Normal reference values of left ventricular volumetric parameters in healthy adults-real-life single-center experience from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

Three-Dimensional Speckle-Tracking Echocardiography-Derived Left Ventricular Global Longitudinal Strain and Mitral Annular Plane Systolic Excursion Are Associated in Healthy Adults-Insights from the MAGYAR-Healthy Study

Introduction: Mitral annular plane systolic excursion (MAPSE) is a quantitative feature of left ventricular (LV) function that can be easily measured by M-mode echocardiography. The more recent LV strains represent LV contractility, and they can be determined for the three main directions in the radial (RS), longitudinal (LS), and circumferential (CS) directions. Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) seems to be ideal for the simultaneous assessment of all LV strains from the same acquired 3D dataset. Their associations, however, have not been fully analyzed in clinical settings in healthy volunteers yet. Therefore, the present study aimed to find associations between MAPSE and 3DSTE-derived LV strains in healthy circumstances. Methods: The present study consisted of 106 healthy adult volunteers (mean age 28.1 ± 6.3 years, 48 men). Complete two-dimensional Doppler echocardiography with MAPSE assessment and 3DSTE-derived LV strain measurements were performed in all cases. Results: Tendentiously reduced LV volumes with preserved LV ejection fraction were present in the case of mean MAPSE as compared to decreased/increased MAPSE. Global and regional LV-RS and LV-CS did not differ if MAPSE was increased, mean or decreased. Global LV-LS was reduced in the case of decreased MAPSE, mainly due to tendentiously higher apical LV-LS. MAPSE did not differ if global LV-RS and LV-CS were increased, mean or decreased. MAPSE was tendentiously increased in the presence of increased global LV-LS. Conclusions: Only 3DSTE-derived global LV-LS and MAPSE are associated in healthy adults; LV global strains in other directions show no relationship with MAPSE.

Complex Associations Between Systolic Left Atrial and Left Ventricular Deformations in Healthy Adults-Detailed Analysis from the Three-Dimensional Speckle-Tracking Echocardiographic MAGYAR-Healthy Study

Introduction. Volumetric changes in the left atrium (LA) and left ventricle (LV) are strongly associated in healthy circumstances, as recent three-dimensional speckle-tracking echocardiographic (3DSTE) studies confirmed. However, the complex relationship of LA and LV deformation in systole has never been assessed in healthy individuals. The present study purposed to perform comparative simultaneous analysis of systolic LA and LV strains in healthy adults by 3DSTE. Methods. The study consisted of 165 healthy adults (mean age: 33.2 ± 12.3 years; 90 males). Complete two-dimensional Doppler echocardiography with 3DSTE was performed in all cases. Results. The increase in global LA radial strain (RS) and longitudinal strain (LS) showed no associations with LV strains. The largest global LA circumferential strain (CS) was associated with the largest basal LV-RS. Lowest basal and global LV-CS could be demonstrated in the presence of mean global LA-CS as compared to the presence of lower than mean global LA-CS. Global LA-RS showed an increase, with global LV-RS being largest when global LV-RS was the largest. Basal and global LA-RS were largest in the case of lowest global LV-CS. Basal LA-LS was largest in the case of mean global LV-CS. With the increase in global LV-LS, basal and global LA-LS showed an increase but only up to a point; in the case of larger than mean global LV-LS, no further increase was detected in basal and global LA-LS. Conclusions. Complex associations between simultaneously assessed LA and LV deformations represented by 3DSTE-derived strains could be demonstrated in healthy adults.

Detailed Insights into the Relationship Between Three-Dimensional Speckle-Tracking Echocardiography-Derived Systolic Left Atrial Global Strains and Left Ventricular Volumes in Healthy Adults from the MAGYAR-Healthy Study

Background and Objectives: The complex relationship between three-dimensional (3D) speckle-tracking echocardiography (3DSTE)-derived left ventricular (LV) and left atrial (LA) volumes and functional properties has been demonstrated in recent studies. A better understanding of LV volumetric dependence on systolic peak LA (reservoir) strains in healthy circumstances could complete this knowledge. Therefore, 3DSTE was used for the simultaneous evaluation of these parameters in healthy adults, aiming to examine their complex relationship. Materials and Methods: The present study consisted of 165 healthy individuals with a mean age of 33.1 ± 12.3 years and 90 men. A complete two-dimensional echocardiography with Doppler with 3DSTE was performed in all the cases. Results: The peak LA global radial (GRS), longitudinal (GLS), and 3D (G3DS) strains were increased in the subjects with a mean LV end-diastolic volume (EDV) as compared to those cases with a lower-than-mean LV-EDV. In the cases with a higher-than-mean LV-EDV, no further increase in these peak global LA strains could be detected. The peak LA global circumferential and area strains showed a tendentious (non-significant) increase with an increasing LV-EDV. The peak LA global strains showed similar non-significant associations with the LV end-systolic volume (except the peak LA-G3DS, which proved to be significant). Conclusions: In healthy adults, the 3DSTE-derived peak LA-GRS and LA-G3DS are increased with a larger LV-EDV up to a point, beyond which a further increase cannot be seen, suggesting a working Frank-Starling mechanism in this context similar to that for LA volumes. Similar associations are present for the peak LA-GLS as well.

Long-Term Prognostic Impact of Three-Dimensional Speckle-Tracking Echocardiography-Derived Left Ventricular Global Longitudinal Strain in Healthy Adults-Insights from the MAGYAR-Healthy Study

INTRODUCTION

Three-dimensional (3D) speckle-tracking echocardiography (STE) combines the advantages of STE and volumetric 3D echocardiography, which shows the left ventricle (LV) in 3D during the cardiac cycle and is also suitable for accurate strain measurements in addition to volumetric assessments using the same virtual 3D LV cast. The present study aimed to confirm the prognostic impact of 3DSTE-derived LV global longitudinal strain (GLS) in healthy adults during a 12-year follow-up period.

PATIENTS AND METHODS

The current study comprised 124 healthy individuals with a mean age of 31.0 ± 11.7 years (64 males) at the time of complete two-dimensional Doppler echocardiography (2DE) and 3DSTE.

RESULTS

During a mean follow-up of 8.01 ± 4.12 years, 10 healthy individuals suffered cardiovascular events, including 2 cardiac deaths. Using ROC analysis, 3DSTE-derived LV-GLS ≥ 14.77% was found to be a significant predictor for cardiovascular event-free survival (sensitivity 70%, specificity 71%, area under the curve 76%, p = 0.007). Using 2DE, higher LV end-diastolic and end-systolic volumes, a larger LV end-systolic diameter and a lower LV ejection fraction could be detected in subjects with LV-GLS < 14.77% as compared to cases with LV-GLS ≥ 14.77%. Subjects with events had thicker interventricular septa, a larger LV mass and lower 3DSTE-derived LV-GLS and a higher ratio of cases had LV-GLS < 14.77%. From subjects with LV-GLS < 14.77%, seven individuals (18%) had events. Multivariate regression analysis identified age and LV-GLS as independent predictors of event-free survival.

CONCLUSIONS

3DSTE-derived LV-GLS is a strong independent predictor of cardiovascular survival in healthy adults.

Left ventricular deformation in the presence of left ventricular 'rigid body rotation' in healthy adults-three-dimensional speckle-tracking echocardiographic insights from the MAGYAR-Healthy Study

Background

During the heart cycle, the left ventricle (LV) not only shows a contraction-relaxation pattern, but LV has a rotational mechanics, as well. It is a known fact that certain pathologies may be associated with an absence of LV twist, when LV basal and apical regions rotate in the same clockwise (cw) or counterclockwise (ccw) direction called LV 'rigid body rotation' (LV-RBR), but it can also occur in healthy subjects. The present cohort study aimed to examine LV strains in healthy subjects with LV-RBR versus with normally directed LV rotational mechanics by three-dimensional speckle-tracking echocardiography (3DSTE).

Methods

The study consisted of 181 healthy individuals, from which 171 cases had normally directed LV rotational mechanics (mean age: 32.5±12.3 years, 79 males) and 10 healthy subject showed LV-RBR (mean age: 35.4±11.3 years, 3 males). Complete two-dimensional (2D) Doppler echocardiography and 3DSTE were performed in all healthy individuals.

Results

None of routine 2D Doppler echocardiographic parameters showed differences between the groups examined. There were no subjects with ≥ grade 1 regurgitation on any valves or with significant stenosis on any valves. 3DSTE-derived LV volumes, global and mean segmental strains did not differ between the groups examined. Apical anterior and lateral segments showed reduced segmental LV circumferential strain (CS) (-18.9%±8.5% vs. -26.7%±10.7%, P=0.02; -27.3%±12.6% vs. -34.8%±13.2%, P=0.08, respectively) and LV area strain (AS) (-26.8%±9.8% vs -36.8%±12.0%, P=0.01; -35.7%±13.2% vs. -45.0%±14.6%) in healthy subjects having LV-RBR as compared to cases with normally directed LV rotational mechanics. These abnormalities were present only in subjects having cwLV-RBR.

Conclusions

Although global LV deformation is normal in the presence of LV-RBR in healthy adults, reduction of apical anterior and lateral LV-CS (and LV-AS) are present in cases with cwLV-RBR only suggesting segmental deformation abnormalities.

Left ventricular rotational mechanics and left ventricular volumes: is there a relationship in healthy adults?-three-dimensional speckle-tracking echocardiography-derived insights from the MAGYAR-Healthy Study

Background

Left ventricular (LV) rotational mechanics play a crucial role in LV pump function by strengthening and improving its efficacy. Dependence of LV rotational parameters on left atrial volumes has already been demonstrated. The evaluation of the effect of LV rotational mechanics on LV volumes was purposed in a population of healthy subjects by three-dimensional speckle-tracking echocardiography (STE).

Methods

The study comprised 175 healthy subjects with a mean age of 32.8±12.2 years (79 males). All subjects underwent a complete physical examination, laboratory assessments, standard 12-lead electrocardiography and two-dimensional Doppler and three-dimensional STE, the results of these examinations were within the normal range.

Results

Increased basal LV rotation was associated with increased LV volume measured in end-systole and impaired LV ejection fraction. Increased apical LV rotation was associated with reduced LV volumes assessed in end-diastole and in end-systole and increased ejection fraction of the LV. Elevated basal LV rotation showed associations with increased LV mass. In case of increasing basal LV rotation, apical LV rotation showed a decreasing tendency and LV twist showed a tendency of increasing. Similarly, lower basal LV rotation and increased LV twist were seen with increasing apical LV rotation. Increasing LV end-diastolic volume was associated with increasing LV volume measured in end-systole and preserved ejection fraction of the LV. Increasing LV end-systolic volume was associated with increasing LV end-diastolic volume and reduction of LV ejection fraction. Increasing LV volumes were associated with increasing LV mass. While increased LV volumes were associated with reduced apical LV rotation and twist, basal LV rotation did not show significant changes.

Conclusions

LV rotational mechanics are strongly associated with LV volumes in healthy adults suggesting its volume-dependence.

Complexity of left ventricular strains in response to elevated volumes in healthy adults - Detailed analysis from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

Introduction

Cardiac haemodynamics is described by the Frank-Starling law, which states that the strength of the left ventricular (LV) systolic contraction is related to the LV diastolic filling, with other words LV stroke volume increases as LV volume increases due to the stretching of the myocyte. The purpose of the present study was to examine how the increasing LV volumes affect LV contractility represented by three-dimensional (3D) speckle-tracking echocardiography (3DSTE) -derived LV strains in healthy adults.

Methods

This is post-hoc analysis of the MAGYAR-Healthy Study employing a novel method for technical analysis of echocardiographic datasets. The present study consisted of 301 healthy adults. Due to inferior image quality, 127 subjects have been excluded, therefore the remaining population included 174 subjects (mean age: 32.9 ± 12.1 years, 80 males). All cases have undergone complete two-dimensional Doppler echocardiography extended with 3DSTE.

Results

LV global longitudinal (gLS) and area (gAS) strains were lowest in case of the highest LV end-diastolic volume (EDV). LV global radial (gRS) and 3D (g3DS) strains tendentiously increased with increasing LV-EDV. When segmental analysis was performed, increased LV-EDV was associated with increase of basal LV-RS and LV-3DS. Increased LV strains were associated with increased LV ejection fraction (EF) due to higher LV-EDV for LV-gRS (and LV-g3DS), lower LV-ESV for LV-gCS and lower LV-EDV and LV-ESV for LV-gLS (and LV-gAS). With increasing LV-gRS, LV-gCS and LV-g3DS, all LV strains increased except LV-gLS. With increasing LV-gLS, LV-gRS did not show any increase, LV-gCS and LV-g3DS were the highest when LV-gLS was the highest, while LV-gAS increased simultaneously. With increasing LV-gAS, all LV strains increased.

Conclusions

There is a complex contractility pattern of LV segments/regions in response to elevated LV volumes in healthy circumstances.

Simultaneously Assessed Three-Dimensional Speckle-Tracking Echocardiography-Derived Left Ventricular and Left Atrial Volumes Are Associated in Healthy Adults-Findings from the MAGYAR-Healthy Study

INTRODUCTION

The left atrium (LA) has a significant role in regulating blood flow from veins to the left ventricle (LV). LV performance is affected by several factors including preload, which is partly, but highly, dependent on LA volumes. The aim of the present study is to perform simultaneous assessment of LA and LV volume changes during the cardiac cycle in healthy circumstances. Therefore, LA and LV volumes and volume-based functional properties were determined in healthy adults, and the associations of these parameters were examined.

METHODS

The present study consists of 164 healthy adults (age: 33.0 ± 12.3 years, 82 males) being in sinus rhythm. All subjects have undergone complete two-dimensional Doppler echocardiography with three-dimensional speckle-tracking echocardiography (3DSTE).

RESULTS

Increased end-systolic maximum LA volume was associated with higher LV volumes and reduced LV ejection fraction. Very high early pre-atrial contraction and late diastolic LA volumes were associated with increased LV volumes, reduced LV ejection fraction and increased LV mass. Increased LA volumes were associated with increased LV mass. Higher LV volumes were associated with tendentiously higher LA volumes. Higher LV end-diastolic volume was associated with tendentiously higher all LA stroke volumes (SVs) and total and active LA emptying fractions (EFs). Higher LV end-systolic volume was associated with tendentiously higher all LA SVs but preserved all LA EFs.

CONCLUSIONS

3DSTE is capable of simultaneous assessment of LA and LV volumes and volume-based functional properties for (patho)physiologic studies. Moreover, 3DSTE-derived LV and LA volumes and functional properties show strong associations.

Left ventricular deformation in athletes playing sports with high dynamics-insights from the three-dimensional speckle-tracking echocardiographic MAGYAR-Sport Study

Background

Earlier results suggest the role of speckle-tracking echocardiography (STE)-derived left ventricular (LV) strains in screening and could help better understanding of adaptation to exercise. The present retrospective cohort study aimed to investigate three-dimensional STE-derived LV strains representing its deformation in athletes playing sports with high dynamics with different grades of static components of their training.

Methods

The study consisted of 67 athletes (mean age: 23.6±6.4 years, 39 males). This group of athletes was further divided into the following groups: Group C.I. (high dynamic/low static) (n=12), Group C.II. (high dynamic/moderate static) (n=22) and Group C.III. (high dynamic/high static) (n=33). The control group comprised 83 age- and gender-matched non-athletic healthy volunteers (mean age: 23.6±3.2 years, 50 males).

Results

Global LV longitudinal strain (LS) representing LV lengthening or shortening (-18.5%±3.0% vs. -16.3%±2.3%, P<0.05), LV circumferential strain (CS) representing LV widening or narrowing (-29.9%±5.2% vs. -28.1%±4.8%, P<0.05) and LV area strain (AS; combination of LS and CS; -43.7%±5.4% vs. -40.9%±4.8%, P<0.05) were increased in elite athletes as compared to those of non-athlete controls. All apical LV strains proved to be increased in all athletes with enhanced basal radial strain (RS, representing LV thickening and thinning) and LS and midventricular LS, AS and 3D strain (3DS, combination of RS, LS and CS).

Conclusions

Increased LV-LS, LV-CS and LV-AS represents enhanced LV deformation in longitudinal and circumferential directions in athletes playing sports with high dynamics. This enhancement is not related to the grade of the static component of training. Some regional differences in LV strains could be detected.

Normal reference values of tricuspid annular dimensions and functional properties in healthy adults using three-dimensional speckle-tracking echocardiography (insights from the MAGYAR-Healthy Study)

Background

Three-dimensional speckle-tracking echocardiography (3DSTE) is a relatively new non-invasive imaging modality with ability for simultaneous chamber quantifications and determination of valvular dimensions. The aim of the present retrospective cohort study was to determine normal reference values of 3DSTE-derived tricuspid annular (TA) dimensions and functional properties and to evaluate their age- and gender dependency.

Methods

The present study comprised 156 healthy adult subjects, from which 28 cases were excluded due to inferior image quality, therefore the remaining group consisted of 128 cases with the mean age of 35.4±12.5 years (72 males). The subject population was further divided into the following categories: 18-29 years (n=57; mean age: 25.2±2.8 years, 51 males), 30-39 years (n=29; mean age: 34.1±2.5 years, 31 males), 40-49 years (n=17; mean age: 44.1±3.2 years, 11 males) and ≥50 years of age (n=25, mean age: 59.2±6.4 years, 14 males).

Results

End-diastolic TA diameter (2.2±0.3 vs. 2.5±0.3 cm, P<0.05), area (7.1±1.3 vs. 8.1±1.7 cm², P<0.05) and perimeter (10.3±0.9 vs. 11.0±1.2 cm, P<0.05) were lower in females than in males in the 18-29 year-old group and TA area (6.1±0.8 vs. 8.0±1.2 cm², P<0.05) and TA perimeter (9.7±0.8 vs. 11.0±0.9 cm, P<0.05) were lower in females than in males in the 40-49 year-old group. End-systolic TA diameter were lower in females than in males in the 18-29 year-old group (1.8±0.2 vs. 1.9±0.3 cm, P<0.05) and TA area (4.7±0.3 vs. 6.3±1.2 cm², P<0.05) and TA perimeter (8.6±0.4 vs. 9.5±0.9 cm, P<0.05) were lower in females than in males in the 40-49 year-old group. TA fractional area change was found to be reduced in the 40-49 year-old group as compared to the 30-39 year-old group (21.7%±8.7% vs. 29.2%±10.0%, P<0.05).

Conclusions

3DSTE is a novel method for non-invasive assessment of TA dimensions and functional properties. Results highlight the importance of age- and gender-specific reference values in case of TA diameter, area and perimeter and calculated functional features respecting the cardiac cycle.

Left ventricular rotational abnormalities in hemophilia-insights from the three-dimensional speckle-tracking echocardiographic MAGYAR-Path Study

BACKGROUND

Hemophilia is an X-linked inherited disorder primarily affecting males, its major types are type A (deficiency in factor VIII) and B (deficiency in factor IX), and is considered to be the most common severe congenital coagulation factor deficiency. The present study was designed to test whether any differences in left ventricular (LV) rotational mechanics could be demonstrated between male patients with hemophilia and healthy controls using three-dimensional speckle-tracking echocardiography (3DSTE)-derived virtual LV models.

METHODS

The present study consisted of 17 patients with hemophilia, however, 3 patients were excluded due to insufficient image quality. In the remaining patient population, 12 patients had hemophilia A and 2 patients had hemophilia B (mean age: 42.2±18.9 years, all males). The control group comprised 16 age-matched healthy subjects (46.0±5.9 years, all males).

RESULTS

None of the routine two-dimensional echocardiographic data differ between patients with hemophilia and controls. None of the patients and controls showed ≥ grade 1 valvular regurgitations and had valvular stenoses. In one subject, the near absence of LV twist called as LV "rigid body rotation" could be detected, data of which were managed separately. While 3DSTE-derived apical LV rotation was 3.65 degrees, basal LV rotation proved to be 3.57 degrees leading to 0.08-degree LV apico-basal gradient suggesting counterclockwise LV "rigid body rotation". In the remaining patients, both LV apical rotation (7.25±6.20 vs. 10.39±4.16 degrees, P<0.02) and LV twist (10.24±5.60 vs. 14.38±3.93 degrees, P<0.003) showed significant impairment in patients with hemophilia.

CONCLUSIONS

LV rotational abnormalities are present in hemophilia with reduced LV apical rotation and twist.

Normal Values of Left Ventricular Size and Function on 3D Echocardiography: Results of the World Alliance of Societies of Echocardiography Study

BACKGROUND

Echocardiography remains the most widely used modality to assess left ventricular (LV) chamber size and function. Currently this assessment is most frequently performed using 2D echocardiography (2DE). Yet, 3D echocardiography (3DE) has been shown to be more accurate and reproducible than 2DE. Current normative reference values for 3D LV analysis are predominantly based on data from North America and Europe. The World Alliance of Societies of Echocardiography (WASE) study was a designed to sample normal subjects from around the world to provide more universal global reference ranges. In this study we sought to assess the world-wide feasibility of LV 3DE and report on size and function measurements.

METHODS

2262 healthy subjects were prospectively enrolled from 19 centers in 15 countries. 3D LV full-volume datasets were obtained and analyzed offline with vendor-neutral software. Measurements included end-diastolic and end-systolic volumes (EDV, ESV), ejection fraction (EF), global longitudinal and circumferential strain (GLS and GCS). Results were categorized by age (18-40, 41-65 and >65 years), sex and race.

RESULTS

1589 subjects (feasibility 70%) had adequate LV datasets for analysis. Mean normal values for indexed EDV, ESV and EF in men and women were 70 ± 15 and 65 ± 12 mL, 28 ± 7 and 25 ± 6 mL and 60 ± 5, 62 ± 5% respectively. Men had larger LV volumes and lower EF than women. GLS and GCS were higher in magnitude in women. In both sexes, LV volumes were lower and EF tended to be higher with increasing age, especially considering the differences between the youngest and oldest age groups. While GLS was similar across age groups in men, in women, the youngest and middle-age cohorts revealed higher magnitudes of GLS when compared to the oldest age group. GCS was higher in magnitude at older age in both men and women. Finally, Asians had smaller chamber sizes and higher EF and absolute strain values than both blacks and whites.

CONCLUSIONS

Age, sex, and race should be considered when defining normal reference values for LV dimension and function parameters obtained by 3DE.

Left ventricular rotational mechanics in elite athletes doing high dynamic sports. Insights from the 3D speckle-tracking echocardiographic MAGYAR-Sport Study

BACKGROUND

In normal circumstances while left ventricular (LV) apex rotates counterclockwise, LV base has a clockwise movement at the same time. This sort of towel-wringing-like movement is called LV twist. The present study was designed to test whether differences in LV rotational mechanics could be detected in elite athletes doing high dynamic sports with different static components in their training.

METHODS

The subject group comprised 80 elite sportsmen. The following groups were created regarding their physical activity: group CI (high dynamic/low static)(N.=13, mean age: 24.0±5.1 years, group CII (high dynamic/moderate static)(N.=23, mean age: 24.6±7.7 years) and group CIII (high dynamic/high static)(N.=34, mean age: 22.8±6.0 years). Their results were compared to 67 age- and gender-matched non-athletic healthy controls (mean age: 24.0±5.1 years). Three-dimensional speckle-tracking echocardiography was used for the evaluation of LV rotational abnormalities.

RESULTS

Reduced LV basal rotation was seen in group CII and CIII subjects compared to the control group (-4.31±1.82 degrees vs. -3.17±2.81 degrees and -2.88±1.88 degrees, P<0.05 and P<0.05, respectively). It was accompanied with LV twist reduction in groups CII and CIII subjects compared to the control group (14.0±3.4 degree vs. 11.3±4.3 degrees and 11.5±4.1 degrees, P<0.05 and P<0.05, respectively). None of the elite athletes showed absence of LV twist called as LV "rigid body rotation."

CONCLUSIONS

Significant LV rotational abnormalities including reduced LV basal rotation and twist could be detected in elite athletes doing high dynamic sports with moderate/high static components in their training.