Strain value in the assessment of left ventricular function and prediction of heart failure markers in aortic regurgitation

Background: This study aimed to examine the relationship between biochemical heart failure markers and conventional left ventricular (LV) measurements and strain assessed by speckle‐tracking echocardiography in chronic aortic regurgitation (AR) patients. Methods and Results: LV strain, rotation assessed by speckle‐tracking echocardiography, LV measurements, mitral annular plane excursion measured by M‐mode, and systolic annular plane velocity measured by tissue Doppler echocardiography were analyzed in 64 controls and 65 chronic AR patients. Reduced LV longitudinal strain with increased apical rotation was seen in normal plasma NT‐proBNP patients. Increased NT‐proBNP (>400 pg/mL) was associated with reduced longitudinal and circumferential strain, diminished mitral annular plane excursions and systolic annular plane velocity. Global systolic longitudinal strain was an indepentent predictor of NT‐proBNP level. Longitudinal strain less than 16.0% was the cutoff value for NT‐proBNP >400 pg/mL (P < 0.05). Conclusions: LV strain analysis in conjunction with NT‐proBNP evaluation is a useful tool in assessing LV function in AR patients. (Echocardiography 2011;28:983‐992)     

Speckle tracking imaging in acute inflammatory pericardial diseases

Background: Left ventricular (LV) function in acute perimyocarditis is variable. We evaluated LV function in patients with acute perimyocarditis with speckle tracking. Methods: Thirty‐eight patients with acute perimyocarditis and 20 normal subjects underwent echocardiographic examination. Three‐layers strain and twist angle were assessed with a speckle tracking. Follow‐up echo was available in 21 patients. Results: Strain was higher in normal subjects than in patients with perimyocarditis. Twist angle was reduced in perimyocarditis—10.9°± 5.4 versus 17.6°± 5.8, P < 0.001. Longitudinal strain and twist angle were higher in normal subjects than in patients with perimyocarditis and apparently normal LV function. Follow‐up echo in 21 patients revealed improvement in longitudinal strain. Conclusions: Patients with acute perimyocarditis have lower twist angle, longitudinal and circumferential strain. Patients with perimyocarditis and normal function have lower longitudinal strain and twist angle. Short‐term follow‐up demonstrated improvement in clinical parameters and longitudinal strain despite of residual regional LV dysfunction. (Echocardiography 2011;28:548‐555)     

Comparison of real-time three-dimensional speckle tracking to magnetic resonance imaging in patients with coronary heart disease

This study compared strain values from 2-dimensional (2D) and real-time 3-dimensional (3D) speckle tracking with hyperenhancement transmural extent by magnetic resonance imaging (MRI). The study included 18 control subjects (mean age 51 ± 10 years) and 25 patients (20 men, mean age 62 ± 16 years) with ischemic left ventricular (LV) dysfunction (mean LV ejection fraction 41 ± 9%) referred for viability assessment using MRI. Longitudinal, radial, and circumferential strain values were computed using 2D speckle tracking. From analysis of 3D speckle tracking, conventional strain markers (longitudinal, radial, and circumferential) and 2 new 3D strain indexes (area and 3D strains) were obtained from apical view 3D datasets. A hyperenhancement transmural extent segment (16-segment model) was defined as delayed contrast enhancement >50%. Overall, 661 of 688 segments (96%) were analyzable by MRI and 3D speckle tracking. All 3D strain components in hyperenhancement transmural extent segments (n = 154) were lower than in nontransmural necrosis (n = 219) and control (n = 288) segments. Longitudinal strain by 3D, but not by 2D, differentiated nontransmural segments with scar <25%. All 3D global strain indexes correlated with LV ejection fraction (r(2) = 0.67 to 0.26, p <0.05 for all comparisons), whereas only area, longitudinal, and circumferential 3D strains correlated with global scar extent. The best reproducibility was provided by 3D longitudinal (6%) and area (8%) strains. In conclusion, longitudinal and area strains by 3D speckle tracking provide an accurate and reproducible measurement of myocardial deformation that correlate with infarct size in patients with ischemic LV dysfunction.     

Myocardial fibrosis is associated with biventricular dysfunction in patients with hypertrophic cardiomyopathy

Aims: To assess left (LV) and right ventricular (RV) function by two‐dimensional (2D) speckle tracking echocardiography and its relation to myocardial fibrosis in hypertrophic cardiomyopathy (HCM). Methods: We enrolled 50 HCM patients (30 male; 47.3 ± 9.9 years) in our study. Each patient received echocardiography with modern high‐end scanners. For speckle tracking analysis of LV and RV function the dedicated software was used. The presence of myocardial fibrosis was detected by cardiac magnetic resonance imaging (MRI). Results: For intraobserver variability of RV global longitudinal strain, we found a correlation of r = 0.89 (p < 0.001) with a minor bias of 4.9 ± 2.9%. On cardiac MRI 30 patients (60%) demonstrated late gadolinium‐enhancement (LGE) of the LV. Of these patients only 7% showed LGE of the RV. HCM patients with myocardial fibrosis had less global longitudinal LV strain in comparison to patients without myocardial fibrosis (?12.8 ± 2.2 vs ?21.1 ± 2.6, P < 0.001), thicker interventricular septums (23.7 ± 4.0 vs 19.2 ± 5.1, P < 0.001), larger left atria (34.9 ± 7.1 vs 23.9 ± 5.1, P < 0.001), and impaired diastolic function (E/A‐ratio: 1.02 ± 0.22 vs 1.15 ± 0.18, P < 0.01). Comparable results were found for RV function. LV and RV strain correlated with r = 0.85 (p < 0.001). Conclusions: HCM is not only a disease of the LV. LGE in HCM is associated with both LV and RV dysfunction. Although RV LGE occurs only in a minority of patients with HCM and LV fibrosis, speckle tracking echocardiography is feasible for evaluating LV and RV dysfunction in these patients. (Echocardiography 2012;29:438‐444)     

Evaluation of left ventricular performance in hypertensive patients by speckle tracking echocardiography: Correlation with brain natriuretic peptide

BackgroundHypertension results in hemodynamic changes ranging from maladaptive left ventricular hypertrophy (LVH) to heart failure. Two-dimensional speckle tracking echocardiography (2D-STE) allows rapid and accurate analysis of regional and global left ventricular (LV) systolic and diastolic functions.ObjectiveAssessments of LV function in hypertensive patients with apparently preserved LV systolic function using 2D-STE in correlation with plasma brain natriuretic peptide (BNP) levels.Patients and MethodsEighty hypertensive patients were enrolled, they were classified into LVH group (group III) and non-LVH group (group II). Twenty sex and age-matched healthy individuals were recruited as controls (group I). 2D-STE was done to all subjects to assess LV longitudinal strain, and strain rate (SR). Plasma BNP levels were measured in all subjects.ResultsGlobal longitudinal systolic strain was significantly reduced in group III compared with group II (P = 0.037) and group I (P = 0.000). Furthermore, group III showed significantly reduced global LV longitudinal systolic SR and early diastolic strain rate compared with group II (P = 0.023 and 0.008 respectively), and group I (P = 0.01 and 0.0001 respectively). On the other hand, the mean values of global SRa s⁻¹ were significantly higher in both group II and group III compared to group I (P = 0.0001). A negative correlation was found between BNP level and global peak systolic strain, global systolic strain rate, early diastolic strain rate and late diastolic strain rate in hypertensive patients (groups II & III) in whom BNP level was significantly higher than controls (group I) (P = 0.000).ConclusionA substantial impairment of LV systolic and diastolic functions is detected in hypertensive patients with apparently preserved LV systolic function, especially if associated with LVH, as evidenced by two-dimensional speckle tracking echocardiography. Plasma BNP level is elevated in hypertensive patients and shows a significant negative correlation with strain and strain rate values.     

Left Ventricular Systolic Function Changes in Primary Hypertension Patients Detected by the Strain of Different Myocardium Layers

This study investigated left ventricular (LV) systolic dysfunction associated with differential strain among myocardial layers in primary hypertension (PH) patients with or without LV hypertrophy (LVH), and normal patients.In 63 PH and 42 healthy patients, two-dimensional speckle tracking echocardiography was used to measure the peak systolic longitudinal and circumferential strain of the myocardial subendocardial, middle and subepicardial layers, and the peak systolic radial strain. To assess LV systolic function, the apical long axis, 4- and 2-chamber views, and parasternal short axis at the basal, middle, and apical levels were acquired by cardiovascular ultrasound (Vivid E9, GE Healthcare, USA).Overall, the pattern in peak systolic longitudinal strain among myocardial layers was subendocardial > middle > subepicardial. In the peak systolic circumferential strain, this was middle > subepicardial > subendocardial. The peak systolic longitudinal strain was normal > NLVH > LVH. Among the groups, the peak systolic circumferential strain at the basal parasternal short-axis level was statistically similar, but at the middle and the apical parasternal short-axis levels were NLVH > normal > LVH. In normal and NLVH patients, the peak radial strain was middle > apical > basal, and in LVH patients was apical > middle > basal. The peak averages of the longitudinal and subendocardial circumferential strains differed significantly when LVH compared with NLVH and normal patients.The systolic function of PH patients was damaged in comparison with normal individuals, which could be detected conveniently and accurately using two-dimensional speckle tracking echocardiography.     

The mechanics of left ventricular dysfunction in patients with Churg-Strauss syndrome

Background: Heart is frequently involved in Churg‐Strauss syndrome (CSS). However, the mechanics of left ventricular (LV) dysfunction in CSS has not been studied. Objective: To assess the mechanics of LV function and to characterize the contribution of longitudinal, circumferential and rotational deformation to LV dysfunction in CSS. Methods: We enrolled 22 CSS patients (eight males, mean age 43.2 ± 9.5 years) in remission of their disease and 22 sex‐ and age‐matched healthy subjects. All patients underwent conventional and two‐dimensional speckle‐tracking echocardiography. Global longitudinal, circumferential and rotational deformation parameters were calculated. Results: CSS subjects demonstrated lower LV ejection fraction (EF) than controls (56.6 ± 15.0% vs 63.8 ± 3.4%; P < 0.05). When compared to those with LVEF ≥ 50% (n = 14), CSS patients with LVEF < 50% (n = 7) had decreased global peak‐systolic longitudinal and circumferential strain/strain rate (all P < 0.001) and tended to have lower global peak‐systolic radial strain (P = 0.05). There were no differences between these two subgroups in global peak‐systolic radial strain rate and LV twist/torsion. When comparing individual systolic and diastolic parameters early diastolic longitudinal and circumferential strain rate demonstrated the highest correlation with corresponding global longitudinal and circumferential peak‐systolic strain/strain rate (r < ?0.80, P < 0.001 for all correlations). Conclusions: In CSS LV systolic dysfunction strongly correlates with longitudinal and circumferential, but not radial or rotational systolic components, indicating that impaired LV systolic function may result predominantly from impaired contraction of inner and middle, but not outer myocardial fiber layers. The spatial correspondence between systolic and diastolic deformation parameters suggests the similar impact of pathologic process on systolic and diastolic function in CSS. (Echocardiography 2012;29:568‐578)     

Subclinical Left Ventricular Longitudinal and Radial Systolic Dysfunction in Children and Adolescents with Type 1 Diabetes Mellitus

Introduction: There are few studies of subclinical systolic dysfunctions in children and adolescents with type 1 diabetes mellitus (DM), and so the available data are limited. The aim of this study was to determine early echocardiographic signs of LV systolic dysfunction in children and adolescents with type 1 DM using two‐dimensional speckle tracking echocardiography (2DSTE). Material and Methods: The study included 84 children and adolescents with type 1 DM and 32 sex‐, age‐, and body mass index–matched healthy subjects. The LV functions were assessed using conventional echocardiography, tissue Doppler imaging, and 2DSTE. Results: The results showed LV diastolic dysfunction as reflected by significantly increased A‐wave velocity, decreased E/A ratio, and increased early filling deceleration time in the patients with diabetes (P = 0.02, P = 0.029, and P = 0.04; respectively). Compared with the control group, patients with diabetes showed significantly lower values for longitudinal systolic strain and strain rate in most segments of the LV; for radial strain values of the LV; for lateral circumferential strain and posterior and anterolateral circumferential strain rate of the LV; and for global longitudinal and radial strain of the LV. Global longitudinal and radial strain values of the LV were significantly lower among patients with poor glycemic control than in the control group. Conclusion: In addition to diastolic dysfunction, LV longitudinal and radial function was found to be impaired in asymptomatic children and adolescents with type 1 DM who have normal LV ejection fraction by 2DSTE. Glycemic control may be the main risk factor for alteration of myocardial function.     

Early Myocardial Deformation Changes in Hypercholesterolemic and Obese Children and Adolescents: A 2D and 3D Speckle Tracking Echocardiography Study

Dyslipidemia and obesity are considered strong risk factors for premature atherosclerotic cardiovascular disease and increased morbidity and mortality and may have a negative impact on myocardial function.Our purpose was to assess the presence of early myocardial deformation abnormalities in dyslipidemic children free from other cardiovascular risk factors, using 2-dimensional speckle tracking echocardiography (2DSTE) and 3-dimensional speckle tracking echocardiography (3DSTE).We studied 80 consecutive nonselected patients (6–18 years of age) with hypercholesterolemia (low-density lipoprotein [LDL] cholesterol levels >95th percentile for age and sex). Forty of them had normal weight and 40 were obese (body mass index >95th percentile for age and sex). Forty healthy age-matched children were selected as controls. Left ventricular (LV) global longitudinal, circumferential, and radial strains were calculated by 2DSTE and 3DSTE. Global area strain (GAS) was calculated by 3DSTE as percentage of variation in surface area defined by the longitudinal and circumferential strain vectors. Right ventricular (RV) global and free-wall longitudinal strain and LV and RV diastolic strain rate parameters were obtained. Data analysis was performed offline.LV global longitudinal strain and GAS were lower in normal-weight and obese dyslipidemic children compared with normal controls and reduced in obese patients compared with normal-weight dyslipidemic children. LV early diastolic strain rate was lower compared with normals. RV global and free-wall longitudinal strain was significantly reduced in obese patients when compared with the control group. A significant inverse correlation was found between LV strain, LDL cholesterol levels, and body mass index.2DSTE and 3DSTE show LV longitudinal strain and GAS changes in dyslipidemic children and adolescents free from other cardiovascular risk factors or structural cardiac abnormalities. Obesity causes an additive adverse effect on LV strain parameters and RV strain impairment.     

Left ventricular hypertrophy or storage disease? the incremental value of speckle tracking strain bull's‐eye

Left ventricular hypertrophy (LVH) develops in response to a variety of physical, genetic, and biochemical stimuli and represents the early stage of ventricular remodeling. In patients with LVH, subclinical left ventricular (LV) dysfunction despite normal ejection fraction (EF) may be present before the onset of symptoms, which portends a dismal prognosis. Strain measurement with two‐dimensional speckle tracking echocardiography (STE) represents a highly reproducible and accurate alternative to LVEF determination. The present review focuses on current available evidence that supports the incremental value of STE in the diagnostic and prognostic workup of LVH. When assessing the components of LV contraction, STE has an incremental value in differentiating between primary and secondary LVH and in the differential diagnosis with storage diseases. In addition, STE provides unique information for the stratification of patients with LVH, enabling to detect intrinsic myocardial dysfunction before LVEF reduction.     

Left ventricular myocardial performance in patients with dengue hemorrhagic fever and thrombocytopenia as assessed by two-dimensional speckle tracking echocardiography

ObjectivesWe obtained longitudinal, radial and circumferential strains in patients with dengue hemorrhagic fever (DhF) and thrombocytopenia using two-dimensional (2D) speckle tracking echocardiography to analyze left ventricular (LV) myocardial performance.MethodsIn this prospective study, 2D echocardiographic images of the left ventricle in the four-, three- and two-chamber views and parasternal short-axis views at the basal, mid and apical levels were obtained in 40 subjects: 20 patients (23 ± 8 years, 12 male) with DhF and thrombocytopenia and 20 healthy controls (23 ± 5 years, 11 male). Of the 20 patients, imaging was performed again in 19 at discharge after a hospital stay of 8 ± 1 days. Longitudinal, circumferential and radial strains were quantified and compared in an 18-segment model using a novel speckle tracking system.ResultsLeft ventricular global ejection fraction was reduced in patients with DhF at presentation as compared with controls (51.25 ± 0.96% vs. 59.32 ± 1.26%; p = 0.032). Peak longitudinal strain in patients with DhF was significantly attenuated in the subendocardial region compared with normal controls (p < 0.001). A significant increase in circumferential strain for patients with DhF was evident only in the subepicardial region (p = 0.009). Patients with DhF showed significantly higher radial strain than controls (p < 0.001). On multivariate analysis, subendocardial longitudinal strain independently predicted the duration of hospital stay in patients with DhF.ConclusionAssessment of speckle tracking echocardiography-derived LV mechanics helps in understanding myocardial mechanics in patients with DhF and thrombocytopenia. Identification of reduced LV longitudinal strain helps in understanding the mechanism of reduced LV myocardial performance seen in patients with DhF.     

Reduced and delayed untwisting of the left ventricle in patients with hypertension and left ventricular hypertrophy: a study using two-dimensional speckle tracking imaging.

AIMS: Newly developed two-dimensional ultrasound speckle tracking imaging allows measurements of left ventricular (LV) rotation and twist. Because LV untwisting predominantly occurs during the isovolumic relaxation period, its assessment reflects the process of LV relaxation. The aim of this study was to examine whether LV hypertrophy (LVH) adversely affects LV untwisting and abnormalities in LV untwisting could become a novel marker in assessing LV relaxation abnormalities. METHODS AND RESULTS: We acquired basal and apical LV short-axis images in 49 hypertensive patients. Using two-dimensional strain software, a time-domain speckle tracking was performed, and the mean value of LV rotation was obtained at each plane. LV twist was defined as apical rotation relative to the base. In order to adjust for inter-subject differences in heart rate, the time sequence was normalized to the percentage of systolic and diastolic duration. The degree of LV untwisting was calculated as the percentage of systolic twist : untwisting = (TwistES-Twistt/TwistES) x 100, where Twistt is twist at time t and TwistES is twist at end-systole. Although peak systolic twist was not different, early diastolic LV untwisting and untwisting rate during isovolumic relaxation period was significantly delayed and reduced in parallel to the severity of LVH, as assessed by LV mass index. CONCLUSION: The observed delayed and reduced diastolic untwisting during the isovolumic relaxation period noted in hypertensive patients with LVH may contribute towards the LV relaxation abnormality. Two-dimensional speckle tracking imaging is a novel tool which can be used for the non-invasive assessment of LV relaxation.     

The Impairment of Endocardial Radial Strain Is Related to Aortic Stenosis Severity in Patients with Aortic Stenosis and Preserved LV Ejection Fraction Using Two‐Dimensional Speckle Tracking Echocardiography

Background: Myocardial function is heterogeneous in different myocardial layers. Recently, two‐dimensional speckle tracking echocardiography has been used to define myocardial deformation parameters of the left ventricular (LV) segment. This study aimed to investigate strain in subendocardial and subepicardial layers in patients with aortic stenosis (AS) and preserved LV ejection fraction (LVEF) using speckle tracking echocardiography. Methods: Parasternal short‐axis and apical long‐axis views of the left ventricle were acquired at the mid‐papillary level in 35 control subjects and 32 patients with AS and preserved LVEF. Radial, circumferential, and longitudinal strain in subendocardial and subepicardial layers at the posterior and anteroseptal segments were calculated. Results: There was no significant difference in circumferential strain in subendocardial and subepicardial layers between the control subjects and the patients with AS. Similarly, there was no significant difference in epicardial radial strain at the posterior and anteroseptal segments between the control subjects and the patients with AS. Longitudinal strain at both the posterior and anteroseptal segments was significantly decreased in the AS group compared with that in the control group. AS patients had significantly decreased values of endocardial radial strain compared with those in controls (anteroseptal: 18.2 ± 11.2 vs. 34.5 ± 14.8, P < 0.005; posterior: 25.2 ± 14.8 vs. 32.6 ± 12.6, P < 0.05). In the AS group, endocardial radial strain in the posterior and anteroseptal segments was significantly correlated with the aortic valve area (posterior: r = 0.41, P < 0.05; anteroseptal: r = 0.33, P < 0.05). Conclusion: Patients with AS and preserved LVEF have impaired longitudinal strain and endocardial radial strain, although circumferential strain and epicardial radial strain are preserved. Despite preserved LVEF, endocardial radial strain was associated with AS severity.     

Regional Heterogeneity of Systolic Dysfunction Is Associated with Ventricular Dyssynchrony in Patients with Idiopathic Dilated Cardiomyopathy and Narrow QRS Complex

Background: Regional heterogeneity of left ventricular (LV) contraction, known as dyssynergy, in idiopathic dilated cardiomyopathy (IDC) patients has been previously reported, but no comprehensive analysis of this abnormality has been made. The purpose of this study was to test the hypothesis that regional heterogeneity of systolic dysfunction is associated with LV dyssynchrony in IDC patients with a narrow QRS complex using novel three‐dimensional (3D) speckle‐tracking strain. Methods: We studied 54 consecutive IDC patients with ejection fraction (EF) of 34 ± 12% and QRS duration of 102 ± 13 msec (all <120 msec), and 30 age‐matched normal controls. The 3D speckle‐tracking LV dyssynchrony (LV dyssynchrony index) was quantified from all 16 LV sites to determine the standard deviation (SD) of time‐to‐peak strain. Similarly, regional heterogeneity of LV systolic function (LV dyssynergy index) was quantified from all 16 LV sites to establish the SD of peak 3D speckle‐tracking strain. Results: The LV dyssynergy and dyssynchrony indices of IDC patients were significantly larger than those of normal controls. Furthermore, IDC patients showed significantly higher Z‐scores for septum and inferior regions than for the free wall (3.34 ± 1.21 vs. 1.69 ± 1.06 and 2.79 ± 1.30 vs. 1.69 ± 1.06, respectively, P < 0.001). An important findings of multivariable analysis was that the LV dyssynergy index (β = 0.69, P < 0.001) and LVEF (β = ?0.34, P = 0.001) were independent determinants of the LV dyssynchrony index. Conclusion: 3D speckle‐tracking strain revealed that the myocardial systolic dysfunction of IDC patients with a narrow QRS complex has a marked heterogeneous regional distribution. This regional heterogeneity as well as systolic dysfunction is thought to lead to LV dyssynchrony.     

二维斑点追踪显像技术预测心脏再同步治疗的疗效

目的旨在比较二维斑点追踪显像技术与现有的超声心动图技术对心脏再同步治疗（CRT）疗效的预测价值。方法施行CRT的患者50例,每个患者植入术前均采用血流多普勒、组织多普勒和二维斑点追踪显像的方法进行收缩不同步的评价,有效者定义为术后6个月左心室收缩末容积缩小〉15％或左心室射血分数（LVEF）绝对值增加〉5％的患者。结果CRT有效组起搏前左心室射血前时间显著长于无效组[（146．0±34．5）ms对（123．5±32．0）ms,P〈0．05],其余常规超声心动图参数和组织多普勒参数在两组间差异无统计学意义。二维斑点追踪显像技术示CRT有效组和无效组的左心室应变达峰时间标准差（Tstrain—SD）的差异无统计学意义（P〉0．05）,而CRT有效组的应变率结束时间标准差（Tsr—SD）显著高于无效组（P〈0．05）。两组间左心室应变均值（Strain-12）的差异亦无统计学意义（P〉0．05）,而CRT有效组的左心室12节段纵轴反向应变总和（Pstrain-12）显著高于无效组[（12．5±7．9）％对（7．1±8．4）％,P〈0．05]。将140．5ms作为截点值,左心室射血前时间预测超声心动图有效的敏感性和特异性分别为63％和79％,将70．7ms作为截点值,Tsr—SD预测CRT有效的敏感性和特异性分别为73％和65％。结论常规超声心动图参数中仅左心室射血前时间能预测CRT疗效,二维斑点追踪显像技术的部分参数预测CRT疗效优于组织多普勒。     

Hypertrophic cardiomyopathy is associated with more severe left ventricular dyssynchrony than is hypertensive left ventricular hypertrophy

OBJECTIVE: To evaluate left ventricular (LV) dyssynchrony in patients with left ventricular hypertrophy (LVH), and to compare abnormalities associated with hypertrophic cardiomyopathy (HCM) and hypertensive heart disease (HHD) using 2D speckle tracking imaging. METHODS: Basal, middle, and apical 2D LV short-axis images were acquired in 43 patients with LVH including 20 with HCM and 23 with HHD, and in 15 age-matched controls. Radial strain, circumferential strain, time interval from the R-wave to peak radial strain (Trs), and time to peak circumferential strain (Tcs) were measured in six equidistant segments at each level of the 3 LV short-axis views using 2D speckle tracking analysis. To assess LV dyssynchrony, Trs(cs)-18SD, the standard deviation (SD) of Trs(cs) in all 18 segments, was calculated. RESULTS: Regional radial strain in the middle and apical short-axis segments was significantly less in patients with HCM than in those with HHD. Regional circumferential strain in the apical short-axis segments was also less in HCM. Trs-18SD and Tcs-18SD were significantly longer in patients with HCM than in age-matched controls and patients with HHD (Trs-18SD: HCM: 88 +/- 32 ms, HHD: 51 +/- 20 ms, control: 45 +/- 12 ms P < 0.001, Tcs-18SD: HCM: 71 +/- 27 ms, HHD: 46 +/- 14 ms, control: 45 +/- 14 ms P < 0.001). CONCLUSIONS: The presence of LVH is thus not always associated with LV dyssynchrony. However, the greater reduction of regional strain and severe LV dyssynchrony in HCM may contribute to the adverse cardiovascular outcomes associated with this disease.     

Left ventricular twisting as determinant of diastolic function: a speckle tracking study in patients with cardiac hypertrophy

Purpose: Left ventricular hypertrophy (LVH) can develop in response to training with morphological changes in the heart and to pathological increase in afterload such as in essential hypertension. Deformation analysis using two‐dimensional (2D) strain echocardiography can detect early systolic function abnormalities in patients with LVH. The aim of this study was to characterize left ventricular twisting (LVT) modifications, in professional athletes, compared with control subjects and with patients with hypertensive cardiopathy. Methods: Seventy‐six patients were enrolled: 37 professional athletes with cardiac hypertrophy (group A), 22 patients with early hypertensive cardiopathy (group B) cross‐matched for LV mass index, and 17 healthy controls (group C), with no evidence of cardiac hypertrophy. All patients had no concomitant cardiac disease. All patients were investigated at rest using transthoracic echocardiography. LVT was obtained with speckle tracking analysis, using dedicated software. Results: LVT was reduced in group A compared to group B and C (group A: 8.0°± 2.4°; group C: 10.3°± 2.3°; group B: 16.0°± 4.2°; P < 0.01). In overall population, LVT showed a significant correlation with transmitral flow pattern (r =–0.58, P < 0.01) and with age (r =–0.57, P < 0.01). LVT showed the best predictive value to diagnose diastolic dysfunction (AUC: 0.86, P < 0.0001). Conclusions: 2D strain can identify specific patterns of myocardial deformation in professional athletes, controls, and patients with early hypertensive cardiopathy. In our study LVT showed a parallel trend with modifications of diastolic function and could represent a promising tool to differentiate functional cardiac hypertrophy from hypertensive cardiac hypertrophy. (Echocardiography 2011;28:892‐898)     

Early detection of isolated left ventricular diastolic dysfunction in high-risk differentiated thyroid carcinoma patients on TSH-suppressive therapy

Objective L‐Thyroxine‐suppressive therapy benefits high‐risk differentiated thyroid cancer patients by decreasing recurrence rates and cancer‐related mortality. However, fully suppressed serum thyroid‐stimulating hormone (TSH) implies a state of subclinical hyperthyroidism (SCH) with associated adverse cardiac effects. Because left ventricular (LV) diastolic dysfunction may be the first manifestation of more severe LV failure, and to balance the risks from thyroid cancer recurrence with risks of cardiac failure, the purpose of this study was to analyse new parameters of LV function in asymptomatic patients with exogenous SCH. Design Case–control study with 24 patients on TSH‐suppressive therapy of short duration (≤4 years) after thyroid ablative therapy for differentiated thyroid carcinoma and 20 age‐ and sex‐matched subjects. Measurements LV function [LV global strain and strain rate (SR) curves] was assessed by speckle tracking imaging echocardiography in each subject. Results Patients and controls do not differ in body mass index, systolic blood pressure and heart rate. No significant differences were observed in LV morphology (LV mass and relative wall thickness), cardiac output and parameters of LV systolic function between patients on suppressive therapy and controls. When compared with controls, patients with exogenous SCH had a significantly impaired longitudinal protodiastolic strain, SR and strain diastolic index but preserved radial strain and SR function. Conclusions In subjects with SCH at the early phase of TSH‐suppressive therapy, evidence of isolated longitudinal LV diastolic dysfunction was observed, despite a normal LV morphology. Further prospective studies to clarify the prognosis of picking‐up early diastolic dysfunction in asymptomatic patients are needed before serial measurements could be recommended.     

Clinical usefulness of tissue Doppler imaging in predicting preclinical Fabry cardiomyopathy

Fabry cardiomyopathy (FC) is characterized by left ventricular hypertrophy (LVH). The aim of this study is to determine whether early changes revealed by tissue Doppler imaging (TDI) are useful for detecting preclinical cardiac abnormalities in patients with this X-linked genetic disorder. If so, this tool could help in deciding whether to begin enzymatic therapy earlier than otherwise. METHODS AND RESULTS: 59 consecutive patients with confirmed Fabry disease (FD) underwent conventional and TD echocardiography. FD patients with and without LVH had significantly lower early diastolic tissue Doppler velocities (Ea) compared with the control group (P<0.001); The isovolumic relaxation time (IVRT) was significantly longer in the FD group with LVH (P<0.001). Isovolumic contraction time (IVCT) was significantly shorter in the FD group without LVH compared with the control group (P<0.001). Additionally, peak systolic wall motion velocity (Sa) was significantly lower in patients with LVH, compared with those without LVH (P<0.001). The systolic myocardial velocity correlates inversely with septum and posterior wall thickness (r: -0.74 and r: -0.90; P<0.001 respectively). In respect of predicting preclinical cardiac impairment, the area under the ROC curve of 0.83 suggests an optimal IVRT cut-off point of 60 ms for separating early cardiac impairment from the established condition. This gives a 96.6% specificity rate for the early detection of cardiac involvement. The best parameter for detecting preclinical FC is the IVCT, with a cut-off point of 105 ms, which shows high sensitivity and specificity (100% and 91%, respectively; AUC: 0.97). CONCLUSIONS: Myocardial contraction and relaxation evaluation confirms that TDI is a reliable method for early identification of preclinical FC, even before FC patients develop LVH.     

Impaired myocardial strain in early stage of Duchenne muscular dystrophy: its relation with age and motor performance

Duchenne muscular dystrophy (DMD) is complicated by an early and progressive left ventricular (LV) dysfunction. Despite the reduction of ejection fraction (EF) usually manifests in the second decade, subtle alterations in LV mechanics can be detected earlier. Longitudinal and circumferential LV deformation, evaluated by speckle tracking echocardiography (STE), are considered sensitive markers of early dysfunction. We retrospectively examined clinical and echocardiographic data of 32 DMD children with preserved LV function. According to the median age, patients were then divided into younger and older than 9 years, and compared to 24 age-matched healthy subjects. Six-minute-walk test (6MWT), North Star Ambulatory Assessment (NSAA), and a comprehensive cardiac evaluation were performed. Although EF was within the normal range, DMD patients had significantly lower values than healthy controls, and the same occurred for the remaining conventional systolic and diastolic indices. Global longitudinal strain (GLS) was reduced in all patients (older and younger, both p < 0.001). Global circumferential strain (GCS) was reduced only in older patients (< 0.001). Both GLS and GCS worsened with age in DMD patients (GLS p = 0.005; GCS p = 0.024). GLS was significantly worse in the apical segments and in the postero-lateral wall. GCS in the antero-septal, anterior and antero-lateral segments was significantly reduced in older patients, with a prevalent involvement of the sole septal wall in the younger boys. 6MWT appeared to be correlated inversely to GLS and directly to EF. A longitudinal evaluation should be scheduled in DMD boys to assess the global cardiac performance over time and to evaluate the impact of therapies.Key words: Duchenne muscular dystrophy, cardiomyopathy, speckle tracking echocardiography, strain, motor performance