Multidirectional global left ventricular systolic function in normal subjects and patients with hypertension: multicenter evaluation

Prognostic value of cardiac magnetic resonance imaging feature tracking technology in patients with light chain amyloidosis

AIM

To undertake a meta-analysis of the prognostic value of cardiac magnetic resonance imaging feature tracking (CMR-FT) in patients with light-chain cardiac amyloidosis (LCA).

MATERIALS AND METHODS

A systematic search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane Library. All analyses were conducted using RevMan 5.3 software.

RESULTS

Eight studies were included with 663 patients. For the left ventricle, the results showed that CMR-FT was statistically significant in predicting death, with less impaired global circumferential (GCS), radial (GRS) and longitudinal (GLS) strain in survivors of LCA (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.09-1.25; 0.95, 0.93-0.96; 1.12, 1.05-1.20, all p<0.001). For ejection fraction (EF) and mass index, surviving patients had higher EFs and mass index (OR 0.96, 95% CI 0.96-0.97; 1.01, 1.01-1.02). For the right ventricle, the results showed that CMR-FT was statistically significant in predicting death, with less impaired GLS and GRS in survivors of LCA (OR 1.11, 95% CI 1.08-1.15; 0.93, 0.90-0.96, all p<0.001). Surviving patients had higher EFs (OR 0.97, 95% CI 0.96-0.98, p<0.001). Upon removing the studies one by one, there was no significant change in the results of the study. Both analyses showed no apparent publication deviation on funnel plots.

CONCLUSION

Parameters derived from CMR-FT technology are promising new predictors for LCA, and are easily available and reliable. Patients with poor myocardial deformability are at highest risk of death.

Weakly supervised video-based cardiac detection for hypertensive cardiomyopathy

INTRODUCTION

Parameters, such as left ventricular ejection fraction, peak strain dispersion, global longitudinal strain, etc. are influential and clinically interpretable for detection of cardiac disease, while manual detection requires laborious steps and expertise. In this study, we evaluated a video-based deep learning method that merely depends on echocardiographic videos from four apical chamber views of hypertensive cardiomyopathy detection.

METHODS

One hundred eighty-five hypertensive cardiomyopathy (HTCM) patients and 112 healthy normal controls (N) were enrolled in this diagnostic study. We collected 297 de-identified subjects' echo videos for training and testing of an end-to-end video-based pipeline of snippet proposal, snippet feature extraction by a three-dimensional (3-D) convolutional neural network (CNN), a weakly-supervised temporally correlated feature ensemble, and a final classification module. The snippet proposal step requires a preliminarily trained end-systole and end-diastole timing detection model to produce snippets that begin at end-diastole, and involve contraction and dilatation for a complete cardiac cycle. A domain adversarial neural network was introduced to systematically address the appearance variability of echo videos in terms of noise, blur, transducer depth, contrast, etc. to improve the generalization of deep learning algorithms. In contrast to previous image-based cardiac disease detection architectures, video-based approaches integrate spatial and temporal information better with a more powerful 3D convolutional operator.

RESULTS

Our proposed model achieved accuracy (ACC) of 92%, area under receiver operating characteristic (ROC) curve (AUC) of 0.90, sensitivity(SEN) of 97%, and specificity (SPE) of 84% with respect to subjects for hypertensive cardiomyopathy detection in the test data set, and outperformed the corresponding 3D CNN (vanilla I3D: ACC (0.90), AUC (0.89), SEN (0.94), and SPE (0.84)). On the whole, the video-based methods remarkably appeared superior to the image-based methods, while few evaluation metrics of image-based methods exhibited to be more compelling (sensitivity of 93% and negative predictive value of 100% for the image-based methods (ES/ED and random)).

CONCLUSION

The results supported the possibility of using end-to-end video-based deep learning method for the automated diagnosis of hypertensive cardiomyopathy in the field of echocardiography to augment and assist clinicians.

TRIAL REGISTRATION

Current Controlled Trials ChiCTR1900025325, Aug, 24, 2019. Retrospectively registered.

Abnormal left ventricular systolic reserve function detected by treadmill exercise stress echocardiography in asymptomatic type 2 diabetes

Aims

Subclinical left ventricular (LV) dysfunction may occur in T2DM patients at the early asymptomatic stage, and LV reserve function is a sensitive index to detect subtle LV dysfunction. The purpose of our study is (1) to assess the LV reserve function using treadmill exercise stress echocardiography (ESE) in asymptomatic type 2 diabetes mellitus (T2DM) patients; (2) to explore the link of serum biological parameters and LV reserve function.

Methods

This study included 84 patients with asymptomatic T2DM from September 2021 to July 2022 and 41 sex- and age-matched healthy controls during the corresponding period. All subjects completed treadmill ESE, LV systolic function-related parameters such as global longitudinal strain (GLS) and systolic strain rate (SRs), as well as diastolic function-related parameters such as E wave (E), early diastolic velocity (e'), E/e' ratio, early diastolic SR (SRe), and late diastolic SR (SRa) were compared at rest and immediately after exercise. The difference between LV functional parameters after treadmill exercise and its corresponding resting value was used to compute LV reserve function. In addition, the associations of LV reserve function and serum biological parameters were analyzed.

Results

Patients with T2DM did not significantly vary from the controls in terms of alterations in LV diastolic reserve measures, the changes of LVGLS and SRs (ΔGLS: 2.19 ± 2.72% vs. 4.13 ± 2.79%, P < 0.001 and ΔSRs:0.78 ± 0.33 s-1 vs. 1.02 ± 0.28 s-1, P < 0.001) in the T2DM group were both lower than those in the control group. Glycated hemoglobin (HbA1c), N-terminal pro-brain natriuretic peptide (NTproBNP), waist circumference, and high-sensitive C-reactive protein (hsCRP) were identified as independent predictors of LV systolic reserve by stepwise multiple linear regression analysis.

Conclusion

LV systolic reserve function, as measured by pre- and post-exercise differences in GLS and SRs were significantly impaired in patients with asymptomatic T2DM, whereas diastolic reserve remained normal during exercise and was comparable to that of the control group. This was different from previous findings. High levels of HbA1c, NTproBNP, hsCRP, and increasing waist circumference were independent predictors of LV systolic reserve.

Potential Prognostic Relevance of Left-Ventricular Global Longitudinal Strain and of the Summation of the Mitral and Tricuspid Regurgitation Volume in Patients with Non-Ischemic Dilated Cardiomyopathy

BACKGROUND

The aim of this pilot study was to determine the potential prognostic relevance of novel multidirectional myocardial and volumetric echocardiographic parameters in patients with non-ischemic dilated cardiomyopathy (NIDCM).

METHODS

Multidirectional myocardial parameters (longitudinal, radial, and circumferential left-ventricular (LV) strain using speckle tracking echocardiography) and a new volumetric parameter (the sum of the mitral and tricuspid regurgitation volume (mitral-tricuspid regurgitation volume) were assessed. The cardiovascular (CV) outcome was a composite of cardiac death and hospitalization for heart failure (HF) at 1 year.

RESULTS

Approximately 102 patients were included in this pilot study. The mean LV ejection fraction (LVEF) was 28.4 ± 8.9%. During a follow-up of 1 year, the CV outcome occurred in 39 patients (10 HF deaths, and 36 hospitalizations for HF). The LV global longitudinal systolic strain (GLS) and mitral-tricuspid regurgitation volume were the main parameters that were seen to be significantly altered in the comparison of patients with events vs. those without events (GLS (absolute values) 7.4 ± 2.7% vs. 10.3 ± 2.6%; mitral-tricuspid regurgitation volume 61.1 ± 20.4 mL vs. 40.9 ± 22.9 mL, respectively; p-value < 0.01). In line with these findings, in a multivariate continuous logistic regression analysis, the GLS and mitral-tricuspid regurgitation volume were the main parameters associated with worse CV outcomes (GLS: OR 0.77 (95%CI 0.65-0.92); mitral-tricuspid regurgitation volume OR 1.09 (95%CI 1.01-1.25)), whereas the radial and circumferential LV global strain and mitral regurgitation volume and tricuspid regurgitation volume were not linked to the CV outcome. Furthermore, in a receiver operating characteristic curve analysis, a GLS cutoff of <7.5% and mitral-tricuspid regurgitation volume > 60 mL were the identified values for the parameters associated with worse CV outcomes.

CONCLUSIONS

The findings of this pilot study suggest that the GLS and a novel volumetric parameter (the sum of the mitral and tricuspid regurgitation volume) are linked to worse CV outcomes in patients with non-ischemic dilated cardiomyopathy. Hence, these promising results warrant further validation in larger studies.

Age-, Sex-, and Race-Based Normal Values for Left Ventricular Circumferential Strain from the World Alliance Societies of Echocardiography Study

BACKGROUND

Left ventricular (LV) circumferential strain has received less attention than longitudinal deformation, which has recently become part of routine clinical practice. Among other reasons, this is because of the lack of established normal values. Accordingly, the aim of this study was to establish normative values for LV circumferential strain and determine sex-, age-, and race-related differences in a large cohort of healthy adults.

METHODS

Complete two-dimensional transthoracic echocardiograms were obtained in 1,572 healthy subjects (51% men), enrolled in the World Alliance Societies of Echocardiography Normal Values Study. Subjects were divided into three age groups (<35, 35-55, and >55 years) and stratified by sex and by race. Vendor-independent semiautomated speckle-tracking software was used to determine LV regional circumferential strain and global circumferential strain (GCS) values. Limits of normal for each measurement were defined as 95% of the corresponding sex and age group falling between the 2.5th and 97.5th percentiles. Intergroup differences were analyzed using unpaired t tests.

RESULTS

Circumferential strain showed a gradient, with lower magnitude at the mitral valve level, increasing progressively toward the apex. Compared with men, women had statistically higher magnitudes of regional and global strain. Older age was associated with a stepwise increase in GCS despite an unaffected ejection fraction, a decrease in LV volume, and relatively stable global longitudinal strain in men, with a small gradual decrease in women. Asian subjects demonstrated significantly higher GCS magnitudes than whites of both sexes and blacks among women only. In contrast, no significant differences in GCS were found between white and black subjects of either sex. Importantly, despite statistical significance of these differences across sex, age, and race, circumferential strain values were similar in all groups, with variations of the order of magnitude of 1% to 2%. Notably, no differences in GCS were found among brands of imaging equipment.

CONCLUSION

This study established normal values of LV regional circumferential strain and GCS and identified sex-, age-, and race-related differences when present.

Associations between Subclinical Myocardial Dysfunction and Premature Fusion of Early and Late Diastolic Filling with Uncertain Cause

PURPOSE

The fusion of early (E) and late diastolic filling (A) on mitral inflow Doppler, even in the absence of tachycardia, is often found during assessment of left ventricular (LV) diastolic function. We evaluated the echocardiographic characteristics and clinical implications of premature E-A fusion of uncertain cause in the absence of tachycardia.

MATERIALS AND METHODS

We identified 1014 subjects who showed E-A fusion and normal LV ejection fraction (LVEF) between January 2019 and June 2021 at two tertiary hospitals. Among these, 105 (10.4%) subjects showed premature E-A fusion at heart rates less than 100 beats per minute (bpm). The conventional echocardiographic parameters and LV global longitudinal strain (GLS) were compared with 1:1 age-, sex-, and heart rate-matched controls without E-A fusion.

RESULTS

The premature E-A fusion group had a heart rate of 96.4±3.7 bpm. Only 4 (3.8%) subjects were classified as having LV diastolic dysfunction according to current guidelines. The group showed prolonged isovolumic relaxation time (107.2±25.3 msec vs. 61.6±15.6 msec, p<0.001), increased Tei index (0.76±0.19 vs. 0.48±0.10, p<0.001), lower LVEF (63.8±7.0% vs. 67.3±5.6%, p<0.001) and lower absolute LV GLS (|LV GLS|) (17.0±4.2% vs. 19.7±3.3%, p<0.001) than controls. As the E-A fusion occurred at lower heart rate, the |LV GLS| was also lower (p for trend=0.002).

CONCLUSION

Premature E-A fusion at heart rates less than 100 bpm is associated with subclinical LV dysfunction. Time-based indices and LV GLS are helpful for evaluating this easily overlooked population.

Echocardiographic Normal Reference of Left Ventricular Contractile Reserve During Treadmill Exercise Stress Echocardiography in Healthy Chinese Adults - New Non-Sex-Specific Parameter for Left Ventricular Contractile Reserve Evaluation

Purpose

Left ventricular (LV) contractile reserve is commonly used for LV systolic function assessment, while data on normal LV contractile reserve to exercise and the effect of gender on it are contradictory and limited, especially in Chinese adults. The aims of the present study are to clarify echocardiographic normal reference of LV contractile reserve during treadmill exercise stress echocardiography in healthy Chinese adults and to evaluate the sex-specific impact on it.

Patients and Methods

The study population consisted of 157 healthy Chinese adults. All subjects underwent comprehensive echocardiographic assessment at rest and immediately after a symptom-limited treadmill stress test. The impact of gender on LV contractile reserve was analyzed.

Results

The study population consisted of 157 healthy Chinese adults. All subjects underwent comprehensive echocardiographic assessment at rest and immediately after a symptom-limited treadmill stress test. The impact of gender on LV contractile reserve was analyzed.

Conclusion

Traditional LV contractile reserve of men was much higher than that of women in a healthy Chinese population. The difference might be because of higher BSA in men. ΔGLS was less influenced by METs and CI at rest compared to ΔEF. ΔGLS, and especially the ΔGLS index, might be considered as a more preferable contractile reserve parameter for clinical cardiac function evaluation.

Myocardial Work by Echocardiography: Principles and Applications in Clinical Practice

Left ventricular (LV) global longitudinal strain (GLS) has established itself in the last decade as a reliable, more objective method for the evaluation of LV systolic function, able to detect subtle abnormalities in LV contraction even in the presence of preserved ejection fraction (EF). However, recent studies have demonstrated that GLS, similar to LV EF, has important load dependency. Non-invasive myocardial work (MW) quantification has emerged in the last years as an alternative tool for myocardial function assessment. This new method, incorporating measurement of strain and LV pressure, has shown to overcome GLS and LV EF limitations and provide a loading-independent evaluation of myocardial performance. The presence of a commercially available echocardiographic software for the non-invasive MW calculation has allowed the application of this new method in different settings. This review sought to provide an overview on the current knowledge of non-invasive MW estimation, showing its potential applications and possible added value in clinical practice.

Biventricular Global Function Index Is Associated With Adverse Outcomes in Repaired Tetralogy of Fallot

INTRODUCTION

Cardiac magnetic resonance (CMR) derived biventricular global function index (BVGFI) is a new CMR parameter that integrates biventricular volumes, mass, and function using clinically available CMR parameters. The associations of BVGFI with clinical outcomes in repaired tetralogy of Fallot are unknown.

METHODS

Patients with repaired tetralogy of Fallot who had a CMR before the occurrence of a composite outcome of death, resuscitated sudden death, or sustained ventricular tachycardia were studied. BVGFI was calculated as the average of right and left GFI. GFI was defined as (ventricular stroke volume×100)/(ventricular mean cavity volume + total ventricular myocardial volume). Ventricular mean cavity volume was defined as ([end-diastolic + end-systolic volume]/2). Cox multivariable regression analysis and classification and regression tree methodology were used.

RESULTS

Of the 736 eligible subjects (mean age at CMR 25.4±14.5 years), with a median follow-up of 28 months, 55 subjects (7.4%) reached the composite outcome (46 deaths and 9 sustained ventricular tachycardia). Independent associations with the composite outcome were as follows: BVGFI <37 (hazard ratio, 2.52; P=0.004), right ventricular end-systolic volume index >85 mL/m² (hazard ratio, 3.25; P<0.001), atrial tachycardia (hazard ratio, 2.03; P=0.021), and age at repair >2.5 years (hazard ratio, 3.37; P<0.001). Classification and regression tree analysis identified BVGFI as the most discriminatory CMR parameter associated with a high risk for adverse outcomes.

CONCLUSIONS

BVGFI, a novel CMR-derived imaging biomarker combining biventricular volumes, mass, and function, may improve risk stratification for adverse clinical outcomes in patients with repaired tetralogy of Fallot.

Aging and myocardial strain

Advanced age is widely recognized as a key risk factor for incident cardiovascular disease. The age-associated changes in cardiac properties alter the substrate on which cardiovascular disease is superimposed in various ways, and thus affect the development and manifestations of cardiovascular disease (CVD) in the elderly. However, it is still unclear whether age-related cardiac alteration is attributed to aging itself or whether it is secondary to other acquired cardiovascular risk factors. Understanding the association between aging and cardiac functional remodeling might provide insight into the pathogenesis of cardiovascular aging and may help inform possible preventive strategies for CVD in older individuals. Speckle-tracking echocardiography enables the objective and quantitative assessment of subtle myocardial alterations that are undetectable with conventional echocardiography, and has excellent feasibility and reproducibility. Left ventricular (LV) global longitudinal strain, a sensitive measure of LV systolic dysfunction, was found to be an independent risk factor for cardiovascular morbidity and mortality. More recently, deformation imaging has been employed to assess right ventricular (RV) and atrial performance, and impaired RV and atrial strain predict unfavorable outcomes in various clinical settings. This article reviews the association between aging and changes in myocardial strain values and describes future perspectives.

Myocardial strain in hypertension: a meta-analysis of two-dimensional speckle tracking echocardiographic studies

AIM

Available evidence on systolic dysfunction in systemic hypertension, as assessed by left ventricular (LV) mechanics, is still based on single studies. Thus, we performed a systematic meta-analysis of two-dimensional speckle-tracking studies in order to provide an updated comprehensive information on this issue.

METHODS

The PubMed, OVID-MEDLINE, and Cochrane library databases were analyzed to search English language articles published from the inception up to 31 December 2020. Studies were identified by using MeSH terms and crossing the following search items: 'myocardial strain', 'left ventricular mechanics', 'speckle tracking echocardiography', 'systolic dysfunction', 'hypertensive heart disease', 'systemic hypertension', 'essential hypertension'.

RESULTS

Data from 4276 individuals (2089 normotensive controls and 2187 mostly uncomplicated hypertensive patients) were included. Left ventricular (LV) mass index, relative wall thickness, left atrial volume index and E/e' ratio were significantly higher in hypertensive patients than in normotensive controls. LV ejection fraction did not differ in the two pooled groups (SMD -0.048 ± 0.054, 95% CI -0.20 to 0.10, P = 0.30), whereas LV global longitudinal strain (GLS) was significantly impaired in the hypertensive group (SMD: 1.07 ± 0. 15, 95% CI 0.77-1.36, P < 0.0001). Similar findings were obtained in a sub-analysis restricted to 15 studies in which mean age was similar in cases and controls (SMD 1.21 ± 0.23, 95% CI 0.76-1.67, P = 0.002).

CONCLUSION

The present meta-analysis suggests that GLS assessment unmasks systolic dysfunction undetected by conventional ejection fraction in the uncomplicated hypertension setting and that this parameter should be incorporated into routine work-up aimed to identify hypertension-mediated cardiac damage.

Left Ventricular Global Longitudinal Strain as a Predictor of Outcomes in Patients with Heart Failure with Secondary Mitral Regurgitation: The COAPT Trial

BACKGROUND

Left ventricular (LV) global longitudinal strain (GLS) is a sensitive marker of LV function and may help identify patients with heart failure (HF) and secondary mitral regurgitation who would have a better prognosis and are more likely to benefit from edge-to-edge transcatheter mitral valve repair with the MitraClip. The aim of this study was to assess the prognostic utility of baseline LV GLS during 2-year follow-up of patients with HF with secondary mitral regurgitation enrolled in the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation trial.

METHODS

Patients with symptomatic HF with moderate to severe or severe secondary mitral regurgitation who remained symptomatic despite maximally tolerated guideline-directed medical therapy (GDMT) were randomized to transcatheter mitral valve repair plus GDMT or GDMT alone. Speckle-tracking-derived LV GLS from baseline echocardiograms was obtained in 565 patients and categorized in tertiles. Death and HF hospitalization at 2-year follow-up were the principal outcomes of interest.

RESULTS

Patients with better baseline LV GLS had higher blood pressure, greater LV ejection fraction and stroke volume, lower levels of B-type natriuretic peptide, and smaller LV size. No significant difference in outcomes at 2-year follow-up were noted according to LV GLS. However, the rate of death or HF hospitalization between 10 and 24 months was lower in patients with better LV GLS (P = .03), with no differences before 10 months. There was no interaction between GLS tertile and treatment group with respect to 2-year clinical outcomes.

CONCLUSIONS

Baseline LV GLS did not predict death or HF hospitalization throughout 2-year follow-up, but it did predict outcomes after 10 months. The benefit of transcatheter mitral valve repair over GDMT alone was consistent in all subgroups irrespective of baseline LV GLS.

Impact of gender on left ventricular deformation in patients with essential hypertension assessed by cardiac magnetic resonance tissue tracking

Left ventricular (LV) myocardial strain impairment has been demonstrated in hypertension despite normal LV ejection fraction (LVEF); however, limited data exist on any difference in results between genders. The aim of this study was to investigate the impact of gender on LV deformation in patients with essential hypertension. This was a cross-sectional study, in which 94 patients (47 men and 47 women) with essential hypertension and 62 age- and gender-matched controls (31 men and 31 women) were enrolled. A 3.0 T/two-dimensional balanced steady-state free precession cine, late gadolinium enhancement was used. The LV endocardial and epicardial contours were drawn by radiologists, then LV volumes, mass, function, and myocardial strain, including peak global radial (GRS), circumferential (GCS), and longitudinal strain (GLS) were automatically calculated. Chi-square test, Student's t-test, general linear model analysis, univariate linear regression analysis, stepwise multivariate linear regression analysis, and intraclass correlation coefficient analysis were performed. Women had significantly higher magnitudes of LV GRS, GCS, and GLS than men in both patients and controls (all p < 0.05). In the overall patients, LV GLS was significantly reduced compared with controls (p < 0.05), while GRS and GCS were preserved (p = 0.092 and 0.27, respectively). Compared with their counterpart controls, LV GRS, GCS, and GLS (all p < 0.05) were significantly reduced in hypertensive men, while only GLS (p < 0.05) was reduced in hypertensive women. Male gender and its interaction with hypertension were associated with higher LV mass and volume, decreased LV GRS, GCS, and GLS compared with hypertensive women. Multivariate analyses revealed that gender and LVEF were independently associated with GRS, GCS, and GLS (all p < 0.001) in hypertension. LV deformation is significantly reduced in hypertension, and gender may influence the response of LV deformation to hypertension, with men suffering more pronounced subclinical myocardial dysfunction. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 3.

Determining the thresholds for abnormal left ventricular strains in healthy subjects by echocardiography: a meta-analysis

Background

Left ventricular global longitudinal strain (LVGLS), circumferential strain (LVGCS) and radial strain (LVGRS) are echocardiographic parameters with wide clinical applicability. However, the thresholds for abnormal left ventricular (LV) strains, particularly the lower limits of normal (LLN), are not well established. This meta-analysis determined the mean and LLN of two- (2D) and three-dimensional (3D) LV strain in healthy subjects and factors that influence strain measurements.

Methods

We searched PubMed, Embase and Cochrane databases until 31 December 2019 for studies reporting left ventricular (LV) global strain in at least 50 healthy subjects. We pooled means and LLNs of 2D and 3D LV strain using random-effects models, and performed subgroup and meta-regression analysis for LVGLS.

Results

Forty-four studies were eligible totaling 8,910 subjects. The pooled means and LLNs (95% confidence intervals) were -20.1% (-20.7%, -19.6%) and -15.4% (-16.0%, -14.7%) respectively for 2D-LVGLS; -21.9% (-23.4%, -20.3%) and -15.3% (-16.9%, -13.8%) respectively for 2D-LVGCS; and 48.4% (43.8%, 53.0%) and 25.5% (17.8%, 33.1%) respectively for 2D-LVGRS. All pooled analyses demonstrated significant heterogeneity, and means and LLNs of and 3D-LV strains differed marginally from 2D. Only vendor software was associated with differences in pooled means and LLN of 2D-LVGLS.

Conclusions

In conclusion, pooled means and LLNs of 2D- and 3D-LV global strain parameters in healthy subjects were reported. Based on the pooled LLNs, thresholds for abnormal, borderline and normal strains can be defined, such as less negative than -14.7%, between -14.7% and -16.0% and more negative than -16.0% respectively for 2D-LVGLS, and 2D-LVGLS values are only affected by vendor software.

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), left ventricular (LV) filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

The additive effects of type 2 diabetes mellitus on left ventricular deformation and myocardial perfusion in essential hypertension: a 3.0 T cardiac magnetic resonance study

Background

Type 2 diabetes mellitus (T2DM) increases the risks of heart failure and mortality in patients with hypertension, however the underlying mechanism is unclear. This study aims to investigate the impact of coexisting T2DM on left ventricular (LV) deformation and myocardial perfusion in hypertensive individuals.

Materials and methods

Seventy hypertensive patients without T2DM [HTN(T2DM−)], forty patients with T2DM [HTN(T2DM+)] and 37 age- and sex-matched controls underwent cardiac magnetic resonance examination. Left ventricular (LV) myocardial strains, including global radial (GRPS), circumferential (GCPS) and longitudinal peak strain (GLPS), and resting myocardial perfusion indices, including upslope, time to maximum signal intensity (TTM), and max signal intensity (MaxSI), were measured and compared among groups by analysis of covariance after adjusting for age, sex, body mass index (BMI) and heart rate followed by Bonferroni’s post hoc test. Backwards stepwise multivariable linear regression analyses were performed to determine the effects of T2DM on LV strains and myocardial perfusion indices in patients with hypertension.

Results

Both GRPS and GLPS deteriorated significantly from controls, through HTN(T2DM−), to HTN(T2DM+) group; GCPS in HTN(T2DM+) group was lower than those in both HTN(T2DM−) and control groups. Compared with controls, HTN(T2DM−) group showed higher myocardial perfusion, and HTN(T2DM+) group exhibited lower perfusion than HTN(T2DM−) group and controls. Multiple regression analyses considering covariates of systolic blood pressure, age, sex, BMI, heart rate, smoking, indexed LV mass and eGFR demonstrated that T2DM was independently associated with LV strains (GRPS: p = 0.002, model R²= 0.383; GCPS: p < 0.001, model R²= 0.472; and GLPS: p = 0.002, model R²= 0.424, respectively) and perfusion indices (upslope: p < 0.001, model R²= 0.293; TTM: p < 0.001, model R²= 0.299; and MaxSI: p < 0.001, model R²= 0.268, respectively) in hypertension. When both T2DM and perfusion indices were included in the regression analyses, both T2DM and TTM were independently associated with GRPS (p = 0.044 and 0.017, model R²= 0.390) and GCPS (p = 0.002 and 0.001, model R²= 0.424), and T2DM but not perfusion indices was independently associated with GLPS (p = 0.002, model R²= 0.424).

Conclusion

In patients with hypertension, T2DM had an additive deleterious effect on subclinical LV systolic dysfunction and myocardial perfusion, and impaired myocardial perfusion by coexisting T2DM was associated with deteriorated LV systolic dysfunction.

Modified Ventricular Global Function Index Correlates With Exercise Capacity in Repaired Tetralogy of Fallot

Background

Cardiac MRI (CMR) derived ventricular global function index (GFI), a ratio of stroke volume to the sum of mean ventricular cavity and myocardial volumes, has demonstrated improved prediction of clinical outcomes in adults with atherosclerotic disease over ejection fraction. We sought to assess CMR derived GFI and a novel modification that accounts for unique loading conditions in patients with repaired tetralogy of Fallot (rTOF) and determine its correlation with exercise performance.

Methods and Results

Seventy‐five patients with rTOF who underwent CMR were identified. Clinical variables were recorded and biventricular GFI calculated. A right ventricular (RV) effective GFI (eGFI) was derived by incorporating effective stroke volume. Thirty‐five pediatric patients were matched with 29 age‐matched healthy controls. Twenty‐five patients completed cardiopulmonary exercise tests within 6 months of CMR. Stepwise regression models were used to determine univariate and multivariable predictors of indexed and percent predicted peak VO₂. Median age at CMR was 20 years (interquartile range, 13–28). Pediatric rTOF patients had lower RV eGFI (P < 0.001), RV ejection fraction (P=0.002), but higher indexed RV end‐diastolic and end‐systolic volumes (P < 0.001, P < 0.001) compared with controls. Univariate analysis demonstrated a correlation between indexed peak VO₂ with RV eGFI (R²=0.32, P=0.004), but with neither RVGFI, RV ejection fraction, indexed RV volumes nor RV mass. RV eGFI remained significantly associated with indexed peak VO₂ during multivariable modeling.

Conclusions

Reduced RV eGFI was associated with reduced exercise capacity in rTOF patients, while RV GFI, RV ejection fraction, indexed RV volumes and mass were not. Our modification of the GFI, RV eGFI, may be a valuable non‐invasive marker of cardiac function in rTOF.

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), LV filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F₁ : Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F₂ : Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

Transient depression of myocardial function after influenza virus infection: A study of echocardiographic tissue imaging

Background

Influenza virus infection (IVI) was reported to be associated with minor cardiac changes, mostly those detected on electrocardiogram with and without elevated blood markers of myocardial injury; however, the characteristics of myocardial involvement in association with IVI are poorly understood. This study used echocardiographic tissue imaging (tissue Doppler, strain, and strain rate) to evaluate changes in left atrial (LA) and left ventricular (LV) myocardial function after IVI.

Methods and results

We examined 20 adult individuals (mean age, 43 years) at 2 and 4 weeks after diagnosis of IVI. For myocardial functional variables, we obtained LV global longitudinal strain (GLS), LV early diastolic strain rate (e'sr), LA strain, and LA stiffness (E/e’/LA strain), in addition to data on tissue Doppler (s’, e’, and a’) and myocardial performance index. Blood markers of myocardial injury were also examined. During follow-up, there were no significant changes in global chamber function such as LV ejection fraction, E/e’, and LA volume. However, significant changes in myocardial function were observed, namely, in s’ (8.0 ± 1.6 cm/s to 9.3 ± 1.5 cm/s; p = 0.01), e’ (10.2 ± 2.8 cm/s to 11.4 ± 3.0 cm/s; p < 0.001), e’sr (1.43 ± 0.44 1/s to 1.59 ± 0.43 1/s; p = 0.005), and LA strain (35 ± 8% to 40 ± 12%; p = 0.025), and the myocardial performance index (0.52 ± 0.20 to 0.38 ± 0.09; p = 0.009), but not in a’, LA stiffness, or GLS. Cardiac troponin T and creatinine kinase isoenzyme MB were not elevated significantly at any examination.

Conclusions

Myocardial dysfunction during IVI recovery appeared to be transient particularly in the absence of myocardial injury. Echocardiographic tissue imaging may be useful to detect subclinical cardiac changes in association with IVI.

Lower limit of normality and clinical relevance of left ventricular early diastolic strain rate for the detection of left ventricular diastolic dysfunction

Aims

The aim of the present study was to determine the lower limit of normality and the clinical relevance of left ventricular (LV) early diastolic strain rate (LVSRe) for the detection of LV diastolic dysfunction (LVDD).

Methods and results

Using 2D speckle-tracking echocardiography, we analysed 377 healthy subjects and 475 patients with risk for LVDD with preserved LV ejection fraction (LVEF). The normal range of LVSRe analysing the healthy subjects was 1.56 ± 0.28 s-1, with a lower limit of normality at 1.00 s-1. Using this cut-off, LVSRe was able to detect high rates of LV diastolic alterations (rate 71.1%), which was significantly better than using indirect diastolic parameters such as left atrial volume index (LAVI) and tricuspid regurgitation velocity (TR) (rates 22.9% and 9.1%) and similar to annular mitral parameters such as lateral and septal e' velocity (rates 70.9% and 72.4%). In line, adding LVSRe to the current evaluation of LVDD increased significantly the rate of detection of LVDD (absolute rate of increase 18.9%; rate of detection of LVDD: from 14.3% to 33.2%, P < 0.01). Regarding the clinical relevance of LVSRe, patients with abnormal LVSRe (i.e. <1.00 s-1) had significantly worse New York Heart Association functional class and symptomatic status than those with normal LVSRe. In addition, in a retrospective post hoc analysis, we found that an abnormal LVSRe had a significant association with the risk of heart failure hospitalization at 2 years (odds ratio 5.0, 95% confidence interval 1.3-18.4), which was better than using conventional diastolic parameters such as septal and lateral e' velocity, LAVI and TR velocity.

Conclusion

The findings from this multicentre study provide important data regarding the normal range of LVSRe and highlight the potential clinical relevance of using this new diastolic parameter in the detection of LVDD in patients with preserved LVEF.

Potential Usefulness and Clinical Relevance of Adding Left Atrial Strain to Left Atrial Volume Index in the Detection of Left Ventricular Diastolic Dysfunction

OBJECTIVES

The purpose of this study was to analyze the potential usefulness and clinical relevance of adding left atrial (LA) strain to left atrial volume index (LAVI) in the detection of left ventricular diastolic dysfunction (LVDD) in patients with preserved left ventricular ejection fraction (LVEF).

BACKGROUND

Recent studies have suggested that LA strain could be of use in the evaluation of LVDD. However, the potential utility and clinical significance of adding LA strain to LAVI in the detection of LVDD remains uncertain.

METHODS

Using 2-dimensional speckle-tracking echocardiography, we analyzed a population of 517 patients in sinus rhythm at risk for LVDD such as those with arterial hypertension, diabetes mellitus, or history of coronary artery disease and preserved LVEF.

RESULTS

In patients with LV diastolic alterations and estimated elevated LV filling pressures, the rate of abnormal LA strain was significantly higher than an abnormal LAVI (62.4% vs. 33.6%, p < 0.01). In line with this, in patients with normal LAVI, high rates of LV diastolic alterations and abnormal LA strain were present (rates 80% and 29.4%, respectively). In agreement with these findings, adding LA strain to LAVI in the current evaluation of LVDD increased significantly the rate of detection of LVDD (relative and absolute increase 73.3% and 9.9%; rate of detection of LVDD: from 13.5% to 23.4%; p < 0.01). Regarding the clinical relevance of these findings, an abnormal LA strain (i.e., <23%) was significantly associated with worse New York Heart Association functional class, even when LAVI was normal. Moreover, in a retrospective post hoc analysis an abnormal LA strain had a significant association with the risk of heart failure hospitalization at 2 years (odds ratio: 6.6 [95% confidence interval: 2.6 to 16.6]) even adjusting this analysis for age and sex and in patients with normal LAVI.

CONCLUSIONS

The findings from this study provide important insights regarding the potential usefulness and clinical relevance of adding LA strain to LAVI in the detection of LVDD in patients with preserved LVEF.

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.

2D and 3D Echocardiography-Derived Indices of Left Ventricular Function and Shape: Relationship With Mortality

OBJECTIVES

This study hypothesized that left ventricular (LV) ejection fraction (EF) and global longitudinal strain (GLS) derived from 3-dimensional echocardiographic (3DE) images would better predict mortality than those obtained by 2-dimensional echocardiographic (2DE) measurements, and that 3DE-based LV shape analysis may have added prognostic value.

BACKGROUND

Previous studies have shown that both LVEF and GLS derived from 2DE images predict mortality. Recently, 3DE measurements of these parameters were found to be more accurate and reproducible because of independence of imaging plane and geometric assumptions. Also, 3DE analysis offers an opportunity to accurately quantify LV shape.

METHODS

We retrospectively studied 416 inpatients (60 ± 18 years of age) referred for transthoracic echocardiography between 2006 and 2010, who had good-quality 2DE and 3DE images were available. Mortality data through 2016 were collected. Both 2DE and 3DE images were analyzed to measure LVEF and GLS. Additionally, 3DE-derived LV endocardial surface information was analyzed to obtain global shape indices (sphericity and conicity) and regional curvature (anterior, septal, inferior, lateral walls). Cardiovascular (CV) mortality risks related to these indices were determined using Cox regression.

RESULTS

Of the 416 patients, 208 (50%) died, including 114 (27%) CV-related deaths over a mean follow-up period of 5 ± 3 years. Cox regression revealed that age and body surface area, all 4 LV function indices (2D EF, 3D EF, 2D GLS, 3D GLS), and regional shape indices (septal and inferior wall curvatures) were independently associated with increased risk of CV mortality. GLS was the strongest prognosticator of CV mortality, superior to EF for both 2DE and 3DE analyses, and 2D EF was the weakest among the 4 functional indices. A 1% decrease in GLS magnitude was associated with an 11.3% increase in CV mortality risk.

CONCLUSIONS

GLS predicts mortality better than EF by both 3DE and 2DE analysis, whereas 3D EF is a better predictor than 2D EF. Also, LV shape indices provide additional risk assessment.

Left atrial strain predicts recurrence of atrial arrhythmias after catheter ablation of persistent atrial fibrillation

Introduction

Success rates of catheter ablation (CA) of persistent atrial fibrillation (AF) are very variable. Identifying patients in whom sinus rhythm maintenance cannot be achieved after CA is a critical issue.

Methods

2D speckle-tracking echocardiography was performed before the first CA procedure in consecutive patients with persistent AF. Left atrial (LA) strain was correlated with recurrence of atrial arrhythmias during the follow-up period of 15 months after one CA procedure with or without antiarrhythmic drugs (primary endpoint). In a secondary analysis, recurrences after two CA procedures were analysed.

Results

102 patients were included. Patients with recurrence of atrial arrhythmias after one CA procedure (n=55) had significantly lower LA strain than those without recurrence (LA strain 9.7±2.4% vs 16.2±3.0%; p<0.001). Recurrence rate was significantly higher in patients with LA strain <10% than in those with LA strain between 10% and 14.5% and >14.5% (97.7%, 42.1% and 10.3%, respectively; p<0.001). In Cox regression analysis including age, comorbidities, left ventricular dysfunction and LA enlargement, low LA strain (<10%) was the strongest factor associated with recurrence of AF (HR 6.4 (2.4–16.9), p<0.001). Even after inclusion of a second CA procedure, LA strain <10% maintained a high predictive value for recurrence of atrial arrhythmias (86.4% (95% CI 73.3% to 93.6%)).

Conclusion

In patients with persistent AF, LA strain imaging could be very useful to select those patients who have a high risk of not benefiting from CA.

Early detection of cardiac involvement in sarcoidosis with 2-dimensional speckle-tracking echocardiography

BACKGROUND/OBJECTIVES

Cardiac sarcoidosis (CS) is associated with high morbidity and sudden death. The absence of specific symptoms and lack of diagnostic gold standard technique is challenging. New imaging methods could improve the diagnosis of CS. The aim of our study was to assess the role of left ventricular (LV) longitudinal and circumferential strain as estimated by 2D speckle-tracking imaging in patients with diagnosed sarcoidosis without cardiac involvement according to the current guidelines. We investigated the prevalence of LV strain impairment in this population and assessed its relationship with clinical outcomes, composite of mortality, heart failure, arrhythmia and/or secondarily development of CS and cardiac device implantation.

METHODS AND RESULTS

We performed a prospective case-control longitudinal study including 35 patients with diagnosed sarcoidosis and normal cardiac function as assessed by standard transthoracic echocardiography and 35 healthy age- and gender-matched controls. All patients underwent a comprehensive echocardiographic study. Mean age of patients was 47.9±14.8years old (22 women). Compared with controls, global LV longitudinal strain (LV GLS) was reduced in sarcoidosis patients: (-17.2±3.1 vs -21.3±1.5%, p<0.0001). Circumferential LV strain was preserved in patients compared to controls (-19.9±-4.3% vs -21.3±1.5%, p=0.12). Impaired LV GLS was significantly associated with clinical outcomes (HR 1.56; [1.16-2.11], p<0.01) on univariate analysis.

CONCLUSION

Speckle-tracking echocardiography revealed decreased longitudinal LV strain in sarcoidosis patients that was associated with outcomes. LV GLS may represent an early marker of myocardial involvement in sarcoidosis patients that needs to be studied further.

Does masked hypertension impact left ventricular deformation?

Our aim was to compare left ventricular (LV) deformation in subjects with masked hypertension (MH) to normotensive and sustained hypertensive patients. This cross-sectional study included 185 untreated subjects who underwent 24-hour ambulatory blood pressure (BP) monitoring and complete two-dimensional echocardiographic (2DE) examination including multilayer strain analysis. MH was diagnosed if clinic BP was normal (<140/90 mm Hg), and 24-hour BP was increased (≥130/80 mm Hg). 2DE LV longitudinal and circumferential strains gradually and significantly decreased from normotensive controls across MH individuals to sustained hypertensive patients. 2DE radial strain was not different between groups. 2DE longitudinal and circumferential endocardial and midmyocardial layer strains progressively decreased from normotensive control to sustained hypertensive individuals. Longitudinal and circumferential epicardial layer strains were lower in sustained hypertensive patients than in normotensive controls. Clinic and 24-hour systolic BP were associated with 2DE LV longitudinal endocardial strain, midmyocardial strain, and 2DE circumferential endocardial strain in the whole-study population independent of LV structure and diastolic function. MH significantly affect LV deformation assessed by 2DE traditional strain and 2DE multilayer strain. Clinic and 24-hour systolic BP were associated with LV mechanics evaluated with comprehensive 2DE strain analysis independent of LV structure and diastolic function.

Cardiac Remodeling in Patients With Primary and Secondary Aldosteronism

Background—

Primary aldosteronism (PA) causes excess left ventricular (LV) hypertrophy and diastolic dysfunction; whether this occurs also in secondary aldosteronism (SA) without hypertension is unknown. We investigated the cardiac modifications in patients with preserved LV ejection fraction who had PA or SA.

Methods and Results—

We measured several Doppler echocardiography–derived variables, including tissue Doppler imaging (TDI) parameters and strain rate analysis, in 262 patients with PA, 117 with SA because of liver cirrhosis, and in 61 control healthy subjects. SA and PA patients showed markedly elevated aldosterone levels (67 versus 39 ng/dL, respectively; normal values <15 ng/dL) but contrasting values of plasma renin activity (15.00 versus 0.56 ng/mL/h; P <0.001). Compared with PA, SA patients showed higher heart rate, and lower blood pressure and vascular resistance values. Both PA and SA showed increased LV diameters, LV volumes, stroke volume, stroke work, and septal peak systolic tissue velocity, and had more LV hypertrophy (61% and 39%, respectively) and diastolic dysfunction (35% and 36%, respectively) than healthy subjects. Peak systolic septal strain (20% versus 23%; P =<0.001) and midwall fractional shortening (15.9% versus 16.7%; P =0.001) were lower in PA than in SA patients.

Conclusions—

Primary and secondary hyperaldosteronism correlate with LV enlargement and high prevalence of LV hypertrophy and diastolic dysfunction; a subclinical systolic dysfunction is evident only in PA. In SA, the high rate of LV hypertrophy, in spite of low peripheral resistances and low-to-normal blood pressure, could be accounted for the high renin and aldosterone values, and the work overload associated with a hyperdynamic circulatory state.

Effect of Coronary Slow Flow on the Longitudinal Left Ventricular Function Assessed by 2-Dimensional Speckle-Tracking Echocardiography

OBJECTIVES

The coronary slow flow phenomenon is defined as the slow progression of an angiographic contrast agent to the distal part of the coronary arteries on selective coronary angiography in the absence of stenosis. There are some studies with different results about the effect of this phenomenon on left ventricular (LV) function. The aim of our study was to evaluate the longitudinal LV function in the coronary slow flow phenomenon using 2-dimensional (2D) speckle-tracking echocardiography.

METHODS

In a study with a patient-to-patient matched design, 36 patients with the coronary slow flow phenomenon and 36 individuals with normal coronary flow matched for age (±5 years), sex, hypertension, and diabetes mellitus were compared in terms of the longitudinal LV systolic and diastolic functions by pulsed wave tissue Doppler echocardiography and 2D speckle-tracking echocardiography-derived indices.

RESULTS

Lateral s' and e' waves were lower in the patients with the coronary slow flow phenomenon, but there were no statistically significant differences between the groups regarding the other tissue Doppler echocardiographic indices and longitudinal systolic strain and systolic and diastolic strain rates derived by 2D speckle-tracking echocardiography.

CONCLUSIONS

Our results showed that the coronary slow flow phenomenon could not impair the longitudinal LV systolic and diastolic functions.

Influence of White-Coat Hypertension on Left Ventricular Deformation 2- and 3-Dimensional Speckle Tracking Study

We sought to compare left ventricular deformation in subjects with white-coat hypertension to normotensive and sustained hypertensive patients. This cross-sectional study included 139 untreated subjects who underwent 24-hour ambulatory blood pressure monitoring and completed 2- and 3-dimensional examination. Two-dimensional left ventricular multilayer strain analysis was also performed. White-coat hypertension was diagnosed if clinical blood pressure was elevated and 24-hour blood pressure was normal. Our results showed that left ventricular longitudinal and circumferential strains gradually decreased from normotensive controls across subjects with white-coat hypertension to sustained hypertensive group. Two- and 3-dimensional left ventricular radial strain, as well as 3-dimensional area strain, was not different between groups. Two-dimensional left ventricular longitudinal and circumferential strains of subendocardial and mid-myocardial layers gradually decreased from normotensive control to sustained hypertensive group. Longitudinal and circumferential strains of subepicardial layer did not differ between the observed groups. We concluded that white-coat hypertension significantly affects left ventricular deformation assessed by 2-dimensional traditional strain, multilayer strain, and 3-dimensional strain.

Structural and functional cardiac analyses using modern and sensitive myocardial techniques in adult Pompe disease

The purpose of this study was to analyze comprehensively the heart using modern and sensitive myocardial techniques in order to determine if structural or functional cardiac alterations are present in adult Pompe disease. Twelve patients with adult Pompe disease and a control group of 187 healthy subjects of similar age and gender were included. Structural and functional cardiac characteristics were analyzed by conventional and 2D speckle-tracking echocardiography. In addition, in a subgroup of adult Pompe patients, we analyzed the myocardial and musculoskeletal features by means of cardiac and whole-body muscle magnetic resonance imaging. Patients with Pompe disease had significant structural and functional musculoskeletal alterations such as atrophy with fatty replacement and weakness in trunk and extremities. In contrast, Pompe patients had similar structural and functional myocardial features to healthy subjects (LV strain -20.7 ± 1.9 vs. -21.3 ± 2.1%; RV strain -24.2 ± 5.3 vs. -24.8 ± 3.8%; LA strain 41.5 ± 10.3 vs. 44.8 ± 11.0%; P > 0.05; and no evidence of LV and RV hypertrophy or LA enlargement). In addition, there was no evidence of valvular cardiac alterations, electrocardiographic abnormalities, or myocardial fibrosis in Pompe patients. In the current study analyzing the heart with modern and sensitive myocardial techniques, we evidenced that functional and structural cardiac alterations are not present when Pompe disease begins in adulthood. Therefore, these findings suggest that adult Pompe disease should not be taken into consideration in the differential diagnostic of structural or functional cardiac disorders.

Association between left ventricular mechanics and heart rate variability in untreated hypertensive patients

The authors sought to investigate left ventricular (LV) mechanics and heart rate variability (HRV), and their relationship, in untreated hypertensive patients. A total of 63 untreated hypertensive patients and 45 healthy patients were included. All patients underwent 24-hour Holter monitoring and echocardiographic examination (two- and three-dimensional). All parameters of time and frequency domain of HRV were decreased in the hypertensive patients. Two-dimensional LV longitudinal and circumferential deformation was significantly reduced in hypertensive patients. Three-dimensional LV strain in all three directions as well as area strain were reduced in the hypertensive group. In two different models of multivariate regression, two-dimensional LV longitudinal and circumferential strain, as well as three-dimensional LV area strain, remained associated with HRV parameters independently of LV structural and functional parameters. This study showed that LV mechanics and HRV were significantly impaired in untreated hypertensive patients. Two- and three-dimensional echocardiographic LV deformation were independently associated with HRV parameters in the whole study population.

Normal values and clinical relevance of left atrial myocardial function analysed by speckle-tracking echocardiography: multicentre study

AIMS

The aim of this multicentre study was to determine the normal range and the clinical relevance of the myocardial function of the left atrium (LA) analysed by 2D speckle-tracking echocardiography (2DSTE).

METHODS AND RESULTS

We analysed 329 healthy adult subjects prospectively included in 10 centres and a validation group of 377 patients with left ventricular diastolic dysfunction (LVDD). LA myocardial function was analysed by LA strain rate peak during LA contraction (LA-SRa) and LA strain peak during LA relaxation (LA-Strain). The range of values of LA myocardial function in healthy subjects was LA-SRa -2.11 ± 0.61 s(-1) and LA-Strain 45.5 ± 11.4%, and the lowest expected values of these LA analyses (calculated as -1.96 SD from the mean of healthy subjects) were LA-SRa -0.91 s(-1) and LA-Strain 23.1%. Concerning the clinical relevance of these LA myocardial analyses, LA-SRa and LA-Strain detected subtle LA dysfunction in patients with LVDD, even though LA volumetric measurements were normal. In addition, in these patients we found that the functional class (dyspnoea-NYHA classification) was inversely related to both LA-Strain and LA-SRa.

CONCLUSION

In the present multicentre study analysing a large cohort of healthy subjects and patients with LVDD, the normal range and the clinical relevance of the myocardial function of the LA using 2DSTE have been determined.

Global cardiac alterations detected by speckle-tracking echocardiography in Fabry disease: left ventricular, right ventricular, and left atrial dysfunction are common and linked to worse symptomatic status

The aim of this study was to test the hypothesis that in patients with Fabry disease, 2D speckle-tracking echocardiography (2DSTE) could detect functional myocardial alterations such as left ventricular (LV), right ventricular (RV), and left atrial (LA) dysfunction, even when conventional cardiac measurements are normal. In addition, we hypothesized that these global cardiac alterations could be linked to worse symptomatic status in these patients. Fifty patients with Fabry disease and a control group of 118 healthy subjects of similar age and gender were included. The myocardial function and structural changes of the LV, RV, and LA were analyzed by 2DSTE and cardiac magnetic resonance imaging. Patients with Fabry disease had significantly lower functional myocardial values of the LV, RV, and LA than healthy subjects (LV, RV, and LA strain -18.1 ± 4.0, -21.4 ± 4.9, and 29.7 ± 9.9 % vs. -21.6 ± 2.2, -25.2 ± 4.0, and 44.8 ± 11.1 %, respectively, P < 0.001) and elevated rates of LV, RV, and LA myocardial dysfunction (24, 20, and 26 %, respectively), even when conventional cardiac measurements such as LVEF, TAPSE, and LAVI were normal. LV septal wall thickness ≥15 mm, RV free wall thickness ≥7 mm, and LV longitudinal dysfunction were the principal factors linked to reduced LV, RV, and LA strain, respectively. In addition, but to a lesser extent, LV and RV fibrosis were linked to reduced LV and RV strain. Patients with reduced LV, RV, and LA strain had worse functional class (dyspnea-NYHA classification) than those with normal cardiac function. In conclusion, in patients with Fabry disease, 2DSTE analyses detect LV, RV, and LA functional myocardial alterations, even when conventional cardiac measurements are normal. These functional myocardial alterations are common and significantly associated with worse symptomatic status in Fabry patients. Therefore, these findings provide important evidence to introduce global myocardial analyses using 2DSTE in the early detection of functional cardiac alterations in Fabry disease.