International Journal of Cardiology 187 (2015) 4–6

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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard

Letter to the editor

Left main percutaneous coronary intervention improves left ventricular systolic function assessed by tissue Doppler echocardiography Takashi Kajiya a, Adrian F. Low a,b, Chi-Hang Lee a,b, Huay-Cheem Tan a,b, Kian-Keong Poh a,b,⁎ a b

Department of Cardiology, National University Heart Centre, National University Health System, Singapore Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

a r t i c l e

i n f o

Article history: Received 21 February 2015 Accepted 17 March 2015 Available online 18 March 2015 Keywords: Left main Percutaneous coronary intervention Left ventricular function Tissue Doppler imaging

Prevalence of left main (LM) percutaneous coronary intervention (PCI) has increased globally. Several studies showed that LM PCI yields mortality and morbidity rates comparable to coronary artery bypass graft (CABG) [1–3]. However, results on LM PCI have been focused only on clinical outcomes and comparison with CABG. Whether LM PCI improves left ventricular function or not has not been elucidated yet. Echocardiography is widely used for evaluation of left ventricular (LV) systolic and diastolic function. In addition, tissue Doppler echocardiography (TDE) has been shown to be useful in the management of patients with coronary heart disease and heart failure [4,5]. Unlike conventional Doppler echocardiography, TDE quantify the higher amplitude, lower-velocity signals of myocardial tissue motion. We aim to examine the utility of TDE and conventional echocardiography on the effects of LV function post-LM PCI. We studied 164 Asian patients who underwent LM PCI at a highvolume tertiary hospital in Singapore from October 1996 to March 2012. We included patients with paired TDE evaluation of pre- and post-PCI. We excluded patients with intervening myocardial infarction between the two echocardiographic examinations. A total 24 patients were included and echocardiographic findings including TDE were compared pre- and post-LM PCI. TDE was performed in an apical 4chamber view, with the sample volume placed at both septal and lateral border of the mitral annulus. We included both unprotected and ⁎ Corresponding author at: Department of Cardiology, National University Heart Centre, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore 119228, Singapore. E-mail address: [email protected] (K.-K. Poh).

http://dx.doi.org/10.1016/j.ijcard.2015.03.233 0167-5273/© 2015 Published by Elsevier Ireland Ltd.

protected LM PCI. The primary endpoints of the study were composite of major adverse cardiac events (MACE) comprising all-cause death, myocardial infarction and target vessel revascularization (TVR). Discrete data were presented as frequencies and/or percentages and continuous variables were presented as means ± SD. Continuous variables were compared using the t-test, and categorical variables were compared using either the chi-square test or Fisher's exact test as appropriate. A P value of less than 0.05 was considered statistically significant. The institutional ethics review board approved the study and global consent for the collection of personal health care information for noncommercial research purposes was obtained from all subjects upon admission. Baseline characteristics of the patients are shown in Table 1. Of these 24 patients, 13 patients had a history of CABG before PCI and 11 patients had unprotected LM PCI. Echocardiographic findings including TDE are presented in Table 2. The time interval between PCI and post-PCI echocardiography was 85.9 ± 87.9 days. LV ejection fraction (LVEF) (45 ± 16 vs. 49 ± 15%, P b 0.05) was significantly improved after LM PCI. LV dimensions, volumes, stroke volume, LV mass, and left atrium dimensions were not significantly different between the two groups. TDE mitral annular systolic velocity (S′) at the septum was significantly improved (increased) after LM PCI (5.7 ± 2.1 vs. 6.9 ± 2.0 cm/s, P b 0.01) (Fig. 1). Early diastolic mitral annular velocity (E′), late diastolic annular velocity (A′), E/E′ and E′/A′ ratios at the septal mitral annulus and all paired parameters at lateral mitral annulus and tricuspid annulus were not significantly different. Major adverse cardiac events (MACE) as defined by all cause death, myocardial infarction, and target vessel revascularization occurred 25% of subjects over a period of 1 year. Septal S′ predicts MACE with an area under the receiver-operative curve of 0.69 (95% CI 0.46–0.93). Preoperative septal S′ of b 5.9 cm/s predicts MACE with a sensitivity of 67% and specificity of 69%. In this single-centre observational study we demonstrated that LM PCI can result in improvement of the LV systolic function as indicated by the increase in septal systolic velocity using TDE and LVEF. TDE systolic velocities have been used to detect impaired systolic function in patients with coronary artery disease. Systolic myocardial velocity (S′) at mitral annulus is a measure of longitudinal systolic function. It has been shown that S′ at the lateral mitral annulus correlated with measurements of LV ejection fraction [6]. In our study, S′ at lateral mitral annulus did not show significant differences between pre and post LM PCI, but S′ at the septal mitral annulus increased after LM PCI.

T. Kajiya et al. / International Journal of Cardiology 187 (2015) 4–6

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Table 1 Baseline characteristics of the patients.

Age (years) Gender (Male) Height (cm) Weight (kg) DM (%, N) HTN (%, N) Dyslipidemia (%, N) Smoking (%, N) CKD (%, N) MACE at 1 year (%, N)

All (N = 24)

CABG+ (N = 13)

CABG− (N = 11)

P value

65.0 ± 11.6 70.8% 161.3 ± 7.7 62.3 ± 10.7 33.3% (8) 75.0% (18) 87.5% (21)

61.9 ± 8.8 61.5% 160.9 ± 9.0 60.7 ± 13.6 23.1% (3) 92.3% (12) 100% (13)

68.5 ± 13.7 81.8% 161.8 ± 6.2 64.1 ± 5.8 45.5% (5) 54.5% (6) 72.7% (8)

0.18 0.27 0.78 0.42 0.25 0.06 0.08

40.0% (10) 8.3% (2) 25.0% (6)

23.1% (3) 7.7% (1) 38.5% (5)

63.6% (7) 9.0% (1) 9.0% (1)

0.09 1.0 0.16

CABG; coronary bypass graft, DM; diabetes mellitus, HTN; hypertension, CKD; chronic kidney disease, MACE; major adverse cardiac events.

Septal and lateral mitral annular TDE velocities have only weak to moderate correlations to each other and are affected by different factors, even in healthy adults [7]. Several studies have shown that LM PCI yields long term clinical outcomes comparable to coronary artery bypass graft (CABG) [1–3]. This appears to be so, even for subgroups such as diabetes mellitus and subjects with triple-vessel disease [8,9]. However, there is paucity of literature on LV function post LM PCI [10,11]. To our best knowledge, this is the first study using TDE to assess the effects of LM PCI on LV function. The increase of LVEF and mitral annular systolic velocity is consistent with improvement in global systolic function post-LM PCI. However, we did not find any differences in LV diastolic function, either on conventional Doppler or tissue Doppler parameters. It has been published that S′ correlated strongly with LVEF [12]. TDE S′ may be a useful parameter in the assessment of LV systolic function especially if the two-dimensional echocardiographic image quality is low. Furthermore, mitral annular S′ and E′ velocities correlate more strongly with plasma brain natriuretic peptide (BNP) levels than conventional echocardiographic parameters [13]. Overall, TDE provides a simple, sensitive, accurate and reproducible tool for evaluation of LV function [14].

LV EDV index (ml/m ) LV ESV index (ml/m2) SV index (ml/m2) LV mass index (g/m2) LA volume index (ml/m2) LVEF (%) TDE Septal Systolic velocity (S′) E′ A′ E′/A′ E/E′ Lateral Systolic velocity (S′) E′ A′ E′/A′ RV Systolic velocity (S′) E′ A′ E′/A′

This study has limitations including the retrospective nature of the study. There is a possibility of selection bias. However we select based on our strict inclusion and exclusion criteria. Secondly, the study population is small. However, we were able to reach significance in the 2 parameters assessing LV systolic function. Lastly, the time period between PCI and post-PCI echocardiography was variable. Besides PCI, drug therapy and other factors may also affect LV function. In conclusion, LM PCI improved LVEF and septal systolic velocity assessed by TDE. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.

Table 2 Echocardiographic findings of pre- and post-LM PCI.

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Fig. 1. Paired septal systolic velocity (S′ in cm/s) of pre- and post-LM PCI.

Pre-LM PCI

Post-LM PCI

P value

83.3 ± 33.0 45.3 ± 31.4 38.1 ± 12.9 108.2 ± 28.3 24.6 ± 5.2 45.2 ± 16.2

80.3 ± 25.1 40.5 ± 22.3 39.9 ± 13.4 115.1 ± 28.9 24.8 ± 4.4 49.3 ± 15.2

0.606 0.314 0.434 0.145 0.746 0.024

5.7 ± 2.0 7.2 ± 3.9 8.5 ± 2.6 0.8 ± 0.3 14.8 ± 10.9

6.9 ± 2.0 6.7 ± 2.2 9.4 ± 2.8 0.7 ± 0.3 13.9 ± 9.6

0.006 0.572 0.251 0.386 0.55

6.7 ± 2.8 8.8 ± 3.1 8.5 ± 3.0 1.1 ± 0.3

7.1 ± 2.6 8.3 ± 3.0 8.4 ± 3.3 1.1 ± 0.4

0.381 0.43 0.89 0.882

10.6 ± 2.9 8.4 ± 2.7 11.4 ± 3.4 0.8 ± 0.3

10.8 ± 2.6 8.8 ± 3.2 11.9 ± 4.6 0.9 ± 0.5

0.77 0.698 0.689 0.585

LV; left ventricle, EDV; end-diastolic volume, ESV; end-systolic volume, SV; stroke volume, LA; left atrium, EF; ejection fraction, TDE; tissue Doppler echocardiography, S′; mitral annular systolic velocity, E′; Early diastolic mitral annular velocity, A′; late diastolic annular velocity, RV; right ventricle.

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Left main percutaneous coronary intervention improves left ventricular systolic function assessed by tissue Doppler echocardiography.

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