Atrial Contraction Phase Research Articles

Myocardial work and left atrial function, by speckle tracking echocardiography, are the only independent predictors of mid-term mortality in HFpEF

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by 2 National grants of Romanian Ministry of Research and Innovation - UEFISCDI (PN-III-P1-1-TE-2016-0669, acronym Heart-Preserved and PN-III-P1-1.2-PCCDI2017-0527, acronym BIOVEA). OnBehalf HEART-PRESERVED Background. Heart failure with preserved ejection fraction (HFpEF), defined by the 2021 ESC guidelines and the new universal definition, is one of the most challenging diagnosis in cardiology. Parameters for predicting mortality in HFpEF are still debatable. Left atrial (LA) function and myocardial work (MW) by speckle-tracking echocardiography (STE) might be promising tools for predicting mortality in HFpEF. Methods. We assessed 88 patients (67 ± 9 years, 33 men) with HFpEF (mean NTproBNP of 357 ± 350 pg/ml) by 2D echo, STE, and CMR. By echo we measured LV ejection fraction (LVEF), E/E’, sPAP, left atrial volume indexed (LAVi), and global longitudinal strain (GLS). We assessed LA function by 2DSTE: reservoir function by strain from MVC to MVO (LASr) and positive strain rate (LASRr), conduit function by strain from MVO to onset of atrial contraction (LAScd) and early negative strain rate during conduit phase (LASRcd), and LA pump function by negative strain at MVC (LASct) and late negative strain rate during atrial contraction phase (LASRct) (Figure 1); and MW by 2DSTE: global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), as GCW/(GCW + GWW) in %. By CMR we evaluated LVEFcmr, LV mass, T1 mapping with mean extracellular volume (ECVm), and pre-gadolinium times quantification (preGDT1m) as markers of myocardial fibrosis. A follow-up visit for cardiovascular mortality was performed by phone at 18 months from the baseline visit. Results. 12 patients died during follow-up (14%). Comparing non-survivors vs. survivors (see tables from Figure 2), NTproBNP level and LV mass were significantly higher in non-survivors (P < 0.001); meanwhile, GWE was lower, whereas GWW was higher in non-survivors vs. survivors. Moreover, LASRct was lower in non-survivors vs. survivors. All the other echo or CMR parameters, including markers of myocardial fibrosis were not different between non-survivors and survivors (Figure 2). By multiple regression analysis, GWE < 92% (AUC = 0.72, p = 0.018) and LASRct <-1 (AUC = 0.70, p = 0.014) were the only independent predictors of mortality, from all conventional echo, STE, and CMR parameters. Conclusions LV assessment by myocardial work and LA assessment by STE are the only independent predictors of mid-term mortality in HFpEF. Abstract Figure. LA deformation analysis Abstract Figure. Survivors vs non-survivors

Atrial longitudinal strain in cardiac aTTR amyloidosis and occurrence of atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND In systemic amyloidosis cardiac infiltration by amyloid fibrils leads to increased stiffness of the myocardium and of the atrial walls. There is a reduction in left atrial mechanical function and a high risk of thrombi formation. Atrial deformation by speckle tracking echocardiography peak atrial longitudinal strain (PALS) can predict the incidence of atrial fibrillation (AF) and ischaemic stroke in the general population and in patients (pts) with cryptogenic stroke. The predictive value of PALS seems to differ in different pts populations according to the prevalence of ventricular versus atrial myopathy (1). PURPOSE to compare parameters of atrial function in cardiac amyloidosis pts in sinus rhythm (SR) and AF and to observe if they are associated with the occurrence of new onset AF at follow-up (FUP). METHODS between 2016-2021 all pts with diagnosis of cardiac aTTR amyloidosis referred to the Clinic underwent an echocardiographic study including 2D-speckle tracking evaluation of left ventricular and left and right atrial strain. All pts received a regular FUP (clinical, echo, ECG and 24 hours Holter monitoring). Atrial function was evaluated by PALS in all pts and by PALS and PACS (peak atrial longitudinal strain during atrial contraction phase) in pts in SR. RESULTS 47 pts with aTTR cardiac amyloid (39/47 wild-tipe) were studied. Mean age = 82 ± 5 years, LV mass = 190 ± 46 g/m2; LV EF= 53%±9, GLS= -10%±4, EF/GLS ratio=-5,5 ± 2, left atrial (LA) volume = 49 ± 9 ml/m2, LA PALS 9,7%±6,6, right atrial (RA) PALS 15,9 ± 9,6. At the time of diagnosis 29 pts were in SR and 18 pts were in AF. Pts in AF had lower PALS (5,1%±3,7 in AF pts vs 11,9%±6,9 in SR pts, p = 0,001) and lower (less negative) GLS (-9,1%±3,1 in AF pts vs -11,8%± 4,2 in SR pts, p = 0,02). LA volume was not significantly different in AF pts compare to SR pts (51,4 ml/m2 ± 7,65 vs 47,6 ml/m2 ± 10,9; p = 0,19). During a median FUP of 21 months 8 pts had a new onset AF. There was no significant difference in atrial size and atrial deformation parameters between pts who had new onset AF at FUP compared to pts who did not (Tab 1). The only parameter associated with new onset AF at FUP was GLS (-8.21%± 2,8 vs -13.01%±4,02, CI -10.8—5.6 vs -14.8—11.18, respectively, in pts who developed new onset AF compared to pts who did not, p = 0.007). 5 pts had a cardioembolic stroke at FUP: at the time of the admission for stroke they were all in AF. CONCLUSIONS Our data show that in this group of pts with aTTR cardiac amyloidosis all echo parameters of LA size and function were overall impaired. In this setting of advanced disease LA volume was not significantly different in pts in AF compared to pts in SR and was not associated with new-onset AF at FUP. Deformation parameters were significantly more impaired in pts in AF compared to pts in SR, however PALS was not associated with the occurrence of new onset AF at follow-up. The only parameter associated with the occurrence of new onset AF at follow-up was GLS. Abstract Table 1

Vector Flow Mapping Application in Local Cardiac Function in Hypertension Assessment.

ObjectiveThis study aims to investigate the clinical significance of vector flow mapping (VFM) by observing and quantifying energy loss (EL) during different phases and in different left ventricle (LV) segments.Methods42 healthy physical examination subjects and 89 patients with hypertension (HTN) were enrolled in the present study. The patients with HTN were divided into two groups: the left ventricular hypertrophy group (LVH) (n = 51) and the non-left ventricular hypertrophy group (NLVH) (n = 38), while the healthy patients were control group. VFM analysis software DSA-RS1 was used to calculate EL during the rapid filling phase (P1), slow filling phase (P2), atrial contraction phase (P3), and rapid ejection phase (P4). The energy loss of basal segment (EL-B), middle segment (EL-M) and apical segment (EL-A) of left ventricle in different phases was calculated and compared among the three groups.ResultsIn controls, segmental EL showed a gradual increase from the apex to the base during diastole; however, the regularity was not found in the HTN patients. During both P1 and P2 EL-B, EL-M and EL-A were significantly higher in the NLVH group and the LVH group compared with the control group (P < 0.05). EL in LVH group was the highest among the three groups (P < 0.05). During P3, EL-B, EL-M and EL-A were increased in the NLVH group and LVH group compared with the control group. However, EL-M and EL-A in LVH group were significantly lower than the NLVH group (P < 0.05). During P4, EL of all segments was significantly higher in the NLVH group and LVH group compared with the control group (P < 0.05).ConclusionVFM can visually quantify hydrodynamic LV changes in healthy subjects. The EL levels in the different LV segments during different phases were significantly higher in the patients with HTN compared with the healthy subjects.

Multichamber Dysfunction in Children and Adolescents With Severe Obesity: A Cardiac Magnetic Resonance Imaging Myocardial Strain Study.

In severe obesity, left ventricular (LV) and right ventricular (RV) remodeling and contractile dysfunction have been documented, but less is known regarding left atrial (LA) dysfunction and its association with LV/RV remodeling, especially in children. To assess the effects of severe childhood obesity on cardiac function by using multichamber strain analysis with MRI. Prospective. Forty-five children aged 7-18 years (including 20 with severe obesity, defined as a body mass index values above the 99th percentile). 5 T. Steady-state-free-precession (SSFP) images in short-axis views and longitudinal two- and four-chamber views. Cardiac strain measurements were derived from standard SSFP cine images by using a dedicated MR imaging feature tracking software. Inter- and intra-rater reliability were evaluated. Independent sample t test, Spearman's correlation coefficient, principal component analysis, Bland-Altman analysis, and intra-class correlation coefficients (ICC). A P value <0.05 was considered statistically significant. As compared to children without obesity, those with obesity showed significantly reduced LA reservoir function (22.2% ± 6.4% vs. 33.8% ± 9.0%) and contractile function (5.4% ± 3.2% vs. 13.3% ± 8.0%) as well as significantly decreased absolute values for LA longitudinal strain in reservoir and contraction phases and LA radial motion fraction in reservoir and contraction phases. Children with severe obesity showed significantly reduced absolute RV radial motion fraction (-10.6% ± 2.9% vs. -18.2% ± 2.9%) and circumferential strain (-10.6% ± 2.9% vs. -16% ± 2.5%) as well as higher LV mass index (28.7% ± 5.1% vs. 21.7 ± 4.6 g/m2 ) along with significantly reduced LV ejection fraction (56.4% ± 3.9% vs. 60% ± 4.1%), LV radial strain (56% ± 6% vs. 61.8% ± 11.3%), and longitudinal strain (-17.8% ± 1.8% vs. -20.3% ± 3.2%). Reliability was good to excellent, with ICC ranging from 79.1% to 97.7%. MR feature-tracking strain analysis revealed multichamber dysfunction in severely obese children with impaired LA reservoir and atrial contraction phases, which suggest an early loss in the compensatory ability of atrial contraction with severe obesity. 2 TECHNICAL EFFICACY STAGE: 3.

Assessing the atria in pediatric sickle cell disease: Beyond the dilation.

Diastolic dysfunction (DD) and pulmonary hypertension (PH) are common causes of mortality for sickle cell disease (SCD) patients in developed countries. We hypothesized that left and right atrial strain (LAS-Ɛ, RAS-rƐ) are decreased in SCD adolescents, and that worsening values correlate with laboratory markers of disease severity. Prospective cohort study of patients with HbSS genotype of SCD was compared with healthy controls. LAS and RAS were measured from 4- and 2-chamber views by a blinded reader. Peak strain and strain rate values were obtained for atrial contraction (ac), reservoir (res), and conduit (con) phases. Mitral/tricuspid Doppler velocities, left atrial volume, right atrial area were obtained. Laboratory variables were obtained from the electronic record with the three prior values being averaged. Differences in variables were assessed with Wilcoxon rank sum test, and correlations assessed with Spearman's coefficient. There were 33 SCD patients compared to 35 healthy controls of similar age, gender, and size. SCD patients had increased left atrial volume and right atrial area. For LAS, Ɛres was significantly lower in SCD patients. For RAS, RƐcon was significantly lower. Neither measurement correlated with clinical markers. The majority of SCD patients had relatively normal atrial strain values. Those with markedly lower values had similar atrial size. A sub-set of SCD patients have markedly low Ɛres and rƐcon. No correlation with clinical markers was identified. Larger, longitudinal studies may determine utility of atrial strain as a screening tool in this at-risk population.

Evaluation of the local atrial function by regional speckle tracking imaging using intracardiac echocardiography

Abstract Background It has been reported that low voltage areas and conduction abnormalities detected by electrophysiology catheters in the left atrium (LA) represent regional degeneration and fibrosis of the atrium and are related to a poor atrial fibrillation (AF) ablation outcome. Assessment of the local atrial function is clinically useful because atrial degeneration does not occur uniformly throughout the atrium. Though evaluating the global atrial function using speckle tracking imaging (STI) by transthoracic echocardiography (TTE) has been attempted, TTE does not have a sufficient image quality to assess local atrial STI. Purpose To evaluate the local atrial function by STI using intracardiac echocardiography (ICE) and to elucidate the characteristics of the STI in normal and abnormal voltage regions in the LA. Methods We included 9 patients undergoing AF ablation with written informed consent for this prospective observational study. After pulmonary vein isolation, we performed voltage mapping of the LA in sinus rhythm using a CARTO system (Biosense). Abnormal regions and normal regions were defined as those with low voltage areas (&amp;lt;0.5 mV) and those with normal voltages, respectively. Echo images were recorded by an ACUSON SC2000 (Siemens) and SOUNDSTAR catheter (Biosense). We inserted the SOUNDSTAR catheter into the LA to obtain clear images, recorded the STI of the anterior and inferior wall, and performed an offline analysis of the atrial strain with an eSie VVI work station (Siemens) and the LA voltage data with CARTO system at each site simultaneously (left figure). We compared the strain during the atrial contraction phase (Sct) between the normal and abnormal regions. Results Among the study population, 5 patients had low voltage areas in the LA. We evaluated the STI at 26 normal regions and 44 abnormal regions. The typical regional speckle tracking waveform in the normal region was similar to a jugular vein pressure waveform (right figure). There was a difference in the amplitude of the Sct between the groups; it was significantly smaller in the abnormal regions (normal and abnormal regions, 9.8±5.0% and 5.6±3.8%, p=0.0001). The duration of the Sct was significantly more prolonged in the abnormal regions than normal regions (98.8±26.3ms and 118.2±33.9ms, p=0.015). Conclusions This pilot study demonstrated that the local atrial function was evaluable by STI using ICE and that the regional strain tracking waveform during the atrial contraction phase in abnormal voltage regions was smaller and more prolonged than that in normal regions. An evaluation of the regional STI with an ICE may be useful to detect regional abnormalities of the atrium. Representative case Funding Acknowledgement Type of funding source: None

409 Left atrial pump function assessed by speckle tracking echocardiography adds important value for the diagnosis of heart failure with preserved ejection fraction

Abstract Funding Acknowledgements “This work was supported by a grant of Ministery of Research and Innovation, CNCS-UEFISCDI, project number PN-III-P1-1-TE-2016-0669, within PNCDI III” Background Differentiation between heart failure with preserved ejection fraction (HFpEF) and isolated diastolic dysfunction (DD) at rest is crucial, since the prognosis is different. Symptoms are often non-specific, while NTproBNP might not be available. Increased NTproBNP is predicted by none of the currently used transthoracic echocardiographic (TTE) parameters. However, assessment of left atrial (LA) function by speckle tracking echocardiography (STE) might be a potential new marker of increased LV filling pressure. Aim. To assess LA function by STE in HFpEF and DD, on top of the currently used TTE parameters, in order to establish the added value of LA deformation in the diagnosis of HFpEF. Methods 70 patients were enrolled prospectively: 40 with HFpEF (68 ± 9 yrs) and 30 with DD (60 ± 10 yrs). TTE was used to assess LV ejection fraction (LVEF), E/E’ ratio, left atrial volume index (LAVi), and systolic pulmonary arterial pressure (sPAP). STE was used to assess LA functions: reservoir function by strain from MVC to MVO (LASr) and positive strain rate (LASRr), conduit function by strain from MVO to onset of atrial contraction (LAScd) and early negative strain rate during conduit phase (LASRcd), and LA pump function by negative strain at MVC (LASct) and late negative strain rate during atrial contraction phase (LASRct). NTproBNP was measured in all patients. Results HFpEF patients had significantly higher LVEF, NTproBNP, E/E’ ratio, and sPAP, but similar LAVi compared to DD, suggesting higher LV filling pressure (Table). LA reservoir and conduit function were similar. However, LA pump function was significantly lower in HFpEF, expressed by LASRct (Tabel). NTproBNP correlated with E/E’ ratio, sPAP, and LASRct (all r = 0.44, p &amp;lt; 0.001), but not with LAVi. By multiple regression analysis, best predictor for NTproBNP &amp;gt; 125pg/ml was LASRct (r = 0.60, r2 =0.30, p &amp;lt; 0.001). LASRct &amp;lt; -1.29 (AUC = 0.82, sensitivity 75%, specificity 81%) was the only predictor of NTproBNP &amp;gt; 125pg/ml (Figure). Conclusion LA pump function is the only predictor of NTproBNP &amp;gt; 125pg/ml. This parameter should be incorporated in the current protocols for the diagnosis of HFpEF. Group (N) NTproBNP ng/ml LVEF (%) E/E’ sPAP (mmHg) LAVi (ml/m2) LASr (%) LASRr LAScd (%) LASRcd LASRct HFpEF (40) 329 ± 383 62 ± 6 10.4 ± 2.7 34 ± 11 40 ± 9 25 ± 4 1.28 ± 0.3 11.6 ± 5.5 -1.37 ± 0.5 -1.07 ± 0.6 DD (30) 37 ± 26 57 ± 8 7.5 ± 1.8 23 ± 7 39 ± 11 26 ± 6 1.26 ± 0.3 11.2 ± 3.6 -1.5 ± 0.6 -1.76 ± 0.7 P value 0.001 0.008 &amp;lt;0.001 &amp;lt;0.001 0.7 0.4 0.8 0.7 0.4 &amp;lt;0.001 Abstract 409 Figure.

P324 Left atrial deformation analysis by 2D speckle tracking echocardiography in liver cirrhosis is a potential new tool for a better characterization of cirrhotic cardiomyopathy

Abstract Funding Acknowledgements “This work was supported by a grant of Ministery of Research and Innovation, CNCS-UEFISCDI, project number PN-III-P1-1-TE-2016-0669, within PNCDI III” Background Cirrhotic cardiomyopathy (CCM) is defined as a cardiac dysfunction that includes mainly diastolic dysfunction (DD), generated by liver cirrhosis (LC). Its present diagnosis is based mostly on 2D conventional transthoracic echocardiography (TTE), with focus on diastolic dysfunction. However, there is no standardized algorithm for diagnosis of CCM. Role of the new methods, such as speckle tracking echocardiography (STE), for the diagnosis of CCM is still controversial. Aim. To assess left atrial (LA) function by STE in LC, on top of conventional TTE, in order to establish role of LA function for the diagnosis of CCM. Methods 107 subjects were assessed by TTE and STE: 52 patients with LC (57 ± 9 yrs, 23 males), free of any cardiovascular disease or diabetes, and 55 age-matched normal subjects. TTE was used to measure LV indexed volumes and ejection fraction (LVEF), E/E’ ratio, left atrial volume index (LAVi), and systolic pulmonary arterial pressure (sPAP); STE to measure global longitudinal strain (GLS) and LA functions: reservoir function by strain from MVC to MVO (LASr) and positive strain rate (LASRr), conduit function by strain from MVO to onset of atrial contraction (LAScd) and early negative strain rate during conduit phase (LASRcd), LA pump function by negative strain at MVC (LASct) and late negative strain rate during atrial contraction phase (LASRct) (Figure). NTproBNP was measured in all patients. Results LC patients vs. controls had lower SBP (112 ± 15 vs. 122 ± 12, P &amp;lt; 0.001), higher LV volumes and NTproBNP, but similar LVEF. They had lower GLS, and higher E/E’, LAVi, and sPAP, suggesting higher LV filling pressure (Table). Meanwhile, they had lower LA reservoir, conduit, and pump functions(Table). By using current algorithm for the diagnosis of DD, 21% of LC patients had DD, 48% had no DD, and 31% had indeterminate grade. By adding assessment of LA reservoir function by STE (LASr &amp;lt; 35%) to the DD algorithm, 50% of patients had DD, without any indeterminate cases. Conclusion LC patients have longitudinal systolic LV dysfunction, diastolic dysfunction with higher estimated LV filling pressure, and lower LA reservoir, conduit, and pump functions. By adding LA deformation analysis by STE to the current diagnosis algorithm, better characterization of CCM is possible. Table Group (N) NTproBNP ng/ml GLS (%) E/E’ LAVi (ml/m2) sPAP (mmHg) LASr (%) LASRr LAScd (%) LASRcd LASRct LC (52) 215 ± 258 -20.8 ± 3 8.5 ± 2.3 44 ± 14 27 ± 9 28 ± 9 1.29 ± 0.4 14.7 ± 8.1 -1.2 ± 0.42 -1.64 ± 0.47 Controls (55) 44 ± 43 -22 ± 2 7.6 ±2.3 28 ±6.5 21 ± 8 35 ± 4 1.54 ± 0.4 18.3 ± 6.7 -1.7 ± 0.61 -1.93 ± 0.44 P value &amp;lt;0.001 0.05 0.05 0.001 0.003 0.011 0.002 0.014 0.001 0.002 Abstract P324 Figure

Successful catheter ablation of atrial fibrillation improves but not reverses the abnormalities of left atrial mechanics and energy loss.

Dissipative energy loss (EL), a new index to quantify the inefficient blood flow, has not been explored within left atrium (LA) in patients with atrial fibrillation (AF). We aimed to study the intra-atrial flow and mechanics in patients with AF before and after successful catheter ablation by evaluating EL and LA global longitudinal strain (LAS). In our study, there were 53 patients undergoing catheter ablation for AF at baseline (AF group) and 33 age- and sex-matched controls. They were both assessed of LA EL using vector flow mapping (VFM) and of LAS using two-dimensional tracking (2DTT) during systole (sys), early diastole (ed), and atrial contraction phase (ac). Out of 53 patients, 37 patients who sustained sinus rhythm and carried out the echocardiographic examination at 3 and 6months follow-up were evaluated of change in EL and LAS. The independent predictors of EL during three phases in AF group were performed using stepwise multivariate linear regression analyses. Left atrium EL and LAS among all phases in AF group were significantly lower than controls (all P<0.01). During follow-up, LASsys and LASac both significantly improved at 3 and 6months (both P<0.01), and ELac significantly increased after 6months (P<0.05); ELsys, ELed and LASed were no significant change; EL and LAS among all phases were no normalized during follow-up. The independent predictors of EL were: for ELsys, BSA (P=0.004) and LASac (P=0.025); for ELed, E (P=0.001) and A (P=0.014); for ELac, E/A (P<0.001). Vector flow mapping and 2DTT revealed impaired intra-atrial flow and mechanics. Successful catheter ablation for AF slightly improves but not reverses the aforementioned impairment, indicating the continuous LA dysfunction.

Successful radiofrequency catheter ablation of atrial fibrillation is associated with improvement in left ventricular energy loss and mechanics abnormalities.

Dissipative energy loss (EL), an index of inefficient blood flow, has not been studied in patients with atrial fibrillation (AF). We therefore assessed the effect of AF and of successful catheter ablation on left ventricular (LV) EL and global longitudinal strain (GLS) to explore the effect of inefficient blood flow on LV remodeling. In 53 patients undergoing catheter ablation for AF (AF group), LV EL (in mW/m) was evaluated by vector flow mapping (VFM) during systole (ELsys), early diastole (ELed) and atrial contraction phase (ELac), and GLS was calculated by two-dimensional tissue tracking (2DTT). Of the 53 patients, 37 patients who sustained sinus rhythm and completed echocardiographic evaluation at baseline and at 3 and 6months follow-up were examined for change in EL and GLS. The latter parameters also were assessed in 44 age- and sex-matched controls. At baseline in AF group, ELsys and ELed were significantly higher (3.97 ± 2.29 vs. 3.14 ± 1.01; and 9.22 ± 5.01 vs. 3.89 ± 1.51; both P < 0.05, respectively), and GLS was lower (- 16.66 ± 3.50 vs. - 19.95 ± 2.40, P < 0.05) than in controls. During follow-up after catheter ablation, ELsys and ELed significantly improved at 3months, and almost normalized at 6months (both P < 0.05); GLS also improved significantly (P < 0.05). In multivariate logistic regression analysis, ELed was the only independent predictor for maintenance of sinus rhythm at 1-year follow-up (hazard ratio, 1.254; 95% confidence interval 1.073-1.467). VFM and 2DTT revealed impaired LV EL and GLS in patients with AF. Successful catheter ablation appeared to ameliorate impairment in intraventricular flow and mechanics.

Positive end-expiratory pressure attenuates hemodynamic effects induced by an overload of inspiratory muscles in patients with COPD.

BackgroundInspiratory muscle training (IMT) using a Threshold® device is commonly used to improve the strength and endurance of inspiratory muscles. However, the effect of IMT, alone or with positive end-expiratory pressure (PEEP), on hemodynamic parameters in patients with chronic obstructive pulmonary disease (COPD) remains unknown.ObjectiveTo assess the effects of an overload of inspiratory muscles using IMT fixed at 30% of the maximal inspiratory pressure (MIP), and IMT associated with 5 cmH2O of PEEP (IMT + PEEP), on the echocardiographic parameters in healthy subjects and patients with COPD.MethodsTwenty patients with COPD (forced expiratory volume in 1 second 53.19±24.71 pred%) and 15 age-matched healthy volunteers were evaluated using spirometry, MIP, the COPD assessment test (CAT), and the modified Medical Research Council (mMRC) dyspnea scale. The E- (fast-filling phase) and A- (atrial contraction phase) waves were evaluated at the tricuspid and mitral valves during inspiration and expiration in the following sequence: at basal conditions, using IMT, and using IMT + PEEP.ResultsPatients with COPD had reduced MIPs versus the control group. Ten patients had CAT scores <10 and 12 patients had mMRC scores <2. E-wave values at the mitral valve were significantly decreased with IMT during the inspiratory phase in both groups. These effects were normalized with IMT + PEEP. During the expiratory phase, use of IMT + PEEP normalized the reduction in E-wave values in the COPD group. During inspiration at the tricuspid valve, reduction in E-wave values during IMT was normalized by IMT + PEEP in COPD group. During the expiratory phase, the value of the E-waves was significantly reduced with overload of the inspiratory muscles in both groups, and these effects were normalized with IMT + PEEP. A-waves did not change under any conditions.ConclusionAcute hemodynamic effects induced by overloading of the inspiratory muscles were attenuated and/or reversed by the addition of PEEP in COPD patients.

Age, Sex, and Blood Pressure-Related Influences on Reference Values of Left Atrial Deformation and Mechanics From a Large-Scale Asian Population.

Left atrial (LA) function is tightly linked to several cardiovascular diseases and confers key prognostic information. Speckle tracking-based deformation as a feasible and sensitive LA mechanical assessment has proven its clinical significance beyond volume measures; however, the reference values remain largely unknown. We studied 4042 participants undergoing annual cardiovascular survey. Among them, 2812 healthy participants (65% men; mean age, 47.4±9.9 years) were eligible for speckle tracking analysis. Peak atrial longitudinal systolic strain and strain rate (SR) at systolic (SRs), early diastolic (SRe), and late diastolic atrial contraction phases (SRa) were analyzed by dedicated software (EchoPAC, GE) and compared in terms of age, sex, and blood pressure. Overall, women demonstrated higher peak atrial longitudinal systolic strain (39.34±7.99% versus 37.95±7.96%; P<0.001) and showed age-dependent more pronounced peak atrial longitudinal systolic strain functional decay than those of men (P value for interaction, <0.05), with men showing higher SRs and SRa, although lower SRe (all P<0.001). Both increasing age and higher blood pressure were independently associated with deteriorated peak atrial longitudinal systolic strain, SRs, and SRe, although augmented LA SRa, even after accounting for baseline clinical covariates in multivariable models that incorporated LA volume, NT-proBNP (N-terminal pro-B-type natriuretic peptide), or left ventricular E/e' (all P<0.001). Our findings suggest LA mechanical functional decays in association with increasing age and higher blood pressure, which seem to be compensated for by augmentation of atrial pump function. We have also provided age- and sex-stratified reference values for strain and SR based on a large-scale Asian population.

Left atrial strain after maximal exercise in competitive waterpolo players.

Left atrial (LA) function is a determinant of left ventricular (LV) filling. It carries out three main functions: reservoir, conduit, contractile. Aim of this study was to evaluate the role of LA and its deformation properties on LV filling at rest (R) and immediately after a maximal exercise (ME) through the speckle tracking echocardiography. Population enrolled was composed by 23 water polo athletes who performed a ME of six repeats of 100m freestyle swim sets. At ME peak atrial longitudinal strain was reduced but all strain rate (SR) parameters increased, respectively positive peak SR at reservoir phase, SR negative peak at rapid ventricular filling (SRep) and SR negative peak at late ventricular filling (SRlp), that corresponds to atrial contraction phase. We showed a parallel increase in E and A pulsed Doppler wave and SRep and SRlp; particularly at ME, A wave and SRlp increased more respectively than E wave and SRep. SRlp was related to ejection fraction (EF) (r=-0.47; p<0.01). At multivariate analysis SRlp was an independent predictor of EF (β: -0.47; p=0.016). The increased sympathetic tone results into increased late diastolic LV filling with augmented atrial contractility and a decrease in diastolic filling time. During exercise LV filling was probably optimized by an enhanced and rapid LA conduit phase and by a vigorous atrial contraction during late LV filling.

CMR left atrial characterization in Cushing's syndrome: a feature tracking study

Background The aim of this study was to automatically assess global and regional left atrium (LA) strain in Cushing’s syndrome (CD). Modifications of LA and LV function in patients have been highlighted followed by the restoration of myocardial function after radical treatment and cortisol normalization. Our hypothesis was that a feature-tracking method could improve the understanding of the mechanisms of LA alteration concerning its reservoir, conduit, and atrial contraction phases.

English

BACKGROUND & OBJECTIVES: Left ventricular diastolic dysfunction is known to occur in early stages of diabetic cardiomyopathy but its exact prevalence is not known. The present study was conducted to assess the prevalence of diastolic dysfunction in diabetic patients in the absence of hypertension or CAD. The role of valsalva maneuver in diagnosis of diastolic dysfunction was also studied. AIMS: To study left ventricular diastolic dysfunction in asymptomatic normotensive patients with Type 2 Diabetes. To study the role of valsalva maneuver in diagnosing diastolic dysfunction. METHODOLOGY: 100 consecutive asymptomatic normotensive patients (mean age 52.34 ±8.6 yrs.) with Type 2 diabetes free of any major clinical diabetic complications and having no evidence of CAD on non-invasive testing were studied for LV diastolic functions, using pulsed Doppler at the tip of mitral valve. The peak velocities of LV filling during the early rapid (E wave) and atrial contraction (A wave) phases, the ratio of the 2 filling velocities (E/A ratio) were recorded at end expiration at baseline and again during phase II of valsalva maneuver. RESULTS: LVDD was found in 54% of subjects of whom 11% had pseudo normal pattern of ventricular filling and 43% had impaired relaxation. LVDD was well correlated with age and duration of diabetes. CONCLUSION: LVDD is much more common in Type 2 diabetes who are free of clinically detectable heart disease. Pseudonormal pattern may account for a significant number of patients with diastolic dysfunction and failure to recognize it may lead to significant underestimation of the true prevalence of LVDD in these patients.

PREDICTION OF CORONARY ARTERY DISEASE BY DETECTION OF POSITIVE ISOVOLUMIC RELAXATION VELOCITY IN PATIENTS WITH NORMAL RESTING WALL MOTIONS "A Tissue Doppler Echocardiographic Study"

Background: Diagnosis of coronary artery disease (CAD) is of importance in the contemporary society of ever-increasing CAD (1,2). Isovolumic relaxation velocity (VIR), Postsystolic motion or postsystolic shortening (PSS) is a delayed ejection motion of the myocardium occurring after the aortic valve closure during a generally prolonged isovolumic relaxation time, which is related with myocardial ischemia in human(3,4) and in experimental studies(5). Spectral tissue Doppler imaging (TDI) is a simple echocardiographic technique that can provide velocity measurement of the myocardial segments(6). A positive myocardial velocity during isovolumic relaxation phase (VIR) detected by TDI, which corresponds to postsystolic motion or PSS, has been shown to indicate severely ischemic myocardium(8). So, detection of positive VIR by spectral TDI may be used as a noninvasive, nonprovocative method to predict possible CAD; specially for those with coexisting morbidities, such as peripheral artery disease in the lower limb, orthopedic diseases. Aim of the work: Diagnostic value of positive myocardial velocity during isovolumic relaxation phase (VIR) by spectral TDI in prediction of CAD in patients with typical ischemic chest pain and normal resting wall motions. Patients and methods: This study was done in Cardiology department, Zagazig University on 80 patients; 41 females (51%) & 39 males (49%)) with typical ischemic chest pain and no regional wall motion abnormalities detected by resting echocardiography. Patients were divided into 2 groups according to presence of significant coronary artery lesion by coronary angiography; group A (patients with CAD) and group B (patients without CAD). All the following parameters were measured by TDI; 5 peak velocities during; Isovolumic contraction phase (VIC), Systolic ejection phase (S'), Early diastolic relaxation phase (Em), Atrial contraction phase (Am) and Isovolumic relaxation phase (VIR) if present and VIR time. Then coronary angiography was done for all patients. Results: As regard to presence of VIR velocity, there was significant difference (<0.05) between group A and group B at mid septal and anterior walls, highly significant difference (<0.001) at basal septal and anterior walls. There was highly significant difference between group A and B at mid and basal lateral and inferior walls. There was highly significant correlation between coronary angiography and VIR velocity regarding detection of positive and negative cases and also there was highly significant correlation between previous 2 tests by Kappa test p value (<0.001). Conclusion: Positive VIR detected by spectral tissue Doppler imaging is a useful indicator of CAD in patients with apparently normal left ventricular contraction and chest pain. Key words: TDI, VIR velocity, coronary angiofraphy, coronary artery disease.

Reference values for variables of fetal cardiocirculatory dynamics at 11–14 weeks of gestation

Despite the increasing popularity of first-trimester fetal echocardiography, the evaluation of fetal heart function during this period remains challenging. The parameters of normal cardiac function at 11-14 weeks' gestation are not well defined and appropriate reference values have not yet been established. The purpose of this study was to evaluate the fetal cardiocirculatory dynamics during routine first-trimester screening and establish cross-sectional reference ranges for 11-14 weeks' gestation. Fetal echocardiography was performed on 202 women with singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation. Global cardiac function was evaluated using the heart : chest area ratio and Tei index of the left (LV) and right (RV) ventricles. The proportion of isovolumic contraction (ICT%) and ejection (ET%) times of the cardiac cycle, and the outflow velocities described the systolic function. Diastolic function was evaluated by the proportion of relaxation (IRT%) and filling (FT%) times, the ratio of the blood velocity through the atrioventricular valves during early filling (E) and atrial contraction (A) phases of the cardiac cycle, and ductus venosus pulsatility index for veins (DV-PIV). All participants had additional fetal echocardiography in the second trimester and neonatal clinical examination after birth to confirm normality. The mean heart : chest area ratio (0.203 +/- 0.04) and the Tei indices of both ventricles did not vary significantly during weeks 11-14, but the mean Tei index of the LV (0.375 +/- 0.092) was significantly higher than that of the RV (0.332 +/- 0.079) (P = 0.001). The fetal heart rate (FHR) decreased with increasing crown-rump length (CRL) (P < 0.00001). The LV-ICT% did not vary significantly (P = 0.27), LV-IRT% (P = 0.03) and LV-ET% decreased (P = 0.01), whereas the LV-FT% increased (P = 0.02) with CRL. The RV-ET% (P = 0.84) and RV-FT% (P = 0.60) remained relatively stable. The LV-ET% was lower than the RV-ET% (P = 0.0001). The LV (P = 0.004) and RV (P < 0.00001) outflow velocities and E : A ratios of both ventricles (P < 0.0001) increased with advancing gestation. The E-velocity of the LV (P = 0.003) and RV (P = 0.002) increased significantly but the increase in A-velocity was not significant. The outflow velocity (P = 0.008) and E-velocity (P = 0.005) of the RV were higher than that of the LV but the A-velocities were similar (P = 0.066). The mean DV-PIV was 0.97 +/- 0.23 and did not change significantly (P = 0.95) during weeks 11-14. The FHR and DV-PIV did not correlate with the Tei index of either ventricle. We have established reference ranges for the noninvasive evaluation of fetal cardiocirculatory dynamics at 11-14 weeks' gestation.

N-acetyl-seryl-aspartyl-lysyl-proline prevents cardiac remodeling and dysfunction induced by galectin-3, a mammalian adhesion/growth-regulatory lectin

Galectin-3 (Gal-3) is secreted by activated macrophages. In hypertension, Gal-3 is a marker for hypertrophic hearts prone to develop heart failure. Gal-3 infused in pericardial sac leads to cardiac inflammation, remodeling, and dysfunction. N-acetyl-seryl-aspartyl-lysyl-proline (Ac-SDKP), a naturally occurring tetrapeptide, prevents and reverses inflammation and collagen deposition in the heart in hypertension and heart failure postmyocardial infarction. In the present study, we hypothesize that Ac-SDKP prevents Gal-3-induced cardiac inflammation, remodeling, and dysfunction, and these effects are mediated by the transforming growth factor (TGF)-beta/Smad3 signaling pathway. Adult male rats were divided into four groups and received the following intrapericardial infusion for 4 wk: 1) vehicle (saline, n = 8); 2) Ac-SDKP (800 microg x kg(-1) x day(-1), n = 8); 3) Gal-3 (12 microg/day, n = 7); and 4) Ac-SDKP + Gal-3 (n = 7). Left ventricular ejection fraction, cardiac output, and transmitral velocity were measured by echocardiography; inflammatory cell infiltration, cardiomyocyte hypertrophy, and collagen deposition in the heart by histological and immunohistochemical staining; and TGF-beta expression and Smad3 phosphorylation by Western blot. We found that, in the left ventricle, Gal-3 1) enhanced macrophage and mast cell infiltration, increased cardiac interstitial and perivascular fibrosis, and causes cardiac hypertrophy; 2) increased TGF-beta expression and Smad3 phosphorylation; and 3) decreased negative change in pressure over time response to isoproterenol challenge, ratio of early left ventricular filling phase to atrial contraction phase, and left ventricular ejection fraction. Ac-SDKP partially or completely prevented these effects. We conclude that Ac-SDKP prevents Gal-3-induced cardiac inflammation, fibrosis, hypertrophy, and dysfunction, possibly via inhibition of the TGF-beta/Smad3 signaling pathway.

Prevalence of left atrial appendage pseudothrombus filling defects in patients with atrial fibrillation undergoing coronary computed tomography angiography

Previous reports have shown that computed tomography (CT) is a useful, noninvasive test for detecting atrial thrombi. However, blood stasis in the left atrial appendage (LAA) of patients with atrial fibrillation (AF) may be a common cause for false-positive results. We retrospectively evaluated the prevalence of filling defects that may simulate thrombus in the LAA of patients with AF during routine coronary CT angiography (CTA). The LAA of 7 patients with AF was studied for the presence of filling defects and compared with 250 healthy persons. LAA volume in the patients with AF was measured at 10 different cardiac phases and compared with 30 healthy patients. Of the 7 patients with AF studied with CTA, 5 were positive for LAA filling defects. Follow-up imaging studies, including transesophageal echocardiogram, contrast-enhanced magnetic resonance angiography, or delayed-CT, were negative for LAA thrombus. Of 250 patients without AF, CTA showed no evidence of LAA filling defects. Patients with AF had significantly larger LAA volumes at all cardiac phases measured compared with patients without AF (15.2 +/- 6.93 mL compared with 6.85 +/- 3.01 mL at atrial contraction [P = 0.0187], 17.4 +/- 7.76 mL compared with 9.46 +/- 3.43 mL at ventricular systole [P = 0.0351], and 14.5 +/- 5.87 mL compared with 8.48 +/- 3.10 mL at mid-diastole [P = 0.0341]). Compared with the healthy persons, the patients with AF showed reduced percentages of change in LAA volume when the atrial contraction phase was compared with other phases: 44.0% +/- 25.6% compared with 16.5% +/- 12.2% compared with ventricular systole (P = 0.0004) and 29.5% +/- 23.7% compared with -1.63% +/- 8.84% at mid-diastole (P < 0.0001). Pseudothrombus filling defects are common in the LAA of patients with AF undergoing coronary CTA and should not be mistaken for real thrombus.

MR Imaging of Right Ventricular Function after the Ross Procedure for Aortic Valve Replacement: Initial Experience

To prospectively assess right ventricular (RV) function after the Ross procedure by using magnetic resonance (MR) imaging. The local ethics committee approved the study and informed consent was obtained from all participants prior to enrollment in the study. Seventeen patients (15 male, two female; mean age +/- standard deviation, 19 years +/- 3.9; imaging performed 8.3 years after surgery +/- 3.2) and 17 matched controls (15 male, two female; mean age +/- standard deviation, 20 years +/- 3.9) were studied by using MR imaging. Standard velocity-encoded and multisection multiphase imaging sequences were used to assess homograft valve function, systolic and diastolic RV function, and RV mass. The two-tailed Mann-Whitney U test and the Spearman rank correlation coefficient were used for statistical analysis. Minor degrees of homograft stenosis (peak flow velocity between 1.5 and 3.0 m/sec across the homograft valve) were found in 12 of 17 patients but not in controls (P < .001). A larger RV mass was present in Ross patients than in controls (17.0 g/m(2) +/- 4.8 vs 10.9 g/m(2) +/- 5.6, P = .004). In addition, impaired diastolic RV function was found, as shown by a decreased mean tricuspid valve early filling phase-atrial contraction phase (E/A) peak flow velocity ratio (1.56 +/- 0.75 vs 2.05 +/- 0.58, P = .03). Peak flow velocity across the homograft valve correlated with RV mass (r = 0.38, P = .03) and tricuspid valve E/A peak flow velocity ratio (r = 0.39, P = .02). RV systolic function was normal in Ross patients (mean RV ejection fraction, 52% +/- 8 vs 51% +/- 5; P = .74). RV hypertrophy and RV diastolic dysfunction are frequently observed in patients after the Ross procedure, even in the absence of overt homograft stenosis. RV systolic function is still preserved.