Left ventricular reverse remodeling in dilated cardiomyopathy- maintained subclinical myocardial systolic and diastolic dysfunction

In idiopathic dilated cardiomyopathy (DCM), myocardial deformational parameters and their relationships remain incompletely characterized. We measured those parameters in patients with DCM, during left ventricular reverse remodeling (LVRR). Prospective study of 50 DCM patients (in sinus rhythm), with left ventricular ejection fraction (EF) <40%. LVRR was defined as an increase of ten units of EF and decrease of diastolic left ventricular diameter (LVDD) in the absence of resynchronization therapy. Performed morphological analysis, myocardial performance quantification (LV and RV Tei indexes) and LV averaged peak systolic longitudinal strain (SSR long) and circumferential strain (SSR circ). At baseline, mean EF was 25.4?±?9.8%, LVDD was 62.4?±?7.4 mm, LVDD/BSA of 34.2?±?4.5 mm/m² and 34% had MR grade >II/IV. LVRR occurred in 34% of patients within 17.6?±?15.6 months and was associated with a reduced rate of death or heart failure hospitalization (5.9% vs. 33.3; p?=?0.03). Patients with LVRR had a final EF of 48.9?±?7.9% (Δ LV EF of 22.4%) and there was a significant decrease (p?<?0.05) in: LVDD/BSA, LV systolic diameter/BSA, LV diastolic volume, LV systolic volume, LV mass; an increase (p?<?0.05) in sphericity index. However, measures of diastolic function (LA volume/BSA, e′velocity and’ E/e′ratio), final LV and RV Tei indexes were not significantly different from baseline. Additionally, final SSR circ and SSR long values were not different from basal. Patients who recovered EF >50% (n?=?10), SSR circ and SSR long were inferior to normal. Improvement in EF occurred in one-third of DCM pts and was associated with a decrease of major cardiac events. There was an improvement of diastolic and systolic volumes and in sphericity index, confirming truly LV reverse reshaping. However, myocardial performance indexes, SSR long and SSR circ in reverse-remodeled DCM were still abnormal, suggesting a maintained myocardial systolic and diastolic dysfunction.     

The interplay between renin-angiotensin system activation,abnormal myocardial deformation and neurohumoral activation in hypertensive heart disease: a speckle tracking echocardiography study

Angiotensin converting enzyme (ACE) promotes cardiac fibrosis. LV myocardial deformation and torsion are markers of subclinical myocardial dysfunction. We investigated the association of serum ACE levels with LV deformation markers in untreated hypertensives. In 120 untreated patients (age: 53.5?±?11.2 years) with essential hypertension and 60 healthy controls, we measured (a) LV longitudinal, circumferential and radial strain (S), peak torsion and the percentage changes between peak twisting and untwisting at the end of early diastolic filling (%dpTw-Utw_EDF) using speckle tracking echocardiography and (b) serum levels of ACE and NTproBNP. Compared to controls, patients had decreased longitudinal strain (?19.1?±?2.9 vs. ?21.7?±?1.8%), increased peak twisting (19.1?±?4.6 vs.14.0?±?3.7 deg) but decreased %dpTw-Utw_EDF (78?±?8 vs. 86?±?8%) and higher serum ACE levels (27.6?±?8.0 vs 20.9?±?7.1 U/ml) (p?<?0.05 for all comparisons). Increasing serum ACE levels were related to impaired radial strain and longitudinal systolic SR (b?=??0.41 and b?=?0.31 respectively, p?<?0.01), as well as to reduced %dpTw-Utw_EDF (b?=??0.37, p?<?0.05). Furthermore, increasing serum ACE levels were related to increasing NTproBNP levels (b?=?0.41, p?<?0.01). In multivariate analysis, the above relations of serum ACE levels and LV function parameters remained significant after adjustment for other confounding factors (p?<?0.01). The close link between serum ACE levels and impaired LV deformation suggests that activation of renin-angiotensin system is involved in the impairment of LV function resulting in elevated LV filling pressures causing the concomitant elevation of BNP levels in untreated hypertensive patients.     

Gestational changes in left ventricular myocardial contractile function: new insights from two-dimensional speckle tracking echocardiography

The goal of this study was to evaluate the impact of pregnancy and labor on left ventricular (LV) myocardial mechanics using speckle tracking echocardiography (STE). Pregnancy is characterized by profound hormonal and hemodynamic alterations that directly or indirectly influence cardiac structure and function. However, the impact of these changes on left ventricular (LV) myocardial contractile function has not been fully elucidated. In this prospective, longitudinal study, 35 pregnant women underwent serial clinical and echocardiographic evaluation during each trimester and at labor. Two dimensional STE was performed to measure global LV longitudinal, circumferential and radial strain (GLS, GCS and GRS, respectively). Similar data obtained from 20 nulliparous, age-matched women were used as control. All strain values during pregnancy were adjusted for age and hemodynamic parameters. There was a progressive increase in heart rate, systolic and diastolic blood pressure, cardiac output and LV stroke-work during pregnancy. LV end-diastolic and end-systolic volumes also increased progressively but LV ejection fraction remained unaltered, except for slight reduction during the second trimester. Compared to the controls, GLS and GCS were reduced in the first trimester itself (GLS ?22.39?±?5.43?% vs. ?18.66?±?0.64?%, P 0.0002; GCS ?20.84?±?3.20 vs. ?17.88?±?0.09, P?<?0.001) and remained so throughout the pregnancy and labor. In contrast, GRS showed an increase during pregnancy which peaked during the second trimester (24.18?±?0.39?% vs. 18.06?±?8.14?% in controls, P?<?0.001). Alterations in loading conditions during pregnancy are associated with counterbalancing changes in the myocardial mechanics. LV longitudinal and circumferential strain are reduced whereas radial strain is increased. These counterbalancing changes serve to maintain overall LV ejection performance within a normal range and enable the maternal heart to meet the hemodynamic demands of pregnancy and labor.     

The effect of different treatment strategies on left ventricular myocardial deformation parameters in patients with chronic renal failure

The aim of this study was to compare left ventricular (LV) functions by speckle tracking echocardiography (STE) in chronic kidney disease (CKD) patients in various stages and under different renal replacement treatments in order to evaluate possible differences between them. This prospective study included 150 patients with CKD. Renal transplantation patients with glomerular filtration rate greater than 60 ml/min/1.73 m², patients receiving hemodialysis three times a week, and patients in the predialysis stage with glomerular filtration rate less than 30 ml/dk/1.73 m² were assigned into Group 1 (n?=?50), Group 2 (n?=?50), and Group 3 (n?=?50), respectively. LV longitudinal, circumferential, and radial myocardial deformation parameters (strain, strain rate [SR], rotation, twist) were evaluated by STE. Peak systolic longitudinal strain was higher in the transplantation group than the hemodialysis group (??19.93?±?3.50 vs???17.47?±?3.28%, p?<?0.017). Peak systolic circumferential strain was lower in the hemodialysis group (??20.97?±?4.90%) than Groups 1 and 3 (??25.87?±?4.20 and ??24.74?±?4.55%, respectively, p?<?0.001). Peak systolic radial SR was higher in the transplantation group than the hemodialysis group (1.84?±?0.52 vs 1.55?±?0.52 s^?1, respectively, p?<?0.017). Other longitudinal and circumferential deformation parameters together with peak early diastolic radial SR and twist were also significantly different between the groups. Strain, SR, and twist values were mostly lower in the hemodialysis patients, but generally higher in the transplantation patients. LV functions evaluated by STE are better in the renal transplantation patients than the hemodialysis patients and than those in the predialysis stage. This may indicate beneficial effects of renal transplantation on cardiac functions.     

The ventricular residence time distribution derived from 4D flow particle tracing: a novel marker of myocardial dysfunction

4D flow cardiac magnetic resonance (CMR) imaging allows visualisation of blood flow in the cardiac chambers and great vessels. Post processing of the flow data allows determination of the residence time distribution (RTD), a novel means of assessing ventricular function, potentially providing additional information beyond ejection fraction. We evaluated the RTD measurement of efficiency of left and right ventricular (LV and RV) blood flow. 16 volunteers and 16 patients with systolic dysfunction (LVEF?<?50%) underwent CMR studies including 4D flow. The RTDs were created computationally by seeding virtual ‘particles’ at the inlet plane in customised post-processing software, moving these particles with the measured blood velocity, recording and counting how many exited per unit of time. The efficiency of ventricular flow was determined from the RTDs based on the time constant (RTDc?=???1/B) of the exponential decay. The RTDc was compared to ejection fraction, T1 mapping and global longitudinal strain (GLS). There was a significant difference between groups in LV RTDc (healthy volunteers 1.2?±?0.13 vs systolic dysfunction 2.2?±?0.80, p?<?0.001, C-statistic?=?1.0) and RV RTDc (1.5?±?0.15 vs 2.0?±?0.57, p?=?0.013, C-statistic?=?0.799). The LV RTDc correlated significantly with LVEF (R?=???0.84, P?<?0.001) and the RV RTDc had significant correlation with RVEF (R?=???0.402, p?=?0.008). The correlation between LV RTDc and LVEF was similar to GLS and LVEF (0.926, p?<?0.001). The ventricular residence time correlates with ejection fraction and can distinguish normal from abnormal systolic function. Further assessment of this method of assessment of chamber function is warranted.     

The utility of global longitudinal strain in the identification of prior myocardial infarction in patients with preserved left ventricular ejection fraction

Prior myocardial infarction (MI) is associated with increased mortality and is prevalent in certain high risk patient groups. Electrocardiogram may be used in diagnosis, however, sensitivity is limited, thus non-invasive imaging techniques may improve diagnosis. We investigated whether global longitudinal strain (GLS) and longitudinal strain parameters are reduced in patients with prior MI but preserved left ventricular ejection fraction (LVEF). The study included 40 clinical patients with prior MI occurring >3 months previously (defined as subendocardial hyperenhancement on late Gadolinium enhancement imaging) with LVEF?≥?55% and 40 controls matched for age and LVEF. GLS, global longitudinal strain rate (GLSR) and early diastolic longitudinal strain rate (GLSRe) were measured from cine imaging feature tracking analysis. Presence of wall motion abnormality (WMA) and minimum systolic wall thickening (SWT) were calculated from cine imaging. GLS was ?17.3?±?3.7% in prior MI versus ?19.3?±?1.9% in controls (p?=?0.012). GLSR was ?88.0?±?33.7%/s in prior MI versus ?103.3?±?26.5%/s in controls (p?=?0.005). GLSRe was 76.4?±?28.4%/s in prior MI versus 95.5?±?26.0%/s in controls (p?=?0.001). GLS accurately identified prior MI [AUC 0.662 (95% CI 0.54–0.785) p?=?0.012] whereas WMA [AUC 0.500 (95% CI 0.386–0.614) p?=?1.0] and minimum SWT [AUC 0.609 (95% CI 0.483–0.735) p?=?0.093] did not. GLS, GLSR and GLSRe are reduced in prior MI with preserved LVEF. Normal LVEF and lack of WMA cannot exclude prior MI. Prior MI should be considered when reduced GLS, GLSR or GLSRe are detected by non-invasive imaging.     

Value of three-dimensional strain parameters for predicting left ventricular remodeling after ST-elevation myocardial infarction

This study was to evaluate the value of multi-directional strain parameters derived from three-dimensional (3D) speckle tracking echocardiography (STE) for predicting left ventricular (LV) remodeling after ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) compared with that of two-dimensional (2D) global longitudinal strain (GLS). A total of 110 patients (mean age, 54?±?9 years) after STEMI treated with primary PCI were enrolled in our study. At baseline (within 24 h after PCI), standard 2D echocardiography, 2D STE and 3D STE were performed to acquire the conventional echocardiographic parameters and strain parameters. At 3-month follow-up, standard 2D echocardiography was repeated to all the patients to determine LV remodeling, which was defined as a 20% increase in LV end-diastolic volume. At 3-month follow-up, LV remodeling occurred in 26 patients (24%). Compared with patients without LV remodeling, patients with remodeling had significantly reduced 2D GLS (?12.5?±?3.2% vs ?15.0?±?3.1%, p?<?0.001), 3D GLS (?9.9?±?2.2% vs ?13.1?±?2.7%, p?<?0.001), 3D global area strain (GAS) (?20.3?±?3.9% vs ?23.3?±?4.8%, p?=?0.005) and 3D global radial strain (GRS) (29.0?±?7.4% vs 34.3?±?8.5%, p?=?0.007) at baseline, but there is no significant difference in 3D global circumferential strain (GCS) (?12.7?±?2.9% vs ?13.0?±?3.2%, p?=?0.822). Separated multivariate analysis shows that 2D GLS, 3D GLS, 3D GAS and 3D GRS all can be independent predictors of LV remodeling. However, receiver-operating characteristic curve analysis showed that the area under the curve of 3D GLS (0.82) for predicting LV remodeling was significantly higher than that of 2D GLS (0.72, p?=?0.034), 3D GAS (0.68, p?<?0.001) and 3D GRS (0.68, p?<?0.001). In patients after STEMI, 2D GLS, 3D GLS, 3D GAS and 3D GRS but not 3D GCS measured after primary PCI are independent predictors of LV remodeling and 3D GLS is the most powerful predictor among them.     

Dynamic changes in aortic impedance after transcatheter aortic valve replacement and its impact on exploratory outcome

Valvulo-arterial impedance (Zva) has been shown to predict worse outcome in medically managed aortic stenosis (AS) patients. We aimed to investigate the association between Zva and left ventricular (LV) adaptation and to explore the predictive value of Zva for cardiac functional recovery and outcome after transcatheter aortic valve replacement (TAVR). We prospectively enrolled 128 patients with AS who underwent TAVR. Zva was calculated as: (systolic blood pressure?+?mean transaortic gradient)/stroke volume index). Echocardiographic assessment occurred at baseline, 1-month and 1-year after TAVR. The primary endpoints were to investigate associations between Zva and global longitudinal strain (GLS) at baseline as well as GLS change after TAVR. The secondary was to compare all-cause mortality after TAVR between patients with pre-defined Zva (=5 mmHg m²/ml), stroke volume index (=35 ml/m²), and GLS (=?15%) cutoffs. The mean GLS was reduced (?13.0?±?3.2%). The mean Zva was 5.2?±?1.6 mmHg*m²/ml with 55% of values ≥5.0 mmHg*m²/ml, considered to be abnormally high. Higher Zva correlated with worse GLS (r?=??0.33, p?<?0.001). After TAVR, Zva decreased significantly (5.1?±?1.6 vs. 4.5?±?1.6 mmHg*m²/ml, p?=?0.001). A reduction of Zva at 1-month was associated with GLS improvement at 1-month (r?=??0.31, p?=?0.001) and at 1-year (r?=??0.36 and p?=?0.001). By Kaplan–Meier analysis, patients with higher Zva at baseline had higher mortality (Log-rank p?=?0.046), while stroke volume index and GLS did not differentiate outcome (Log-rank p?=?0.09 and 0.25, respectively). As a conclusion, Zva is correlated with GLS in AS as well as GLS improvement after TAVR. Furthermore, a high baseline Zva may have an additional impact to traditional parameters on predicting worse mortality after TAVR.     

Reference ranges for three-dimensional feature tracking cardiac magnetic resonance: comparison with two-dimensional methodology and relevance of age and gender

Myocardial deformation is a sensitive marker of sub-clinical myocardial dysfunction that carries independent prognostic significance across a broad range of cardiovascular diseases. It is now possible to perform 3D feature tracking of SSFP cines on cardiac magnetic resonance imaging (FT-CMR). This study provides reference ranges for 3D FT-CMR and assesses its reproducibility compared to 2D FT-CMR. One hundred healthy individuals with 10 men and women in each of 5 age deciles from 20 to 70 years, underwent 2D and 3D FT-CMR of left ventricular myocardial strain and strain rate using SSFP cines. Good health was defined by the absence of hypertension, diabetes, obesity, dyslipidaemia, or any cardiovascular, renal, hepatic, haematological and systemic inflammatory disease. Normal values for myocardial strain assessed by 3D FT-CMR were consistently lower compared with 2D FT-CMR measures [global circumferential strain (GCS) 3D ??17.6?±?2.6% vs. 2D ??20.9?±?3.7%, P?<?0.005]. Validity of 3D FT-CMR was confirmed against other markers of systolic function. The 3D algorithm improved reproducibility compared to 2D, with GCS having the best inter-observer agreement [intra-class correlation (ICC) 0.88], followed by global radial strain (GRS; ICC 0.79) and global longitudinal strain (GLS, ICC 0.74). On linear regression analyses, increasing age was weakly associated with increased GCS (R²?=?0.15, R?=?0.38), peak systolic strain rate, peak late diastolic strain rate, and lower peak early systolic strain rate. 3D FT-CMR offers superior reproducibility compared to 2D FT-CMR, with circumferential strain and strain rates offering excellent intra- and inter-observer variability. Normal range values for myocardial strain measurements using 3D FT-CMR are provided.     

Myocardial deformation and volume of exercise: a new overlap between pathology and athlete’s heart?

Regular physical exercise induces cardiac adaptations that can overlap pathological conditions. Controversy still persists about the variability of myocardial deformation in different types and intensity of exercise. The aim of this study was to assess myocardial longitudinal deformation in athletes with different level of exercise. Two groups of young athletes involved in endurance sports characterized by high intensity dynamic component were enrolled. According to the level and the number of exercise training hours/week, two groups were defined: Group 1—high level (national/international and ≥?20 training-hours/week; N?=?60); Group 2—low level (recreational/regional and <?10 training-hours/week; N?=?48). A comprehensive transthoracic echocardiogram including evaluation of global longitudinal strain (GLS) assessed by 2D speckle-tracking was performed. Athletes in Group 1 showed more pronounced cardiac remodeling and enhanced diastolic function. No significant differences were evident in left ventricle ejection fraction (LVEF) between groups. Overall, GLS (absolute values) was 18.0?±?2.5%, but significantly lower in Group 1 compared to Group 2 (17.3?±?2.6% vs. 18.9?±?2.1%; p?=?0.001). Thirty-three (31%) athletes had GLS below 17%, more frequently in Group 1 (79% vs. 45%; p?=?0.001), with higher LV and left atrium volumes, lower E wave and A wave peak velocities and E/e′ ratio. In a multivariate analysis to belong to Group 1 was the only independent variable associated with GLS?<?17% (OR 6.5; 95% CI 2.4–17.4; p?<?0.001). The athletes with a GLS?<?17% were all men, more frequently involved in high level exercise, with higher chamber volumes and lower E/e′ ratio. Left ventricular global myocardial longitudinal deformation evaluated by GLS was significantly lower in athletes with higher level of exercise. Although GLS in athletes overlap several pathological conditions, these lower values are associated with an enhanced diastolic performance that allows discrimination between physiologic adaptations and pathology.     

Radiotherapy-induced global and regional differences in early-stage left-sided versus right-sided breast cancer patients: speckle tracking echocardiography study

Radiotherapy (RT) to the thoracic region increases late cardiovascular morbidity and mortality. The impact of breast cancer laterality on cardiac function is largely unknown. The aim of this prospective study was to compare RT-induced changes in left-sided and right-sided breast cancer patients using speckle tracking echocardiography (STE). Sixty eligible patients with left-sided breast cancer and 20 with right-sided breast cancer without chemotherapy were evaluated prospectively before and early after RT. A comprehensive echocardiographic examination included three dimensional measurements and STE of the left ventricle (LV). The global longitudinal strain (GLS) was reduced from ?18.3?±?3.1 to ?17.2?±?3.3% (p?=?0.003) after RT in patients with left-sided breast cancer. Similarly, regional analysis showed a reduction in the apical strain from ?18.7?±?5.3 to ?16.7?±?4.9% (p?=?0.002) and an increase in basal values from ?21.6?±?5.0 to ?23.3?±?4.9% (p?=?0.024). Patients with right-sided breast cancer showed deterioration in basal anterior strain segments from ?26.3?±?7.6 to ?18.8?±?8.9% (p?<?0.001) and in pulsed tissue Doppler by 0.825 [0.365, 1.710] cm/s (p?<?0.001). In multivariable analysis, the use of aromatase inhibitor (β?=??2.002, p?=?0.001) and decreased LV diastolic volume (β?=??0.070, p?=?0.025) were independently associated with the decrease in GLS. RT caused no changes in conventional LV systolic measurements. RT induced regional changes corresponded to the RT fields. Patients with left-sided breast cancer experienced apical impact and global decline, whereas patients with right-sided breast cancer showed basal changes. The regional differences in cardiac impact warrant different methods in screening and in the follow-up of patients with left-sided versus right-sided breast cancer.     

Very early stage left ventricular endocardial dysfunction of patients with hypereosinophilic syndrome

Cardiac involvement in hypereosinophilic syndrome (HES) patients entails significant morbidity and mortality. Left ventricular (LV) endocardial damage is important for the development of cardiac involvement in HES patients. However very early stage LV endocardial damage, such as prior to the first stage of an acute necrotic stage, remains uncertain. We studied 32 HES patients, all with normal conventional echocardiographic findings. Global radial and circumferential strain (GRS and GCS) were determined for each peak global strain curve from the mid-LV short-axis view, and global longitudinal strain (GLS) was averaged each peak global strain curve from standard apical views by means of two-dimensional speckle-tracking method. Thirty-one age-, gender-, LV ejection fraction-matched normal subjects were studied for comparison. GRS and GRS were similar for HES patients and normal controls, but GLS for HES patients was significantly lower than that for normal controls (16.2?±?3.3?% vs 19.3?±?2.9?%, p?<?0.001). Furthermore, receiver operating characteristic curve analysis identified GLS ≤17.0?% as the best predictor of LV endocardial dysfunction with a sensitivity of 66?%, specificity of 78?%, and area under the curve of 0.781 (p?=?0.0001). In conclusions, LV endocardial dysfunction pre-existed even in HES patients without apparent cardiac involvement. GLS as assessed with the two-dimensional speckle-tracking method is a promising tool for the better management of very early stage of HES patients.     

Improvement of left ventricular relaxation as assessed by tissue Doppler imaging in fluid-responsive critically ill septic patients

Purpose

Left ventricular (LV) diastolic function is often impaired in critically ill septic patients. The peak velocity of the mitral annulus early wave during diastole (E′), measured by Doppler echocardiography, is a major tool to evaluate LV relaxation, the ATP-dependent part of diastole. The authors hypothesized that if volume expansion (VE) is followed by an increase in stroke volume (SV) (“adequate” VE), LV relaxation and consequently E′ may be increased.

Methods

This was a prospective study in which 83 mechanically ventilated septic patients with circulatory failure were enrolled. Doppler echocardiography was performed before and after the infusion of 500?ml of saline over 20?min. Patients were then classified into two groups according to their response to VE: responders (R) were those in whom SV increased by at least 15?%; all others were considered to be non-responders (NR). SV, mitral flow early wave velocity (E), E′ and the E/E′ ratio were measured before and after VE. VE-induced variations (?) in all parameters were compared in R and NR. Patients with an E′?Results Fifty-nine patients (71?%) were R and 24 (29?%) were NR. Fifty-six percent of R patients and 58?% of NR patients had LV diastolic dysfunction. For patients with LV diastolic dysfunction (n?=?47), ?E′ was significantly higher in the R group (29?±?5 vs. 5?±?8?%; p?=?0.01) whilst ?E/E′ was higher in the NR group (35?±?9 vs. 2?±?6?%; p?=?0.02).

Conclusions

E′ maximal velocity increased with adequate VE, suggesting an improvement of LV relaxation with the correction of hypovolaemia in patients with septic shock.     

Early detection of cardiac alterations by left atrial strain in patients with risk for cardiac abnormalities with preserved left ventricular systolic and diastolic function

This study sought to examine whether early cardiac alterations could be detected by left atrial (LA) strain in patients with risk for cardiac abnormalities. In this cross-sectional and retrospective study, we included patients with (n?=?234) and without (n?=?48) risk for cardiac abnormalities (i.e. those with arterial hypertension, diabetes mellitus and/or a history of coronary artery disease) of similar age and with preserved left ventricular (LV) systolic and diastolic function according to standard criteria. LA strain was significantly altered in patients with risk for cardiac abnormalities in comparison to those without risk (29.2?±?8.6 vs. 38.5?±?12.6%; rate of impaired LA strain: 18.8% vs. 0%; all p?<?0.01) and was the most sensitive parameter to detect early LA alterations in comparison with other LA functional parameters (rate of impaired LA strain rate, LA total emptying fraction, and LA expansion index 3.8%, 7.3%, and 3.8%, respectively). Moreover, in patients with risk for cardiac abnormalities LA strain was altered even in the absence of subtle LV systolic and diastolic alterations (rates 13.9% and 6.8%), albeit to a lesser extent than in patients with an abnormal LV longitudinal systolic strain or abnormal mitral annular e′ velocities (rates 48.5% and 24.4%). Regarding the clinical relevance of these findings, an impaired LA strain (i.e. <?23%) was significantly linked to exertional dyspnea (OR 3.5 [1.7–7.0]) even adjusting the analyses by age, gender and subtle LV abnormalities. In conclusion, the findings from this study suggest that LA strain measurements could be useful to detect early cardiac alterations in patients with risk for cardiac abnormalities with preserved LV systolic and diastolic function and that these early LA strain alterations could be linked to exertional dyspnea.     

Non‐invasive left ventricular myocardial work indices in healthy adolescents at rest

Global myocardial work (GMW) provides a metric of left ventricular (LV) function and energy consumption. Its non-invasive assessment by echocardiography correlates with invasive measures and normal values have been reported in healthy adults. We aimed to establish normal values in a healthy adolescent population. Fifty-two healthy adolescents (mean age?=?14.5?±?2.0 years, range 11–19 years, 62% male) with normal echocardiograms were included. Brachial cuff blood pressure was obtained immediately following apical imaging in the supine position. Post-processing of echocardiograms for speckle tracking strain measurement and derivation of global myocardial work indices from LV pressure–strain loops was performed. The mean global work index (GWI) was 1802.0?±?264.4 mmHg% with mean global work efficiency of 95.5?±?1.1%. The mean global constructive work (GCW) was 2054.5?±?297.3 mmHg%, and the mean global wasted work 83.8?±?28.1 mmHg%. On multivariable analysis, there were significant associations between both GWI and GCW with systolic blood pressure (β coefficient?=?0.57, p?<?0.001; β coefficient?=?0.67, p?<?0.001 respectively) and LV global longitudinal strain (GLS) (β coefficient = ? 0.56, p?<?0.001; β coefficient = ? 0.52, p?<?0.001 respectively). There were no associations with any of the work indices with age, sex, body surface area, heart rate or LV ejection fraction. This study provides echocardiographic reference ranges for non-invasive indices of GMW in normal adolescents.

     

Impact of surgical pulmonary valve replacement on ventricular mechanics in children with repaired tetralogy of Fallot

Impaired ventricular myocardial mechanics are observed in patients with repaired tetralogy of Fallot (rTOF). Effects of pulmonary valve replacement (PVR) on ventricular remodeling are controversial. The objective was to assess the impact of surgical PVR on ventricular mechanics in pediatric patients after rTOF. Speckle-tracking analysis was performed in 50 rTOF children, aged 12.6?±?3.3 years, pre-operatively and 14.5?±?2.2 months post-PVR. Early post-operative studies 2.2?±?0.6 months post-PVR were performed in 28 patients. Cardiac magnetic resonance (CMR) pre- and post-PVR was collected. Mid-term post-PVR right ventricular (RV) longitudinal strain increased above pre-operative strain (?19.2?±?2.7 to ?22.0?±?3.0%, p?<?0.001) with increases observed in individual RV segments. Left ventricular (LV) strain did not differ at medium-term follow-up. LV and RV longitudinal strain was reduced early post-operatively, followed by recovery of biventricular systolic strain by mid-term follow-up. CMR RV end-diastolic indexed volumes correlated with RV strain pre-operatively (r?=?0.432, p?=?0.005) and at mid-term follow-up (r?=?0.532, p?=?0.001). Volume-loaded RVs had reduced early RV basal longitudinal strain compared to pressure-loading conditions. Reversed basal counterclockwise rotation was associated with lower mid-term global LV and basal RV strain compared to patients with normal rotation. An increase in mid-term global and regional RV strain beyond pre-operative values suggests positive RV remodeling and adaptation occurs in children post-PVR. Patients with larger pre-operative RV volumes had lower RV strain post-operatively. The impact of LV rotation on RV mechanics highlights the presence of ventriculo-ventricular interactions. These findings have important clinical implications in pediatric rTOF patients towards identifying pre-operative factors that predict RV post-operative remodeling.     

Left and right ventricular longitudinal strain-volume/area relationships in elite athletes

We propose a novel ultrasound approach with the primary aim of establishing the temporal relationship of structure and function in athletes of varying sporting demographics. 92 male athletes were studied [Group IA, (low static–low dynamic) (n?=?20); Group IC, (low static–high dynamic) (n?=?25); Group IIIA, (high static–low dynamic) (n?=?21); Group IIIC, (high static–high dynamic) (n?=?26)]. Conventional echocardiography of both the left ventricles (LV) and right ventricles (RV) was undertaken. An assessment of simultaneous longitudinal strain and LV volume/RV area was provided. Data was presented as derived strain for % end diastolic volume/area. Athletes in group IC and IIIC had larger LV end diastolic volumes compared to athletes in groups IA and IIIA (50?±?6 and 54?±?8 ml/(m²)^1.5 versus 42?±?7 and 43?±?2 ml/(m²)^1.5 respectively). Group IIIC also had significantly larger mean wall thickness (MWT) compared to all groups. Athletes from group IIIC required greater longitudinal strain for any given % volume which correlated to MWT (r?=?0.4, p?<?0.0001). Findings were similar in the RV with the exception that group IIIC athletes required lower strain for any given % area. There are physiological differences between athletes with the largest LV and RV in athletes from group IIIC. These athletes also have greater resting longitudinal contribution to volume change in the LV which, in part, is related to an increased wall thickness. A lower longitudinal contribution to area change in the RV is also apparent in these athletes.     

Subclinical left ventricular systolic impairment in steady state young adult patients with sickle-cell anemia

Chronic volume overload in sickle-cell anemia (SCA) is associated with left ventricular (LV) enlargement and hypertrophy. The effect of the disease on LV systolic function remains debated. The aim of our study was to investigate LV systolic function in SCA patients using 2D speckle-tracking imaging. We compared 30 steady state asymptomatic adult SCA patients (17 women, mean age 24.7 ± 5.1 years) with 30 age and sex-matched healthy subjects (17 women, mean age 25.0 ± 4.9 years). In addition to conventional echocardiographic parameters including LV ejection fraction (LVEF) and LV mass index (LVMi), global longitudinal strain (GLS) and strain rate (GLSR) were measured. GLS (?17.9 ± 2.0 vs. ?19.7 ± 2.5 %, p = 0.004) and GLSR (?0.92 ± 0.09 vs. ?1.07 ± 0.17 s^?1, p < 0.0001) values were lower in SCA patients while LVEF values (60.1 ± 3.8 vs. 61.7 ± 4.7 %, p = 0.30) were not different. LVMi was increased in SCA patients (100.7 ± 23.5 vs. 72.4 ± 15.2 g/m², p = 0.0001) and GLSR was significantly lower in the subgroup of patients with LV hypertrophy (?0.88 ± 0.09 vs. ?0.96 ± 0.08 s^?1, p = 0.02). In SCA patients LVMi was correlated to GLS (r = 0.58, p = 0.001) and GLSR (r = 0.45, p = 0.015) pleading in favor of a pathological LV remodeling. Asymptomatic SCA patients exhibited a subclinical alteration of LV systolic function. Myocardial dysfunction appears to be linked to the degree of LV hypertrophy. 2D speckle-tracking imaging might be useful for long-term follow-up and to study the natural course of LV dysfunction in SCA patients.     

Speckle tracking determination of mitral tissue annular displacement: comparison with strain and ejection fraction,and association with outcomes in haemodialysis patients

Abnormal Global longitudinal strain (GLS) and reduced left ventricular ejection fraction (LVEF) are established poor prognostic risk factors in haemodialysis patients. Tissue motion annular displacement of mitral valve annulus (TMAD), determined by speckle tracking echocardiography (STE), can be performed rapidly and is an indicator of systolic dysfunction, but has been less well explored. This study aims to compare TMAD with GLS and LVEF and its association with outcomes in haemodialysis patients. 198 haemodialysis patients (median age 64.2 years, 69?% men) had 2D echocardiography, with STE determined GLS and TMAD. Bland–Altman analysis and linear regression assessed relationship between GLS, LVEF and TMAD. Cox regression analysis investigated association of TMAD with mortality and cardiac events. TMAD had low inter- and intra-observer variability with small biases and narrow limits of agreement (LOA) (bias of ?0.01?±?1.32 (95?% LOA was ?2.60 to 2.58) and ?0.07?±?1.27 (95?% LOA ?2.55 to 2.41) respectively). There was a moderate negative correlation between GLS and LVEF (r?=??0.383, p?<?0.001) and a weak positive correlation between TMAD and LVEF (r?=?0.248, p?<?0.001). There was strong negative correlation of TMAD with GLS (r?=??0.614, p?<?0.001). In a multivariable Cox regression analysis, TMAD was not associated with mortality (HR 1.04, 95?% CI 0.91–1.19), cardiac death (HR 1.03, 95?% CI 0.80–1.32) or cardiac events (HR 0.91, 95?% CI 0.80–1.02). TMAD is a quick and reproducible alternative to GLS which may be very useful in cardiovascular risk assessment, but does not have the same prognostic value in HD patients as GLS.     

New perspective on fatigue in hemodialysis patients with preserved ejection fraction: diastolic dysfunction

The relationship between diastolic dysfunction and fatigue in hemodialysis patients with preserved ejection fraction is unknown. In this context, the objective of this study is to assess fatigue using the relevant scales and to demonstrate its relationship with diastolic dysfunction. The patients who underwent hemodialysis were evaluated prospectively. Patients’ fatigue was assessed using the Visual Analogue Scale to Evaluate Fatigue Severity (VAS-F). The echocardiographic works were performed as recommended in the American Society of Echocardiography guidelines. A total of 94 patients [mean age 64.7?±?13.5 years, 54 males (57.4%)] were included in the study. The median VAS-F score of these patients was 68.5 (33.25–91.25), and they were divided into two groups according to this value. Peak myocardial velocities during early diastole (e′) and tricuspid annular plane systolic excursion (TAPSE) values were found to be significantly lower in the group with high VAS-F scores, whereas the early diastolic flow velocities (E)/e′ ratio and pulmonary artery peak systolic pressures (PAP) were found to be significantly higher (p?<?0.05, for all). E/e′ ratio (r 0.311, p 0.002) and PAP (r 0.281, p 0.006) values were found to be positively correlated with the VAS-F score, as opposed to the TAPSE (r ? 0.257, p 0.012) and e′ (r ? 0.303, p 0.003) values, which were found to be negatively correlated with the VAS-F score. High fatigue scores in hemodialysis patients may be associated with diastolic dysfunction. In addition, in our study, we determined the correlation of VAS-F score with E/e′ ratio, PAP and TAPSE.