Assessment of left ventricular systolic function by deformation imaging derived from speckle tracking: a comparison between 2D and 3D echo modalities

Imaging predictors of adverse prognosis in Fabry disease cardiomyopathy: A systematic review and meta-analysis

BACKGROUND

Cardiac involvement represents the main cause of death in patients with Fabry disease (FD). Echocardiography and cardiovascular magnetic resonance (CMR) have an established diagnostic role, but their prognostic value remains unresolved. This systematic review and meta-analysis sought to assess the prognostic implications of imaging parameters in FD.

METHODS

PubMed, ClinicalTrials.gov, Embase, Cochrane Library and Web of Science databases were searched for studies from inception through 1 May 2024. Studies including FD patients undergoing baseline imaging assessment and clinical follow-up were selected. Pre-defined study outcomes were a cardiovascular endpoint and a composite clinical endpoint. The study protocol was registered in PROSPERO (ID CRD42022342394).

RESULTS

Fourteen studies, including 1713 FD patients (44.7% males), were selected. At pooled analysis, late gadolinium enhancement (hazard ratio [HR]: 4.45; 95% CI: 2.82-7.02), left atrium volume indexed (HR: 1.02 per mL/m2; 95% CI: 1.01-1.03), E/e' (HR: 1.14 per unit increase; 95% CI: 1.08-1.21), left ventricular (LV) mass indexed (HR: 1.01 per mg/m2; 95% CI: 1.00-1.02), maximum LV wall thickness (HR: 1.19 per mm, 95% CI: 1.04-1.36) and LV-global longitudinal strain (HR: 1.20 per unit increase; 95% CI: 1.16-1.25) were significantly associated with the cardiovascular endpoint, whereas T1-mapping and LV-ejection fraction were not. T1-mapping was associated with the composite endpoint (HR: 0.99 per msec increase; 95% CI: 0.98-1.00). Meta-regression analysis did not show any significant interaction between each of the potential effect modifiers.

CONCLUSIONS

Several imaging parameters were significant predictors of adverse clinical outcomes in patients with FD. Late gadolinium enhancement showed the strongest association with adverse prognosis.

Feedback Attention to Enhance Unsupervised Deep Learning Image Registration in 3D Echocardiography

Cardiac motion estimation is important for assessing the contractile health of the heart, and performing this in 3D can provide advantages due to the complex 3D geometry and motions of the heart. Deep learning image registration (DLIR) is a robust way to achieve cardiac motion estimation in echocardiography, providing speed and precision benefits, but DLIR in 3D echo remains challenging. Successful unsupervised 2D DLIR strategies are often not effective in 3D, and there have been few 3D echo DLIR implementations. Here, we propose a new spatial feedback attention (FBA) module to enhance unsupervised 3D DLIR and enable it. The module uses the results of initial registration to generate a co-attention map that describes remaining registration errors spatially and feeds this back to the DLIR to minimize such errors and improve self-supervision. We show that FBA improves a range of promising 3D DLIR designs, including networks with and without transformer enhancements, and that it can be applied to both fetal and adult 3D echo, suggesting that it can be widely and flexibly applied. We further find that the optimal 3D DLIR configuration is when FBA is combined with a spatial transformer and a DLIR backbone modified with spatial and channel attention, which outperforms existing 3D DLIR approaches. FBA's good performance suggests that spatial attention is a good way to enable scaling up from 2D DLIR to 3D and that a focus on the quality of the image after registration warping is a good way to enhance DLIR performance. Codes and data are available at: https://github.com/kamruleee51/Feedback_DLIR.

Changes in Left Ventricular Function Assessed by 3D Echocardiography During Severe Central Hypovolemia in Healthy Humans

PURPOSE

Central hypovolemia is considered to lead to a compensatory increase in cardiac contractility. From a physiological perspective, left ventricular (LV) twisting motion, which plays an important role in maintaining cardiac output, should be enhanced during central hypovolemia, but previous studies have shown inconsistent findings. Using 3D echocardiography, we tested the hypothesis that the LV twisting and untwisting motion would be enhanced during severe central hypovolemia.

METHODS

Thirteen healthy men (25 ± 5 years old) underwent the maximal lower body negative pressure (LBNP) protocol; graded increase in LBNP loads up to presyncope. We evaluated the basic hemodynamics and LV function with 3D and Doppler echocardiography at each stage of LBNP. Indices were compared among baseline, half maximal LBNP (LBNP1/2max), and one stage before the presyncope (LBNPpre-max) to consider individual differences in orthostatic tolerance.

RESULTS

In response to LBNP, ejection fraction (baseline: 62 ± 3, LBNP1/2max: 55 ± 5, LBNPpre-max: 43% ± 9%, mean ± SD, p < 0.01, ANOVA), global longitudinal strain (-20.5 ± 2.8, -17.6 ± 2.7, -13.6% ± 4.7%, p < 0.01), and global circumferential strain (-31.2 ± 3.7, -26.8 ± 3.3, -19.4% ± 5.3%, p < 0.01) were weakened. Twist (15.2 ± 5.1, 14.5 ± 5.4, 20.9° ± 7.7°, p = 0.012) and peak untwisting rate (-138 ± 42, -164 ± 50, -245°/cm ± 88°/cm, p < 0.01) were strengthened at the LBNPpre-max. e' (14.1 ± 2.0, 11.1 ± 1.5, 8.2° ± 2.2 cm/s, p < 0.01) decreased in response to LBNP, while E/e' (5.8 ± 0.8, 5.4 ± 1.0, 7.8 ± 2.3, p < 0.01) increased at LBNPpre-max.

CONCLUSION

The present findings indicate that LV twisting motion is enhanced during severe central hypovolemia. On the other hand, conventional echocardiographic indices appeared to deteriorate. Intriguingly, an index of LV filling (E/e') was paradoxically enhanced during severe central hypovolemia.

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.

Patterns of left ventricular remodeling post-myocardial infarction, determinants, and outcome

AIM

Left ventricular remodeling (LVR) after myocardial infarction (MI) can lead to heart failure, arrhythmia, and death. We aim to describe adverse LVR patterns at 6 months post-MI and their relationships with subsequent outcomes and to determine baseline.

METHODS AND RESULTS

A multicenter cohort of 410 patients (median age 57 years, 87% male) with reperfused MI and at least 3 akinetic LV segments on admission was analyzed. All patients had transthoracic echocardiography performed 4 days and 6 months post-MI, and 214 also had cardiac magnetic resonance imaging performed on day 4. To predict LVR, machine learning methods were employed in order to handle many variables, some of which may have complex interactions. Six months post-MI, echocardiographic increases in LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), and LV ejection fraction (LVEF) were 14.1% [interquartile range 0.0, 32.0], 5.0% [- 14.0, 25.8], and 8.7% [0.0, 19.4], respectively. At 6 months, ≥ 15% or 20% increases in LVEDV were observed in 49% and 42% of patients, respectively, and 37% had an LVEF < 50%. The rate of death or new-onset HF at the end of 5-year follow-up was 8.8%. Baseline variables associated with adverse LVR were determined best by random forest analysis and included stroke volume, stroke work, necrosis size, LVEDV, LVEF, and LV afterload, the latter assessed by Ea or Ea/Ees. In contrast, baseline clinical and biological characteristics were poorly predictive of LVR. After adjustment for predictive baseline variables, LV dilation > 20% and 6-month LVEF < 50% were significantly associated with the risk of death and/or heart failure: hazard ratio (HR) 2.12 (95% confidence interval (CI) 1.05-4.43; p = 0.04) and HR 2.68 (95% CI 1.20-6.00; p = 0.016) respectively.

CONCLUSION

Despite early reperfusion and cardioprotective therapy, adverse LVR remains frequent after acute MI and is associated with a risk of death and HF. A machine learning approach identified and prioritized early variables that are associated with adverse LVR and which were mainly hemodynamic, combining LV volumes, estimates of systolic function, and afterload.

Evaluation of left ventricular systolic function in patients with iron deficiency anemia based on non-invasive left ventricular pressure-strain loops

BACKGROUND

Iron deficiency anemia (IDA) is a common health problem worldwide. The objective of this study was to noninvasively and quantitatively evaluate early changes in left ventricular systolic function in patients with IDA using the left ventricular press-strain loop (LV-PSL).

METHODS

Sixty-two patients with IDA were selected and divided into two groups based on hemoglobin (Hb) concentration: Group B with Hb > 9 g/dL and group C with 6 g/dL < Hb < 9 g/dL. Thirty-three healthy individuals were used as the control (Group A). The global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global waste work (GWW), global work efficiency (GWE) were derived using LV-PSL analysis. Receiver operating characteristic (ROC) curves were constructed for MW parameters to detect abnormal left ventricular systolic function in IDA patients.

RESULTS

Compared to group A, GWI and GCW were reduced in group B (both P < 0.01). Compared with groups B and A, GLS, GWI, GCW and GWE, and E/A were all diminished, and GWW, LVEDV, LVESV, and E/mean e' were all increased in group C (all P < 0.01). GLS was positively correlated with GWI, GCW, and GWE (r = 0.679, 0.681, and 0.447, all P < 0.01), and negatively associated with GWW (r = - 0.411, all P < 0.01). For GWI, area under the ROC curve (AUROC) was 0.783. The optimal GWI threshold for detecting abnormal LV systolic function in IDA was1763 mmHg%, with sensitivity of 0.71 and specificity of 0.78.

CONCLUSIONS

LV-PSL allows noninvasive quantitative assessment of early impaired LV systolic function in IDA patients with preserved LV ejection fraction, and GWI has high sensitivity and specificity compared with other parameters.

Subtle myocardial effects of rheumatic heart disease in children are revealed earlier with two-dimensional speckle tracking echocardiography

OBJECTIVE

Rheumatic heart disease (RHD) is the most common cause of acquired heart disease in developing countries and remains a serious public health problem. In the subclinical course of carditis, the absence of typical symptoms and the normal range of classical echocardiographic measurements used to evaluate cardiac functions have required new echocardiographic methods and parameters. Previous studies regarding rheumatic heart disease in children and adults have shown that strain patterns obtained by speckle tracking echocardiography, are in fact affected although left ventricular systolic functions are preserved, yet some studies have suggested otherwise. The aim of our study is to compare the use of speckle tracking echocardiography with conventional methods in the evaluation of cardiac functions and myocardial involvement in children with subclinical RHD.

MATERIALS AND METHODS

The study group consisted of 24 patients with asymptomatic cardiovascular who had no history of acute rheumatic fever, but had definite or probable rheumatic valve disease. This study group was determined according to the World Heart Federation guidelines by an echocardiographic examination performed for different reasons, as well as the control group of 22 healthy children. In order to evaluate the left ventricular regional myocardial functions of the patients, tissue Doppler echocardiography (TDE) and speckle tracking echocardiographic parameters were compared with the control group.

RESULTS

The mean ages of the patient and control groups were 14.1±2.7 years and 13.9±2.3 years, respectively. There was no statistically significant difference between the two groups in terms of conventional methods (p>0.05) but global longitudinal strain and strain rate values were found to be significantly lower in the patient group (p<0.01). These changes appeared to be relevant throughout the duration of the illness.

CONCLUSION

In patients with subclinical rheumatic heart disease, conventional echocardiographic evaluations are likely negative, whereas two-dimensional speckle tracking echocardiography reveal systolic and diastolic dysfunctions of the disease.

Impact of Bariatric Surgery on Left Ventricular Structure and Function

BACKGROUND

Obesity leads to an increased risk of cardiovascular disease morbidity and death, including heart failure. Bariatric surgery has been proven to be the most effective long-term weight management treatment. This study investigated the changes in cardiac structure and function after bariatric surgery, including left ventricular global longitudinal strain.

METHODS AND RESULTS

There were 398 consecutive patients who underwent bariatric surgery with pre- and postoperative transthoracic echocardiographic imaging at a US health system between 2004 and 2019. We compared cardiovascular risk factors and echocardiographic parameters between baseline and follow-up at least 6 months postoperatively. Along with decreases in weight postoperatively, there were significant improvements in cardiovascular risk factors, including reduction in systolic blood pressure levels from 132 mm Hg (25th-75th percentile: 120-148 mm Hg) to 127 mm Hg (115-140 mm Hg; P=0.003), glycated hemoglobin levels from 6.5% (5.9%-7.6%) to 5.7% (5.4%-6.3%; P<0.001), and low-density lipoprotein levels from 97 mg/dL (74-121 mg/dL) to 86 mg/dL (63-106 mg/dL; P<0.001). Left ventricular mass decreased from 205 g (165-261 g) to 190 g (151-236 g; P<0.001), left ventricular ejection fraction increased from 58% (55%-61%) to 60% (55%-64%; P<0.001), and left ventricular global longitudinal strain improved from -15.7% (-14.3% to -17.5%) to -18.6% (-16.0% to -20.3%; P<0.001) postoperatively.

CONCLUSIONS

This study has shown the long-term impact of bariatric surgery on cardiac structure and function, with reductions in left ventricular mass and improvement in left ventricular global longitudinal strain. These findings support the cardiovascular benefits of bariatric surgery.

Altered ventricular longitudinal strain in children with sickle cell disease: Role of TGF-β and IL-18

BACKGROUND

Cardiovascular involvement in sickle cell disease (SCD) has a great impact on patients' morbidity and mortality. Recently, interleukin-18 (IL-18) and transforming growth factor beta (TGF-β) were suggested as potential biomarkers for sickle cell cardiomyopathy. Global longitudinal strain (GLS) is a reliable early parameter for estimation of deformed myocardium. This study evaluated the role of TGF-β and IL-18 as risk indicators of altered strain in patients with SCD.

METHODS

Forty children with SCD (age >5 years) and 40 healthy children as controls, matched in age and sex, were enrolled in the study. All participants were subjected to clinical examination, complete blood count, serum ferritin, TGF-β, IL-18, and assessment of cardiac function by echocardiography.

RESULTS

TGF-β, IL-18, and lactic acid dehydrogenase (LDH) were significantly higher among cases (mean age: 10.6 ± 3.5 years) when compared to controls (p < .001), at cutoff values 41.7 ng/mL, 128.9 pg/mL, and 340 unit, respectively. The LS of free wall of RV (FW-RV) was significantly lower among cases when compared to controls (-23.55% ± 5.55% vs. -28.73% ± 2.43%, p < .001). Free wall longitudinal strain of the right ventricle (FWLS-RV) was significantly correlated to IL-18 and LDH (p < .001), while GLS-RV was significantly correlated to TGF-β. The GLS-LV was correlated to frequency of vaso-occlusive crises (VOCs) per year (p < .001). Diastolic function, E/A of LV, and RV were negatively correlated to the hemoglobin and serum ferritin levels.

CONCLUSIONS

The TGF-β, IL-18, and LDH along with frequent VOCs are correlated to altered LS, especially the right ventricle, and could serve as risk indicators for subclinical cardiomyopathy in children with SCD.

Use of speckle tracking echocardiography in evaluating cardiac dysfunction in patients with acromegaly: an update

In recent years, cardiovascular disease has garnered increasing attention as the second leading cause of death in individuals with acromegaly, following malignancy. Identifying cardiac dysfunction early in acromegaly patients for timely intervention has become a focal point of clinical research. Speckle tracking echocardiography, a well-established ultrasound technique, surpasses conventional Doppler ultrasound in its sensitivity to assess both local and global cardiac mechanics. It can accurately detect subclinical and clinical myocardial dysfunction, including myocardial ischemia, ventricular hypertrophy, and valvular changes. Over the past five years, the use of speckle tracking echocardiography in acromegaly patients has emerged as a novel approach. Throughout the cardiac cycle, speckle tracking echocardiography offers a sensitive evaluation of the global and regional myocardial condition by quantifying the motion of myocardial fibres in distinct segments. It achieves this independently of variations in ultrasound angle and distance, effectively simulating the deformation of individual ventricles across different spatial planes. This approach provides a more accurate description of changes in cardiac strain parameters. Importantly, even in the subclinical stage when ejection fraction remains normal, the strain parameters assessed by speckle tracking echocardiography hold a good predictive value for the risk of cardiovascular death and hospitalization in acromegaly patients with concomitant cardiovascular disease. This information aids in determining the optimal timing for interventional therapy, offering important insights for cardiac risk stratification and prognosis. In the present study, we comprehensively reviewed the research progress of speckle tracking echocardiography in evaluating of cardiac dysfunction in acromegaly patients, to pave the way for early diagnosis of acromegaly cardiomyopathy.

Demonstration of subclinical left ventricular electrical and mechanical dysfunction in overweight subjects by frontal QRS-T angle and 3D-speckle tracking echocardiography

BACKGROUND

Overweightness is a considerable step in the process leading to obesity. There are no sufficient studies on the effect of cardiomyopathy defined in obese patients about overweight subjects. We thought that it may be useful to examine the myocardial involvement in overweight individuals electro-mechanically with more sensitive techniques before the development of obesity cardiomyopathy.

AIM

The aim of the present study was to demonstrate whether or not there are subclinical left ventricular (LV) electrical and mechanical dysfunctions in overweight patients using frontal QRS-T (fQRS-T) angle (electrically) and 3D-speckle tracking echocardiography (mechanically).

METHODS

A total of 80 overweight patients and 80 age- and sex-matched normal weight individuals were enrolled into the study. 3D-STE examinations of the patients were performed. Electrocardiographic recordings were obtained for fQRS-T angle assessment.

RESULTS

The LV-GLS and LV-GCS were significantly depressed in the overweight group than in the normal weight group (-14.5 ± 3.4 vs. -21.7 ± 3.6, p < .001; -15.2 ± 4.6 vs. -24.3 ± 4.8, p < .001, respectively). The fQRS-T angle was found to be increased in the overweight group (142.5 ± 39.2 vs. 114.7 ± 43.5, p = < .001). Statistically significant positive linear correlations were observed between BMI with LV-GLS, LV-GCS, and fQRS-T angle. LV-GLS and LV-GCS were found to be disrupted linearly as BMI increased (r = .718 for BMI and LV-GLS, r = .653 for BMI and LV-GCS). As BMI increased, it was found that the fQRS-T angle increased (r = .692 for BMI and fQRS-T angle).

CONCLUSION

Our results support that, overweight individuals, despite their being apparently healthy, may have subclinical LV myocardial mechanical and electrical dysfunction.

Non-alcoholic Fatty Liver Disease and Its Association With Left Ventricular Diastolic Dysfunction: A Systematic Review

The commonest cause of hepatic illness globally is non-alcoholic fatty liver disease (NAFLD). This multisystemic disease affects extrahepatic organs, including the heart. It causes cardiac remodeling and a disruption of the systolic and diastolic functioning of the left ventricle. Numerous studies have investigated the connection between NAFLD and left ventricular diastolic dysfunction (LVDD). The results, nevertheless, are often contradictory. This systematic review looked at the relationship between NAFLD and LVDD generally and among different patient groups since it is a topic of interest. A thorough search approach was used to locate relevant publications published between 2003 and 2023 using major medical databases. Studies were chosen based on the pre-established eligibility criteria; the studies selected then underwent a critical evaluation using standardized quality assessment tools. For the systematic review, 13 articles were chosen, comprising nine cross-sectional studies, three narrative reviews, and one meta-analysis. There were a total of 13,341 NAFLD patients in these studies. Data extraction and qualitative synthesis from the selected research articles were conducted to determine the relationship between NAFLD and LVDD in various patient categories. We found a significant association between NAFLD and LVDD. Therefore, patients with NAFLD should be treated early to avoid complications since they are more likely to develop cardiac dysfunction in the future.

Characterization of myocardial mechanics and its prognostic significance in patients with severe aortic stenosis undergoing aortic valve replacement

AIMS

Aortic stenosis (AS) induces characteristic changes in left ventricular (LV) mechanics that can be reversed after aortic valve replacement (AVR). We aimed to comprehensively characterize LV mechanics before and after AVR in patients with severe AS and identify predictors of short-term functional recovery and long-term survival.

METHODS AND RESULTS

We prospectively performed comprehensive strain analysis by 2D speckle-tracking echocardiography in 88 patients with severe AS and LV ejection fraction ≥50% (mean age 71 ± 12 years, 42% female) prior to and within 7 days after AVR. Patients were followed for up to 5.2 years until death from any cause or last encounter. Within days after AVR, we observed an absolute increase in global longitudinal strain (GLS) (-16.0 ± 2.0% vs. -18.5 ± 2.1%, P<0.0001) and a decrease in apical rotation (10.5 ± 4.0° vs. 8.3 ± 2.8°, P = 0.0002) and peak systolic twist (18.2 ± 5.0° vs. 15.5 ± 3.8°, P = 0.0008). A baseline GLS is less negative than -16.2% was 90% sensitive and 67% specific in predicting a ≥ 20% relative increase in GLS. During a median follow-up of 3.8 years, a global circumferential systolic strain rate (GCSRs) less negative than -1.9% independently predicted lower survival.

CONCLUSION

In patients with severe AS, a reversal in GLS, apical rotation, and peak systolic twist abnormalities towards normal occurs within days of AVR. Baseline GLS is the strongest predictor of GLS recovery but neither was associated with long-term survival. In contrast, abnormal baseline GCSRs are associated with worse outcomes.

Clinical Utility of Three-Dimensional Speckle-Tracking Echocardiography in Heart Failure

Heart failure (HF) is an extremely major health problem with gradually increasing incidence in developed and developing countries. HF may lead to cardiac remodeling; thus, advanced imaging techniques are required to comprehensively evaluate cardiac mechanics. Recently, three-dimensional speckle-tracking echocardiography (3D-STE) has been developed as a novel imaging technology that is based on the three-dimensional speckle-tracking on the full volume three-dimensional datasets. Three-dimensional speckle-tracking echocardiography allows a more accurate evaluation of global and regional myocardial performance, assessment of cardiac mechanics, detection of subclinical cardiac dysfunction, and prediction of adverse clinical events in a variety of cardiovascular diseases. Therefore, this review summarizes the clinical usefulness of 3D-STE in patients with HF.

Cardiovascular Imaging in Cardio-Oncology: The Role of Echocardiography and Cardiac MRI in Modern Cardio-Oncology

Cardiovascular (CV) events are an increasingly common limitation of effective anticancer therapy. Over the last decade imaging has become essential to patients receiving contemporary cancer therapy. Herein we discuss the current state of CV imaging in cardio-oncology. We also provide a practical apparatus for the use of imaging in everyday cardiovascular care of oncology patients to improve outcomes for those at risk for cardiotoxicity, or with established cardiovascular disease. Finally, we consider future directions in the field given the wave of new anticancer therapies.

Prediction of prognosis in patients with left ventricular dysfunction using three-dimensional strain echocardiography and cardiac magnetic resonance imaging

BACKGROUND

We evaluated three-dimensional speckle tracking echocardiography (3DSTE) strain and cardiac magnetic resonance (CMR) with delayed contrast enhancement (DCE) for the prediction of cardiac events in left ventricular (LV) dysfunction.

METHODS

CMR and 3DSTE in 75 patients with ischaemic and 38 with non-ischaemic LV dysfunction were analysed and temporally correlated to cardiac events during 41 ± 9 months of follow-up.

RESULTS

Cardiac events occurred in 44 patients, more in patients with ischaemic LV dysfunction. LV ejection fraction (LVEF), global circumferential and global area strain were reduced more in patients with more cardiac events, whereas 3DSTE LV end-systolic volumes and 3DSTE LV masses were larger. However, the area under the curve using receiver-operating characteristic analysis showed modest sensitivity and specificity for all evaluated parameters. Additionally, DCE did not differ significantly between the two groups. Univariate analysis showed ischaemic aetiology of LV dysfunction, LVEF and LV mass by CMR to be predictors of cardiac events with an increased relative risk of 2.4, 1.6 and 1.5, respectively. By multivariate analysis, only myocardial ischaemia and LVEF ≤ 39% were independent predictors of events (p = 0.004 and 0.005, respectively). Subgroup analysis in ischaemic and non-ischaemic patients showed only 3DSTE LV mass in ischaemic patients to have a significant association (p = 0.033) but without an increased relative risk.

CONCLUSION

LVEF calculated by 3DSTE or CMR were both good predictors of cardiac events in patients with LV dysfunction. A reduced LVEF ≤ 39% was associated with a 1.6-fold higher probability of a cardiac event. 3DSTE strain measurements and DCE-CMR did not add to the prognostic value of LVEF.

The Agreement of a Two- and a Three-Dimensional Speckle-Tracking Global Longitudinal Strain

Background: Two-dimensional (2D) and three-dimensional (3D) speckle-tracking echocardiography (STE) enables assessment of myocardial function. Here, we examined the agreement between 2D and 3D STE measurement of a global longitudinal strain (GLS) in patients with normal left ventricle, reduced ejection fraction, and cardiac pacing. Methods: Our analysis included 90 consecutive patients (59% males; average age: 73.2 ± 11.2 years) examined between May 2019−December 2020, with valid 2D and 3D loops for further speckle-tracking strain analysis. Linear regression, Pearson correlation, and a Bland−Altman plot were used to quantify the association between 2D and 3D GLS and related segments, using the 17-segment American Heart Association (AHA) model. Analyses were performed in the entire study group and subgroups. Intra- and inter-observer variability of 2D and 3D GLS measurement was also performed in all participants. Results: We observed a strong correlation between 2D and 3D GLS measurements (R = 0.76, p < 0.001), which was higher in males (R = 0.78, p < 0.001) than females (R = 0.69, p < 0.001). Associated segment correlation was poor (R = 0.2−0.5, p < 0.01). The correlation between 2D and 3D GLS was weaker in individuals with ventricular pacing of >50% (R = 0.62, p < 0.001) than <50% (R = 0.8, p < 0.001), and in patients with LVEF of <35% (R = 0.69, p = 0.002) than >35% (R = 0.72, p < 0.001). Intra-observer variability for 2D and 3D GLS was 2 and 2.3%, respectively. Inter-observer variability for 2D and 3D GLS was 3.8 and 3.6%, respectively Conclusion: Overall 2D and 3D GLS were closely associated but not when analyzed per segment. It seems that GLS comparison is more representative of global shortening than local displacement. Right ventricular pacing and reduced left ventricular ejection fraction were associated with a reduced correlation between 2D and 3D GLS.

Comprehensive evaluation of left ventricular deformation using speckle tracking echocardiography in normal children: comparison of three-dimensional and two-dimensional approaches

Background

Three-dimensional (3D) speckle tracking echocardiography (STE) can overcome some of the inherent limitations of two-dimensional (2D) STE; however, clinical experience is lacking. We aimed to assess and compare the feasibility, agreement, and reproducibility of left ventricular (LV) global longitudinal (GLS), and regional strain by 3D vs 2D STE in normal children.

Methods

Healthy pediatric subjects (n = 105, age mean = 11.2 ± 5.5 years) were prospectively enrolled. Three-dimensional and 2D LV GLS, as well as regional strain in 16 myocardial segments were quantified. Bland Altman analysis, intra- class correlation coefficients (ICC), percent error and linear regression were used for agreement and correlation between the two techniques. Analysis and acquisition times were compared. Inter- and intra-observer reproducibility was assessed in 20 studies.

Results

There was good to excellent agreement for 2D and 3D global longitudinal strain (ICC =0.82) and modest agreement for regional strain (ICC range 0.43–0.71). Both methods had high feasibility (88.6% for 2D vs 85.7% for 3D, p = 0.21), although 3D STE required significantly shorter acquisition and analysis time than 2D STE (acquisition time 1 ± 1.2 mins vs 2.4 ± 1 mins; p = 0.03, analysis time = 3.3 ± 1 mins vs 8.2 ± 2.5 mins; p = 0.001, respectively). Inter and intra-observer reproducibility was excellent for GLS by the two techniques (ICC = 0.78–0.93) but moderate to poor for regional strain (ICC = 0.21–0.64).

Conclusion

Three-dimensional global LV strain is as feasible and reproducible as 2D strain, with good agreement yet significantly more efficient acquisition and analysis. Regional strain is less concordant and 2D and 3D values should not be used interchangeably. 3D LV GLS may represent a viable alternative in evaluation of LV deformation in pediatric subjects.

1. Adequate feasibility of 3D STE in pediatrics; comparable to 2D STE.

2. Significantly shorter acquisition and analysis time for 3D GLS compared to 2D GLS.

3. Excellent agreement between 3D and 2D LV GLS and moderate to poor agreement between regional strain values.

4. Excellent inter and intra-observer reproducibility for GLS by the two techniques, and fair to poor reproducibility for regional strain (higher for apical than basal regions).

Early onset left ventricular remodeling in juvenile systemic lupus erythematosus; Insight from 3-dimensional speckle tracking echocardiography

BACKGROUND

Early diagnosis and treatment of myocardial affection in patients with systemic lupus erythematosus (SLE) are crucial.

OBJECTIVES

To evaluate the ventricular systolic function in juvenile-onset systemic lupus erythematosus (j-SLE) patients by 3-D speckle tracking echocardiography (3D-STE) and to determine the predictors of left ventricular (LV) dysfunction if present.

METHODS

Twenty-six SLE patients without heart failure and 21 healthy controls were studied by standard echocardiogram and 3D-STE. Conventional parameters included LV ejection fraction (EF), fractional shortening (FS), and mitral annular plane systolic excursion (MAPSE). Global LV strain (GLS) and global area strain (GAS) were obtained by 3D-STE. Medical records, including diagnosis criteria, duration of disease, and SLE disease activity index (SLEDAI) were evaluated.

RESULTS

The mean age was similar in patients and controls 11.42 vs 11.48 years p  =  0.93. The mean duration of the disease was 1.87 ± 1.02 years and SLEDAI ranged from 0 to 9. By conventional and tissue Doppler imaging echocardiography, only MAPSE was significantly lower in SLE patients compared to controls (14.56 vs 18.46 mm, p < 0.001). By 3D speckle tracking echocardiography, GLS and GAS were significantly reduced in SLE patients compared to controls (-15.07 vs -19.9.4%, -34.6% vs -39.7%, respectively, p < 0.001). Multiple linear regression and ROC analyses indicated that the SLEDAI score was the only predictive factor for the left ventricular remodeling.

CONCLUSIONS

These results indicate that early subclinical LV dysfunction occur in jSLE patients even with normal EF and SLE disease activity might be a potential driver for LV deformation.

Heart Model A.I. Three-Dimensional Echocardiographic Evaluation of Left Ventricular Function and Parameter Setting

Objective

This study aims to explore the feasibility of HeartModel ^A.I. (HM) three-dimensional echocardiography (3DE) to assess left ventricular function and discover suitable border parameter settings.

Methods

A total of 113 patients that underwent echocardiography in our hospital were eligible for inclusion. The HM 3DE (HM method) and conventional 3DE (3D method) were used to analyze echocardiography images. The HM was set to different border settings (end-diastolic [ED] and end-systolic [ES] settings) to assess different left ventricular systolic function parameters including left ventricular end diastolic volume (LVEDV), left ventricular end systolic volume (LVESV), and left ventricular ejection fraction (LVEF), and left ventricular diastolic function parameters including maximal left atrium volume (LAV_MAX). All of these parameters were evaluated using the HM method and then compared with the 3D method.

Results

The differences in LVEDV, LVESV, and LVEF measured with different HM border settings were statistically significant (P<0.05) and were strongly correlated with the 3D method. For LVEF, the reading using the HM method with ED and ES = 70 and 30 showed the best agreement with the 3D method, and the difference in the readings was not statistically significant (P > 0.05). For LVEDV and LVESV, the reading using the HM method with ED and ES = 40 and 20 showed the best agreement with the 3D method, but the difference in the readings was statistically significant (P < 0.05). The measurements taken using the HM method were more reproducible than those taken using the 3D method (P<0.05). The measurement time when using the HM method was significantly less than the 3D method (P<0.05). In terms of LAV_MAX, the correlation between the HM and 3D methods was strong, but the requirements for agreement were not satisfied.

Conclusion

Evaluation of the left ventricular function using HM 3DE is feasible, saves time, and is reproducible. To assess the left ventricular function, the border parameter setting of ED and ES = 70 and 30 provided the best fit for the Chinese population.

Ultrastructural aberrations, histological disruption and upregulation of the VEGF, CD34 and ASMA immunoexpression in the myocardium of anemic albino rats

Iron deficiency anemia (IDA) is a global health problem affecting various body systems and tissues including the cardiovascular system. Several literatures described the associated physiological and clinical changes in the cardiovascular system and heart. However, the associated structural changes were poorly investigated. Therefore, the main aim of the present work was to elucidate whether IDA induces structural changes and alterations in the VEGF, CD34 and ASMA immunoexpression in the myocardium of albino rats. Thirty adult male albino rats were divided into two groups (fifteen rats each); control and anemic. Hematological data for all animals were assessed weekly and statistically analyzed. Three weeks later, animals were sacrificed, and heart specimens were obtained and processed for light and electron microscopy. All hematological parameters showed a statistically significant decrease in the anemic group. Structurally, the anemic group showed markedly degenerated, disrupted and disorganized cardiomyocytes in addition to markedly congested blood vessels, fibroblasts, collagen fibers deposition and perivascular cellular infiltration were noted. Also, positive immunostaining for VEGF, CD34 and ASMA was observed. Ultra-structurally, the myocardium of the anemic group showed disrupted and degenerated myofibrils with degenerated nuclei, perinuclear edema, widened interstitial spaces and marked collagen deposition. Mitochondria markedly increased with abnormal shapes. IDA induced myocardial injury that may propagate to regeneration through activated CD34 progenitor cells and increased VEGF or to degeneration and fibrosis through collagen fibers deposition and enhanced ASMA. So, early diagnosis and treatment of IDA is mandatory to avoid the associated myocardial structural changes.

Myocardial deformation in patients with a single left ventricle using 2D cardiovascular magnetic resonance feature tracking: a case-control study

Ventricular dysfunction is a well-known complication in single ventricle patients in Fontan circulation. As studies exclusively examining patients with a single left ventricle (SLV) are sparse, we assessed left ventricular (LV) function in SLV patients by using 2D-cardiovascular magnetic resonance (CMR) feature tracking (2D-CMR-FT) and 2D-speckle tracking echocardiography (2D-STE). 54 SLV patients (11.4, 3.1–38.1 years) and 35 age-matched controls (12.3, 6.3–25.8 years) were included. LV global longitudinal, circumferential and radial strain (GLS, GCS, GRS) and strain rate (GLSR, GCSR, GRSR) were measured using 2D-CMR-FT. LV volumes, ejection fraction (LVEF) and mass were determined from short axis images. 2D-STE was applied in patients to measure peak systolic GLS and GLSR. In a subgroup analysis, we compared double inlet left ventricle (DILV) with tricuspid atresia (TA) patients. The population consisted of 19 DILV patients, 24 TA patients and 11 patients with diverse diagnoses. 52 patients were in NYHA class I and 2 patients were in class II. Most SLV patients had a normal systolic function but median LVEF in patients was lower compared to controls (55.6% vs. 61.2%, p = 0.0001). 2D-CMR-FT demonstrated reduced GLS, GCS and GCSR values in patients compared to controls. LVEF correlated with GS values in patients (p < 0.05). There was no significant difference between GLS values from 2D-CMR-FT and 2D-STE in the patient group. LVEF, LV volumes, GS and GSR (from 2D-CMR-FT) were not significantly different between DILV and TA patients. Although most SLV patients had a preserved EF derived by CMR, our results suggest that, LV deformation and function may behave differently in SLV patients compared to healthy subjects.

Dissecting myocardial mechanics in patients with severe aortic stenosis: 2-dimensional vs 3-dimensional-speckle tracking echocardiography

Background

Aortic stenosis (AS) causes left ventricular (LV) pressure overload, leading to adverse LV remodeling and dysfunction. Identifying early subclinical markers of LV dysfunction in patients with significant AS is critical as this could provide support for earlier intervention, which may result in improved long-term outcomes. We therefore examined the impact of severe AS and its consequent increase in LV afterload on myocardial deformation and rotational mechanics by 2-dimensional (2D) and 3-dimensional (3D) speckle-tracking echocardiography.

Methods

We prospectively measured various strain parameters in 168 patients (42% female, mean age 72 ± 12 years) with severe AS and LV ejection fraction (EF) ≥50%, and compared them to normal values found in literature. 2D and 3D images were analyzed for global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), basal rotation, apical rotation, and peak systolic twist. We further assessed the degree of concordance between 2D and 3D strain, and examined their association with measures of LV preload and afterload.

Results

Patients with severe AS exhibited significantly lower GLS and GRS but higher GCS, apical rotation, and twist by 2D and 3D echocardiography compared with published normal values (P = 0.003 for 3D twist, P < 0.001 for all others). Agreement between 2D- and 3D-GLS by concordance correlation coefficient was 0.49 (95% confidence interval: 0.39–0.57). GLS was correlated with valvulo-arterial impedance, a measure of LV afterload (r = 0.34, p < 0.001 and r = 0.23, p = 0.003, respectively).

Conclusion

Patients with severe AS demonstrated lower-than-normal GLS and GRS but appear to compensate with higher-than-normal GCS, apical rotation, and twist in order to maintain a preserved LVEF. GLS showed a modest correlation with valvulo-arterial impedance.

Speckle tracking deformation imaging to detect regional fibrosis in hypertrophic cardiomyopathy: a comparison between 2D and 3D echo modalities

AIMS

We aimed at directly comparing three-dimensional (3D) and two-dimensional (2D) deformation parameters in hypertrophic hearts and depict which may best reflect underlying fibrosis in hypertrophic cardiomyopathy (HCM), defined by late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR).

METHODS AND RESULTS

We included 40 HCM [54.1 ± 14.3 years, 82.5% male, maximum wall thickness (MWT) 19.3 ± 4.8 mm] and 15 hypertensive (HTN) patients showing myocardial hypertrophy (58.1 ± 15.6 years, 80% male, MWT 12.8 ± 1.4 mm) who have consecutively undergone 2D-, 3D-speckle tracking echocardiography and LGE CMR. Deformation parameters (2D and 3D) presented overall poor to moderate correlations, with 3D_longitudinal strain (LS) and 3D_circumferential strain (CS) values being constantly higher compared to 2D derivatives. By regression analysis, hypertrophy substrate (HCM vs. hypertension) and hypertrophy magnitude were the parameters to influence 2D-3D LS and CS strain correlations (R2 = 0.66, P < 0.001 and R2 = 0.5, P = 0.001 accordingly). Among segmental deformation indices, 2D_LS showed the best area under the curve [AUC = 0.78, 95% confidence intervals (CI) (0.75-0.81), P < 0.0005] to detect fibrosis, with 3D deformation parameters showing similar AUC (0.65) and 3D_LS presenting the highest specificity [93.1%, 95% CI (90.6-95.1)].

CONCLUSIONS

In hypertrophic hearts, 2D and 3D deformation parameters are not interchangeable, showing modest correlations. Thickness, substrate, and tracking algorithm calculating assumptions seem to induce this variability. Nevertheless, among HCM patients 2D_peak segmental longitudinal strain remains the best strain parameter for tissue characterization and fibrosis detection.

A Comparison of Three-Dimensional Speckle Tracking Echocardiography Parameters in Predicting Left Ventricular Remodeling

Three-dimensional speckle tracking echocardiography (3D STE) is an emerging noninvasive method for predicting left ventricular remodeling (LVR) after acute myocardial infarction (AMI). Previous studies analyzed the predictive value of 3D STE with traditional models. However, no models that contain comprehensive risk factors were assessed, and there are limited data on the comparison of different 3D STE parameters. In this study, we sought to build a machine learning model for predicting LVR in AMI patients after effective percutaneous coronary intervention (PCI) that contains the majority of the clinical risk factors and compare 3D STE parameters values for LVR prediction. We enrolled 135 first-onset AMI patients (120 males, mean age 54 ± 9 years). All patients went through a 3D STE and a traditional transthoracic echocardiography 24 hours after reperfusion. A second echocardiography was repeated at the three-month follow-up to detect LVR (defined as a 20 percent increase in left ventricular end-diastolic volume). Six models were constructed using 15 risk factors. A receiver operator characteristic curve and four performance measurements were used as evaluation methods. Feature importance was used to compare 3D STE parameters. 26 patients (19.3%) had LVR. Our evaluation showed that RF can best predict LVR with the best AUC of 0.96. 3D GLS was the most valuable 3D STE parameters, followed by GCS, global area strain, and global radial strain (feature importance 0.146, 0.089, 0.087, and 0.069, respectively). To sum up, RF models can accurately predict the LVR after AMI, and 3D GLS was the best 3D STE parameters in predicting the LVR.

A review of current trends in three-dimensional analysis of left ventricular myocardial strain

Three-dimensional (3D) left ventricular (LV) myocardial strain measurements using transthoracic 3D echocardiography speckle tracking analysis have several advantages over two-dimensional (2D) LV strain measurements, because 3D strain values are derived from the entire LV myocardium, yielding more accurate estimates of global and regional LV function. In this review article, we summarize the current status of 3D LV myocardial strain. Specifically, we describe how 3D LV strain analysis is performed. Next, we compare characteristics of 2D and 3D strain, and we explain validation of 3D strain measurements, feasibility and measurement differences between 2D and 3D strain, reference values of 3D strain, and its applications in several clinical scenarios. In some parts of this review, we used a meta-analysis to draw reliable conclusions. We also describe the added value of 3D over 2D strain in several specific pathologies and prognoses. Finally, we discuss novel techniques using 3D strain and suggest its future directions.

Assessment of left ventricular function in type 2 diabetes mellitus patients with non-alcoholic fatty liver disease using three-dimensional speckle-tracking echocardiography

Objective:

Using three-dimensional speckle-tracking echocardiography (3D-STE), we aimed to evaluate left ventricular (LV) function in type 2 diabetes mellitus (T2DM) patients with non-alcoholic fatty liver disease (NAFLD).

Methods:

In total, 97 T2: DM patients were categorized into three groups based on hepatic ultrasonography group A (those without NAFLD, n=30), group B (those with mild NAFLD, n=32), and group C (those with moderate-to-severe NAFLD, n=35). Our conventional echocardiographic parameters included transmitral peak early and late diastolic velocity (E and A), septal and lateral early (e’) mitral annular diastolic tissue velocities, and left atrial maximum volume index (LAVImax). LV end-diastolic and -systolic volume, LV mass index (LVMI), and LV ejection fraction were measured using real-time three-dimensional echocardiography. The 3D-STE parameters included LV global radial strain (GRS), global longitudinal strain (GLS), global area strain (GAS), and global circumferential strain (GCS).

Results:

Our results showed that in group C, GCS, GRS, GLS, GAS, and septal and lateral e’ velocity decreased, whereas average E/e’ and LAVImax increased compared to groups B and A (p<0.05). Multiple linear regression analysis showed that NAFLD is independently associated with 3D-STE parameters, and glycosylated hemoglobin also has negative impacts on all LV 3D strains.

Conclusion:

When combined with conventional echocardiography, 3D-STE can assess LV function effectively in T2DM patients with NAFLD. Additionally, the severity of LV dysfunction in the moderate-to-severe NAFLD group (group C) was worse than the mild and absent NAFLD groups (groups A and B).

3-Dimensional Echocardiography: Latest Developments and Future Directions

The ongoing refinements in 3-dimensional (3D) echocardiography technology continue to expand the scope of this imaging modality in clinical cardiology by offering new features that stem from the ability to image the heart in its complete dimensionality. Over the years, countless publications have described these benefits and tested new frontiers where 3D echocardiographic imaging seemed to offer promising ways to improve patients' care. These include improved techniques for chamber quantification and novel ways to visualize cardiac valves, including 3D printing, virtual reality, and holography. The aims of this review article are to focus on the most important developments in the field in the recent years, discuss the current utility of 3D echocardiography, and highlight several interesting future directions.

Left Ventricular Strain and Rotation in Patients with Dilated Cardiomyopathy and Severe Systolic Dysfunction

INTRODUCTION

In dilated cardiomyopathy (DCM) left ventricular (LV) strain and twist are significantly decreased. However, the rate of attenuation has not been investigated well in patients with varying degrees of systolic dysfunction.

AIM

The present study aimed to investigate the relationship between LV deformational and rotational mechanics and conventional and tissue Doppler imaging (TDI) parameters, and to search for a constellation of findings distinguishing patients with severe systolic dysfunction (SSD) in DCM.

METHODS

Fifty-two patients with heart failure NYHA class III-IV and ejection fraction (EF) ≤45% were prospectively enrolled (mean age 61.8 ± 13.4 years; 36 males, 69%). Severe systolic LV dysfunction was considered as EF <30%. Echocardiography with 2D-speckle tracking analysis was performed.

RESULTS

The relationships of global longitudinal strain (GLS) with EF, circumferential strain at mid-level (CSmid), and systolic medial mitral annulus velocity were strong (r = -0.53, 0.67, and -0.56, respectively, p < 0.0001 for all). A good correlation was found between CSmid and EF (r = -0.50, p < 0.0001). There were weak correlations between basal endocardial rotation (BRendo) and EF and CSmid. Multiple regression analysis found GLS (p < 0.0001) and BRendo (p = 0.04) to be predictors of the change of EF. In ROC curve analysis, the cut-off values of GLS -7.2% (AUC 0.81, p < 0.0001), CSmid -7.5% (AUC 0.76, p = 0.002), and BRendo -2.43° (AUC 0.68, p = 0.03) identified SSD.

CONCLUSIONS

Parameters of LV mechanics were related to conventional and TDI systolic parameters in patients with DCM. The degree of alterations of LV longitudinal and circumferential deformation and basal rotation may identify patients with SSD and a higher risk, and may help in therapeutic decision making.

Evaluation of subclinical left ventricular dysfunction in overweight people with 3D speckle-tracking echocardiography

OBJECTIVE

Obesity is associated with cardiovascular risk factors and is a major predictor of cardiovascular disease and mortality. This global burden affects myocardial function by inducing structural and functional alterations. Although subclinical left ventricular (LV) dysfunction is known in obese subjects, there is not sufficient information about overweight people. The aim of the present study was to evaluate subclinical LV dysfunction in overweight people with three-dimensional speckle-tracking echocardiography (3D-STE).

METHODS

One hundred eighteen consecutive patients between 18 and 80 years old were enrolled into the study. Patients were divided into three groups according to body mass index (BMI): normal (BMI: 18.5-24.9 kg/m2) (n=35), overweight (BMI: 25-29.9 kg/m2) (n=43), and obese (BMI ≥30 kg/m2) (n=40). 3D-STE was performed, and global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS) were measured. 3D-STE results were compared between the groups.

RESULTS

The mean age of the patients was 60.97+-8.94 years, and 55.1% of the patient population were male. Mean GCS was -13.5, GLS was -11.9, GRS was 32.3, and GAS was -22. As BMI increased, GCS and all other strain parameters were significantly worse [p<0.001 (normal-overweight), p<0.001 (normal-obese), and p<0.001 (overweight-obese) for GCS, GLS, GRS, and GAS]. A positive linear correlation was observed between BMI and all measured strain parameters (r=0.673, p<0.001 for BMI and GCS).

CONCLUSION

3D-STE is a non-invasive parameter to detect subclinical LV dysfunction, and global strain values are significantly correlated with BMI. Subclinical LV dysfunction was detected in overweight people in addition to obese subjects.

Regional Left Ventricular Myocardial Dysfunction After Cardiac Surgery Characterized by 3-Dimensional Strain

BACKGROUND

Three-dimensional (3D) strain is an echocardiographic modality that can characterize left ventricular (LV) function with greater accuracy than ejection fraction. While decreases in global strain have been used to predict outcomes after cardiac surgery, changes in regional 3D longitudinal, circumferential, radial, and area strain have not been well described. The primary aim of this study was to define differential patterns in regional LV dysfunction after cardiac surgery using 3D speckle tracking strain imaging. Our secondary aim was to investigate whether changes in regional strain can predict postoperative outcomes, including length of intensive care unit stay and 1-year event-free survival.

METHODS

In this prospective clinical study, demographic, operative, echocardiographic, and clinical outcome data were collected on 182 patients undergoing aortic valve replacement, mitral valve repair or replacement, coronary artery bypass graft, and combined cardiac surgery. Three-dimensional transthoracic echocardiograms were performed preoperatively and on the second to fourth postoperative day. Blinded analysis was performed for LV regional longitudinal, circumferential, radial, and area strain in the 17-segment model.

RESULTS

Regional 3D longitudinal, circumferential, radial, and area strains were associated with differential patterns of myocardial dysfunction, depending on the surgical procedure performed and strain measure. Patients undergoing mitral valve repair or replacement had reduced function in the majority of myocardial segments, followed by coronary artery bypass graft, while patients undergoing aortic valve replacement had reduced function localized only to apical segments. After all types of cardiac surgery, segmental function in apical segments was reduced to a greater extent as compared to basal segments. Greater decrements in regional function were seen in circumferential and area strain, while smaller decrements were observed in longitudinal strain in all surgical patients. Both preoperative regional strain and change in regional strain preoperatively to postoperatively were correlated with reduced 1-year event-free survival, while postoperative strain was not predictive of outcomes. Only preoperative strain values were predictive of intensive care unit length of stay.

CONCLUSIONS

Changes in regional myocardial function, measured by 3D strain, varied by surgical procedure and strain type. Differences in regional LV function, from presurgery to postsurgery, were associated with worsened 1-year event-free survival. These findings suggest that postoperative changes in myocardial function are heterogeneous in nature, depending on the surgical procedure, and that these changes may have long-term impacts on outcome. Therefore, 3D regional strain may be used to identify patients at risk for worsened postoperative outcomes, allowing early interventions to mitigate risk.

Correlation and agreement between 2D and 3D speckle-tracking echocardiography for left ventricular volumetric, strain, and rotational parameters in healthy volunteers and in patients with mild mitral stenosis

BACKGROUND

Recent advances had allowed measurement of myocardial deformation parameters using 3D speckle-tracking echocardiography (STE). Agreement between these two modalities and interchangeability of findings remain as an issue since 2DSTE is more widely available than 3DSTE. The aim of this study was to investigate the correlation and agreement between 2DSTE and 3DSTE in healthy volunteers and in patients with mild mitral stenosis (MS).

METHODS

Data from 31 patients with mild MS and 27 healthy volunteers were included in this study. Data were analyzed for the correlation and agreement between 2DSTE and 3DSTE for volumetric, strain, and rotational parameters.

RESULTS

There were no significant differences between 2DSTE and 3DSTE in both control and MS groups for left ventricular volumetric and rotational parameters. 3D global longitudinal strain (GLS) and global circumferential strain (GCS) were significantly higher in healthy volunteers (P < 0.001 for both), while only 3DGCS was significantly higher than 2DGCS in MS group (P < 0.001). The correlation between 3DSTE and 2DSTE was weak-to-moderate in both groups for strain and rotational parameters, and overall, correlation coefficients were higher in MS group. An exception was GLS in MS group, where coefficient of correlation was excellent (r = 0.907). Agreement between two modalities was poor for strain and rotational parameters, and the average bias was high.

CONCLUSIONS

Overall, the agreement between 2DSTE and 3DSTE for strain and rotational measures was poor with a high average bias. The agreement between 2DSTE and 3DSTE is affected by the presence of underlying MS and the direction of strain.

Comparison of vector velocity imaging and three-dimensional speckle tracking echocardiography for assessment of left ventricular longitudinal strain in hypertrophic cardiomyopathy

Background: Vector velocity imaging (VVI) is a two-dimensional wall motion tracking method that can measure cardiac mechanics in hypertrophic cardiomyopathy (HCM). 3D-speckle tracking echocardiography (3D-STE) has been proven to be superior to conventional measures in assessment of LV function. The aim of this study was to compare the two technologies in the assessment of LV longitudinal strain (LS) in HCM patients. Methods: A total of 50 patients with HCM were investigated using VVI and 3D-STE in same setting. 3D-STE allows obtaining longitudinal, circumferential, radial and area strains (AS). Values of longitudinal strain (LS) and AS by 3D-STE were compared to VVI- derived analyses. Thereafter, VVI-LS values were correlated with LV phenotype. Last, the variability of VVI versus 3DE strain measurements as well as recorded time of analysis was assessed. Results: The absolute value of 3D-STE LS and AS is significantly higher than VVI-LS (P < 0.0001). VVI provided complete longitudinal LV strain information, similar to 3D-STE. There is excellent agreement between the two technologies-derived values, however, a greater number of segments could be analyzed using VVI (94.7%), compared with 3DE (62.1%). Despite VVI being more time consuming, VVI-LS is more correlated to LV mass index, mitral regurgitation severity and functional class when compared with 3D-STE LS and AS. Conclusions: VVI is a feasible modality for assessing LV longitudinal strain. Although VVI agreed well with 3D-STE for most of regional and global LS, a better correlation was found between VVI-LS and HCM phenotype. It is hypothesized that this discrepancy originates from the inferior imaging quality using 3D tracking algorithms.

Subtle Myocardial Dysfunction and Fibrosis in Children with Rheumatic Heart Disease: Insight from 3D Echocardiography, 3D Speckle Tracking and Cardiac Magnetic Resonance Imaging

Rheumatic heart disease (RHD) is a major cause of morbidity and mortality in developing countries, so early diagnosis and treatment can reduce morbidity and mortality resulting from subsequent valvular damage. The aim of this study was to detect subtle myocardial dysfunction among children with RHD with preserved left ventricular systolic function. This is a cross-sectional case-control study that was conducted on 30 children with RHD (who had valvular affection of any degree and were not in activity) compared to 23 healthy children. After history taking and cardiac examination, 2D echocardiography, tissue Doppler imaging, 3D-echocardiography and 3D speckle tracking echocardiography were done to both groups, whereas cardiac magnetic resonance imaging was done only to the patient group. The 3D-derived left ventricular end-diastolic volume and sphericity index among patients were significantly increased when compared to controls [131.5 (101.5 to 173.7) vs. 69 (58 to 92), P = 0.001, and 0.46 (0.36 to 0.59) vs. 0.33 (0.29 to 0.38), P = 0.001, respectively]. The 3D-derived ejection fraction and longitudinal strain did not differ significantly among both groups. The 3D-derived global circumferential strain was higher in patients when compared to controls [- 14 (- 16 to - 10) vs. - 11(- 13 to - 10), P = 0.04]. None of the examined patients demonstrated late enhancement myocardial fibrosis. In children with RHD and preserved systolic function, subtle systolic dysfunction could not be detected using conventional and novel non-conventional methods. This may indicate that the myocardial affection during the acute stage of rheumatic carditis is minimal with almost complete resolution.

3D-speckle tracking echocardiography for assessment of coronary artery disease severity in stable angina pectoris

BACKGROUND AND AIM

Stable angina pectoris is a common disease that may cause disability. Some noninvasive new methods can be useful for the detection of early-stage coronary artery disease. The relationship between coronary artery disease (CAD) severity and resting 3-dimensional-speckle tracking echocardiography (3D-STE) in stable angina pectoris patients was evaluated in this study.

METHODS

One hundred and twenty consecutive patients between 18-80 years of age and without a history of CAD to whom elective coronary angiography was planned after positive stress test or myocardial perfusion scintigraphy were enrolled in the study. 3D-STE was performed and global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS) were measured before coronary angiography. A Gensini score of ≥20 was accepted as critical CAD. Correlation between Gensini scores and 3D-STE results were evaluated.

RESULTS

Mean age was 60.7 ± 10.01 years, and 55% of the patient population were male. There were not any significant differences between critical CAD and noncritical CAD groups for age, gender, history of hypertension, diabetes mellitus, hyperlipidemia, and Left Ventricular Ejection Fraction. Mean GLS was -12, GCS was -18.8, GRS was 33.4, GAS was -28.9, and mean Gensini score was 18.8. GLS and all other strain parameters were significantly worse in patients with critical CAD group compared with noncritical CAD group and also positive linear correlation was observed between Gensini score and all measured strain parameters (r = 0.568, P < 0.001 for Gensini score and GLS; r = 0.617, P < 0.001 for Gensini score and GAS). A GLS value of >-10 has 88.9% sensitivity and 92.9% specificity; A GAS value of >-21 has 97.2% sensitivity and 88.1% specificity to detect critical CAD.

CONCLUSIONS

3D-STE is a noninvasive and handy parameter to detect subclinical left ventricular dysfunction and global strain values were significantly correlated with CAD severity. GAS has the sensitivity of 97.2% and specificity of 88.1% to detect critical CAD. Adding 3D strain echocardiography to exercise test or myocardial perfusion scintigraphy might increase sensitivity to detect critical CAD in clinical practice.

Echocardiography for the management of patients with biventricular pacing: Possible roles in cardiac resynchronization therapy implementation

Cardiac resynchronization therapy (CRT) is an established therapeutic option for the subset of patients with heart failure (HF), reduced ejection fraction (EF), and dyssynchrony evidenced by electrocardiography. Benefit from CRT has been proven in many clinical trials, yet a sizeable proportion of these patients with wide QRS do not respond to this intervention, despite the updated practice guidelines. Several echocardiographic indices, targeting mechanical rather than electrical dyssynchrony, have been suggested to address this issue, but research so far has not succeeded in providing a single and simple measurement with adequate sensitivity and specificity for identification of responders. While there is still ongoing research in this field, echocardiography proves helpful in other aspects of CRT implementation, such as site selection for left ventricular (LV) lead pacing and optimization of pacing parameters during follow-up visits.

Comparison of two-dimensional and three-dimensional echocardiographic strain in children with CHD

BACKGROUND

In CHD, three-dimensional strain analysis may overcome limitations of Doppler and two-dimensional strain of the left ventricle. The aims of this study were to evaluate feasibility and reproducibility of three-dimensional longitudinal, circumferential, and radial systolic strain by three-dimensional speckle-tracking echocardiography compared with two-dimensional echocardiography.

METHODS

Patients with CHD, biventricular circulation with a systemic left ventricle, and who had two- and three-dimensional imaging performed on the same day from 2010 to 2014 were included. Quantitative two- and three-dimensional strain analyses were performed (two-dimensional cardiac performance analysis version 1.2 and four-dimensional left ventricular analysis version 3.1). Intra- and inter-observer variabilities were calculated on 25 studies.

RESULTS

A total of 30 patients, including 19 (61%) males, with a median age of 3.6 years (0.1-22 years) were included. The mean fractional shortening was 34.6±5.3%, and the mean ejection fraction was 62.0±6.4%. Measurement of two- and three-dimensional strain was feasible in >95% of segments. Good correlation was observed between longitudinal and circumferential strain (r=0.92, p⩽0.001 and r=0.87, p⩽0.001), but not radial strain (r=0.29, p=0.2). Intra- and inter-observer agreements were better for three-dimensional compared with two-dimensional strain, and better for both two- and three-dimensional longitudinal and circumferential strains compared with radial strain.

CONCLUSION

Left ventricular three-dimensional strain analysis is feasible in children with CHD. The reproducibility of longitudinal and circumferential strain by three-dimensional analyses is better. Further longitudinal studies are warranted for the potential clinical application of this new technology.

Assessment of left ventricular systolic function in patients with iron deficiency anemia by three-dimensional speckle-tracking echocardiography

Objective:

The present study aimed to evaluate left ventricular (LV) systolic function in patients with iron deficiency anemia (IDA) by 3-dimensional speckle-tracking echocardiography (3DSTE).

Methods:

Participants were grouped by hemoglobin (Hb) levels in order to study the effect of anemia on cardiac function. Group A included 40 healthy volunteers. Eighty-three patients who were diagnosed with IDA were divided into 2 groups according to the Hb level. Group B (Hb 9 g/dL) included 44 patients, while group C (Hb 6–9 g/dL) included 39 patients. Left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular mass index (LVMI), and left ventricular ejection fraction (LVEF) were calculated by real-time 3-dimensional echocardiography (RT3D). Left ventricular global longitudinal strain (GLS), global area strain (GAS), global radial strain (GRS), and global circumferential strain (GCS) were obtained by 3DSTE.

Results:

LVMI, LVEDV and LVESV of group C increased and GCS, GRS, GLS, and GAS of group C decreased compared with those of groups A and B (all p<0.05). GAS and GLS decreased significantly compared with other parameters (both p<0.01).

Conclusion:

LV remodeling and LV systolic dysfunction occurred in patients when the hemoglobin level was in the range of 6–9 g/dL. 3DSTE can evaluate LV systolic function in patients with IDA, and GAS and GLS are more sensitive than other parameters.