Conventional Echocardiographic Indices Research Articles

Differences in the Impact of Left Ventricular Outflow Tract Obstruction on Intraventricular Pressure Gradient in Feline Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a common form of cardiomyopathy in cats, and heart failure occurs as diastolic dysfunction progresses. HCM in cats is broadly classified as non-obstructive and obstructive hypertrophic cardiomyopathy, depending on the presence or absence of outflow tract obstruction. Measurement of the intraventricular pressure differences (IVPD) using color M-mode (CMM) has attracted attention as a reliable diastolic index as it correlates with catheterization, the gold standard for the assessment of diastolic performance. Because IVPD is affected by the size of the heart, the intraventricular pressure gradient (IVPG) index, which is unaffected by heart size, is by calculated by dividing IVPD by LV length. In the present study, CMM IVPG was used to non-invasively assess diastolic impairment in cats with obstructive hypertrophic cardiomyopathy. This study was conducted on 10 control cats and 18 cats in the HCM group. Although no severe left atrial enlargement was observed in the HCM group, the basal IVPG was significantly increased in the HOCM group compared to the control group. Although IVPD typically suggests impaired diastolic function and reduced ventricular compliance, the significant increase observed in the HOCM group compared to controls may suggest an indirect elevation in left atrial pressure, likely secondary to left ventricular outflow tract obstruction. The increase in IVPG in HOCM, as shown in this study, is a pathological effect of left ventricular outflow tract obstruction that cannot be detected by conventional echocardiographic indices, and evaluating IVPG is useful to evaluate cardiac function from a perspective that differs from conventional methods.

Left atrial function predicts long-term outcome in hypertension and diabetes across genders

Abstract Introduction In the last decade, peak atrial longitudinal strain (PALS) was ascertained to be superior to conventional echocardiographic indices for secondary cardiovascular (CV) prevention. Purpose Standard and advanced echocardiography including PALS was evaluated to find predictors of prognosis in patients with arterial hypertension and/or diabetes for the optimization of primary CV prevention. Methods Hypertensive and/or diabetic patients >40 years old and in sinus rhythm who underwent a complete cardiological evaluation at our centre in 2008-2015 were retrospectively included. Personal history, physical examination, standard and advanced (speckle tracking) echocardiographic data were collected. The exclusion criteria were previous cv events or cardiac surgery, active pacemaker, more than moderate valvular regurgitation and/or stenosis, missing informed consent. All patients were followed up for a mean time of 11.2±1.3 years for the development of first atrial fibrillation (AF) episode, congestive heart failure hospitalization, transient ischemic attack, stroke, myocardial infarction/coronary revascularization, and CV death. Univariate and multivariable stepwise Cox regressions were performed to estimate Hazard Ratio (HR). Kaplan Meier curves (KM) compared the survival between patients with different ranges of Global PALS. Log-rank test was performed to compare the KM curves. Results This retrospective study included 292 adults (mean age 63.0±9.0 years, 50% female), among which 210 hypertensives and 67 diabetics. Mean left ventricular (LV) ejection fraction (EF) was 58.2±4.9%, mean GLS was -17.0±6.6%, mean left atrial volume was 52.9±24.9ml and mean PALS 29.7±11.1%. During follow up, 110 patients developed at least one cv event: 52 all-cause deaths, 28 CV deaths, 30 heart failure admissions, 31 first AF episode, 18 TIA/strokes, 25 myocardial infarction/revascularization. Dividing the population according to events occurrence, patients with events had similar EF (p= 0.06), while being older (65.8±9.6 vs 61.3±9.0 years) and with a worse diastolic function (E/E’ ratio 10.6±5.0 vs 8.7±3.6), LV longitudinal strain (GLS, -17.7±2.9 vs -15.7±3.4%) and PALS (34.6±9.9 vs 21.6±7.7%, all p <0.001). From univariate statistical analysis, age, E/E’, PAPs, GLS and PALS were all predictors of events, but only age (HR 1.03, p=0.03) and PALS (PALS<22.5% HR 18.99 and PALS 22.5-30 HR 7.68, both p<0.001) remained independently associated with outcome at multivariate analysis. Patients with PALS<22.5 have an event-free survival of 82.4% at 1 year, 49.8% at 5 years and 25.3% at 10 years compared to 100% at 1 year, 98.5% at 5 years and 92.5% at 10 years if PALS PALS>30% (Fig.1). The same results were confirmed in female population (Fig.2). Conclusions If confirmed by larger studies, PALS could be a quick, feasible and reliable part of cardiologic evaluation for prognostic stratification in primary CV prevention in hypertensive and/or diabetic patients.Fig. 1Fig. 2

Speckle tracking of left ventricle in pediatric patients with hemodynamically significant patent ductus arteriosus (PDA): case–control study

BackgroundLeft ventricle (LV) volume overload is observed with hemodynamically significant PDA as it causes left to right shunting, leading to increased pulmonary blood flow. This overload causes LV remodeling as LV increases stroke volume in trial for compensation, but in larger shunts, patients may develop symptoms of congestive heart failure. Two-dimensional (2D) speckle-tracking echocardiography has emerged as a technique for objective and quantitative evaluation of global and regional myocardial function, independent of the angle of myocardial insonation.Aim of the workThis study aimed to evaluate left ventricular function by 2-dimensional speckle tracking in children with hemodynamically significant PDA.MethodsThis prospective controlled study was performed on 54 children divided into two groups (34 as cases and 20 as controls) to compare echocardiographic measurements. Conventional Echocardiography, tissue Doppler, and Speckle tracking were done for all patients, and measurements were compared.ResultsThere was a statistically significant difference (p value < 0.001) in global longitudinal strain (GLS) in the PDA group indicating a decrease in LV function in PDA patients. This difference was observed in several conventional echocardiographic parameters but not in tissue Doppler in our study.ConclusionLeft ventricle global strain is an important predictor of the myocardial performance index of the Left ventricle in patients with hemodynamically significant PDA and outweighs other conventional echocardiographic parameters and tissue Doppler indices.

Multimodality Imaging for Right Ventricular Function Assessment in Severe Tricuspid Regurgitation.

Severe tricuspid regurgitation (TR) is a pathological condition associated with worse cardiovascular outcomes. In the vicious cycle of right ventricular compensation and maladaptation to TR, the development of right ventricle (RV) dysfunction has significant prognostic implications, especially in patients undergoing surgical or percutaneous treatments. Indeed, RV dysfunction is associated with increased operative morbidity and mortality in both surgical and percutaneously treated patients. In this context, the identification of clinical or subtle right ventricle dysfunction plays a critical role inpatient selection and timing of surgical or percutaneous tricuspid valve intervention. However, in the presence of severe TR, evaluation of RV function is challenging, given the increase in preload that may lead to an overestimation of systolic function for the Frank-Starling law, reduced reliability of pulmonary artery pressure estimation, the sensitivity of RV to afterload that may result in afterload mismatch after treatment. Consequently, conventional echocardiographic indices have some limitations, and the use of speckle tracking for right ventricular free wall longitudinal strain (RV-FWLS) analysis and the use of 3D echocardiography for RV volumes and ejection fraction estimation are showing promising data. Cardiac magnetic resonance (CMR) represents the gold standards for volumes and ejection fraction evaluation and may add further prognostic information. Finally, cardiac computer tomography (CCT) provides measurements of RV and annulus dimensions that are particularly useful in the transcatheter field. Identification of subtle RV dysfunction may need, therefore, more than one imaging technique, which will lead to tip the balance between medical therapy and early intervention towards the latter before disease progression. Therefore, the aim of this review is to describe the main imaging techniques, providing a comprehensive assessment of their role in RV function evaluation in the presence of severe TR.

Noninvasive pressure-strain loop quantitative assessment of left ventricular function in anemic preterm infants with different modes of respiratory support

To investigate noninvasive pressure-strain loop (PSL) combined with two-dimensional speck tracking imaging and left ventricular pressure measurement in the evaluation of cardiac function changes in anemia of prematurity (AOP) with different modes of respiratory support, and to explore its value in detecting subclinical myocardial injury in preterm infants. This retrospective study included 79 preterm infants with anemia, according to different modes of respiratory support, who were divided into invasive respiratory support group (39 cases) and noninvasive respiratory support group (40 cases). A control group of 40 nonanemic preterm infants with matched age, sex, and gestational age were also included. Complete echocardiography was performed for each included infant. There are PSL parameters that used to evaluate cardiac function, including global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) among the three groups were compared. Compared with the control group, the value of GWI, GCW, and GWE were significantly lower and GWW was higher in the AOP groups (P < 0.05), and GWI, GCW and GWE were much significantly lower in the invasive respiratory support group than in the noninvasive respiratory support group (P < 0.05). There was no significant difference in GLS among the three groups (P > 0.05). Noninvasive PSL analysis can quantitatively assess myocardial work in AOP with different respiratory support, which is more sensitive than other conventional echocardiographic indices. This technique may provide a new method for monitoring subclinical myocardial injury with AOP.

Left Ventricular Diastolic Dysfunction Is Associated with Poor Functional Outcomes after Endovascular Thrombectomy.

With the advent of endovascular thrombectomy (ET), patients with acute ischaemic strokes (AIS) with large vessel occlusion (LVO) have seen vast improvements in treatment outcomes. Left ventricular diastolic dysfunction (LVDD) has been shown to herald poorer prognosis in conditions such as myocardial infarction. However, whether LVDD is related to functional recovery and outcomes in ischaemic stroke remains unclear. We studied LVDD for possible relation with clinical outcomes in patients with LVO AIS who underwent ET. We studied a retrospective cohort of 261 LVO AIS patients who had undergone ET at a single comprehensive stroke centre and correlated LVDD to short-term mortality (in-hospital death) as well as good functional recovery defined as modified Rankin Scale of 0-2 at 3 months. The study population had a mean age of 65-years-old and were predominantly male (54.8%). All of the patients underwent ET with 206 (78.9%) achieving successful reperfusion. Despite this, 25 (9.6%) patients demised during the hospital admission and 149 (57.1%) did not have good function recovery at 3 months. LVDD was present in 82 (31.4%) patients and this finding indicated poorer outcomes in terms of functional recovery at 3 months (OR 2.18, 95% CI 1.04-4.54, p = 0.038) but was not associated with increased in-hospital mortality (OR 2.18, 95% CI 0.60-7.99, p = 0.240) after adjusting for various confounders. In addition to conventional echocardiographic indices such as left ventricular ejection fraction, LVDD may portend poorer outcomes after ET, and this relationship should be investigated further.

Role of automated functional imaging and myocardial work in assessment of cardiac function in children with obstructive sleep apnea.

Early identification of abnormal left ventricular function in children with obstructive sleep apnea (OSA) is difficult using conventional echocardiographic indices and commonly used clinical markers of myocardial damage. We sought to investigate the value of automatic function imaging and myocardial work parameters in predicting early cardiac impairment in children having OSA with preserved left heart function and thereby identifying an optimal index for assessment. Fifty-two children who presented with symptoms of nocturnal sleep snoring and open-mouth breathing and 34 healthy controls were enrolled in this study. Clinical characteristics and conventional echocardiographic data were collected, and image analysis was performed using two-dimensional speckle-tracking echocardiography to obtain left ventricular global longitudinal strain (GLS), post-systolic index, peak strain dispersion, global work index (GWI), global constructive work (GCW), global wasted work, and global work efficiency. Children with OSA had significantly lower GLS, GWI, and GCW than those without (P < 0.05). Additionally, GWI (β = -32.87, 95% CI: -53.47 to -12.27), and GCW (β = -35.09, 95% CI: -55.35 to -14.84) were found to correlate with the disease severity in the multiple linear regression mode, with worsening values observed as the severity of the disease increased. ROC curve analysis revealed that GCW was the best predictor of myocardial dysfunction, with an AUC of 0.809 (P < 0.001), and the best cutoff point for diagnosing myocardial damage in children with OSA was 1965.5mmHg%, with a sensitivity of 92.5% and a specificity of 58.7%. GLS, GWI, and GCW were identified as predictors of myocardial dysfunction in children with OSA, with GCW being the best predictor.

Right ventricle free wall longitudinal strain screening of lung transplant candidates.

Lung transplant (LUTX) candidates have subclinical right ventricular (RV) dysfunction, which has not yet been assessed by speckle-tracking echocardiography (STE)-derived RV free-wall longitudinal strain (RVFWLS). To evaluate the prevalence of RV dysfunction by RVFWLS and its relationship with conventional RV echocardiographic indexes in LUTX candidates. In a single-center prospective observational cohort study, from January 2021 to March 2023 consecutive LUTX candidates underwent cardiac catheterization, radionuclide ventriculography, standard and STE. The diagnostic accuracy of RV ejection fraction by ventriculography (RVEF), tricuspid annular plane excursion (TAPSE), fractional area change (FAC), tricuspid peak annulus systolic velocity (S') versus RVFWS were computed. Thirty-four patients (female, 41%) with a mean age of 48 [36-59] years old enlisted for pulmonary fibrosis (35%) and cystic fibrosis (30%) were included. At cardiac catheterization, only 7 (23%) had pulmonary hypertension. Around 15-25% presented right heart enlargement. Tricuspid regurgitation was present in 20 (60%) of the patients. Median RVFWLS was -20.1% [-22.5%--17%], being impaired (> -20%) in 16 (47%) of the patients. RVFWLS identified the highest percentage (47%) of RV dysfunction, compared to TAPSE (32%), S' (27%), FAC (26%), and ventriculography (15%), which had very low sensitivity for detecting RV dysfunction compared to RVFWLS. In patients enlisted for LUTX, RV dysfunction assessed by STE-derived RVFWLS is highly prevalent. STE can detect RV dysfunction better than standard two-dimensional echocardiography and ventriculography. Further studies are urgently needed to define the clinical implications and the prognostic value of RV dysfunction measured with RVFWLS.

Right ventricular function in moderate-to-severe ventricular tricuspid regurgitation: Is there a pseudo-normalization of conventional echocardiographic parameters?

Abstract Background A reliable evaluation of right ventricular (RV) function in the presence of moderate-to-severe tricuspid regurgitation (m/s-TR) is of paramount importance for surgical or interventional risk stratification. Due to the significant systolic regurgitation of blood from the RV to the low-pressure right atrium, conventional echocardiographic parameters could appear normal and thus overestimate RV function (pseudo-normal). The aim of this study was to analyse and compare RV function in trace TR versus m/s-TR by the invasive pressure-volume-loop (PV-loop) technique, the gold standard of RV function analysis, with conventional echocardiographic indices in patients with the ventricular form of mild/no vs. m/s-TR. Methods The study was conducted in 134 patients with HFrEF in a post-hoc analysis (110 from the Magdeburg CRT Responder Trial, and 24 from a local CRT-optimization trial). Results The logistic regression analysis demonstrated that RV size (RV-end-diastolic volume, RVEDV) and RV function (measured as RV fractional area change, FAC), TAPSE, and lower fractional shortening (FS) of proximal the RV-outflow tract (RVOTprox) was closely associated with PV-loop-derived RV total afterload (pulmonary arterial elastance, Ea) and coupling of RV contractility (end-systolic RV elastance, Ees) to Ea (Ees/Ea) (all, p&amp;lt;0.001). Compared to trace TR (n=98, 73%), m/s-TR (n=36, 27%) was accompanied with significant higher total afterloads (Ea: 0.75 vs.0.41, p&amp;lt;0.001) and lower RV-PA coupling ratios (Ees/Ea, 0.4 vs. 0.79, p&amp;lt;0.001). This was associated with enlarged RVs (RVEDV: 210ml vs. 166ml), lower FAC (31% vs. 50%), TAPSE (13mm vs. 18mm), and RVOTprox (22% vs. 39%) (all p&amp;lt;0.001). For better comparability between trace TR and m/s-TR tertiles (T1-T3) of similar afterloads (Ea) were formed. The m/s-TR patients showed significant lower RV-PA coupling ratios than trace TR at the lower two Ea tertiles T1 (p=0.034) and T2 (p&amp;lt;0.001). At Ea T3 the difference was no longer significant (p=0.055). The hemodynamic data are mirrored by significant lower FACs, FS RVOTprox, and TAPSE at T1 and T2 (all p&amp;lt;0.05), and a nonsignificant difference at T3 in m/s-TR. In conclusion: In our cohort of HFrEF patients, echocardiographic RV function reflects very closely the hemodynamic coupling efficiency of RV contractility (Ees) to afterload (Ea) and seems independent from the extent of TR. We found no evidence for pseudo-normal or overestimated echocardiographic RV function in m/s-TR.

Unmet Needs in the Assessment of Right Ventricular Function for Severe Tricuspid Regurgitation.

Tricuspid regurgitation (TR) is a highly prevalent valvular heart disease that has been long overlooked, but lately its independent association with adverse cardiovascular outcomes was recognized. The time point to intervene and repair the tricuspid valve is defined by the right ventricular (RV) dilation and dysfunction that comes up at a later stage. While guidelines favor tricuspid valve repair before severe RV dysfunction ensues, the definition of RV dysfunction in a universal manner remains vague. As a result, the candidates for transcatheter or surgical TR procedures are often referred late, when advanced RV dysfunction is established, and any derived procedural survival benefit is attenuated. Thus, it is of paramount importance to establish a universal means of RV function assessment in patients with TR. Conventional echocardiographic indices of RV function routinely applied have fundamental flaws that limit the precise characterization of RV performance. More recently, novel echocardiographic indices such as strain via speckle-tracking have emerged, demonstrating promising results in the identification of early RV damage. Additionally, evidence of the role of alternative imaging modalities such as cardiac computed tomography and cardiac magnetic resonance, for RV functional assessment in TR, has recently arisen. This review provides a systematic appraisal of traditional and novel multimodality indices of RV function in severe TR and aims to refine RV function assessment, designate future directions, and ultimately, to improve the outcome of patients suffering from severe TR.

Right Ventricular Global Longitudinal Strain and Short-Term Prognosis in Patients With First Acute Myocardial Infarction

Right ventricular (RV) dysfunction after acute myocardial infarction (AMI) is a recognized predictor of dismal prognosis. However, the most reliable RV index to predict mortality early after revascularization remains undetermined. This study aimed to explore the ability of RV global longitudinal strain (GLS) to predict inhospital mortality in patients with first AMI. All consecutive patients with first AMI were prospectively enrolled from March 2022 until February 2023. An echocardiogram was performed 24 hours after successful revascularization and RV GLS alongside conventional echocardiographic indexes were measured. Inhospital mortality was recorded. A total of 300 patients (age 61.2 ± 11.8 years, 74% male) were included in the study. RV GLS was the only RV performance index that differed significantly between anterior and inferior ST-segment-elevation patients with AMI (14.5 ± 5.2% vs 17.4 ± 5.1% respectively, p <0.001). After revascularization, 23 patients (7.7%) died in hospital. The model of Global Registry of Acute Coronary Event risk score and left ventricular ejection fraction, built for predicting inhospital mortality, significantly improved its prognostic performance only by the addition of RV GLS (chi-square value increase by 7.485, p=0.006) compared with the other RV function indexes. RV GLS was independently associated with inhospital mortality (odds ratio 0.83, 95% confidence interval 0.71 to 0.97, p=0.017) after adjustment for Global Registry of Acute Coronary Event risk score and left ventricular ejection fraction. Echocardiographic RV GLS measured 24 hours after revascularization in patients with first AMI outperformed conventional RV function indexes in predicting inhospital mortality.

Prognostic Performance of Right Ventricular Global Longitudinal Strain Measurements in Patients With Ebstein Anomaly

BackgroundThere are limited data on the prognostic role of right ventricular global longitudinal strain (RVGLS) in patients with Ebstein anomaly. ObjectivesThis study sought to assess the relationship between RVGLS and mortality and to compare prognostic performance of RVGLS with conventional echocardiographic indices of right ventricular (RV) systolic function. MethodsThis study identified adults with Ebstein anomaly with echocardiographic assessment of RV systolic function (RVGLS, RV fractional area change [RVFAC], RV tissue Doppler systolic velocity [RV s′], and tricuspid annular plane systolic excursion [TAPSE]) from 2003 to 2020. For ease of presentation, RVGLS was modeled as absolute values (ie, without the negative sign). ResultsOf 620 patients (median age 37 years; men 261 [42%]), the mean absolute RVGLS, RVFAC, RV s′, and TAPSE were 18% ± 5%, 32% ± 9%, 14 ± 6 cm/s, and 22 ± 8 mm, respectively. There were correlations between absolute RVGLS and RVFAC (r = 0.71; P < 0.001), between absolute RVGLS and RV s′ (r = 0.41; P = 0.03), and between absolute RVGLS and TAPSE (r = 0.44; P = 0.002). Of 620 patients, 47 (8%) died during follow-up, and 34 of these deaths were cardiovascular. Absolute RVGLS was independently associated with all-cause mortality (adjusted HR: 0.94; 95% CI: 0.92-0.96 per unit increase) and cardiovascular mortality (adjusted HR: 0.92; 95% CI: 0.90-0.94 per unit increase). Absolute RVGLS had superior prognostic power (ie, ability to predict mortality) as compared with RVFAC, RV s′, or TAPSE. ConclusionsThese data support the use of RVGLS for risk stratification in Ebstein anomaly, and further studies are required to assess how interventions may affect different patients according to risk stratification.

Impact of pulmonary valve replacement on left and right ventricular function using strain analysis, in children with repaired tetralogy of Fallot

BackgroundIn repaired Tetralogy of Fallot (rTOF), pulmonary regurgitation and resulting right ventricular (RV) and left ventricular (LV) dysfunction are associated with adverse clinical outcomes. We performed an echocardiographic assessment of LV and RV function using Global Longitudinal Strain (GLS) and conventional echo method prior to and following Pulmonary Valvular Replacement (PVR) to help inform proper timing of operation.ResultsA total of 30 rTOF patients (12.17 ± 2.5 years, 70% male) were included. Regarding to LV function, the study revealed a significant reverse correlation between LV GLS (absolute value) and early (mean = 10.4 days) and late (mean = 7.4 months) postop LVEF. Paired T-Test showed significant difference between GLS of LV and RV before and late after operation (op), however, without significant changes early postop. Late postop significant improvements occurred in other conventional echo indices of LV and RV function as well. There was also a significant correlation between echo-measured LVEF & Fraction Area Change (RV FAC) and MRI-derived LVEF & RVEF, respectively.ConclusionIn this cross-sectional study in rTOF patients, RV and LV GLS as well as conventional echocardiographic indices regarding LV and RV function improved significantly after 6 months (mean = 7.4mo) following PVR.

Prognostic value of right ventricular function in patients with severe tricuspid regurgitation undergoing tricuspid valve intervention

Abstract Funding Acknowledgements Type of funding sources: None. Background Indications and optimal timing of intervention for severe tricuspid regurgitation (TR) remain controversial due to insufficient evidence. Right ventricular (RV) function assessment, a key factor of preoperative evaluation, remains challenging due to limitations of conventional echocardiographic indexes, particularly with concomitant severe TR. Right ventricular free wall longitudinal strain (RVFWLS) is able to evaluate intrinsic systolic function and to identify RV dysfunction at early stage compared to conventional echocardiographic indices. Purpose to analyze the prognostic implications of pre-operative RV dysfunction, evaluated through conventional and speckle-tracking echocardiography, in patients with severe TR undergoing tricuspid valve intervention. Methods In this single-center retrospective study, we enrolled consecutive patients with severe TR who underwent surgical or transcatheter tricuspid valve intervention (TTVI) between November 2016 and July 2021. The primary endpoint was all-cause mortality. For a secondary exploratory analysis, to compare outcomes of operated versus conservatively treated patients, we enrolled consecutive patients with severe TR who underwent echocardiographic evaluation in the same time period and who undergo conservative management. Results Study population included 100 patients: 78 patients underwent isolated TV surgical intervention and 22 TTVI. ROC curve analysis showed RVFWLS as the best echocardiographic parameter to predict all-cause mortality (AUC: 0.726, IC 0.57–0.88 P = 0.006). Estimated 4-years survival was significantly lower in patients with RV dysfunction (defined as an absolute value of RVFWLS ≤ 21%, cutoff derived from ROC analysis with sensitivity 60% and specificity 87%) compared to patients with normal RV function: 70.0% vs 93.9% p = 0.002 (Figure 1). Independent prognostic role of RVFWLS was confirmed at multivariable analysis adjusted for significative clinical and echocardiographic variables (OR 0.88, 95% CI 0.80–0.98; P = 0.016). At secondary exploratory analysis, patients treated conservatively had a worst estimated 4-year survival compared to operated patients (59.6% vs 84.0%, p = 0.001). Stratifying this population according to the presence of RV dysfunction, in the group with lower RVFWLS values there were no significative differences in overall survival between operated and conservatively-treated patients (Figure 2). Conclusions Preoperative RV dysfunction defined by echocardiographic strain analysis is independently associated with outcomes after TV intervention. RVFWLS could be useful for indication and timing of intervention for severe TR.

Right ventricular function in patients with significant tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Aim The aim of this meta-analysis was to systematically investigate the prognostic value of right ventricular (RV) function in all-comers patients with significant (at least moderate, ≥ 2+) tricuspid regurgitation (TR). Background Chronic significant TR imposes a volume overload to the RV leading to a progressive RV dilatation and dysfunction. A comprehensive assessment of RV function is of paramount importance to guide the therapeutic management of these patients; however, it remains challenging, particularly in presence of altered loading conditions. Methods MEDLINE, ISI Web of Science, and SCOPUS databases were searched for studies published up to July 2022. Studies reporting data on at least one echocardiographic RV function parameter and outcome in patients with significant TR were included. This study was designed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) requirements. The primary endpoint was all-cause long-term mortality (more than one year). Results Out of 3,152 studies, a total of 10 were included in the analytic synthesis, enrolling 3435 subjects. The median follow-up in our study population was 28 [22 – 70] months. All-cause long-term mortality was 40% (95% confidence interval [CI]: 32–49%, p = 0.028; Figure 1). To explore the potential impact of effect size modifiers on all-cause long-term mortality, we performed a meta-regression analysis of the baseline characteristics of the included studies. At long-term, a significant relation was found between RV fractional area change (RV-FAC), tricuspid annular plane systolic excursion (TAPSE), tricuspid annular tissue doppler imaging systolic velocity (TDI s’) and mortality. In particular, RV-FAC was associated with reduced incidence of all-cause mortality [7 studies enrolling 2,611 subjects, intercept 5.18, slope −0.15, P = 0.007; Figure 2]; whereas both TAPSE and TDI s’ were unsatisfactory to predict the outcome in these patients [TAPSE 9 studies enrolling 2,891 subjects, intercept 1.73, slope −0.12, P = 0.36; TDI s’ 5 studies enrolling 1429 subjects, intercept −2.06, slope 0.15, P = 0.78]. Interestingly, diabetes mellitus (DM) and hyperlipidaemia were associated with an increased risk of mortality [DM 9 studies enrolling 3371 subjects, intercept −2.62, slope 0.09, P = 0.004; hyperlipidaemia 6 studies enrolling 2338 subjects, intercept −2.91, slope 0.05, P = 0.01]. Conclusions Significant TR is associated with increased risk of all-cause. To our knowledge, this is the first study to demonstrate that only RV-FAC, and not conventional echocardiographic indexes of RV longitudinal function, correlates with adverse outcomes in patients with significant TR.

Right ventricular global longitudinal strain and short-term prognosis in patients with first acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Background Right ventricular (RV) dysfunction is recognized as an adverse prognostic feature in patients with Acute Coronary Syndromes (ACS). However, conventional echocardiographic indices for the evaluation of RV function have considerable limitations. Right Ventricular Global Longitudinal Strain (RV GLS) is a novel speckle-tracking echocardiographic index that assesses the overall intramyocardial function of the RV free wall and interventricular septum. Purpose The present study aimed to investigate the short-term prognostic value of RV GLS in patients with first ACS. Methods A total of 300 consecutive patients with first ACS (mean age 61.2±11.8 years, 74% males) were prospectively studied. A comprehensive transthoracic echocardiographic assessment was undertaken within 24 hours after revascularization and in-hospital mortality was assessed. Multiple multivariable Cox Regression analysis models were constructed to compare the predictive value of RV function indices for in-hospital mortality. Only significant variables (P&amp;lt;0.05) in the univariate analysis were included in the models. Due to the limited number of events, all multivariable models were constructed including a maximum of 3 variables. To further assess the prognostic value of RV GLS over a baseline model the change in χ2 was assessed using the likelihood ratio test. The absolute value of strain parameters was used for all analysis. Results Patients with anterior-STEMI had significantly more impaired RV GLS (anterior-STEMI 14.52±5.23 vs. inferior-STEMI 17.41±5.06 vs. lateral-STEMI 19.50±4.17 vs. Non-STEMI 20.61±3.69%, P&amp;lt;0.001). A total of 23 (7.7%) patients died in-hospital after revascularization. In univariate analysis RV GLS was significantly associated with in-hospital mortality (HR=0.717, 95% CI=0.642–0.801, P&amp;lt;0.001). After adjustment for Global Registry of Acute Coronary Event (GRACE) risk score and Left Ventricular Ejection Fraction (LVEF), RV function indices that retained independent association with in-hospital mortality were RV GLS, Fractional Area Change, and Tricuspid Annular Plane Systolic Excursion (Table). The model that included RV GLS demonstrated the highest overall χ2 value (Table). To prove the incremental value of RV GLS on in-hospital mortality prognosis, a baseline model including the GRACE risk score was created, and then LVEF was added. The further addition of RV GLS significantly increased the prognostic value the model (Figure). Conclusions RV GLS measured by transthoracic echocardiography within 24 hours after revascularization in patients with first ACS showed the strongest association with in-hospital mortality outperforming other RV function indices. RV GLS provides additine prognostic information over GRACE risk score and LVEF to predict in-hospital mortality.

Clinical Value of Novel Echocardiographic Biomarkers Assessing Myocardial Work in Acute Heart Failure-Rationale and Design of the "Beyond Myo-HF Study".

Despite ongoing treatment advancements in chronic heart failure (HF), mortality and readmission rates remain high for patients hospitalized for decompensated acute HF. These patients represent a distinct HF group, which requires emergent echocardiographic evaluation in an attempt to provide optimal and individualized acute care. The role of serial advanced echocardiographic assessment in acute HF for risk stratification and treatment guidance has not been thoroughly explored. The "Beyond Myo-HF Study" is a prospective, non-interventional cohort trial designed to enroll acutely admitted patients with symptoms and/or signs of HF. The aim of this study is to investigate whether intrahospital changes of conventional and novel echocardiographic indices of myocardial function and congestion-related markers can predict early mortality, late mortality, and HF rehospitalization. As per the protocol, all patients undergo a pair of state-of-the-art echocardiographic assessments, with a rigorous protocol including speckle tracking analysis of all cardiac chambers and myocardial work analysis for the left and right ventricle, upon admission and pre-discharge. Their laboratory profile is captured at those two time-points, and their therapeutic management is recorded. Patients will be followed-up for a median period of 12 months after enrollment. The "Beyond Myo-HF" study is an ongoing, prospective trial aspiring to provide deep insight into the pathophysiology of acute HF, to enlighten the reverse cardiac functional and anatomical remodeling during hospitalization, and to recognize echocardiographic patterns capable of predicting adverse outcomes during and post decompensation of acute HF.

Prognostic Impact of Right Ventricular Strain in Isolated Severe Tricuspid Regurgitation

Right ventricular (RV) systolic function is an established marker of outcomes in patients with severe tricuspid regurgitation (TR). Timely detection of RV dysfunction using conventional two-dimensional echocardiography is challenging. RV strain has emerged as an accurate and sensitive tool for the evaluation of RV function, with the capability to detect subclinical RV dysfunction. The aim of this study was to evaluate the prognostic value of RV strain parameters in early stages of severe TR. Consecutive patients with at least severe TR (severe, massive, or torrential) and the absence of a formal indication for tricuspid valve intervention in secondary TR evaluated in the Heart Valve Clinic were prospectively included. RV systolic function was measured using conventional echocardiographic indices (RV fractional area change, tricuspid annular plane systolic excursion, and Doppler tissue imaging S wave [S']) and speckle-tracking echocardiography-derived automatic peak global longitudinal strain and free wall longitudinal strain (FWLS) using an automated two-dimensional strain analytic software. A combined end point of hospital admission due to heart failure or all-cause mortality was defined. A total of 266 patients were enrolled in the study, and 151 were ultimately included. Strain parameters detected a higher percentage of abnormal RV values compared with conventional indices. During a median follow-up period of 26months (interquartile range, 13-42months), 35% of the patients reached the combined end point. Cumulative event-free survival was significantly worse in patients with impaired RV global longitudinal strain and RV FWLS. Conventional indices of RV systolic function were not associated with outcomes (P>.05 for all). On multivariate analysis, RV FWLS was independently associated with mortality and heart failure (adjusted hazard ratio for abnormal RV FWLS, 5.90; 95% CI, 3.17-10.99; P<.001). In early stages of severe TR, RV FWLS is more frequently impaired compared with conventional indices of RV function. Among all parameters, RV FWLS is the strongest predictor of mortality and heart failure, independent of additional prognostic markers.

Right ventricular systolic function and associated anatomic risk factors in fetuses with transposition of the great arteries: Evaluation by velocity vector imaging.

The aim of this study was to evaluate right ventricular (RV) systolic function in fetuses with transposition of the great arteries (TGA) using velocity vector imaging (VVI) and to investigate the impact of different factors on RV systolic function in TGA fetuses. This was a retrospective cross-sectional study of fetuses referred to our tertiary center between 2015 and 2019. Maternal and fetal baseline characteristics and conventional echocardiographic and myocardial deformation indices were collected in fetuses with TGA at 20-28 weeks' gestation, which were compared with normal fetuses with comparable gestational age (GA). RV deformational parameters including global and regional longitudinal peak systolic strain, strain rate, and velocity were measured using off-line speckle tracking analysis. The univariate and multivariate linear regression analyses were established to evaluate the independent risk factors for RV global longitudinal systolic strain (RVGLSs) and strain rate (RVGLSRs). In total, 78 fetuses with TGA [including 49 fetuses with complete transposition of the great arteries (d-TGA) and 29 fetuses with Taussig-Bing anomaly (TBA)] and 49 normal fetuses were included. Compared with normal controls, global and most regional RV longitudinal systolic peak velocity, strain, and strain rate were lower in d-TGA and TBA fetuses (P < 0.05). Compared with normal controls, global and most regional RV longitudinal systolic strain was lower in d-TGA fetuses without pulmonary stenosis (PS) and ventricular septal defect (VSD), while RVGLSs and RVGLSRs were lower in TBA fetuses without PS. The VSD was an independent determinant of RVGLSRs (P = 0.024) in the d-TGA group. Additionally, PS was an independent determinant of RVGLSs and RVGLSRs (P = 0.012, P = 0.027) in the TBA group. Early impairment of RV systolic function has already occurred in TGA fetuses during the 2nd trimester of pregnancy. PS, VSD, and foramen ovale (FO) were independent risk factors for decreased RV function.

852 DAPAGLIFOZIN IN PATIENTS WITH CARDIAC HEART FAILURE

Abstract Dapaglifozin on diastolic function in patients with type 2 diabetic mellitus and chronic heart failure Heart failure (HF) with reduced ejection fraction (HFrEF) remains a challenging problem due to its high mortality rate. Another novelty in HF therapy is dapagliflozin, a sodium-glucose transporter-2 inhibitor (SGLT2i) which decreased the rates of cardiac death and worsening of HF in the DAPA-HF trial, when added in other guideline recommended therapy. Material and methods A prospective cohort study of 30 symptomatic HF patients with EF &amp;lt; 35% (aged 65 ±10 years) (20 males and 10 females) was conducted. Diabetic (2TDM) patients of NYHA status II–III, previously treated with ARNI, β-blocker, and mineralocorticoid receptor antagonists (MRA) were included. Dapagliflozin 10 mg was added as an adjunct therapy for 2TDM but also as a novel therapy of HF in diabetic patients. Clinical examination and complete echocardiographic evaluation were performed at baseline and 30 days after the addition of SGLT2i to their treatment. 2D echocardiography and Doppler measurements were used for the evaluation of left ventricular function, and more specifically, peak early (E-wave) and late (A-wave) transmitral filling velocities and their ratio E/A, deceleration time of E velocity (DTE). To classify diastolic dysfunction according to the ASE/EACVI guidelines published in 2016, transmitral E and A waves velocities, septal and lateral E’ tissue velocities, indexed left atrium volume and peak velocity of tricuspid regurgitation were collected. Results After 30 days of therapy with dapagliflozin, blood pressure was reduced significantly and the echocardiographic parameters of diastolic function were improved. More specifically, after 6.1±3.6 months of treatment E/A ratio decreased from 1.7 ±1.5 to 1.01±0.70 (P &amp;lt;0.05), the E/Ea ratio decreased from 13.5± 6.3 vs. 10.2± 5.2 (P &amp;lt;0.05), tricuspid regurgitation peak velocity decreased from 3.0±0.4 to 2.4± 0.5m/s (P =0.03) and left atrial volume decreased from 53 ±29.3 to 40.3±11.5ml/m2 (P &amp;lt;0.05). Subsequently, both left-ventricular diastolic function and filling pressure improved significantly (P &amp;lt;0.05,). Discussion Our data support the evidence that SGLT2i ameliorate both the conventional echocardiographic indexes of diastolic function and this effect is noted quite promptly. The ratio of early diastolic transmitral flow velocity seems to correlate well with LV filling pressures, and may be use das a prognostic tool in patients with HFrEF. We have to emphasize that the diastolic function improvement was observed 30 days after the initiation of dapagliflozin treatment, and thus it may be considered an early marker of improvement and adequacy of treatment apart from BNP. Conclusions in this study classical diastolic echocardiographic parameters were improved promptly after initiation of dapagliflozin therapy. The ratio of early diastolic transmitral flow velocity at the early filling phase of diastole (E/SRE) may be considered a reliable index of HF therapy responders.