Global Myocardial Constructive Work Research Articles

The relationships between non-invasive myocardial work indices, myocardial blood flow and viability determined by PET

Abstract Backgrounds Myocardial work (MW) indices are new echocardiography parameters of left ventricular (LV) performance that consider afterload and global longitudinal strain analysis. However, the relationships between MW indices, myocardial perfusion and viability remain unclear after acute myocardial infarction (AMI). Aims To evaluate relationships between echocardiographic MW indices, myocardial blood flow and viability based on positron emission tomography (PET) in patients with AMI. Methods Thirty prospectively recruited patients (64±9 years, 90% males) underwent PET scans 7.7±3.8 days after primary percutaneous coronary intervention (PCI) for ST-elevation AMI. Global and segmental absolute myocardial blood flow (MBF) and perfusable tissue fraction (PTF) at rest were assessed using 15O-water PET. Myocardial segments were graded as viable or non-viable using the previously defined PTF cut-off value of 0.69 per segment (reference). LV function was evaluated by transthoracic echocardiography on the day of the PET scan (baseline) and at 6 months follow-up. MW index (MWI), constructive MW (CMW), MW efficiency (MWE), and myocardial wasted work (MWW) were measured. The myocardial area at risk (AAR) is based on the culprit coronary arterial segment, determined from the invasive coronary angiography. Two segments remote from the AAR were considered as the remote area. Results At baseline, resting global MBF was 0.84±0.19 ml/g/min, global MWI 1327± 334.9 mm Hg %, global MWE 87% [IQR 83- 92], global CMW 1649.8±415.9 mm Hg %, and global MWW 210.9±133.7 mm Hg %. There was a positive correlation between global MBF and CMW (r=0.42, p=0.02), whereas MWI, MWE, and MWW were not correlated with MBF. However, none of the MW indices correlated with MBF corrected for rate pressure product. In the AAR, MWI and MWE correlated with regional MBF (r= 0.53, p= 0.003, and r= 0.59, p<0.001) and PTF (r= 0.41, p = 0.03, and r= 0.65, p<0.001. Figure 1). The average ejection fraction was similar at baseline and after 6 months (55.8±66.9 vs. 57.5±67.3 %, p=0.2). Of the 156 segments in the AAR, 114 were viable and 42 were non-viable based on based on PTF. There was no difference in MW indices between viable and non-viable segments in the AAR at baseline. However, viable segments in the AAR showed improved MWI, MWE, CMW, and MWW at 6 months compared to baseline (P<0.001, P=0.02, P<0.001, and P<0.001, respectively), whereas there was no change in non-viable segments (Table 1). Moreover, MWI in the remote area increased at 6-month follow-up (p <0.001). Conclusions Although echocardiographic MWE was not associated with global MBF, it correlated with residual myocardial blood flow and PTF in the AAR after reperfused AM. Furthermore, echocardiographic MW indices improved in viable segments of the AAR at the 6-month follow-up. Our results provide evidence that myocardial viability is an important determinant of MWE measured by echocardiography.

Normal Values for Echocardiographic Myocardial Work in a Large Pediatric Population.

Echocardiographic myocardial work is a new load-independent echocardiographic technique to quantify left ventricle (LV) systolic performance. Our aim was to establish normal values for echocardiographic myocardial work in a large population of healthy children. For all the subjects 4-, 2-, and 3-chamber-view videos were stored. The following parameters were obtained by offline analysis: the global myocardial work (GMW), the global myocardial constructive work (GCW), the global myocardial wasted work (GWW), and the global myocardial work efficiency (GWE). Age, weight, height, heart rate, and body surface area (BSA) were used as independent variables in the statistical analysis. In all, 516 healthy subjects (age range, 1 day-18 years; median age, 8.2 ± 5.3 years; 55.8% male; body surface area (BSA) range, 0.16 to 2.12 m2) were included. GWI, GCW, and GWW increased with weight, height, and BSA (ρ ranging from 0.635 to 0.226, p all < 0.01); GWI and GCW positively correlated with age (ρ 0.653 and 0.507). After adjusting for BSA differences, females showed higher mean GWI (p = 0.002) and GCW values (p < 0.001), thus Z-score equations for gender have been presented. We provided MW values in a large population of healthy pediatric subjects including lower ages. MW values increased with age and body size and, interestingly, were higher in females than in men. These data cover a gap in current nomograms and may serve as a baseline for the evaluation of MW analysis in children with congenital and acquired heart diseases.

The value of speckle-tracking stratified strain combined with myocardial work measurement in evaluating left ventricular function in patients with heart failure with preserved ejection fraction.

Heart failure with preserved ejection fraction (HFpEF) is a highly prevalent progressive disease accompanied by poor quality of life, high utilization of medical resources, morbidity, and mortality. However, the role of left ventricular (LV) systolic dysfunction has yet to be well elaborated despite the preservation of the LV ejection fraction. This study aimed to explore the diagnostic value of speckle-tracking stratified strain combined with myocardial work (MW) measurement in evaluating LV systolic dysfunction in patients with HFpEF. A total of 125 study consecutive individuals, 64 HFpEF patients, and 61 controls were prospectively enrolled in the Fourth Affiliated Hospital of Harbin Medical University. In addition to the conventional echocardiographic parameters, LV stratified strain and MW parameters were statistically compared between the HFpEF and control groups. The global longitudinal strain (GLS) of the subendocardium, myocardium, and subepicardium (GLSendo, GLSmyo, and GLSepi); the transmural gradient (ΔGLS); the global myocardial work index (GWI), global myocardial work efficiency (GWE), global myocardial constructive work (GCW), and the global myocardial wasted work (GWW) were included. Area under the receiver operating characteristic curve analysis was used to evaluate the diagnostic performance of these univariate and multivariable logistic models in detecting impaired LV systolic function in HFpEF. Ten-fold cross-validation was used to evaluate the generalizability of the predictive model. Stratified strains values showed a gradient decline from GLSendo to GLSepi in both control and HFpEF patients. Compared with the control group, HFpEF patients had a significantly reduced GLSepi, GLSmyo, GLSendo, ΔGLS, GWI, GWE, and GCW and a significantly increased GWW (all P<0.001). In the derivation set, the optimal logistic model (combined stratified strain and MW variables) demonstrated the highest performance in predicting LV systolic function impairment in HFpEF patients. The best-performing model with a mean area under the curve (AUC) of 0.966 [95% confidence interval (CI): 0.88 to 1] accessed by 10-fold cross-validation. In the validation set, the AUC of the optimal logistic model was 0.933 (95% CI: 0.85 to 1), the sensitivity was 87%, and the specificity was 93%. Both speck-tracking stratified strain and MW measurement may sensitively detect impairment of LV myocardial function at an early stage for patients with HFpEF. Combining the two techniques may improve the quality of HFpEF diagnosis and may provide a reference value for the early diagnosis of HFpEF in the future.

Application of the Left Ventricular Pressure-Strain Loop Technique in Monitoring Improvement Factors of Patients With Heart Failure Reduced Ejection Fraction.

The left ventricular pressure-strain loop (PSL) is a new technique based on ultrasound for noninvasive quantitative evaluation of global and local myocardial work (MW). This study is aimed at evaluating improvement factors of patients with heart failure (HF) reduced ejection fraction (HFrEF) using the PSL technique. A total of 88 patients with HF were enrolled in this study, which had ≤ 40% left ventricular ejection fraction (LVEF). The EchoPAC workstation was used to obtain the global longitudinal strain (GLS) and MW parameters of the left ventricle. All patients have taken medicines for HF treatments for 6-12 months. The improvements of HF after therapies were evaluated according to the following recommended criteria. The clinical characteristics of patients with improved and nonimproved groups were stratified via univariate or multivariate logistic regression analysis, receiver operating characteristic (ROC), and the area under ROC (area under the curve (AUC)). There were no significant differences in general medical information, the underlying diseases, laboratory findings, myocardial enzyme activities, and taking medicines between the improved and nonimproved LVEF patients (p > 0.05). There were significant differences in LVEF of patients at admission, left ventricular end-diastolic diameter (LVEDD), interventricular septum thickness (IVST), early diastolic mitral flow peak velocity E (E peak), GLS, global myocardial work index (GWI), global myocardial constructive work (GCW), and global myocardial work efficiency (GWE) between the two groups (p < 0.05). Univariate and multivariate logistic regression analyses confirmed that GWI and GCW were critical predictive factors for LVEF improvement in patients with HF. ROC curve showed that the AUC of GWI and GCW were 0.796 and 0.779 at the cut-off of 741 mmHg% for GWI and 973.5 mmHg% for GCW, respectively. The sensitivities of GWI and GCW were 65% and 75%, and the specificities of GWI and GCW were 83.3% and 79.2% at given cut-off values. These results revealed that GWI and GCW were independent predictors of improvement of LVEF in patients with HFrEF.

Segmental and global myocardial work in hypertensive patients with different left ventricular geometry

BackgroundMyocardial work acquired by echocardiography has emerged as a novel method to evaluate myocardial function. We investigated global and segmental myocardial work in hypertension (HT) among patients with different patterns of left ventricular (LV) geometry in order to analyze the contribution of segmental myocardial work to global myocardial work.Methods and resultsOne hundred twenty-five patients with HT were divided into 4 groups: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH) and eccentric hypertrophy (EH). Longitudinal strain (LS) and the following indices were obtained by echocardiography: myocardial work index (MWI), myocardial constructive work (MCW), myocardial wasted work (MWW), and myocardial work efficiency (MWE). The global longitudinal strain (GLS) decreased gradually among the groups: NG, CR, CH and EH (P < 0.001). Global MWI (GWI) and global MCW (GCW) did not change across the different LV remodeling groups. Global MWW (GWW) increased and global MWE (GWE) decreased in both CH and EH group (P < 0.001). The LS of basal and middle regions reduced gradually in all HT subgroups, while apical LS decreased only in the CH and EH groups (P < 0.001). Basal MWI and MCW decreased in the CH and EH groups (P = 0.025, 0.007, respectively). Apical MWI and MCW increased in the NG and CR groups (P = 0.015, 0.044, respectively), with a decreasing trend in the CH and EH groups. All segmental MWW elevated and MWE reduced significantly in the CH and EH groups (P < 0.001). Univariate and multivariate logistic regression analyses demonstrated a significant association between left atrial volume index (LAVI), GLS, GWE and LV hypertrophy. At the receiver operating characteristic (ROC) analysis, optimal cutoff values of GLS, Apical LS, GWE and Apical MWE discriminating LV hypertrophy were 0.9072, 0.8049, 0.8325 and 0.7414, respectively.ConclusionApical myocardial work increases in the early stages of LV remodeling, likely as a compensatory mechanism to maintain normal global myocardial work. Segmental myocardial work analysis offers a reliable means to explore the distribution of myocardial impairment in hypertensive patients at different LV remodeling stages.Graphical

Myocardial work in children with Wolff-Parkinson-White syndrome.

Wolff-Parkinson-White Syndrome (WPW) has been associated with reduced local myocardial deformation, and when left ventricular dysfunction is present, catheter ablation of the accessory pathway may be required, even in asymptomatic patients. We aimed to evaluate the diagnostic value of non-invasive myocardial work in predicting subtle abnormalities in myocardial performance in children with WPW.Seventy-five paediatric patients (age 8.7 ± 3.5years) were retrospectively recruited for the study: 25 cases with manifest WPW and 50 age- and sex- matched controls (CTR). Global myocardial work index (MWI) was measured as the area of the left ventricle (LV) pressure-strain loops. From MWI, global Myocardial Constructive Work (MCW), Wasted Work (MWW), and Work Efficiency (MWE) were estimated. In addition, standard echocardiographic parameters of LV function were evaluated. Despite normal LV ejection fraction (EF) and global longitudinal strain (GLS), children with WPW had worse MWI, MCW, MWW, and MWE. At multivariate analysis, MWI and MCW were associated with GLS and systolic blood pressure, and QRS was the best independent predictor of low MWE and MWW. In particular, a QRS > 110ms showed good sensitivity and specificity for worse MWE and MWW values. In children with WPW, myocardial work indices were found significantly reduced, even in the presence of normal LV EF and GLS. This study supports the systematic use of myocardial work during the follow-up of paediatric patients with WPW. Myocardial work analysis may represent a sensitive measure of LV performance and aid in decision-making.

Aumento do Trabalho Miocárdico Desperdiçado como Indicador de Lesão Coronariana Significativa

Introduction: The assessment of global myocardial work indices under baseline conditions may be useful for the clinical stratification of patients with suspected coronary obstruction. Objective: To correlate the value of global myocardial work indices and the presence of significant obstructive coronary lesions. Method: Cross-sectional study, with patients referred for elective coronary angiography. An echocardiogram was performed to obtain measurements to calculate the value of myocardial work and evaluated the presence or presence of significant obstructive coronary lesions at coronary angiography. Results: The sample consisted of 30 patients, with a mean age of 64.2±12.8 years, the majority being male (63.3%), of which 68.4% had significant obstructive coronary lesions. The global myocardial work indices was 1,876mmHg%±253.8 in the group with significant obstructive coronary lesions and 2,054.2mmHg%±417.3 in those without significant lesions (p=0.089). Global constructive myocardial work in patients without significant obstructive coronary lesions was higher (2,329.3mmHg%±462.9) than in those with significant obstructive coronary lesions (2,109.5mmHg%±332.3; p=0.064). Global wasted myocardial work was higher in patients with significant obstructive coronary lesions (103.7mmHg%±47.1 versus 68.3mmHg%±33.8; p=0.038). The cutoff point of 115 mmHg% was the one with the best area under the curve (0.625), with a sensitivity of 83.3%. Conclusion: The increase in global wasted myocardial work correlated with the presence of significant obstructive coronary lesions in our sample.

Speckle tracking imaging evaluation of left ventricular myocardial work comparing right ventricular septal pacing with His-Purkinje system area pacing.

We sought to objectively assess left ventricular myocardial work (MW) parameters after right ventricular septal pacing (VSP) and His-Purkinje system area pacing (HPSAP) procedures. Patients undergoing double-chamber pacemaker implantation for III-degree atrioventricular block (III° AVB) were assessed 1 year after implantation. VSP and HPSAP groups (20 and 23 patients, respectively) were compared against 40 healthy age-matched volunteers. Two-dimensional ultrasound speckle tracking imaging was used to obtain the global myocardial work index (GWI), global myocardial work efficiency (GWE), global myocardial constructive work (GCW), global myocardial wasted work (GWW), left ventricular stratified strain, and peak strain dispersion (PSD). GWI, GWE, and GCW parameters were improved in HPSAP compared to VSP, while GWW was significantly larger in the VSP group compared to the HPSAP group (all p < 0.05). HPSAP outperformed the VSP group in comparisons of global left ventricular longitudinal strain and stratified strain. Compared to controls, the GCW of all segmental myocardium (17/17 segments) in the VSP group was significantly reduced, while 70.59% (12/17 segments) in the HPSAP group was lower than the control group. GCW in the left ventricular segment of the HPSAP group was bigger than the VSP group (29.41%; 5/17 segments) and mainly concentrated in the ventricular septum and inferior wall. Our findings suggest that HPSAP performance outcomes are improved over VSP after 1 year, especially in left ventricular contractile synchrony, and HPSAP is beneficial to the effective myocardial work of the left ventricle.

Global constructive myocardial work predicts reduction of ejection fraction in patients with heart failure with preserved ejection fraction

Abstract Background Despite advances in treatment of heart failure with preserved ejection fraction (HFpEF) its management remains challenging. SGLT2 inhibitors benefits across the full range of ejection fraction, and sacubitril/valsartan benefits up to the lower end of preserved EF &amp;lt;57% implies that in some patients with HFpEF some pathophysiological mechanisms of HFrEF might co-exist, and some subset of HFpEF patients might benefit from proven treatment of HFrEF, particularly those with EF deterioration over time. We aimed to found out predictors of EF deterioration in HFpEF patients assuming that we can start treating them earlier with therapies of HFrEF, preventing further deterioration. Methods We studied 215 patients (63% women) 73±8 years with HFpEF. All patients had records of comorbidity Charlson index (CI), glomerular filtration rate (GFR). Echocardiography (EchoCG) was performed with offline analysis, including calculations of myocardial work (MW), global longitudinal (LS), radial (RS), circumferential (SS) and area strain (AS) by one experienced specialist. GW index was obtained from pressure-strain loops derived from speckle tracking analysis multiplied by brachial systolic blood pressure. Global constructive work (GCW) as the sum of positive work due to myocardial shortening during systole and negative work due to lengthening during isovolumic relaxation, global wasted work as energy loss by myocardial lengthening in systole and shortening in isovolumic relaxation, and GW efficiency as the percentage ratio of constructive work to the sum of constructive work and wasted work were obtained. RS, SS and AS were calculated in 3D by dedicated software. Patients followed up for 3 years. Results 5 patients developed myocardial infarction and were excluded from the study. Baseline EF was higher in women (61,2±3,1 vs 56,4±2,7; P&amp;lt;0.002), in patients &amp;gt;70 years (62,4±2,1 vs 57,1±2,3; p&amp;lt;0.005), and with end-diastolic volume index &amp;lt;60 ml/m2 (56,1±3,2 vs 63,4±2,3; p&amp;lt;0.001). Overall decline in EF compare to baseline was −7.3±1.6%, p&amp;lt;0.01. Reduction in EF was more prominent in patients &amp;gt;70 years (−6,9±1,8 vs −5,7±1,7; P&amp;lt;0,002), and in patients with coronary artery disease (CAD) (−7,2±1,9 vs −5,8±1,6; P&amp;lt;0,001) and did not relate to sex, LV size, CI, and GFR. During follow up 58 (27%) patients had EF &amp;lt;50%. We observed significant worsening in AS (−27.9±8.5% vs −24.7±5.3%, p&amp;lt;0.003), LS (−19.7±2.4% vs −17.1±1.6%, p&amp;lt;0.005), and GCW (GCW 2378±117 vs 2107±102 mmHg%, p&amp;lt;0.002). Patients with EF &amp;lt;50% at the end of the study had significantly less AS and GCW baseline values compared with patients with EF&amp;gt;50% (22.4±7.2% vs −27.6±8.1%, p&amp;lt;0.002; 2081±92 vs 2489±127 mmHg%, p&amp;lt;0.001). GCW was the predictor of EF deterioration (area under curve 0,875). Conclusion GCW predicts reduction of EF in patients with HFpEF which may help earlier identify the subset of HFpEF patients who may benefit from proven therapies for HFrEF and prevent upcoming deterioration. Funding Acknowledgement Type of funding sources: None.

Effects of postsystolic shortening and diastolic dyssynchrony on myocardial work in untreated early hypertension patients.

Myocardial work is estimated from noninvasive pressure-strain loop for advanced assessment of left ventricular function. Postsystolic shortening and diastolic dyssynchrony of left ventricle were noted early in hypertension. Their novel effects on myocardial work will be illustrated in this study. We recruited 43 newly diagnosed hypertensive patients (mean age 51.3 ± 12.5 years, 55.8% men) and 32 age-matched and sex-matched healthy individuals (mean age 52.7 ± 10.5 years, 37.5% men) as control. Pressure-strain loop derived myocardial work incorporated global longitudinal strain from speckle tracking echocardiography with brachial artery cuff pressure. Postsystolic strain index (PSI) was defined by the percentage of postsystolic shortening over peak strain. Diastolic dyssynchrony was assessed by standard deviation of time to peak early diastolic strain rate (TDSr-SD) of 18 segments, and maximal difference of time to peak early diastolic strain rate (TDSr-MD) between any two segments. After multivariate regression analysis, global myocardial work index (GWI) was independently correlated with TDSr-SD (B = -0.498, P = 0.001) and TDSr-MD (B = -0.513, P = 0.001). Global myocardial constructive work (GCW) was independently correlated with TDSr-SD (B = -0.334, P = 0.025) and TDSr-MD (B = -0.397, P = 0.007). Global myocardial wasted work (GWW) was independently correlated with PSI (B = 0.358, P = 0.019). Global myocardial work efficiency (GWE) was lower in hypertensive patients than healthy control (P = 0.001). The untreated hypertensive patients were different from the healthy individuals with higher TDSr-SD, TDSr-MD, GWI, GCW, GWW, and PSI (all P < 0.05). In conclusion, the effect of diastolic dyssynchrony mainly influenced constructive work, whereas postsystolic shortening affected wasted work in early untreated hypertension.

Do diurnal changes in blood pressure affect myocardial work indices?

Do diurnal changes in blood pressure affect myocardial work indices?

Evaluation of non-invasive myocardial work in Takotsubo cardiomyopathy

Tako-tsubo cardiomyopathy(TTC) is characterized by transient left ventricular(LV) wall motion abnormalities(WMA). However, whether systolic performance fully recover is unclear. Non-invasive myocardial work (MW) is a new index of global and regional myocardial performance never described in this setting. To assess global and regional MW in apical TTC. 50 patients with typical TTC(mean age 77 ± 10 y, 47 women) were prospectively enrolled and underwent a transthoracic echocardiography within 24 h of admission and a median of 32 days at follow-up. MW is derived from the non-invasive strain-pressure loop obtained from the 2D strain data, integrating non-invasive arterial pressure. Constructive MW(CMW), MW index(MWI), MW efficiency(MWE), and wasted work(WW) were measured. Hospital complications(HC) were defined as a composite of heart failure, right ventricular extension, and LV apical thrombus. A control group of 24 patients matched for age and sex without overt cardiovascular disease served as a comparative group. In the TTC group, global and regional MW improved significantly between the two examinations (global, regional apical and medial CMW, MWI, MWE, WW, and regional basal CMW, and MWI, all P < 0.01). The acute apical–basal gradient of MW inverted at FU. In TTC, global CMW and MWI were significantly correlated to acute LV systolic function parameters, and were significantly impaired in patients with HC( n = 13, all, P < 0.01). At FU, despite total recovery of WMA, global and regional MW was significantly reduced in TTC by comparison to the control group ( P < 0.01 for all components), although hemodynamics, LV ejection fraction, and 2D global longitudinal strain were similar (all P = NS). Global and regional myocardial performance is transiently impaired in typical TTC and significantly associated to HC. Despite total recovery of WMA, subtle dysfunction of myocardial performance persist at FU.

Evaluation of non-invasive myocardial work in tako-tsubo cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Background Tako-tsubo cardiomyopathy (TTC) is characterized by the presence of transient left ventricular (LV) wall motion abnormalities (WMA). However, whether systolic performance fully recover is unclear. Non-invasive myocardial work (MW) is a new index of global and regional myocardial performance which has never been described in this setting. Objective: to assess global and regional MW in typical TTC (apical variant). Methods: fifty patients with typical TTC (mean age, 77 ± 10 years, 47 women) were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 24 hours of admission and a median of 32 days at follow-up (FU). MW is derived from the non-invasive strain-pressure loop obtained from the 2D strain data, integrating in its calculation the non-invasive brachial arterial pressure. Constructive MW (CMW), MW index (MWI), MW efficiency (MWE), and wasted work (WW) were measured. Hospital complications (HC) were defined as a composite of heart failure, right ventricular extension, and LV apical thrombus. A control group of 24 patients matched for age and sex without overt cardiovascular disease served as a comparative group. Results: In the TTC group, global and regional MW improved significantly between the two examinations (global, regional apical and medial CMW, MWI, MWE, WW, and regional basal CMW, and MWI, all p &amp;lt; 0.01). The acute apical –basal gradient of MW inverted at FU. In TTC, global CMW and MWI were significantly correlated to acute LV systolic function parameters and their change, and were significantly impaired in patients with HC (n = 13) (all, p &amp;lt; 0.01). At FU, despite total recovery of WMA, global and regional MW was significantly reduced in TTC by comparison to the control group (p &amp;lt; 0.01 for all components), although hemodynamics, LV ejection fraction, and 2D global longitudinal strain were similar (all, p = NS). Conclusion: Global and regional myocardial performance is transiently impaired in typical TTC and significantly associated to HC. And despite total recovery of WMA, subtle dysfunction of myocardial performance persist at FU.

Prognostic role of myocardial work in patients with heart failure and reduced ejection fraction treated by sacubitril/valsartan

Abstract Funding Acknowledgements Type of funding sources: None. Background the non-invasive assessment of myocardial work (MW) by pressure-strain loops analysis (PSL) is a relative new tool for the evaluation of myocardial performance. Sacubitril/Valsartan is a treatment for heart failure with reduced ejection fraction (HFrEF) which has a spectacular effect on the reduction of cardiovascular events (MACEs). Purposes of this study were to evaluate 1) the short and medium term effect of Sacubitril/Valsartan treatment on MW parameters; 2) the prognostic value of MW in this specific group of patients. Methods 79 patients with HFrEF (mean age: 66 ± 12 years; LV ejection fraction: 28 ± 9%) were prospectively included in the study and treated with Sacubitril/Valsartan. Echocardiographic examination was performed at baseline, and after 6- and 12-month of therapy with Sacubitril/Valsartan. Results Sacubitril/Valsartan significantly increased myocardial constructive work (CW) (1023 ± 449 vs 1424 ± 484 mmHg%, p &amp;lt; 0.0001) and myocardial work efficiency (WE) [87 (78-90) vs 90 (86-95), p &amp;lt; 0.0001]. During FU (2.6 ± 0.9 years), MACEs occurred in 13 (16%) patients. After correction for LV size, LVEF and WE, global myocardial constructive work (CW) was the only predictor of MACEs [HR 0.99 (0.99-1.00), p = 0.05]. (Table 1). A CW &amp;lt; 910 mmHg (AUC = 0.81, p &amp;lt; 0.0001, Figure 1, left panel) identified patients at particularly increase risk of MACEs [HR 11.09 (1.45-98.94), p = 0.002, log-rank test p &amp;lt; 0.0001] (Figure 2, Right panel). Conclusions in patients with HFrEF who receive a comprehensive background beta-blocker and mineral-corticoid receptor antagonist therapy, Sacubitril/Valsartan induces a significant improvement of myocardial CW and WE. In this population, the estimation of CW before the initiation of Sacubitril/Valsartan therapy allows the prediction of MACEs. Univariable analysis Multivariable analysis HR (95% CI) p-value HR (95% CI) p-value Age, per year 0.99 (0.95-1.04) 0.81 Ischemic cardiomyopathy 1.07 (0.36-3.21) 0.89 LVEDVi*, per ml/m2 1.01 (1.00-1.03) 0.03 LVESVi, per ml/m2 1.01 (1.00-1.03) 0.009 1.01 (0.99-1.02) 0.35 LVEF, per % 0.91 (0.85-0.98) 0.01 1.02 (0.93-1.12) 0.71 CW, per mmHg% 0.99 (0.99-1.00) 0.002 0.99 (0.99-1.00) 0.04 WE, per mmHg% 0.91 (0.86-0.96) 0.001 0.95 (0.88-1.02) 0.16 Predictors of MACEs at univariable and multivariable analysis Abstract Figure 1 A and B

Prognostic role of myocardial work in patients with heart failure and reduced ejection fraction treated by sacubitril/valsartan

The non-invasive assessment of myocardial work (MW) by pressure-strain loops analysis (PSL) is a relative new tool for the evaluation of myocardial performance. Sacubitril/Valsartan is a treatment for heart failure with reduced ejection fraction (HFrEF) which has a spectacular effect on the reduction of cardiovascular events (MACEs). Purposes of this study were to evaluate 1) the short and medium term effect of Sacubitril/Valsartan treatment on MW parameters; 2) the prognostic value of MW in this specific group of patients. 79 patients with HFrEF (mean age: 66 ± 12 years; LV ejection fraction: 28 ± 9%) were prospectively included in the study and treated with Sacubitril/Valsartan. Echocardiographic examination was performed at baseline, and after 6- and 12-month of therapy with Sacubitril/Valsartan. Sacubitril/Valsartan significantly increased myocardial constructive work (CW) (1023 ± 449 vs. 1424 ± 484 mmHg%, P < 0.0001) and myocardial work efficiency (WE) [87 (78–90) vs. 90 (86–95), P < 0.0001]. During FU (2.6 ± 0.9 years), MACEs occurred in 13 (16%) patients. After correction for LV size, LVEF and WE, global myocardial constructive work (CW) was the only predictor of MACEs [HR 0.99 (0.99–1.00), Fig. 1 = 0.05]. ( Table 1 ). A CW < 910 mmHg (AUC = 0.81, P < 0.0001, Fig. 1 A) identified patients at particularly increase risk of MACEs [HR 11.09 (1.45–98.94), P = 0.002, log-rank test P < 0.0001] ( Fig. 1 B). in patients with HFrEF who receive a comprehensive background beta-blocker and mineral-corticoid receptor antagonist therapy, Sacubitril/Valsartan induces a significant improvement of myocardial CW and WE. In this population, the estimation of CW before the initiation of Sacubitril/Valsartan therapy allows the prediction of MACEs.

Usefulness of non-invasive myocardial work to predict left ventricular recovery and acute complications after acute anterior myocardial infarction treated by primary percutaneous intervention

Predicting left ventricular (LV) recovery after acute ST-elevation myocardial infarction (STEMI) is challenging and of prognostic importance. To evaluate the usefulness of non-invasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LV recovery and in-hospital complications after STEMI. In total, 93 consecutive patients with anterior STEMI (mean age, 59 ± 12 years) treated by primary percutaneous intervention (PCI) underwent transthoracic echocardiography (TTE) within 24–48 hours after angioplasty and a median of 92 days at follow-up. MW is derived from the non-invasive strain-pressure loop obtained from the 2D strain data, integrating in its calculation the non-invasive brachial arterial pressure. Segmental LV recovery was defined as a normalization of segmental wall motion abnormalities of the affected segments and global recovery as an absolute improvement of left ventricular ejection fraction (LVEF) greater than 5% in patients with baseline LVEF < 50%. In-hospital complications were defined as a composite of death, reinfarction, heart failure, and LV apical thrombus. In total, 1642 segments were studied and MW was impaired in infarct segments, more severely in no recovering versus recovering segments (MW index, constructive MW, MW efficiency, all, P < 0.01). Furthermore, global MW was significantly correlated to acute and follow-up LVEF and global longitudinal strain (GLS) (all, P < 0.01). Constructive MW was the best index to predict segmental ( P < 0.01 versus MW index, MW efficiency, and wasted work), and global recovery ( P < 0.05 versus GLS) with an independent association (all, P < 0.01). Moreover, global constructive MW was independently associated to in-hospital complications, which occurred in 18 patients ( P < 0.01). In patients with anterior STEMI treated by PCI, acute constructive MW is an independent predictor of segmental and global LV recovery, as well as in-hospital complications.

Assessment of left ventricular systolic function by non-invasive pressure-strain loop area in young male strength athletes

BackgroundThe health of athletes has been recognized as a worldwide public concern with more reported sudden cardiac deaths (SCD). Therefore, early detection of abnormal heart function in athletes can help reduce the risk of exercise. A novel valid non-invasive method to evaluate left ventricular (LV) myocardial work (MW) using LV pressure-strain loop (PSL), was used in this paper to explore LV systolic function in young male strength athletes.MethodsThirty-six professional young male strength athletes (the athlete group) and 32 healthy, age-matched young men (the control group) were involved in the study. The LVMW parameters were calculated as the area of PSL by two-dimensional speckle tracking echocardiography (2D-STE) and peak systolic LV pressure. The differences between two groups of data and the predictive efficacy of MW parameters for LV systolic function were analyzed.ResultsThe athlete group had significantly higher values of global wasted myocardial work (GWW) and peak strain dispersion (PSD) than did the control group (P<0.05). Global myocardial work index (GWI), global constructive myocardial work (GCW) and global longitudinal strain (GLS) were lower in the athlete group than that in the control group, although statistical significance was not reached (P>0.05). Due to the proportion of GWW and GCW, statistically significant reduction was found in global myocardial work efficiency (GWE) in the athlete group. Conventional echocardiography parameters were well correlated with GWW and GWE (P<0.05). The best predictor of LV myocardial contractile performance in the athletes using receiver operating characteristic curve (ROC) was GWE, with the area under ROC (AUC) of 0.733, sensitivity of 83.3% and specificity of 59.4%.ConclusionsSubclinical changes have appeared in the hearts of young male strength athletes after long-term intensive exercise and LVMW parameters by PSL play an important role in the evaluation of athlete’s LV contractile performance.

Prognostic value of global myocardial constructive work in patients with secondary mitral regurgitation

Abstract Background Left ventricular (LV) myocardial contractility evaluation is of crucial importance in patients with secondary mitral regurgitation (SMR). The most widespread echocardiographic tool, left ventricular ejection fraction (LVEF), might overestimate LV function, since it calculates the volume changes regardless of the flow direction. Global myocardial constructive work (GMCW) might be a more suitable tool, as LV myocardial work derived from pressure-strain loops obtained with speckle tracking echocardiography incorporates non-invasive blood pressure measurements. Purpose To evaluate the prognostic value of LV GMCW in patients with SMR. Methods 378 patients (72% men, median age 68 [range 60 to 74 years]) with various grades of SMR were retrospectively analysed. LV global myocardial constructive work, wasted work and work efficiency were measured with speckle tracking echocardiography. Results There were 145 patients with mild SMR, 130 with moderate SMR and 103 with severe SMR. Patients with severe SMR had larger LV volumes, lower LVEF and more impaired LV GLS. GMCW was more impaired in patients with severe SMR, compared with mild MR (678 mmHg% vs. 845 mmHg% p&amp;lt;0.001 respectively). After a mean follow-up of 59±37 months, 162 patients died. When dividing the population according to prognostically relevant cut offs derived by spline curve analysis, patients with a GMCW≤700 mmHg% had a worse prognosis, compared with their counterparts (Figure 1). Conclusion Global myocardial constructive work ≤700 mmHg% is associated with worse long-term survival in patients with SMR. Kaplan-Meier survival curves Funding Acknowledgement Type of funding source: None

Non-invasive estimation of myocardial work in aortic stenosis from modelling approach

Abstract Background The noninvasive assessment of myocardial work by pressure-strain loops (PSL) analysis is a recently introduced tool to estimate myocardial performance. PSL analysis cannot be applied to patients having an obstacle to LV ejection, as in the case of aortic stenosis (AS), because of the difficulty to estimate left ventricular (LV) pressure. The purpose of this work is to propose a non-invasive model-based estimation of the left ventricular pressure curve in AS patients in order to evaluate myocardial work indices. Methods Twelve patients with moderate-to-severe AS underwent cardiac catheterization to acquire the LV pressure (Pexp-LV). All patients underwent a standard trans-thoracic echocardiography to extract regional myocardial strain curves and estimate the aortic valve area (AVA). Systolic and diastolic arterial pressures were also measured. The proposed cardiovascular system (CVS) model is composed of four main coupled sub-models simulating: i) cardiac electrical activities, ii) cardiac cavity, iii) the systemic and pulmonary circulation, and iv) cardiac valves (Figure 1, upper panel). A 2-step parameter identification strategy, based evolutionary algorithms, was implemented to learn LV parameters from Pexp-LV and to estimate patient-specific model-based LV pressure curves (Pmodel-LV) starting from parameters obtained from non-invasive hemodynamics. Global myocardial constructive work (GCW) and myocardial wasted work (GWW) were calculated using Pexp-LV and Pmodel-LV. Results A close match was observed between Pexp-LV and Pmodel-LV, with a mean total relative error of 12.27% (range 5.9% to 17.40%). When considering GCW and GWW, global correlation was equal to 0.92 (p&amp;lt;0.0001). In BA analysis, mean bias was −2.9 mmHg.%, which corresponds to relative bias equal to 0.11% with respect to the mean value of work indices (Figure 1, lower panel). Conclusions A model-based approach can be used to estimate LV pressure and myocardial work indices in patients with AS, and be provide a promising tool for the assessment of myocardial performance in patients with AS Funding Acknowledgement Type of funding source: None

Usefulness of non-invasive myocardial work to predict left ventricular recovery and acute complications after acute anterior myocardial infarction treated by primary angioplasty

Abstract Background Predicting left ventricular (LV) recovery after acute ST-elevation myocardial infarction (STEMI) is challenging and of prognostic importance. Objective To evaluate the usefulness of non-invasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LV recovery and in-hospital complications after STEMI. Methods Ninety-three consecutive patients with anterior STEMI (mean age, 59±12 years) treated by primary angioplasty underwent transthoracic echocardiography (TTE) within 24–48 hours after angioplasty and a median of 92 days at follow-up. MW is derived from the non-invasive strain-pressure loop obtained from the 2D strain data, integrating in its calculation the non-invasive brachial arterial pressure. Segmental LV recovery was defined as a normalization of segmental wall motion abnormalities of the affected segments and global recovery as an absolute improvement of left ventricular ejection fraction (LVEF) greater than 5% in patients with baseline LVEF &amp;lt;50%. In-hospital complications were defined as a composite of death, reinfarction, heart failure, and LV apical thrombus. Results 1642 segments were studied and MW was impaired in infarct segments, more severely in no recovery versus recovery segments (MW index, constructive MW, MW efficiency, all, p&amp;lt;0.01). Furthermore, global MW was significantly correlated to acute and follow-up LVEF and global longitudinal strain (GLS) (all, p&amp;lt;0.01). Constructive MW was the best indice to predict segmental (p&amp;lt;0.01 versus MW index, MW efficiency, and wasted work), and global recovery (p&amp;lt;0.05 versus GLS) with an independent association (all, p&amp;lt;0.01). Moreover, global constructive MW was independently associated to in-hospital complications which occurred in 18 patients (p&amp;lt;0.01). Conclusion In patients with anterior STEMI treated by primary angioplasty, acute constructive MW is an independent predictor of segmental and global LV recovery, as well as in-hospital complications. Funding Acknowledgement Type of funding source: None