Impaired Longitudinal Strain Research Articles

3D right ventricular strain and shape in volume overload: Comparative analysis of tetralogy of Fallot and atrial septal defect patients

RV function assessment is crucial in congenital heart disease (CHD) patients, especially in atrial septal defect (ASD) and tetralogy of Fallot (TOF) patients. Indeed, prognosis substantially differs between TOF and ASD and little is known about 3D deformation and shape in RV volume overload. To assess Right ventricular (RV) remodeling differences between ASD, TOF patients and controls. We prospectively included 55 patients (older than 16 yo) into this case-control study: 19 patients with an ASD (and left-to-right shunt), 15 with TOF and 21 healthy controls. 3D transthoracic RV echocardiographic sequences were acquired. Myocardial tracking was performed by a semi-automatic software. Output RV meshes including spatial correspondences were post-processed to temporally align the data and extract local deformation. Global and local statistics provided deformation and shape patterns for each subject. No difference in RV strain was found between ASD patients and controls. There was a trend toward increased longitudinal strain in patients with small ASD. TOF patients had lower RV area and longitudinal strain, especially in the inferior, lateral wall and in the trabecular septum. TOF patients had predominant circumferential over longitudinal strain. Using curvature indices, differences in RV shape were highlighted between controls and RV volume overload patients whereas there was almost no difference between ASD and TOF patients regarding RV shape, except at the septum. RV inferior and lateral curvatures were strongly correlated to QRS duration ( Fig. 1 ). Volume overload alters RV shape to the same extent in ASD and TOF whereas it has differential effects on strain. In ASD patients the strain is relatively preserved whereas TOF patients had particularly impaired longitudinal strain. Such detailed analyses of strain and shape could help refine RV function assessment in particular in CHD patients.

Relative Apical Sparing of Myocardial Longitudinal Strain Is Explained by Regional Differences in Total Amyloid Mass Rather Than the Proportion of Amyloid Deposits

ObjectivesThis study sought to test whether relative apical sparing (RELAPS) of left ventricular (LV) longitudinal strain (LS) in cardiac amyloidosis (CA) is explained by regional differences in markers of amyloid burden (18F-florbetapir uptake by positron emission tomography [PET] and/or extracellular volume fraction [ECV] by cardiac magnetic resonance (CMR)]. BackgroundFurther knowledge of the pathophysiological basis for RELAPS can help understand the adverse outcomes associated with apical LS impairment. MethodsThis was a prospective study of 32 subjects (age 62 ± 7 years; 50% males) with light chain CA. All subjects underwent two-dimensional echocardiography for LS estimation and 18F-florbetapir PET for quantification of LV florbetapir retention index (RI). A subset also underwent CMR (n = 22) for ECV quantification. Extracellular LV mass (LV mass*ECV) and total florbetapir binding (extracellular LV mass*florbetapir RI) were also calculated. All parameters were measured globally and regionally (base, mid, and apex). ResultsThere was a significant base-to-apex gradient in LS (−7.4 ± 3.2% vs. −8.6 ± 4.0% vs. −20.8 ± 6.6%; p < 0.0001), maximal LV wall thickness (15.7 ± 1.9 cm vs. 15.4 ± 2.9 cm vs. 10.1 ± 2.4 cm; p < 0.0001), and LV mass (74.8 ± 21.2 g vs. 60.8 ± 17.3 g vs. 23.4 ± 6.2 g; p < 0.0001). In contrast, florbetapir RI (0.089 ± 0.03 μmol/min/g vs. 0.097 ± 0.03 μmol/min/g vs. 0.085 ± 0.03 μmol/min/g; p = 0.45) and ECV (0.53 ± 0.08 vs. 0.49 ± 0.08 vs. 0.49 ± 0.07; p = 0.15) showed no significant base-to-apex gradient in the tissue concentration or proportion of amyloid infiltration, whereas markers of total amyloid load, such as total florbetapir binding (3.4 ± 1.7 μmol/min vs. 2.8 ± 1.5 μmol/min vs. 0.93 ± 0.49 μmol/min; p < 0.0001) and extracellular LV mass (40.0 ± 15.6 g vs. 30.2 ± 10.9 g vs. 11.6 ± 3.9 g; p < 0.0001), did show a marked base-to-apex gradient. ConclusionsSegmental differences in the distribution of the total amyloid mass, rather than the proportion of amyloid deposits, appear to explain the marked regional differences in LS in CA. Although these 2 matrices are clearly related concepts, they should not be used interchangeably.

Speckle Tracking Echocardiography Identifies Impaired Longitudinal Strain as a Common Deficit in Various Cardiac Diseases

The use of speckle-tracking echocardiography (STE) is becoming an increasingly useful tool in the evaluation of myocardial disease. STE software can track the motion of the specular pattern created by the interference of ultrasound with the myofibers of the heart and provide a quantitative means to evaluate subtle changes in ventricular function that often occur before changes in ventricular ejection fraction are observed. STE is most often used to measure the change in shape (strain) of myocardial segments in the circumferential, radial, and longitudinal directions. In various diseases, including coronary artery disease, aortic stenosis, and mitral regurgitation, deficits in longitudinal strain appear to occur earlier than deficits in other measures of strain or in ejection fraction. Consideration of STE measures of left ventricular contraction has the potential to significantly affect clinical management and outcomes of ischemic and valvular heart disease given the ability to separate those with asymptomatic disease who may benefit from earlier interventions than current guidelines may suggest.

Ischemic Mitral Regurgitation: Abnormal Strain Overestimates Nonviable Myocardium

Therapy for moderate ischemic mitral regurgitation remains unclear. Determination of myocardial viability, a necessary prerequisite for an improvement in regional contractility, is a likely key factor in determining response to revascularization alone. Myocardial strain has been proposed as a viability measure but has not been compared with late gadolinium enhancement (LGE) cardiac magnetic resonance imaging. We hypothesized that abnormal strain overestimates nonviable left ventricular (LV) segments measured with LGE and that ischemia and mechanical tethering by adjacent transmural myocardial infarction (TMI) also decreases strain in viable segments. Sixteen patients with mild or greater ischemic mitral regurgitation and 7 healthy volunteers underwent cardiac magnetic resonance imaging with noninvasive tags (complementary spatial modulation of magnetization [CSPAMM]), LGE, and stress perfusion. CSPAMM images were post-processed with harmonic phase and circumferential and longitudinal strains were calculated. Viability was defined as the absence of TMI on LGE (hyperenhancement >50% of wall thickness). The borderzone was defined as any segment bordering TMI. Abnormal strain thresholds (±1 to 2.5 SDs from normal mean) were compared with TMI, ischemia, and borderzone. 7.4% of LV segments had TMI on LGE, and more than 14.5% of LV segments were nonviable by strain thresholds (p < 0.005). In viable segments, ischemia impaired longitudinal strain (least perfused one-third of LV segments:-0.18 ± 0.08 versus most perfused:-0.22 ± 0.1, p = 0.01) and circumferential strain (-0.12 ± 0.1 versus-0.16 ± 0.08, p < 0.05). In addition, infarct proximity impaired longitudinal strain (-0.16 ± 0.11 borderzone versus-0.18 ± 0.09 remote, p= 0.05). Impaired LV strain overestimates nonviable myocardium compared with TMI on LGE. Ischemia and infarct proximity also decrease strain in viable segments.

Central Obesity is the Key Component in the Association of Metabolic Syndrome With Left Ventricular Global Longitudinal Strain Impairment

Introduction and objectivesSubclinical systolic dysfunction is one of the proposed mechanisms for increased cardiovascular risk associated with metabolic syndrome (MS). This study investigated the association between MS and impaired left ventricular global longitudinal strain (GLS) and the role of each MS criteria in this association. MethodsWe analyzed a random sample of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) after excluding participants with prevalent heart disease. ResultsAmong the 1055 participants fulfilling the inclusion criteria (53% women; 52±9 years), 444 (42%) had MS. Those with MS had worse GLS (–18.0%±2.5%) than those without (–19.0%±2.4%; P<.0001). In multiple linear regression models, MS was associated with worse GLS after adjustment for various risk factors (GLS difference=0.86%; P <.0001), even after inclusion of body mass index. Adjusted PR for impaired GLS as assessed by 3 cutoffs (1, 1.5, and 2 standard deviations) were higher among participants with than without MS: GLS –16.1% (PR, 1.76; 95%CI, 1.30-2.39); GLS –14.8% (PR, 2.35; 95%CI, 1.45-3.81); and GLS –13.5% (PR, 2.07; 95%CI, 0.97-4.41). After inclusion of body mass index in the models, these associations were attenuated, suggesting that they may, at least in part, be mediated by obesity. In quantile regression analyses, elevated waist circumference was the only MS component found to be independently associated with GLS across the whole range of values. ConclusionsMetabolic syndrome is independently associated with impaired GLS. Among the MS criteria, central obesity best depicted the link between metabolic derangement and cardiac function.

The association of surgical versus natural menopause with future left ventricular structure and function: The Coronary Artery Risk Development in Young Adults (CARDIA) Study.

To evaluate the association between surgical menopause (SM) versus natural menopause (NM) in relation to later left ventricular (LV) structure and function, while taking into account the LV parameters and other cardiovascular disease risk factor (CVDRF) levels that predate the menopausal transition. We studied 825 premenopausal women from the Coronary Artery Risk Development in Young Adults study in 1990 to 1991 (baseline, mean age 32 years) who later reached menopause by 2010 to 2011 and had echocardiograms at these two time points. During 20 years of follow-up, 508 women reached NM, whereas 317 underwent SM (34% had bilateral oophorectomy). At baseline, women who later underwent SM were more likely to be black, younger, have greater parity, and higher mean values of systolic blood pressure, body mass index, and also lower mean high-density lipoprotein cholesterol and physical activity than women who reached NM. No significant differences in LV structure/function were found between groups. In 2010 to 2011, SM women had significantly higher LV mass, LV mass/volume ratio, E/e' ratio, and impaired longitudinal and circumferential strain than NM women. SM women with bilateral oophorectomy had adverse LV measures than women with hysterectomy with ovarian conservation. Controlling for baseline echocardiographic parameters and CVDRF in linear regression models eliminated these differences between groups. Further adjustment for age at menopause/surgery and hormone therapy use did not change these results. In this study, the adverse LV structure and function observed among women with SM compared with NM were explained by their unfavorable presurgical CVDRF profiles, suggesting that premenopausal CVDRF rather than gynecologic surgery predispose SM women to elevated future cardiovascular disease risk.

Differential Myocardial Fibre Involvement by Strain Analysis in Patients With Aortic Stenosis

Aortic stenosis (AS) is the most common valvular heart disease and can result in left ventricular (LV) systolic impairment. LV myocardial fibres are organised in layers: the subendocardial layer is orientated longitudinally and the subepicardial layer circumferentially. We hypothesised that there is differential involvement of myocardial fibres in patients with aortic stenosis. We performed multi-directional, multi-layered systolic strain analysis in 70 patients (aged 72±10.7years) with varying grades of AS severity (mean gradient 32.3±20mmHg, aortic valve area 1.1±0.6cm2) and in 30 controls. Clinical, demographic and resting echocardiographic data were recorded. Left ventricular subendocardial and subepicardial systolic strains were measured in the longitudinal, radial and circumferential axes. Systolic subendocardial strain was significantly higher than subepicardial strain in all three axes in patients and in controls. There were significant differences in longitudinal, but not in circumferential and radial strain, or left ventricular ejection fraction (LVEF), between patient groups. Aortic valve mean gradient (MG) and valve area (AVA) correlated better with subendocardial longitudinal strain (r=0.548, p<0.001; r=-0.54, p<0.001 respectively) than with subepicardial longitudinal strain (r=0.496, p<0.001, r=-0.544, p<0.001 respectively). Correlations between circumferential and radial strain and MG or AVA were poor. There was differential impairment in LV systolic strain in all three cardiac axes in patients with AS. Left ventricular longitudinal strain impairment was proportional to AS severity. Subendocardial longitudinal strain correlated better with AS severity than subepicardial longitudinal strain while correlations between circumferential and radial strain and AS severity were weak.

Influence of Aging on Level and Layer-Specific Left Ventricular Longitudinal Strain in Subjects Without Structural Heart Disease

Values for level- (apical, mid, and basal) and layer-based (endocardial, mid-myocardial, and epicardial) left ventricular (LV) longitudinal strain across age are scarce. The present study evaluates the effect of aging on level- and layer-specific LV longitudinal strain in subjects without structural heart disease. A total of 408 subjects (mean age 58 years [range 16 to 91]; 49% men) were evaluated retrospectively. Subjects were divided into equal groups based on age and gender. Subjects with evidence of structural heart disease or arrhythmias were excluded. Mean LV ejection fraction was 62 ± 6.2%. A gradual increase in magnitude of level LV longitudinal strain was observed from basal to mid and apical levels (-16.7 ± 2.1%, -18.8 ± 2.0%, -22.6 ± 3.8%; p <0.001, respectively). Across age groups, there was a borderline significant decrease in magnitude of basal longitudinal strain in older subjects, whereas the magnitude in the apical level significantly increased. On layer-based analysis, the magnitude of longitudinal strain increased from epicardium to endocardium across all age groups. On multivariable analysis, only diabetes mellitus was associated with more impaired longitudinal strain in the endocardium, and male gender was associated with more impaired longitudinal strain at the epicardium layer. In conclusion, with increasing age, the magnitude of LV longitudinal strain at the basal level declines while the apical LV longitudinal strain increases. In contrast, layer-specific LV longitudinal strain remains unchanged with aging. The presence of diabetes mellitus modulated the effect of age on the LV endocardial layer, and male gender was associated with more impaired longitudinal strain at the epicardial layer.

P6120Left ventricular longitudinal strain impairment predicts cardiovascular events in asymptomatic type 1 myotonic dystrophy

P6120Left ventricular longitudinal strain impairment predicts cardiovascular events in asymptomatic type 1 myotonic dystrophy

Left ventricular longitudinal strain impairment predicts cardiovascular events in asymptomatic type 1 myotonic dystrophy

BackgroundType 1 myotonic dystrophy (DM1) patients' prognosis is very poor. Up until now, only a few prognostic factors for cardiovascular events have been identified, and they are predictive of end-stage disease. The aim was to assess the prognostic value of global longitudinal strain (GLS) for cardiovascular events in asymptomatic DM1 patients. MethodsDM1 patients were included between 2011 and 2015 and followed up until January 2016. Patients underwent a transthoracic echocardiography at inclusion. The primary endpoint was a composite of all-cause mortality, type 2 Mobitz 2 and type 3 atrioventricular block, symptomatic sino-atrial block, HV interval≥70ms at invasive electrophysiology exploration, left ventricular ejection fraction (LVEF) ≤45% and newly developed atrial fibrillation. ResultsForty-six patients (25 males, mean age 40years old) were included. The primary outcome was reached in 14 patients with a mean follow-up of 38months. GLS of patients who reached the primary endpoint was significantly impaired as compared to those who did not (−15.1 [−16.7; −12.7] vs. −18.2 [−19.2; −16.7] respectively; P=0.001). According to ROC curve analysis, probability of primary outcome occurrence was significantly greater in patients with GLS values≥−17.2% (P=0.001). On multivariate analysis, PR electrocardiogram interval and GLS remained significantly and independently associated with the primary endpoint [hazard ratio (HR) 1.03, 95% confidence interval (CI) 1.01–1.04, P=0.006 for PR interval; HR 1.4, 95% CI 1.1–1.7, P=0.002 for GLS] while LVEF alone was not. ConclusionLeft ventricular GLS is a powerful marker to predict cardiovascular events in asymptomatic DM1 patients, independently of LVEF.

Global and regional patterns of longitudinal strain in screening for chemotherapy-induced cardiotoxicity

IntroductionSerial echocardiographic assessment of left ventricular ejection fraction (LVEF) is the gold standard in screening for chemotherapy-induced cardiotoxicity (CIC). Measurement of myocardial deformation using speckle tracking enables more detailed assessment of myocardial contractility. The aim of this study was to determine the relationship between global and regional longitudinal strain and CIC. MethodsThis was a prospective study of 158 breast cancer patients undergoing chemotherapy with anthracyclines with or without adjuvant trastuzumab who underwent serial monitoring by transthoracic echocardiography with assessment of myocardial deformation. CIC was defined as a decrease in LVEF to <53%. Global longitudinal strain (GLS) was estimated using EchoPAC BT12 software on a GE Vivid E9 cardiac ultrasound system. Patients were classified according to the 2015 ASE/EACVI criteria as having impaired myocardial deformation when GLS was reduced (less negative), with a cutoff of -18%. ResultsDuring a mean follow-up of 5.4 months (1-48 months), the incidence of CIC was 18.9%. A decrease in GLS was observed during follow-up for the entire cohort (baseline GLS -20.1±3.5% vs. -18.7±3.4% at last follow-up assessment, p=0.001). A total of 97 patients (61.4%) were observed to have impaired myocardial deformation (GLS ≥18%) at some point during follow-up. This decrease was more significant in patients who eventually developed CIC (GLS -17.2±2.5%, p=0.02). On analysis of regional strain, impaired contractility was observed in the septal (6 out of 6) and anterior (2 out of 3) segments. Multivariate logistic regression showed that patients who developed impaired longitudinal strain had a 4.9-fold increased risk of developing CIC (odds ratio 4.88, confidence interval 1.32-18.0, p=0.017). ConclusionsWorsening of myocardial deformation as assessed by speckle tracking is common in breast cancer patients undergoing chemotherapy, with predominantly septal and anterior wall involvement. Impaired myocardial deformation was independently associated with increased incidence of CIC.

Importância da deformação longitudinal na deteção da cardiotoxicidade induzida por quimioterapia e na identificação de padrões específicos de afetação segmentar

IntroductionSerial echocardiographic assessment of left ventricular ejection fraction (LVEF) is the gold standard in screening for chemotherapy‐induced cardiotoxicity (CIC). Measurement of myocardial deformation using speckle tracking enables more detailed assessment of myocardial contractility. The aim of this study was to determine the relationship between global and regional longitudinal strain and CIC. MethodsThis was a prospective study of 158 breast cancer patients undergoing chemotherapy with anthracyclines with or without adjuvant trastuzumab who underwent serial monitoring by transthoracic echocardiography with assessment of myocardial deformation. CIC was defined as a decrease in LVEF to <53%. Global longitudinal strain (GLS) was estimated using EchoPAC BT12 software on a GE Vivid E9 cardiac ultrasound system. Patients were classified according to the 2015 ASE/EACVI criteria as having impaired myocardial deformation when GLS was reduced (less negative), with a cutoff of ‐18%. ResultsDuring a mean follow‐up of 5.4 months (1‐48 months), the incidence of CIC was 18.9%. A decrease in GLS was observed during follow‐up for the entire cohort (baseline GLS ‐20.1±3.5% vs. ‐18.7±3.4% at last follow‐up assessment, p=0.001). A total of 97 patients (61.4%) were observed to have impaired myocardial deformation (GLS ≥18%) at some point during follow‐up. This decrease was more significant in patients who eventually developed CIC (GLS ‐17.2±2.5%, p=0.02). On analysis of regional strain, impaired contractility was observed in the septal (6 out of 6) and anterior (2 out of 3) segments. Multivariate logistic regression showed that patients who developed impaired longitudinal strain had a 4.9‐fold increased risk of developing CIC (odds ratio 4.88, confidence interval 1.32‐18.0, p=0.017). ConclusionsWorsening of myocardial deformation as assessed by speckle tracking is common in breast cancer patients undergoing chemotherapy, with predominantly septal and anterior wall involvement. Impaired myocardial deformation was independently associated with increased incidence of CIC.

Impaired right ventricular contractile function in childhood obesity and its association with right and left ventricular changes: a cine DENSE cardiac magnetic resonance study

BackgroundPediatric obesity is a growing public health problem, which is associated with increased risk of cardiovascular disease and premature death. Left ventricular (LV) remodeling (increased myocardial mass and thickness) and contractile dysfunction (impaired longitudinal strain) have been documented in obese children, but little attention has been paid to the right ventricle (RV). We hypothesized that obese/overweight children would have evidence of RV remodeling and contractile dysfunction.MethodsOne hundred and three children, ages 8–18 years, were prospectively recruited and underwent cardiovascular magnetic resonance (CMR), including both standard cine imaging and displacement encoding with stimulated echoes (DENSE) imaging, which allowed for quantification of RV geometry and function/mechanics. RV free wall longitudinal strain was quantified from the end-systolic four-chamber DENSE image. Linear regression was used to quantify correlations of RV strain with LV strain and measurements of body composition (adjusted for sex and height). Analysis of variance was used to study the relationship between RV strain and LV remodeling types (concentric remodeling, eccentric/concentric hypertrophy).ResultsThe RV was sufficiently visualized with DENSE in 70 (68%) subjects, comprising 36 healthy weight (13.6 ± 2.7 years) and 34 (12.1 ± 2.9 years) obese/overweight children. Obese/overweight children had a 22% larger RV mass index (8.2 ± 0.9 vs 6.7 ± 1.1 g/m2.7, p < 0.001) compared to healthy controls. RV free wall longitudinal strain was impaired in obese/overweight children (−16 ± 4% vs −19 ± 5%, p = 0.02). Ten (14%) out of 70 children had LV concentric hypertrophy, and these children had the most impaired RV longitudinal strain compared to those with normal LV geometry (−13 ± 4% vs −19 ± 5%, p = 0.002). RV longitudinal strain was correlated with LV longitudinal strain (r = 0.34, p = 0.004), systolic blood pressure (r = 0.33, p = 0.006), as well as BMI z-score (r = 0.28, p = 0.02), waist (r = 0.31, p = 0.01), hip (r = 0.40, p = 0.004) and abdominal (r = 0.38, p = 0.002) circumference, height and sex adjusted.ConclusionsObese/overweight children have evidence of RV remodeling (increased RV mass) and RV contractile dysfunction (impaired free wall longitudinal strain). Moreover, RV longitudinal strain correlates with LV longitudinal strain, and children with LV concentric hypertrophy show the most impaired RV function. These results suggest there may be a common mechanism underlying both remodeling and dysfunction of the left and right ventricles in obese/overweight children.

Abstract P224: The Association of Surgical versus Natural Menopause with Future Left Ventricular Structure and Function: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

Introduction: The association of surgical and natural menopause (SM and NM, respectively) with CVD outcomes is controversial. We assessed the hypothesis that CVD risk factor levels antecedent to menopause explain differences in future left ventricular (LV) structure and function parameters rather than type of menopause. Methods: We studied 825 premenopausal women (49% black) from the CARDIA study in 1990-1991 (baseline, mean age: 32 years) who later reached menopause by 2010-2011 and had echocardiographs at these two time points. Results: During 20 years of follow up, 508 women reached NM while 317 underwent SM (34% with bilateral oophorectomy). At baseline, women who later underwent SM were more likely to be black, younger, have higher mean values of systolic blood pressure, body mass index as well as lower mean HDL cholesterol, physical activity, parity and years of education. With the exception of race, no statistically significant differences were found by ovarian status among women with SM. In 1990-1991, no differences in LV structure and function were found between women who later reach NM or SM. In 2010-2011, women with SM had significantly higher LV mass, LV mass/volume ratio, E/e’ ratio, and impaired longitudinal and circumferential strain than women with NM (Table 1). No significant differences in these measures were found among SM by ovarian status. Controlling for baseline echocardiographic parameters, demographics, BMI, physical activity, parity, smoking, systolic blood pressure and age at menarche in linear regression models attenuated these differences between groups (Table 1). Further adjustment for age at menopause and hormone therapy use did not change these results. Conclusion: In this study, presurgical CVD risk factors among women with SM attenuated the adverse postsurgical measures of LV structure and function found among such women. These data suggest that premenopausal CVD risk factors rather than gynecologic surgery predispose women with SM to elevated future CVD risk.

Speckle-tracking imaging in patients with Eisenmenger syndrome

Adults with Eisenmenger syndrome have a survival advantage over those with idiopathic pulmonary arterial hypertension. Improved survival may result from preservation of right ventricular (RV) function. To assess left ventricular (LV) and RV remodelling in patients with Eisenmenger syndrome compared to a control population, using speckle-tracking imaging. Adults with Eisenmenger syndrome and healthy controls were enrolled into this prospective two-centre study. Patients with Eisenmenger syndrome with low acoustic windows, irregular heart rhythm or complex congenital heart disease were excluded. Clinical assessment, B-type natriuretic peptide (BNP), 6-minute walk test and echocardiography (including dedicated views to perform offline two-dimensional-speckle-tracking analysis) were performed on inclusion. Our patient population (n=37; mean age 42.3 ± 17 years) was mostly composed of patients with ventricular septal defect (37.8%) or atrial septal defect (35.1%). Compared with the control population (n=30), patients with Eisenmenger syndrome had reduced global LV longitudinal strain (-17.4 ± 3.5 vs. -22.4 ± 2.3; P<0.001), RV free-wall longitudinal strain (-15.0 ± 4.7 vs. -29.9 ± 6.8; P<0.001) and RV transverse strain (25.8 ± 25.0 vs. 44.5 ± 15.1; P<0.001). Patients with Eisenmenger syndrome also more frequently presented a predominant apical longitudinal and transverse strain profile. Among patients with Eisenmenger syndrome, those with a post-tricuspid shunt presented with reduced global LV longitudinal strain but increased RV transverse strain, compared to patients with pre-tricuspid shunt. Patients with Eisenmenger syndrome had impaired longitudinal RV and LV strain, but present a relatively important apical deformation. RV and LV remodelling, as assessed by speckle-tracking imaging, differ between patients with pre- and post-tricuspid shunt.

Subclinical Alterations of Cardiac Mechanics Present Early in the Course of Pediatric Type 1 Diabetes Mellitus: A Prospective Blinded Speckle Tracking Stress Echocardiography Study.

Diabetic cardiomyopathy substantially accounts for mortality in diabetes mellitus. The pathophysiological mechanism underlying diabetes-associated nonischemic heart failure is poorly understood and clinical data on myocardial mechanics in early stages of diabetes are lacking. In this study we utilize speckle tracking echocardiography combined with physical stress testing in order to evaluate whether left ventricular (LV) myocardial performance is altered early in the course of uncomplicated type 1 diabetes mellitus (T1DM). 40 consecutive asymptomatic normotensive children and adolescents with T1DM (mean age 11.5 ± 3.1 years and mean disease duration 4.3 ± 3.5 years) and 44 age- and gender-matched healthy controls were assessed using conventional and quantitative echocardiography (strain and strain rate) during bicycle ergometer stress testing. Strikingly, T1DM patients had increased LV longitudinal (p = 0.019) and circumferential (p = 0.016) strain rate both at rest and during exercise (p = 0.021). This was more pronounced in T1DM patients with a longer disease duration (p = 0.038). T1DM patients with serum HbA1c > 9% showed impaired longitudinal (p = 0.008) and circumferential strain (p = 0.005) and a reduced E/A-ratio (p = 0.018). In conclusion, asymptomatic T1DM patients have signs of hyperdynamic LV contractility early in the course of the disease. Moreover, poor glycemic control is associated with early subclinical LV systolic and diastolic impairment.

Paradoxical low-flow aortic stenosis is defined by increased ventricular hydraulic load and reduced longitudinal strain.

Patients with paradoxical low-flow severe aortic stenosis (PLF-AS) reportedly have higher left ventricular hydraulic load and more systolic strain dysfunction than patients with normal-flow aortic stenosis. This study investigates the relationship of systolic loading and strain to PLF-AS to further define its pathophysiology. One hundred and twenty patients (age 79 ± 12 years, 37% men) with an indexed aortic valve area (AVAi) of 0.6 cm/m or less and an ejection fraction of 50% or higher were divided into two groups based on indexed stroke volume (SVi): PLF-AS, SVi ≤ 35 ml/m, N = 46; normal-flow aortic stenosis, SVi > 35 ml/m, N = 74). Valvular and arterial load were assessed using multiple measurements, and strain was assessed using speckle-tracking echocardiography. Patients with PLF-AS were found to have more valvular load (lower AVAi, P = 0.028; lower energy loss coefficient, P = 0.001), more arterial load [decreased arterial compliance and increased systemic vascular resistance (SVR), both P < 0.001] and more total hydraulic load [increased valvuloarterial impedance (Zva), P < 0.001]. Transvalvular gradients and arterial pressures were similar. Longitudinal strain was lower in PLF-AS (P < 0.001), but circumferential and rotation strains were similar. On adjusted regression, AVAi, SVR and longitudinal strain were associated with PLF-AS [odds ratio (OR) = 1.34, P = 0.043; OR = 1.31, P = 0.004; OR = 1.34, P = 0.011, respectively]. When SVR and AVAi were replaced with Zva, longitudinal strain and Zva (OR = 1.38, P = 0.015; OR = 1.33, P < 0.001 for both, respectively) were associated with PLF-AS. Increased hydraulic load, from more severe valvular stenosis and increased vascular resistance, and longitudinal strain impairment are associated with PLF-AS and their interplay is likely fundamental to its pathophysiology.

Association of impaired left ventricular twisting-untwisting with vascular dysfunction, neurohumoral activation and impaired exercise capacity in hypertensive heart disease.

We investigated the association between left ventricular (LV) torsional deformation and vascular dysfunction, fibrosis, neurohumoral activation, and exercise capacity in patients with normal ejection fraction In 320 newly-diagnosed untreated hypertensive patients and 160 controls, we measured: pulse wave velocity (PWV); coronary flow reserve (CFR) by Doppler echocardiography; global longitudinal strain and strain rate, peak twisting, the percentage changes between peak twisting, and untwisting at mitral valve opening (%dpTw - UtwMVO ), at peak (%dpTw - UtwPEF ), and the end of early LV diastolic filling (%dpTw - UtwEDF ) by speckle tracking imaging; transforming growth factor (TGFb-1), metalloproteinase-9 (MMP-9), tissue inhibitor of matrix metalloptoteinase-1(TIMP-1), markers of collagen synthesis, and N-terminal pro-brain natriuretic peptide (NT-proBNP). Oxygen consumption (VO2 ), measured by means of cardiopulmonary exercise test, was assessed in a subset of 80 patients. The PWV, CFR, longitudinal strain and strain rate, %dpTw-UtwMVO , %dpTw-UtwPEF , and %dpTw-UtwEDF were impaired in hypertensive patients compared with controls. In multivariable analysis, CFR, PWV, LV mass, and systolic blood pressure were independent determinants of longitudinal strain, strain rate, and untwisting markers (P < 0.05). Increased TGFb-1 was related with increased collagen synthesis markers, TIMP-1 and MMP-9 and these biomarkers were associated with impaired longitudinal systolic strain rate, untwisting markers, CFR and PWV (P < 0.05). Delayed untwisting as assessed by reduced %dpTw - UtwEDF was related with increased NT-proBNP and reduced VO2 (P < 0.05). Impaired LV untwisting is associated with increased arterial stiffness and coronary microcirculatory dysfunction, and is linked to reduced exercise capacity and neurohumoral activation in hypertensive heart disease. A fibrotic process may be the common link between vascular dysfunction and abnormal myocardial deformation.

Prognostic Importance of Impaired Systolic Function in Heart Failure With Preserved Ejection Fraction and the Impact of Spironolactone.

Impairment in left ventricular systolic function has been described in heart failure (HF) with preserved ejection fraction (HFpEF), but its prognostic relevance is not known. We determined whether left ventricular longitudinal strain (LS) is predictive of cardiovascular outcomes in HFpEF beyond clinical and conventional echocardiographic measures. LS was assessed by 2-dimensional speckle-tracking echocardiography at baseline in 447 patients with HFpEF enrolled in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) trial. At a median follow-up of 2.6 years (interquartile range, 1.5-3.9 years), 115 patients experienced the primary composite outcome of cardiovascular death, HF hospitalization, or aborted cardiac arrest. Impaired LS, defined as an absolute LS <15.8%, was present in 52% of patients and was predictive of the composite outcome (adjusted hazard ratio, 2.14; 95% confidence interval, 1.26-3.66; P=0.005), cardiovascular death alone (adjusted hazard ratio, 3.20; 95% confidence interval, 1.44-7.12; P=0.004), and HF hospitalization alone (adjusted hazard ratio, 2.23; 95% confidence interval, 1.16-4.28; P=0.016) after adjustment for clinical and conventional echocardiographic variables. LS was the strongest echocardiographic predictor of the composite outcome. Exploratory analysis in a subset of 131 patients with follow-up LS assessed after 12 to 18 months demonstrated a trend toward improvement in LS associated with spironolactone in patients enrolled in the Americas but not in Russia or Georgia. Impaired left ventricular systolic function is a powerful predictor of HF hospitalization, cardiovascular death, or aborted cardiac arrest in HFpEF independent of clinical predictors. Impaired LS represents a novel imaging biomarker to identify patients with HFpEF at particularly high risk for cardiovascular morbidity and mortality. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00094302.

Assessment of cardiovascular physiology using magnetic resonance myocardial stress testing reveals impaired contractile reserve in patients with cirrhotic cardiomyopathy

Background Liver cirrhosis has been shown to affect cardiac performance. However cardiac dysfunction may only be revealed under stress conditions. The value of non-invasive stress tests in diagnosing cirrhotic cardiomyopathy is unclear since their ability to detect abnormalities has been inconsistent using different imaging modalities. We sought to investigate the response to pharmacological stimulation with dobutamine in patients with cirrhosis using cardiovascular magnetic resonance. Methods Thirty-six patients and eight controls were studied. Conventional volumetric and myocardial deformation parameter analysis using feature tracking at rest and during low to intermediate dose dobutamine stress were performed. Results Whilst volumetry based parameters were similar between patients and controls at rest, patients had a smaller increase in cardiac output during stress (2.2 l/min vs. 3.8 l/min), p=0.015). Chronotropic response was not different in the two groups (24 bpm vs 25 bpm, p=0.44). Ejection fraction increase was impaired in patients during 10 μg/Kg/min dobutamine as compared to controls (6.9% vs. 16.5%, p=0.007), but not with 20 μg/Kg/min (12.1% vs. 17.6%, p=0.12). This was paralleled by an impaired improvement in circumferential strain with low dose (median percentual increase of 14.4% vs. 30.9%, p=0.03), but not with intermediate dose dobutamine (median percentual increase of 29.4% vs. 33.9%, p=0.54). There was an impaired longitudinal strain increase in patients as compared to controls during low (median percentual increase of 6.6% vs 28.6%, p<0.001) and intermediate dose dobutamine (median percentual increase of 2.6%vs, 12.6% p=0.016). Radial strain response to dobutamine was similar in patients and controls (median percentual increase of 7.7% (-2.4-15.2) vs 13.6% (5.7-26), p=0.11 with10 μg/Kg/min of dobutamine and 4.3% (0.6-8.1) vs 3.1% (-0.2-9.3), p=0.82 with 20 μg/Kg/min of dobutamine). Conclusions Cirrhotic cardiomyopathy is characterized by an impaired cardiac pharmacological response that can be detected with magnetic resonance myocardial stress testing. Deformation analysis parameters may be more sensitive in identifying abnormalities in inotropic response to stress than conventional methods. Funding NA.