Assessment Of Diastolic Function Research Articles

Obstructive Sleep Apnea and Right Ventricular Remodeling: Do We Have All the Answers?

Obstructive sleep apnea (OSA) syndrome is a very important sleep-related breathing disorder related to increased cardiovascular and overall morbidity and mortality. It is associated with multisystemic target organ damage due to micro- and macrovascular changes, resulting in carotid and coronary atherosclerosis, increased arterial stiffness, retinal damage, microalbuminuria, and cardiac remodeling. The latter consists of left ventricular (LV) hypertrophy, as well as diastolic and systolic dysfunction. The increasing burden of evidence shows that OSA also induces right ventricular (RV) remodeling that is more difficult to diagnose, but may also contribute to cardiovascular morbidity and mortality in these patients. Conventional echocardiographic parameters for assessment of RV systolic and diastolic functions are often not sensitive enough to detect subclinical and subtle changes in the RV function. Data published over last decade showed that the RV function, particularly systolic, is impaired in OSA patients and related with its severity. However, the introduction of speckle tracking echocardiography and the particularly longitudinal strain enabled the earlier detection of functional and mechanical changes even when conventional echocardiographic parameters of RV systolic function remained unchanged. The 3D echocardiography provided the possibility to evaluate the entire RV, with its unique shape, and determine 3D RV ejection fraction, which is comparable with results obtained by cardiac magnetic resonance. The use of this modality also provided a new insight into RV systolic (dys)function in OSA patients. In addition to weight loss, which has been proven very helpful in OSA patients, the only approved therapeutic approach is continuous positive airway pressure (CPAP) therapy. It is very important to assess if this therapy induces any improvement in cardiac structure and function. Limited data on this topic show that RV longitudinal strain is a more sensitive parameter rather than other conventional RV indexes in the detection of improvement in RV systolic function and mechanics. The aim of this review article is to summarize the current understanding of RV structural, functional, and mechanical changes in patients with OSA. Furthermore, we sought to provide the current knowledge regarding the effect of CPAP therapy on RV reverse remodeling in OSA patients.

Echo Doppler Parameters of Diastolic Function.

The purpose of this review is to highlight the echo Doppler parameters that form the cornerstone for the evaluation of diastolic function as per the guideline documents of the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI). In addition, the individual Doppler-based parameters will be explored, with commentary on the rationale behind their use and the multi-parametric approach to the assessment of diastolic dysfunction (DD) using echocardiography. Previous guidelines for assessment of diastolic function are complex with modest diagnostic performance and significant inter-observer variability. The most recent guidelines have made the evaluation of DD more streamlined with excellent correlation with invasive measures of LV filling pressures. This is a review of the echo-derived Doppler parameters that are integral in the diagnosis and gradation of DD. A brief description of the physiological principles that govern changes in echocardiographic parameters during normal and abnormal diastolic function is also discussed for the appropriate diagnosis of DD using non-invasive Doppler echocardiography techniques.

Left ventricular strain-volume loops and diastolic dysfunction in suspected heart failure with preserved ejection fraction

BackgroundPresence of left ventricular diastolic dysfunction (DD) is key in the pathogenesis of heart failure with preserved ejection fraction (HFpEF). However, non-invasive assessment of diastolic function is complex, cumbersome, and largely based on consensus recommendations. Novel imaging techniques may help detecting DD. Therefore, we compared left ventricular strain-volume loop (SVL) characteristics and diastolic (dys-)function in suspected HFpEF patients. Method and results257 suspected HFpEF patients with sinus rhythm during echocardiography were prospectively included. 211 patients with quality-controlled images and strain and volume analysis were classified according to the 2016 ASE/EACVI recommendations. Patients with indeterminate diastolic function were excluded, resulting in two groups: normal diastolic function (control; n = 65) and DD (n = 91). Patients with DD were older (74.8 ± 6.9 vs. 68.5 ± 9.4 years, p < 0.001), more often female (88% vs 72%, p = 0.021), and more often had a history of atrial fibrillation (42% vs. 23%, p = 0.024) and hypertension (91% vs. 71%, p = 0.001) compared to normal diastolic function. SVL analysis showed a larger uncoupling i.e., a different longitudinal strain contribution to volume change, in DD compared to controls (0.556 ± 1.10% vs. -0.051 ± 1.14%, respectively, P < 0.001). This observation suggests different deformational properties during the cardiac cycle. After adjustment for age, sex, history of atrial fibrillation and hypertension, we found an adjusted odds ratio of 1.68 (95% confidence interval 1.19–2.47) for DD per unit increase in uncoupling (range: −2.95–3.20). ConclusionUncoupling of the SVL is independently associated with DD. This might provide novel insights in cardiac mechanics and new opportunities to assess diastolic function non-invasively.

Left Atrial Strain in the Assessment of Diastolic Function in Heart Failure: A Machine Learning Approach.

Diastolic dysfunction (DD) assessment in heart failure is still challenging. Peak atrial longitudinal strain (PALS) is strongly related to end-diastolic pressure and prognosis, but it is still not part of standard DD assessment. We tested the hypothesis that a machine learning approach would be useful to include PALS in DD classification and refine prognostic stratification. In a derivation cohort of 864 heart failure patients in sinus rhythm (age, 66.6±12 years; heart failure with reduced ejection fraction, n=541; heart failure with mildly reduced ejection fraction, n=129; heart failure with preserved ejection fraction, n=194), machine learning techniques were retrospectively applied to PALS and guideline-recommended diastolic variables. Outcome (death/heart failure rehospitalization) of the identified DD-clusters was compared with that by guidelines-based classification. To identify the best combination of variables able to classify patients in one of the identified DD-clusters, classification and regression tree analysis was applied (with DD-clusters as dependent variable and PALS plus guidelines-recommended diastolic variables as explanatory variables). The algorithm was subsequently validated in a prospective cohort of 189 heart failure outpatients (age, 65±13 years). Three distinct echocardiographic DD-clusters were identified (cluster-1, n=212; cluster-2, n=376; cluster-3 DD, n=276), with modest agreement with guidelines-recommended classification (kappa=0.40; P<0.001). DD-clusters were predicted by a simple algorithm including E/A ratio, left atrial volume index, E/e' ratio, and PALS. After 36.5±29.4 months follow-up, 318 events occurred. Compared to guideline-based classification, DD-clusters showed a better association with events in multivariable models (C-index 0.720 versus 0.733, P=0.033; net reclassification improvement 0.166 [95% CI, 0.035-0.276], P=0.013), without interaction with ejection fraction category. In the validation cohort (median follow-up: 18.5 months), cluster-based classification better predicted outcome than guideline-based classification (C-index 0.80 versus 0.78, P=0.093). Integrating PALS by machine learning algorithm in DD classification improves risk stratification over recommended current criteria, regardless of ejection fraction status. This proof of concept study needs further validation of the proposed algorithm to assess generalizability to other populations.

Impact of left atrial and diastolic ventricular dysfunction on mortality in patients with aortic stenosis

BackgroundDiastolic dysfunction (DD) is common in severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF≥50%). AimTo determine the impact of American Society of Echocardiography/European Association of Cardiovascular Imaging-recommended DD grading and left atrial strain on mortality in a cohort of patients with severe AS and preserved LVEF. MethodsWe studied patients with severe AS (aortic valve area indexed<0.6 cm2/m2 and/or aortic valve area<1cm2), LVEF≥50% and no or mild AS-related symptoms. The endpoint was all-cause mortality. ResultsA total of 387 patients (median age 76years; 53% women) were studied. During a median follow-up of 57 (interquartile range 37; 83) months, 158 patients died. After adjustment for prognostic factors, patients with grade II or III DD had an increased mortality risk versus patients with grade I DD (adjusted hazard ratio (aHR) 1.62, 95% confidence interval (CI) 1.11–2.38; P=0.013; aHR 4.73, 95% CI 2.49–8.99; P<0.001; respectively). Adding peak atrial longitudinal strain (PALS)≤14% to a multivariable model including DD grade improved predictive performance, with better global model fit, reclassification and discrimination. Patients with grade III DD or grade II DD+PALS≤14% displayed an increased mortality risk versus patients with grade I DD+PALS>14% (aHR 4.17, 95% CI 2.46–7.06; P<0.0001). Those with grade I DD+PALS≤14% or grade II DD+PALS>14% were at intermediate risk (aHR 1.63, 95% CI 1.07–2.49; P=0.024). ConclusionsOur results demonstrate the strong relationship between DD and mortality in patients with severe AS and preserved LVEF. Patients with grade III or grade II DD and impaired PALS are at very high risk. These data demonstrate the importance of a comprehensive assessment of diastolic function in patients with severe AS.

Assessment of Early Diastolic Intraventricular Pressure Difference in Children by Blood Speckle-Tracking Echocardiography

The lack of reliable echocardiographic techniques to assess diastolic function in children is a major clinical limitation. Our aim was to develop and validate the intraventricular pressure difference (IVPD) calculation using blood speckle-tracking (BST) and investigate the method's potential role in the assessment of diastolic function in children. Blood speckle-tracking allows two-dimensional angle-independent blood flow velocity estimation. Blood speckle-tracking images of left ventricular (LV) inflow from the apical 4-chamber view in 138 controls, 10 patients with dilated cardiomyopathies (DCMs), and 21 patients with hypertrophic cardiomyopathies (HCMs)<18years of age were analyzed to study LV IVPD during early diastole. Reproducibility of the IVPD analysis was assessed, IVPD estimates from BST and color M mode were compared, and the validity of the BST-based IVPD calculations was tested in a computer flow model. Mean IVPD was significantly higher in controls (-2.28±0.62mm Hg) compared with in DCM (-1.21±0.39mm Hg, P<.001) and HCM (-1.57±0.47mm Hg, P<.001) patients. Feasibility was 88.3% in controls, 80% in DCM patients, and 90.4% in HCM patients. The peak relative negative pressure occurred earlier at the apex than at the base and preceded the peak E-wave LV filling velocity, indicating that it represents diastolic suction. Intraclass correlation coefficients for intra- and interobserver variability were 0.908 and 0.702, respectively. There was a nonsignificant mean difference of 0.15mm Hg between IVPD from BST and color M mode. Estimation from two-dimensional velocities revealed a difference in peak IVPD of 0.12mm Hg (6.6%) when simulated in a three-dimensional fluid mechanics model. Intraventricular pressure difference calculation from BST is highly feasible and provides information on diastolic suction and early filling in children with heart disease. Intraventricular pressure difference was significantly reduced in children with DCM and HCM compared with controls, indicating reduced early diastolic suction in these patient groups.

The Outcomes of Coronary Artery Bypass Surgery after 18 Months-Is There an Influence of the Initial Right Ventricle Diastolic Dysfunction?

This study aimed to investigate the association of preoperative right heart filling indicators with outcomes after coronary artery bypass grafting (CABG) at an 18 month follow up. Patients who underwent CABG at a single center were included in this study. In addition to the baseline preoperative indicators and perioperative data, initial parameters of the right ventricle (RV) systolic and diastolic function were assessed. Among the 189 patients, a total of 19 (10.0%) MACE (cardiovascular death, nonfatal myocardial infarction and stroke) were recorded during an 18 month follow up. In patients with the development of MACE during the initial examination, the following changes in RV function were revealed compared with the group without MACE: a decrease in the e't index (8.2 versus 9.6 cm/s, p = 0.029), an increase in the Et/e't ratio (5.25 vs. 4.42, p = 0.049) and more frequent presence of RV pseudonormal filling (p = 0.03). In the binary logistic regression analysis, the development of MACE 18 months after CABG was associated with the nonconduction of PCI before surgery, the presence of peripheral atherosclerosis, an increase in IVST and Et/e't and a decrease in LVEF. RV diastolic dysfunction in the preoperative period was associated with the development of MACE within 18 months after CABG, and the ratio Et/e't was one of the independent predictors of MACE in a multiple regression analysis. This makes it expedient to include an assessment of not only systolic but also diastolic RV function in the preoperative examination. The inclusion of an assessment of RV diastolic function in the pre-CABG evaluation of patients deserves further study.

Organization and Activity of Italian Echocardiographic Laboratories: A Survey of the Italian Society of Echocardiography and Cardiovascular Imaging.

The Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) conducted a national survey to understand better how different echocardiographic modalities are used and accessed in Italy. We analyzed echocardiography laboratory activities over a month (November 2022). Data were retrieved via an electronic survey based on a structured questionnaire, uploaded on the SIECVI website. Data were obtained from 228 echocardiographic laboratories: 112 centers (49%) in the northern, 43 centers (19%) in the central, and 73 (32%) in the southern regions. During the month of observation, we collected 101,050 transthoracic echocardiography (TTE) examinations performed in all centers. As concern other modalities there were performed 5497 transesophageal echocardiography (TEE) examinations in 161/228 centers (71%); 4057 stress echocardiography (SE) examinations in 179/228 centers (79%); and examinations with ultrasound contrast agents (UCAs) in 151/228 centers (66%). We did not find significant regional variations between the different modalities. The usage of picture archiving and communication system (PACS) was significantly higher in the northern (84%) versus central (49%) and southern (45%) centers (P < 0.001). Lung ultrasound (LUS) was performed in 154 centers (66%), without difference between cardiology and noncardiology centers. The evaluation of left ventricular (LV) ejection fraction was evaluated mainly using the qualitative method in 223 centers (94%), occasionally with the Simpson method in 193 centers (85%), and with selective use of the three-dimensional (3D) method in only 23 centers (10%). 3D TTE was present in 137 centers (70%), and 3D TEE in all centers where TEE was done (71%). The assessment of LV diastolic function was done routinely in 80% of the centers. Right ventricular function was evaluated using tricuspid annular plane systolic excursion in all centers, using tricuspid valve annular systolic velocity by tissue Doppler imaging in 53% of the centers, and using fractional area change in 33% of the centers. When we divided into cardiology (179, 78%) and noncardiology (49, 22%) centers, we found significant differences in the SE (93% vs. 26%, P < 0.001), TEE (85% vs. 18%), UCA (67% vs. 43%, P < 0001), and STE (87% vs. 20%, P < 0.001). The incidence of LUS evaluation was similar between the cardiology and noncardiology centers (69% vs. 61%, P = NS). This nationwide survey demonstrated that digital infrastructures and advanced echocardiography modalities, such as 3D and STE, are widely available in Italy with a notable diffuse uptake of LUS in the core TTE examination, a suboptimal diffusion of PACS recording, and conservative use of UCA, 3D, and strain. There are significant differences between northern and central-southern regions and echocardiographic laboratories that pertain to the cardiac unit. This inhomogeneous distribution of technology represents one of the main issues that must be solved to standardize the practice of echocardiography.

Assessment of Diastolic Myocardial Function in Neonates with Patent Ductus Arteriosus by Tissue Doppler Imaging

Assessment of Diastolic Myocardial Function in Neonates with Patent Ductus Arteriosus by Tissue Doppler Imaging

Epicardial Fat Volume, Cardiac Function, and Incident Heart Failure: The Rotterdam Study.

Background Larger epicardial fat volume (EFV) has been associated with increased risks of cardiovascular disease and atrial fibrillation. Yet, evidence on the association of EFV with cardiac function and incident heart failure (HF) remains scarce. Methods and Results We included 2103 participants (mean age, 68 years; 54.4% women) from the prospective population-based RS (Rotterdam Study) with computed tomography-based EFV and repeated echocardiography-based assessment of left ventricular (LV) systolic and diastolic function. Linear mixed effects and Cox-proportional hazard regression models, adjusted for cardiovascular risk factors, were used to assess the associations of EFV with repeated measurements of echocardiographic parameters and with incident HF. During a median follow-up of 9.7 years, 124 HF events occurred (incidence rate, 6.37 per 1000 person-years). For LV systolic function, 1-SD larger EFV was associated with 0.76 (95% CI, 0.54-0.98) mm larger LV end-diastolic dimension, 0.66 (95% CI, 0.47-0.85) mm larger LV end-systolic dimension, and 0.56% (95% CI, -0.86% to -0.27%) lower LV ejection fraction. Interactions between EFV and time were small. For LV diastolic function, 1-SD larger EFV was associated with 1.02 (95% CI, 0.78-1.27) mm larger left atrial diameter. Larger EFV was also associated with incident HF (hazard ratio per 1-SD increase in EFV, 1.34 [95% CI, 1.07-1.68] per 1-SD larger EFV). Conclusions We report an independent association between EFV with new-onset HF in the general population. EFV seems to exert its influence on HF through different pathways contributing to deteriorations in systolic function and larger left atrial size in part, likely through mechanical restraint and hypertrophy.

Study of the Echocardiographic Changes in Patients with Diabetic Nephropathy

Background: Diabetes mellitus (DM) is a metabolic disorder of multiple etiologies. Cardiovascular changes are one of the important macro vascular complications which are a major cause of mortality in diabetic patients with diabetic nephropathy. The aim of this work was to evaluate the structural and functional cardiovascular changes using echocardiography in diabetic patients with diabetic nephropathy (DN) in comparison with those without diabetic nephropathy. &#x0D; Methods: This observational cross-sectional study was carried out on 60 diabetic patients with type 2 diabetes mellitus (T2DM) only or had T2DM with DN Patients were subdivided in to two equal groups: group A included patients without DN and group B included patients with DN. All patients were subjected to laboratory investigations, echocardiography (tricuspid annular plane systolic excursion (TAPSE), pulmonary artery pressure measuring, left ventricular systolic and diastolic function assessment).&#x0D; Results: There was a significantly lower Hb and significantly higher creatinine level and AL/CR ratio in group B in comparison to group A. There was significantly higher number of sclerotic aortic valve patients, higher numbers of low TAPSE, higher estimated systolic pulmonary artery pressure (ESPAP), higher end diastolic diameter (EDD), higher end systolic diameter (ESD), heavier left ventricular mass and thicker posterior wall thickness in group B in comparison to group A (P ≤ 0.05). There was a positive relationship between AL/CR ratio and EDD, left ventricular mass, TAPSE, and posterior wall thickness, while negative relationship between it and ESD in the two studied groups, and it was found that high EPASP and sclerosis of the Aortic valve were more prevalent with DN group.&#x0D; Conclusions: Risks of cardiovascular events increase substantially with increasing stage of kidney disease in T2DM patients. Asymptomatic diabetic subjects are at high risk for major adverse cardiovascular events, such as those with, chronic diabetic kidney disease (DKD), or proteinuria.

Assessment of left ventricular diastolic function in children with HIV/AIDS attending a tertiary health Facility in Enugu, Nigeria: a Doppler echocardiographic study

ObjectiveTo determine the prevalence and factors associated with left ventricular diastolic dysfunction in children with HIV/AIDS.MethodEchocardiographic studies were carried out in 90 children/adolescents aged 18 months to 14 years.with HIV/AIDS and a healthy control group of 90 age and gender matched.Results47.8% of the HIV/AIDS patients (subjects) had LVDD. This was more pronounced in the AIDS group (100%). The E/A ratio was 1.9 ± 0.56 in the HIV group, 2.09 ± 0.04 in the AIDS group, and 1.20 ± 0.39 in the control group (p = 0.04). The mean Left ventricular isovolumic relaxation time (IVRT) was 79.4 ± 20.12 in the HIV group, 110.4 ± 10.12 in the AIDS group and 89.22 ± 25.76 in the control group. (p = 0.04). Deceleration time (DT) was also lower in HIV carrier group compared to AIDS group, p = 0.02. A restrictive filling pattern was the most described; with 27 (36.5%) in the HIV group, 16 (100.0%) in the AIDS group and 2 (2.2%) in the control group. (p = 0.02). The impaired relaxation pattern, 3 (4.0%) seen in the HIV group only. Positive correlation exists between body surface area (BSA) and LVDD. Body surface area and younger age were the significant predictors (BSA: r = 0.425, p = 0.038 in HIV and r = 0.827, p = 0.042) of LVDD in the AIDS group.ConclusionThis study showed a high prevalence of LVDD in Nigerian children with HIV and AIDS. This justifies inclusion of echocardiographic studies in the policy care of children with HIV/AIDS in sub-Sahara Africa region.

Echocardiographic strain imaging: what do paediatric cardiologists need to know?

: Assessment of systolic and diastolic function of both the left and right ventricles is an integral part of the assessment and management of children with heart disease. Despite corrective or palliative repair of congenital heart disease, dysfunction of the systemic ventricle, which may a morphologic left or a right ventricle, subpulmonary right ventricle, and the functional single ventricle may occur in the long term. Conventional echocardiographic indices of cardiac function can be regarded as parameters of indirect changes consequential to the shortening and lengthening of the myocardium in the cardiac cycle. Direct interrogation of myocardial deformation, on the other hand, may shed important lights on the understanding, diagnosis and prognosis of cardiac dysfunction in the paediatric cardiac population. In the past decade, technological advances in echocardiographic strain imaging have enabled direct interrogation of global and regional deformation of the myocardium. In this review, the concept of strain imaging, the evolution of echocardiographic strain imaging, the methods of ventricular and atrial strain quantification, and clinical applications of strain imaging in children and young adults with congenital heart disease are discussed. The gaps and challenges in the clinical translational use of echocardiographic strain imaging are also highlighted. Given the emerging data on potential prognostic values of strain measures in the prediction of occurrence of adverse cardiovascular outcomes in the congenital heart population, it is timely for paediatric cardiologists to consider the incorporation of strain imaging into the clinical management algorithm.

The Role of Novel Cardiac Imaging for Contemporary Management of Heart Failure.

Heart failure is becoming the central problem in cardiology. Its recognition, differential diagnosis, and the monitoring of therapy are intimately coupled with cardiac imaging. Cardiac imaging has witnessed an explosive growth and differentiation, with echocardiography continuing as the first diagnostic step; the echocardiographic exam itself has become considerably more complex than in the last century, with the assessment of diastolic left ventricular function and strain imaging contributing important information, especially in heart failure. Very often, however, echocardiography can only describe the fact of functional impairment and morphologic remodeling, whereas further clarification of the underlying disease, such as cardiomyopathy, myocarditis, storage diseases, sarcoidosis, and others, remains elusive. Here, cardiovascular magnetic resonance and perfusion imaging should be used judiciously to arrive as often as possible at a clear diagnosis which ideally enables specific therapy.

Additional Prognostic Value of Tissue Doppler Evaluation in Patients with Aortic Stenosis and Left-Ventricular Systolic Dysfunction Undergoing Aortic Valve Replacement.

Background and Objectives: Patients with surgical aortic stenosis (AS) show impaired diastolic filling, which is a risk factor for early and late mortality after aortic valve replacement (AVR). There is a paucity of information concerning the impact of restrictive diastolic filling and the evolution of diastolic dysfunction in the early and medium terms post-AVR. We aimed to determine the prognostic value of the presence of a restrictive left-ventricular (LV) diastolic filling pattern (LVDFP) and dilated left atrium (LA) in patients with AS and LV systolic dysfunction (LVEF < 40%) who underwent AVR, and to define the independent predictors for immediate and long-term prognosis and their value for preoperative risk estimation. Materials and Methods: The study was prospective and included 197 patients with surgical AS and LVEF <40% who underwent AVR. Preoperative echocardiographic examinations were repeated at day 10, at 1, 3 and 6 months, and at 1 and 2 years after surgery, with evaluation of LVEF, diastolic function and LA dimension index (mm/m2). Depending on LV systolic performance, patients were classified as Group A (LVEF: 30–40%) or Group B (LVEF < 30%). Results: The main echographic independent parameters for early and late postoperative death were: restrictive LVDFP, significant pulmonary hypertension, LV end-systolic diameter (LVESD) >55 mm and the presence of second-degree mitral regurgitation. Restrictive LVDFP and LA dimension >30 mm/m2 were independent predictors for fatal outcome (p = 0.0017). Conclusions: Assessment of diastolic function and LA dimension are reliable parameters in predicting fatal outcome and hospitalization for heart failure, having an independent and incremental prognostic value in patients with surgical AS. Complete evaluation of LVDFP with all the echographic measurements (including TDI) should routinely be part of the preoperative assessment of patients with LV systolic dysfunction undergoing AVR.

Full and simplified assessment of left ventricular diastolic function in covid-19 patients admitted to ICU: Feasibility, incidence, and association with mortality.

Left ventricular diastolic dysfunction (LVDD) is associated with poor outcomes in the intensive care unit (ICU). Nonetheless, precise reporting of LVDD in COVID-19 patients is currently lacking and assessment could be challenging. We performed an echocardiography study in COVID-19 patients admitted to ICU with the aim to describe the feasibility of full or simplified LVDD assessment and its incidence. We also evaluated the association of LVDD or of single echocardiographic parameters with hospital mortality. Between 06.10.2020 and 18.02.2021, full diastolic assessment was feasible in 74% (n=26/35) of patients receiving a full echocardiogram study. LVDD incidence was 46% (n=12/26), while the simplified assessment produced different results (incidence 81%, n=21/26). Nine patients with normal function on full assessment had LVDD with simplified criteria (grade I=2; grade II=3; grade III=4). Nine patients were hospital-survivors (39%); the incidence of LVDD (full assessment) was not different between survivors (n=2/9, 22%) and non-survivors (n=10/17, 59%; p=.11). The E/e' ratio lateral was lower in survivors (7.4 [3.6] vs. non-survivors 10.5 [6.3], p=.03). We also found that s' wave was higher in survivors (average, p=.01). In a small single-center study, assessment of LVDD according to the latest guidelines was feasible in three quarters of COVID-19 patients. Non-survivors showed a trend toward greater LVDD incidence; moreover, they had significantly worse s' values (all) and higher E/e' ratio (lateral).

Body mass index associated differences in cardiac stress energetics in type 2 diabetes

Abstract Background Patients with T2D and heart disease have normal body mass index (BMI), suggesting that diabetes and obesity mediate cardiovascular change by different mechanisms. Changes in cardiac energy metabolism in lean diabetic patients during exercise stress have not been previously reported. Objectives We aimed to assess if there are BMI-associated differences in cardiac stress metabolism in patients with T2D. Methods Twenty-five overweight T2D patients (O-T2D) and eleven lean T2D patients (LnT2D), age- and ethnicity-matched and with no other comorbidities were studied. Patients were on oral hypoglycaemics only and were free of diabetes complications. Participants underwent rest and dobutamine stress phosphorus magnetic resonance spectroscopy (31P-MRS) and cardiovascular magnetic resonance (CMR) at 3T for the assessment of myocardial phosphocreatine to ATP ratio (PCr/ATP) as a measure of myocardial energetics, biventricular volumes, rest and stress left ventricular (LV) ejection fraction, global longitudinal shortening, and mitral in-flow E/A ratio for assessment of diastolic function and perfusion. Intravenous Dobutamine was administered at a dose of 10μg/kg/min, increasing at 90 second intervals up to a maximum of 40 μg/kg/min to achieve a target heart rate of 65% of the age-predicted maximal heart rate. Mean rate pressure product (RPP) was recorded at rest and stress. Heart rate was maintained at target for the duration of the 31P-MRS and stress CMR cine, mitral in-flow and perfusion acquisitions. Results The cardiac volumes, systolic or diastolic function and LV mass were similar between LnT2D and O-T2D. Although the O-T2D patients had a numerically lower rest and stress PCr/ATP ratio, this did not reach statistical significance. Resting PCr/ATP was reduced in LnT2D and O-T2D patients similarly. However, LnT2D showed a greater reduction in PCr/ATP (stress PCr/ATP LnT2D 1.51±0.2 vs O-T2D 1.41±0.25, p=0.02) despite similar increases in RPP. Stress myocardial blood flow (MBF) was also significantly lower in the O-T2D patients. There were significant correlations of BMI with LV mass (r=0.35, p=0.03); stress LVEF (r=−0.34, p=0.04); stress MBF stress (r=−0.53, p=0.001) and stress E/A (r=0.46, p=0.01) (figure 1). Conclusions Despite their better stress perfusion and similar glycaemic control, LnT2D show worse metabolic reserve characterised by more significant decrements in energetics in response to hemodynamic stress compared to overweight patients with T2D. Higher BMI correlates inversely with stress myocardial blood flow and with stress left ventricular ejection fraction. The presence of these subtle alterations in measures of stress metabolism and perfusion might signify a distinct metabolic phenotype of “lean diabetic cardiomyopathy”. Future studies are needed to further delineate alterations in cardiac energy metabolism in lean and overweight/obese type 2 diabetes patients, and their role in the development of cardiac dysfunction. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Wellcome TrustBHF

Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction In Patients With Resistant Hypertension and Type 2 Diabetes Mellitus.

Aim To study the incidence and clinical and pathophysiological features of diastolic dysfunction (DD) and chronic heart failure with preserved ejection fraction (HFpEF) in patients with resistant arterial hypertension (RAH) associated with type 2 diabetes mellitus (DM).Material and methods A cross-sectional study that included 36 patients with RAH associated with type 2 DM (mean age, 61.4±6.4 years; 14 men) was performed. Measurement of office and 24-h blood pressure (BP), standard echocardiography with assessment of diastolic function (DF) and ventricular-arterial coupling, doppler ultrasound imaging of renal blood flow, and laboratory tests (blood glucose, glycated hemoglobin, blood creatinine, tumor necrosis factor α (TNF-α), brain natriuretic peptide (BNP), type 2 and type 9 matrix metalloproteinases (MMP-2 and MMP-9), tissue inhibitor of MMP 1 (TIMP-1), 24-h urine protein test, and 24-h urine volume test were performed for all patients. HFpEF was diagnosed according to criteria of the American Society of Echocardiography and the European Society of Cardiology 2019, and the Russian Clinical Guidelines on Diagnosis and Treatment of CHF 2017 and 2020.Results All patients had DD. Incidence of HFpEF detection according to the Russian Guidelines 2017 was 100%; according to the Russian Guidelines 2020, that included a required increase in BNP, and according to the criteria of the European Guidelines 2019, this incidence was 89 %. In 55.6 % of patients, DD corresponded to grade 2 (pseudonormal type). According to the correlation analysis, the DF impairment was associated with increases in pulse BP, myocardial mass, arterial and left ventricular elastance (arterial wall and left ventricular elasticity), basal glycemia and DM duration, MMP-2 level, proteinuria, blood creatinine, renal vascular resistance, and also with decreases in 24-h urine volume, MMP-9, TIMP-1, and TIMP-1/MMP-2. Significance of the relations of mean E / e' ratio with nighttime pulse BP, MMP-9, and 24-h urine volume were confirmed by results of multiple linear regression analysis. Increased myocardial and vascular wall stiffness, concentrations of MMP-2 and TNF-α and reduced 24-h urine volume were associated with progressive impairment of DF.Conclusion The combination of RAH and DM-2 is characterized by an extremely high incidence of DD that determines a great prevalence of HFpEF. The development and progression of DD in such patients are closely related with a complex of metabolic, proinflammatory and profibrotic biomarkers, increased vascular wall stiffness, pronounced left ventricular hypertrophy, and with structural and functional alterations in kidneys.

A pacing-controlled protocol for frequency-diastolic relations distinguishes diastolic dysfunction specific to a mouse HFpEF model.

Heart failure with preserved ejection fraction (HFpEF), characterized by diastolic dysfunction and insufficient exercise capacity, is a growing health problem worldwide. One major difficulty with experimental research on HFpEF is the lack of methods to consistently detect diastolic dysfunction in mouse models. We developed a pacing-controlled pressure-volume (PV) loop protocol for the assessment of diastolic function at different heart rates in mice and tested if the protocol could detect diastolic dysfunction specific to a HFpEF model. A HFpEF model was generated by high-fat diet (HFD) feeding with concomitant NG-nitro-l-arginine methyl ester administration, and a pressure-overload hypertrophy (PO) model was produced by surgical constriction of the transverse aorta (TAC). Heart rate (HR) was slowed below 400 beats/min by intraperitoneal injection of ivabradine. PV loop data were acquired and analyzed at HR incrementing from 400 to 700 beats/min via atrial pacing using a miniature pacing catheter inserted into the esophagus, and comparisons were made among control, HFpEF, and PO mice. At baseline without pacing, no diastolic abnormalities were detected in either PO or HFpEF models. Frequency-diastolic relations, however, revealed the significant diastolic impairment specific to the HFpEF model; both relaxation time constant (Tau) and end-diastolic pressure-volume relationship (EDPVR) were worsened as heart rate increased. Peak positive first derivative of left ventricular pressure (dP/dtmax) was significantly lower in HFpEF versus controls only at a high HR of 700 beats/min. A pacing-controlled protocol would be a feasible and potent method to detect diastolic dysfunction specific to a mouse HFpEF model.NEW & NOTEWORTHY We developed a pacing-controlled PV loop protocol for the assessment of diastolic function at different heart rates in mice, which is a feasible and potent method for the characterization of diastolic dysfunction in a murine HFpEF model whose diastolic dysfunction might be difficult to be detected under resting conditions without pacing.

Impact of 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging Recommendations for the Evaluation of Left Ventricular Diastolic Function on Predicting Outcomes in Patients with Diabetes and Hypertension without a History of Cardiovascular Disease

Background: The prognostic value of diastolic dysfunction estimates in clinical settings is not well established. We aimed to evaluate the impact of the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging recommendations on estimates of diastolic dysfunction and predicting cardiovascular outcomes in patients with diabetes and hypertension. Methods: In total, 111 patients with diabetes and hypertension without a known history of cardiovascular diseases were enrolled. All patients had preserved left ventricular ejection fraction on echocardiography at screening. Echocardiography was performed at baseline. The 2009 and 2016 algorithms were applied in diastolic function assessment. All patients were followed up for 1 year to assess clinical outcomes. Results: There were 65 (58.6%) female patients. The mean age was 59.86 ± 7.45 years, and the mean duration of diabetes was 10.5 ± 5.41 years. Fifty-five (50.5%) patients had left ventricular hypertrophy on echocardiography. The prevalence of diastolic dysfunction was lower and that of indeterminate diastolic function was higher with 2016 recommendations. Concordance between 2016 and 2009 recommendations was poor with a reclassification rate of 41.4%. No patients diagnosed with indeterminate and normal diastolic function using the 2016 algorithm and diastolic dysfunction using the 2009 algorithm developed major adverse cardiac events at 1 year. Two of 11 patients diagnosed with diastolic dysfunction using both recommendations and two of five patients diagnosed with diastolic dysfunction and indeterminate diastolic function using 2016 and 2009 recommendations, respectively, developed major adverse cardiac events at 1 year. The 2016 algorithm showed better accuracy in predicting major adverse cardiac events at 1 year. Conclusion: The updated 2016 criteria detect more advanced diastolic dysfunction cases and predict 1-year cardiovascular outcomes. Further studies are warranted to investigate the prognostic impact of these criteria. Trial registration number: NMRR-16-436-29619.