Assessment of strain and dyssynchrony in normal fetuses using speckle tracking echocardiography - comparison of three different ultrasound probes

Assessment of cardiac adverse events following COVID-19 vaccination by speckle tracking echocardiography

Cardiac discomfort has been reported periodically in COVID-19-vaccinated individuals. Thus, this study aimed to evaluate the role of myocardial strains in the early assessment of the clinical presentations after COVID-19 vaccination. Totally, 121 subjects who received at least one dose of vaccine within 6 weeks underwent laboratory tests, electrocardiogram (ECG), and echocardiogram. Two-dimensional speckle tracking echocardiography (2D-STE) was implemented to analyze changes in the left ventricular myocardium. After vaccination, 66 individuals (55.4 ± 17.4 years) developed cardiac discomforts, such as chest tightness, palpitations, dyspnea, and chest pain. The ECG readings exhibited both premature ventricular contractions and premature atrial contractions (n = 24, 36.4%), while none of the individuals in the control group manifested signs of cardiac arrhythmia. All had normal serum levels of creatine phosphokinase, creatine kinase myocardial band, troponin, N-terminal pro b-type natriuretic peptide, platelets, and D-dimer. Left ventricular ejection fraction in the symptomatic group (71.41% ± 7.12%) and the control group (72.18% ± 5.11%) (p = 0.492) were normal. Use of 2D-STE presented global longitudinal strain (GLS) and global circumferential strain (GCS) was reduced in the symptomatic group (17.86% ± 3.22% and 18.37% ± 5.22%) compared to the control group (19.54% ± 2.18% and 20.73% ± 4.09%) (p = 0.001 and p = 0.028). COVID-19 vaccine-related cardiac adverse effects can be assessed early by 2D-STE. The prognostic implications of GLS and GCS enable the evaluation of subtle changes in myocardial function after vaccination.

Importance of frame rate for the measurement of strain and synchrony in fetuses using speckle tracking echocardiography

OBJECTIVES

To assess the influence of frame rate settings on longitudinal strain (LS) and mechanical synchrony (SYN) values in Speckle Tracking Echocardiography (STE) of healthy fetuses.

METHODS

In this prospective study, we collected transversal or apical four-chamber-views of 121 healthy fetuses between 20 and 38 weeks of gestation using three different frame rate (FR) settings (≥ 110, 100 ± 10, 60 ± 10 frames per second). We assessed the segmental and the global LS of both ventricles (2C) and of the left ventricle (LV) offline with QLab 10.8 (Philips Medical Systems, Andover, MA, USA). Inter- and intraventricular SYN were calculated as time difference in peak myocardial strain between the mid-segments of left and right ventricle (interventricular, 2C_Syn) and lateral wall and septum of the left ventricle (intraventricular, LV_Syn), respectively.

RESULTS

In 84.3% STE was feasible at all three FR settings. The LS increased in both views at higher FRs to a statistically noticeable extent. SYN measurements and the absolute differences at patient level between the FR settings showed no statistically noticeable alterations.

CONCLUSIONS

STE is feasible at low and high FR settings. SYN emerges to be a robust parameter for fetal STE as it is less affected by the FR. High FRs enable high temporal resolutions and thus an accurate examination of fetal hearts. Future research for the technical implementation of tailored fetal STE software is necessary for reliable clinical application.

Fetal ventricular strain in uncomplicated and selective growth-restricted monochorionic diamniotic twin pregnancies and cardiovascular response in pre-twin-twin transfusion syndrome

OBJECTIVES

Our primary aim was to confirm whether intertwin discordance in ventricular strain and ductus venosus (DV) time intervals predicts twin-twin transfusion syndrome (TTTS). Secondary aims were to create gestational-age ranges for ventricular strain in uncomplicated monochorionic diamniotic (MCDA) twin pregnancies without selective intrauterine growth restriction (sIUGR) and to characterize the relationship of ventricular strain with gestational age in MCDA twin pregnancies with sIUGR that did not develop TTTS.

METHODS

In the period 2015-2018, we enrolled 150 MCDA twin pregnancies consecutively into this prospective, blinded study of global longitudinal left and right ventricular strain. With the observer blinded to twin pairing and pregnancy outcome, videoclips of the four-chamber view, which had been recorded during ultrasound surveillance in the usual window for development of TTTS (16-26 completed gestational weeks), underwent offline measurement of strain. Uncomplicated MCDA twin pregnancies, without sIUGR, were used to test the association between strain, gestational age and estimated fetal weight using mixed-effects multilevel regression. Inter-rater reliability was tested in 208 strain measurements in 31 fetuses from pregnancies which did not develop TTTS and within-fetus variation was assessed in 16 such fetuses, in which multiple four-chamber views were taken on the same day. The effect of sIUGR on strain in otherwise uncomplicated MCDA twin pregnancy was analyzed. MCDA twin pregnancies were defined as 'pre-TTTS' when, having been referred for TTTS evaluation, they did not satisfy Quintero staging criteria, but subsequently developed TTTS requiring laser treatment. MCDA pregnancies which did not develop TTTS comprised the 'non-TTTS' group. Cardiovascular parameters measured in these cases included tissue Doppler parameters and DV early filling time as a percentage of the cardiac cycle (DVeT%). Intertwin strain and DVeT% discordance was compared between non-TTTS and pre-TTTS cases, matched for gestational age.

RESULTS

Paired strain data were available for intertwin comparison in 127/150 MCDA twin pregnancies, comprising 14 pre-TTTS and 113 non-TTTS pregnancies, after exclusions. Scans were collected at a median frame rate of 97 (range, 28-220) Hz. Laser therapy was performed at a median gestational age of 20.6 (range, 17.2-26.6) weeks. There were no group differences in right (RV) or left (LV) ventricular strain discordance between 68/113 non-TTTS and 13/14 pre-TTTS MCDA twin pregnancies < 20 completed gestational weeks (RV, P = 0.338; LV, P = 0.932). DVeT% discordance > 3.6% was found in eight of 13 pre-TTTS pregnancies. In non-TTTS pregnancies, the estimated variability in ventricular strain within each twin during the day was high (RV, 19.7; LV, 12.9). However, within each pair (intertwin variation), variability was low (RV, 5.5; LV, 2.9). Interclass correlation reflecting the proportion of total variability represented by the variability between twin pairs was low (RV, 0.22; LV, 0.18). Both RV (P < 0.001) and LV (P = 0.025) strain showed a negative association with gestational age. Among non-TTTS MCDA twin pregnancies, LV strain was, on average, higher by 1.83 in sIUGR compared with normally grown fetuses (P = 0.023), with no statistically significant difference in RV strain (P = 0.271).

CONCLUSIONS

Although ventricular strain has been reported previously as a possible predictor of developing TTTS, in this blinded, prospective study, we found no significant intergroup differences in ventricular strain in pre-TTTS compared with age-matched non-TTTS MCDA twin pregnancies. We recommend using DVeT% discordance as a more practical screening tool in MCDA twin pregnancies. This study also provides new information on the changes with gestational age, and the biological and technical variation, of global longitudinal ventricular strain in uncomplicated MCDA twin pregnancies and those with isolated sIUGR. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Paired maternal and fetal cardiac functional measurements in women with gestational diabetes mellitus at 35-36 weeks' gestation

BACKGROUND

Gestational diabetes mellitus is associated with early-onset cardiovascular disease and increased incidence of adverse cardiovascular outcomes in mothers and their offspring. Few studies with a limited number of patients have reported subclinical cardiac changes in association with gestational diabetes mellitus; however, it remains unclear whether the mother and the fetus respond in a similar fashion to gestational diabetes mellitus; thus, by assessing the heart of one, we can estimate or predict changes in the other.

OBJECTIVE

This study aimed to compare maternal and fetal cardiovascular functions in the third trimester between women with gestational diabetes mellitus and women with uncomplicated pregnancy and to explore whether gestational diabetes mellitus affects to the same extent the maternal and fetal heart.

STUDY DESIGN

This was a cross-sectional study of maternal and fetal echocardiography for assessment of cardiovascular function in the third trimester in women with singleton pregnancies who received a diagnosis of gestational diabetes mellitus and the control group with uncomplicated pregnancies.

RESULTS

In this study, we included 161 women with gestational diabetes mellitus and 483 women with uncomplicated pregnancies. Compared with women in the control group, women with gestational diabetes mellitus were older (34.5, standard deviation, 5.3 years] vs 32.5, standard deviation, 4.8 years]; P<.001), had higher body mass index (31.3 kg/m² [standard deviation, 5.8] vs 28.6 kg/m² [standard deviation, 4.4]; P<.001), had lower weight gain during pregnancy (8.3 [interquartile range, 4.8-11 kg] vs 10.8 [interquartile range, 8.2-13.5 kg]; P<.001), and delivered babies with lower birthweight (P<.001). After multivariable analysis, accounting for differences in maternal characteristics and fetal weight, mothers with gestational diabetes mellitus had lower left ventricular diastolic and systolic (tissue Doppler systolic [s'] wave) functional indices (P<.01 for both) compared with those of mothers in the control group. The noted cardiac changes did not fulfill the adult criteria for clinical cardiac dysfunction. No differences in hemodynamic indices (cardiac output and peripheral vascular resistance) and left ventricular mass were noted between the groups. Fetuses of mothers with gestational diabetes mellitus had more globular-shaped hearts with increased right and left ventricular sphericity indices (P<.001 for both) and reduced global longitudinal right and left ventricular systolic functional indices (P<.001 for both). The effect of gestational diabetes mellitus on maternal and fetal hearts was different, and there was no clear association between the two.

CONCLUSION

In the third trimester, in pregnancies with gestational diabetes mellitus, there were subclinical cardiac changes in both the mother and the fetus, but there was no significant difference in any of the fetal cardiac parameters between women with and women without unfavorable cardiac profile. This suggests that the stimulus for cardiovascular responses in the mother and fetus may not be the same in pregnancies with gestational diabetes mellitus.

Behavior of fetal longitudinal myocardial fibers assessed by speckle tracking to obtain strain and strain rate values for low-risk pregnancies

Objective To analyze the behavior of fetal longitudinal myocardial fibers assessed by speckle tracking (STE) after fetal viability. Methods A cross-sectional study was performed in 156 women with normal singleton pregnancies from 22 to 31 weeks of gestation. Strain (S) and strain rate (SR) values were measured in both ventricles during the fetal cardiac cycle. The population was divided into five gestational age groups based on 2-week intervals. The correlations of maternal variables with the S and SR variables and intra-observer analysis were performed. Results There was a significant difference in the S and SR values of the left ventricle (LV) among the gestational age groups (P = 0.007). Significantly higher S and SR values were observed in early age groups demonstrating reductions in LV S and SR values at 26 weeks, followed by stabilization. For the right ventricle (RV), there was no significant difference between gestational age groups. Significant intra-observer agreement was observed for S values of the RV (P = 0.008) and LV (P = 0.0004) and SR values of the RV (P = 0.0001) and LV (P = 0.015). Conclusion Decreases in the S and SR values of the LV occurred after 26 weeks, followed by stabilization. No significant difference was observed in the S or SR value of the RV among the gestational age groups, and no significant association of any maternal variable evaluated with S and SR values was observed. Significant intra-observer agreement was obtained among the results.

Normal fetal cardiac deformation values in pregnancy; a prospective cohort study protocol

Background

Myocardial deformation imaging offers the potential to measure myocardial function. Remodelling, the change in size, shape and function, appears as a result of pressure or volume changes and is thought to be the first sign of fetal adaptation to placental dysfunction. Deformation can be measured using speckle tracking echocardiography (STE). STE in the fetus might be useful for detection and follow up of the fetus endangered by placental dysfunction. Reference values for fetal myocardial deformation during gestation have not been comprehensively described and need further investigation before STE can be introduced in daily clinical practice. The aim of this study is to determine reference values for fetal myocardial deformation throughout gestation in uncomplicated pregnancies.

Methods

A longitudinal cohort will be performed. 150 Women, pregnant from a non-anomalous singleton, will be included from 19 to 21 + 6 weeks gestational age. Thereafter, fetal heart ultrasounds will be performed 4 weekly, until 41 weeks gestational age or delivery. Ultrasound data will be analysed using STE software to determine reference values for fetal cardiac deformation during gestation.

Discussion

Measuring cardiac deformation changes in pregnancy can be a promising tool to detect preclinical cardiac adaptation to placental dysfunction. However, previous studies used different ultrasound scans and STE software resulting in incomparable and contradictory results on deformation values. In this prospective study reference values during pregnancy, cardiac deformation values will be assessed with the same ultrasound and software package in 150 uncomplicated pregnancies.

Trial registration

National Trial Register number: NTR7132. Date of inclusion: 2018/04/06.

Strain and dyssynchrony in fetuses with congenital heart disease compared to normal controls using speckle tracking echocardiography (STE)

Objective To compare myocardial strain and mechanical dyssynchrony in fetuses with congenital heart disease (CHD) to normal controls using speckle tracking echocardiography (STE). Methods In this comparative cross-sectional study 23 fetuses with CHD and 105 normal controls between 19 and 41 weeks of gestation were assessed with STE. The STE sample box was placed over the myocardium of both ventricles. The parameters of interest included the segmental strain of the left (LV-S) and right lateral ventricle wall (RV-S) and the global ventricular strain of both chambers (2C-S). In order to separately assess the LV, we placed the STE sample box over the myocardium of the LV. We calculated the strain of the LV lateral wall (LW-S), the septum (SEPT-S) and the global ventricular strain of the single LV (1C-S). Furthermore, we analyzed the differences in timing of negative peak myocardial strain between the LV and RV (two-chamber dyssynchrony, 2C-DYS) and also within the LV between the lateral wall and the septum (one-chamber dyssynchrony, 1C-DYS). Results The evaluation of strain and mechanical dyssynchrony was feasible in all cases. Compared to normal controls, fetuses with CHD showed lower segmental and global strain values and the extent of 2C-DYS and 1C-DYS was higher than in the healthy control group. Conclusion The deterioration of myocardial function in CHD can be measured with STE. The assessment of strain and dyssynchrony with STE may be useful for distinguishing fetuses with CHD from healthy fetuses.

Quantification of fetal myocardial function in pregnant women with diabetic diseases and in normal controls using speckle tracking echocardiography (STE)

Background The purpose of our study was to quantify the fetal myocardial function in pregnant women with diabetic diseases (FDM) and in normal controls (FC) using speckle tracking echocardiography (STE). Methods In this prospective study, the myocardial strain and dyssynchrony were analyzed using STE in a transversal four-chamber view in 180 fetuses (53 FDM, 127 FC) between 19 and 39 weeks of gestation. The measurements of the global and segmental longitudinal strain of both chambers (2C) and of the single left chamber (1C) were executed offline via QLab 10.5 (Philips Medical Systems, Andover, MA, USA). We assessed dyssynchrony as the time difference between peaks in strain in the mid segments of both chambers (interventricular dyssynchrony, 2C_DYS) and of the single left chamber (intraventricular dyssynchrony, 1C_DYS). Results Measurements were feasible with a high median frame rate of 199 frames/s (1st quartile: 174, 3rd quartile: 199). The global and segmental myocardial longitudinal strain of 2C and 1C were decreased and 2C_DYS and 1C_DYS were increased in pregnancies with diabetes compared to normal controls. Conclusion Our study demonstrates that fetal hearts affected by maternal diabetes mellitus (DM) show low myocardial strain values and high interventricular dyssynchrony. Two-chamber interventricular dyssynchrony has the potential to become a diagnostic marker for DM.