro YM. Changes of mitral inflow according to position in patients with dilated cardiomyopathy. J Korean Soc Echocardiogr 1998;6:5-10.
  8. Youn HJ. Unusual form of cardiomyopathy. J Korean Soc Echocardiogr 2005;13:51-65.
  9. Visser CA, Kan G, David GK, Lie KI, Durer D. Two dimensional echocardiography in the diagnosis of left ventricular thrombus: a prospective study of 67 patients with anatomic validation. Chest 1983;83:228-32. https://doi.org/10.1378/chest.83.2.228
  10. Arvan S. Mural thrombi in coronary artery disease: recent advances in pathogenesis, diagnosis, and approaches to treatment. Arch Intern Med 1984;144:113-6. https://doi.org/10.1001/archinte.144.1.113
  11. Shaw LJ. Impact of contrast echocardiography on diagnostic algorithms: pharmacoeconomic implications. Clin Cardiol 1997;20:139-48.
  12. Thomas JD, Rubin DN. Tissue harmonic imaging: why does it work? J Am Soc Echocardiogr 1998;11:803-8. https://doi.org/10.1016/S0894-7317(98)70055-0
  13. Rubin DN, Yazbek N, Garcia MJ, Stewart WJ, Thomas JD. Qualitative and quantitative effects of harmonic echocardiographic imaging on endocardial edge definition and side-lobe artifacts. J Am Soc Echocardiogr 2000;13:1012-8. https://doi.org/10.1067/mje.2000.108348
  14. Mele D, Campana M, Sclavo M, Seveso G, Aschieri D, Nesta F, D'Aiello I, Ferrari R, Levine RA. Impact of tissue harmonic imaging in patients with distorted left ventricles: improvement in accuracy and reproducibility of visual, manual and automated echocardiographic assessment of left ventricular ejection fraction. Eur J Echocardiogr 2003;4:59-67. https://doi.org/10.1053/euje.2002.0619
  15. Mele D, Teoli R, Cittanti C, Pasanisi G, Guardigli G, Levine RA, Ferrari R. Assessment of left ventricular volume and function by integration of simplified 3D echocardiography, tissue harmonic imaging and automated extraction of endocardial borders. Int J Cardiovasc Imaging 2004;20:191-202. https://doi.org/10.1023/B:CAIM.0000021948.96454.3a
  16. Ono M, Asanuma T, Tanabe K, Yoshitomi H, Shimizu H, Ohta Y, Shimada T. Improved visualization of the left atrial appendage by transthoracic 2-dimensional tissue harmonic compared with fundamental echocardiographic imaging. J Am Soc Echocardiogr 1998;11:1044-9. https://doi.org/10.1016/S0894-7317(98)70155-5
  17. Mele D, Soukhomovskaia O, Pacchioni E, Merli E, Avigni N, Federici L, Levine R, Ferrari R. Improved detection of left ventricular thrombi and spontaneous echocontrast by tissue harmonic imaging in patients with myocardial infarction. J Am Soc Echocardiogr 2006;19:1373-81. https://doi.org/10.1016/j.echo.2006.05.011
  18. Meltzer RS, Visser CA, Fuster V. Intracardiac thrombi and systemic immobilization. Ann Intern Med 1986;104:689-98. https://doi.org/10.7326/0003-4819-104-5-689
  19. Kidwell CS, Warach S. Acute ischemic cerebrovascular syndrome: diagnostic criteria. Stroke 2003;34:2995-8. https://doi.org/10.1161/01.STR.0000098902.69855.A9
  20. Sharma ND, McCullough PA, Philbin EF, Weaver WD. Left ventricular thrombus and subsequent thromboembolism in patients with severe systolic dysfunction. Chest 2000;117:314-20. https://doi.org/10.1378/chest.117.2.314
  21. Richardson P, McKenna W, Bristow M, Maisch B, Mauter B, O'connell J, Olsen E, Thiene G, Goodwin J, Gyarfas I, Martin I, Nordet P. Report of the 1995 World health organization/international society and federation of cardiology task force on the definition and classification of cardiomyopathies. Circulation 1996;93:841-2. https://doi.org/10.1161/01.CIR.93.5.841
  22. Sahn DJ, DeMaria A, Kisslo J, Weyman A. Recommendations regarding quantitation in M-mode echocardiography: results of a survey of echocardiographic measurements. Circulation 1978;58:1072-83. https://doi.org/10.1161/01.CIR.58.6.1072
  23. Gottdiener JS, Gay JA, Van Voorhees L, DiBianco R, Fletcher RD. Frequency and embolic potential of left ventricular thrombus in dilated cardiomyopathy: assessment by 2-dimensional echocardiography. Am J Cardiol 1983;52:1281-5. https://doi.org/10.1016/0002-9149(83)90588-X
  24. Fuster V, Halperin JL. Left ventricular thrombi and cerebral embolism. N Engl J Med 1989;320:392-4. https://doi.org/10.1056/NEJM198902093200610
  25. Kozdag G, Ciftci E, Vural A, Selekler M, Sahin T, Ural D, Kahraman G, Agacdiken A, Demirci A, Komsuoglu S, Komsuoglu B, Fici F. Silent cerebral infarction in patients with dilated cardio-myopathy: echocardiographic correlates. Int J Cardiol 2006;107:376-81. https://doi.org/10.1016/j.ijcard.2005.03.055
  26. Falk RH, Foster E, Coats MH. Ventricular thrombi and thromboembolism in dilated cardiomyopathy: a prospective follow-up study. Am Heart J 1992;123:136-42. https://doi.org/10.1016/0002-8703(92)90757-M
  27. Hunt SA, Baker DW, Chin HM, Cinquegrani MP, Feldman AM, Francis GS, Ganiats TG, Goldstein S, Gregoratos G, Jessup ML, Noble RJ, Packer M, Silver MA, Stevenson LW, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Jacobs AK, Hiratzka LF, Russell RO, Smith SC Jr. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary a report of the American college of cardiology/American heart association task force on practice guidelines (committee to revise the 1995 guidelines for the evaluation and management of heart failure): developed in collaboration with the international society for heart and lung transplantation: endorsed by the heart failure society of America. Circulation 2001;104:2996-3007. https://doi.org/10.1161/hc4901.102568
  28. Ansari A, Maron BJ. Spontaneous echo contrast and thromboembolism. Hosp Pract (Minneap) 1997;32:109-11, 115-6.
  29. Belohlavek M, Tanabe K, Mulvagh SL, Foley DA, Greenleaf JF, Seward JB. Image enhancement by noncontrast harmonic echocardiography: part II. Quantitative assessment with use of contrast-to-speckle. Mayo Clin Proc 1998;73:1066-70. https://doi.org/10.4065/73.11.1066
  30. Main ML, Asher CR, Rubin DN, Odabashian JA, Cardon LA, Thomas JD, Klein AL. Comparison of tissue harmonic imaging with contrast (sonicated albumin) echocardiography and Doppler myocardial imaging for enhancing endocardial border resolution. Am J Cardiol 1999;83:218-22.
  31. Hwang JH, Yang DH, Shin SC, Cho S, Kim TI, Park HS, Cho YK, Chae SC, Jun JE, Park WH. Value of tissue harmonic imaging for the left ventricular wall imaging. J Kor Soc Echocardiogr 2000;8:198-205.
  32. Ha JW, Chung N, Kang SM, Jang KJ, Kim IJ, Rim SJ, Jang Y, Shim WH, Cho SY, Kim SS. Enhanced detection of left atrial spontaneous echo contrast by transthoracic harmonic imaging in mitral stenosis. J Am Soc Echocardiogr 2000;13:849-54. https://doi.org/10.1067/mje.2000.106791
  33. Daniel WG, Nellessen U, Schroder E, Nonnast-Daniel B, Bednarski P, Nikutta P, Lichtlen PR. Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thromboembolic risk. J Am Coll Cardiol 1988;11:1204-11. https://doi.org/10.1016/0735-1097(88)90283-5