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.     

Comparison between left atrial features in well-controlled hypertensive patients and normal subjects assessed by three-dimensional speckle tracking echocardiography

BackgroundThree-dimensional speckle tracking echocardiography (3D-STE) has a major advantage in the improvement of accuracy in the evaluation of cardiac chamber volume without any geometrical assumption. Thus, the aim of this study was to use 3D-STE to elucidate the features of left atrial (LA) volume and function that are altered by hypertension (HTN) by comparing well-controlled HTN patients with normal subjects.MethodsConventional echocardiographic parameters and LA phasic volume and function were measured from apical view by 3D-STE in 40 patients with well-controlled HTN [systolic blood pressure (BP) <140 and diastolic BP <90 mmHg for more than one year] and 40 normotensive subjects.ResultsThe passive LA emptying function (EF) in the patients with well-controlled HTN significantly decreased (16 ± 7% vs. 22 ± 8%, p = 0.0013) and the active LAEF in patients with well-controlled HTN significantly increased (35 ± 10% vs. 30 ± 9%, p = 0.029) compared with the values in normotensive subjects. Multivariate logistic regression analysis revealed that E/e′ was an independent determinant of well-controlled HTN. The maximum LA volume index was correlated with elevated E/e′ (r = 0.30, p = 0.0064), whereas the maximum LA volume index was not correlated with LV mass index or systolic BP. This change was independent of age.ConclusionsThese results suggest that LV diastolic dysfunction occurs before structural changes of left atrium and left ventricle even in patients with well-controlled HTN.     

Impact of papillary muscles on ventricular function measurements in 3 T cardiac magnetic resonance

BackgroundPrior studies revealed, that left and right ventricular (LV, RV) volume, mass and function differ significantly, depending on trabeculae papillary and papillary muscles (TPM) have been included or excluded in LV and RV calculations.MethodsA cohort of 101 patients underwent CMR. It constituted of 26 patients without pathological findings in CMR (reference group), patients with ischemic cardiomyopathy (ICM), dilated cardiomyopathy (DCM) and patients with left ventricular hypertrophy (25 per group). Left and right ventricular parameters were determined using previously established methods: Method 1 inclusion and method 2 exclusion of TPM in cavity volume.ResultsCompared with inclusion of TPM, exclusion of TPM in the LV and RV cavity volume resulted in significantly lower end-diastolic and end-systolic volume (EDV, ESV) and myocardial mass, and larger stroke volume and ejection fraction (SV, EF) (p0.001). The fraction of the TPM on the LV and RV mass was highest in DCM (18.4 ± 3.8%,) and in ICM (17.8 ± 3.2%) compared to the reference group (15.2 ± 2.5%, both p < 0.05), which resulted in a significant larger difference between the two methods (method 1- method 2) in calculating ESV, EDV, SV, EF and myocardial mass among DCM and ICM patients vs. reference group.ConclusionGlobal CMR LV parameters are significantly affected by whether TPM are considered as part of the LV blood pool or as part of LV mass. Therefore, a consistent method of LV cavity delineation may be crucial during longitudinal follow-up to avoid misinterpretation and erroneous clinical decision-making.     

Evaluation of automated measurement of left ventricular volume by novel real-time 3-dimensional echocardiographic system: Validation with cardiac magnetic resonance imaging and 2-dimensional echocardiography

BackgroundTraditional 3-dimensional echocardiography (3DE) with volumetric scanning technique requires several heart cycles for full-volume acquisition and complicated manual contouring of left ventricular (LV) endocardium. The new real-time 3DE (RT3DE) system allows acquisition of an instantaneous full-volume dataset in a single heart cycle and automated measurement of LV volume by the algorithm software. However, it has not been evaluated adequately whether automated measurement by RT3DE has better agreement with cardiac magnetic resonance imaging (CMR) than 2-dimensional echocardiography (2DE) with CMR.PurposeThis study aimed to evaluate the accuracy of automated measurement of LV volume using RT3DE compared with 2DE and CMR.Methods and resultsForty-four consecutive patients who underwent RT3DE, 2DE, and CMR were evaluated in this study. The feasibility of automated measurement by RT3DE was 93.2% and the mean operation time was 6 min. LV volume and ejection fraction (EF) from semi-automated measurement [end-diastolic volume: r = 0.96, limits of agreement (LOA) ?30.5 to 39.3 ml; end-systolic volume: r = 0.97, LOA ?22.6 to 32.7 ml; EF: r = 0.90, LOA ?16.1 to 14.2%, respectively] had better agreement with CMR than those from 2DE (r = 0.87, LOA ?50.5 to 72.2 ml; r = 0.93, LOA ?34.1 to 65.2 ml; r = 0.89, LOA ?20.9 to 10.0%, respectively).ConclusionSemi-automated measurement by RT3DE has better agreement with CMR than 2DE in LV volume and EF. In addition, it is simple to operate and acceptable in feasibility for the clinical setting although there may be room for further learning required to incorporate small hypertrophic LV into the automated algorithm software.     

Ventricular twist in isolated left ventricular noncompaction

The study aimed at assessing the rotational motion of the left ventricle around the long axis in patients affected by isolated left ventricular noncompaction (LVNC) and comparing their results with those of healthy volunteers.Patients and methodsThe study comprised eight patients with LVNC confirmed by echocardiography and magnetic resonance imaging (mean age 41 ± 19 years; four males; left ventricular ejection fraction [LVEF] 45 ± 25%). The patients were divided into Group A with an LVEF above 50% (four patients; one male) and Group B with an LVEF below 50% (four patients; three males). For both groups, age- and sex-matched volunteers were found. The focus was on myocardial twist, rotation of the LV apex and base, times to reach maximal apical and maximal basal rotation and myocardial twist, as well as correlations between systolic function, rotation of individual planes and LV twist.ResultsWhen comparing LVNC patients with healthy volunteers, there were statistically significantly decreased systolic function (p = 0.004), larger diastolic dimension (p = 0.045) and decreased apical rotation (p = 0.01). Left ventricular twist was significantly decreased in the group of patients with LVNC and systolic dysfunction (p = 0.04). A statistically significant correlation was found between systolic function and LV apical rotation.ConclusionThe study showed a significant decrease in apical rotation and twist mechanism of the LV as measured using two-dimensional speckle tracking in patients with LVNC and decreased LV systolic function. Measuring these parameters could contribute to more accurate diagnosis and risk stratification of patients affected by this condition.     

Low-dose dobutamine induces left ventricular mechanical dyssynchrony in patients with dilated cardiomyopathy and a narrow QRS: A study using real-time three-dimensional echocardiography

AimsThe effects of inotropic agents on left ventricular (LV) synchrony in heart failure patients are still unknown. The purpose of this study was to investigate the effects of dobutamine on LV mechanical dyssynchrony and LV systolic performance in patients with dilated cardiomyopathy (DCM) and a narrow QRS using real-time three-dimensional echocardiography (RT3DE).Methods and resultsThirty-three patients with idiopathic DCM and a narrow QRS underwent low-dose dobutamine stress echocardiography (LDSE) with RT3DE. A time-global LV volume curve and time-regional LV volume curves were derived from RT3DE. Regional LV stroke volumes were summed in each stage, and the dobutamine-induced increase in the sum of regional LV stroke volumes was considered as the sum of regional contractile reserve. Systolic dyssynchrony index (SDI) was calculated as follows: (standard deviation of time to minimal volume for regional LV segments) × 100/RR duration. Among the 33 patients, low-dose dobutamine increased global LV stroke volume (SV) in 28 (85%), but decreased global LVSV in the remainder (15%). The sum of regional contractile reserve was modestly correlated with the dobutamine-induced increase in global LVSV (R = 0.57, p < 0.001). In contrast, low-dose dobutamine increased SDI in 14 (42%) patients without a significant change in QRS duration, and there was an inverse correlation between the increase in SDI and the increase in global LVSV induced by dobutamine (R = ?0.67, p < 0.001).ConclusionsDobutamine may induce LV mechanical dyssynchrony in a substantial proportion of patients with DCM and a narrow QRS. In such cases, regional LV contractile reserve does not fully contribute to an increase in global LVSV.     

Real-time three-dimensional echocardiographic left heart parameters in healthy indian adults

ObjectiveCardiac chamber dimensions are race and anthropometry dependent. We determined the age and gender specific 3-Dimensional echocardiographic (3DE) reference values for dimensions and function of left ventricle (LV) and left atrium (LA) in normal Indian adults.MethodsThis single center prospective study enrolled 133 adult Indians free of heart disease and/or hypertensions, subjecting them to 3DE measurements of left atrial (LA) & left ventricular (LV) volumes, function and left ventricular mass (LVM). The higher limits of normal cut-offs were determined for these parameters and their dependency on age, gender and anthropometry were analyzed.ResultsThe body surface area (BSA) corrected higher limit cut-offs were: 59.37 ml/m² for LV end diastolic volume (59.19 ml/m² and 59.61 ml/m² for men and women, respectively; P = NS); 23.48 ml/m² for LV end systolic volume (23.27 ml/m2 and 23.11 ml/m² for men and women, P = NS). Mean LVEF was 64.79% ± 7.26 (62.99% ± 6.51 and 67.05% ± 7.58 in men and women, P = NS). Men had higher LVM than women (119.79 g±23.95 vs. 103.26 g±23.76, P < 0.001), this difference disappeared after BSA indexing. The higher limit cut-offs for normal LA volumes were 20.49 ml for minimum volume (21.18 ml and 19.46 ml for men and women, P = NS) and 39.76 ml for maximum volume (39.60 ml and 40.03 ml in men and women, P = NS). The parameters were smaller compared to western populations but the differences attenuated after BSA indexing.ConclusionsThe study reports normal 3DE parameters of size and function of left heart chambers in Indians.     

Hypocalcemia is related to left ventricular diastolic dysfunction in patients with chronic kidney disease

BackgroundLeft ventricular (LV) diastolic dysfunction in patients with chronic kidney disease (CKD) is of a complex nature and is the predominant cause of congestive heart failure in this group of patients. This work aimed to evaluate the potential effect of disturbances in calcium-phosphorus (Ca-P) metabolism in patients with CKD on LV diastolic function as assessed by echocardiography.Materials and methodsThe study group consisted of 81 ambulatory patients with CKD, stages 2–5, with preserved LV systolic function–LV ejection fraction >50% and with sinus rhythm. Standard echocardiography was performed in all patients with tissue Doppler echocardiography for the evaluation of the systolic velocity and both diastolic velocities of LV (EmLV and AmLV). The following laboratory parameters were measured: serum creatinine concentration, estimated glomerular filtration rate, and the levels of urea, P, Ca, parathormone, platelet count, hemoglobin level, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. Patients were divided into two groups according to the results of EmLV: group with LV diastolic dysfunction (EmLV < 8 cm/s) DF (+) and group with normal LV diastolic function DF (−), when EmLV was ≥8 cm/s.ResultsPatients in DF (+) group, as compared to DF (−) patients, manifested a lower serum Ca level and an elevated NT-proBNP level [9.03 ± 0.76 mg/dL vs 9.44 ± 0.78 mg/dL, p = 0.02, and 257.9 (32.6–12,633) pg/ml vs 149 (11.7–966) pg/ml, p = 0.035, respectively]. The area under the receiver operating characteristics (ROC) curve of Ca for diastolic dysfunction was 0.627, 95% CI (0.511–0.734), p = 0.04, whereas ROC derived Ca value of ≤9.82 mg/dL was characterized by a sensitivity of 91.8% and specificity of 38.1% for diagnosing LV diastolic dysfunction. The only independent variable predicting LV diastolic dysfunction as measured by a multivariate logistic regression analysis was Ca level ≤ 9.82 mg/dL with odds ratio = 8.81 (95% CI 1.49–51.82), p = 0.014.ConclusionsHypocalcemia is an independent predictive factor for LV diastolic dysfunction in patients with CKD.     

Middle-term stability of epicardial left ventricular electrodes for cardiac resynchronization therapy

IntroductionCardiac resynchronization therapy (CRT) is currently considered an effective and safe way to treat patients with severe heart failure. Unsuccessful attempts at endovascular insertion of the left ventricular (LV) electrode should prompt a consideration of having the electrode implanted by a cardiac surgeon.AimsThe aims of our work were to evaluate the electric parameters of CS-implanted LV electrodes and to compare them with transvenous implanted electrodes, identify the causes of endovascular implantation failure, compare the clinical and echocardiographic resynchronization effects, and compare the safety of both approaches.Methods and resultsPatients indicated for CRT had the LV electrode implanted either endovascularly (“endo” group) or epicardially (“epi” group; in cases of endovascular approach failure or as a part of another CS procedure). The trial was planned as a case–control study. Each group comprised 92 patients (26 females, 66 males) with an average age of 69 (epi) and 68 (endo) years, respectively. LV stimulation was effective at the 3-year follow-up in 98.1% of patients in the epi group and in 96.6% of patients in the endo group (p = NS). The groups were comparable with respect to the stimulation threshold both before discharge and at the 3-year follow-up. At the 1-month follow-up, this threshold was significantly higher in the epi group (1.62 V vs. 1.06 V, p < 0.001) and the same was true for the 1-year and 2-year follow-ups (1.57 V vs. 1.09 V and 1.54 V vs. 1.21 V, respectively; p < 0.001). Energetic output during LV stimulation was significantly higher in the epi group at all time points. The overall procedural effectiveness of endovascular implantation was 94.6%. Clinical response to CRT was noted in 71.4% of epi group patients and in 68.1% of endo group patients (p = NS). The average absolute increase in LV ejection fraction was comparable in both groups (6.0% vs. 7.2%, p = NS). Significantly higher 1- and 3-year mortality was noted in the epi group (19.0% vs. 5.5% and 21.7% vs. 6.5%, respectively; p < 0.001).ConclusionEpicardial electrodes are capable of effective LV stimulation, as shown during middle-term follow-up. Epicardial LV stimulation is more demanding energetically. Resynchronization effects are similar in patients with epicardial and endocardial LV electrodes; however, the mortality of patients with epicardial LV electrodes seems to be significantly higher.     

Impact of pre-excitation syndrome on left ventricular systolic function and cardiac synchronization assessed by tissue Doppler imaging and speckle tracking techniques

BackgroundThe pathogenic mechanism for the development of left ventricular (LV) dysfunction in patients with asymptomatic pre-excitation syndrome has not yet been fully elucidated. We sought to assess the impact of pre-excitation on LV systolic function and whether the use of tissue Doppler imaging (TDI) and speckle tracking is more helpful in detection of the LV dyssynchrony than conventional echo parameters in these patients.MethodsThis observational case control study was carried out on adults with manifest pre-excitation syndromes. A detailed echocardiographic assessment was performed including TDI and speckle tracking examination.ResultsOur study patients were divided into two groups, group 1: with lateral accessory pathways (AP) (23 patients aged 31.65 ± 6.5 years), group 2: with septal AP (25 patients, 34.84 ± 10.8 years). Echocardiography showed a lower ejection fraction (EF) in group 2 than in group 1 (0.60 ± 0.07% in group 1 vs. 0.50 ± 0.08% in group 2, p = 0.000). The radial strain dyssynchrony index was higher in group 2 than in group 1 (58.78 ± 33.47 vs. 139.52 ± 21.14 ms; p < 0.0001) with a significant negative correlation with EF (r = −0.8, p = 0.000). Dyssynchrony detection was higher using speckle tracking technique than M mode/Doppler methods (p = 0.006).ConclusionPatients with pre-excitation syndrome may have depressed LV function unrelated to tachyarrhythmia, especially if the AP has a septal location. This dysfunction may be associated with the LV dyssynchronus contraction caused by pre-excitation. The use of TDI and speckle tracking echocardiographic techniques may be associated with an increase in the identification of manifest pre-excitation patients with significant LV dyssynchrony.     

Factors contributing to left atrial enlargement in adults with normal left ventricular systolic function

BackgroundCauses of left atrial (LA) enlargement and its gender difference in patients with normal left ventricular (LV) systolic function have not been clarified. We investigated the factors contributing to LA enlargement in patients with normal LV systolic function, addressing its gender difference.MethodsWe enrolled 380 patients (175 males and 205 females; mean age: 63 ± 15 years) with LV ejection fraction ≥50% who underwent Doppler echocardiography and blood tests at the same time as echocardiography. Patients with arrhythmias, significant valvular heart disease, and LV asynergy were excluded. The LA volume was measured by Simpson's method from apical 2- and 4-chamber views, and LA volume index (LAVI) was calculated as LA volume/body surface area. All patients, male and female were assigned to a group with a low or a high LAVI based on the median LAVI value, respectively.ResultsAge, female gender, hypertension, diabetes, hemoglobin concentration, LV mass index, Doppler parameters of LA contraction, and the ratio of mitral early diastolic velocity to early diastolic velocity of the mitral annulus (E/E′) were significantly associated with a high LAVI in all patients. Multivariate analysis showed that LV mass index [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.03–1.06, P < 0.0001], hemoglobin concentration (OR 0.76, 95% CI 0.64–0.90, P < 0.01), and female gender (OR 1.92, 95% CI 1.12–3.30, P < 0.05) independently contributed to a high LAVI in all patients. In addition, LV mass index and hemoglobin concentration independently contributed to a high LAVI in both genders despite the absence of overt LV hypertrophy or anemia.ConclusionIncreased LV wall thickness and decreased hemoglobin concentration might contribute to LA enlargement in patients with normal LV systolic function irrespective of gender.     

Effect of ventricular function and volumes on exercise capacity in adults with repaired Tetralogy of Fallot

ObjectivesInvestigate the effects of left and right ventricular function and severity of pulmonary valve regurgitation, quantified by cardiac magnetic resonance (CMR), on exercise tolerance in adult patients who underwent ToF repair at a young age.MethodsThis is a retrospective cohort study of 52 patients after ToF surgery and 33 age- and sex-matched healthy volunteers. CMR and cardiopulmonary exercise testing (CPET) were performed on all patients; CPET was performed on control subjects.ResultsThe main finding of CPET was a severe decrease in oxygen uptake at peak exercise VO_2peak in TOF patients. The patients were characterized also by lower pulse O_2peak and heart rate at peak exercise. Ejection fraction of the right and left ventricles was correlated (r = 0,32; p = 0,03). Left ventricle ejection fraction was negatively correlated with right ventricular volumes (r = −0,34; p = 0,01) and right ventricular mass (r = −046; p < 0,00). Right ventricular mass was positively correlated with left ventricular variables (left ventricle end diastolic volume, r = 0,43; p = 0,002; left ventricle end systolic volume, r = 0,54; p < 0,00) as was VO_2peak: LVEDV (r = 0,38; p = 0,01); LVESV (r = 0,33; p = 0,03) and LV mass (r = 0,42; p = 0,006).ConclusionExercise intolerance in adults with repaired ToF is markedly depressed. The decreased exercise capacity is correlated with impaired RV function and may be associated also with LV dysfunction, which suggests right-to-left ventricular interaction.     

Left Ventricular Mass is Preserved in Patients with Idiopathic Pulmonary Arterial Hypertension and Eisenmenger's Syndrome

BackgroundLeft ventricular (LV) atrophic remodelling was described for chronic thromboembolic pulmonary hypertension (PH) but not in other forms of PH. We aimed to assess LV morphometric changes in idiopathic pulmonary arterial hypertension (IPAH) and Eisenmenger's syndrome(ES).MethodsFifteen patients with IPAH, 15 patients with ES and 15 healthy volunteers were included. Magnetic resonance was used to measure masses of LV, interventricular septum (IVS), LV free wall (LVFW), and LV end diastolic volume (LVEDV) indexed for body surface area.ResultsBetween patients with IPAH, ES and controls no differences in LVmass_index (54.4[45.2-63.3] vs 58.7[41.5-106.1] vs 52.8[46.5-59.3], p = 0.50), IVSmass_index (21.6[18.2-21.9)] vs 27.4[18.0-32.9] vs 20.7[18.2-23.2], p = 0.18), and LVFWmass_index ([32.4[27.1-40.0] vs 36.7[30.9-62.1] vs 32.5[26.9-36.1], p = 0.29) were found. LVEDV_index was lower in IPAH patients than in controls and in ES patients (54.9[46.9-58.5] vs 75.2[62.4-88.9] vs 73.5[62.1-77.5], p < 0.001). In IPAH LVEDV but not LV mass correlated with pulmonary vascular resistance (r = -0.56, p = 0.03) and cardiac output (r = 0.59, p = 0.02).ConclusionsLV mass is not reduced in patients with IPAH and with ES and is not affected by haemodynamic severity of PH. LVEDV is reduced in IPAH patients in proportion to reduced pulmonary flow but preserved in patients with ES, where reduced pulmonary flow to LV is compensated by right-to left shunt.     

Metabolic manipulation in dilated cardiomyopathy: Assessing the role of trimetazidine

ObjectivesTo study the role of metabolic modulator (trimetazidine: TMZ) in dilated cardiomyopathy (DCM). Optimizing altered substrate metabolism in heart failure (HF) with metabolic modulators allows more efficacious energy production from glucose than from free fatty acids.Methods100 patients of DCM (47.7 years, NYHA class 2.17, LVEF 27.3%) were randomized to TMZ (20 mg tid, n = 50) vs conventional therapy (n = 50). Functional status, BNP and various echocardiographic parameters were assessed at 3–6 months.ResultsAt 3 months, TMZ group had significantly improved NYHA class (2.25 vs 1.85), 6 min walk test (349.7 vs 402 m), LVD-36 score (25.5 vs 21) and BNP (744.7 vs 248.3 pg/ml), all p 0.001. Significant improvement was also seen in LV end-systolic (LVESV, 87.1 ± 27.5 vs 78.5 ± 24.9 ml/m², p 0.001), LV end-diastolic volumes (LVEDV, 117.6 ± 29.3 vs 110.9 ± 27.4 ml/m², p 0.001), LVEF (27 vs 30.9%, p 0.001) and LV wall stress (90.2 ± 18.9 vs 71.1 ± 13.2 dyn/cm², p 0.0001). The % change in LVESV, LVEDV, LVEF and LV wall stress was −9.5%, −5.4%, +8.4% and −21.8%. Other echo parameters also improved after 3 months of TMZ (E/A ratio 1.9 vs 1.2, p = 0.001, E/A VTI 2.7 vs 1.6, p = 0.001, myocardial performance index, MPI 0.8 vs 0.7, p = 0.0001), Tissue Doppler parameters (E/E′ septal (19.7 vs 12.5, p = 0.001) and E/E′ lateral (13.3 vs 9.4, p = 0.0001)). Patients in control group had no change in NYHA class, LVD-36 scores, LV volumes or LVEF at 3 months although BNP and LV wall stress reduced to a slight extent. Patients on TMZ had further improvement in NYHA class, walk test, BNP levels and echocardiographic parameters at 6 months.ConclusionsMetabolic modulators (TMZ) may help in improving LV function in DCM. In this study, benefit was noted by 3 months with further improvement at 6 months.     

Elevated left ventricular filling pressure estimated by E/E′ ratio after exercise predicts development of new-onset atrial fibrillation independently of left atrial enlargement among elderly patients without obvious myocardial ischemia

ObjectiveTo determine whether elevated left ventricular (LV) filling pressure estimated by raised Doppler E velocity to tissue Doppler E′ velocity ratio (E/E′) after exercise is associated with increased risk of new-onset atrial fibrillation (AF) in non-ischemic elderly patients.BackgroundPrognostic importance of exercise induced LV diastolic dysfunction remains uncertain.Patients and methodsWe studied 147 elderly patients (73 ± 5 years) who underwent treadmill stress echocardiography. Patients with exercise induced LV wall motion abnormality were not included. Doppler and tissue Doppler measurements were done before treadmill exercise and immediately after the post-stress image acquisition, and E/E′ ratio was measured. Raised E/E′ was defined as E/E′ ≥ 15, and left atrial (LA) enlargement was defined as LA volume index ≥ 34 ml/m². Using Cox proportional hazards regression analysis, predictor of new-onset AF was determined. Using Kaplan–Meier analysis, we evaluated association between raised post-exercise E/E′ or LA enlargement with new-onset AF.ResultsDuring the follow-up period (median = 67 months), there were 25 new-onset AF. Cox proportional hazards regression analysis demonstrated that male gender [hazard ratio (HR) 3.294; p = 0.0117], LA enlargement (HR 3.576; p = 0.0017), and raised post-exercise E/E′ (HR 3147; p = 0.0068) were the best predictors of new-onset AF. Kaplan–Meier survival plot demonstrated that patients with both LA enlargement and raised post-exercise E/E′ developed new-onset AF most frequently. There was no significant difference in outcome between patients with isolated raised post-exercise E/E′ or isolated LA enlargement.ConclusionsRaised E/E′ ratio after exercise provides significant prognostic information for predicting new-onset AF in non-ischemic elderly patients. This prognostic value of raised post-exercise E/E′ is independent of and incremental to the LA enlargement.     

Evaluación multiparamétrica de la función ventricular derecha en la hipertensión arterial pulmonar asociada a cardiopatías congénitas

Introduction and objectivesOutcome in patients with congenital heart diseases and pulmonary arterial hypertension (PAH) is closely related to right ventricular (RV) function. Two-dimensional echocardiographic parameters, such as strain imaging or RV end-systolic remodeling index (RVESRI) have emerged to quantify RV function.MethodsWe prospectively studied 30 patients aged 48 ± 12 years with pretricuspid shunt and PAH and investigated the accuracy of multiple echocardiographic parameters of RV function (tricuspid annular plane systolic excursion, tricuspid annular peak systolic velocity, RV systolic-to-diastolic duration ratio, right atrial area, RV fractional area change, RV global longitudinal strain and RVESRI) to RV ejection fraction measured by cardiac magnetic resonance.ResultsRV ejection fraction < 45% was observed in 13 patients (43.3%). RV global longitudinal strain (ρ [Spearman's correlation coefficient] = −0.75; P = .001; R² = 0.58; P = .001), right atrium area (ρ = −0.74; P < .0001; R² = 0.56; P < .0001), RVESRI (ρ = −0.64; P < .0001; R² = 0.47; P < .0001), systolic-to-diastolic duration ratio (ρ = −0.62; P = .0004; R² = 0.47; P < .0001) and RV fractional area change (ρ = 0.48; P = .01; R² = 0.37; P < .0001) were correlated with RV ejection fraction. RV global longitudinal strain, RVESRI and right atrium area predicted RV ejection fraction < 45% with the greatest area under curve (0.88; 95%CI, 0.71-1.00; 0.88; 95%CI, 0.76-1.00, and 0.89; 95%CI, 0.77-1.00, respectively). RV global longitudinal strain > −16%, RVESRI ≥ 1.7 and right atrial area ≥ 22 cm² predicted RV ejection fraction < 45% with a sensitivity and specificity of 87.5% and 85.7%; 76.9% and 88.3%; 92.3% and 82.4%, respectively.ConclusionsRVESRI, right atrial area and RV global longitudinal strain are strong markers of RV dysfunction in patients with pretricuspid shunt and PAH.     

Increased aortic wave reflection and longitudinal regional diastolic dysfunction in patients with left ventricular hypertrophy

ObjectivesIncreased arterial stiffness is associated with the progression of left ventricular hypertrophy (LVH); however, the endocardial layer (End) contracts more than the epicardial layer (Epi), and it is unclear whether increased arterial stiffness affects regional wall deformation in both the End and Epi in LVH.MethodsWe performed echocardiography and measured the radial augmentation index (rAIx) in 41 patients with LVH. We evaluated the longitudinal strain, and early diastolic strain rate (SRdia) (measures of regional wall deformation) in both End and Epi in addition to measures of global diastolic function. The ratios of End strain to Epi strain (End/Epi strain) and End SRdia to Epi SRdia (End/Epi SRdia) were also calculated.ResultsAll of the patients had a decreased LV diastolic function (E/e′ > 8) and preserved ejection fraction (>45%). The rAIx was slightly related to the End/Epi SRdia (r = 0.29, P = 0.063); the relationship of rAIx to End/Epi SRdia (beta = 0.52, P = 0.034) was significant after adjustment for potential confounding factors. The rAIx at heart rate 75 beats per minute (rAIx@HR75) was significantly related to End/Epi SRdia (r = 0.36, P = 0.023); the relationship of rAIx@HR75 to End/Epi SRdia remained significant even after the adjustment (P = 0.032). The relationships of rAIx@HR75 to End/Epi strain did not reach the level of statistical significance (r = 0.30, P = 0.06) in this study.ConclusionIncreased rAIx, a measure of aortic wave reflection, may be associated with a regional diastolic function in the ratio of endocardial to epicardial layer of the left ventricular wall in patients with left ventricular hypertrophy.     

Urinary type IV collagen is related to left ventricular diastolic function and brain natriuretic peptide in hypertensive patients with prediabetes

AimUrinary type IV collagen is an early biomarker of diabetic nephropathy. Concomitant prediabetes (the early stage of diabetes) was associated with left ventricular (LV) diastolic dysfunction and increased brain natriuretic peptide (BNP) in hypertensive patients. We hypothesized that urinary type IV collagen may be related to these cardiac dysfunctions.MethodsWe studied hypertensive patients with early prediabetes (HbA1c < 5.7% and fasting glucose > 110, n = 18), those with prediabetes (HbA1c 5.7–6.4, n = 98), and those with diabetes (HbA1c > 6.5 or on diabetes medications, n = 92). The participants underwent echocardiography to assess left atrial volume/body surface area (BSA) and the ratio of early mitral flow velocity to mitral annular velocity (E/e’). Left ventricular diastolic dysfunction (LVDD) was defined if patients had E/e’ ≥ 15, or E/e’ = 9–14 accompanied by left atrial volume/BSA ≥ 32 ml/mm². Urinary samples were collected for type IV collagen and albumin, and blood samples were taken for BNP and HbA1c.ResultsUrinary type IV collagen and albumin increased in parallel with the deterioration of glycemic status. In hypertensive patients with prediabetes, subjects with LVDD had higher levels of BNP and urinary type IV collagen than those without LVDD. In contrast, in hypertensive patients with diabetes, subjects with LVDD had higher urinary albumin and BNP than those without LVDD. Urinary type IV collagen correlated positively with BNP in hypertensive patients with prediabetes, whereas it correlated with HbA1c in those with diabetes.ConclusionsIn hypertensive patients with prediabetes, urinary type IV collagen was associated with LV diastolic dysfunction and BNP.     

High prevalence of vitamin D deficiency and its association with left ventricular dilation: An echocardiography study in elderly patients with chronic heart failure

Background and aimsVitamin D deficiency has been associated with chronic heart failure (CHF). We evaluated vitamin D levels in relationship with New York Heart Association (NYHA) classes, N-terminal pro-brain natriuretic peptide (NT-proBNP) values and left ventricular (LV) measures in ≥60 year old patients with stable CHF. Differently from previous investigations, LV function was assessed by transthoracic echocardiography, to provide easily reproducible results.Methods and resultsThe study was performed at geographic latitude 44° N, from March to May and from September to November 2008. Acute HF and diseases or drugs altering vitamin D status were exclusion criteria. NYHA scores and 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D and NT-proBNP concentrations were assessed in 90 (45 F, 45 M) Caucasian patients with CHF secondary to hypertension and/or coronary artery disease. Vitamin D levels were also measured in 31 subjects without heart disease (controls). LV echocardiography was performed in 52 (26 F, 26 M) representative patients. Vitamin D concentrations were significantly lower in CHF cases than in controls. Among subject with CHF, 97.8% presented vitamin D deficiency (25(OH)D < 75 nmol/L), being severe (<25 nmol/L) in 66.7%. LV end-diastolic and end-systolic diameters were significantly longer, LV end-diastolic and end-systolic volumes bigger and fractional shortening lower in CHF patients with 25(OH)D < 25 nmol/L than with 25(OH)D ≥ 25 nmol/L (p < 0.05). Log-values of 25(OH)D were negatively correlated with LV end-systolic diameter and volume (r = ?0.28; p < 0.05). On subgroup analysis, these results persisted only in male patients.ConclusionsIn elderly CHF patients, vitamin D deficiency was highly prevalent and often severe. This first addressed echocardiography study showed a sex-specific association between vitamin D deficiency and LV dilation. Since further echocardiography data are easily obtainable, larger investigations are demanded.     

Radiofrequency catheter ablation of premature ventricular complexes from right ventricular outflow tract in patients with left ventricular dilation and/or dysfunction

Left ventricular (LV) dysfunction caused by frequent premature ventricular complexes (PVCs) can be reversed by suppression of PVCs with antiarrhythmic agents or radiofrequency catheter ablation (RFA). However, there is a paucity of data on the efficacy and safety of RFA among the local population. We aimed in this study to evaluate the effect of RFA of frequent PVCs originating from right ventricular outflow tract (RVOT-PVCs) on cardiac function in patients with depressed cardiac function and/or LV dilation. The study included sixteen patients with monomorphic RVOT-PVCs without overt underlying structural heart disease. Frequency of PVCs by 24-h Holter monitoring, left ventricular ejection fraction (LVEF), end-diastolic diameter (LVEDD), end-systolic diameter (LVESD), mitral regurgitation (MR) by echocardiogram and NYHA functional class were evaluated before and 3 and 6 months after RFA. All patients underwent RFA.ResultsThe higher the number of PVCs/24 h, the bigger the LVESD and the lower the EF. Procedural success was achieved in 13 (81%) of the patients with no complications. Six months follow-up after successful ablation, LVEDD decreased significantly (from 56.62 ± 5.87 to 49.23 ± 5.31 mm; p = 0.002), LVESD decreased significantly (from 41.85 ± 7.82 to 33.69 ± 4.66 mm; p = 0.002), LVEF increased significantly (from 46.69 ± 4.92% to 60.54 ± 5.39%; p < 0.001) and NYHA functional class improved in all patients after successful ablation.ConclusionRF catheter ablation of frequent RVOT-PVC has a beneficial effect on cardiac function in patients with depressed cardiac function.It carries a high degree of success and safety. Frequent RVOT-PVCs are burden on LV function even in patients without overt underlying structural heart disease.