Evidence of Left Ventricular Systolic Dysfunction Detected by Automated Function Imaging in Patients With Heart Failure and Preserved Left Ventricular Ejection Fraction

BackgroundLeft ventricular ejection fraction (LVEF) cannot reflect cardiac contractile function in patients with heart failure and preserved LVEF (HFPEF). LV systolic impairment is actually debated in HFPEF patients. Automated function imaging (AFI) is a novel algorithm of speckle-tracking echocardiography and efficiently to assess global LV peak systolic longitudinal strain (PSLS), an index for systolic function. The purpose of the study is to examine whether contractile function is impaired in HFPEF patients.Methods and ResultsThis study included 49 heart failure patients (23 with systolic dysfunction [SHF] and 26 with HFPEF), and 40 patients, matched for age, sex, as well as concomitant disease and without heart failure as controls. All patients underwent transthoracic echocardiography. LVEF was measured by Simpson's method. Two-dimensional speckle tracking imaging with AFI assessment was applied to measure longitudinal strain. LVEF was 66 ± 5% in the controls, 63 ± 8% in the HFPEF group (P = .14), and 34 ± 10% in the SHF group (P < .001). The value of LV global PSLS (controls: –20%, HFPEF: –14%, SHF: –8%, P < .001) was significantly less negative in both heart failure groups.ConclusionsDeteriorated LV systolic function is demonstrated by decreased global PSLS in HFPEF patients. AFI is an effective and facile method for assessing LV systolic abnormalities.     

Assessment of Subclinical Left Ventricular Dysfunction in Aortic Stenosis

Left ventricular (LV) systolic dysfunction is an adverse consequence of the pressure overload of severe aortic stenosis (AS). The enlargement of the interstitial space with reactive fibrosis and subsequently with replacement fibrosis and cell death has been suggested to be the main driver of the transition to symptoms, heart failure, and adverse cardiovascular events even after aortic valve replacement (AVR). Early and accurate recognition of myocardial dysfunction offers the potential to optimize the timing of intervention in severe AS. In the asymptomatic patient, an LV ejection fraction (EF) cutpoint of <50% has been used for this purpose. However, in most asymptomatic patients, an LVEF <50% is uncommon, and patients with an LVEF of 50% to 59% fare almost as badly. Moreover, the presence of a small LV cavity, the reliability and automation of the global longitudinal strain (GLS) signal, and the independent prognostic role of GLS are reasons why GLS could be expected to be a better marker of subclinical LV dysfunction in these patients. This review seeks to define whether the existing EF cutoff in AS should be modified or whether GLS should replace it as the marker of subclinical LV dysfunction.     

Measurement of Left Ventricular Ejection Fraction by Real Time 3D Echocardiography in Patients with Severe Systolic Dysfunction: Comparison with Radionuclide Angiography

Aim: Measurement of left ventricular ejection fraction (LVEF) using real time 3D echocardiography (3DE) has been performed in subjects with preserved or modestly reduced systolic function. Our aim was to evaluate this technique in the subset of patients with severe systolic dysfunction. Methods and results: Consecutive patients with LVEF less than 0.35 at two-dimensional echocardiography were included. LVEF obtained by 3DE was compared to the value measured by radionuclide angiography (RNA). Real time full-volume 3DE was performed, with offline semiautomated measurement of LVEF using dedicated software (Cardioview RT, Tomtec) by a single observer blinded to the results of RNA. A total of 50 patients were evaluated, of whom 38 (76%, 27 males, age 69 ± 13 years) had a 3DE of sufficient quality for analysis. LVEF for this group was 0.21 ± 0.07 using 3DE and 0.27 ± 0.08 using RNA. The agreement between the two techniques was rather poor (r = 0.49; P < 0.001; 95% limits of agreements of −0.20 to 0.09). Truncation of the apex was observed in 6 of 38 (16%) patients. Conclusion: In patients with severe systolic dysfunction, 3DE shows poor agreement for measurement of LVEF as compared to RNA. There may be underestimation of up to 20% in absolute terms by 3DE. Accordingly, the two methods are not interchangeable for the follow-up of LV function. A limitation of 3DE may, at least in part, be related to the incomplete incorporation of the apical region into the pyramidal image sector in patients with dilated hearts. (Echocardiography 2010;27:58-63)     

Left Atrial Structure and Function,and Left Ventricular Diastolic Dysfunction: JACC State-of-the-Art Review

Defining left atrial (LA) function has recently emerged as a powerful parameter, particularly in evaluation of left ventricular (LV) diastolic dysfunction (LVDD) and heart failure with preserved ejection fraction. Echocardiographic assessment of LVDD by echocardiography remains a challenging task; recent recommendations provide a simpler approach than previous. However, the shortcomings of the proposed approach (including transmitral flow, tissue velocity, maximum left atrial volume [LAV], and estimated pulmonary artery systolic pressure), lead to the presence and severity of LVDD remaining undetermined in a significant proportion of patients. Maximum LAV is a surrogate measure of the chronicity and severity of LVDD, but LAV alone is an insensitive biomarker of early phases of LVDD, because the LA may take time to remodel. Because the primary function of the LA is to modulate LV filling, it is not surprising that functional LA changes become evident at the earliest stages of LVDD. Moreover, LA function may provide additive value, not only in diagnosing LVDD, but also in grading its severity and in monitoring the effects of treatment. The current review provides a critical appraisal on the existing evidence for the role of LA metrics in evaluation of LVDD and consequent heart failure with preserved ejection fraction.     

Reduced Myocardial Flow Reserve Is Associated With Diastolic Dysfunction and Decreased Left Atrial Strain in Patients With Normal Ejection Fraction and Epicardial Perfusion

Introduction

Coronary microvascular dysfunction (MVD) may contribute to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). Using myocardial flow reserve (MFR) measured by positron emission tomography (PET) as an assessment of microvascular function, we hypothesized that abnormal MFR is associated with LV diastolic dysfunction (DD) and reduced LV and LA strain in patients with risk factors for HFpEF and normal epicardial perfusion on cardiac PET.

Quantification of Regional Left Ventricular Systolic Dysfunction in Patients With Coronary Artery Disease by Strain Rate Imaging

Objectives To detect and compare the systolic strain rate (SR) and strain in the infarct and ischemic myocardium by strain rate imaging (SRI), in order to explore the clinical value of SRI in evaluating regional left ventricular systolic dysfunction. Methods Patients with coronary artery disease were divided into angina pectoris (11 cases) and myocardial infarction (21 cases) groups. Twenty age-matched normal subjects served as the control group. Septal, lateral, anterior, inferior, anteroseptal and posterior walls of the left ventricle were respectively scanned using color tissue Doppler imaging (TDI). Then SR and strain curves were derived from TDI for basal, middle and apical segments of each wall. SRI parameters were: Systolic SR (SRsys), systolic strain (εsys) and maximum strain (εmax). Results Compared with normal segments, SRsys, εsys and εmax decreased significantly in the infarct and ischemic segments (P<0.01). Compared with ischemic segments, SRsys, εsys and εmax decreased significantly in the infarct segments (P<0.05). Conclusions SRsys, εsys and εmax measured by SRI can be used to quantitatively analyze regional left ventricular systolic dysfunction in patients with coronary artery disease, and aid in differentiating infarct from ischemic myocardium.     

Incremental Prognostic Utility of Left Ventricular Global Longitudinal Strain in Asymptomatic Patients With Significant Chronic Aortic Regurgitation and Preserved Left Ventricular Ejection Fraction

Objectives

This study sought to examine the prognostic utility of left ventricular (LV) global longitudinal strain (GLS) in asymptomatic patients with ≥III+ aortic regurgitation (AR), an indexed LV end-systolic dimension of <2.5 cm/m², and preserved left ventricular ejection fraction (LVEF).

Distribution and Prognostic Significance of Left Ventricular Global Longitudinal Strain in Asymptomatic Significant Aortic Stenosis: An Individual Participant Data Meta-Analysis

Objectives

In this individual participant data meta-analysis on left ventricular global longitudinal strain (LVGLS), our objective was to: 1) describe its distribution; 2) identify the most predictive cutoff values; and 3) assess its impact on mortality in asymptomatic patients with significant aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF).

Rationale and Design of the Strain Surveillance of Chemotherapy for Improving Cardiovascular Outcomes: The SUCCOUR Trial

Objectives

This study sought to evaluate the hypothesis that global longitudinal strain (GLS) guidance of cardioprotective therapy would improve cardiac function of at-risk patients undergoing potentially cardiotoxic chemotherapy, compared with usual care.

Evaluation of Left Ventricular Function and its Relationship With Multidimensional Grading System (BODE Index) in Patients With COPD

Cardiovascular disease (CVD) is one of the main causes of morbidity and mortality in chronic obstructive pulmonary disease (COPD) patients however data regarding left ventricle (LV) function in COPD is limited. We, in this study, aimed to evaluate the LV systolic function and its relation to BODE index in COPD patients with the utility of two-dimensional speckle tracking echocardiography (2D-STE). The study involved 125 COPD patients and 30 control subjects. All patients underwent 2D-echocardiography, pulmonary function tests and -minute walk tests. The patients were divided into four quartiles according to BODE index score. COPD patients had lower mitral annulus systolic velocity (Sm), average global longitudinal strain (GLS), average global longitudinal strain rate systolic (GLSRs), average GLSR early diastolic (GLSRe), average GLSR late diastolic (GLSRa), tricuspid annular plane systolic excursion (TAPSE) and peak systolic myocardial velocity (Sm-RV) (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001 and p = 0.002 respectively) than control subjects. There were significant differences between BODE index quartiles in terms of Sm, average GLS and average GLSRs. Patients were divided into two groups according to median value of GLS (> –18.6 and ≤ –18.6). BODE index quartiles were found to be independent predictors of decreased GLS in multivariate logistic regression analysis (p = 0.030). Increased BODE index was associated with impaired LV mechanics in patients with COPD.     

Correlation between Left Ventricular Global and Regional Longitudinal Systolic Strain and Impaired Microcirculation in Patients with Acute Myocardial Infarction

Objectives: We investigated the correlation between left ventricular global and regional longitudinal systolic strain (GLS and LRS) and coronary flow reserve (CFR) assessed by transthoracic echocardiography (TTE) in patients with a recent acute myocardial infarction (AMI). Furthermore, we investigated if LRS and GLS imaging is superior to conventional measures of left ventricle (LV) function. Methods: In a consecutive population of first time AMI patients, who underwent successful revascularization, we performed comprehensive TTE. GLS and LRS were obtained from the three standard apical views. Assessment of CFR by TTE was performed in a modified apical view using color Doppler guidance. Results: The study population consisted of 183 patients (51 females) with a median age of 63 [54;70] years. Eighty‐nine (49%) patients had a non‐ST elevation myocardial infarction and 94 (51%) patients had a ST elevation myocardial infarction. The GLS was ?15.2 [?19.3;?10.1]% in the total population of 183 patients. Total wall motion score index (WMSI) in the population was 1.19 [1;1.5]. Eighty‐five patients suffered from culprit lesion in left anterior descending artery (LAD). The CFR in these patients was 1.86 [1.36;2.35] and the GLS was ?14.3 [?18.9; ?9.8]%. A significant difference was observed in the LRS in LAD territory in culprit LAD infarction patients with a CFR ≤ 2 (?9.6 [?13.77;?6.44]) compared with the LRS in LAD territory in culprit LAD infarction patients with a CFR > 2 (?19.33 [?21.1;?16.5]), P < 0.0001. We found no significant difference between WMSI in LAD territory in culprit LAD infarction patients with a CFR ≤ 2 (1.56 [1.06;2.23]) compared with WMSI in LAD territory in culprit LAD infarction patients with a CFR > 2 (1.37 [1.03;2.11]); P = 0.18. The same pattern was observed in both circumflex coronary artery (CX) and right coronary artery (RCA) territories. In the total population, we found a strong correlation between CFR and GLS (r = ?0.85, P < 0.0001). This was also seen in the multivariate regression model adjusting for possible confounders including WMSI (P < 0.001). Conclusion: In this study, we have shown a close association between myocardial deformation in patients with a recent AMI and the degree of diminished microcirculation. We found that both GLS and LRS correlated with CFR. We conclude that GLS and LRS are significantly better tools to assess impaired CFR and LV function after a recent AMI, than conventional echocardiographic measurements.     

Association of Abnormal Left Ventricular Functional Reserve With Outcome in Heart Failure With Preserved Ejection Fraction

Objectives

This study sought to determine the prognostic value of abnormal diastolic and systolic responses to exercise (on the basis of exertional E/e′ and global longitudinal strain rate [GSR]) in a well-characterized population of patients with heart failure with preserved ejection fraction (HFpEF).