Cardiac structure and function in elite Native Hawaiian and Pacific Islander Rugby Football League athletes: an exploratory study

The aim of this exploratory study was to define the Athletes Heart (AH) phenotype in Native Hawaiian & Pacific Islander (NH&PI) Rugby Football League (RFL) athletes. Specifically, (1) to describe conventional echocardiographic indices of left ventricle (LV) and right ventricle (RV) structure and function in NH&PI RFL players and matched RFL Caucasian controls (CC) and (2) to demonstrate LV and RV mechanics in these populations. Ethnicity is a contributory factor to the phenotypical expression of the AH. There are no data describing the cardiac phenotype in NH&PI athletes. Twenty-one male elite NH&PI RFL athletes were evaluated using conventional echocardiography and myocardial speckle tracking, allowing the assessment of global longitudinal strain (ε) and strain rate (SR); and basal, mid and global radial and circumferential ε and SR. Basal and apical rotation and twist were also assessed. Results were compared with age-matched Caucasian counterparts (CC; n?=?21). LV mass [42?±?9 versus 37?±?4 g/(m^2.7)], mean LV wall thickness (MWT: 9.5?±?0.7 and 8.7?±?0.4 mm), relative wall thickness (RWT: 0.35?±?0.04 and 0.31?±?0.03) and RV wall thickness (5?±?1 and 4?±?1 mm, all p?<?0.05) were greater in NH&PI compared with CC. LV and RV cavity dimensions and standard indices of LV and RV systolic and diastolic function were similar between groups. NH&PI demonstrated reduced peak LV mid circumferential ε and early diastolic SR, as well as reduced global radial ε. There was reduced basal rotation at 25–35% systole, reduced apical rotation at 25–40% and 60–100% systole and reduced twist at 85–95% systole in NH&PI athletes. There were no differences between the two groups in RV wall mechanics. When compared to Caucasian controls, NH&PI rugby players have a greater LV mass, MWT and RWT with concomitant reductions in circumferential and twist mechanics. This data acts to prompt further research in NH&PI athletes.     

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.     

Can ischemia and dyssynchrony be detected during early stages of dobutamine stress echocardiography by 2-dimensional speckle tracking echocardiography?

Strain and strain rate (SR) measured with 2-dimensional speckle tracking echocardiography (2-D STE) can quantitatively assess myocardial function. Our aim was to evaluate whether we could detect abnormalities in strain, strain rate, and dyssynchrony by applying 2-D STE in patients with severe coronary artery disease during early stages of dobutamine stress echocardiography. Thirty-four patients with angiographically documented severe 3-vessel coronary artery disease and preserved left ventricular ejection fraction were compared with 42 control patients without evidence of coronary artery disease. Circumferential and longitudinal strain, SR, and left ventricular synchrony using standard deviation (SD) of time to systolic peak strain and SR were analyzed with 2-D STE at rest and at intermediate doses of dobutamine stress echocardiography. Compared with control subjects, patients with coronary artery disease showed lower circumferential SR [?1.42 (0.34) s^?1 vs ?1.64 (0.34) s^?1; P < .02] and significantly lower longitudinal strain [?15.41 % (3.52 %) vs ?19.37 % (3.21 %); P < .001] and SR [?0.91 (0.18) s^?1 vs ?1.19 (0.24) s^?1; P < .001] at intermediate doses; these values were also compromised at peak dose. The SD of longitudinal time to systolic peak strain at intermediate dose was significantly greater in patients with coronary artery disease than in control patients [37.89 (12.32) vs 27.21 (10.86); P < .001]. The 2-D STE-derived strain and SR detected myocardial dysfunction and asynchrony in patients with coronary artery disease during intermediate doses of dobutamine stress, with minimal changes in regional wall motion abnormalities at this stage.     

Cardiac function in patients with polymyositis or dermatomyositis: a three-dimensional speckle-tracking echocardiography study

Cardiac event is a major cause of death in patients with idiopathic inflammatory myopathies (IIM). The most frequent IIMs are polymyositis (PM) and dermatomyositis (DM). The purpose of this study was to analyze cardiac involvement by three-dimensional speckle-tracking echocardiography (3D STE) in patients with PM or DM, and to identify the relationship of cardiac injury with clinical characteristics and disease-specific parameters. 60 PM/DM patients with preserved left ventricular ejection fraction and 30 matched healthy controls were assessed by conventional echocardiography, 3D STE with biventricular strain analysis and electrocardiogram. Compared to controls, patients with PM/DM had significantly diminished left ventricular global longitudinal systolic strain and right ventricular longitudinal systolic strain (LVGLS, ? 20.3?±?2.5 vs. ? 23.4?±?1.7%; RVLS, ? 19.4?±?4.2 vs ? 24.8?±?2.0%; both P?<?0.001), and longer QTc intervals(421.0?±?38.4 vs 400.6?±?14.5 ms, P?=?0.001). Multiple regression analysis showed that Myositis Damage Index (MDI) was independently associated with LVGLS (R²?=?0.44, P?=?0.002) and RVLS (R²?=?0.56, P?<?0.001) in PM/DM patients with established disease course more than 1 year. In multivariate analysis of pooled data for all the PM/DM patients, when MDI was excluded due to missing observations, disease duration correlated with worse LVGLS (R²?=?0.24, P?=?0.002), while concomitant interstitial lung disease correlated with worse RVLS (R²?=?0.30, P?<?0.001). Disease activity scores (Myositis Intention to Treat Activities Index) had a weak positive correlation with QTc intervals (r_sp = 0.31, P?=?0.02). Our results suggest that cardiac injury in PM/DM is a long-term process and its severity depends on patients’ heterogeneous clinical features and systemic disease burden.     

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.     

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.     

Less pronounced reverse left ventricular remodeling in patients with bicuspid aortic stenosis treated with transcatheter aortic valve replacement compared to tricuspid aortic stenosis

To compare reverse left ventricular (LV) remodeling after transcatheter aortic valve replacement (TAVR) between patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV). We retrospectively reviewed data of patients with at least two serial echocardiographic follow-ups (1, 3, 6 months and 1 year) post-TAVR. A total of 116 patients were identified. BAV morphology was documented in 67 patients. LV mass index (LVMi) at baseline was not significantly different between the TAV and BAV group (178.0?±?6.9 vs. 166.3?±?6.4 g/m², P?=?0.14). Reverse LV remodeling was observed in both BAV and TAV patients, but the reduction of LVMi from baseline was significantly more pronounced in TAV patients compared with BAV patients from 6 months post-TAVR (??56.3?±?8.1 vs. ??30.0?±?4.7 g/m², P?<?0.01 at 6-month follow-up; ??60.6?±?7.6 vs. ??37.9?±?6.2 g/m², P?=?0.02 at 1-year follow-up). EDV value changes during follow-up were similar between patient with TAV and BAV. There were no significant differences in the proportions of patients with more than mild PVL or new permanent pacemaker between TAV and BAV morphology throughout the follow-up. Patients with bicuspid morphology might experience less pronounced reverse LV remodeling post-TAVR than patients with tricuspid morphology.     

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.     

Normal references of right ventricular strain values by two-dimensional strain echocardiography according to the age and gender

Right ventricular (RV) strain values by 2-dimensional strain echocardiography (STE) can be used as objective markers of RV systolic function. However, there is little data about normal reference RV strain values according to age and gender. We measured normal RV strain values by STE. RV strain values were analyzed from the digitally stored echocardiographic images from NORMAL (Normal echOcardiogRaphic diMensions and functions in KoreAn popuLation) study for the measurement of normal echocardiographic values performed in 23 Korean university hospitals. We enrolled total 1003 healthy persons in the NORMAL study. Of them, we analyzed 2-dimensional RV strain values in 493 subjects (261 females, mean 47?±?15 years old) only with echocardiographic images by GE machines. Their LV systolic and diastolic functions were normal. RV fractional area change was 48?±?6% and tricuspid annular plane systolic excursion was 23?±?3 mm. Total RV global longitudinal peak systolic strain (RVGLS_total) was ?21.5?±?3.2%. Females had higher absolute RVGLS_total (?22.3?±?3.3 vs ?20.7?±?2.9%, p?<?0.001) than males. Younger (<50 years old) females had higher absolute RVGLS_total (?22.9?±?3.2 vs ?20.5?±?2.8%, p?<?0.001) than age matched males. RVGLS_total in females gradually increased according to age (p for trend?=?0.002) and becomes almost similar in age ≥50 years. However, this trend was not seen in males (p for trend?=?0.287), and younger males had similar RVGLS_total value to that of older males (age ≥50 years, ?20.5?±?2.8 vs ?20.9?±?3.1%, p?=?0.224). We calculated normal RVGLS values in normal population. Females have higher absolute strain values than males, especially in younger age groups (<50 years old).     

Comparison of effects of losartan and metoprolol on left ventricular and aortic function at rest and during exercise in chronic aortic regurgitation

Aortic regurgitation (AR) increases the hemodynamic load on both the left ventricle (LV) and the aorta. Vasodilators and beta-blockers both reduce systemic blood pressure, but their relative effects on the LV and aortic function and aortic regurgitant fraction in chronic AR are uncertain. We aimed to compare short-term effects of losartan and metoprolol on LV and aortic function in asymptomatic patients with chronic moderate to severe AR, both at rest and during exercise, using cardiac magnetic resonance (CMR) imaging. 17 chronic AR patients were randomized to 4–6 weeks losartan followed by metoprolol, or vice versa, in a cross-over design. Aortic regurgitant fraction, aortic distensibility, pulse wave velocity and LV function were assessed at rest and after moderate exercise stress (29?±?7 W, heart rate increase 25?±?6 bpm) using CMR. Chronic AR patients on metoprolol had a significantly lower mean heart rate, cardiac power index and rate-pressure product, than on losartan (all p?<?0.01). However, aortic regurgitant fraction was greater on metoprolol compared to losartan (by 7?±?11%, p?=?0.02). Metoprolol was also associated with a greater reduction in aortic distensibility during exercise than losartan (??2.4?±?1.5?×?10^?3 vs ??1.7?±?2.1?×?10^?3 mmHg^?1 respectively, p?=?0.04). End-diastolic volume index was higher on metoprolol than losartan at exercise (difference 6.6?±?7.8 ml/m², p?<?0.01), as was end-systolic volume index (difference 4.0?±?5.2 ml/m², p?<?0.01). Losartan and metoprolol have significantly different short-term effects on aortic regurgitation and LV and aortic function in chronic AR. Further research is required to determine the long-term clinical significance of these changes.     

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.     

Echocardiographic assessment of regional right ventricular systolic function using two-dimensional strain echocardiography and evaluation of the predictive ability of longitudinal 2D-strain imaging for pulmonary arterial hypertension in systemic sclerosis patients

Systemic sclerosis (SSc) is a generalized connective tissue disorder, and SSc patients are at risk of developing pulmonary arterial hypertension (PAH). The aims of this study are to evaluate the right ventricular regional systolic function using two-dimensional speckle-tracking echocardiography (2D STE) and to determine the predictive ability of peak longitudinal systolic strain (PLSS) at the RV lateral wall for PAH in SSc patients. 80 SSc patients (mean age 51?±?12 years) were included in the study. Echocardiography and 2D STE were performed at baseline and after 12 months. RHC was performed only in SSc patients with clinical indications. PLSS at the apical segment of the RV free wall was significantly impaired in PAH patients compared with non-PH patients (–14.6?±?5.9 vs. ??22.2?±?7.5%, p?=?0.034). PLSS at the basal, mid, and apical segments of the RV free wall was lower in both groups at follow-up compared to baseline, but the drop in strain values was statistically significant only in the non-PH group (p?<?0.05). Right atrial area (OR 1.758; p?=?0.023), peak tricuspid regurgitation velocity (OR 24.23; p?=?0.011) and PLSS at the apical segment of the RV lateral wall (OR 2.47; p?=?0.005) were independent predictors of PAH. A cut-off value of ??14.48% PLSS at the apical segment of the RV lateral wall resulted in 100% specificity for predicting PAH in SSc patients. RV pressure overload affects RV systolic function as manifested by impaired RV longitudinal deformation. Evaluating RV regional systolic function with 2D STE could be useful as an additional echocardiographic parameter for screening PAH in SSc patients.     

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.     

Estimation of myocardial strain from non-rigid registration and highly accelerated cine CMR

Sparsely sampled cardiac cine accelerated acquisitions show promise for faster evaluation of left-ventricular function. Myocardial strain estimation using image feature tracking methods is also becoming widespread. However, it is not known whether highly accelerated acquisitions also provide reliable feature tracking strain estimates. Twenty patients and twenty healthy volunteers were imaged with conventional 14-beat/slice cine acquisition (STD), 4× accelerated 4-beat/slice acquisition with iterative reconstruction (R4), and a 9.2× accelerated 2-beat/slice real-time acquisition with sparse sampling and iterative reconstruction (R9.2). Radial and circumferential strains were calculated using non-rigid registration in the mid-ventricle short-axis slice and inter-observer errors were evaluated. Consistency was assessed using intra-class correlation coefficients (ICC) and bias with Bland–Altman analysis. Peak circumferential strain magnitude was highly consistent between STD and R4 and R9.2 (ICC?=?0.876 and 0.884, respectively). Average bias was ?1.7?±?2.0?%, p?<?0.001, for R4 and ?2.7?±?1.9?%, p?<?0.001 for R9.2. Peak radial strain was also highly consistent (ICC?=?0.829 and 0.785, respectively), with average bias ?11.2?±?18.4?%, p?<?0.001, for R4 and ?15.0?±?21.2?%, p?<?0.001 for R9.2. STD circumferential strain could be predicted by linear regression from R9.2 with an R² of 0.82 and a root mean squared error of 1.8?%. Similarly, radial strain could be predicted with an R² of 0.67 and a root mean squared error of 21.3?%. Inter-observer errors were not significantly different between methods, except for peak circumferential strain R9.2 (1.1?±?1.9?%) versus STD (0.3?±?1.0?%), p?=?0.011. Although small systematic differences were observed in strain, these were highly consistent with standard acquisitions, suggesting that accelerated myocardial strain is feasible and reliable in patients who require short acquisition durations.     

Relationship between cardiovascular risk factors and myocardial strain values of both ventricles in asymptomatic Asian subjects: measurement using cardiovascular magnetic resonance tissue tracking

The purpose of this study was to evaluate the association between myocardial deformation parameters and cardiovascular risk factors in asymptomatic Asian subjects and to provide reproducibility for deformation parameters of both ventricles using cardiovascular magnetic resonance (CMR) tissue tracking (TT). We enrolled 129 asymptomatic healthy adults who underwent CMR and assessed the cardiovascular risk factors in all individuals. All subjects had normal left ventricular systolic function. Commercial software was used to derive myocardial deformation parameters of both ventricles from short-axis cine images and long-axis cine images with two-, three-, and four-chamber views. Linear regression analysis was performed for evaluation of the association with all strain parameters for each age and systolic blood pressure. Intra class correlation was also calculated in CMR-TT to determine interobserver variability. In all 129 patients, the strain values for the left ventricle (LV) were 48.90?±?9.05 for radial strain (RS, %), ??22.30?±?2.33 for circumferential strain (CS, %), and ??19.76?±?2.22 for longitudinal strain (LS, %). The strain values for the right ventricle (RV) were 18.63?±?6.52 for RS, ??10.60?±?3.33 for CS, and ??25.06?±?3.01 for LS. In all 129 patients (male, n?=?105), all strain parameters of LV and RV was significantly different among males and females (all p values?<?0.05). The LV strain parameters were significantly associated with age by univariate linear regression analysis: RS, beta?=?0.219, p?=?0.002; CS, beta?=???0.668, p?=?0.014 (except for LS, beta?=???0.104, p?=?0.720). With regard to hypertension, diabetes mellitus and dyslipidemia, the values of all strain parameters in both ventricles were not significantly different between individuals with or without risk factors. Inter-observer agreement for three strain variables of LV and RV was 0.915 and 0.715 by iota index, and intra-observer agreement of LV and RV was 0.955 and 0.959 by iota index. The strain parameters by CMR-TT showed an association with age and significant difference in gender, on the other hands, not significantly different between with or without of the other conventional cardiovascular risk factors. The reproducibility of three LV strain parameters was higher than that of the respective RV strain parameters.     

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.     

Right ventricular function and mechanics in chemotherapy- and radiotherapy-naïve cancer patients

The present research evaluated right ventricular (RV) structure, function and mechanics in the cancer patients before initiation of chemo- or radiotherapy, and the association between cancer and decreased RV longitudinal strain. This retrospective investigation included 101 chemo- and radiotherapy-naïve patients with solid cancer and 38 age- and gender-matched controls with similar cardiovascular risk profile. Echocardiographic examination and strain evaluation was performed in all participants. RV structure and RV systolic and diastolic function estimated with conventional echocardiographic parameters were similar between the cancer patients and controls. However, RV global longitudinal strain (??22.7?±?2.6% vs. ??21.1?±?2.4%, p?<?0.001) was significantly decreased in the cancer patients than in controls. The same was revealed for RV free wall endocardial (??33.6?±?4.3% vs. ??31.4?±?4.0%, p?=?0.006) and mid-myocardial (??25.2?±?3.6% vs. ??23.7?±?3.8%, p?=?0.035) longitudinal RV strains, whereas difference was not found in RV free wall epicardial longitudinal strain. The presence of cancer was independently of age, gender, body mass index, left ventricular hypertrophy, diabetes, hypertension and pulmonary pressure associated with reduced RV global longitudinal strain (OR 3.79; 95% CI 2.18–10.92, p?<?0.001), as well as with decreased free wall RV longitudinal strain (OR 5.73; 95% CI 3.17–9.85, p?<?0.001). RV strain is deteriorated in the chemo- and radiotherapy-naïve cancer patients. Endocardial and mid-myocardial layers are more affected than epicardial strain in the cancer patients. The presence of cancer is independently of other clinical parameters associated with reduced RV longitudinal strain.     

Fibrosis assessment by integrated backscatter and its relationship with longitudinal deformation and diastolic function in heart failure with preserved ejection fraction

Myocardial reflectivity, as assessed by calibrated integrated backscatter (cIB) analysis, is a non-invasive surrogate for the amount of left ventricular (LV) fibrosis. The aim of this study was to assess the myocardial reflectivity pattern in patients with heart failure and preserved ejection fraction (HFpEF), and to evaluate its relationship with longitudinal systolic deformation of LV by 2D-speckle tracking echocardiography, and degree of diastolic dysfunction. Transthoracic echocardiography, myocardial Doppler-derived systolic (Sm) and early diastolic velocity (E′), global longitudinal strain (GLS), and tissue characterization by cIB, were obtained in 86 subjects, 46 with HFpEF, and 40 controls. GLS was significantly impaired in HFpEF patients (?15.4?±?3.5?% vs ?21.5?±?2.9?% in controls; P?<?0.0001). Increased myocardial reflectivity, as evidenced by less negative values of cIB, was also found in HFpEF compared to controls (?21.2?±?4.4 dB vs ?25.3?±?3.9 dB, P?<?0.0001). In HFpEF patients, myocardial reflectivity was positively related to GLS (r?=?0.68, P?<?0.0001), E/E′ ratio (r?=?0.38, P?=?0.009), and Tau (r?=?0.43, P?=?0.002), and inversely related to E′ velocity (r?=??0.46, P?=?0.0012). These associations remained significant after adjustment for age, preload and afterload indices. Patients with HFpEF show changes of LV structure consistent with enhanced fibrosis—as evidenced by increased myocardial reflectivity- which parallel the degree of diastolic dysfunction, and of longitudinal systolic dysfunction.     

Association between left ventricular mechanics and diffuse myocardial fibrosis in patients with repaired Tetralogy of Fallot: a cross-sectional study

Background

Patients with repaired tetralogy of Fallot (TOF) have progressive, adverse biventricular remodeling, leading to abnormal contractile mechanics. Defining the mechanisms underlying this dysfunction, such as diffuse myocardial fibrosis, may provide insights into poor long-term outcomes. We hypothesized that left ventricular (LV) diffuse fibrosis is related to impaired LV mechanics.

Methods

Patients with TOF were evaluated with cardiac magnetic resonance in which modified Look-Locker (MOLLI) T1-mapping and spiral cine Displacement encoding (DENSE) sequences were acquired at three LV short-axis positions. Linear mixed modeling was used to define the association between regional LV mechanics from DENSE based on regional T1-derived diffuse fibrosis measures, such as extracellular volume fraction (ECV).

Results

Forty patients (26?±?11 years) were included. LV ECV was generally within normal range (0.24?±?0.05). For LV mechanics, peak circumferential strains (?15?±?3%) and dyssynchrony indices (16?±?8 ms) were moderately impaired, while peak radial strains (29?±?8%) were generally normal. After adjusting for patient age, sex, and regional LV differences, ECV was associated with log-adjusted LV dyssynchrony index (β?=?0.67) and peak LV radial strain (β?=??0.36), but not LV circumferential strain. Moreover, post-contrast T1 was associated with log-adjusted LV diastolic circumferential strain rate (β?=?0.37).

Conclusions

We observed several moderate associations between measures of fibrosis and impaired mechanics, particularly the LV dyssynchrony index and peak radial strain. Diffuse fibrosis may therefore be a causal factor in some ventricular dysfunction in TOF.

     

Acute recoordination rather than functional hemodynamic improvement determines reverse remodelling by cardiac resynchronisation therapy

Purpose: Cardiac resynchronisation therapy (CRT) improves left ventricular (LV) function acutely, with further improvements and reverse remodelling during chronic CRT. The current study investigated the relation between acute improvement of LV systolic function, acute mechanical recoordination, and long-term reverse remodelling after CRT. Methods: In 35 patients, LV speckle tracking longitudinal strain, LV volumes & ejection fraction (LVEF) were assessed by echocardiography before, acutely within three days, and 6 months after CRT. A subgroup of 25 patients underwent invasive assessment of the maximal rate of LV pressure rise (dP/dt_max,) during CRT-implantation. The acute change in dP/dt_max, LVEF, systolic discoordination (internal stretch fraction [ISF] and LV systolic rebound stretch [SRSlv]) and systolic dyssynchrony (standard deviation of peak strain times [2DS-SD18]) was studied, and their association with long-term reverse remodelling were determined. Results: CRT induced acute and ongoing recoordination (ISF from 45?±?18 to 27?±?11 and 23?±?12%, p?<?0.001; SRS from 2.27?±?1.33 to 0.74?±?0.50 and 0.71?±?0.43%, p?<?0.001) and improved LV function (dP/dt_max 668?±?185 vs. 817?±?198 mmHg/s, p?<?0.001; stroke volume 46?±?15 vs. 54?±?20 and 52?±?16 ml; LVEF 19?±?7 vs. 23?±?8 and 27?±?10%, p?<?0.001). Acute recoordination related to reverse remodelling (r?=?0.601 and r?=?0.765 for ISF & SRSlv, respectively, p?<?0.001). Acute functional improvements of LV systolic function however, neither related to reverse remodelling nor to the extent of acute recoordination. Conclusion: Long-term reverse remodelling after CRT is likely determined by (acute) recoordination rather than by acute hemodynamic improvements. Discoordination may therefore be a more important CRT-substrate that can be assessed and, acutely restored.