Perioperative echocardiographic strain analysis: what anesthesiologists should know

PURPOSE

Echocardiographic strain analysis by speckle tracking allows assessment of myocardial deformation during the cardiac cycle. Its clinical applications have significantly expanded over the last two decades as a sensitive marker of myocardial dysfunction with important diagnostic and prognostic values. Strain analysis has the potential to become a routine part of the perioperative echocardiographic examination for most anesthesiologist-echocardiographers but its exact role in the perioperative setting is still being defined.

CLINICAL FEATURES

This clinical report reviews the principles underlying strain analysis and describes its main clinical uses pertinent to the field of anesthesiology and perioperative medicine. Strain for assessment of left and right ventricular function as well as atrial strain is described. We also discuss the potential role of strain to aid in perioperative risk stratification, surgical patient selection in cardiac surgery, and guidance of anesthetic monitor choice and clinical decision-making in the perioperative period.

CONCLUSION

Echocardiographic strain analysis is a powerful tool that allows seeing what conventional 2D imaging sometimes fails to reveal. It often provides pathophysiologic insight into various cardiac diseases at an early stage. Strain analysis is readily feasible and reproducible thanks to the use of highly automated software platforms. This technique shows promising potential to become a valuable tool in the arsenal of the anesthesiologist-echocardiographer and aid in perioperative risk-stratification and clinical decision-making.

Utilizing Artificial Intelligence-Based Deformable Registration for Global and Layer-Specific Cardiac MRI Strain Analysis in Healthy Children and Young Adults

RATIONALE AND OBJECTIVES

The absence of published reference values for multilayer-specific strain measurement using cardiac magnetic resonance (CMR) in young healthy individuals limits its use. This study aimed to establish normal global and layer-specific strain values in healthy children and young adults using a deformable registration algorithm (DRA).

MATERIALS AND METHODS

A retrospective study included 131 healthy children and young adults (62 males and 69 females) with a mean age of 16.6 ± 3.9 years. CMR examinations were conducted using 1.5T scanners, and strain analysis was performed using TrufiStrain research prototype software (Siemens Healthineers, Erlangen, Germany). Global and layer-specific strain parameters were extracted from balanced Steady-state free precession cine images. Statistical analyses were conducted to evaluate the impact of demographic variables on strain measurements.

RESULTS

The peak global longitudinal strain (LS) was -16.0 ± 3.0%, peak global radial strain (RS) was 29.9 ± 6.3%, and peak global circumferential strain (CS) was -17.0 ± 1.8%. Global LS differed significantly between males and females. Transmural strain analysis showed a consistent pattern of decreasing LS and CS from endocardium to epicardium, while radial strain increased. Basal-to-apical strain distribution exhibited decreasing LS and increasing CS in both global and layer-specific analysis.

CONCLUSION

This study uses DRA to provide reference values for global and layer-specific strain in healthy children and young adults. The study highlights the impact of sex and age on LS and body mass index on RS. These insights are vital for future cardiac assessments in children, particularly for early detection of heart diseases.

Limitations of Apical Sparing Pattern in Cardiac Amyloidosis: A Multicenter Echocardiographic Study

BACKGROUND

Although impaired left ventricular (LV) global longitudinal strain (GLS) with apical sparing is a feature of cardiac amyloidosis (CA), its diagnostic accuracy has varied across studies. We aimed to determine the ability of apical sparing ratio (ASR) and most common echocardiographic parameters to differentiate patients with confirmed CA from those with clinical and/or echocardiographic suspicion of CA, but with this diagnosis ruled out.

METHODS

We identified 544 patients with confirmed CA and 200 controls as defined above (CTRL Patients). Measurements from transthoracic echocardiograms (TTE) were performed using artificial intelligence software (Us2.AI, Singapore) and audited by an experienced echocardiographer. Receiver-operating characteristic curve analysis was used to evaluate the diagnostic performance and optimal cutoffs for the differentiation of CA patients from CTRL Patients. Additionally, a group of 174 healthy subjects (Healthy CTRL) was included to provide insight on how Patients and Healthy controls differed echocardiographically.

RESULTS

LV GLS was more impaired (-13.9 ± 4.6% vs -15.9 ± 2.7%, p < 0.0005) and ASR was higher (2.4 ± 1.2 vs 1.7 ± 0.9, p < 0.0005) in the CA group vs. CTRL Patients. Relative wall thickness and ASR were the most accurate parameters for differentiating CA from CTRL Patients (AUC: 0.77 and 0.74, respectively). However, even with the optimal cutoff of 1.67, ASR was only 72% sensitive and 66% specific for CA, indicating presence of apical sparing in 32% of CTRL Patients and even in 6% Healthy CTRLs.

CONCLUSIONS

Apical sparing did not prove to be a CA-specific biomarker for accurate identification of CA, when compared to clinically similar controls with no CA.

Myocardial strain of the left ventricle by speckle tracking echocardiography: From physics to clinical practice

Speckle tracking echocardiography (STE) is a reliable imaging technique of recognized clinical value in several settings. This method uses the motion of ultrasound backscatter speckles within echocardiographic images to derive myocardial velocities and deformation parameters, providing crucial insights on several cardiac pathological and physiological processes. Its feasibility, reproducibility, and accuracy have been widely demonstrated, being myocardial strain of the various chambers inserted in diagnostic algorithms and guidelines for various pathologies. The most important parameters are Global longitudinal strain (GLS), Left atrium (LA) reservoir strain, and Global Work Index (GWI): based on large studies the average of the lower limit of normality are -16%, 23%, and 1442 mmHg%, respectively. For GWI, it should be pointed out that myocardial work relies primarily on non-invasive measurements of blood pressure and segmental strain, both of which exhibit high variability, and thus, this variability constitutes a significant limitation of this parameter. In this review, we describe the principal aspects of the theory behind the use of myocardial strain, from cardiac mechanics to image acquisition techniques, outlining its limitation, and its principal clinical applications: in particular, GLS have a role in determine subclinical myocardial dysfunction (in cardiomyopathies, cardiotoxicity, target organ damage in ambulatory patients with arterial hypertension) and LA strain in determine the risk of AF, specifically in ambulatory patients with arterial hypertension.

Biventricular Tissue Tracking with Cardiovascular Magnetic Resonance: Reference Values of Left- and Right-Ventricular Strain

We derived reference values of left-ventricular (LV) and right-ventricular (RV) strain parameters in a cohort of 100 healthy subjects by feature tracking cardiac magnetic resonance (FT-CMR). Global and regional strain values were calculated for the LV; circumferential and radialSAX strain parameters were derived from the short-axis (SAX) stack, while longitudinal and radialLAX strain parameters were assessed in three long-axis (LAX) views. Only global longitudinal strain (GLS) was calculated for the RV. Peak global LV circumferential strain was -16.7% ± 2.1%, LV radialSAX strain was 26.4% ± 5.1%, LV radialLAX strain was 31.1% ± 5.2%, LV GLS was -17.7% ± 1.9%, and RV GLS was -23.9% ± 4.1%. Women presented higher global LV and RV strain values than men; all strain values presented a weak relationship with body surface area, while there was no association with age or heart rate. A significant association was detected between all LV global strain measures and LV ejection fraction, while RV GLS was correlated to RV end-diastolic volume. The intra- and inter-operator reproducibility was good for all global strain measures. In the regional analysis, circumferential and radial strain values resulted higher at the apical level, while longitudinal strain values were higher at the basal level. The assessment of cardiac deformation by FT-CMR is feasible and reproducible and gender-specific reference values should be used.

Right ventricular contraction patterns in healthy children using three-dimensional echocardiography

Background

The right ventricle (RV) has complex geometry and function, with motion along three separate axes-longitudinal, radial, and anteroposterior. Quantitative assessment of RV function by two-dimension echocardiography (2DE) has been limited as a consequence of this complexity, whereas newer three dimensional (3D) analysis offers the potential for more comprehensive assessment of the contributors to RV function. The aims of this study were to quantify the longitudinal, radial and anteroposterior components of global RV function using 3D echocardiography in a cohort of healthy children and to examine maturational changes in these parameters.

Methods

Three-dimensional contours of the RV were generated from a cohort of healthy pediatric patients with structurally normal hearts at two centers. Traditional 2D and 3D echo characteristics were recorded. Using offline analysis of 3D datasets, RV motion was decomposed into three components, and ejection fractions (EF) were calculated (longitudinal-LEF; radial-REF; and anteroposterior-AEF). The individual decomposed EF values were indexed against the global RVEF. Strain values were calculated as well.

Results

Data from 166 subjects were included in the analysis; median age was 13.5 years (range 0 to 17.4 years). Overall, AEF was greater than REF and LEF (29.2 ± 6.2% vs. 25.1 ± 7.2% and 25.7 ± 6.0%, respectively; p < 0.001). This remained true when indexed to overall EF (49.8 ± 8.7% vs. 43.3 ± 11.6% and 44.4 ± 10%, respectively; p < 0.001). Age-related differences were present for global RVEF, REF, and all components of RV strain.

Conclusions

In healthy children, anteroposterior shortening is the dominant component of RV contraction. Evaluation of 3D parameters of the RV in children is feasible and enhances the overall understanding of RV function, which may allow improvements in recognition of dysfunction and assessment of treatment effects in the future.

Microvascular Dysfunction Is Associated With Impaired Myocardial Work in Obstructive and Nonobstructive Hypertrophic Cardiomyopathy: A Multimodality Study

Background Two-dimensional speckle tracking echocardiography has been shown to correlate with microvascular dysfunction, a hallmark of hypertrophic cardiomyopathy (HCM). We hypothesized that there is an association between myocardial work and left ventricular ischemia, with incremental value to global longitudinal strain, in patients with HCM. Methods and Results We performed a prospective assessment of patients with HCM, undergoing 2-dimensional speckle tracking echocardiography and stress perfusion cardiac magnetic resonance. Results were stratified according to obstructive or nonobstructive HCM and the presence of significant replacement fibrosis (late gadolinium enhancement ≥15% of left ventricular mass). Seventy-five patients with HCM (63% men, age 55±15 years) were evaluated, 28% with obstructive HCM (mean gradient 89±60 mm Hg). Perfusion defects were found in 90.7%, involving 22.5±16.9% of left ventricular mass, and 38.7% had late gadolinium enhancement ≥15%. In a multivariable analysis, a lower global work index (r=-0.519, β-estimate -10.822; P=0.001), lower global work efficiency (r=-0.379, β-estimate -0.123; P=0.041), and impaired global constructive work (r=-0.532, β-estimate -13.788; P<0.001) significantly correlated with ischemia. A segmental analysis supported these findings, albeit with lower correlation coefficients. A global work index cutoff ≤1755 mm Hg% was associated with hypoperfusion with a sensitivity of 88% and a specificity of 71%, while the best cutoff for global longitudinal strain (>-15.5%) had a sensitivity of 64% and a specificity of 57%. The association between myocardial work and perfusion defects was significant independently of late gadolinium enhancement ≥15% and obstructive HCM. Conclusions Impaired myocardial work was significantly correlated with the extent of ischemia in cardiac magnetic resonance, independently of the degree of left ventricular hypertrophy or fibrosis, with a higher predictive power than global longitudinal strain.

Reduced functional capacity is associated with the proportion of impaired myocardial deformation assessed in heart failure patients by CMR

Aims

Heart failure (HF) does not only reduce the life expectancy in patients, but their life is also often limited by HF symptoms leading to a reduced quality of life (QoL) and a diminished exercise capacity. Novel parameters in cardiac imaging, including both global and regional myocardial strain imaging, promise to contribute to better patient characterization and ultimately to better patient management. However, many of these methods are not part of clinical routine yet, their associations with clinical parameters have been poorly studied. An imaging parameters that also indicate the clinical symptom burden of HF patients would make cardiac imaging more robust toward incomplete clinical information and support the clinical decision process.

Methods and results

This prospective study conducted at two centers in Germany between 2017 and 2018 enrolled stable outpatient subjects with HF [n = 56, including HF with reduced ejection fraction (HFrEF), HF with mid-range ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF)] and a control cohort (n = 19). Parameters assessed included measures for external myocardial function, for example, cardiac index and myocardial deformation measurements by cardiovascular magnetic resonance imaging, left ventricular global longitudinal strain (GLS), the global circumferential strain (GCS), and the regional distribution of segment deformation within the LV myocardium, as well as basic phenotypical characteristics including the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the 6-minute walk test (6MWT). If less than 80% of the LV segments are preserved in their deformation capacity the functional capacity by 6MWT (6 minutes walking distance: MyoHealth ≥ 80%: 579.8 ± 177.6 m; MyoHealth 60-<80%: 401.3 ± 121.7 m; MyoHealth 40-<60%: 456.4 ± 68.9 m; MyoHealth < 40%: 397.6 ± 125.9 m, overall p-value: 0.03) as well as the symptom burden are significantly impaired (NYHA class: MyoHealth ≥ 80%: 0.6 ± 1.1 m; MyoHealth 60-<80%: 1.7 ± 1.2 m; MyoHealth 40-<60%: 1.8 ± 0.7 m; MyoHealth < 40%: 2.4 ± 0.5 m; overall p-value < 0.01). Differences were also observed in the perceived exertion assessed by on the Borg scale (MyoHealth ≥ 80%: 8.2 ± 2.3 m; MyoHealth 60-<80%: 10.4 ± 3.2 m; MyoHealth 40-<60%: 9.8 ± 2.1 m; MyoHealth < 40%: 11.0 ± 2.9 m; overall p-value: 0.20) as well as quality of life measures (MLHFQ; MyoHealth ≥ 80%: 7.5 ± 12.4 m; MyoHealth 60-<80%: 23.4 ± 23.4 m; MyoHealth 40-<60%: 20.5 ± 21.2 m; MyoHealth < 40%: 27.4 ± 24.4 m; overall p-value: 0.15)-while these differences were not significant.

Conclusion

The share of LV segments with preserved myocardial contraction promises to discriminate between symptomatic and asymptomatic subjects based on the imaging findings, even when the LV ejection fraction is preserved. This finding is promising to make imaging studies more robust toward incomplete clinical information.

CMR detects decreased myocardial deformation in asymptomatic patients at risk for heart failure

Aims

The main management strategy of heart failure with preserved ejection fraction (HFpEF) is prevention since HFpEF is associated with many cardiovascular (CV) risk factors, especially since HFpEF is linked to a high risk for both mortality and recurrent heart failure (HF) hospitalizations. Therefore, there is a need for new tools to identify patients with a high risk profile early. Regional strain assessment by CMR seems to be superior in describing deformation impairment in HF. The MyoHealth score is a promising tool to identify cardiac changes early.

Methods and results

Heart failure patients irrespective of LVEF and asymptomatic controls were recruited, and CMR based measures were obtained. For this analysis the asymptomatic control group (n = 19) was divided into asymptomatic subjects without CV co-morbidities or evidence of cardiac abnormalities and (n = 12) and asymptomatic subjects with CV co-morbidities or evidence of cardiac abnormalities (n = 7) as well as patients with HFpEF (n = 19). We performed CMR scans at rest and during a stress test using isometric handgrip exercise (HG). Assessing the MyoHealth score at rest revealed preserved regional strain in 85 ± 9% of LV segments in controls, 73 ± 11% in at Risk subjects and 73 ± 8% in HFpEF patients. During stress the MyoHealth score was 84 ± 7% in controls, 83 ± 7 in at risk subjects and 74 ± 11 in HFpEF patients.

Conclusion

In summary, we show for the first time that asymptomatic subjects with increased CV risk present with HFpEF like impaired myocardial deformation at rest, while they show results like controls under HG stress. The potential of preventive treatment in this group of patients merits further investigation in future.

Clinical trial registration

[https://drks.de/search/de/trial/DRKS00015615], identifier [DRKS00015615].

Evaluation of ventricular function and myocardial deformation in children with repaired tetralogy of Fallot by real-time three-dimensional (four-dimensional) echocardiography

AIM

The left and right ventricular dysfunction are important clinical course indicators in patients with repaired tetralogy of Fallot. This study aimed to evaluate ventricular volumes, functions, and myocardial deformation in children with repaired tetralogy of Fallot by real-time three-dimensional (four-dimensional) echocardiography and compared with healthy children. It also aimed to investigate the relationships between ventricular volumes, functions, and myocardial deformation parameters in the patients.

MATERIALS AND METHODS

In this cross-sectional study, 35 patients (mean age 15.1 ± 2.8 years, 54% male) and 35 healthy controls of similar age, gender, and body measurements underwent echocardiography. End-diastolic volume index, end-systolic volume index, and ejection fractions of both ventricles; global longitudinal, circumferential, radial strain, twist, and torsion of the left ventricle; the longitudinal strain of the right ventricle free wall and septum were measured.

RESULTS

Left ventricular ejection fraction, global circumferential and radial strain, twist and torsion were significantly lower in patients compared with controls. Left ventricular ejection fraction correlated with global circumferential (r = -0.446, p < 0.001) and radial strain (r = -0.433, p < 0.001) in the patients. Right ventricular volumes were significantly higher, and ejection fraction was significantly lower in patients compared with controls. All right ventricular parameters correlated with each other in the patients.

CONCLUSION

Left ventricular contraction pattern was changed, circumferential and radial fibres were most affected in the patients. Right ventricular dilatation and dysfunction were detected, and right ventricular ejection fraction correlated well with strain measurements of the right ventricle.

Post-cardiopulmonary bypass longitudinal strain provides higher prognostic ability than baseline strain or change in strain

CONTEXT

Global longitudinal strain (GLS) measured by speckle-tracking echocardiography demonstrates excellent prognostic ability in predicting major adverse cardiac events after cardiac surgery. However, the optimal timing of intraoperative GLS measurement that provides the best prognostic value is unclear.

AIM

Our goal was to evaluate whether GLS measured prior to cardiopulmonary bypass (pre-CPB GLS), following CPB (post-CPB GLS), or change in GLS provides the strongest association with postoperative complications.

SETTING AND DESIGN

Post hoc analysis of prospectively collected data from a clinical trial (NCT01187329). 72 patients with aortic stenosis undergoing elective AVR ± coronary artery bypass grafting between January 2011 and August 2013.

MATERIAL AND METHODS

Myocardial deformation analysis from standardized transesophageal echocardiographic examinations were performed after anesthetic induction and chest closure. We evaluated the association between pre-CPB GLS, post-CPB GLS, and change in GLS (percent change from pre-CPB baseline) with postoperative atrial fibrillation and hospitalization >7 days. The association of post-CPB GLS with duration of mechanical ventilation, N-terminal pro-BNP (NT-proBNP) and troponin T were also assessed.

STATISTICAL ANALYSIS

Multivariable logistic regression.

RESULTS

Risk-adjusted odds (OR[97.5%CI] of prolonged hospitalization increased an estimated 27% (1.27[1.01 to 1.59];P_adj =0.035) per 1% decrease in absolute post-CPB GLS. Mean[98.3%CI] NT-proBNP increased 98.4[20 to 177]pg/mL; P_adj =0.008), per 1% decrease in post-CPB GLS. Pre-CPB GLS or change in GLS were not associated with any outcomes.

CONCLUSIONS

Post-CPB GLS provides the best prognostic value in predicting postoperative outcomes. Measuring post-CPB GLS may improve risk stratification and assist in future study design and patient outcome research.

Evaluation of left ventricular function and myocardial deformation in children with beta-thalassemia major by real-time three-dimensional (four-dimensional) and speckle tracking echocardiography

AIM

This study aimed to evaluate the role of real-time three-dimensional (four-dimensional) and speckle tracking echocardiography for early detection of left ventricular systolic dysfunction and also for the relationship between myocardial deformation parameters and myocardial iron load which is measured by cardiac magnetic resonance relaxation time T2* values in asymptomatic children with beta-thalassemia major.

MATERIAL AND METHODS

This multicenter cross-sectional study included 40 patients (mean age 15.4 ± 2.9, 42.1% male) and 40 healthy children whose age, gender, and body mass index-matched with patients. Each participant underwent conventional echocardiography and tissue Doppler imaging. Left ventricular ejection fraction; global longitudinal, circumferential, radial strains; twist; and torsion were measured by real-time three-dimensional and speckle tracking echocardiography. Cardiac magnetic resonance imaging T2* was measured in patients.

RESULTS

Left ventricular global longitudinal, circumferential, and radial strains were decreased despite preserved global ventricular function in patients compared to healthy children (p = p = .029, p = p < .001, p = .003, respectively). There were no statistically significant differences between patients with T2* ≥ 20 ms and patients with T2* < 20 ms for all echocardiographic parameters. Also, there were no significant correlations between all echocardiographic parameters and T2* values in all patients, those with T2* ≥ 20 ms, and T2* < 20 ms.

CONCLUSION

We found that even in asymptomatic children with beta-thalassemia major, left ventricular longitudinal, circumferential and, radial functions were impaired by real-time three-dimensional (four-dimensional) and speckle tracking echocardiography. This novel echocardiographic method might be an important tool for detecting subclinical left ventricular systolic dysfunction irrespective of T2* values.

The Association of Pulmonary Flow Characteristics With Cardiac Function in Tricuspid Valve Malformation Fetuses: Study With Two-Dimensional Speckle Tracking Echocardiography

OBJECTIVES

To explore the relationship between cardiac function and pulmonary flow characteristics in tricuspid valve malformation (TVM) fetuses by conventional and speckle tracking echocardiography.

METHODS

Eighty-eight TVM fetuses were retrospectively included and compared with 80 normal controls. TVM fetuses in each trimester were divided into two subgroups according to pulmonary flow characteristics: those with normal pulmonary flow (TVM-N) and those with reduced or absent pulmonary flow (TVM-R/A). Cardiac measurements, Celermajer index, and Simpson-Andrews-Sharland (SAS) score were obtained. Speckle tracking echocardiography was used to compute ventricular deformation parameters.

RESULTS

TVM fetuses demonstrated significantly lower global longitudinal strain (GLS) and strain rate for both ventricles than controls (all P < .05). When compared with TVM-N, left ventricular (LV) ejection fraction, LV fractional area change, right ventricular (RV) fractional area change, LVGLS, and RVGLS were significantly reduced (all P < .05), while the RV diameter Z-score, RV/LV diameter, SAS score, and Celermajer index were obviously increased in TVM-R/A in both trimesters (all P < .05). Both LVGLS and RVGLS correlated with cardiothoracic circumference ratio, RV diameter Z-score, RV/LV diameter, Celermajer index, and SAS score (all P < .01). There was a slow decline for LVGLS and RVGLS in TVM-N fetuses throughout the gestation. Conversely, these two parameters worsened rapidly in TVM-R/A group.

CONCLUSIONS

TVM fetuses present biventricular dysfunction by deformation analysis in the second and third trimester of pregnancy. TVM fetuses with reduced or absent pulmonary flow exhibit significantly greater impairment and more rapid deterioration of cardiac function, which may contribute to poor outcomes.

Detection of early signs of right ventricular systolic impairment in unoperated Ebstein's anomaly by cardiac magnetic resonance feature tracking

BACKGROUND

Cardiovascular magnetic resonance feature-tracking analysis (CMR-FT) provides a quantitative assessment of myocardial contraction with potential for diagnostic and prognostic ability in a wide spectrum of diseases. Ebstein's anomaly (EA) is a rare congenital heart disease characterized by apical displacement of the tricuspid valve. However, it is also considered a disorder of development affecting the global right ventricular myocardium. Aim of our study is to describe the complex contractile mechanics of the functional right ventricle (RV) in patients affected by EA through CMR-FT.

METHODS

Fifty surgery-free EA patients who had undergone a complete CMR protocol at our institution between January 2017 and December 2020 were selected for the retrospective study. A historical control group of twenty-five healthy subjects was also included. CMR-FT analysis was performed at a dedicated workstation by manually tracing RV endo- end epicardial borders on steady-state-free-precession (SSFP) cine images. Strain values were calculated. Apical displacement of the tricuspid valve (TV) was measured on a 4-chamber cine image from the right atrio-ventricular junction to the functional annulus of the TV.

RESULTS

EA patients presented significantly impaired RV global radial strain (GRS) and global circumferential strain (GCS) compared to controls (P<0.0001 and P=0.0008, respectively). In a subgroup analysis, GRS was significantly compromised in patients with a severely displaced TV (>16 mm/m²) compared to milder forms (P=0.03) and to controls (P<0.0001). Among EA patients with a preserved ejection fraction, 12 (48%) vs. 6 (24%) controls had reduced both GRS and GCS.

CONCLUSIONS

The contractile pattern of the functional RV in EA is characterised by prevalent alterations in the short-axis direction as indicated by reduced GRS and GCS. Strain values might be reduced prior to routine used functional parameters like RV ejection fraction (RVEF) and can possibly serve as an early predictor of myocardial dysfunction in EA patients.

Evaluation of the left ventricular systolic function and myocardial deformation by real-time three-dimensional (four-dimensional) and speckle-tracking echocardiography in children with type 1 diabetes mellitus

AIM

This study aimed to evaluate the role of real-time three-dimensional (known as four-dimensional) echocardiography and three-dimensional speckle-tracking echocardiography for the early detection of left ventricular systolic dysfunction in asymptomatic children with type 1 diabetes mellitus.

MATERIALS AND METHOD

This cross-sectional study included 38 patients (mean age 15.4 ± 2.9, 42.1% male) and 38 age, gender, and body measurements matched healthy children. Each patient underwent an interview about medical history, a detailed clinical examination, blood laboratory tests, conventional echocardiography, and tissue Doppler imaging. Left ventricular ejection fraction; global longitudinal, circumferential, radial strain; twist; and torsion were measured by real-time three-dimensional and speckle-tracking echocardiography.

RESULTS

Conventional echocardiography and tissue Doppler imaging showed normal left ventricular systolic function in the patients. Although left ventricular ejection fraction (61.6 ± 1.4%, 61.8 ± 1.1%, p = 0.386), global longitudinal [-26.6 (-27.7 to -26.1)%, -26.2 (-27.7 to -24.9)%, p = 0.224], and radial strain [44.4 (42.4-45.9)%, 43.9 (41-46.1)%, p = 0.513] were similar to the controls, circumferential strain (-27.3 ± 1.3%, -28.0 ± 1.6%, p = 0.048) and twist (9.5 ± 2.3°, 11.4 ± 3.0°, p = 0.003) were decreased in the patients compared with controls.

CONCLUSION

We found that even in children with asymptomatic type 1 diabetes mellitus with normal left ventricular ejection fraction, circumferential function was impaired and rotation pattern was changed. This novel echocardiographic method might be an important tool for detecting left ventricular systolic dysfunction in type 1 diabetes mellitus children before it becomes overt on conventional echocardiography and tissue Doppler imaging.

Myocardial Deformation Imaging by Speckle Tracking Echocardiography for Assessment of Cardiotoxicity in Children During and After Chemotherapy: A Systematic Review and Meta-analysis

BACKGROUND

Childhood cancer patients and childhood cancer survivors (CCS) are at risk of developing chemotherapy-induced cardiomyopathy. Myocardial deformation imaging has shown potential in the early detection of subclinical myocardial damage with implications on therapeutic interventions and improvement of outcomes. We aimed to perform a systemic review and meta-analysis of literature on the assessment of left (LV) and right ventricular (RV) myocardial deformation by speckle tracking echocardiography (STE) at rest and during stress in childhood cancer patients during and in survivors after chemotherapy.

METHODS

A systematic review was performed through searching MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and Scopus. Search hedges were created to cover the concepts of childhood cancer, chemotherapy, radiotherapy, anthracycline, cardiotoxicity, speckle tracking, myocardial strain, and myocardial deformation. Two independent investigators reviewed the eligibility of the articles for inclusion. Weighted mean difference in ventricular strain between pre-and post-chemotherapy treatment and that between long-term CCS and healthy subjects were estimated by random-effect models with 95% confidence intervals. Heterogeneity and publication bias were assessed by I2 statistics and Egger test, respectively.

RESULTS

Of the total of 8703 records initially identified, 42 studies with a total of 430 childhood cancer patients were included. Of these 42 studies that showed heterogeneities, 9 assessed early myocardial injury during chemotherapy, 30 assessed late myocardial injury after chemotherapy with no publication bias, and 3 studied myocardial mechanics during stress. The main findings were 1) impairment of LV systolic deformation in childhood cancer patients during the initial treatment phase and among long-term CCS, while data on changes in RV deformation are limited and inconclusive, 2) the predictive value of early reduction of myocardial strain imaging in forecasting subsequent development of cardiotoxicity is unknown as it has not been studied, 3) limited data suggest possibility of impaired LV contractile mechanics during stress in CCS, and 4) cumulative anthracycline dose and chest-directed radiotherapy are consistently identified as factors associated with impaired myocardial deformation.results CONCLUSIONS: Myocardial strain imaging by STE unveils early evidence of myocardial injury in childhood cancer patients and long-term CCS. To support its adoption for clinical use, more data are required for the better understating of myocardial deformation parameters in the risk stratification of childhood cancer patients and prediction of development of cardiomyopathy among CCS.

Cardiac Imaging for the Assessment of Left Atrial Mechanics Across Heart Failure Stages

The left atrium (LA) is emerging as a key element in the pathophysiology of several cardiac diseases due to having an active role in contrasting heart failure (HF) progression. Its morphological and functional remodeling occurs progressively according to pressure or volume overload generated by the underlying disease, and its ability of adaptation contributes to avoid pulmonary circulation congestion and to postpone HF symptoms. Moreover, early signs of LA dysfunction can anticipate and predict the clinical course of HF diseases before the symptom onset which, particularly, also applies to patients with increased risk of HF with still normal cardiac structure (stage A HF). The study of LA mechanics (chamber morphology and function) is moving from a research interest to a clinical application thanks to a great clinical, prognostic, and pathophysiological significance. This process is promoted by the technological progress of cardiac imaging which increases the availability of easy-to-use tools for clinicians and HF specialists. Two-dimensional (2D) speckle tracking echocardiography and feature tracking cardiac magnetic resonance are becoming essential for daily practice. In this context, a deep understanding of LA mechanics, its prognostic significance, and the available approaches are essential to improve clinical practice. The present review will focus on LA mechanics, discussing atrial physiology and pathophysiology of main cardiac diseases across the HF stages with specific attention to the prognostic significance. Imaging techniques for LA mechanics assessment will be discussed with an overlook on the dynamic (under stress) evaluation of the chamber.

Early changes in left ventricular myocardial function by 2D speckle tracking layer-specific technique in neonates with hyperbilirubinemia

Background

Hyperbilirubinemia (HBN) can cause myocardial injury in neonates. Advancement in myocardial deformation imaging allows the detection of subclinical changes in myocardial contractility. The present study aimed to evaluate the changes in left ventricular contractility in newborns with hyperbilirubinemia by 2D speckle tracking imaging (STI).

Methods

A group of 134 neonates who reached the diagnostic level of HBN as the HBN group was selected. The control group included 56 healthy newborns. The interventricular septum, anterior partition, anterior wall, sidewall, posterior wall, and inferior wall were separated into the basal, middle, and apical segments. In each segment, speckle tracking analysis was performed in the subintimal, middle, and subadventitial myocardium. The overall longitudinal strain of the myocardium in different ventricular walls and segments and global longitudinal strain (GLS) were computed. At the same time, the laboratory results of blood gas analysis, blood routine tests, liver function, and myocardial enzyme spectrum in HBN neonates were collected and correlated with the left ventricular stratified strain parameters.

Results

The gradient of the left ventricular GLS had the same characteristics in both groups of newborns. There was a decreasing trend of longitudinal strain (LS) from the intima to the adventitia (i.e., GLSendo > GLSmid > GLSepi). This gradient was also present in stratified LS in each myocardial segment (P<0.001). The LS showed an increasing trend from the basal to the apical segment (P<0.001). The LS of the ventricular septum, anterior wall (or anterior septum), inferior wall, lateral wall, and posterior wall showed a decreasing trend (P<0.001). Stratified strain parameters of the ventricular wall (i.e., the 3-layer myocardium: LSendo-SEPT, LSmid-SEPT, and LSepi-SEPT) were all significantly lower in the HBN group than in the control group (P=0.019, P=0.019, and P=0.023, respectively). LSedo-ANT, LSmid-ANT, and LSepi-ANT were also reduced, and the difference between LSendo-ANT and LSepi-ANT was statistically significant. The segmental stratified strain parameters (i.e., the apical 3-layer myocardium: LSepi-a, LSmid-a, and LSepi-a) decreased, and the difference in LSepi-a was statistically significant (P=0.043). Overall strain parameters (i.e., the 3-layer myocardial overall strain: GLSendo, GLSmid, and GLSepi) were reduced, but the difference was not statistically significant (P=0.612, P=0.653, and P=0.585, respectively). The subclinical changes in systolic function in the HBN group, reflected by the parameters of longitudinal myocardial strain, correlate to some extent with multiple results of laboratory tests.

Conclusions

2DSTI stratified strain technology can quantitively evaluate changes in the LS of the left ventricle in different ventricular walls, wall segments, and layers of the myocardium.

Ventricular Myocardial Deformation in Fetuses With Tetralogy of Fallot: A Necessary Field of Investigation

Background: Tetralogy of Fallot (TOF) is one of the most common cyanotic congenital heart defects (CHDs). The patterns of fetal myocardial deformations in TOF have not been well-studied. This study aimed to assess biventricular myocardial deformations in fetuses with TOF compared with normal fetuses.

Methods: A retrospective cohort study of fetuses with TOF and gestational age (GA)-matched controls was conducted at a single tertiary referral center from 2014 to 2020. All enrolled fetuses underwent detailed echocardiography, and four-chamber video-clips were recorded and analyzed offline for deformation assessment by using two-dimensional speckle tracking echocardiography (2D-STE). Comparisons for baseline characteristics, cardiac morphological measurements (ventricular, atrial, and great arterial diameters or ratios, global sphericity index), systolic function parameters [ejection fraction (EF), fractional area change (FAC)], and strain parameters [global longitudinal strain (GLS), global longitudinal strain rate in systole and diastole (GLSRs, GLSRd)] were performed between fetuses with TOF and GA-matched controls.

Results: Fifty-two fetuses with TOF and 52 GA-matched controls were enrolled in this study. Fetuses with TOF exhibited similar left ventricular (LV) EF (58.51 ± 5.11% vs. 57.59 ± 5.38%, P = 0.16) and right ventricular (RV) FAC (43.64 ± 2.89% vs. 44.27 ± 3.04%, P = 0.25), compared to normal fetuses. While, in deformational analysis, TOF fetuses demonstrated significantly lower LV and RV GLS values (−22.57 ± 2.91% vs. −27.39 ± 4.38%, P < 0.001 for LV GLS; −24.27 ± 3.18% vs. −28.71 ± 4.48%, P < 0.001 for RV GLS). Both LV GLS (r = −0.518, P < 0.001) and RV GLS (r = −0.534, P < 0.001) were found negatively correlated with the aortic valve-to-pulmonary valve diameter ratio (AV:PV ratio). Z-scores of PV annulus and main pulmonary artery (MPA) also had positive correlation with LV and RV GLS, respectively.

Conclusions: Decreased biventricular myocardial deformations can appear even in fetuses with TOF with normal systolic ventricular function. Both LV and RV GLS values are correlated with the severity of right ventricular outflow tract obstruction. It indicates 2D-STE may be a more sensitive tool to assess fetal cardiac function than the conventional echocardiographic methods.

Predictive Value of Cardiac Magnetic Resonance Feature Tracking after Acute Myocardial Infarction: A Comparison with Dobutamine Stress Echocardiography

In acute ST-segment elevation myocardial infarction (STEMI) late gadolinium enhancement (LGE) may underestimate segmental functional recovery. We evaluated the predictive value of cardiac magnetic resonance (CMR) feature-tracking (FT) for functional recovery and whether it incremented the value of LGE compared to low-dose dobutamine stress echocardiography (LDDSE) and speckle-tracking echocardiography (STE). Eighty patients underwent LDDSE and CMR within 5–7 days after STEMI and segmental functional recovery was defined as improvement in wall-motion at 6-months CMR. Optimal conventional and FT parameters were analyzed and then also applied to an external validation cohort of 222 STEMI patients. Circumferential strain (CS) was the strongest CMR-FT predictor and addition to LGE increased the overall accuracy to 74% and was especially relevant in segments with 50–74% LGE (AUC 0.60 vs. 0.75, p = 0.001). LDDSE increased the overall accuracy to 71%, and in the 50–74% LGE subgroup improved the AUC from 0.60 to 0.69 (p = 0.039). LGE + CS showed similar value as LGE + LDDSE. In the validation cohort, CS was also the strongest CMR-FT predictor of recovery and addition of CS to LGE improved overall accuracy to 73% although this difference was not significant (AUC 0.69, p = 0.44). Conclusion: CS is the strongest CMR-FT predictor of segmental functional recovery after STEMI. Its incremental value to LGE is comparable to that of LDDSE whilst avoiding an inotropic stress agent. CS is especially relevant in segments with 50–74% LGE where accuracy is lower and further testing is frequently required to clarify the potential for recovery.

Assessment of Myocardial Function During Blood Pressure Manipulations Using Feature Tracking Cardiovascular Magnetic Resonance

Background: Coronary autoregulation is a feedback system, which maintains near-constant myocardial blood flow over a range of mean arterial pressure (MAP). Yet in emergency or peri-operative situations, hypotensive or hypertensive episodes may quickly arise. It is not yet established how rapid blood pressure changes outside of the autoregulation zone (ARZ) impact left (LV) and right ventricular (RV) function. Using cardiovascular magnetic resonance (CMR) imaging, measurements of myocardial tissue oxygenation and ventricular systolic and diastolic function can comprehensively assess the heart throughout a range of changing blood pressures.

Design and methods: In 10 anesthetized swine, MAP was varied in steps of 10–15 mmHg from 29 to 196 mmHg using phenylephrine and urapidil inside a 3-Tesla MRI scanner. At each MAP level, oxygenation-sensitive (OS) cine images along with arterial and coronary sinus blood gas samples were obtained and blood flow was measured from a surgically implanted flow probe on the left anterior descending coronary artery. Using CMR feature tracking-software, LV and RV circumferential systolic and diastolic strain parameters were measured from the myocardial oxygenation cines.

Results: LV and RV peak strain are compromised both below the lower limit (LV: Δ1.2 ± 0.4%, RV: Δ4.4 ± 1.2%, p < 0.001) and above the upper limit (LV: Δ2.1 ± 0.4, RV: Δ5.4 ± 1.4, p < 0.001) of the ARZ in comparison to a baseline of 70 mmHg. LV strain demonstrates a non-linear relationship with invasive and non-invasive measures of oxygenation. Specifically for the LV at hypotensive levels below the ARZ, systolic dysfunction is related to myocardial deoxygenation (β = −0.216, p = 0.036) in OS-CMR and both systolic and diastolic dysfunction are linked to reduced coronary blood flow (peak strain: β = −0.028, p = 0.047, early diastolic strain rate: β = 0.026, p = 0.002). These relationships were not observed at hypertensive levels.

Conclusion: In an animal model, biventricular function is compromised outside the coronary autoregulatory zone. Dysfunction at pressures below the lower limit is likely caused by insufficient blood flow and tissue deoxygenation. Conversely, hypertension-induced systolic and diastolic dysfunction points to high afterload as a cause. These findings from an experimental model are translatable to the clinical peri-operative environment in which myocardial deformation may have the potential to guide blood pressure management, in particular at varying individual autoregulation thresholds.

Long-term outcome of myocardial scarring and deformation with cardiovascular magnetic resonance in out of hospital cardiac arrest survivors

AIMS

Cardiovascular magnetic resonance (CMR) is increasingly recognized as a diagnostic and prognostic tool in out of hospital cardiac arrest (OHCA) survivors. After assessing CMR findings early after ventricular fibrillation (VF) OHCA, we sought to explore the long-term outcome of myocardial scarring and deformation.

METHODS AND RESULTS

We included 121 consecutive VF OHCA survivors (82% male, median 62 years) undergoing CMR within 2 weeks from cardiac arrest. Late gadolinium-enhancement (LGE) was quantified using the full width at half maximum method and tissue tracking analysis software was used to assess myocardial deformation. LGE was found in 71% of patients (median LGE mass 6.2% of the left ventricle, LV), mainly with an ischaemic pattern. Myocardial deformation was overall impaired and showed a significant correlation with LGE presence and extent (P < 0.001). A composite end-point of all-cause mortality and appropriate ICD discharge/anti-tachycardia pacing was met in 24% of patients. Patients meeting the end-point had significantly greater LGE extent (8.6% of LV myocardium vs. 4.1%, P = 0.02), while there was no difference with regards to myocardial deformation. Survival rate was significantly lower in patients with LGE (P = 0.05) and LGE mass >4.4% of the LV identified a group of patients at higher risk of adverse events (P = 0.005).

CONCLUSIONS

We found a high prevalence of LGE, early after OHCA, and an overall impaired myocardial deformation. On long-term follow-up both LGE presence and extent showed a significant association with recurrent adverse events, while LV ejection fraction and myocardial deformation did not identify patients with an unfavourable outcome.

Skewed Cytokine Responses Rather Than the Magnitude of the Cytokine Storm May Drive Cardiac Dysfunction in Multisystem Inflammatory Syndrome in Children

Background

Cardiac dysfunction is a prominent feature of multisystem inflammatory syndrome in children (MIS‐C), yet the etiology is poorly understood. We determined whether dysfunction is global or regional, and whether it is associated with the cytokine milieu, microangiopathy, or severity of shock.

Methods and Results

We analyzed echocardiographic parameters of myocardial deformation and compared global and segmental left ventricular strain between 43 cases with MIS‐C ≤18 years old and 40 controls. Primary outcomes included left ventricular global longitudinal strain, right ventricular free wall strain), and left atrial strain. We evaluated relationships between strain and profiles of 10 proinflammatory cytokines, microangiopathic features (soluble C5b9), and vasoactive‐inotropic requirements. Compared with controls, cases with MIS‐C had significant impairments in all parameters of systolic and diastolic function. 65% of cases with MIS‐C had abnormal left ventricular function (|global longitudinal strain|<17%), although elevations of cytokines were modest. All left ventricular segments were involved, without apical or basal dominance to suggest acute stress cardiomyopathy. Worse global longitudinal strain correlated with higher ratios of interleukin‐6 (ρ −0.43) and interleukin‐8 (ρ −0.43) to total hypercytokinemia, but not absolute levels of interleukin‐6 or interleukin‐8, or total hypercytokinemia. Similarly, worse right ventricular free wall strain correlated with higher relative interleukin‐8 expression (ρ −0.59). There were no significant associations between function and microangiopathy or vasoactive‐inotropic requirements.

Conclusions

Myocardial function is globally decreased in MIS‐C and not explained by acute stress cardiomyopathy. Cardiac dysfunction may be driven by the relative skew of the immune response toward interleukin‐6 and interleukin‐8 pathways, more so than degree of hyperinflammation, refining the current paradigm of myocardial involvement in MIS‐C.

Left ventricular myocardial deformation pattern, mechanical dispersion, and their relation with electrocardiogram markers in the large population-based STANISLAS cohort: insights into electromechanical coupling

AIMS

Mechanical alterations in patients with electrical conduction abnormalities are reported to have prognostic value in patients with left ventricular asynchrony or long QT syndrome beyond electrocardiogram (ECG) variables. Whether conduction and repolarization patterns derived from ECG are associated with speckle tracking echocardiography parameters in subjects without overt cardiac disease is yet to be investigated. To report ranges of longitudinal deformation according to conduction and repolarization values in a population-based cohort.

METHODS AND RESULTS

One thousand, one hundred, and forty subjects (48.6 ± 14.0 years, 47.7% men) enrolled in the fourth visit of the STANISLAS cohort (Lorraine, France) were studied. Echocardiography strain was performed in all subjects. RR, PR, QRS, and QT intervals were retrieved from digitalized 12-lead ECG. Echocardiographic data were stratified according to quartiles of QRS and QTc duration values. Full-wall global longitudinal strain (GLS) was -21.1 ± 2.5% with a mechanical dispersion (MD) value of 34 ± 12 ms. Absolute GLS value was lower in the longest QRS quartile and shortest QTc quartile (both P < 0.001). Time-to-peak of strain was not significantly different according to QRS duration although significantly higher in patients with higher QTc (P < 0.001). MD was significantly greater in patients with longer QTc (32 ± 12 ms for QTc < 396 ms vs. 36 ± 12 ms for QTc > 421 ms; P = 0.002).

CONCLUSION

Longer QTc is related to increased MD and better longitudinal strain values. In a population-based setting, QRS is not associated with MD, suggesting that echocardiography-based dyssynchrony does not largely overlap with ECG-based dyssynchrony.

Myocardial Deformation Assessed by MR Feature Tracking in Groups of Patients With Ischemic Heart Disease

BACKGROUND

Global myocardial strain assessments have been shown to provide useful measures of contractility in many diseases, but whether feature tracking (FT)-derived strain at rest can differentiate ischemic myocardium from infarcted and remote myocardium in patients with coronary artery disease (CAD) remains unclear.

PURPOSE

To evaluate the performance of magnetic resonance imaging FT-derived strain in the detection of regional myocardial deformation in ischemic, infarcted, and apparent normal myocardium in CAD.

STUDY TYPE

Retrospective POPULATION: A total of 109 patients with CAD.

FIELD STRENGTH/SEQUENCES

Steady-state free-precession rest cine, T1-weighted saturation-recovery fast gradient echo stress/rest perfusion, and two-dimensional phase-sensitive inversion recovery breath-hold late gadolinium enhancement (LGE) tests were performed at 3.0 T.

ASSESSMENT

Based on perfusion and LGE images, left ventricular (LV) myocardial segments of CAD patients were categorized into ischemic, infarcted, and negative groups. The FT longitudinal (LS) and circumferential strain (CS) of normal subjects and the three CAD groups were calculated. Z-scores of each segment of CAD patients were calculated.

STATISTIC TESTS

χ² testing, analysis of variance (ANOVA), and Kruskal-Wallis tests. Z-scores were used to compare the strain between CAD groups.

RESULTS

There were significant differences in global LS (GLS) and CS (GCS) between healthy controls (GLS: -19.0% ± 1.4%, GCS, -20.9% ± 1.8%), ischemia (GLS: -17.4% ± 2.1%, GCS, -19.6% ± 1.9%), infarction (GLS: -16.4% ± 1.9%, GCS, -17.8% ± 1.9%), and negative patients (GLS: -17.7% ± 1.4%, GCS, -20.9% ± 2.4%) (all P < 0.05). There were significant differences in regional LS and CS between ischemic (LS, -16.1% ± 5.0%, CS, -18.7% ± 5.0%), infarcted (LS, -14.8% ± 5.2%, CS, -15.3% ± 4.8%), and negative segments (LS, -17.6% ± 5.2%, CS, -19.8% ± 4.8%) (all P < 0.05). The differences in the z-scores of regional LS and CS between the ischemic, infarcted, and negative segments were also significant (all P < 0.05).

DATA CONCLUSION

FT-derived rest strain indices of the LV myocardium of CAD patients were higher compared to healthy controls and varied between ischemic, infarcted, and negative segments.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY: Stage 5.

Resolution of Strain Abnormalities During Extracorporeal Rewarming From Accidental Hypothermic Cardiac Arrest Following Avalanche Burial

A hypothermic avalanche victim underwent, during extracorporeal warming from asystolic arrest, 3-dimensional transesophageal echocardiography. At 33°C core temperature, left ventricular ejection fraction had recovered, whereas myocardial strain still demonstrated significant dysfunction until 36°C. Deformation analysis seems more sensitive than global assessment during myocardial recovery from hypothermic cardiac arrest. (Level of Difficulty: Intermediate.)

Echocardiography in Autoimmune Rheumatic Diseases for Diagnosis and Prognosis of Cardiovascular Complications

Autoimmune rheumatic diseases are systemic diseases frequently affecting the heart and vessels. The main cardiovascular complications are pericarditis, myocarditis, valvular disease, obstructive coronary artery disease and coronary microcirculatory dysfunction, cardiac failure and pulmonary hypertension. Echocardiography, including transthoracic two and three-dimensional echocardiography, Doppler imaging, myocardial deformation and transesophageal echo, is an established and widely available imaging technique for the identification of cardiovascular manifestations that are crucial for prognosis in rheumatic diseases. Echocardiography is also important for monitoring the impact of drug treatment on cardiac function, coronary microcirculatory function, valvular function and pulmonary artery pressures. In this article we summarize established and evolving knowledge on the role of echocardiography for diagnosis and prognosis of cardiovascular abnormalities in rheumatic diseases.

Silent myocardial dysfunction in vitamin D deficiency

Introduction

Vitamin D (VD) deficiency is a common disease that occurs in all stages of life. A growing number of studies call attention to the relationship between VD deficiency and cardiovascular disease. The aim of this study was to investigate the effect of VD on subclinical left ventricular (LV) function in diabetic and non-diabetic patients with no significant coronary artery disease.

Material and methods

We recruited 140 patients (80 diabetics and 60 non-diabetics) with symptoms of stable ischemic heart disease who underwent coronary angiography and who had no significant coronary artery disease in our clinic. The 25(OH)D₃ levels were measured and patients who had 25-(OH)D₃ levels below 20 ng/dl were defined as the VD deficient group. In addition to conventional echocardiographic parameters, tissue Doppler echocardiography was used for LV diastolic functions and 2D speckle tracking strain echocardiography (2D STE) for evaluating the longitudinal deformation indices of the LV myocardium.

Results

In all groups, LV global longitudinal strain (GLS) was significantly impaired in patients with VD deficiency (p < 0.001) compared to patients without VD deficiency. LV global longitudinal strain rate (GLSR) was significantly impaired in patients with VD deficiency (p = 0.003). The GLS was negatively associated with 25-(OH)D₃ in the VD deficiency group (r = –0.52623, p < 0.001). Conversely, GLS was positively associated with 25-(OH)D₃ levels in the normal VD group (r = 0.28, p = 0.048).

Conclusions

VD deficiency is associated with impaired myocardial GLS. The present study demonstrated that VD deficiency may be the cause of subclinical myocardial dysfunction in patients with or without diabetes mellitus and no history of significant coronary artery disease.

Comparison of myocardial deformation indices during rest and after activity in untreated hyperthyroid patients with normal population

BACKGROUND

Thyroid hormones play an essential role on the cardiovascular system. Also, thyroid diseases have a prominent adverse effect on myocardial and vascular functions. Therefore, the aim of this study was to compare myocardial deformation indices during resting and after activity between the untreated hyperthyroid patients and normal population.

METHODS

We included 26 untreated participants who were newly diagnosed with hyperthyroidism and 26 healthy participants matched in terms of age and sex. The left ventricular end-diastolic volume index (LVEDVI), Heart Rate (HR), Cardiac Output (CO), systolic and diastolic blood pressures, Global Longitudinal Strain (GLS), Global Circumferential Strain (GCS), Rate-Pressure Product (RPP), systolic and diastolic strains rates were measured in rest and peak of exercise in stress echocardiography.

RESULTS

Age and sex distributions were similar among the groups. Also, mean serum TSH was 0.08 ± 0.08 ng/dL in the case group. The participants with the untreated hyperthyroidism had lower Ejection Fraction change (ΔEF), GLS, peak stress systolic and diastolic strains rates compared to the control group. Also, there was a positive association between TSH levels and basal HR, RPP, CO, as well as a negative correlation with basal and maximum GLS, ΔHR, ΔEF, and ΔCO. Also, a duration of symptoms had a linear association with rest HR, CO, and LVEDVI, as well as a negative correlation with rest and maximal GLS, ΔHR, and ΔGLS.

CONCLUSION

Myocardial deformation assessed by 2DE imaging are significantly impaired in the hyperthyroid patients. In this regard, further studies with a larger sample size are required to confirm the results of this study.

Decreased biventricular myocardial deformation in fetuses with lower urinary tract obstruction

BACKGROUND

To observe myocardial deformations in fetuses with isolated lower urinary tract obstruction (LUTO) and identify the correlation between myocardial deformation and the severity of obstruction.

METHODS

The strain (S), strain rate in systole (SRs) and strain rate in diastole (SRd) of the left and right ventricles at the first examination were prospectively analyzed and compared between fetuses with isolated LUTO and gestational age (GA)-matched normal control fetuses. Multiple regression analyses were used to assess the obstructive factors for impaired strain and strain rate, and the independent variables included bladder volume, sum of the bilateral pelvic diameters, sum of the bilateral ureteral diameters, mean bilateral renal artery pulsatility index, and amniotic fluid index.

RESULTS

Thirty-six fetuses with isolated LUTO and 36 normal controls were enrolled. Overall, decreased S, SRs and SRd of both ventricles were noted in fetuses with LUTO (p < 0.001). Moreover, S and SR were significantly negatively related to distended bladder volume (p < 0.001).

CONCLUSIONS

Fetuses with LUTO demonstrated decreased left and right myocardial deformation, and this impaired cardiac dysfunction was correlated with the urinary bladder volume. Evaluating the myocardial deformation in fetal LUTO could provide information to aid in parental counselling and intervention monitoring.

Exercise echocardiography demonstrates potential myocardial damage in patients with repaired tetralogy of Fallot using layer-specific strain analysis

INTRODUCTION

Exercise stress echocardiography and layer-specific strains are emerging as important tools for cardiac assessment. This study was aimed to evaluate layer-specific strains and torsion parameters during exercise in order to investigate the characteristics of cardiac dysfunction in patients with repaired tetralogy of Fallot and to detect subclinical left ventricular dysfunction.

MATERIALS AND METHODS

Thirteen patients with repaired tetralogy of Fallot (median age, 17.3 [interquartile range, 14.5-22.9] years; 6 males) and 13 controls (median age, 28.5 [interquartile range, 27.6-31.6] years; 13 males) underwent echocardiography at rest and during supine exercise. Layer-specific longitudinal strain and circumferential strain of three myocardial layers (endocardium, midmyocardium, and epicardium), torsion, and untwisting rate were measured using two-dimensional speckle-tracking echocardiography.

RESULTS

Peak endocardial papillary circumferential strain (-21.1 ± 2.6% vs. -25.8 ± 3.8%, p = 0.007), midmyocardial apical circumferential strain (-11.1 ± 4.0% vs. -15.6 ± 3.2%, p = 0.001), epicardial apical circumferential strain (-11.1 ± 4.0% vs. -15.6 ± 3.2%, p = 0.021), and torsion (8.9 ± 6.0 vs. 14.9 ± 4.8 degree, p = 0.021) were significantly lower in the repaired tetralogy of Fallot group than in the control group during exercise, though no significant difference was found between patients and controls at rest.

CONCLUSIONS

Analysis of layer-specific strains and torsion parameters during exercise could detect subclinical left ventricular dysfunction in patients with repaired tetralogy of Fallot, which might reflect potential myocardial damage, at a stage where these parameters have normal values at rest. This finding provides new insight into the mechanisms of cardiac dysfunction in patients with repaired tetralogy of Fallot.

Three-dimensional echocardiography to assess left ventricular geometry and function

Introduction: Quantification of left ventricular (LV) size and function represents the most frequent indication for an echocardiographic study. New echocardiographic techniques have been developed over the last decades in an attempt to provide a more comprehensive, accurate, and reproducible assessment of LV function.Areas covered: Although two-dimensional echocardiography (2DE) is the recommended imaging modality to evaluate the LV, three-dimensional echocardiography (3DE) has proven to be more accurate, by avoiding geometric assumptions about LV geometry, and to have incremental value for outcome prediction in comparison to conventional 2DE. LV shape (sphericity) and mass are actually measured with 3DE. Myocardial deformation analysis using 3DE can early detect subclinical LV dysfunction, before any detectable change in LV ejection fraction.Expert opinion: 3DE eliminates the errors associated with foreshortening and geometric assumptions inherent to 2DE and 3DE measurements approach very closely those obtained by CMR (the current reference modality), while maintaining the unique clinical advantage of a safe, highly cost/effective, portable imaging technique, available to the cardiologist at bedside to translate immediately the echocardiography findings into the clinical decision-making process.

Assessment of Global Longitudinal and Circumferential Strain Using Computed Tomography Feature Tracking: Intra-Individual Comparison with CMR Feature Tracking and Myocardial Tagging in Patients with Severe Aortic Stenosis

In this study, we used a single commercially available software solution to assess global longitudinal (GLS) and global circumferential strain (GCS) using cardiac computed tomography (CT) and cardiac magnetic resonance (CMR) feature tracking (FT). We compared agreement and reproducibility between these two methods and the reference standard, CMR tagging (TAG). Twenty-seven patients with severe aortic stenosis underwent CMR and cardiac CT examinations. FT analysis was performed using Medis suite version 3.0 (Leiden, The Netherlands) software. Segment (Medviso) software was used for GCS assessment from tagged images. There was a trend towards the underestimation of GLS by CT-FT when compared to CMR-FT (19.4 ± 5.04 vs. 22.40 ± 5.69, respectively; p = 0.065). GCS values between TAG, CT-FT, and CMR-FT were similar (p = 0.233). CMR-FT and CT-FT correlated closely for GLS (r = 0.686, p < 0.001) and GCS (r = 0.707, p < 0.001), while both of these methods correlated moderately with TAG for GCS (r = 0.479, p < 0.001 for CMR-FT vs. TAG; r = 0.548 for CT-FT vs. TAG). Intraobserver and interobserver agreement was excellent in all techniques. Our findings show that, in elderly patients with severe aortic stenosis (AS), the FT algorithm performs equally well in CMR and cardiac CT datasets for the assessment of GLS and GCS, both in terms of reproducibility and agreement with the gold standard, TAG.

Beyond apical ballooning: computational modelling reveals morphological features of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TCM) is characterized by transient myocardial dysfunction, typically at the left ventricular (LV) apex. Its pathophysiology and recovery mechanisms remain unknown. We investigated LV morphology and deformation in n = 28 TCM patients. Patients with MRI within 5 days from admission ("early TCM") showed reduced LVEF and higher ventricular volumes, but no differences in ECG, global strains or myocardial oedema. Statistical shape modelling described LV size (Mode 1), apical sphericity (Mode 2) and height (Mode 3). Significant differences in Mode 1 suggest that "early TCM" LV remodeling is mainly influenced by a change in ventricular size rather than apical sphericity.

Comprehensive left ventricular myocardial deformation assessment in children with Kawasaki disease

OBJECTIVE

Children with Kawasaki disease (KD) with persistent coronary artery aneurysms (CAAs) can develop chronic vasculopathy and subsequent myocardial ischemia. Early detection of this process is challenging. Myocardial deformation analysis can detect early alterations in myocardial performance. We aim to determine whether there are differences in myocardial deformation between KD patients with and without CAAs.

DESIGN

This is a cross-sectional study of 123 echocardiograms performed on 103 children with KD. Myocardial deformation was measured with two-dimensional speckle tracking (2DSTE). The echocardiograms were divided into groups according to the KD phase in which they were performed: acute, subacute, and convalescent/chronic. The convalescent/chronic phase group was then divided based on the presence or absence of CAAs. Left ventricular (LV) global longitudinal strain (GLS), global longitudinal strain rate (GLSSR), global circumferential strain (GCS), global circumferential systolic strain rate (GCSSR), peak torsion, and torsion rate were measured.

RESULTS

The numbers of echocardiograms analyzed in each of the KD phase groups were: 31 acute, 25 subacute, and 67 convalescent/chronic. Myocardial deformation was within normal limits in all groups. However, GLSSR, GCSSR, peak torsion, and torsion rate were lower in the convalescent/chronic phase group than in the acute phase group (mean, -1.37 ± 0.24 vs -1.55 ± 0.21 1/s; -1.63 ± 0.27 vs -1.84 ± 0.35 1/s; 2.49 ± 1.13 vs 3.41 ± 2.60 °/cm, and 21.97 ± 8.36 vs 26.69 ± 10.86 °/cm/s; P < .05 for all). The convalescent/chronic phase subgroup with CAAs had lower GLSSR and GCSSR than the subgroup without CAAs (mean, -1.23 ± 0.22 vs -1.42 ± 0.22 1/s; -1.46 ± 0.25 vs -1.68 ± 0.26 1/s, P < .05 for both).

CONCLUSIONS

Children in the convalescent/chronic phase of KD have a subtle decrease in strain rate when compared to the acute phase, although within the normal range. This decrease is more pronounced in children with CAAs than those without CAAs. Longitudinal studies are needed to discern whether low-normal strain rate predicts decreased myocardial function in the long term.

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

OBJECTIVE

To evaluate segmental left (LV-S) and right (RV-S) ventricular strain as well as longitudinal mechanical myocardial dyssynchrony as a time difference between peaks in strain of both ventricles in fetuses (two-chamber-dyssynchrony, 2C-DYS) using speckle tracking echocardiography (STE). The aim of our study was to evaluate the influence of data acquisition on the results of STE measurement using different ultrasound probes.

METHODS

We prospectively recorded cardiac cycles of four-chamber views of 56 normal fetuses with three different ultrasound probes and analyzed them offline with speckle tracking imaging software. Furthermore, we looked at a possible influence of heartbeat variability (beat-to-beat variability).

RESULTS

The evaluation of the parameters was feasible with all three probes in 53 cases. There was no influence of heartbeat variability and no noticeable differences in 2C-DYS, LV-S and RV-S in all cases and for all three probes determined.

CONCLUSION

Assessment of strain and dyssynchrony using STE with three different probes is comparable. Further research is needed to validate dyssynchrony as a predictor for fetal outcome.

Myocardial strain assessment using velocity vector imaging in normally grown fetuses at term

OBJECTIVES

To assess prospectively fetal myocardial deformation at term in normally grown fetuses using the velocity vector imaging (VVI) two-dimensional speckle-tracking technique, and to explore myocardial deformation changes over the last 4 weeks of pregnancy.

METHODS

This was a prospective, observational cohort study of 276 women with an uncomplicated singleton pregnancy who underwent fortnightly ultrasound from 36 weeks' gestation until delivery at the Mater Mother's Hospital, Brisbane, Australia. Fetal myocardial deformation (assessed by global and segmental longitudinal systolic myocardial strain and strain rate of both right and left ventricles) was measured using VVI software.

RESULTS

Mean global longitudinal left and right ventricular strain and strain rate values decreased between each time point. At 36, 38 and 40 weeks' gestation, left ventricular global strain (%) and strain rate (/s) decreased, respectively, as follows: -14.6 ± 3.8% and -1.2 ± 0.3/s at 36 weeks; -13.6 ± 3.3% and -1.1 ± 0.3/s at 38 weeks; and -12.3 ± 3.1% and -1.0 ± 0.3/s at 40 weeks. At 36, 38 and 40 weeks, mean right ventricular global strain (%) and mean strain rate (/s) decreased, respectively, as follows: -14.2 ± 3.4% and -1.2 ± 0.2/s at 36 weeks; -13.4 ± 3.0% and -1.1 ± 0.2/s at 38 weeks; and -12.8 ± 2.8% and -1.1 ± 0.2/s at 40 weeks.

CONCLUSIONS

Global ventricular strain values diminish with advancing gestational age. Myocardial deformation imaging is feasible in late gestation and may be useful as an adjunct for the assessment of fetal cardiac function close to birth. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

[Structural and Functional Characteristics of the Heart in Patients With "Constrictive", "Pseudo-Normal" and "Restrictive" Types of the Left Ventricular Diastolic Dysfunction]

PURPOSE

to study structural functional characteristics of the heart in patients with various types of abnormalities of diastolic function (DF) based on data obtained at stress echocardiography (stress EchoCG) and echocardiographic indexes of myocardial deformation.

MATERIALS AND METHODS

We included in this study 110 patients with hypertensive disease (HD), clinically manifest chronic heart failure (CHF), and abnormal DF of the left ventricle (LV) in the absence of coronary artery stenosis. All patients underwent standard clinical and laboratory examination, EchoCG with measurement of 3‑dimensional global longitudinal strain (GLS), and stress EchoCG on treadmill with evaluation of DF parameters.

RESULTS

In the group with abnormal relaxation in patients with Е/e' >13 left atrial (LA) passive emptying fraction and distensibility index (27.1±14.5 and 127.8±96.1 %, respectively) were significantly smaller than in other patients of this group (34.8±14.2 и 207.7±86.8 %, respectively; р13 during exercise had lower LA passive emptying fraction and distensibility index (р13 during exercise, degree of reduction of LV contractility was similar irrespective of type of DF abnormality. In patients with different degrees of DF derangements (abnormal relaxation, transitional or restrictive type) Е/e' >13 during exercise was accompanied by similar lowering of mitral annular systolic velocity at rest (7.1±1.58, 6.9±1.13, and 6.79±0.93 cm / s, respectively). There were also no significant differences between these groups in values of 3‑dimensional GLS (-11.2±1.5, -10.4±0.94, and -11.8±1.97 %, respectively).

CONCLUSION

Elevation of LV filing pressure during stress EchoCG evidence for non-homogeneity of groups of patients with different degrees of DF abnormalities, presence of deeper structural-functional changes of the cardiovascular system, accompanied by reduction of myocardial contractility as well as LA reservoir and pump function. The use of stress EchoCG for evaluation of parameters of myocardial deformation allows to improve diagnostics of CHF in patients with preserved LV ejection fraction and directs to determination of criteria of preclinical manifestations of CHF.

Prelabour myocardial deformation and cardiac output in fetuses that develop intrapartum compromise at term: a prospective observational study

Objective: Redistribution of cardiac output is responsible for the "brain sparing" effect seen during periods of acute or chronic fetal stress. We investigated the relationship between prelabour cardiac function in fetuses that subsequently developed intrapartum fetal compromise (IFC). Methods: A blinded, prospective, observational, cohort study, at Mater Mother's Hospital, Brisbane, Australia. A cohort of 284 women with uncomplicated singleton pregnancies underwent ultrasound every 2 weeks from 36 weeks until delivery. Fetal cardiac output was assessed by conventional Doppler ultrasound and myocardial deformation was measured using velocity vector imaging. Results: Two hundred and seventy three women were included in the final analysis, of which 19% had an emergency operative delivery for intrapartum fetal compromise (IFC). Global left ventricular strain (-12.1%, interquartile ranges (IQR) - 10.3 to -14% versus 13%, IQR -11.3 to -14.2%, p = .01) and strain rate (-1.00, IQR 0.85-1.16 s^-1 versus -1.11, IQR -1.00 to -1.21 s^-1, p < .001) were lower in fetuses that required any emergency operative delivery for IFC compared to those that did not. Global longitudinal right ventricular strain rate was lower in fetuses that developed IFC (-1.04 ± 0.22 s^-1 versus 1.13 ± 0.22 s^-1, p < .001), whereas global right ventricular strain did not show any significance differences between the two groups. Additionally, left ventricular cardiac output was lower in fetuses that developed IFC or had a composite neonatal morbidity (560 ± 44 mL/min versus 617 ± 72 mL/min, p < .001) or (581 ± 44 mL/min versus 612 ± 72 mL/min, p < .01), respectively. Conclusion: Lower global left ventricular strain and strain rate and cardiac output are associated with IFC and poorer condition of the newborn. Assessment of fetal cardiac function may be useful for risk stratification for intrapartum fetal compromise in apparently "low risk" term pregnancies.

Three-dimensional speckle-tracking echocardiography: benefits and limitations of integrating myocardial mechanics with three-dimensional imaging

Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) is an advanced imaging technique designed for left ventricular (LV) myocardial deformation analysis based on 3D data sets. 3DSTE has the potential to overcome some of the intrinsic limitations of two-dimensional STE (2DSTE) in the assessment of complex LV myocardial mechanics, offering additional deformation parameters (such as area strain) and a comprehensive quantitation of LV geometry and function from a single 3D acquisition. Albeit being a relatively young technique still undergoing technological developments, several experimental studies and clinical investigations have already demonstrated the reliability and feasibility of 3DSTE, as well as several advantages of 3DSTE over 2DSTE. This technique has provided new insights into LV mechanics in several clinical fields, such as the objective assessment of global and regional LV function in ischemic and non-ischemic heart diseases, the evaluation of LV mechanical dyssynchrony, as well as the detection of subclinical cardiac dysfunction in cardiovascular conditions at risk of progression to overt heart failure. However, 3DSTE generally requires patient's breathhold and regular rhythm for enabling an ECG-gated multi-beat 3D acquisition. In addition, the measurements, normal limits and cut-off values pertaining to 3D strain parameters are currently vendor-specific and highly dependent on the 3D ultrasound equipment used. Technological advances with improvement in spatial and temporal resolution and a standardized methodology for obtaining vendor-independent 3D strain measurements are expected in the future for a widespread application of 3DSTE in both clinical and research arenas. The purpose of this review is to summarize currently available data on 3DSTE methodology (feasibility, accuracy and reproducibility), strengths and weaknesses with respect to 2DSTE, as well as the main clinical applications and future research priorities of this emerging technology.

[Current Echocardiographic Techniques for Evaluation of the Right Ventricle]

The review is dedicated to the new echocardiographic techniques in the assessment of right ventricular (RV) function, such as two-dimensional speckle tracking and determining the RV volume by a three-dimensional model. Subclinical changes in RV function are of great importance for the diagnosis and assessment of prognosis of multiple cardiovascular as well as non-cardiac pathologies. Two-dimensional speckle tracking allows to assess longitudinal strain of the RV myocardium and to detect pathological changes before their clinical manifestations. Three-dimensional echocardiography enables calculation of the RV ejection fraction, what was not possible before with the use of ultrasound. Currently, both methods are promising for a comprehensive assessment of RV function.

Combined myocardial deformation to predict cardiac resynchronization therapy response in nonischemic cardiomyopathy

BACKGROUND

20-30% of patients do not benefit from cardiac resynchronization therapy (CRT) when the established selection criteria were applied. We hypothesized that a combined assessment of mechanical dyssynchrony, myocardial deformation, and diastolic function would identify patients who would benefit most from CRT.

METHOD

In 36 CRT patients, clinical evaluation and echocardiography were performed before and after CRT. Patients were classified into three subgroups according to their amount of response: echocardiographic responders, clinical responders, and nonresponders. Radial dyssynchrony and left ventricular (LV) global longitudinal, radial, and circumferential peak strain was assessed by speckle-tracking image. Diastolic function was quantified by conventional echocardiography.

RESULT

In addition to left bundle branch block, nonspecific intraventricular conduction disturbance with intraventricular dyssynchrony could also improve LV remodeling. Echocardiographic responders had better global longitudinal strain, global circumferential peak strain, and global radial strain at baseline which significantly increased at 12-month follow-up. An improvement in estimates of LV filling pressure and a decrease in mitral regurgitation and left atrial dimensions were observed only in echocardiographic responders to CRT. Patients with clinical but without echocardiographic response showed a significant improvement in atrioventricular (AV) synchrony and a nonsignificant improvement in other parameters. The nonresponder group did not improve the AV and intraventricular dyssynchrony. CRT could not improve restrictive filling pattern with normal filling time. Overall, those patients with AV and intraventricular dyssynchrony and those with best contractile function and short diastolic filling time of restrictive filling pattern at baseline demonstrated the greatest benefit from CRT.

CONCLUSIONS

Mechanical dyssynchrony, contractile function, and filling pattern are important determinants of the benefits in CRT.

The associations among co-morbidity, cardiac geometries and mechanics in hospitalized heart failure with or without preserved ejection fraction

BACKGROUND

The associations among chronic health conditions, ventricular geometric alterations or cardiac contractile mechanics in different phenotypes heart failure (HF) remain largely unexplored.

METHODS

We studied 438 consecutive hospitalized patients (mean age: 64.9 ± 16.6 years, 52.5% female) with or without clinical evidence of HF. We examined the associations among clinical co-morbidities, LV geometries and systolic mechanics in terms of global myocardial strains.

RESULTS

Increasing clinical co-morbidities was associated with greater LV mass, worse longitudinal deformations and higher proportion of admission with HF diagnosis, which was more pronounced in HFpEF (from 6.4% to 40.7%, X² < 0.001). The independent association between co-morbidity burden and longitudinal functional decay remained unchanged after adjusting for age and sex for all admissions and in HFpEF (Coef: 0.82 & 0.71, SE: 0.13 & 0.21, both p≤0.001). By using co-morbidity scores, the area under receiver operating characteristic curves (AUROC) in identifying HFpEF was 0.71 (95% CI: 0.65 to 0.77), 0.64 (95% CI: 0.58 to 0.71) for HFrEF and 0.72 for both (95% CI: 0.67 to 0.77). Co-morbidity burden superimposed on LV mass index and LV filling pressure (E/E') further expanded the AUROC significantly in diagnosing both types HF (c-statistics from 0.73 to 0.81, p for ΔAUROC: 0.0012).

CONCLUSION

Chronic health conditions in the admission population were associated with unfavorable cardiac remodeling, impair cardiac contractile mechanics and further added significantly incremental value in HF diagnosis. Our data suggested the potentiality for better cardiac function by controlling baseline co-morbidities in hospitalized HF patients, especially HFpEF.

ABBREVIATIONS

CAD: coronary artery disease; CKD: chronic kidney disease; DT: deceleration time; eGFR: Estimated glomerular filtration rate; HF: heart failure; IVRT: iso-volumic relaxation time; LV: left ventricular; LVEF: left ventricular ejection fraction; RWT: relative wall thickness; TDI: Tissue Doppler imaging.

Improved detection of myocardial damage in sarcoidosis using longitudinal strain in patients with preserved left ventricular ejection fraction

BACKGROUND

Cardiac infiltration is an important cause of death in sarcoidosis. Transthoracic echocardiography (TTE) has limited sensitivity for the detection of cardiac sarcoidosis (CS). Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is used to diagnose CS but has limitations of cost and availability. We sought to determine whether TTE-derived global longitudinal strain (GLS) may be used to identify individuals with CS, despite preserved left ventricular ejection fraction (LVEF), and whether abnormal GLS is associated with major cardiovascular events (MCE).

METHODS

We studied 31 patients with biopsy-proven extra-cardiac sarcoidosis, LVEF>50% and LGE on CMR (CS+ group), and 31 patients without LGE (CS- group), matched by age, sex, and severity of lung disease. GLS was measured using vendor-independent speckle tracking software. Parameters of left and right ventricular systolic and diastolic function were also studied. Receiver-operating characteristic curves were used to identify GLS cutoff for CS detection, and Kaplan-Meier plots to determine the ability of GLS to predict MCE.

RESULTS

LGE was associated with reduced GLS (-19.6±1.9% in CS- vs -14.7±2.4% in CS+, P<.01) and with reduced E/A ratio (1.1±0.3 vs 0.9±0.3, respectively, P =.01). No differences were noted in other TTE parameters. GLS magnitude inversely correlated with LGE burden (r=-.59). GLS cutoff of -17% showed sensitivity and specificity 94% for detecting CS. Patients who experienced MCE had worse GLS than those who did not (-13.4±0.9% vs -17.7±0.4%, P=.0003).

CONCLUSIONS

CS is associated with significantly reduced GLS in the presence of preserved LVEF. GLS measurements may become part of the TTE study performed to screen for CS.

Mechanical effects of left ventricular midwall fibrosis in non-ischemic cardiomyopathy

BACKGROUND

Left ventricular (LV) mid-wall fibrosis (MWF), which occurs in about a quarter of patients with non-ischemic cardiomyopathy (NICM), is associated with high risk of pump failure. The mid LV wall is the site of circumferential myocardial fibers. We sought to determine the effect of MWF on LV myocardial mechanics.

METHODS

Patients with NICM (n = 116; age: 62.8 ± 13.2 years; 67% male) underwent late gadolinium enhancement cardiovascular magnetic resonance (CMR) and were categorized according to the presence (+) or absence (-) of MWF. Feature tracking (FT) CMR was used to assess myocardial deformation.

RESULTS

Despite a similar LVEF (24.3 vs. 27.5%, p = 0.20), patients with MWF (32 [24%]) had lower global circumferential strain (Ɛcc: -6.6% vs. -9.4 %, P = 0.004), but similar longitudinal (Ɛll: -7.6 % vs. -9.4 %, p = 0.053) and radial (Ɛrr: 14.6% vs. 17.8% p = 0.18) strain. Compared with - MWF, + MWF was associated with reduced LV systolic, circumferential strain rate (-0.38 ± 0.1 vs. -0.56 ± 0.3 s(-1), p = 0.005) and peak LV twist (4.65 vs. 6.31°, p = 0.004), as well as rigid LV body rotation (64 % vs. 28 %, P <0.001). In addition, +MWF was associated with reduced LV diastolic strain rates (DSRcc: 0.34 vs. 0.46 s(-1); DSRll: 0.38 vs. 0.50s(-1); DSRrr: -0.55 vs. -0.75 s(-1); all p <0.05).

CONCLUSIONS

MWF is associated with reduced LV global circumferential strain, strain rate and torsion. In addition, MWF is associated with rigid LV body rotation and reduced diastolic strain rates. These systolic and diastolic disturbances may be related to the increased risk of pump failure observed in patients with NICM and MWF.

Myocardial dysfunction in patients with aortic stenosis and hypertensive heart disease assessed by MR tissue phase mapping

PURPOSE

To identify abnormalities of myocardial velocities in patients with left ventricular pressure overload using magnetic resonance tissue phase mapping (TPM).

MATERIAL AND METHODS

Thirty-three patients (nine with hypertensive heart disease [HYP], 24 with aortic stenosis [AS]) and 41 healthy controls were enrolled. To assess left ventricular motion, a basal, midventricular, and apical slice were acquired using three-directional velocity-encoded phase-contrast MR with a 3T system. Target parameters were peak longitudinal (Vz ) and radial (Vr ) velocity in systole and diastole (Peaksys , Peakdias ). Analysis was done on each myocardial segment. In a subgroup (n = 7 HYP, n = 12 AS, n = 24 controls), measurement was repeated during handgrip exercise.

RESULTS

AS had significantly lower Vz -Peaksys in the inferolateral and inferoseptal wall (P = 0.003-0.029) and Vr -Peaksys in the septum and anterior wall (P = 0.001-0.013) than controls. Vz -Peakdias and Vr -Peakdias were lower in AS than in controls in almost all segments (P < 0.001-0.028). HYP showed reduced Vz -Peakdias compared to controls in all basal segments as well as in the lateral midventricular wall (P < 0.001-0.045), and reduced Vr -Peakdias compared to controls predominantly in the midventricular and apical segments (P = 0.004-0.042). AS patients with focal fibrosis had significantly reduced myocardial velocities (P = 0.001-0.047) in segments without late enhancement. During exercise, Vz -Peaksys , Vr -Peaksys , and Vz -Peakdias remained unchanged in AS and HYP, but decreased in the lateral wall in controls (P < 0.001-0.043).

CONCLUSION

Even with preserved left ventricle (LV) ejection fraction, peak longitudinal and radial velocities of the LV are reduced in AS and HYP, indicating early functional impairment. J. Magn. Reson. Imaging 2016;44:168-177.

Assessment of ventricular function in adults with repaired Tetralogy of Fallot using myocardial deformation imaging

AIMS

Many patients with repaired Tetralogy of Fallot (ToF) have right ventricular (RV) volume overload due to pulmonary regurgitation (PR). We studied the effect of volume overload on global and regional RV and left ventricular (LV) deformation, and their relationships with conventional diagnostic parameters.

METHODS AND RESULTS

In this cross-sectional study, 94 prospectively recruited ToF patients (61% male, age 32.8 ± 9.5 years, age at repair 1.9 [0.8-5.7] years, 39% pulmonary homograft) and 85 healthy controls of similar age and sex underwent echocardiography and electrocardiography. In a subset of patients, cardiac magnetic resonance imaging, bicycle ergometry, and NT-proBNP measurement were performed within the same day. With speckle-tracking echocardiography, we analysed peak systolic global longitudinal strain (GLS), segmental longitudinal strain and strain rate of the RV free wall, LV lateral wall, and septum. Patients had a lower RV free wall strain than controls (-18.1 ± 4.5 vs. -26.5 ± 4.5%, P < 0.001), especially at the apical segment (-15.9 ± 7.4 vs. -28.2 ± 7.7%, P < 0.001), and lower RV strain rate. LV GLS was also lower (-17.4 ± 2.5 vs. -19.6 ± 1.9%, P < 0.001), mainly due to the interventricular septum. Patients with PR >25% had higher LV GLS and RV free wall strain than patients with PR ≤25% (P = 0.004, P = 0.039, respectively). No relationships were found with NT-proBNP or exercise capacity.

CONCLUSION

RV free wall strain and strain rate are decreased in adults late after ToF repair, especially at the apical segment suggesting that apical function is most affected in these RVs. Regarding the LV, septal strain is decreased indicating that RV dysfunction adversely affects LV function, probably by mechanical coupling of the ventricles.

Increased LV apical untwist during preload reduction in healthy humans: an echocardiographic speckle tracking study during lower body negative pressure

We sought to investigate the effect of reduced preload on left ventricle (LV) untwist and early diastolic filling in healthy individuals. Twelve healthy men, 22 (22, 23) years of age, were examined at rest and during applied lower body negative pressure (LBNP) of −20 mmHg and −40 mmHg, respectively. Regional untwist and untwist rate during IVRT were calculated at LV basal, papillary, subpapillary, and apical short axis levels by two dimensional speckle tracking echocardiography. Left ventricle early diastolic filling was assessed by transmitral E-wave (E) peak velocity by pulsed Doppler and flow propagation velocity (Vp) by color M-mode Doppler and early diastolic pulsed Doppler tissue velocities (E') from septal and lateral mitral annulus. From rest to LBNP −40 mmHg, the LV untwist and untwist rate at subpapillary level increased from 2.3 (1.4, 3.5) to 4.5 (3.1, 7.6) degrees and from −36 (−51, −25) to −69 (−127, −42) °/s (P < 0.001, P = 0.003), respectively, while apical untwist and untwist rate increased from 3.9 (2.3, 4.3) to 7.6 (6.4, 10.5) degrees and from −51 (−69, −40) to −118 (−170, −84) °/s (P < 0.001, P < 0.001), respectively. Since untwist and untwist rate at the basal level were unchanged, this created markedly larger base to apical untwist and untwist rate gradients from rest to LBNP −40 mmHg. E, Vp, and E' were reduced by 34, 32, and 39%, respectively. LV untwist and untwist rate during IVRT were increased at apical levels, which might be a physiological mechanism to minimize the impairment in LV early diastolic filling during preload reduction.