To the Editor, Acute myocarditis associated with a normal left ventricular (LV) ejection fraction is challenging to diagnose. Echocardiography is the initial imaging modality used, but diagnostic accuracy is limited, especially in patients with chest pain in whom LV function and size are almost always normal [1]. The current reference standard for noninvasive diagnosis of myocarditis is cardiac magnetic resonance (CMR) imaging [2]. Here we describe a case of a 19-year-old man who presented with severe chest pain that mimicked acute coronary syndrome but was subsequently diagnosed with acute regional myocarditis by two-dimensional (2D) speckle echocardiography. The patient was successfully treated medically for myocarditis. A 19-year-old male with no cardiovascular risk factors was admitted due to chest discomfort and fever. On admission, blood pressure, heart rate and body temperature were 140/65 mmHg, 92 beats per minute, and 38℃, respectively. Initial electrocardiography showed upwardly concave ST elevations in II, III, and aVF leads, with no reciprocal change in the anterior chest lead. Laboratory tests revealed elevated serum C-reactive protein (CRP) and cardiac biomarker (CRP, 1.5 mg/L; creatine kinase [CK], 616 IU/L; CK-MB, 53.0 IU/L; and troponin-I, 4.81 ng/mL). A 2D-echocardiogram showed normal regional wall motion with preserved LV systolic and diastolic function, but automated function imaging, which was assessed by a 2D speckle-tracking imaging (STI), showed a decreased peak in the systolic longitudinal strain of the basal inferior and lateral walls (Fig. 1D, Bull's eye view) and the circumferential strain also decreased in the basal inferior and lateral walls (Fig. 2). Strain curves showed that abnormal longitudinal systolic shortening was detected by strain echocardiography in the lateral and posterior wall, where there were abnormalities indicating longitudinal strain such as a reduced systolic shortening and a postsystolic peak (Fig. 1A, yellow line; Fig. 1B, red line); however, longitudinal systolic shortening in the anterior, inferior and septal walls was normal (Fig. 1C). This pattern was also observed in the circumferential strain curve (Fig. 2). Elevated cardiac biomarkers and decreased regional peak systolic strain usually suggest regional coronary ischemia. However, in this patient, ischemic disease was extremely unlikely due to his young age, lack of family history of coronary artery disease, and lack of regional wall motion abnormalities on the conventional 2D echocardiogram, despite a decreased regional peak longitudinal strain. Therefore, conservative treatment was initiated, including pain medications and diuretics, rather than invasive procedures such as a coronary angiography or myocardial biopsy. To confirm the diagnosis and to examine the change in the myocardium, CMR imaging was performed on the day following admission. Gadolinium-enhanced CMR on the fifth day of admission demonstrated subepicardial delayed hyperenhancement at the basal inferior, lateral wall and the mid lateral wall on short axis, 10 minutes after the enhancement of the image in accordance with myocarditis (Fig. 3). Surprisingly, abnormalities in automated functional imaging and strain curve analysis correlate closely with findings on CMR imaging. Antigen tests for cosackie and influenza viruses were positive. With the suspicion of acute viral myocarditis associated with influenza, we prescribed tamiflu (Genentech, Basel, Switzerland) for 5 days. The patient's clinical signs resolved along with the normalization of the ST segment changes and the serum CK level. Figure 1 Two-dimensional speckle tracking imaging. Strain curves showed that abnormal longitudinal systolic shortening was detected by strain echocardiography in the lateral and posterior wall, where there were abnormalities indicating longitudinal strain such ... Figure 2 Two-dimensional segmental circumferential strain curves and color M mode depicting attenuated strain in inferior and lateral segments at the mid-ventricular level. Figure 3 (A, B) Cardiac magnetic resonance imaging showed subepicardial delayed hyperenhancement at the basal inferior, lateral, and mid lateral walls on short axis on a 10 minute-delayed enhancement image. Acute myocarditis has myriad presentations, and often mimics acute coronary syndrome at initial presentation. CMR imaging and myocardial biopsy at the initial acute presentation is not feasible for a differential diagnosis and cannot confirm myocarditis. However, conventional 2D echocardiography, plus strain imaging were crucial in this case to determine the best course of treatment. This case demonstrated that decreased myocardial strain as assessed by 2D speckle echocardiography and different strain curve pattern such as reduction in systolic shortening and postsystolic peak may lead clinicians to the accurate diagnosis of acute myocarditis in patients with chest pain and elevated cardiac biomarkers, but normal wall motion, mimicking acute coronary syndrome. Although the diagnosis of myocarditis has traditionally required a histologic diagnosis, according to the classic Dallas criteria, new diagnostic strategies such as CMR can strongly indicate and diagnose myocarditis. CMR imaging can characterize tissue according to water content and changes in contrast kinetics, which allows visualization of the entire myocardium. Thus, it is well suited to detect patchy myocarditic lesions [3]. Recently, CMR imaging has become the noninvasive diagnostic tool of choice to diagnose myocarditis, and is recommended in patients whose symptoms suggest this condition [2]. However, CMR does have some disadvantages, notably its high cost and the time needed to perform it; therefore, it is not feasible in an acute emergency setting. Conventional 2D echocardiography has traditionally played a limited role in the diagnostic armamentarium for acute myocarditis due to the lack of specific distinguishing features and/or apparently normal examinations encountered in less severe forms of myocarditis [1]. Nevertheless, segmental and global wall motion abnormalities do occur, and patterns of hypertrophic, dilated, and restrictive cardiomyopathy have been reported in histologically proven myocarditis [1]. The advent of novel echocardiographic modalities, such as strain echocardiography, has dramatically expanded the scope of echocardiography, which provides an accurate bedside assessment of regional contractility and can identify longitudinal myocardial dysfunction derived from edema in acute myocarditis [4,5]. Particularly for myocardial damage of only the epicardial layer of the ventricular wall during acute myocarditis, Doppler echocardiography can identify longitudinal segmental myocardial dysfunction derived from edema [5]. These newer techniques are more efficacious than conventional echocardiography in the diagnosis of myocarditis. Interestingly, decreased myocardial longitudinal strain and circumferential strain assessed by the 2D speckle tracking technique, in the absence of wall motion abnormalities, may represent a useful additional diagnostic finding in acute regional myocarditis, while longitudinal segmental myocardial dysfunction derived from edema also supports the diagnosis. This methodological improvement allowed us to evaluate myocardial damage using CMR rather than subjecting the patient to invasive methods such as coronary angiography. In conclusion, in young patients with chest pain who have elevated cardiac biomarkers and dynamic EKG changes but who do not fit the signalment for coronary disease, 2D STI analysis, including longitudinal and circumferential strain, can help physicians to diagnose acute myocarditis and to devise an appropriate treatment plan.

BACKGROUND:This study was conducted to determine the early cardiac valvular changes in young male ankylosing spondylitis (AS) patients.METHODS:A total of 70 AS patients on treatment without clinical cardiac symptoms were divided into group I (< 10 years, n = 50) and group II (≥ 10 years, n = 20) depending on their disease duration after first diagnosis. Twenty-five healthy volunteers were selected as control subjects. All the subjects underwent transthoracic and transesophageal echocardiography, electrocardiography, and rheumatologic evaluation for AS patients.RESULTS:The thickness of both the aortic and mitral valve was more increased in AS patients than in controls. Aortic valve thickness over 1.3 mm could predict AS with a sensitivity of 73% and specificity of 76%. The prevalence of aortic valve thickening was higher in the AS group compared to the controls. The prevalence of aortic and mitral regurgitation was very low and there was no difference between the controls and the patients. The aortic valve thickening was related to longer disease duration, high blood pressure, disease activity and inflammatory markers.CONCLUSION:Thickening of the aortic and mitral valve was observed without regurgitation in male AS patients early in the course of their disease without clinical cardiac manifestations. This subclinical change of aorto-mitral valve in early AS should be considered and followed up to determine its prognostic implication and evolution.

BACKGROUND AND OBJECTIVES:Treadmill exercise stress echocardiography (TSE) has superior diagnostic accuracy than exercise electrocardiography (ECG). The objectives of the study are 1) to define the diagnostic accuracy and safety of TSE in patients without a history of coronary artery disease (CAD), 2) to identify the clinical characteristics that predict positive TSE results and 3) to assess the differential predictive value between TSE and concomitant exercise ECG in a Korean population.SUBJECTS AND METHODS:A total of 1,287 patients among 1,500 consecutive patients with no prior history of CAD and who were referred for TSE during a 4-year 3-month period were enrolled.RESULTS:Of the 1,287 patients, 95 (7.4%) showed positive TSE results (newly developed regional wall motion abnormality). Among the 154 patients with coronary angiography, 94 patients (61%) showed significant CAD (30 of 77 patients with negative TSE results and 64 of 77 patients with positive TSE results). The TSE positive population had more cardiovascular risk factors and showed a higher Duke treadmill score and wall motion score index than the TSE negative group. TSE showed relatively good sensitivity (68%), specificity (78%) and positive and negative predictive values (83% and 61%, respectively), and TSE also had higher diagnostic accuracy than concomitant exercise ECG (72% vs. 64%, respectively).CONCLUSION:TSE is safe and offers greater diagnostic power for CAD than exercise ECG in Korean population without a history of CAD. Its prognostic value in this population needs to be confirmed in a larger prospective study.

The aim of this study was to determine whether assessment of global longitudinal strain (GLS) before revascularization could predict adverse cardiac events after ST-segment elevation myocardial infarction (STEMI). In addition, the relation between GLS and cardiac biomarkers was investigated. From July 2006 through December 2009, 98 patients with first STEMI underwent conventional and speckle tracking echocardiography at initial presentation and 3 days after primary coronary intervention. Patients were divided into 3 groups according to percent changes of GLS compared to baseline GLS values: group 1, improved GLS >10%; group 2, unchanged GLS from -10% to 10%; and group 3, decreased GLS <-10%. Subsequent complications including all-cause mortality and readmission because of congestive heart failure during a 6-month period of follow-up were prospectively evaluated. After coronary intervention, GLS was improved in 29 patients (30%, group 1), unchanged in 55 patients (56%, group 2), and worsened in 14 patients (14%, group 3). Complications developed in 7 patients (group 1, n = 0, 0%; group 2, n = 2, 28%; group 3, n = 5, 72%, p <0.01). Multivariate Cox analysis showed an independent association of GLS before and after coronary intervention with subsequent complications. Significant correlations were observed between GLS and cardiac biomarkers. In conclusion, GLS assessment before coronary intervention was a good predictor of complications in patients with STEMI comparable to predictions using GLS after intervention at 6-month follow-up. (C) 2011 Elsevier Inc. All rights reserved. (Am J Cardiol 2011;108:340-347)

BACKGROUND:Waon therapy has beneficial effects on chronic heart failure (CHF), peripheral arterial disease, and other various diseases. This was to assess the safety and effect of Waon therapy by echocardiography for the first time in Korea.METHODS:Ten patients with CHF were enrolled. The patients with a light gown were placed in a sitting-position in an evenly maintained 60 dry sauna system for 15 minutes, and then after leaving the sauna, they underwent bed rest with a blanket to keep them warm for an additional 30 minutes. Waon therapy was performed once a day, 5 days a week.RESULTS:Four of the 5 patients who had been treated for more than 2 weeks as protocol noted improvement of heart failure (HF) symptoms and decrease in left ventricular (LV) volume. There were trends in improvement of LV ejection fraction and parameters of diastolic function after the therapy although statistical significance was lack. No one complained of worsening of HF symptoms. In each session, body weight (61.8+/-10.2 kg vs. 61.6+/-10.3 kg, p=0.008) and blood pressure (systolic, 119+/-28 vs. 111+/-27 mmHg, p=0.005; diastolic, 69+/-12 mmHg vs. 63+/-10 mmHg, p=0.005) were significantly decreased, oral temperature (35.9+/-0.4 vs. 37.0+/-0.9, p=0.017) was increased by 1.0 at the end of sauna bathing, but the heart rate (71+/-10/min vs. 72+/-8/min, p=0.8) was not changed.CONCLUSION:We have experienced Waon therapy which was safe and well tolerated and some beneficial effects for patients with CHF. Large scale randomized study is needed to apply Waon therapy as a promising therapy in Korean HF patients.

The relation between remodeling and left ventricular (LV) torsion has not yet been fully investigated. The aim of this study was to determine whether LV torsion assessed by speckle tracking imaging can predict progressive LV dilation after acute myocardial infarction (AMI). From January 2006 through June 2008, 91 patients with AMI who were successfully treated with primary coronary intervention underwent conventional and speckle tracking echocardiographies at initial presentation and 3 days and 6 months after first AMI. Patients were divided into 2 groups based on presence of LV remodeling (increase of LV end-diastolic volume >20%) at 6-month follow-up. LV remodeling developed in 23 patients. At initial presentation, LV end-diastolic volume was not significantly different between the no-remodeling and remodeling groups (91.27 ± 35.68 vs 85.74 ± 28.89 ml, p = 0.51), but LV torsion (2.23 ± 0.67 vs 1.70 ± 0.58°/cm, p <0.05) was significantly decreased in the remodeling group. At 6-month follow-up speckle tracking echocardiography, apical rotation and global torsion in patients with remodeling were 6.7 ± 2.6 (p <0.05) and 1.7 ± 0.7°/cm (p = 0.76 from baseline), respectively, and in patients without remodeling, 8.8 ± 3.4 (p <0.01) and 2.5 ± 0.7°/cm (p <0.01 from baseline), respectively. According to receiver operating characteristic analysis, LV torsion of 1.9°/cm (area under curve 0.79, sensitivity 75%, specificity 78%) at initial presentation was selected as a significant predictor of remodeling. In conclusion, decreased LV torsion assessed by speckle tracking echocardiography may predict late LV remodeling after reperfusion therapy after AMI.

Secondary (amyloid A [AA]) amyloidosis is a systemic disease characterized by amyloid deposition in many organs, leading to impaired function. Although cardiac involvement may occur with AA amyloidosis, significant deposition of amyloid in the heart is considered an infrequent observation and is rarely the cause of death. It occurs in 5% of patients with poorly controlled chronic inflammatory disease, mainly rheumatoid arthritis, ankylosing spondylitis, and familial Mediterranean fever. The authors report a case of AA amyloidosis diagnosed by rectal and skin biopsies, with cardiac involvement demonstrated by typical echocardiographic features in the presence of low voltage on electrocardiography. (J Am Soc Echocardiogr 2009;22:542.e5-542.e7.)

Cardiac hypertrophy in a patient with severe iron deficiency anaemia associated with long-term blood-letting using cupping, called 'puhang' in oriental medicine, is discussed using chest electrocardiographic and radiographic images. With iron supply, the patient showed remarkable improvement of cardiomegaly, which is a unique feature of chronic severe iron deficiency anaemia.

This is a case of full-blown Takayasu's arteritis in a young woman complicated with recurrent strokes, which was diagnosed late, after echocardiographic examination identifying concentric left ventricular hypertrophy of unknown cause and falsely normal blood pressure due to arterial stenoses in all four limbs. Herein we describe this interesting and instructive case with a short review of literature.

Background and Objectives：We investigated whether prehypertensives (PHs) exhibit more prevalent electrocardiographic and echocardiographic left ventricular hypertrophy (ECG LVH) and if they are are more associated with impaired left ventricular (LV) diastolic function than are normotensives (NTs). Subjects and Methods：A total of 608 subjects≥40 years of age with normal BP (SBP<120 mmHg and DBP<80 mmHg, n=335) and PH (n=273) and who were without a history of hypertension, diabetes and any other known cardiovascular diseases underwent blood sampling for obtaining the lipid profile, and they also underwent 12-lead electrocardiography and echocardiography. Results：Compared with the NTs, the PHs had significantly higher Sokolow-Lyon and Cornell voltage for ECG LVH, and they ahd a higher prevalence of ECG LVH (men: 16.9% vs 5.9%, women: 2.0% vs 1.0%, respectively). The PHs had a more increased left ventricular mass index (LVMI, Men: 118.1± 24.4 g/m 2

Background and Objectives：A new Doppler time index of myocardial performance (the Tei index) has been studied as a useful predictor of global cardiac function. It is defined as (a-b)/b, where a is the interval between the end and onset of the mitral inflow, and b is the ejection time of the left ventricular outflow. However, the Doppler time intervals are not measured on the same cardiac cycle. Subjects and Methods：We compared the tissue Doppler imaging (TDI)-derived Tei index, which can be measured on the same cardiac cycle, with the conventional Tei index as measured by pulsed wave Doppler method, in healthy persons (n=44), in patients having diastolic dysfunction with an E/E’ ratio >10 (DD, n=56), and in patients having systolic dysfunction with an ejection fraction <50% (SD, n=10). At the septal and lateral mitral annulus from the apical 4-chamber view, the time interval between the end and onset of the mitral annular velocities during diastole (a’) minus the duration of the systolic wave (b’) divided by b’, which is (a’-b’)/b’, is defined as the TDI-tei index. Results： The TDI-Tei index and the conventional Tei index were significantly higher in the SD group than in the DD group, and they were also higher in the DD group than in the healthy controls. The TDI-Tei index at the septal and lateral annulus correlated well with the Tei index (r=0.71, r=0.65, respectively, p<0.001) and this showed a good correlation with other echocardiographic parameters of diastolic function. Conclusion：We demonstrated that the TDI-Tei index correlates well with the conventional Tei index along with having the advantage of simultaneous recording of the systolic and diastolic velocities in adults. (Korean Circulation J 2005;35:315-321)

Background and Objectives:We sought to characterize the lesion characteristics of mitral valve prolapse (MVP), which is being increasingly recognized as a cause of mitral regurgitation (MR) in Koreans Subjects and Methods:497 Patients with MVP that was diagnosed by echocardiography in 13 university-affiliated hospitals from Jan to Dec 2003 were prospectively enrolled in our study. Results:A total of 497 patients (270 males, 54%) were enrolled and their mean age was 52±17 years. Grade 4 MR was present in 272 patients (54.7%); grade 3, 2 and 1 MR as present in 30.2%, 10.7% and 4.2%, respectively. MVP of the anterior and posterior mitral leaflet was present in 170 patients (34.2%) and 223 patients (44.9%), respectively; MVP developed in both leaflets in 104 patients (20.9%). In 37 patients (7.4%), MVP developed in all 6 segments of the mitral leaflet and these patients were younger (37±14 versus 54±16 years, respectively, p<0.05) and had a lower prevalence of chordae rupture and severe MR compared to the other patients. Among the 266 mitral segments showing prolapse in the 132 patients (26.6%) who underwent transesophageal echocardiography, the posterior medial scallop was the most frequently diseased one (26%), and this was followed by the posterior middle scallop (18%), the medial (17%), lateral (14%) and middle (13%) part of the anterior leaflet, and the posterior lateral scallop (12%). Younger patients with a mean age <45 years showed a lower prevalence of single segment prolapse, hypertension, severe MR and chordae rupture compared to the older patients (p<0.001, each). Conclusion:The medial part of both mitral leaflets was the predilection site for the development of MVP in Koreans and the lesion characteristics were different according to the patients’ age. (Korean Circulation J 2005;35:904-909)

Background and Objectives:A non-dipping pattern in hypertensive patients has been shown to be associated with a greater left ventricular (LV) hypertrophy, LV diastolic impairments and prolonged ventricular repolarization. The dynamic parameters of the QT dispersion (QTd) have been highlighted as markers of ventricular repolarization heterogeneity. The aim of this study was to demonstrate if the extent of nocturnal blood pressure (BP) fall was related to the LV mass, LV diastolic function and dynamic parameters of the QTd. Subjects and Methods:122 subjects, receiving electrocardiography, 24-hour ambulatory BP monitoring, 12 lead-24hr Holter monitoring and 2-dimensional Doppler echocardiography examinations, were enrolled. The subjects were classified as normotensive, dipper and non-dipper. The LV mass (LVM) and LV diastolic indices were measured. Using the QT Guard software, with 12 lead-24hr Holter monitoring, the QTd, mean QTd, QTd variation (the difference between the maximum minus the minimum QTd value observed over the recording time), QTd maximum (the maximum difference of QTd between consecutive beats) and QTd variability (QTd standard deviation) were analyzed. Results:Of the 122 patients, 39 and 40 were placed in the dipper and non-dipper groups, respectively. The non-dipper group had a greater LVM index (LVMI) than the dipper group (p<0.01). The nondipper group had greater increases in their A velocity (p<0.01), and more prolonged deceleration (p<0.01) and isovolumic relaxation (p<0.01) times than the dipper group. There were no significant differences in the QT and QTc interval between the 3 groups, but the QTd was much more increased in the non-dipper than the dipper and normotensive groups (p<0.01). For the dynamic parameters of the QTd, the QTd variation, QTd maximum and QTd variability were significantly increased in the non-dipper compared to the dipper and normotensive groups (p<0.05). Comparing the dipper and normotensive groups, there were no significant differences in the LVMI, LV diastolic indices, QTd and dynamic parameters of the QTd. Conclusion:The nondipper group of hypertensive patients had a greater LVMI, more impaired LV diastolic function and greater increases in their QTd and dynamic parameters of the QTd compared to the dipper and normotensive groups, suggesting the possibility of a much greater chance of cardiovascular events, and their complications, in the nondipper compared to the dipper group. (Korean Circulation J 2005;35:382-388)

The nonbacterial valvular and mural verrucous endocarditis known as Libman-Sacks endocarditis is found in 40-60% of patients with systemic lupus erythematosus. the Libman-Sacks endocarditis mostly affects the mitral and aortic valves and frequently displays valvular dysfunction. In rare cases, the Libman-Sacks endocarditis can embolize and cause stroke syndrome. We report a case of Libman-Sacks endocarditis confused with infective endocarditis because its clinical manifestations were very similar to those of infective endocarditis. We confirmed systemic lupus erythematosus with Libman-Sacks endocarditis by means of serology and successfully treated patient with steroid.

Background and Objectives:Tissue Doppler imaging (TDI)-derived tissue velocity (TV) and strain rate (SR) are new ultrasonic parameters for assessing the regional myocardial function by quantitatively measuring the myocardial velocity. The aim of this study was to investigate the changes of these indices after exercise, in patients with coronary artery disease (CAD), for comparison with the wall motion score index (WMSI). Subjects and Methods:Twenty-one patients with CAD and 21 normal subjects were studied, before and after an exercise stress test, using the Bruce protocol. TDI data were obtained, and analyzed offline, for peak systolic TV (PSTV) and peak systolic SR (PSSR), using a 16 segment-model. The segmental PSTV and PSSR were compared with the WMSI. Results:The number of segments with a significant increase in the PSTV or PSSR, after exercise (p<0.05), was less in the CAD patients than the normal subjects (9 vs. 14 segments, 7 vs. 10 segments, respectively). The PSTV, after exercise, progressively decreased from the base to the apex in both the normal and CAD groups, but the absolute values were significantly lower in the CAD group (base:8.44±1.28 vs. 6.56±1.6, mid: 6.31±1.18 vs. 4.26±1.25 and apex: 3.48±0.83 vs. 1.25±1.27 cm/sec, p<0.05, respectively). In the normal subjects, the PSSRs, after exercise, were uniform in all segments, whereas this was not the cases in the CAD group (p<0.05). The PSSR showed a negative correlation with the WMSI (r=-0.45, p<0.05). Conclusion:This study has shown that TV and SR can detect the ischemic myocardium with exercise stress, and objectively measure the systolic function in patients with CAD. The quantification of stress echocardiography may overcome the training requirement, and subjective nature, of conventional wall motion scoring. (Korean Circulation J 2003;33 (7):590-598)