Speckle Tracking Echocardiographic Assessment of Left Ventricular Function by Myocardial Strain Before and After Aortic Valve Replacement

Background & objectivesIn patients of aortic stenosis and regurgitation, pressure and volume effects on left ventricular function are occult and missed by routine echocardiography markers like ejection fraction (EF). Speckle tracking analysis by measuring global longitudinal strain and global circumferential strain seems to ascertain this occult LV function parameters at an early phase in a more comprehensive manner. Limited studies have examined these parameters pre/post aortic valve replacement (AVR).Methods94 consecutive patients with symptomatic severe aortic stenosis (AS) or aortic regurgitation (AR), planned for AVR were included (as per set inclusion criteria) along with 15 normal controls-15 months prospective study. Routine echocardiography and speckle tracking imaging was done at baseline (pre AVR) and post AVR at 1st week, 1st month and 3rd month of follow up.Results90 patients completed study (70 in AS and 20 in AR group). In AS group mean values (± 2 standard deviations) of global longitudinal strain (GLS) improved from a baseline −10.9% (± 3.9) to −19.4% (±3.8) at 3rd month (p value < 0.0001). Mean values of global circumferential strain (GCS) too improved from −17.3% (±4.5) to −21.4% (±3.6) respectively (p value < 0.0001). In AR group too mean values of global longitudinal strain progressed from a baseline −12.6% (±3.9) to −19.4% (±3.4) at three months of follow (p value < 0.0001) and mean values of global circumferential strain also progressed from −15.3% (±3.4) at baseline to −21.7% (±3.1) respectively (p value < 0.0001).ConclusionMagnitude of recovery of GLS and GCS after AVR was more as compared to recovery in EF. Poor GLS/GCS values at baseline were associated with lesser recovery pressing need for an earlier intervention.     

Value of global longitudinal strain by two dimensional speckle tracking echocardiography in predicting coronary artery disease severity

Background

Significant coronary artery stenosis might cause persistently impaired longitudinal left ventricle (LV) function at rest. LV global longitudinal strain (LVGLS) can be accurately assessed by 2D speckle-tracking strain echocardiography(2D-STE).

Incremental Value of Three-dimensional Speckle-tracking Echocardiography for Evaluating Left Ventricular Systolic Function in Patients with Coronary Slow Flow

The purpose was to evaluate left ventricular (LV) systolic function in patients with coronary slow flow (CSF), and compared the incremental values of 3-dimensional (3D) speckle-tracking echocardiography (STE). Seventy-three patients with CSF and 60 control subjects were enrolled. CSF was diagnosed during coronary angiography. Two-dimensional (2D) and 3D global strain were measured using STE. Sex, mitral E, 2D GLS, and all 3D strain parameters were independent predictors of CSF. Combination of sex, mitral E, and 3D GTS had the highest area under the curve (AUC) for identifying CSF (AUC, 0.81; P < 0.001). Integrated discrimination index (IDI) improved adding 3D GTS to the combined sex and mitral E model (IDI = 0.12, P = 0.01) or 2D GLS model (IDI = 0.14, P < 0.001). LV systolic function was impaired in CSF patients. 3D GTS had an independent and incremental value for predicting CSF compared with 2D echocardiography.     

Association between left ventricular perfusion defects and myocardial deformation indexes in heart transplantation recipients

The aim of the study was to analyze possible correlations between strain echocardiography (STE) and PET myocardial perfusion in a population of heart transplantation (HTx) recipients showing preserved left ventricular (LV) ejection fraction. By STE, LV global longitudinal strain (LV GLS) was lower in HTx. PET showed no transient or chronic ischemia in 83 of 115 HTx (73%). Fixed perfusion defects were observed in 17% of HTx and reversible ischemia in 10%. Significant coronary stenosis was observed only in 10 cases. GLS was independently associated with age at HTx and fixed perfusion defects (HR 0.41; P<.001). Such relationships underline STE ability to early identify HTx pts with subclinical myocardial dysfunction during long‐term follow‐up.     

Comparison of two-dimensional speckle and tissue Doppler strain measurement during dobutamine stress echocardiography: an angiographic correlation.

AIMS: Two-dimensional (2D)-strain derived from speckle-tracking is an alternative to tissue velocity imaging (TVI)-based strain. We compared their feasibility and accuracy in 150 patients undergoing dobutamine stress echocardiography (DSE) and coronary angiography. METHODS AND RESULTS: 2D- and TVI-strain were obtained in three apical views at rest and peak stress. Peak systolic strain rate (SR), endsystolic strain (epsilon(end-sys)), and peak strain (epsilon(peak)) were measured off-line at rest and peak stress, and results were compared with wall motion analysis and significant coronary artery disease (CAD > or = 70% diameter stenosis). Optimal cut-offs were derived from receiver operating characteristic (ROC) curves for sentinel segments. The most feasible method was 2D-strain at rest, and TVI-strain at peak stress. The average peak SR and epsilon(end-sys) at peak stress in segments of patients with significant CAD was less than in segments of patients without CAD (P < 0.0001) and mean PSI at peak stress was higher (P < 0.0001) with both 2D- and TVI-strain. Peak systolic SR at peak stress had the best area under the ROC for both 2D- (AUC 0.67) and TVI-strain (AUC 0.71) for the diagnosis of CAD. The accuracy of WMS (75%) for diagnosis of CAD per patient was similar to 2D-SR (69%) and TVI-SR (74%). The accuracy of 2D-SR and TVI-SR at peak stress was 78 vs. 79% (P = NS) for LAD, 67 vs. 73% (P = NS) for LCX, and 59 vs. 74% (P = 0.008) for RCA disease. CONCLUSION: Measurement of speckle tracking strain during DSE is feasible and similar in accuracy to TVI-strain in the anterior, but not in the posterior circulation.     

Diagnostic value of dobutamine stress Doppler tissue imaging in diabetic patients with suspected coronary artery disease

BackgroundCoronary artery disease (CAD) is often silent in diabetic patients, and it is typically in advanced stages of development by the time it manifests. Various forms of stress testing have been investigated to detect obstructive CAD in diabetes mellitus.ObjectivesTo assess the diagnostic value of dobutamine stress pulsed-wave Doppler tissue imaging (DTI) compared with standard wall motion analysis in detection of myocardial ischemia in diabetic patients with suspected CAD.MethodsThe study comprised 46 diabetic patients with suspected CAD who underwent dobutamine stress echocardiography (DSE) with DTI within 4 weeks before coronary angiography (CA). Dobutamine infusion started at 5 μ/kg/min and increased up to 40 μ/kg/min with additional atropine during submaximal heart rate responses. In addition to wall-motion score index (WMSI) analysis, pulsed-wave DTI examination of basal and mid segments of posteroseptal, lateral, anterior, inferior and anteroseptal walls was performed. Myocardial velocities were measured at rest in the apical 4, 3 and 2-chamber views. The measurements were repeated at low dose (10–15 μ/kg/min) and at peak stress (40 μ/kg/min). DTI measurements included peak systolic velocity (S), peak early diastolic velocity (E) and peak late diastolic velocity (A) and the results were compared to WMSI analysis. Patients were classified into two groups according to CA results; group (I) diabetics with positive CA (n = 27) and group (II) diabetics with negative CA (n = 19).ResultsThere was no significant difference between the two groups in duration of diabetes, global WMSI at rest or the Δ changes (stress-rest/rest) of WMSI (p > .05). Global S and global E were significantly lower in group I compared to group II at peak stress (11.3 ± 3.7 cm/s vs. 14.5 ± 2.2 cm/s, p < 0.01) and (11.3 ± 1.6 cm/s vs. 13.1 ± 2.1 cm/s, p < 0.01) respectively. The cutoff points for global S and global E to detect obstructive CAD in diabetics were 11.3 cm/s and 11.2 cm/s respectively with 75.7%, 73.4% sensitivity and 94.7%, 89.47% specificity respectively. An increment (Δ changes) less than 0.56 in S or 0.26 in E from rest to peak stress identified CAD with 78.8%, 89.3% sensitivity and 94.7%, 90.7% specificity respectively. The accuracy of DTI parameters during peak stress was higher than WMSI analysis (sensitivity 74.1% vs. 59.3% and specificity 90% vs. 79%, p < 0.01 for each). In multivariate regression analysis, only ΔS and ΔE were independent predictors of obstructive CAD in diabetics (odd ratio: 36.16, 95% CI, 1.34–532.01 and 63.77, 95% CI, 3.19–721.47) respectively.ConclusionQuantitative analysis, using DTI during DSE, adds new dimension in diagnosis of myocardial ischemia. It is more sensitive, specific, accurate and reproducible compared with standard wall motion analysis for recognition of significant CAD in diabetic patients.     

Speckle tracking echocardiography in patients with systemic lupus erythematosus: A meta-analysis

BackgroundSystemic lupus erythematosus (SLE), is characterized by a systemic involvement including myocardial dysfunction. Being standard echocardiography not able at fully detecting subclinical alterations, speckle tracking echocardiography (STE) has recently emerged as a quantitative ultrasound technique to accurately estimate myocardial function.MethodsWe conducted a systematic review with meta-analysis of studies reporting STE parameters in patients with SLE.ResultsA total of 9 studies were included in the analysis. Left ventricle global longitudinal strain (GLS) was significantly lower in SLE patients than in non-SLE controls (MD: −2.331, 95% CI: −3.083, −1.580, p < 0.001). In addition, we found significant differences between SLE patients and non-SLE controls in left ventricle GLS rate (MD: −0.115, 95% CI: −0.177 to 0.063, p < 0.001), left ventricle circumferential strain(MD: −1.841, 95% CI: −3.160 to 0.521, p = 0.006) and left ventricle radial strain(MD: −11.03, 95% CI: −13.819 to 8.241, p < 0.001). Right ventricle strain was significantly lower in SLE patients than in non-SLE controls (MD: −5.814, 95% CI: −7.347, −4.281, p < 0.001). Meta-regression models showed a lower difference in left ventricle GLS between SLE cases and controls for studies with a higher prevalence of female gender and higher prevalence of hypertension.ConclusionsSLE patients have lower STE parameters than controls, thus suggesting the presence of an impaired myocardial function involving both left and right ventricle.     

Role of dobutamine-atropine stress echocardiography in prognostic evaluation of 300 women

BACKGROUND: Dobutamine-atropine stress echocardiography (DASE) is a safe and accurate method to diagnose coronary artery disease (CAD), and can identify individuals at high risk for cardiac events such as myocardial infarction and cardiac-related death. The literature is limited regarding the prognostic value of DASE in women. OBJECTIVE: The objective was to determine the prognostic value of DASE in 300 women with known or suspected CAD. RESULTS: The 300 women underwent DASE and were followed up for 65 months (mean: 27 months). Ninety-five women had positive tests and 205 had negative tests. We demonstrated that women with negative tests had a 94% hard-event-free survival rate at follow-up (myocardial infarction and death), and in those with positive tests the event-free survival rate was 27% (P = 0.0003). The difference between women with positive and negative tests was also significant when minor events and total events were considered. Women with positive tests had 16.7 times more chance of having events than women with negative tests. Furthermore, women with positive tests but without cardiac events at follow-up (mean of peak WMSI - rest WMSI = 0.24 +/- 0.16) had less ischemic myocardium than women with positive tests and cardiac events at follow-up (mean of peak WMSI - rest WMSI = 0.34 +/- 0.26)(P < 0.04). CONCLUSION: Dobutamine-atropine stress echocardiography has good prognostic value for cardiac events in women. Women with negative tests have low probability for follow-up infarction or death. Women with positive tests and higher severity of induced ischemia have the highest incidence of cardiac events.     

Subclinical left ventricular dysfunction during systemic lupus erythematosus activity with follow-up after remission – A speckle tracking echocardiographic study

Aim of the workTo investigate the subclinical left ventricular (LV) dysfunction in patients with active systemic lupus erythematosus (SLE) using speckle tracking echocardiography (STE). The echocardiographic parameters were followed up when the disease activity was controlled.Patients and methodsThis prospective study included 63 patients with active SLE and LV ejection fraction (EF) ≥50%.Safety of Estrogens in Lupus Erythematosus: National Assessment – Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) was assessed and categorized as mild/moderate (≤12) or severe (>12). Fifty SLE patients continued follow-up after 3–6 months of the disease remission. Fifty age- and gender-matched healthy individuals acted as the control group. The measured STE parameters included LV deformation (global longitudinal strain [GLS] and global circumferential strain [GCS]) and rotational parameters (rotation, twist, and torsion).ResultsThe patients were 56 females and 7 males (F:M 8:1) and median age 26 years (IQR: 21–31 years) and a disease duration of 3 years (IQR 2–5 years. Active SLE patients showed worse strain parameters than controls (mean GLS ?19.9%±2.1 vs ?22.7%±1.3 and mean GCS ?21.2 ± 2.5% vs ?25.1 ± 1.7% respectively; p < 0.001 for both). Patients had lower LV rotational parameters (p < 0.001 for all). STE parameters were similar in patients with mild-moderate and severe activity and improved after remission in both groups.ConclusionActive SLE patients had modest LV dysfunction by STE despite having normal function by traditional echocardiography. Disease remission resulted in the improvement of STE parameters. STE is a simple tool to use in SLE activity scores to detect early cardiac dysfunction.     

Myocardial Deformation in the Systemic Right Ventricle: Strain Imaging Improves Prediction of the Failing Heart

BackgroundPredicting heart failure events in patients with a systemic right ventricle (sRV) due to transposition of the great arteries (TGA) is important for timely intensification of follow-up. This study assessed the value of strain compared with currently used parameters as predictor for heart failure–free survival in patients with sRV.MethodsIn participants of a multicentre trial, speckle-tracking echocardiography (STE) was performed to assess global longitudinal strain (GLS), mechanical dispersion (MD), and postsystolic shortening (PSS). Cox regression was used to determine the association of STE parameters with the combined end point of progression of heart failure and death, compared with cardiovascular magnetic resonance (CMR) and computed tomography (CT) derived parameters.ResultsEchocardiograms of 60 patients were analyzed (mean age 34 ± 11 years, 65% male, 35% congenitally corrected TGA). Mean GLS was −13.5 ± 2.9%, median MD was 49 (interquartile range [IQR] 30-76) ms, and 14 patients (23%) had PSS. During a median 8 (IQR 7-9) years, 15 patients (25%) met the end point. GLS, MD, and PSS were all associated with heart failure–free survival in univariable analysis. After correction for age, only GLS (optimal cutoff > −10.5%) and CMR/CT-derived sRV ejection fraction (optimal cutoff < 30%) remained associated with heart failure–free survival: hazard ratio (HR) 8.27, 95% confidence interval (CI) 2.50-27.41 (P < 0.001), and HR 4.34, 95% CI 1.48-12.74 (P = 0.007), respectively). Combining GLS and ejection fraction improved prediction, with patients with both GLS > −10.5% and sRV ejection fraction < 30% at highest risk (HR 19.69, 95% CI 4.90-79.13; P < 0.001).ConclusionsThe predictive value of GLS was similar to that of CMR/CT-derived ejection fraction. The combination of GLS and ejection fraction identified patients at highest risk of heart failure and death. Easily available STE parameters can be used to guide follow-up intensity and can be integrated into future risk prediction scores.     

The effect of type 2 diabetes mellitus on multiple obstructive coronary artery disease

Background

Although type 2 diabetes mellitus (T2DM) individuals easily develop three-vessel disease (3VD) coronary artery disease (CAD), there is very little information available about their left ventricle (LV) functions. The purpose of this study is to evaluate the LV function using two-dimensional speckle tracking echocardiography (2-D STE) in T2DM patients with 3VD.

Methods

One hundred and three consecutive patients with confirmed 3VD CAD were enrolled and divided into two groups, while 53 patients with DM and 50 patients without. The control group was composed of 30 age- and sex-matched healthy individuals. All patients underwent 2-D STE and standard echocardiograms. The durations of DM and the level of HbA1c were also recorded.

Result

Between the 3VD-DM and 3VD-non-DM groups, normal echocardiography did not reveal any appreciable differences. However, patients with 3VD-DM had significantly lower global longitudinal strain (GLS) than those with 3VD-non-DM (15.87 ± 2.51 vs.17.56 ± 2.72, p < .05) by 2-D STE strain measurement. Besides, patients whose duration of DM excess 5 years showed significant lower GLS than those with less than 5 years duration (14.25 ± 2.31 vs. 16.65 ± 1.96, p = .007). However, there was no difference in GLS between the 3VD-DM patients with HbA1c ≥ 7% and HbA1c < 7%.

Conclusions

Compared to patients with 3VD alone, those with 3VD-DM have a lower cardiac function. In 3VD-DM patients, the duration of DM is a significant factor that contributes to cardiac function deterioration, whereas, the glucose control state has limited influence.     

Tissue tracking of segmental strain as a predictor of provoked dynamic left ventricular outflow tract obstruction

BackgroundLeft ventricular outflow tract obstruction (LVOTO) is commonly observed in patients with hypertrophic cardiomyopathy (HCM) or left ventricular hypertrophy (LVH). Some patients develop LVOTO provoked by physical exertion, and hence termed dynamic LVOTO (DLVOTO). However, its precise prevalence and mechanism are still unclear.AimTwo-dimensional speckle tracking echocardiography (2D STE) seems to be helpful for the detection of early LV structural abnormalities. This study aimed to examine the possible role of segmental as well as global longitudinal strain in identifying DLVOTO non-HCM patients as detected by dobutamine stress echocardiography (DSE).Methods and resultsTwo hundred and fifty patients without structural heart disease had undergone conventional transthoracic echocardiography, 2D STE, and DSE. All patients with non-ischemic evidence were divided into two groups according to the DSE results; DLVOTO (+) and DLVOTO (?).Among 250 patients, 50 patients (36%) had shown DLVOTO after DSE (15 males, 35 females; mean age 55±7years). They were compared with 90 non -LVOTO obstruction patients (43 males, 47 females; mean age 57±6years). Based on multivariate logistic regression analysis, the independent predictors of provoked DLVOTO during DSE were resting basal septal longitudinal strain BS-LS _average (p < 0.001), resting LA reservoir strain (p < 0.001), and systolic LVOT diameter (p = 0.03). Resting BS-LS _average with cut-off - 17.5% was recognized as a critical indicator of DLVOTO, with sensitivity 78%, and specificity 95% (better than systolic LVOT diameter of sensitivity 76%, and specificity 15% and resting LA reservoir strain which showed poor AUC at ROC curve 0.007).ConclusionWe demonstrate that provoked LVOTO during DSE in non HCM symptomatic patients is directly correlated to resting regional LS, where the increased BS-LS of ≥ ?17.5% was a key determinant of LVOT gradient provocation. Assessment of baseline BS-LS _average might be a bedside simple tool for detection of patients with DLVOTO not able to do DSE.     

The correlation between speckle tracking echocardiography and coronary artery disease in patients with suspected stable angina pectoris

BackgroundTo examine the value of speckle tracking echocardiography to detect the presence, extent and severity of coronary artery affection in patients with suspected stable angina pectoris.MethodsTwo hundred candidates with suspected stable angina pectoris and normal resting conventional echocardiography were subjected to speckle tracking echocardiography and coronary angiography. Global and segmental longitudinal peak systolic strain were assessed and were correlated to the results of coronary angiography for each patient.ResultsThere was a statistically significant difference in the mean of global longitudinal peak systolic strain between normal coronaries and different degrees of coronary artery disease (CAD) (−20.11 ± 0.8 for normal, −18.34 ± 2.52 for single vessel, −16.14 ± 2.85 for two vessels, −14.81 ± 2.12 for three vessels, −13.01 ± 2.92 for left main disease). GLPSS showed high sensitivity for the diagnosis of single vessel CAD (90%, specificity 95.1%, cutoff value: −18.44, AUC: 0.954); two vessels disease (90%, sensitivity 88.9%, cutoff value −17.35, AUC: 0.906) and for three vessels CAD (cutoff value −15.33, sensitivity 63% and specificity 72.2% AUC 0.681) segmental LPSS also showed statistical significance for localization of the affected vessel for left anterior descending, left circumflex and right coronary artery (ρ = 0.001) and inverse correlation with syntax score that was significant with high and intermediate score (ρ = 0.001) and insignificant for low syntax score (ρ value 0.05).ConclusionTwo-dimensional speckle tracking echocardiography has good sensitivity and specificity to predict the presence, extent and severity of CAD.     

Left Ventricular Longitudinal Strain by Speckle-Tracking Echocardiography is Associated With Treatment-Requiring Cardiac Allograft Rejection

BackgroundNoninvasive detection of rejection is a major objective in the management of heart transplant recipients.Methods and ResultsTo investigate the utility of 2-dimensional speckle-tracking echocardiography (2D-STE), we retrospectively evaluated 160 sets of endomyocardial biopsies and echocardiograms from 59 asymptomatic heart transplant recipients. Conventional International Society for Heart and Lung Transplantation grade 1B or higher rejection was considered as treatment-requiring rejection (group R), whereas International Society for Heart and Lung Transplantation grade 0 or 1A was classified as group Non-R. Left ventricular global longitudinal strain (GLS), global circumferential strain, and global radial strain were assessed by 2D-STE. Twenty-five specimens were classified into group R. GLS was significantly associated with treatment-requiring rejection, whereas neither global radial strain nor global circumferential strain were. Lower GLS remained significantly associated with an increased risk of treatment-requiring rejection (odds ratio, 1.15 [95% CI, 1.01-1.30]; P=0.03) even in multivariate analysis. GLS with the absolute value of less than 14.8% showed sensitivity and specificity of 64% and 63%, respectively, for detection of treatment-requiring rejection.ConclusionThe 2D-STE–derived left ventricular GLS was associated with treatment-requiring rejection. Two-dimensional STE might be useful as a noninvasive supplemental tool for monitoring heart transplant recipients for possible treatment-requiring rejection.     

Right ventricular contractility decreases during exercise in patients with non-advanced idiopathic pulmonary fibrosis

Early right ventricular dysfunction in patients with non-advanced idiopathic pulmonary fibrosis (IPF) has not been fully elucidated. Thus, we aimed to assess right ventricular functions in IPF patients and controls by speckle-tracking strain echocardiography at rest and peak exercise.We screened 116 IPF patients from February to August 2019 to include 20 patients with no history of oxygen therapy, peripheral saturation levels ≥92% at rest, Gender-Age-Physiology Index score ≤5, and modified Medical Research Council score ≤3. Additionally, we enrolled 10 matched controls. Transthoracic echocardiography images were acquired at rest and during a cardiopulmonary exercise test. We analyzed 2-dimensional echocardiographic parameters and right ventricular function using the global longitudinal strain assessed by the 2-dimensional speckle-tracking technique.In the control group, we found normal values of right ventricle longitudinal strain (RVLS) at rest and at peak exercise, the latter being much more negative (−23.6 ± 2.2% and −26.8 ± 3.1%, respectively; P < .001). By contrast, RVLS values in the IPF group increased from −21.1 ± 3.8% at rest to −17.0 ± 4.5% at peak exercise (P < .001). The exercise revealed a difference between the 2 groups as the mean RVLS values moved during peak exercise in opposite directions. Patients with IPF got worse, whereas control patients presented improved right ventricular contractility.Right ventricular dysfunction was unveiled by speckle-tracking echocardiography during exercise in non-advanced IPF patients. We suggest that this reflects an inadequate right ventricular-arterial coupling decreasing the right ventricular longitudinal contraction during exercise in these patients. This parameter may be useful as an early index of suspected pulmonary hypertension.     

Myocardial strain analysis by 4D-speckle tracking echocardiography for prediction of coronary artery disease severity in patients with stable angina pectoris

ObjectiveWe sought to evaluate the myocardial strain by four-dimensional speckle-tracking echocardiography (4D-STE) in patients with stable angina pectoris (SAP) to determine the severity of coronary artery disease (CAD) based on the Gensini score.MethodsThe present study comprised of 150 patients with SAP. Patients with history of SAP, normal left ventricular ejection fraction, and without regional wall motion abnormalities (RWMA) were scheduled for elective coronary angiography. Based on Gensini score, there were two groups: non-critical stenosis group [Gensini score (0–19), n = 117] and critical stenosis group [Gensini score ≥20, n = 33]. Correlation between Gensini score and 4D-STE strain parameters were investigated.ResultsOut of 150 patients, critical stenosis group had significantly depressed values of all 4D-STE strain parameters than non-critical stenosis group (p < 0.001), except global radial strain (GRS) parameter. Significant positive correlation was found between Gensini score and 4D global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS) with Spearman's correlation coefficient (ρ) as 0.626, 0.548, and 0.631, respectively (p < 0.001), whereas significant negative correlation was found between Gensini score and GRS (ρ = −0.433, p < 0.001). A 4D GLS value of ≥ −17 had 84.9% sensitivity and 97.4% specificity, GAS ≥ −31 (90.9% sensitivity, 78.6% specificity), GCS ≥ −17 (69.7% sensitivity, 92.3% specificity), and GRS <47 (sensitivity 72.7%, specificity 76.1%) to detect critical CAD described by Gensini score ≥20.ConclusionThe 4D-STE can aid in the assessment of severe CAD stenosis with good sensitivity and specificity in the patients with SAP without RWMA on traditional echocardiography.     

Prognostic Significance of Left Ventricular Dyssynchrony Assessed with Nuclear Cardiology for the Prediction of Major Cardiac Events after Revascularization

Objective This retrospective study was aimed at determining whether or not stress phase bandwidth (SPBW), a left ventricular (LV) mechanical dyssynchrony index, predicts major cardiac events (MCEs) and stratifies the risk of those in patients with coronary artery disease (CAD) who undergo revascularization. Methods Patients were followed up to confirm the prognosis for at least one year. The SPBW was calculated by a phase analysis using the Heart Risk View-F software program. The composite endpoint was the onset of MCEs, consisting of cardiac death, non-fatal myocardial infarction, unstable angina pectoris, and severe heart failure requiring hospitalization. Patients The study subjects were 332 patients with CAD who underwent coronary angiography and revascularization after confirming ≥5% ischemia detected by rest ²⁰¹Tl and stress ^99mTc-tetrofosmin electrocardiogram-gated single-photon emission computed tomography myocardial perfusion imaging. Results During the follow-up, 35 patients experienced MCEs of cardiac death (n=5), non-fatal myocardial infarction (n=3), unstable angina pectoris (n=11), and severe heart failure requiring hospitalization (n=16). A receiver operating characteristics analysis indicated that the optimal cut-off value of the SPBW was 52° for predicting MCEs, and the MCE rate was significantly higher in the patients with an SPBW >52° than in those with an SPBW ≤52°. Results of the multivariate analysis showed the SPBW and estimated glomerular filtration rate to be independent predictors for MCEs. In addition, the cut-off value of the SPBW significantly stratified the risk of MCEs according to the results of the Kaplan-Meier analysis. Conclusion Evaluating the SPBW before revascularization may help predict future MCEs in patients with CAD who intended to undergo treatment.     

Predicting Cardiotoxic Effects of Carbon Monoxide Poisoning Using Speckle Tracking Echocardiography

Carbon monoxide (CO) poisoning could cause significant cardiac injury. This study aimed to evaluate patients with CO poisoning by using speckle tracking echocardiography (STE), a potentially more sensitive technique, to identify left systolic ventricular dysfunction for the first time in the literature. Seventy-two patients who were exposed to CO poisoning were studied. Blood collection and echocardiography were performed at admission and after patients’ discharge on days 10–15 (mean 12 days). Global longitudinal strain (GLS) and global circumferential strain (GCS) were calculated using STE. In order to find the normal strain levels and to compare it to the patient with CO poisoning, 35 healthy subjects were included in the study. Left ventricular ejection fraction was analyzed according to Simpson’s method. Patients were divided into two groups based on their LVEF values. LVEF < 55%, Group 1 (n = 24); LVEF ≥ 55%, Group 2 (n = 48). The reduction in Group 1 strain levels decreased in correlation with LVEF (p < 0.001) while in Group 2, there were no significant changes in LVEF but strain levels were significantly reduced (p = 0.091; p < 0.001). Compared with the control group patients, admission GLS and GLC values of CO-poisoned patients were significantly low both in Group 1 and 2. On the contrary, no significant difference was observed when compared with follow-up GLS value. For prediction of CO cardiotoxicity, the cutoff value of GLS was ≥ ? 19.1 with a sensitivity of 70.3% and a specificity of 100% [(AUC) 0.840, 95% (CI) 0.735?0.916; p < 0.001] in the ROC curve analyses. GLS was found as independent predictors of cardiotoxicity. Our study demonstrates the potential of using systolic strain values obtained using 2D-STE in determining cardiotoxicity due to CO poisoning. Speckle tracking echocardiography has the potential of demonstrating subtle LV systolic dysfunction even in CO poisoning patients with preserved EF.     

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

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

The predictive value of global longitudinal strain in patients with heart failure mid-range ejection fraction

BackgroundHeart failure (HF) with mid-range ejection fraction (HFmrEF) is defined as HF with a left ventricular (LV) ejection fraction (LVEF) of 41–49%. However, the change in LV function and the subsequent prognosis in these patients remain unclear. We aimed to investigate whether LV global longitudinal strain (LV GLS) could differentiate the changes in LVEF and predict the clinical outcomes in patients with HFmrEF.MethodsAccording to the changes in LVEF on follow-up echocardiography, 273 outpatients with HFmrEF were divided into 3 groups: HFwEF (HF with worse EF: <40%), HFsEF (HF with similar EF: 40–49%), and HFrecEF (HF with recovered EF: >50%). Further, the LV GLS at diagnosis was evaluated.ResultsThe average follow-up duration was 31 months. Among patients with HFmrEF, the more impaired the LV GLS at baseline, the higher probability of HFwEF development. In comparison with patients with HFwEF and HFsEF, those with HFrecEF had a lower risk of hospitalization for HF. At a cut-off value of ?11%, LV GLS differentiated the subsequent risk of cardiovascular death in patients with HFmrEF. In Cox regression, patients with LV GLS >?11% had a high risk of cardiovascular death.ConclusionIn patients with HFmrEF, LV GLS is associated with LVEF changes and subsequent cardiovascular death. Patients with HFrecEF had a lower risk of hospitalization for HF.