Early impairment of left ventricular longitudinal and radial deformation in primary mitral regurgitation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant TE 137/2020

Background. In primary mitral regurgitation (PMR) left ventricular (LV) remodeling is an adaptive process with prognostic significance.

Aim. To characterize LV deformation parameters related to PMR severity for a better understanding of LV pathophysiology, in patients with mild to severe PMR and preserved LV ejection fraction (EF).

Methods. 48 patients (56 ± 14 years, 42% men) with PMR (mild - 12 patients, moderate - 12 patients, severe - 24 patients) and 50 age and sex matched-controls (56 ± 12 years, 48% men) were analyzed by 2-dimensional speckle-tracking echocardiography (2D STE) for LV endo, mid, and epicardial longitudinal strain (LS); endo, mid, and epicardial circumferential strain (CS); and radial strain (RS). LV volumes and EF, and LA volumes and emptying fraction (EmF) were measured by 3D echocardiography. MR severity was quantified by vena contracta (VC), PISA radius, MR regurgitant volume, and EROA measurements, according to the 2021 ESC guidelines.

Results. 3D LVEF had no significant difference between PMR patients and controls (p= 0.11). From control subjects to mild, moderate, and severe PMR, there was a progressive reduction of LS and RS (Figures 1 and 2), but not of CS. By 2D STE multilayer analysis, when compared to controls, PMR patients had decreased endo-, mid-, and epi-LS (p < 0.04), with a compensatory increase of endo-LS in mild PMR (Figure 2). Basal, middle, and apical segments LS decreased similarly and progressively from control subjects to PMR patients (p < 0.01). In addition, in patients with PMR only LS, but not RS or CS, correlated with MR severity (PISA radius, VC, and MR regurgitant volume: r= -0.43, r= -0.32, r= -0.38, all p < 0.01), and LA function (EmF: r = -0.41, p < 0.01).

Conclusion. When compared to normal subjects, patients with PMR and preserved LVEF have altered LV longitudinal and radial deformation, with preserved circumferential strain. All longitudinal layers and all LV segments were similarly affected. Only longitudinal strain correlates with MR severity and atrial function. Our study suggests that a comprehensive evaluation of the LV deformation should be included in the assessment of patients with PMR, in order to identify early stages of LV dysfunction, starting even from mild MR. Abstract Figure. LV deformation - PMR vs controls  Abstract Figure. Multilayer LS in PMR patients

Systemic inflammation in the acute myocardial infarction can predict early negative left ventricular remodeling assessed by myocardial work analysis

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): UEFISCDI

Background. Left ventricular (LV) remodeling after acute myocardial infarction (AMI) is an important predictor of heart failure (HF). Systemic inflammatory response in the acute phase of AMI is of particular interest, while the relation to the remodeling process is still under debate. New imaging techniques derived from speckle tracking echocardiography (STE), such as myocardial work (MW), are attractive tools since they can detect myocardial remodeling before decrease of global LVEF. However, there is insufficient data regarding MW in AMI patients, and its relation to the inflammatory process.

Methods. We assessed 57 patients (53 ± 9 years, 45 men, 64% smokers, 59% hypertensive, 54% with type 2 diabetes) with AMI, by clinical, 2D echo, and STE. Biomarkers panel was evaluated within the first 24 hours from admission: hsTpI and CRP. A second visit with clinical and echo assessment was performed at 6-8 weeks from the baseline visit. Exclusion criteria were unstable patients, non-sinus rhythm, significant valvular disease (>grade 2), other significant pathologies leading to decreased life expectancy, and low quality 2DE. At both visits, global longitudinal stain (GLS) and MW by 2DSTE were measured, on top of conventional echo parameters: global work index (GWI), global constructive work (GCW), global wasted work (GWW), global work efficiency (GWE) (Figure 1: upper panel - an example of a patient with increase of GWE from baseline to visit 2 ; lower panel - an example of a patient with decrease of the GWE from baseline to visit 2).

Results. At baseline, myocardial necrosis by hsTpI significantly corelated with GLS (r = 0.44, p = 0.001) and MW (GWI: r=-0.44, p = 0.001; GCW: r=-0.40, p = 0.002), but not with LVEF. However, systemic inflammation by CRP did not correlate with LVEF or any of the STE parameters.  Interestingly, systemic inflammation by CRP significantly correlated with changes of MW between the two visits: for GWE r=-0.53, p < 0.001; and for GWW r = 0.48, p < 0.001 (Figure 2). A CRP level >28 mg/l was able to predict decrease of GWE from baseline to visit 2.

Conclusions. Magnitude of necrosis, expressed by hsTpI, corelates only with GLS and MW parameters, but not with LVEF. CRP level in the acute phase of AMI correlates with myocardial work changes, as an early marker of negative LV remodeling. Abstract Figure 1  Abstract Figure 2

Right ventricular dysfunction by 3D echocardiography is the best predictor for death and re-hospitalization in patients with heart failure with reduced ejection fraction

Background

In patients with heart failure with reduced ejection fraction (HFrEF), right ventricular (RV) size and dysfunction by 2-dimensional echocardiography (2DE) were identified as risk factors for mortality and morbidity, but 3-dimensional echocardiography (3DE) enabled itself as a more reproducible and accurate method.

Aim

To assess the comparative prognostic value of parameters of RV size and dysfunction, measured by 2DE and 3DE, in patients with ischemic and non-ischemic HFrEF, on optimal clinical care, at long-term follow-up.

Methods

142 consecutive patients (62±12 yrs, 104 males) with HFrEF, in sinus rhythm, were assessed by 2DE and 3DE, including RV full-volume acquisitions. RV diameter (RVd), RV end-systolic (RV_EDA) and end-diastolic areas (RV_ESA), RV fractional area change (RVFAC), and 2D_TAPSE were measured by 2DE. RV end-diastolic (RV_EDV) and end-systolic volumes (RV_ESV), RV ejection fraction (RV_EF), and 3D_TAPSE were measured by a dedicated 3DE software. Patients were followed for 37±16 months after the index event. Primary outcome was cardiac death (CD). Secondary outcomes were: 1) HF hospitalizations (HFH); 2) a composite cardiac events (CE) end-point of CD or HFH, myocardial infarction, coronary revascularization, arrhythmias, or CRT.

Results

38 CD, 47 HFH, and 62 CE occurred during follow-up. Mean RVd was 34±7 mm, RV_EDA 20±11 cm2, RV_ESA 12±5 cm2, RV_FAC 37±13%, RV_EDV 84±25 ml/m2, RV_ESV 52±22 ml/m2, and RV_EF 39±10%. Mean 2D_TAPSE was 18±4 mm, while mean 3D_TAPSE was 16±4 mm. By 2DE, only RV_ESA and RV_FAC, but not RV_EDA or RVd, correlated with CD, HFH, and CE. 2D_TAPSE correlated with HFH, but not with CD or CE, while 3D_TAPSE correlated with all primary and secondary outcomes. By 3DE, RV_ESV, but not RV_EDV, correlated with CD, HFH, and CE. Moreover, 3D RV_EF had better correlations with primary and secondary outcomes than 2D RV_FAC (z=3.8, z=2.5, and z=2.5, all p<0.01). By multivariate linear regression analysis including RV_ESA, RV_FAC, RV_ESV, RV_EF, and 3D_TAPSE, only RV_EF was an independent predictor for CD and HFH (r2=0.68 and r2=0.30, both p<0.001).

Conclusion

In patients with ischemic and non-ischemic HFrEF, 3DE parameters of RV size and dysfunction are better predictors for death and re-hospitalization than 2DE parameters. The RV_EF measured by 3DE was the best predictor for death in patients with HFrEF.

Funding Acknowledgement

Type of funding source: None