A Test in Context: Myocardial Strain Measured by Speckle-Tracking Echocardiography

The Effect of Smoothing and Drift Compensation on Fetal Strain

OBJECTIVE

The aim of this study was to assess the effect of user-regulated image-processing settings (spatial smoothing, temporal smoothing and drift compensation) on fetal left ventricular strain.

METHODS

Left ventricular average longitudinal strain was acquired from the four-chamber view of the fetal heart from 34 fetuses, with 30 fetuses presenting adequate quality. A total of 18 different settings for spatial smoothing, temporal smoothing and drift compensation were examined. At each setting the average strain for the 30 fetuses was calculated, whereby one could examine whether there was an average difference in fetal strain at the different settings. Furthermore, the difference between the highest and lowest strain values across the 18 settings was assessed for each fetus (min-max difference). The average min-max difference was then calculated across the 30 fetuses to calculate the mean discrepancy in fetal strain due to smoothing settings.

RESULTS

The average effect of the smoothing settings as well as drift compensation by them was small. However, when examining the discrepancy induced by the different settings together, they induced average proportional differences of approximately 18% for the endocardial and epicardial layers and 15% for the mid-wall layer.

CONCLUSION

This study shows that while the average effect of different smoothing settings and drift compensation was small, they induced significant discrepancy in strain values on the individual level. We recommend that examiners be consistent with regard to smoothing and drift compensation settings.

Reduced left atrial compliance exacerbates primary graft dysfunction after lung transplantation

OBJECTIVE

Primary graft dysfunction (PGD) after lung transplantation (LTx) heralds significantly worse short- and long-term outcomes. The preoperative presence of recipient left ventricular diastolic dysfunction elevates postcapillary hydrostatic pressures and increases the risk for PGD. In this study, we investigated the role of the left atrial strain (LAS), a recently established sensitive marker of left atrial compliance, as a predictor of PGD.

METHODS

Preoperative echocardiography of all patients who underwent bilateral LTx at a single center from 2014 to 2024 was analyzed for global myocardial deformation, including the standard phases of LAS reservoir, conduit, and pump as well as left ventricular global longitudinal strain. The presence of PGD grade 3 was defined as P:F <200 at 48 or 72 hours after the operation. Right heart catheterization, standard echocardiographic, and strain indices were subjected to univariable and multivariable analysis to predict PGD.

RESULTS

In total, 132 patients were analyzed, from whom 35 (26.5%) developed PGD. There were no differences in traditional echocardiographic left ventricular diastolic dysfunction biomarkers, including Doppler and tissue Doppler indices, between the PGD (+) and PGD (-) groups. Preoperative right heart catheterization revealed increased mean pulmonary arterial pressure (36 vs 26 mm Hg, P = .003) and median pulmonary vascular resistance (7.8 vs 4.6, P = .001) in the PGD group. Reservoir LAS was reduced in PGD (22.7 ± 7.7 vs 31.5 ± 10.7%, P < .001), followed by reduced conduit LAS (-11.4 ± 6.6 vs -16.0 ± 8.2%, P = .002) and reduced LV GLS (-13.9 ± 3.6 vs -15.8 ± 3.7%, P = .014). In final multivariable model, conduit LAS was independently associated with a greater risk of PGD (odds ratio, 0.88; 95% confidence interval, 0.81-0.95; P = .002) along with greater pulmonary vascular resistance index (odds ratio, 1.13; 95% confidence interval, 1.05-1.25; P = .003). The final model yielded a c-statistic of 0.82, specificity of 93.8%, sensitivity of 40.0%, positive predictive value of 80.8%, and negative predictive value of 70.6%.

CONCLUSIONS

Patients with decreased preoperative left atrial compliance assessed by LAS who undergo LTx have a greater risk of developing PGD in the setting of normal LV systolic and diastolic function. Given the increasing use of strain indices, LAS should be considered a risk factor for PGD in prospective studies.

A bioactive hydrogel patch accelerates revascularization in ischemic lesions for tissue repair

Background

Magnesium ions play crucial roles in maintaining cellular functions. Research has shown that Mg2+ can promote angiogenesis, indicating its potential for treating cardiovascular ischemic diseases. However, conventional intravenous or oral administration of Mg2+ presents several challenges, including the risk of systemic side effects, diminished bioavailability, and a lack of targeted delivery mechanisms. In this study, we designed an Mg2+-releasing adhesive tissue patch (MgAP) that enables the dural release of Mg2+ ions.

Methods

A novel MgAP was developed on the basis of ionic crosslinking. Fourier transform infrared spectroscopy confirmed the chemical structure, whereas rheological analysis demonstrated stable mechanical properties and adaptability to dynamic loads. Sustained Mg2+ release was quantified over 7 days by inductively coupled plasma-mass spectrometry. In a rat acute myocardial infarction model, we performed echocardiography and strain analysis to assess cardiac function and histological staining to evaluate adverse remodeling. We also verified the proangiogenic effect through in vitro tube formation and in vivo immunofluorescence assays. Furthermore, transcriptomics and Western blotting were performed to explore the underlying mechanism. Additional assessments were also carried out in a rat model of lower limb ischemia.

Results

Compared with intravenous administration of magnesium chloride, MgAP application effectively improved cardiac function and reduced adverse remodeling in the myocardial infarction rat model. The left ventricular ejection fraction increased by 20.3 ± 6.6%, and the cardiac radial strain improved by 27.4 ± 4.1%. The cardiac fibrosis area and cell apoptosis rate decreased by 10.9 ± 1.2% and 32.1 ± 5.5%, respectively. RNA sequencing analysis also highlighted the upregulation of genes related to cardiac electrophysiological properties, structural and functional intercellular connections, and revascularization. The increased gap junction protein expression and restored local blood supply could contribute to the cardiac repair process posttreatment. The proangiogenic effect of MgAP was also observed in the rat limb ischemia model.

Conclusions

The above results revealed the convincing vascular regeneration effect of an ion therapy-based hydrogel, which enabled the local delivery of Mg2+ to the targeted ischemic tissue, aiding in cardiac and lower limb repair. This study presents a novel strategy and highlights its potential for use across various ischemic conditions.

Evaluation of changes in cardiac longitudinal strain rate in patients with systemic sclerosis undergoing iloprost treatment: an observational study

OBJECTIVES

SSc is characterized by widespread microangiopathy and fibrosis of skin and visceral organs. Left ventricle involvement is usually subclinical, characterized by systolic and/or diastolic dysfunction. The global longitudinal strain (GLS), a validated and reliable technique for the measurement of ventricular longitudinal deformation by means of echocardiography, may detect subclinical systolic dysfunction of SSc myocardium. The improvement of myocardial perfusion by means of intravenous Iloprost administration could ameliorate the contractility of SSc heart. Therefore, we aimed to evaluate GLS in a series of SSc patients prior and after Iloprost infusion.

METHODS

Fifteen consecutive SSc patients (age: 54 ± 11 years; 12 females) treated with Iloprost because of the presence/history of digital ulcers underwent echocardiography, including GLS technique. This evaluation was conducted immediately before Iloprost administration and at the end of the 6-h infusion session.

RESULTS

Significant improvement in the mean GLS was observed after Iloprost administration (from -13.5 ± 2.5 to -15 ± 3.3; P = 0.011). The echocardiographic data obtained from the four-chamber view showed the best quality for GLS analysis and showed a highly significant improvement of the strain after Iloprost administration (from -13.4 ± 2.2 to -15.6 ± 3; P = 0.001). The degree of GLS improvement did not correlate with any SSc parameters.

CONCLUSION

Iloprost administration improved GLS, suggesting that the increase of myocardial perfusion allowed, at least in part, a correction of left ventricular systolic dysfunction. Further studies are needed to confirm these findings, further exploring the mid/long-term effects of Iloprost on myocardial contraction.

A 2D-STI echocardiographic diagnostic model established for cardiac amyloidosis complicated with multiple myeloma

OBJECTIVE

This study aimed to investigate the clinical characteristics of multiple myeloma(MM) with amyloidosis(AL) and evaluate the diagnostic utility of two-dimensional speckle tracking imaging(2D-STI) echocardiography in MM with cardiac amyloidosis(CA), with the goal of providing guidance for early screening and differentiation.

METHODS

Among 616 newly diagnosed multiple myeloma (NDMM) patients, 359 met the inclusion and exclusion criteria, and divided into MM-AL and MM without AL according to the histopathological results. MM-AL patients were subdivided into MM-CA and MM without CA subgroups according to cardiac involvement criteria. Baseline characteristics and 2D-STI echocardiographic parameters were comparatively analyzed. Variables potentially predictive of MM-CA were identified through univariate analysis, with accuracy assessed by area under the curve (AUC). Variables were dichotomized using optimal cut-off values to construct a multivariate logistic regression model.

RESULTS

The initial symptoms of MM-AL were mainly bone pain and anemia, but the incidence of ostealgia was lower (45.7 %) and the prevalence of congestive heart failure (CHF) was higher (12.8 %) compared with MM without AL patients. No significant differences were observed in myocardial injury biomarkers, tumor burden, or t(11,14) translocation. MM-CA patients presented with 40.0 % severe heart failure (HF) NYHA class III-IV at diagnosis and experienced 33.3 % adverse cardiovascular events. An echocardiographic model incorporating left ventricular ejection fraction(LVEF), pulmonary artery systolic pressure(PASP), hydropericardium, and global longitudinal strain (GLS) demonstrated the highest diagnostic accuracy for MM-CA, with an AUC of 0.90 (95 % CI, 0.81-1.00) (sensitivity: 95.6 %, specificity: 80.0 %, accuracy: 90.8 %).

CONCLUSION

There was no specific difference between the clinical manifestations and routine examinations of MM with or without AL patients. This study introduces a novel multi-parameter echocardiographic model for MM-CA diagnosis, providing a clinically valuable tool for early screening and differentiation.

Pro: Speckle-tracking Echocardiographic Strain Analysis of the Right Ventricle Should Be Incorporated into the Assessment of Right Ventricular Function After Left Ventricular Mechanical Support

Right ventricular (RV) dysfunction is a major concern in patients requiring left ventricular assist devices (LVADs). Speckle-tracking echocardiography offers superior sensitivity for RV function assessment compared with traditional methods. This article advocates for the routine integration of RV strain analysis in perioperative and intensive care unit settings to enhance early detection and management of RV dysfunction following LVAD placement.

Three-dimensional speckle-tracking imaging for the prognosis of childhood-onset systemic lupus erythematosus: a pilot study

Background

To assess the early alterations in the architecture and performance of the left ventricle for childhood-onset systemic lupus erythematosus (cSLE) patients utilizing three-dimensional speckle tracking imaging (3D-STI).

Methods

The aggregate of 31 cSLE patients were recruited and categorized into two groups based on the SLE disease activity index (SLEDAI) score: the mild-to-moderate group (≤12, n = 14) and the severe group (>12, n = 17). Univariate as well as multivariate logistic regression were used to investigate the relationship between 3D-STI parameters and the activity of the disease. Four diagnostic patterns were employed to amalgamate 3D-STI data (global longitudinal strain, GLS, and left ventricular twist angle, LVtw): isolation, series, parallel, and integration, subsequently leading to the development of a 3D myocardial comprehensive index (3D-MCI). The primary aim was severe disease activity, whereas the secondary objectives were growth failure, lupus nephritis, hypocomplementemia, and serious hematological issues.

Results

In the multivariate analysis, GLS and LVtw emerged as significant indicators of severe disease activity (p = 0.028 and p = 0.047). The comprehensive method, which integrates GLS with LVtw value using the logistic algorithm, achieves a balanced sensitivity and specificity of 81.4% and 94.1%, respectively. Subsequently, the 3D-MCI is computed as follows: 7.650-0.367*GLS (%) - 0.281*LVtw (°). Furthermore, the 3D-MCI exhibited a strong significant correlation with both the primary endpoint and the secondary outcomes.

Conclusions

3D-STI technology may facilitate the early detection of cardiac injury in individuals with cSLE, whereas 3D-MCI serves as suitable prognostic indicators for cSLE patients.

The prognostic value of global longitudinal strain in patients with myocardial infarction and preserved ejection fraction: a prespecified substudy of the REDUCE-AMI trial

AIMS

The REDUCE-AMI trial showed that beta-blockers in patients with preserved left ventricular ejection fraction (LVEF) after acute myocardial infarction (AMI) had no effect on mortality or cardiovascular outcomes. The aim of this substudy was to evaluate whether global longitudinal strain (GLS) is a better prognostic marker than LVEF, and if beta-blockers have a beneficial effect in patients with decreased GLS.

METHODS AND RESULTS

REDUCE-AMI was a registry-based randomized clinical trial. Conventional echocardiographic parameters and GLS were obtained and a likelihood ratio test between models adjusted for age, sex, hypertension, smoking, diabetes, previous AMI, and multi-vessel disease was used to compare LVEF and GLS as prognostic methods. A Cox regression model evaluated the impact of beta-blocker treatment on the composite endpoint of death from any cause or new AMI. A total of 1436 patients (28.6% of the total population) were included in this substudy. Due to poor image quality or incompatible equipment, 324 (22.6%) patients were excluded from the analysis of GLS. The median GLS was 17.3%. The likelihood ratio test resulted in no difference (P = 0.56) when comparing the combination of GLS to LVEF. The results were robust when adding beta-blocker randomization status as an independent variable.

CONCLUSION

In patients after AMI with preserved LVEF, GLS did not add prognostic value regarding death from any cause or new AMI. In addition, beta-blocker treatment did not alter the prognostic information obtained from GLS. Consequently, this study does not support an additive value of GLS compared with standard echocardiographic measurement in this patient population.

Effect of Global Longitudinal Strain at Discharge Period on Predicting Cardiac Defibrillator Implantation in STEMİ Patients with Impaired Left Ventricle Systolic Functions

Background and Objectives: Contemporary studies have shown that low ejection fraction (EF) is a significant predictor of sudden cardiac death in ischemic heart failure. However, relying solely on EF and waiting 90 days for ICD implantation is inadequate for preventing sudden death in STEMI patients. Materials and Methods: This study aims to explore if left ventricular global longitudinal strain (GLS) measured at discharge can predict EF < 35% at the third-month follow-up in STEMI patients with impaired systolic function (EF < 35%). The study involved 69 patients diagnosed with STEMI. The results from 29 patients with EF ≤ 35% and 40 patients with EF between 36 and 49% were compared. Echocardiographic images were recorded, and the LV GLS value was measured. Results: In both univariate and multivariate regression analyses, LV GLS at discharge was the only independent predictor of EF ≤ 35% after three months. An LV GLS value below 9.55% at discharge predicted an EF below 35% at 90 days, with 75% sensitivity and 76.5% specificity (AUC = 0.814, p = 0.005). Conclusions: Current guidelines recommend waiting three months before ICD implantation in STEMI patients with EF ≤ 35%, but this study suggests that low GLS can help identify high-risk patients earlier, potentially reducing the waiting period for ICD implantation.

Myocardial Viability: Evolving Insights and Challenges in Revascularization and Functional Recovery

The prevalence of heart failure, driven significantly by ischemic heart disease, continues to rise globally. Myocardial viability-the potential ability of dysfunctional myocardium to recover contractile function after revascularization-remains an ongoing key area of research in managing ischemic cardiomyopathy. Advances in imaging modalities, including PET/SPECT, cardiac MRI, and dobutamine stress echocardiography, have enabled identification of viable myocardium that can potentially predict their functional recovery following revascularization. Despite these advances, recent evidence from major trials questions the routine reliance on viability testing for revascularization guidance. These studies found a limited correlation between myocardial viability and improved outcomes in key metrics including mortality. Furthermore, they highlighted the effectiveness of guideline-directed medical therapy in improving left ventricular function independent of revascularization. This narrative review explores the concept of myocardial viability, its assessment through contemporary imaging techniques, its clinical utility in decision making for revascularization, and future directions.

Assessment of Left Ventricular Strain Echocardiography in Individuals with Hashimoto's Thyroiditis and Its Association with Serum TIMP-1 Concentration

Background: Hashimoto's thyroiditis (HT), which is an autoimmune condition and the primary cause of hypothyroidism, has numerous impacts on the cardiovascular system. This research aimed to compare TIMP-1 levels and LV strain values in euthyroid HT, hypothyroid HT, and healthy control persons. Materials and Methods: This study included 40 hypothyroid HT patients, 42 HT patients who became euthyroid with thyroid hormone replacement therapy, and 40 healthy controls. All subjects had conventional echocardiography and STE. Global and segmental LV longitudinal strain values (LVGLS) were calculated. Participants' blood was tested for TIMP-1, thyroid function, and anti-TPO. Results: Higher serum TIMP-1 levels were found in euthyroid and hypothyroid HT patients than in the control group. Additionally, patients with euthyroid and hypothyroid HT displayed lower segmental and global LV strain values than the control group. A negative correlation was observed between strain values and TIMP-1 and anti-TPO levels. No significant difference was observed in serum TIMP-1 and strain values between euthyroid and hypothyroid HT patients. Patients with hypothyroid HT exhibited impaired diastolic function and reduced ejection fraction when compared to both euthyroid HT and control groups. However, euthyroid HT patients and the controls had similar diastolic function and ejection fractions. Conclusions: Hashimoto's thyroiditis causes impairment of LV strain, regardless of thyroid hormone levels. Additionally, the condition is associated with elevated TIMP-1 levels. The relationship between LV strain values and anti-TPO levels indicates that the autoimmune component of the disease may be responsible for the impaired LV strain.

Association of Fibroblast Growth Factor 23 and Cardiac Mechanics in the Cardiovascular Health Study

Key Points

Evaluation of cardiac mechanics through two-dimensional speckle tracking echocardiography can identify early alterations in cardiac function. In a subset of the Cardiovascular Health Study, c-terminal and intact fibroblast growth factor 23 were not independently associated with cardiac mechanic indices.

Background

Elevated levels of fibroblast growth factor 23 (FGF23) are associated with left ventricular hypertrophy and heart failure in individuals with and without kidney disease. Prior studies investigated the association of FGF23 and structural cardiac changes using conventional echocardiography, which is limited in its ability to detect early cardiac dysfunction. We investigated the relationship between FGF23 levels and cardiac dynamics using two-dimensional speckle tracking echocardiography (2D-STE), a novel imaging modality.

Methods

This was a cross-sectional analysis of data from the Cardiovascular Health Study (CHS), an ongoing prospective, population-based cohort study. The study population included 506 participants from CHS with available c-terminal FGF23 (cFGF23) and intact FGF23 (iFGF23) measurements from 1996 to 1997 and 2D-STE images from 1994 to 1995. Forty-two percent of the study population had CKD, defined as an eGFR <60 ml/min per 1.73 m2, and the mean eGFR was 63 ml/min per 1.73 m2. The primary exposures were cFGF23 and iFGF23. The primary outcomes were six 2D-STE parameters performed at the 1994–1995 study visit. Linear regression models were used to examine the independent associations of FGF23 with six cardiac 2D-STE indices adjusting for demographics, cardiovascular risk factors, markers of kidney disease severity, and inflammation.

Results

cFGF23 levels were moderately correlated with iFGF23 levels in the CHS population. In fully adjusted models, cFGF23 was associated with left atrial dysfunction, but no other cardiac imaging parameter (β estimate, −2.47; 95% confidence interval, −4.68 to −0.25; Table 2 ). iFGF23 was not associated with any of the six 2D-STE indices. Limitations include small sample size and noncurrent FGF23 measurements and 2D-STE imaging.

Conclusions

In a limited sample of individuals enrolled in the CHS with cFGF23 and iFGF23 measurements, we did not find consistent associations between FGF23 levels and 2D-STE parameters. Further investigations in a larger population with concurrent 2D-STE are needed to better understand the associations of FGF23 with early changes in cardiac mechanics.

Evaluation the Effect of Anthracyclines on Cardiac Function in Children Lymphoma Survivors by Left Ventricular Myocardial Work

Anthracycline chemotherapy is associated with the left ventricular (LV) dysfunction, but the conventional echocardiographic parameter is insensitive in detecting subclinical cardiac dysfunction, and the role of echocardiography in children cancer survivors (CCSs) has not been well established. Here, the myocardial work (MW) was employed to evaluate the early effect of the anthracyclines on LV function in children lymphoma survivors, as well as to explore the clinical application value of this modality. 51 children lymphoma survivors treated with anthracyclines were included. During the treatments, the echocardiography was performed at baseline (T0 phase), the 3rd (T1 phase) and 6th (T2 phase) chemotherapeutic cycle, respectively. After that, the conventional echocardiographic parameters, LV global longitudinal strain (GLS), and global myocardial work (GMW) parameters were obtained. Finally, these echocardiographic parameters were compared to distinguish the differences among three groups, and correlation analysis was used to identify relationship between GMW parameters and LV GLS. Compared with the baseline, we found that there are no significant differences for LVEF and other conventional echocardiographic parameters after chemotherapy, but the value of LV lateral E/E' increased at T1 and T2 group. The GLS, global work index, global constructed work, and global work efficiency were decreased, while the global wasted work was increased after chemotherapy (all P < 0.05). The correlation analysis showed that the GLS has significant correlation with GMW parameters (all P < 0.001). The MW, as a new noninvasive echocardiography modality, could be used to quantitatively evaluate the LV MW in children lymphoma survivors treated with anthracyclines, which providing a sensitive method to early detect the children's LV dysfunction after the chemotherapy.

Assessment of atrial strain variations in amateur runners: A 10-week unsupervised training program and half-Marathon impact study using 2D and speckle-tracking echocardiography

BACKGROUND

Competitive running leads to cardiac remodeling and functional changes in cardiovascular haemodynamics in professional runners. Data on atrial changes in amateur runners completing a half-marathon are limited. The study sought to analyze the impact of training and a 21.0975-km run on echocardiographic parameters of left (LA) and right (RA) atrial anatomy and function in recreational runners.

METHODS

The study group comprised 52 amateur runners [mean age 32.96 (5.12) years], including 32 men. Echocardiographic evaluations were performed at three stages: prior to the ten-week unsupervised training, and then before and after the run. Morphological and functional parameters were assessed using two-dimensional imaging, Doppler, and speckle-tracking technique.

RESULTS

During the training period, both LA dimension [31.87 mm vs. 33.96 mm; p < 0.001] and LA volume [59.00 ml vs. 68.00 ml; p < 0.001] increased and no changes were found for RA morphological parameters. Ten weeks of preparatory training resulted in an increase in LA contractile strain (LASct) [10.50 % vs. 11.00 %; p = 0.030], without affecting the RA function. Change of LASct was particularly pronounced in young women (<32 years; p = 0.029). Half-marathon performance decreased the LA volume.

CONCLUSIONS

Amateur training for 21.0975-km run remodels LA and enhances LA active contractile function (especially in young women) without influencing RA. The half-marathon decreases LA volume and does not affect RA morphology and function in recreational runners.

Obesity Predisposes Anthracycline-Treated Survivors of Childhood and Adolescent Cancers to Subclinical Cardiac Dysfunction

Anthracyclines are effective chemotherapeutics used in approximately 60% of pediatric cancer cases but have a well-documented risk of cardiotoxicity. Existing cardiotoxicity risk calculators do not include cardiovascular risk factors present at the time of diagnosis. The goal of this study is to leverage the advanced sensitivity of strain echocardiography to identify pre-existing risk factors for early subclinical cardiac dysfunction among anthracycline-exposed pediatric patients. We identified 115 pediatric patients with cancer who were treated with an anthracycline between 2013 and 2019. Peak longitudinal left ventricular strain was retroactively calculated on 495 surveillance echocardiograms via the TOMTEC AutoSTRAIN software. Cox proportional hazards models were employed to identify risk factors for abnormal longitudinal strain (> - 16%) following anthracycline treatment. High anthracycline dose (≥ 250 mg/m2 doxorubicin equivalents) and obesity at the time of diagnosis (BMI > 95th percentile-for-age) were both significant predictors of abnormal strain with hazard ratios of 2.79, 95% CI (1.07-7.25), and 3.85, 95% CI (1.42-10.48), respectively. Among pediatric cancer survivors, patients who are obese at the time of diagnosis are at an increased risk of sub-clinical cardiac dysfunction following anthracycline exposure. Future studies should explore the incidence of symptomatic cardiomyopathy 10-15 years post-treatment among patients with early subclinical cardiac dysfunction.

Echocardiographic Updates in the Assessment of Cardiomyopathy

PURPOSE OF REVIEW

This review aims to provide an updated overview of the role of echocardiography in the assessment of cardiomyopathies, highlighting recent findings and technological advancements.

RECENT FINDINGS

Over the past few years, significant advancements in echocardiographic techniques have improved diagnostic accuracy and provided important prognostic value in the assessment of cardiomyopathies. Cardiomyopathy is a group of diseases affecting the heart muscle. Echocardiography, a non-invasive imaging modality provides crucial information on cardiac structure, function, and hemodynamics. Recent advancements, including strain imaging, speckle-tracking, and 3D echocardiography enhance the precision of structural and functional assessments, while artificial intelligence integration improves diagnostic accuracy and workflow efficiency. These advancements not only refine diagnostic capabilities but also provide prognostic insights and facilitate better patient outcomes.

Advances of research in diabetic cardiomyopathy: diagnosis and the emerging application of sequencing

Diabetic cardiomyopathy (DCM) is one of the most prevalent and severe complications associated with diabetes mellitus (DM). The onset of DCM is insidious, with the symptoms being obvious only in the late stage. Consequently, the early diagnosis of DCM is a formidable challenge which significantly influences the treatment and prognosis of DCM. Thus, it becomes imperative to uncover innovative approaches to facilitate the prompt identification and diagnosis of DCM. On the traditional clinical side, we tend to use serum biomarkers as well as imaging as the most common means of diagnosing diseases because of their convenience as well as affordability. As we delve deeper into the mechanisms of DCM, a wide variety of biomarkers are becoming competitive diagnostic indicators. Meanwhile, the application of multiple imaging techniques has also made efforts to promote the diagnosis of DCM. Besides, the spurt in sequencing technology has made it possible to give hints about disease diagnosis from the genome as well as the transcriptome, making diagnosis less difficult, more sensitive, and more predictive. Overall, sequencing technology is expected to be the superior choice of plasma biomarkers for detecting lesions at an earlier stage than imaging, and its judicious utilization combined with imaging technologies will lead to a more sensitive diagnosis of DCM in the future. Therefore, this review meticulously consolidates the progress and utilization of various biomarkers, imaging methods, and sequencing technologies in the realm of DCM diagnosis, with the aim of furnishing novel theoretical foundation and guide future research endeavors towards enhancing the diagnostic and therapeutic landscape of DCM.

Application prospect of speckle tracking echocardiography in pacemaker implantation

More than 1 million permanent pacemakers are implanted worldwide each year, half of which are in patients with high-grade atrioventricular block. Pacemakers provide adequate frequency support in the initial stage, but traditional right ventricular (RV) pacing may lead to or aggravate left ventricular dysfunction and arrhythmia. Several potential risk factors for heart failure and arrhythmias after pacemaker surgery have been identified, but their occurrence remains difficult to predict clinically. Compared with RV pacing, His bundle pacing (HBP) and left bundle branch pacing (LBBP) activate the intrinsic His-Purkinje conduction system and provide physiological activation, but whether HBP and LBBP also cause ventricular mechanical dyssynchrony remains uncertain. The implantation of cardiac resynchronization therapy and implantable cardioverter defibrillator depends on left ventricular ejection fraction (LVEF). LVEF This depends on volume changes and is less reproducible. Speckle tracking echocardiography (STE) is a technique that can accurately quantify the degree and duration of systolic deformation. STE detects changes in myocardial function more sensitively than traditional measures of diastolic and systolic function, including LVEF. Clinicians can evaluate myocardial strain and synchrony based on strain (percent change in segmental length from baseline) and strain rate (strain per unit time). This review and case series investigate the clinical use of speckle tracking echocardiography in pacemaker implantation.

Prognostic Value of Advanced Echocardiography in Patients with Ischemic Heart Disease: A Comprehensive Review

Cardiovascular (CV) diseases caused 20.5 million deaths in 2021, making up nearly one-third of global mortality. This highlights the need for practical prognostic markers to better classify patients and guide treatment, especially in ischemic heart disease (IHD), which represents one of the leading causes of CV mortality. Transthoracic echocardiography (TTE) is a key, non-invasive imaging tool widely used in cardiology for diagnosing and managing a range of CV conditions. It is the first choice for diagnosing and monitoring patients with acute coronary syndrome (ACS). Alongside well-established echocardiographic measures, new techniques have proven useful for predicting adverse events in IHD patients, such as three-dimensional (3D) and tissue Doppler imaging (TDI), and speckle tracking technology. This review aims to explore the latest echocardiographic tools that could provide new prognostic markers for patients in the acute phase and during follow-up after an acute myocardial infarction (AMI). We focus on new imaging methods like TDI, myocardial work index (MWI), speckle-tracking strain, and 3D technologies using TTE, which are easy to use and widely available at all stages of coronary artery disease (CAD).

Image-Based Estimation of Left Ventricular Myocardial Stiffness

Elevation in left ventricular (LV) myocardial stiffness is a key remodeling-mediated change that underlies the development and progression of heart failure (HF). Despite the potential diagnostic value of quantifying this deterministic change, there is a lack of enabling techniques that can be readily incorporated into current clinical practice. To address this unmet clinical need, we propose a simple protocol for processing routine echocardiographic imaging data to provide an index of left ventricular myocardial stiffness, with protocol specification for patients at risk for heart failure with preserved ejection fraction. We demonstrate our protocol in both a preclinical and clinical setting, with representative findings that suggest sensitivity and translational feasibility of obtained estimates.

Layer-Specific Strain Analysis in Patients with Dilated Cardiomyopathy

BACKGROUND/OBJECTIVES

This study aimed to evaluate layer-specific strain according to etiology and assess whether subtle changes in longitudinal and circumferential layer strain are involved in predicting cardiac mortality during a two-year follow-up in patients with dilated cardiomyopathy admitted with heart failure decompensation.

METHODS

97 patients with dilated cardiomyopathy and a left ventricle ejection fraction ≤ 40% were recruited, 51 with ischemic and 46 with nonischemic etiologies. Conventional and two-dimensional speckle-tracking echocardiography (2D-STE) were conducted in dilated cardiomyopathy patients with a compensated phase of heart failure before discharge. Layer-specific longitudinal and circumferential strain was assessed from the endocardium, mid-myocardium, and epicardium by two-dimensional (2D) speckle-tracking echocardiography. The gradient between the endocardium and epicardium was calculated.

RESULTS

Patients with nonischemic etiology of dilated cardiomyopathy presented smaller values of global and layer strain than patients in the ischemic group. GLS, GLSend, GLSend-GLSepi, CSPMend, CSPMend-CSPMepi, CSAP, CSAPend, and CSAPend-CSAPepi were the parameters with statistically significant decreased values in non-survivors compared with survivors. In multivariate analysis, only CSPMend showed an independent value in predicting mortality at two-year follow-up. Receiver operator curve analysis provided CSPMend of -10.8% as a cut-off value with a sensitivity of 80% and specificity of 61.05% in identifying the dilated cardiomyopathy and heart failure patients with a risk of death at two-year follow-up.

CONCLUSIONS

GLS, GCS, and layer-specific strain analysis showed decreased values in nonischemic compared with ischemic dilated cardiomyopathy and also in non-survivors compared with survivors. CSPMend was the most sensitive strain parameter to identify patients with increased mortality risk at two-year follow-up.

Global longitudinal strain and the risk of major adverse cardiac events in post-myocardial infarction patients: A retrospective cohort study

BACKGROUND

This study evaluates the relationship between global longitudinal strain (GLS) and late major adverse cardiovascular events (MACEs) in patients after acute myocardial infarction (AMI).

METHODS

Data of newly diagnosed AMI patients between March 2010 and July 2014 were retrospectively evaluated. The patients underwent serial echocardiography at admission and at third and sixth months post-admission. We calculated GLS by averaging the strain from all myocardial segments using speckle-tracking echocardiography (STE). We used multivariate Cox regression analysis and receiver operating characteristic (ROC) curve analyses to assess the relationship between GLS at admission and late MACEs.

RESULTS

Eighty-nine newly diagnosed AMI patients were enrolled. The average age at diagnosis was 61 ± 12.5 years, and approximately 89.9% of the patients were men. The average level of GLS was -17.5 ± 3.9%. The overall prevalence of MACEs was 23.6% (21/89), compared with 44% (11/25) in the group with GLS≥-15% and 17.9% (5/28) in the group with GLS<-20%. GLS was positively linked with MACEs in the fully adjusted Cox proportional hazard model (hazard ratio [HR], 1.19; 95% confidence interval [CI], 1.04-1.37; P=0.014) after adjusting potential confounders. The ROC curve analysis for one year MACEs between GLS at admission, with the most significant area under the curve(AUC) 78.1% (95% CI, 63.8% - 92.6%).

CONCLUSIONS

Myocardial dysfunction, characterized by impaired GLS, is often observed in AMI patients, and a decrease in GLS levels at admission were associated with an increased risk of long-term MACEs in post-myocardial infarction patients.

Anthracycline-Induced Subclinical Right Ventricular Dysfunction in Breast Cancer Patients: A Systematic Review and Meta-Analysis

AIM

This meta-analysis aims to evaluate the impact of anthracycline chemotherapy on subclinical right ventricular (RV) dysfunction in breast cancer patients, using traditional echocardiographic parameters and strain-based measures, such as the RV global longitudinal strain (RV GLS) and the RV free-wall longitudinal strain (RV FWLS).

METHODS AND RESULTS

A systematic search was conducted according to PRISMA guidelines, including 15 studies with a total of 1148 breast cancer patients undergoing anthracycline chemotherapy. The primary outcome was the evaluation of changes in RV GLS and RV FWLS pre- and post-chemotherapy. Secondary outcomes included changes in traditional echocardiographic parameters: TAPSE, FAC, and TDI S'. Meta-analysis revealed significant declines in RV function post-chemotherapy across all parameters. RV GLS decreased from 23.99% to 20.35% (SMD: -0.259, p < 0.0001), and RV FWLS from 24.92% to 21.56% (SMD: -0.269, p < 0.0001). Traditional parameters like TAPSE, FAC, and TDI S' also showed reductions, but these were less consistent across studies. A meta-regression analysis showed no significant relationship between post-chemotherapy left ventricular ejection fraction (LVEF) and the changes in RV GLS and RV FWLS, suggesting that RV dysfunction may not be solely a consequence of LV impairment.

CONCLUSIONS

Anthracycline chemotherapy induces subclinical RV dysfunction in breast cancer patients. RV strain analysis, especially 3D strain, shows greater sensitivity in detecting early dysfunction. However, further research is needed to clarify the clinical significance and prognostic value of these findings, as well as the role of routine RV strain analysis in guiding early interventions.

Global longitudinal strain manually measured from mid-myocardial lengths is a reliable alternative to speckle tracking global longitudinal strain

BACKGROUND

Global longitudinal strain (GLS) is a useful marker for the echocardiographic evaluation of left ventricular (LV) systolic dysfunction. Presently GLS is derived from speckle tracking of LV images, but speckle tracking software is not always available. We seek to determine if manually measured GLS (MM-GLS) by assessing mid-myocardial lengths can be a reliable alternative to speckle tracking GLS (ST-GLS).

METHODS

Transthoracic echocardiogram images of a tertiary hospital in Australia were retrospectively analyzed to study the relationships between ST-GLS, MM-GLS, and LV ejection fraction (LVEF). We further evaluated the impact of image quality and regional wall motion abnormalities on those relationships.

RESULTS

Echocardiography studies from 154 patients were included (female sex, 36%; mean age, 61.7 ± 14.8 years). The average LVEF was 51.3% ± 11.3% and the average ST-GLS was 16.7 ± 3.8. MM-GLS strongly correlated with ST-GLS (intraclass correlation coefficient, 0.986; P < 0.001) and with LVEF regardless of the presence of regional wall motion abnormalities. If using GLS cutoff of more than 18% as normal, 97.5% of studies with normal ST-GLS had normal MM-GLS. If using GLS cutoff as less than 16% as abnormal, 95.5% of studies with abnormal ST-GLS had abnormal MM-GLS. There was no case with ST-GLS > 18% and MM-GLS < 16%, nor were there any case in with ST-GLS < 16% and MM-GLS > 18%.

CONCLUSIONS

MM-GLS correlates strongly with ST-GLS. If ST-GLS cannot be accurately assessed, MM-GLS may be a useful alternative to provide GLS values in both clinical and research studies.

Impact of Aficamten on Echocardiographic Cardiac Structure and Function in Symptomatic Obstructive Hypertrophic Cardiomyopathy

BACKGROUND

Aficamten, a next-in-class cardiac myosin inhibitor, improved peak oxygen uptake (pVO2) and lowered resting and Valsalva left ventricular outflow (LVOT) gradients in adults with symptomatic obstructive hypertrophic cardiomyopathy (oHCM) in SEQUOIA-HCM (Phase 3 Trial to Evaluate the Efficacy and Safety of Aficamten Compared to Placebo in Adults With Symptomatic oHCM), a phase 3, multicenter, randomized, double-blinded, placebo-controlled study.

OBJECTIVES

The authors sought to evaluate the effect of aficamten on echocardiographic measures of cardiac structure and function in SEQUOIA-HCM.

METHODS

Serial echocardiograms were performed over 28 weeks in patients randomized to receive placebo or aficamten in up to 4 individually titrated escalating doses (5-20 mg daily) over 24 weeks based on Valsalva LVOT gradients and left ventricular ejection fraction (LVEF).

RESULTS

Among 282 patients (mean age 59 ± 13 years; 41% female, 79% White, 19% Asian), mean LVEF was 75% ± 6% with resting and Valsalva LVOT gradients of 55 ± 30 mm Hg and 83 ± 32 mm Hg, respectively. Over 24 weeks, aficamten significantly lowered resting and Valsalva LVOT gradients, and improved left atrial volume index, lateral and septal e' velocities, and lateral and septal E/e' (all P ≤ 0.001). LV end-systolic volume increased and wall thickness decreased (all P ≤ 0.003). Aficamten resulted in a mild reversible decrease in LVEF (-4.8% [95% CI: -6.4% to -3.3%]; P < 0.001) and absolute LV global circumferential strain (-3.7% [95% CI: 1.8%-5.6%]; P < 0.0010), whereas LV global longitudinal strain was unchanged. Several measures, including LVEF, LVOT gradients, and E/e' returned to baseline following washout. Among those treated with aficamten, improved pVO2 and reduction in N-terminal pro-B-type natriuretic peptide (NT-proBNP) were associated with improvement in lateral e' velocity and septal and lateral E/e' (all P < 0.03), whereas improvement in Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores (KCCQ-CSS) was associated with a decrease in both LVOT gradients (all P < 0.001).

CONCLUSIONS

Compared with placebo, patients receiving aficamten demonstrated significant improvement in LVOT gradients and measures of LV diastolic function, and several of these measures were associated with improvements in pVO2, KCCQ-CSS, and NT-proBNP. A modest decrease in LVEF occurred yet remained within normal range. These findings suggest aficamten improved multiple structural and physiological parameters in oHCM without significant adverse changes in LV systolic function. (Phase 3 Trial to Evaluate the Efficacy and Safety of Aficamten Compared to Placebo in Adults With Symptomatic oHCM [SEQUOIA-HCM]; NCT05186818).

Early Detection of Left Ventricular Dysfunction With Machine Learning-Based Strain Imaging in Aortic Stenosis Patients

PURPOSE

Aortic stenosis (AS) is a common cardiovascular condition where early detection of left ventricular (LV) dysfunction is essential for timely intervention and optimal management. Current echocardiographic measurements, such as ejection fraction (EF), are insensitive to minor changes in LV function, and strain imaging is typically limited to the global longitudinal strain (GLS) parameter due to robustness issues. This study introduces a novel, fully automatic algorithm to enhance the detection of LV dysfunction in AS patients using multiple strain imaging parameters.

METHODS

We applied supervised machine-learning techniques to classify data from 82 severe AS patients, 96 chest pain subjects, and 319 healthy volunteers.

RESULTS

Our model significantly outperformed EF and GLS in distinguishing AS patients from healthy volunteers (area under the curve [AUC] = 0.97 vs. 0.88 and 0.82, respectively). It also surpassed EF and GLS in differentiating AS patients from chest pain subjects (AUC = 0.95 vs. 0.90 and 0.55, respectively).

CONCLUSION

This novel, clinically interpretable model leverages the potential of strain imaging to enhance diagnostic accuracy and guide clinical decision-making in LV dysfunction, thereby improving clinical practice.

Prognostic Value of CT-Derived Myocardial Biomarkers: Extracellular Volume Fraction and Strain in Patients with Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-analysis

RATIONALE AND OBJECTIVES

This study aimed to investigate the prognostic value of preoperative CT scan-derived myocardial biomarkers in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).

MATERIALS AND METHODS

In April 2024, three databases (PubMed, Web of Science and Embase) were searched to identify studies. A random-effects model for meta-analysis was conducted to calculate pooled hazard ratios (HR) and 95% confidence intervals (CI) to assess the prognostic value. The I2 statistic was used to assess heterogeneity. Meta-regression analysis was conducted to appraise which variables yielded a significant impact on the HR of included biomarkers.

RESULTS

11 studies were identified, of which six studies involved 678 patients reporting extracellular volume fraction (ECV), one study involved 300 patients reporting ECV and left ventricular global longitudinal strain (LVGLS), three studies involved 868 patients reporting LVGLS and one study involved 376 patients reporting LVGLS and peak left atrial longitudinal strain (PALS). The endpoints included all-cause mortality, major adverse cardiovascular events (MACE) and a composite outcome of the previous two. The meta-analysis revealed that ECV, whether considered as a dichotomous variable (pooled HR: 3.87, 95% CI: 2.63-5.70, I2 = 0%), or as a continuous variable (pooled HR: 1.12, 95% CI: 1.05-1.19, I2 = 66%), and LVGLS, whether considered as a dichotomous variable (pooled HR: 1.70, 95% CI: 1.30-2.22, I2 = 0%) or a continuous variable (pooled HR: 1.07, 95% CI: 1.04-1.10, I2 = 0%) were all significant predictors for outcomes in patients with severe AS after TAVR. Age, sex, follow-up time and mean pressure gradient had a significant impact on the model of ECV (continuous).

CONCLUSION

The higher CT-derived ECV and impaired LVGLS are able to predict worse outcomes in patients with severe AS who have undergone TAVR.

An Artificial Intelligence-Based Automated Echocardiographic Analysis: Enhancing Efficiency and Prognostic Evaluation in Patients With Revascularized STEMI

BACKGROUND AND OBJECTIVES

Although various cardiac parameters on echocardiography have clinical importance, their measurement by conventional manual methods is time-consuming and subject to variability. We evaluated the feasibility, accuracy, and predictive value of an artificial intelligence (AI)-based automated system for echocardiographic analysis in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

The AI-based system was developed using a nationwide echocardiographic dataset from five tertiary hospitals, and automatically identified views, then segmented and tracked the left ventricle (LV) and left atrium (LA) to produce volume and strain values. Both conventional manual measurements and AI-based fully automated measurements of the LV ejection fraction and global longitudinal strain, and LA volume index and reservoir strain were performed in 632 patients with STEMI.

RESULTS

The AI-based system accurately identified necessary views (overall accuracy, 98.5%) and successfully measured LV and LA volumes and strains in all cases in which conventional methods were applicable. Inter-method analysis showed strong correlations between measurement methods, with Pearson coefficients ranging 0.81-0.92 and intraclass correlation coefficients ranging 0.74-0.90. For the prediction of clinical outcomes (composite of all-cause death, re-hospitalization due to heart failure, ventricular arrhythmia, and recurrent myocardial infarction), AI-derived measurements showed predictive value independent of clinical risk factors, comparable to those from conventional manual measurements.

CONCLUSIONS

Our fully automated AI-based approach for LV and LA analysis on echocardiography is feasible and provides accurate measurements, comparable to conventional methods, in patients with STEMI, offering a promising solution for comprehensive echocardiographic analysis, reduced workloads, and improved patient care.

Comprehensive echocardiographic and biomarker assessment of patients with diabetic ketoacidosis

BACKGROUND

Systemic stress, inflammation, and hydroelectrolytic and acid‒base abnormalities observed during diabetic ketoacidosis (DKA) can cause changes in the heart and even induce cardiovascular damage. We aimed to evaluate the structure and function of the heart during and after a DKA episode via echocardiography and biomarker assessment.

METHODS

We performed a transthoracic echocardiogram (TTE) in subjects with an episode of DKA in the first 4-6 h of treatment. We evaluated left ventricular wall thickness, diameters and volumes, as well as systolic and diastolic function using tissue Doppler imaging, pulsed wave Doppler and left ventricular ejection fraction (LVEF). Left ventricular function was also assessed with global longitudinal strain (GLS). We obtained cardiac troponin levels in the first 24 h after admission. A second TTE was performed following the same protocol 6-12 h after the resolution of the DKA episode.

RESULTS

We included a total of 20 subjects. The mean age was 33 ± 13.6 years; 70% were female, and 70% had type 1 DM. 75% of the patients experienced severe episodes, and the rest experienced moderate episodes. Left ventricular isovolumetric contraction and ejection time were significantly shorter during DKA and prolonged after the resolution of the episodes (47.6 ± 9.9 vs. 62.2 ± 14.1, p = < 0.001) and (218.6 ± 37.9 vs. 265.06 ± 34.7). The isovolumetric relaxation time was also shorter during DKA, (41.72 ± 8.29 vs. 59.32 ± 17.98, p = < 0.001). Volumes and diameters of the left ventricle increased significantly after DKA resolution. We found no difference between LVEF or GLS during and after DKA resolution. 20% of the participants had troponin elevations, half of whom had moderate episodes and half of whom had severe episodes. 35% had LV dysfunction, 28.5% both in GLS and LVEF. 28.5% occurred after DKA resolution, with alterations in GLS.

CONCLUSIONS

Diabetic ketoacidosis induces changes in the structure and function of the heart, which are mostly transient, reflect the presence of a hyperdynamic state and resolve after the resolution of the episode. Some subjects present with evidence of myocardial injury with elevated cardiac troponin and left ventricular dysfunction.

Comparison of Left Ventricular Global Longitudinal Strain and Left Ventricular Ejection Fraction in Acute Respiratory Failure Patients Requiring Invasive Mechanical Ventilation

Left ventricular (LV) dysfunction is associated with poor clinical outcomes in acute respiratory failure (ARF). This study evaluates the efficacy of LV strain in detecting LV dysfunction in ARF patients requiring invasive mechanical ventilation (IMV) compared to conventionally measured left ventricular ejection fraction (LVEF). ARF patients requiring IMV who had echocardiography performed during MICU admission were included. LV global longitudinal strain (LVGLS) and LVEF were measured retrospectively using speckle tracking (STE) and traditional transthoracic echocardiography (TTE), respectively, by investigators blinded to the status of IMV and clinical data. The cohort was divided into three groups: TTE during IMV (TTE-IMV), before IMV (TTE-bIMV), and after IMV (TTE-aIMV). Multivariable regression models, adjusted for illness severity score, chronic cardiac disease, acute respiratory failure etiology, body mass index, chronic obstructive pulmonary disease, and obstructive sleep apnea, evaluated associations between LV function parameters and the presence of IMV. Among 376 patients, TTE-IMV, TTE-bIMV, and TTE-aIMV groups constituted 223, 68, and 85 patients, respectively. The median age was 65 years (IQR: 56-74), with 53.2% male participants. Adjusted models showed significantly higher LVGLS in groups not on IMV at the time of TTE (TTE-bIMV: β = 4.19, 95% CI 2.31 to 6.08, p < 0.001; TTE-aIMV: β = 3.79, 95% CI 2.03 to 5.55, p < 0.001), while no significant differences in LVEF were observed across groups. In a subgroup analysis of patients with LVEF ≥55%, the significant difference in LVGLS among the groups remained (TTE-bIMV: β = 4.18, 95% CI 2.22 to 6.15, p < 0.001; TTE-aIMV: β = 3.45, 95% CI 1.50 to 5.40, p < 0.001), but was no longer present in those with LVEF < 55%. This suggests an association between IMV and lower LVGLS in ARF patients requiring IMV, indicating that LVGLS may be a more sensitive marker for detecting subclinical LV dysfunction compared to LVEF in this population. Future studies should track and assess serial echocardiography data in the same cohort of patients pre-, during, and post-IMV in order to validate these findings and prognosticate STE-detected LV dysfunction in ARF patients requiring IMV.

Hypertrophic Cardiomyopathy as a Form of Heart Failure with Preserved Ejection Fraction: Diagnosis, Drugs, and Procedures

Hypertrophic cardiomyopathy (HCM) is a complex and heterogeneous cardiac disorder characterized by cardiac hypertrophy disproportionate to loading stimuli (e.g. hypertension or aortic stenosis). Diagnosing HCM requires a thorough examination of clinical symptoms, with echocardiography as the key initial imaging tool. Multimodality imaging further supports diagnosis, helps assess left ventricular outflow obstruction, and aids in risk stratification for sudden cardiac death. The cornerstone of HCM management remains pharmacological therapy with β-blockers and calcium channel blockers serving as first-line agents to alleviate symptoms and reduce left ventricular outflow tract obstruction. More recently, cardiac myosin inhibitors have revolutionized the treatment paradigm for obstructive HCM. Procedural interventions such as septal reduction therapy are reserved for refractory cases. Genetic testing and risk stratification for sudden cardiac death play a critical role in treatment decisions, guiding further testing in first-degree relatives and ICD implantation in high-risk individuals. Exercise recommendations have evolved based on recent data, challenging traditional restrictions and emphasizing individualized plans.

Association between myocardial layer-specific strain and high 10-year risk of atherosclerotic cardiovascular disease in hypertension-findings from the China-PAR project study

Objectives

Myocardial layer-specific strain is a sensitive tool for detecting myocardial dysfunction. The objective of this study was to assess changes in the left ventricle (LV) function using myocardial layer-specific strain and its association with 10-year atherosclerotic cardiovascular disease risk (10Y-ASCVDR) in individuals with hypertension (HP).

Methods

The parameters of LV structure, including layer-specific global longitudinal strain (GLSww, GLSendo, GLSmid, GLSepi) and layer-specific global circumferential strain (GCSww, GCSendo, GCSmid, GCSepi), were analyzed by two-dimensional speckle-tracking echocardiography in 239 hypertensive patients and 124 control subjects. In addition, participants were divided into low-risk (LR) and high-risk (HR) subgroups according to 10Y-ASCVDR scores . The correlation between myocardial layer-specific strain and 10Y-ASCVDR was further analyzed by the restricted cubic spline (RCS) function.

Results

The values of GLSww, GLSepi, GLSmid, and GLSendo were significantly lower in HP patients with HR than in HP patients with LR and controls (p < 0.05). However, no significant differences in layer-specific GCS were observed between the groups (p > 0.05). RCS analysis revealed that 10Y-ASCVDR exhibited a significant J-shaped relationship with layer-specific GLS and GCS. After adjusting for confounding factors, GLSww (β = 0.156, p = 0.042), GLSmid (β = 0.161, p = 0.032), GCSendo (β = 0.163, p = 0.024), and GCSmid (β = -0.175, p = 0.030) were identified as independent influencing factors for high 10Y-ASCVDR.

Conclusions

In hypertensive patients, myocardial layer-specific strain, especially GLS, sensitively detected LV dysfunction and showed a significant J-shaped relationship with 10Y-ASCVDR. GCSmid may have a compensatory effect on myocardial impairment. LV myocardial layer-specific strain may help to understand the early compensatory mechanisms of the myocardium in hypertension.

Ablation-induced left atrial mechanical dysfunction recovers in weeks after ablation

BACKGROUND

The immediate impact of catheter ablation on left atrial mechanical function and the timeline for its recovery in patients undergoing ablation for atrial fibrillation (AF) remain uncertain. The mechanical function response to catheter ablation in patients with different AF types is poorly understood.

METHODS

A total of 113 AF patients were included in this retrospective study. Each patient had three magnetic resonance imaging (MRI) studies in sinus rhythm: one pre-ablation, one immediate post-ablation (within 2 days after ablation), and one post-ablation follow-up MRI (≤ 3 months). We used feature tracking in the MRI cine images to determine peak longitudinal atrial strain (PLAS). We evaluated the change in strain from pre-ablation, immediately after ablation to post-ablation follow-up in a short-term study (< 50 days) and a 3-month study (3 months after ablation).

RESULTS

The PLAS exhibited a notable reduction immediately after ablation, compared to both pre-ablation levels and those observed in follow-up studies conducted at short-term (11.1 ± 9.0 days) and 3-month (69.6 ± 39.6 days) intervals. However, there was no difference between follow-up and pre-ablation PLAS. The PLAS returned to 95% pre-ablation level within 10 days. Paroxysmal AF patients had significantly higher pre-ablation PLAS than persistent AF patients in pre-ablation MRIs. Both type AF patients had significantly lower immediate post-ablation PLAS compared with pre-ablation and post-ablation PLAS.

CONCLUSION

The present study suggested a significant drop in PLAS immediately after ablation. Left atrial mechanical function recovered within 10 days after ablation. The drop in PLAS did not show a substantial difference between paroxysmal and persistent AF patients.

Effect of Coronary Collateral Supply on Left Ventricular Global Longitudinal Strain after Recanalization of Chronic Total Occlusion

Percutaneous coronary intervention (PCI) to chronic total occlusion (CTO) is still a subject of debate. The primary goal of revascularization is to provide symptomatic relief and enhance left ventricular (LV) functions. Global longitudinal strain (GLS) is proven to be more sensitive than the ejection fraction (EF), especially for subtle ischemic changes. The purpose of this study was to investigate the improvement in LV GLS after revascularization of symptomatic stable coronary patients with single-vessel CTO, categorized according to their collateral supply grades. Sixty-nine patients with successful CTO-PCI were grouped, according to their collateral supply grades, as well-developed (WD) and poor collateral groups and followed-up for 3 months. Basal characteristics were similar for both groups, except for a lower EF (p = 0.04) and impaired GLS (p < 0.0001) in the poor collateral group. At the end of 3 months follow-up, symptomatic relief was similar in both groups (p = 0.101). GLS improvement reached statistical significance only for the poor collateral, not for the WD group (p < 0.0001 and p = 0.054, respectively). The EF did not change significantly in both groups. Poorly collateralized CTO lesions may not only result in baseline LV dysfunction, but also appear to carry potential for recovery after revascularization. This may not be the case for WD collaterals.

Advanced myocardial characterization and function with cardiac CT

Non-invasive imaging with characterization and quantification of the myocardium with computed tomography (CT) became feasible owing to recent technical developments in CT technology. Cardiac CT can serve as an alternative modality when cardiac magnetic resonance imaging and/or echocardiography are contraindicated, not feasible, inconclusive, or non-diagnostic. This review summarizes the current and potential future role of cardiac CT for myocardial characterization including a summary of late enhancement techniques, extracellular volume quantification, and strain analysis. In addition, this review highlights potential fields for research about myocardial characterization with CT to possibly include it in clinical routine in the future.

Contemporary Multimodality Imaging for Diagnosis and Management of Fabry Cardiomyopathy

Fabry disease (FD) is an X-linked lysosomal storage disorder which leads to the accumulation of globotriaosylceramide (Gb3) in various organs, including the heart. FD can be subdivided into classic disease resulting from negligible residual enzyme activity and a milder, atypical phenotype with later onset and less severe clinical presentation. The use of multimodality cardiac imaging including echocardiography, cardiac magnetic resonance and nuclear imaging is important for the diagnostic and prognostic evaluation in these patients. There are gaps in the literature regarding the comprehensive description of cardiac findings of FD and its evaluation by multimodality imaging. In this review, we describe the contemporary practices and roles of multimodality cardiac imaging in individuals affected with Fabry disease.

Multidirectional myocardial function in bicuspid aortic valve stenosis patients: a three-dimensional speckle tracking analysis

Purpose

The impact of aortic stenosis (AS) severity on multidirectional myocardial function in patients with bicuspid aortic valve (BAV) remains unclear, despite the recognized presence of early left ventricular longitudinal myocardial dysfunction in BAV patients with normal valve function. The aim of the study was to evaluate the multidirectional myocardial functions of BAV patients.

Methods

A total of 86 BAV patients (age 46.71 ± 13.62 years, 69.4% men) with normally functioning (BAV-nf), mild AS, moderate AS, and severe AS with preserved left ventricular ejection fraction (LVEF ≥ 52%) were included. 30 healthy volunteers were recruited as the control group. Multidirectional strain and volume analysis were performed by three-dimensional speckle tracking echocardiography(3D-STE).

Results

Global longitudinal strain (GLS), and global radial strain (GRS) were reduced in BAV-nf patients compared with the controls. With each categorical of AS severity from BAV-nf to severe AS, there was an associated progressive impairment of GLS and GRS (all P < 0.001). Global circumferential strain (GCS) did not show a significant decrease from BAV-nf to mild AS but began to decrease from moderate AS. Multiple linear regressions indicated that indexed aortic valve area (AVA/BSA), as a measure of AS severity, was an independent determinant of GLS, GCS and GRS.

Conclusions

Left ventricular longitudinal myocardial reduction is observed even in patients with well-functioning bicuspid aortic valves. With each categorical increase in the grade of AS severity from normally functioning to severe aortic stenosis, there was an associated progressive impairment of longitudinal myocardial function. Furthermore, circumferential myocardial function was starting damaged from moderate AS. AVA/BSA was independently associated with multidirectional myocardial function injuries.

Use of Speckle-Tracking Echocardiography in Septic Cardiomyopathy in Critically Ill Children: A Narrative Review

OBJECTIVES

In critically ill children with severe sepsis, septic cardiomyopathy (SCM) denotes the subset of patients who have myocardial dysfunction with poor response to fluid and inotropic support, and higher mortality risk. The objective of this review was to evaluate the role of speckle-tracking echocardiography (STE) in the diagnosis and prognosis of pediatric SCM in the PICU setting.

DATA SOURCES

We performed detailed searches using PubMed, Scopus, Web of Science, and Google Scholar. Reference lists of all included studies were also examined for further identification of potentially relevant studies.

STUDY SELECTION

Studies with the following medical subject headings and keywords were selected: speckle-tracking echocardiography, strain imaging, global longitudinal strain, echocardiography, sepsis, severe sepsis, septic shock, septic cardiomyopathy, and myocardial dysfunction.

DATA EXTRACTION

The following data were extracted from all included studies: demographics, diagnoses, echocardiographic parameters, severity of illness, PICU management, and outcomes.

DATA SYNTHESIS

STE is a relatively new echocardiographic technique that directly quantifies myocardial contractility. It has high sensitivity in diagnosing SCM, correlates well with illness severity, and has good prognosticating value as compared with conventional echocardiographic parameters. Further studies are required to establish its role in evaluating biventricular systolic and diastolic dysfunction, and to investigate whether it has a role in individualizing treatment and improving treatment outcomes in this group of patients.

CONCLUSIONS

STE is a useful adjunct to conventional measures of cardiac function on 2D-echocardiography in the assessment of pediatric SCM in the PICU.

Preoperative right ventricular strain as an early predictor of perioperative cardiac failure in patients undergoing mitral surgery: An exploratory study

Objectives

This study's primary purpose was to demonstrate the correlation of preoperative right ventricular free-wall longitudinal strain (RVFWLS) and pre-/postsurgical variation in strain (delta strain) with the clinical and echocardiographic diagnosis of right ventricular dysfunction. Its secondary purpose was to determine the correlation of RVFWLS and delta strain with length of stay (LOS) in the intensive care unit (ICU), ventilation days, trend of natriuretic peptide test. (NT-proBNP) and lactate in the first 48 h, incidence of acute renal failure, and 28-day mortality.

Design

Prospective observational study.

Setting

Cardio-thoracic and Vascular Anaesthesia Department and ICU of the University Hospital Integrated Trust of Verona.

Participants

Patients scheduled for mitral surgery.

Interventions

None.

Measurements and Main Results

All clinical and transoesophageal echocardiographic (TEE) parameters were collected at baseline, before surgery (T1) and at admission in the ICU postsurgery (T2). During the postoperative period, the clinical and echocardiographic diagnoses of right, left, or biventricular dysfunction were evaluated. TEE parameters were evaluated by a cardiologist offline. The patients were divided into two subgroups according to the development of any type of ventricular dysfunction. No statistically significant differences emerged between the two groups. According to a logistic regression model, a T1-RVFWLS value of -15% appeared to predict biventricular dysfunction (sensitivity: 100%; specificity: 91.3%). No correlation between T1- or T2-RVFWLS and creatinine, hours of ventilation or ICU LOS was found.

Conclusions

Our study introduces a new parameter that could be used in perioperative evaluations to identify patients at risk of postoperative biventricular dysfunction.

Quantitative evaluation of adhesion severity around subscapularis and its relationship with shoulder range of motion in frozen shoulder and rotator cuff disorder: an observational study using dynamic ultrasonography

Background

This study aimed to evaluate the severity of adhesion between muscles in the shoulder joint using dynamic ultrasonography and to confirm whether adhesions cause range of motion (ROM) restrictions.

Methods

Twenty-four shoulders from 15 frozen shoulder patients and 24 shoulders from 18 rotator cuff disorder patients were enrolled. We obtained ultrasound video sequences of the subscapularis (SSC) and deltoid muscles during shoulder external rotation. The mean stretching velocities of the deltoid and SSC were subsequently analyzed using a personal computer. If adhesions occurred between both muscles, the deltoid was stretched more vigorously, and we calculated mean stretching velocity of the deltoid / SSC as adhesion severity. The coracohumeral ligament thickness was measured using the same images. Shoulder ROM was measured by using a universal goniometer.

Results

The intraclass correlation coefficients (1.1) and (2.1) of the adhesion severity measurements were 0.85 and 0.91, respectively. Multiple linear regression analysis revealed that the adhesion severity is a significant predictor for external rotation ROM in the rotator cuff disorder group (R2 = 0.44, F = 10.1, P < .01, t = -2.9), while coracohumeral ligament thickness predicts ROM in the frozen shoulder group (R2 = 0.28, F = 5.5, P = .01, t = -3.0).

Conclusion

The proposed method is reliable. Muscle adhesion causes ROM restriction of the shoulder joint. The primary cause of shoulder ROM restriction differed between the diagnostic groups.

Deficiency in Prader-Willi syndrome gene necdin leads to attenuated cardiac contractility

Prader-Willi syndrome (PWS) is a genetic disorder characterized by behavioral disturbances, hyperphagia, and intellectual disability. Several surveys indicate that PWS is also associated with cardiac abnormalities, possibly contributing to a high incidence of sudden death. However, the pathological mechanisms underlying cardiac dysfunction in PWS remain unclear. In this study, we found that deficiency in necdin, an intronless gene within PWS region, led to heart systolic and diastolic dysfunction in mice. Through yeast two-hybrid screening, we identified an interaction between necdin and non-muscle myosin regulatory light chain 12a/b (MYL12 A/B). We further showed that necdin stabilized MYL12 A/B via SGT1-heat shock protein 90 (HSP90) chaperone machinery. The zebrafish lacking the MYL12 A/B analog, MYL12.1, exhibited impaired heart function, while cardiac-specific overexpression of MYL12A normalized the heart dysfunction in necdin-deficient mice. Our findings revealed necdin dysfunction as a contributing factor to cardiomyopathy in PWS patients and emphasized the importance of HSP90 chaperone machinery and non-muscle myosin in heart fitness.

Speckle-Tracking Echocardiography in Right Ventricular Function of Clinically Well Patients with Heart Transplantation

Heart transplantation (HT) is the mainstream therapy for end-stage heart disease. However, the cardiac graft function can be affected by several factors. It is important to monitor HT patients for signs of graft dysfunction. Transthoracic echocardiography is a simple, first-line, and non-invasive method for the assessment of cardiac function. The emerging speckle-tracking echocardiography (STE) could quickly and easily provide additive information over traditional echocardiography. STE longitudinal deformation parameters are markers of early impairment of ventricular function. Although once called the "forgotten ventricle", right ventricular (RV) assessment has gained attention in recent years. This review highlights the potentially favorable role of STE in assessing RV systolic function in clinically well HT patients.

Two-dimensional speckle-tracking echocardiography in left ventricular systolic function in patients with systemic lupus erythematosus

OBJECTIVES

To investigate whether two-dimensional speckle-tracking echocardiography (2DSTE) can be considered a criterion for early left ventricular (LV) systolic impairment in patients with systemic lupus erythematosus (SLE) and to further explore the association with each other.

METHODS

We included 38 patients with SLE and assessed the degree of disease activity according to the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) 2000 scoring criteria, together with 38 healthy controls who were matched by sex and age. Routine LV systolic function evaluation parameters were obtained by echocardiography as well as 2DSTE measurement of LV strain parameters to obtain global longitudinal strain (GLS) values, respectively.

RESULTS

(I) On routine LV function parameters such as ejection fractions (EF) and left ventricular end-diastolic internal diameter (LVIDd), the SLE group and the control group did not reflect differences. In contrast, on the LV strain parameter obtained from 2DSTE measurements, the GLS values in all cardiac planes were lower in the SLE group than in the control group and showed statistically significant differences. (II) Correlation analysis showed that there was a correlation between SLEDAI and GLS, especially a meaningful correlation with GLS Avg and GLS A4C, with correlation coefficients of 0.35 and 0.47, respectively.

CONCLUSIONS

The use of 2DSTE can detect early impaired LV systolic function in SLE patients, and GLS is progressively gaining attention as an indicator of subclinical myocardial injury and LV function in SLE patients. The correlation that exists between GLS and SLEDAI might contribute to a better assessment of cardiac involvement in SLE patients. Key Points • Cardiac involvement has become one of the major factors in the poor prognosis of SLE patients, which directly affects the mortality of SLE patients. Traditional echocardiography is difficult to detect early left ventricular function impairment, thus affecting clinicians' judgment and diagnosis. • 2DSTE can recognize subclinical myocardial injury in SLE patients at an early stage, and its derived strain parameters may be used as an indicator to evaluate myocardial involvement and reflect disease activity in SLE patients.

Association between speckle tracking echocardiography and pressure-volume loops during cardiogenic shock development

BACKGROUND

The relationship between speckle tracking assessed global longitudinal strain (GLS) and Doppler-based echocardiography with basic physiological markers of cardiac function derived from pressure-volume loops is poorly elucidated.

OBJECTIVE

We aimed to describe the association between LS and Doppler-based echocardiography and direct measurements of central haemodynamic parameters from conductance catheter-based pressure-volume loops in an animal model with increasing left ventricular (LV) dysfunction.

METHODS

12 Danish landrace female pigs (75-80 kg) were used. All instrumentations were performed percutaneously, including the conductance catheter in the LV. Progressive LV dysfunction was induced by embolisation through the left main coronary artery with microspheres every 3 min until a >50% reduction in cardiac output (CO) or mixed venous saturation (SvO2), compared with baseline, or SvO2 <30%. Echocardiography was performed at baseline and 90 s after each injection.

RESULTS

With progressive LV dysfunction, mean CO decreased from 5.6±0.9 L/min to 2.1±0.9 L/min, and mean SvO2 deteriorated from 61.1±7.9% to 35.3±6.1%. Mean LS and LV outflow tract velocity time integral (LVOT VTI) declined from -13.8±3.0% to -6.1±2.0% and 16.9±2.6 cm to 7.8±1.8 cm, respectively. LS and LVOT VTI showed the strongest correlation to stroke work in unadjusted linear regression (r2=0.53 and r2=0.49, respectively). LS correlated significantly with stroke volume, end-systolic elastance, systolic blood pressure, ventriculo-arterial coupling and arterial elastance.

CONCLUSION

In an animal model of acute progressive LV dysfunction, echocardiographic and conductance catheter-based measurements changed significantly. LS and LVOT VTI displayed the earliest and the largest alterations with increased myocardial damage and both correlated strongest with stroke work.

Comparative analysis of left ventricle function and deformation imaging in short and long axis plane in cardiac magnetic resonance imaging

Background

Advancements in cardiac imaging have revolutionized our understanding of ventricular contraction. While ejection fraction (EF) is still the gold standard parameter to assess left ventricle (LV) function, strain imaging (SI) has provided valuable insights into ventricular mechanics. The lack of an integrative method including SI parameters in a single, validated formula may limit its use. Our aim was to compare different methods for evaluating global circumferential strain (GCS) and their relationship with global longitudinal strain (GLS) and EF in CMR and how the different evaluations fit in the theoretical relationship between EF and global strain.

Methods

Retrospective monocenter study. Inclusion of every patient who underwent a CMR during a 15 months period with various clinical indication (congenital heart defect, myocarditis, cardiomyopathy). A minimum of three LV long-axis planes and a stack of short-axis slices covering the LV using classical steady-state free precession cine sequences. A single assessment of GLS on long axis (LAX) slices and a double assessment of GCS and EF with both short axis (SAX) and LAX slices were made by a single experienced CMR investigator.

Results

GCS-SAX and GCS-LAX were correlated (r = 0.77, P < 0.001) without being interchangeable with a high reproducibility for GCS, GLS and EF. EF calculated from LAX images showed an overestimation compared to EF derived from SAX images of 7%. The correlation between calculated EF and theoretical EF derived from SI was high (r = 0.88 with EF-SAX, 0.95 with EF-LAX).

Data conclusion

This study highlights the need to integrate strain imaging techniques into clinical by incorporating strain parameters into EF calculations, because it gives a deeper understanding of cardiac mechanics.

Prognostic impact of MRI-derived feature tracking myocardial strain in patients with non-ischaemic dilated cardiomyopathy: a systematic review and meta-analysis

AIM

To evaluate the clinical utility of feature tracking (FT)-derived myocardial strain in patients with non-ischaemic dilated cardiomyopathy (NIDCM).

MATERIALS AND METHODS

Electronic database searches of PubMed, Web of Science Core Collection, Cochrane advanced search, and EMBASE were performed. Studies on NIDCM were divided into categories according to left ventricular ejection fraction (LVEF; <30%, 30-40%, >40%), and correlations between strains and prevalence of late gadolinium enhancement (LGE) were evaluated by weighted correlation coefficients. Global longitudinal strain (GLS) hazard ratios were also integrated for prediction of future adverse events.

RESULTS

The present meta-analysis analysed data from 5,767 patients with NIDCM from 30 eligible studies. GLS and global circumferential strain significantly differed across the three LVEF categories (all p<0.05); however, global radial strain did not. Only GLS showed a strong correlation with the prevalence of LGE (Spearman's correlation coefficient = 0.61). The pooled HR of GLS for predicting adverse events was 1.15 (95% confidence interval [CI]: 1.07-1.23, p<0.001).

CONCLUSION

In this meta-analysis, FT-derived GLS was strongly correlated with myocardial fibrosis and was an important predictor of future adverse events. These results suggest that FT-derived GLS may be useful in the pathological evaluation and risk stratification of NIDCM.

Prevalence and risk factors for cirrhotic cardiomyopathy: a prospective cross-sectional study

BACKGROUND

This study aimed to assess cardiac structure and function in patients with cirrhosis, to investigate the prevalence of cirrhotic cardiomyopathy (CCM) in patients with cirrhosis of different etiologies and to analyze the risk factors for the development of CCM.

METHODS

This study selected cirrhotic patients aged 18-75 years who were hospitalized in Qilu Hospital of Shandong University. Patients with known heart disease, chronic lung disease, severe renal insufficiency, malignancy, thyroid disease, hypertension, diabetes or pregnancy were excluded. A total of 131 patients with cirrhosis were finally included. Based on the results of echocardiography, patients who met the diagnostic definition of CCM were included in the CCM group, otherwise, they were classified as the non-CCM group. The demographic and clinical data of the two groups were compared, and the clinical characteristics and risk factors of CCM were evaluated.

RESULTS

The overall prevalence of CCM was 24.4%, and the occurrence of CCM was not related to the etiology of liver cirrhosis. The prevalence of CCM was significantly higher among cirrhotic patients complicated with ascites (31.4% vs. 16.4%; P  = 0.046) or with portal vein thrombosis (PVT) (42.9% vs. 17.1%; P  = 0.003). Older age [odds ratio (OR) = 1.058; 95% confidence interval (CI), 1.005-1.113; P  = 0.032] and PVT (OR = 2.999; 95% CI, 1.194-7.533; P  = 0.019) were independent risk factors for the development of CCM.

CONCLUSION

The prevalence of CCM in cirrhotic patients was 24.4%, and the occurrence of CCM was not related to the etiology of cirrhosis. The prevalence of CCM was higher in cirrhotic patients with ascites or PVT. Older age and PVT are independent risk factors for CCM, but validation in larger sample studies is still needed.