Global Longitudinal Left Ventricular Research Articles

Evolution and prognostic impact of left ventricular myocardial work indices after transcatheter aortic valve replacement in patients with severe aortic stenosis

Abstract Introduction Left ventricular myocardial work (LVMW) is an echocardiographic-based technique to evaluate LV function using pressure-strain loops and therefore correcting for the left ventricular (LV) afterload. LVMW indices have been shown to be of prognostic importance in patients with aortic stenosis (AS) before transcatheter aortic valve replacement (TAVR), but no data is available on the evolution and the prognostic value of these parameters after TAVR. Purpose To measure LVMW indices before and after TAVR in patients with severe AS and explore the association with outcome. Methods As previously validated, LV global longitudinal strain (GLS) and LV systolic pressure (as the sum of the brachial arterial blood pressure and mean aortic valve gradient before TAVR and as brachial arterial blood pressure after TAVR) were incorporated to build pressure-strain loops and to calculate the following LVMW indices: global work index (LV GWI), global constructive work (LV GCW), global wasted work (LV GWW) and global work efficiency (LV GWE). The endpoint was all-cause mortality. Results A total of 255 patients were included with a median age of 82 years (IQR 77-85); 51% were men and 67% presented with NYHA class III/IV. After TAVR, LVEF and LV GLS remained in average unchanged (from 56 to 55%, p=0.470 and from 13.6 to 13.2%, p=0.068). While LV GWW remained unchanged after TAVR (from 247 to 258mmHg%, p=0.080), LV GWI, LV GCW and LV GWE significantly decreased (from 1882 to 1291mmHg%, p <0.001, from 2248 to 1671mmHg%, p <0.001 and from 89 to 85%, p <0.001 respectively). During a median follow-up of 59 months (IQR 40-72), 129 patients died. Univariable Cox regression analysis identified an association between all-cause mortality and male sex, diabetes mellitus, chronic obstructive pulmonary disease (COPD), renal function, atrial fibrillation, Charlson comorbidity index, pacemaker implantation, and post-TAVR LV GLS, LV GWI and LV GCW. These clinical parameters were used as a basal multivariable Cox regression model of which on top either post-TAVR LV GLS, LV GWI or LV GCW were added. All these parameters of post-TAVR LV systolic function showed an independent association with all-cause mortality, but LV GWI demonstrated the highest increase in model predictivity (Figure 1). Given the prognostic relevance of post-TAVR LV GWI, the population was divided into LV GWI tertiles. The group with the lowest LV GWI tertile showed a significantly higher proportion of male patients, higher prevalence of atrial fibrillation and also worse pre-TAVR LVEF, LV GLS, LV GWI, LV GCW and LV GWE. Kaplan Meier survival analysis confirmed the worse survival in the group with the lowest LV GWI compared to the highest tertile (log-rank ꭓ2: 8,224, p 0.016, Figure 2). Conclusion LVMW indices change after TAVR and post-TAVR LV GLS, LV GWI, LV GCW are independently associated with all-cause mortality. Among these parameters, LV GWI yielded the highest prognostic value.

Assessment of Biventricular Systolic and Diastolic Function Using Conventional and Strain Echocardiography in Children with Sickle Cell Disease Surviving 1-year After Hematopoietic Stem Cell Transplant.

Hematopoietic stem cell transplant (HSCT) is a potentially curative therapy for children with sickle cell disease (SCD). The effects of HSCT on ventricular function are not well characterized in children with SCD. Echocardiograms from children with SCD who underwent HSCT between 2007 and 2017 were retrospectively analyzed before and 1-year after HSCT. Left ventricular (LV) volumes, mass, and ejection fraction were calculated by the 5/6 area*length method. LV end-diastolic and systolic dimensions, septal, and posterior wall thickness, and fractional shortening were measured by M-mode. Mitral and tricuspid inflow Dopplers (E and A waves) as well as mitral, tricuspid, and septal tissue Dopplers (E', A') were assessed. E/A, E'/A' and E/E' ratios were calculated. Biventricular strain imaging was performed using speckle-tracking echocardiography. Peak global systolic longitudinal and circumferential LV strain, and global longitudinal right ventricular strain, as well as early and late diastolic strain rate, were measured on LV apical 4-chamber, LV short-axis mid-papillary, and RV apical views, respectively. Forty-seven children (9.7 ± 5.5years, 60% male) met inclusion criteria. Pre-HSCT, subjects had mild LV dilation with normal LV systolic function by conventional measure of ejection fraction and fractional shortening. There was a significant reduction in LV volume, mass, and ejection fraction after HSCT, but measurements remained within normal range. LV longitudinal and circumferential strain were normal pre-HSCT and showed no significant change post-HSCT. RV strain decreased after HSCT, but the absolute change was small, and mean values were normal both pre- and post-HSCT. Conventional measures of diastolic function were all normal pre-HSCT. Post-HSCT there was a reduction in select parameters, but all parameters remained within normal range. Early and late diastolic strain rate parameters showed no significant change from pre- to post-HSCT. At one-year after HSCT in children with SCD conventional measures of systolic and diastolic function are within normal limits. Except for a small decrease in RV systolic strain with values remaining within normal limits, systolic strain and diastolic strain rate values did not significantly change 1-year after HSCT.

Influence of mitral transcatheter edge-to-edge repair in patients with severe mitral regurgitation on left ventricle function

Aim. To study the changes of left ventricular (LV) contractile function in patients with severe mitral valve (MV) insufficiency with assessment of global longitudinal strain (GLS) indicators and LV myocardial function after the mitral transcatheter edge-to-edge repair (TEER) within 12-month follow-up.Material and methods. The study consisted of 43 patients with severe mitral regurgitation (MR) as follows: 23 patients with functional MR (FMR), 20 patients with degenerative MR (DMR). A comprehensive echocardiographic study, including speckle tracking echocardiography, was performed at baseline, 4-5 days, 6 and 12 months after TEER. Standard structural and functional indicators of the LV, LV GLS and myocardial performance parameters were assessed.Results. The early postoperative period (4-5 days) was characterized by a decrease in global constructive work (GCW) (FMR group — from 977 [684; 1253] to 857 [736; 1488] mm Hg%, (p=0,038); DMR group — from 1458 [1283; 1848] to 1350 [1010; 1488] mm Hg% (p=0,011)), an increase in global wasted work (GWW) (FMR group — from 177 [130; 280] to 336 [242; 388] mm Hg% (p=0,004); DMR group — from 128 [81; 172] to 216 [164; 279] mm Hg% (p=0,043)), which was accompanied by a decrease in myocardial efficiency (FMR group — from 81,5 [77; 87] to 76 [73; 79]%, (p=0,021); DMR group — from 90 [85; 93] to 82 [79; 85]% (p=0,018)). After 12-month follow-up, there was a significant increase in GCW relative to the initial values in both cohorts of patients as follows: FMR group — to 1128 [890; 1711] mm Hg% (p=0,048); DMR group — to 1818 [1478; 2034] mm Hg% (p<0,001). There was also an increase in GWW in the FMR group to 255 [214; 363] mm Hg% (p=0,024) and in the DMR group to 230 [140; 270] mm Hg% (p=0,043). There were no significant improvement of LV GLS in both groups.Conclusion. The early postoperative period after TEER was characterized by a temporary deterioration in all LV performance parameters, which recovered by 6 and 12 months of follow-up. Myocardial function restoration by one year of follow-up was noted due to an increase in GCW. LV GLS and ejection fraction did not change significantly by 1 year of follow-up compared to baseline values.

Cardiac Mechanics and Valvular and Vascular Abnormalities in Hypereosinophilic Syndrome.

Hypereosinophilic syndrome (HES) is considered to be a rare myeloproliferative disease that is characterized by persistent eosinophilia with associated multiple-organ damage. The heart is often involved in HES, representing a major cause of morbidity and mortality. HES is a heterogeneous group of disorders; the majority of the cases are idiopathic. Summarizing the findings regarding myocardial, valvular, and vascular abnormalities in a series of patients with HES, most studies found normal left ventricular (LV) volumes with reduced LV global longitudinal strain and LV apical rotation and twist in HES cases, accompanied by increased left atrial (LA) volumes and stroke volumes, reduced peak LA circumferential strain (representing systolic abnormalities), and mitral annular dilation and functional deterioration. Regarding the right heart, preserved right ventricular volumes and functional properties, increased right atrial volumes, mild RA functional abnormalities, and dilated tricuspid annular dimensions without functional impairment could be seen in these studies. Aortic and pulmonary valves showed no specific disease-related alterations. Vascular abnormalities included increased aortic stiffness without dilation of the aorta and pulmonary hypertension in some cases. These results suggest disease-specific but relatively mild myocardial, valvular, and vascular abnormalities in HES. The present review aimed to summarize the available clinical data about cardiac mechanics and valvular and vascular abnormalities in a series of patients with HES.

Impact of interstitial lung disease on left ventricular myocardial function.

Interstitial lung disease (ILD) comprises a wide variety of pulmonary parenchymal disorders within which progressive fibrosing ILD (PF-ILD) constitutes a phenotypic subset. By use of speckle tracking-based strain analysis we aimed to evaluate the degree of left ventricular (LV) dysfunction in progressive vs. non-progressive fibrosing ILD (non-PF-ILD). A total of 99 ILD patients (mean age 63.7 ± 13.5 years, 37.4% female), composed of 50 PF-ILD and 49 non-PF-ILD patients, and 33 controls were prospectively enrolled and underwent conventional and speckle tracking echocardiography. Additional laboratory and pulmonary function testing, as well as six-minute walk test were performed. As compared to the non-PF-ILD cohort, PF-ILD patients exhibited a significantly impaired forced vital capacity (2.4 ± 1.0l vs. 3.1 ± 0.9l, p = 0.002), diffusion capacity for carbon monoxide (DLCO, 25.6 ± 16.3% predicted vs. 43.6 ± 16.67% predicted, p <0.001) and exercise capacity response as measured by the six-minute walk test distance (268.1 ± 178.2m vs. 432.6 ± 94.2m, p <0.001). Contrary to conventional echocardiographic LV parameters, both regional and global longitudinal LV strain measurements were significantly altered in ILD patients as compared to controls. No differences in LV strain were found between both patient groups. Significant correlations were observed between global longitudinal strain, on the one hand, and systemic inflammation markers, total lung capacity (TLC) and DLCO, on the other hand (high-sensitivity C-reactive protein: Pearson´s r = -0.30, p< 0.001; interleukin-6: Pearson´s r = -0.26, p = 0.007; TLC % predicted: Pearson´s r = 0.22, p = 0.02; DLCO % predicted: Pearson´s r = 0.21, p = 0.02). ILD is accompanied by LV dysfunction. LV functionality inversely correlates with the severity of the restrictive ventilatory defect and inflammation marker levels. These observations support the assumption of persistent low-grade systemic inflammation that may link systemic cardiovascular function to ILD status.

Diagnostic capabilities of instrumental methods for studying early cardiovascular adverse events in patients with lymphoproliferative disorders, quality and safety issues

Aim. To study the possibilities of instrumental research methods in relation to the earliest detection of cardiovascular events in oncohematological patients receiving antitumor immunochemotherapy, as well as to deter­mine the requirements for documenting adverse events.Material and methods. For the study, 63 patients were prospectively selected with a diagnosis of indolent non-Hodgkin lymphoma, who were indicated for antitumor immunochemotherapy. The patients were examined in three stages (before treatment, after 3 and 6 cycles of therapy) and divided into 2 groups by simple randomization. Cardiovascular toxicity in the main group of patients was assessed using 3D transthoracic echocardiography, analysis of left ventricular (LV) global longitudinal systolic strain and electrocardiography. The control group underwent a standard 3D echocardiography with analysis of LV ejection fraction. Clinical manifestations of cardiovascular events were assessed in all patients during treatment.Results. According to the study, significant changes were obtained in LV ejection fraction on the third visit — a decrease from 58,9±1,07 to 48,1±0,73% (p&lt;0,05) and from 57,7±1,13 to 49,4±0,58% (p&lt;0,05) in patients of the main and control groups and global longitudinal LV strain from |21,1±1,18 to |14,0±1,61 |% (p&lt;0,05) in patients of the main group. A mixed clinical phenotype of cardiovascular toxicity was the most common among all patients. An integrated approach to the early diagnosis of cardiovascular events makes it possible to identify a larger percentage of patients with subclinical myocardial dysfunction.Conclusion. The long period of latent cardiovascular toxicity emphasizes the need for early verification of cardiovascular complications of antitumor therapy and expansion of the established paraclinical diagnostic minimum. In addition, taking into account the accumulated experience, recommendations are presented for the preparation of medical documentation in order to ensure the safety and quality of care.

Prognostic impact of left ventricular systolic dysfunction in patients with mixed aortic valve disease undergoing aortic valve replacement.

The implications of left ventricular remodeling and dysfunction before and after aortic valve replacement (AVR) for mixed aortic valve disease (MAVD) are not well understood. This study aims to evaluate the impact of AVR on left ventricular (LV) systolic function in MAVD, and determine the prognostic value of postoperative LV global longitudinal strain (LV-GLS) and LV ejection fraction (LVEF). We retrospectively assessed 489 consecutive patients with MAVD (defined as at least moderate aortic stenosis and at least moderate aortic regurgitation) and baseline LVEF ≥50%, who underwent AVR between February 2003 and August 2018. All patients had baseline echocardiography, whereas 192 patients underwent postoperative echocardiography between 3 and 18 months after AVR. The primary endpoint was all-cause mortality. Mean age was 65±15 years, and 65% were male. AVR in MAVD patients has a neutral effect on LV systolic function quantitated by LVEF and LV-GLS. During a median follow-up period of 5.8 years, 65 patients (34%) of 192 patients with follow-up echocardiography died. The patients with postoperative LVEF ≥50% had better survival than those with postoperative LVEF<50% (P<.001). Furthermore, among patients with postoperative LVEF ≥50%, mortality differed between patients with postoperative LV-GLS worse than -15% and those with postoperative LV-GLS better than -15% (P<.001). In patients with MAVD who underwent AVR, the mean postoperative LV-GLS and LVEF remain at a similar value to baseline. However, worse postoperative LV-GLS and LVEF were both independently associated with higher mortality in this population.

Abstract 15539: Echocardiographic Predictors of Early Myocardial Dysfunction in Duchenne Muscular Dystrophy

Introduction: Cardiomyopathy, a well described complication of Duchenne Muscular Dystrophy (DMD), typically presents in adolescence or early adulthood. Transthoracic echocardiography (TTE) is a widely utilized and cost-effective tool to diagnose and monitor its progression. To our knowledge, there is no standardized, echocardiography-based risk stratification to predict progression to DMD cardiomyopathy. We aim to identify markers associated with eventual left ventricular (LV) dysfunction in patients with DMD cardiomyopathy, while they still demonstrate preserved normal LV ejection fraction (LVEF). Methods: We reviewed TTEs of patients with DMD from a single institution and identified their first instance of reduced LVEF (&lt;55%), as well as two preceding TTEs occurring 6-24 months prior. At each time point, we assessed LVEF, LV diastolic parameters, LV global longitudinal strain (LVGLS), LV and atrial volumes. We compared these parameters to 26 age-matched control DMD patients without evidence of LV dysfunction. Results: We identified 28 pediatric DMD patients with LVEF &lt;55%. At each time point preceding reduced LVEF, the average LVGLS and average LVEF were lower, compared to controls. Study patients also demonstrated increased LV end systolic volume, and diminished LVEF and LVGLS over the course of the 3 time points (p&lt;0.05 for all). Logistical regression showed EF and LVGLS one year prior were independently associated with ventricular dysfunction (p = 0.029 and 0.028); age did not correspond with diminished EF. Conclusions: Patients with DMD demonstrate reduced LVGLS, as well as sequentially increasing LV systolic volume and decreasing LVEF prior to the onset of LVEF &lt;55%. These findings suggest a decline in myocardial mechanics &gt;1 year prior to a diagnosis of DMD cardiomyopathy. Recognizing changes in LV strain and volumes while patients are still in a compensated state of cardiac output, may lead to earlier detection of subclinical LV dysfunction.

The role of cardiac magnetic resonance-based feature-tracking strain analysis in the differential diagnosis and prognostic assessment of patients with left ventricular hypertrophy

Abstract Background Cardiac magnetic resonance (CMR) examinations have an essential role in the diagnosis of myocardial diseases with left ventricular (LV) hypertrophy; however, limited data are available from CMR-based feature-tracking strain analysis in this patient population. The aim of our study was to investigate the differential diagnostic and prognostic importance of feature-tracking strain analysis in patients with LV hypertrophy caused by myocardial disease. Methods We investigated 404 patients who underwent CMR examination and were diagnosed with myocardial disease causing LV hypertrophy. Hypertrophic cardiomyopathy (HCM) was detected in 330 patients, cardiac amyloidosis (CA) in 46 patients, Fabry disease (FD) in 12 patients, and endomyocardial fibrosis (EMF) in 16 patients. LV strain analysis was performed with feature-tracking. Global longitudinal (GLS), circumferential (GCS) and radial (GRS) LV strain parameters were measured. Strain values for the six basal, six midventricular, and five apical segments were averaged to obtain regional longitudinal and circumferential strain values (basal LS, midventricular LS, apical LS, basal CS, midventricular CS, apical CS). The apex-to-base regional LS and CS ratios were calculated as apical LS/basal LS and apical CS/basal CS, respectively. To assess global dyssynchrony, mechanical dispersion (MD) was measured. The all-cause mortality of the patients was analyzed. Results In the differentiation of CA from HCM, GLS had the highest sensitivity with a cutoff of more than −23%, and basal LS and basal CS had the highest specificity with a cutoff of more than −16% and −38%, respectively (p&amp;lt;0.001). FD patients had the lowest longitudinal and circumferential MD values, meaning that compared to that of other patients with LV hypertrophy, global dyssynchrony is least pronounced in this patient population (p&amp;lt;0.01). EMF patients had impaired global and regional CS and the lowest apex-to-base CS and LS ratios. CA patients had the highest apex-to-base CS and LS ratios, suggestive of apical sparing (p&amp;lt;0.001). CA patients had the worst prognosis; the significant independent predictors of mortality were a diagnosis of CA, the LV stroke volume index and basal LS (p&amp;lt;0.01). Conclusions Myocardial diseases with left ventricular hypertrophy have remarkable differences in CMR-based strain characteristics which can be helpful in the differential diagnosis and provides incremental information on adverse outcomes. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Development and Innovation Fund of Hungary, Ministry for Innovation and Technology in Hungary

Global and regional left ventricular deformation evaluation with feature tracking in transthyretin cardiac amyloidosis. Comparison with echocardiographic findings

Abstract Background Diagnosis of cardiac amyloidosis (CA) is basically based on imaging techniques. Transthoracic echocardiography (TTE) is crucial to raise suspicion of this disease through detection of the classical features. An specific left ventricular (LV) deformation pattern with apical sparing (“cherry on top”) has been described on speckle tracking (ST) TTE. However, there is no data regarding the role of the LV global and regional analysis with the new tool feature tracking (FT) of cardiac magnetic resonance (CMR) in CA. Purpose Our aim is to analyze the concordance of LV deformation between ST-TTE and FT-CMR. Methods Consecutive patients with definitive diagnosis of transthyretin (TTR) CA, based on DPD scintigraphy, and imaging evaluation with TTE and CMR were retrospectively included. LV volumes and ejection were calculated from both TTE and CMR following the ongoing recommendations. Global and segmental longitudinal strain values were obtained from apical 2-, 3- and 4-chambers projections on TTE, while the same parameters were calculated on the same cine views of CMR using a dedicated software of FT analysis. Student t-test was used to compared mean measurements derived from both imaging techniques. Apical index was calculated as the ratio between apical and basal-mid longitudinal values. Moreover, agreement was established using Passing-Bablok regression analysis. Results 27 patients (80 years-old, 88% men) with definitive diagnosis of TTR CA from our tertiary hospital were included. Regarding echocardiographic findings, 80% showed concentric LV hypertrophy with low normal ejection fraction in the majority (52±10%). When longitudinal LV strain parameters were compared (Table 1), no differences were noted in global and apical values whereas basal and mid measurements were higher from CRM resulting in different apical indexes. Although 42% showed a typical “cherry on top” pattern in ST analysis, in only 18% of the FT apical sparing was detected. Consistently, decremental pattern was observed in 60% of TTE and in 20% of CMR. Concordance analysis with Passing-Bablok showed no constant or proportional differences, meaning both techniques were comparable. Conclusions Among patients with TTR CA there were no differences in global longitudinal LV strain analysis between ST-TTE and FT-CMR. Nevertheless, discordance in regional parameters resulted in a less frequent detection of apical sparing in CMR. Funding Acknowledgement Type of funding sources: None.

Premature Ventricular Contractions Are Presaged by a Mechanically Abnormal Sinus Beat.

Frequent premature ventricular contractions (PVCs) can lead to cardiomyopathy; it is unclear if there are abnormal myocardial mechanics operative in the PVC and non-PVC beats. The aim of this study was to investigate regional and global myocardial mechanics, including dyssynchrony, in patients with frequent PVCs. Fifty-six consecutive patients referred for PVC ablation were prospectively studied. During sinus rhythm (SR) and PVC beats, left ventricular (LV) global longitudinal strain (GLS), LV dyssynchrony (measured as the SD of time to peak GLS), and dyssynergy (measured as maximum regional strain minus minimum regional strain at aortic valve closure) were quantified using 2-dimensional strain echocardiography. GLS, dyssynchrony, and dyssynergy were compared in remote SR, pre-PVC SR, PVC, and post-PVC SR beats. In SR beats remote from the PVC, GLS was-17.3% ± 4%, dyssynchrony was 49 ± 14ms, and dyssynergy was22% ± 9%. Myocardial mechanics were significantly abnormal during PVCs compared with remote SR beats (GLS-7.7% ± 3% [P< 0.001], dyssynchrony 115 ± 37 milliseconds [P< 0.001], and dyssynergy 26% ± 10% [P<0.001]). There were significant mechanical abnormalities in the SR beat preceding the PVC, which demonstrated significantly lower LV strain (pre-PVC SR,-13% ± 4%; P< 0.001) and more dyssynchrony (pre-PVC SR, 63 ± 19 milliseconds; P< 0.001) compared with remote SR beats. Dyssynergy was significantly higher for pre-PVC SR and PVC beats compared with remote SR (pre-PVC SR, 25% ± 8% [P< 0.001]; PVC, 26% ± 10% [P< 0.001]). In patients with frequent PVCs, the SR beat preceding the PVC demonstrates significant mechanical abnormalities. This finding suggests that perturbations in cellular physiological processes such as excitation-contraction coupling may underlie the generation of frequent PVCs.

Features of left ventricular myocardial deformation in female patients of reproductive age with connective tissue dysplasia

Features of longitudinal left ventricular (LV) myocardial deformation in female patients of reproductive age with undifferentiated connective tissue dysplasia (UCTD) have not been specifically studied before.Aim. To study the features of longitudinal LV myocardial deformation using speckle tracking echocardiography in female patients of reproductive age with UCTD.Material and Methods. A noninvasive assessment of systolic LV myocardial deformation in the longitudinal direction using echocardiography was performed in 20 young adult female patients with UCTD (the average age was 23.5 ± 2.6 years). A control group composed of 34 apparently healthy women of comparable age (the average age was 24.8 ± 2.4 years) with no signs of UCTD were examined.Results. The indices of longitudinal systolic myocardial deformation in female patients with UCTD practically did not differ from the control group. Significant differences were found only for the median segment: excessive shortening of the interventricular septum and a decrease in deformation in the lateral wall of the left ventricle. Segments 8–10 (mid anteroseptal, mid inferolateral, and mid inferior) and all apical LV segments (13–17: apical anterior, apical septal, apical inferior, and apical lateral) were subjected to maximum deformation, p &lt; 0.05.Conclusions. In patients of reproductive age with UCTD, a significant decrease in global longitudinal systolic LV deformity was recorded in the basal segment of the interventricular septum and the apical segment of the anterior LV wall. Segments 8–10 (median anterior-septum, median inferior-septum, and lower) and all apical LV segments (13–17: apical anterior, apical septum, apical lower, and apical lateral) were subjected to the greatest deformation in the examined patients.

PO-700-04 PREDICTING RISK OF SUDDEN CARDIAC DEATH BY ARRHYTHMIA IN HYPERTROPHIC CARDIOMYOPATHY PATIENTS BY APPLYING MACHINE LEARNING TO CARDIAC MAGNETIC RESONANCE IMAGES AND CLINICAL COVARIATES

Hypertrophic cardiomyopathy (HCM) is a leading cause of sudden cardiac death (SCD) by ventricular arrhythmia (VA) in young adults. Current clinical criteria outlined in AHA/ACC and ESC guidelines fail to accurately identify HCM patients at risk for SCD. Mechanistically, myocardial fibrosis, a hallmark of HCM, creates substrates for VA. However, few studies have explored whether features of myocardial fibrosis visualized on late gadolinium enhanced cardiac magnetic resonance imaging (LGE-CMR) can be used, in combination with other clinical data, to forecast VA in a large cohort of HCM patients. This study aims to predict risk of VA in HCM patients by applying machine learning (ML) to LGE-CMR images and clinical covariates. In a single-center retrospective study, LGE-CMR images and clinical covariates were acquired from 819 patients with HCM to develop an algorithm for VA (tachycardia or fibrillation) risk prediction. The left ventricular (LV) myocardium was automatically segmented from LGE-CMR images by a pre-validated deep learning model which preserves the shape of the LV with anatomical fidelity. Multiple features quantifying fibrosis burden were calculated using various standard thresholding techniques. These were fed, together with most discriminative clinical covariates selected in a univariate analysis with outcome, into a tree-based ensemble learning model to identify patients who experienced VA. In the univariate analysis, 9 numerical covariates exhibited significant (p<0.05) discrimination of the outcome in Mann-Whitney U test. The top 3 covariates were maximum interventricular septal thickness, LV global longitudinal systolic strain and LV outflow tract stress. The model incorporating LGE-CMR-derived information and clinical covariates identified HCM patients with VA with area under the ROC curve (AUC) of 0.69 and 0.72, respectively, in a 5-fold cross validation (n=570) and a held-out test (n=143). As a comparison, a model we developed using only demographic covariates and major risk factors outlined in AHA/ACC guidelines had AUC of 0.63 and 0.60.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Our ML algorithm offers improved and generalizable prediction of VA in HCM patients compared with current clinical guidelines. It could be used to identify HCM patients at high risk for SCD.

The effect of left ventricular longitudinal strain on left atrial function and ventricular filling in hypertension

To assess the relationship of global longitudinal strain during left atrial (LA) and left ventricular (LV) filling and emptying. Using magnetic resonance imaging in 47 hypertensive patients, biplane global LV longitudinal strain was evaluated and related to LA and LV filling and emptying (by volumetric analysis), and to pulmonary vein and trans-mitral flow (by phase-contrast imaging). The results were compared to normal subjects. In hypertensive patients, reduced global longitudinal LV strain was associated with reduced LA reservoir (47±10 versus 53±9%, p<0.05), reduced LA conduit function (21±9 versus 32±11%, p<0.004), reduced LA early peak emptying rate (150±77 versus 230±88 ml/s, p=0.007), and slower early LV filling (373±141 versus 478±141 ml/s, p=0.03). LA peak filling rate showed a positive correlation to LV peak emptying rate (R=0.331, p=0.02). In hypertensive heart disease, impaired LV longitudinal systolic function causes reduced LA filling and emptying, and this leads directly to impaired LV filling and diastolic dysfunction.

Echocardiographic study of myocardial work in patients with type 2 diabetes mellitus

BackgroundA noninvasive left ventricular (LV) pressure-strain loop (PSL) provides a new method to quantify myocardial work (MW) by combining global longitudinal strain (GLS) and LV pressure, which exerts potential advantages over traditional GLS. We studied the LV PSL and MW in patients with type 2 diabetes mellitus (T2DM).MethodsThis cross-sectional study included 201 subjects (54 healthy controls and 147 T2DM patients) who underwent complete two-dimensional echocardiography (2DE), including 2D speckle-tracking echocardiography (STE), as well as brachial artery pulse pressure measurement. The PSL was used to determine the global myocardial work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) of all study participants. The association between T2DM and LV function was evaluated according to these MW indices.ResultsThe GLS was significantly lower in the T2DM group than in the control group (P < 0.001), indicating that the LV myocardium had been damaged, although the LV ejection fraction (LVEF) was still normal. The GWI and GWE were decreased (P = 0.022) and the GWW was increased (P < 0.001) in diabetic patients compared with controls, but the GCW was comparable in the two groups (P = 0.160). In all diabetic patients, age, body mass index, systolic blood pressure, smoking history, and LVEF were correlated with GWI, GWW and GWE.ConclusionsThe use of LV PSL is a novel noninvasive technique that could help to depict the relationship between LV myocardial damage and MW in patients with T2DM.

Echocardiographic predictors of ventricular arrhythmias in patients with non-ischemic cardiomyopathy.

ObjectiveVentricular arrhythmias (VA) portend a poor prognosis in non-ischemic cardiomyopathy (NICM). In this meta-analysis we evaluated if left ventricular (LV) global longitudinal strain (GLS) and LV mechanical dispersion (LVMD) are associated with VA, specifically in NICM patients.MethodsA systematic review and meta-analysis was performed to determine the predictive value of LV GLS and LVMD for VA in NICM patients. VA endpoints were a composite of sudden cardiac death, VA events (including ventricular tachycardia or ventricular fibrillation), cardiac arrest and appropriate implantable cardioverter-defibrillator (ICD) therapy. Hazard or odds ratios for univariate models were extracted for the relationship between LV GLS and LVMD with VA endpoints.ResultsA total of 984 patients from 6 published studies were included; 231 patients (23.5%) experienced the composite endpoint. NICM patients who experienced VA endpoints had LV GLS impairment compared to those without (weighted mean difference −1.93%; 95% confidence interval (CI) −2.77 to −1.10; p < 0.001) and LV GLS was related to VA endpoints (hazard ratio: 1.12, 95% CI 1.07–1.17, p < 0.001; odds ratio: 1.22, 95% CI 1.08–1.38, p = 0.002). Four studies reported mean LVMD (weighted mean −10.05 ms; 95% CI −28.25 to 8.14; p = 0.28), with 3 reporting risk ratios (1 reported odds ratio and 2 hazard ratios). Only odds ratio demonstrated statistical significance (hazard ratio: 0.47, 95% CI 0.01–22.25, p = 0.70; odds ratio: 1.59, 95% CI 1.14–2.22, p = 0.007).ConclusionLV GLS impairment demonstrates value for predicting VA endpoints in NICM patients. Inclusion of LV GLS may be appropriate in the surveillance, screening, and clinical management of NICM patients.

Comparison of clinical and echocardiographic parameters of patients with COVID-19 pneumonia three months and one year after discharge.

Aim To study changes in clinical and echocardiographic parameters in patients after documented COVID-19 pneumonia at 3 months and one year following discharge from the hospital.Material and methods The study included 116 patients who have had documented COVID-19 pneumonia. Patients underwent a comprehensive clinical evaluation at 3 months ± 2 weeks (visit 1) and at one year ± 3 weeks after discharge from the hospital (visit 2). Mean age of the patients was 49.0±14.4 years (from 19 to 84 years); 49.6 % were women. Parameters of global and segmentary longitudinal left ventricular (LV) myocardial strain were studied with the optimal quality of visualization during visit 1 in 99 patients and during visit 2 in 80 patients.Results During the follow-up period, the incidence rate of cardiovascular diseases (CVD) increased primarily due to development of arterial hypertension (AH) (58.6 vs. 64.7 %, р=0.039) and chronic heart failure (CHF) (35.3% vs. 40.5 %, р=0.031). Echocardiography (EchoCG) showed decreases in values of end-diastolic dimension and volume, LV end-systolic and stroke volumes (25.1±2.6 vs. 24.5±2.2 mm /m2, p&lt;0.001; 49.3±11.3 vs. 46.9±9.9 ml /m2, p=0.008; 16.0±5.6 vs. 14.4±4.1 ml /m2, p=0.001; 36.7±12.8 vs. 30.8±8.1 ml /m2, p&lt;0.001, respectively). LV external short-axis area (37.1 [36.6-42.0] vs. 38.7 [35.2-43.1] cm2, р=0.001) and LV myocardial mass index calculated with the area-length formula (70.0 [60.8-84.0] vs. 75.4 [68.2-84.9] g /m², р=0.024) increased. LV early diastolic filling velocity (76.7±17.9 vs. 72.3±16.0 cm /sec, р=0.001) and lateral and septal early diastolic mitral annular velocities decreased (12,10±3,9 vs. 11.5±4.1 cm /sec, р=0.004 and 9.9±3.3 vs. 8.6±3.0 cm /sec, р&lt;0.001, respectively). The following parameters of LV global longitudinal (-20.3±2.2 vs. -19.4±2.7 %, р=0.001) and segmental strain were impaired: apical segments (anterior, from -22.3±5.0 to -20.8±5.2 %, р=0.006; inferior, from -24.6±4.9 to -22.7±4.6, р=0.003; lateral, from -22.7±4.5 to -20.4±4.8 %, р&lt;0.001; septal, from -25.3±4.2 to -23.1±4.4 %, р&lt;0.001; apical, from -23.7±4.1 to -21.8±4.1 %, р&lt;0.001), mid-cavity (anteroseptal, from -21.1±3.3 to -20.4±4.1 %, р=0.039; inferior, from -21.0±2.7 to -20.0±2.9 %, р=0.039; lateral, from -18.4±3.7 to -17.6±4.4 %, р=0.021). RV basal and mid-cavity sphericity indexes increased (0.44±0.07 vs. 0.49±0.07 and 0.37±0.07 vs. 0.41±0.07, respectively, р&lt;0.001 for both). A tendency for increased calculated pulmonary arterial systolic pressure (22.5±7.1 and 23.3±6.3 mm Hg, р=0.076) was observed. Right ventricular outflow tract velocity integral decreased (18.1±4.0 vs. 16.4±3.7 cm, р&lt;0.001).Conclusion Patients after COVID-19 pneumonia one year after discharge from the hospital, compared to the follow-up data 3 months after the discharge, had an increased incidence of CVD, primarily due to the development of AH and CHF. EchoCG revealed changes in ventricular geometry associated with impairment of LV diastolic and systolic function evident as decreases in LV global longitudinal strain and LV myocardial apical and partially mid-cavity strain.

Reference Ranges of Left Ventricular Hemodynamic Forces in Healthy Adults: A Speckle-Tracking Echocardiographic Study.

Background: The normal limits of left ventricular (LV) hemodynamic forces (HDFs) are not exactly known. The aim of this study was to explore the full spectrum of HDF parameters in healthy subjects and determine their physiologic correlates. Methods: 269 healthy subjects were enrolled (mean age: 43 ± 14 years; 123 (45.7%) men). All participants underwent an echo-Doppler examination. Tri-plane tissue tracking from apical views was used to measure 2D global endocardial longitudinal strain (GLS), circumferential strain (GCS), and LV HDFs. HDFs were normalized with LV volume and divided by specific weight. Results: LV systolic longitudinal HDFs (%) were higher in men (20.8 ± 6.5 vs. 18.9 ± 5.6, p = 0.009; 22.0 ± 6.7 vs. 19.8 ± 5.6, p = 0.004, respectively). There was a significant correlation between GCS (increased) (r = −0.240, p < 0.001) and LV longitudinal HDFs (reduced) (r = −0.155, p = 0.01) with age. In a multivariable analysis age, BSA, pulse pressure, heart rate and GCS were the only independent variables associated with LV HDFs (β coefficient = −0.232, p < 0.001; 0.149, p = 0.003; 0.186, p < 0.001; 0.396, p < 0.001; −0.328, p < 0.001; respectively). Conclusion: We report on the physiologic range of LV HDFs. Knowledge of reference values of HDFs may prompt their implementation into clinical routine and allow a more comprehensive assessment of the LV function.

Type 1 and 2 matrix metalloproteinases, tissue inhibitor of metalloproteinases and left ventricular diastolic dysfunction in hypertensive patients

Abstract The purpose of the study. To assess the level of matrix metalloproteinases of types 1 and 2 (MMP1, MMP2), as well as tissue inhibitor of metalloproteinases (TIMP) in relation to indicators of left ventricular myocardial deformation in patients with essential hypertension, depending on the presence of left ventricular (LV) diastolic dysfunction (DD). Materials and methods 114 hypertensive patients (40 women and 74 men) were involved in the study. The average age of the patients was 42±8.3 years. The diagnosis was confirmed by a thorough clinical and instrumental examination. Patients had no CVD or renal disease. LV diastolic filling parameters were assessed according to ASE/EACVI criteria (2016). The indicators of myocardial deformation were studied as well. The level of MMP1, MMP2 and TIMP was assessed by the method of enzyme-linked immunosorbent assay. Statistical methods such as Cruskell-Walles criteria and Spearman's correlation coefficient were used. Results 1st group consisted of 66 patients with normal LV filling parameters, 2nd group was represented by 48 patients with LV DD, control group consisted of 35 healthy men and women, matching by age. The level of MMP1 in group 2 was increased by 112% compared with group 1 and by 117% compared with the control group (101.1±10.4, 47.7±13.2 ng/ml and 46.6±26.1 ng/ml, respectively, p&amp;lt;0.01). In group 2 patients, there was an increased level of MMP2 by 107% compared with patients in group 1 and by 112% compared with the control group (2519.0±233.9 ng/ml, 1216.1±189.8 ng/ml and 1186, 9±64.0 ng/ml, respectively, p&amp;lt;0.01). The TIMP level was higher in hypertensive patients with LV DD: 2.3 times higher than in the group of patients without diastole disturbance, and 2.4 times higher than in the control group (158±24 ng/ml, 68.2±18.8 ng/ml and 66.3±14.0 ng/ml, respectively, p&amp;lt;0.05). Differences between groups 1 and controls were not found for any of the studied parameters. The study of global longitudinal myocardial deformation (Avg) depending on the presence of LV DD showed that in the 2nd group patients this indicator was 22.8% lower than in 1st group patients (p&amp;lt;0.05). Compared with healthy people in groups 1 and 2, there was a decrease in Avg by 23.3% and 40.7%, respectively (p&amp;lt;0.05). The analysis revealed a moderate negative correlation between the global longitudinal LV deformity and the level of MMP2 (r=−0.64, p&amp;lt;0.05). Conclusion Thus, in hypertensive patients with LV DD, an increase in the level of MMP1, MMP2, and TIMP interrelated with global myocardial deformation was revealed, which suggests the participation of these markers in the formation of impaired LV diastolic filling in hypertension. Funding Acknowledgement Type of funding sources: None.

Neurocardiac injury associated with the severity of motor involvement in pediatric patients with Guillain Barre Syndrome

BackgroundThe term neurogenic stunned myocardium has been used to summarize the myocardial abnormalities in the setting of nervous system injury. Over the past 10 years, numerous case reports have been documenting reversible neurologically stunned myocardium coinciding with clinical manifestations of Guillain Barre Syndrome (GBS). However, most case reports were performed in adult GBS patients, with no reports in the pediatric population. ObjectivesThe primary outcome of this paper was to prove or rule out myocardial dysfunction in GBS patients, while secondary outcomes were to correlate the observed dysfunction with the degree of motor disability using the motor function measure (MFM) score and with the degree of autonomic dysfunction in affected patients. MethodsForty patients with GBS were assessed for motor disability using the MFM. Left ventricular (LV) diastolic function was assessed using tissue Doppler imaging, while LV systolic function was assessed using 3D speckle tracking echocardiography (3D-STE). Forty healthy controls were recruited to benchmark the echocardiographic parameters. ResultsPatients' group showed elevated LV E/E' compared to control denoting LV diastolic dysfunction. The 3 D derived LV global longitudinal strain (GLS) and LV EF were significantly lower in cases indicating LV systolic dysfunction in the patients' group. MFM was significantly correlated to LV E/E′ (r = −0.51 p = 0.001), LV 3D EF (r = 0.38, p = 0.016) and 3D LVGLS (r 0.37, p = 0.02). Moreover, systolic and diastolic dysfunction was more evident in cases with autonomic dysfunction. ConclusionsPediatric patients with GBS could have subtle myocardial dysfunction that can be detected by non-conventional echocardiography. Myocardial involvement seems to be induced by autonomic dysfunction. Motor function was closely linked to myocardial involvement, and the severity of motor affection could be used as predictors for myocardial dysfunction in these patients.