Left Ventricular Function In Patients Research Articles

Impact of cardiac rehabilitation on ventricular-arterial coupling and left ventricular function in patients with acute myocardial infarction.

To maintain efficient myocardial function, optimal coordination between ventricular contraction and the arterial system is required. Exercise-based cardiac rehabilitation (CR) has been demonstrated to improve left ventricular (LV) function. This study aimed to investigate the impact of CR on ventricular-arterial coupling (VAC) and its components, as well as their associations with changes in LV function in patients with acute myocardial infarction (AMI) and preserved or mildly reduced ejection fraction (EF). Effective arterial elastance (EA) and index (EAI) were calculated from the stroke volume and brachial systolic blood pressure. Effective LV end-systolic elastance (ELV) and index (ELVI) were obtained using the single-beat method. The characteristic impedance (Zc) of the aortic root was calculated after Fourier transformation of both aortic pressure and flow waveforms. Pulse wave separation analysis was performed to obtain the reflection magnitude (RM). An exercise-based, outpatient cardiac rehabilitation (CR) program was administered for up to 6 months. Twenty-nine patients were studied. However, eight patients declined to participate in the CR program and were subsequently classified as the non-CR group. At baseline, E' velocity showed significant associations with EAI (beta -0.393; P = 0.027) and VAC (beta -0.375; P = 0.037). There were also significant associations of LV global longitudinal strain (LV GLS) with EAI (beta 0.467; P = 0.011). Follow-up studies after a minimum of 6 months demonstrated a significant increase in E' velocity (P = 0.035), improved EF (P = 0.010), and LV GLS (P = 0.001), and a decreased EAI (P = 0.025) only in the CR group. Changes in E' velocity were significantly associated with changes in EAI (beta -0.424; P = 0.033). Increased aortic afterload and VA mismatch were associated with a negative impact on both LV diastolic and systolic function. The outpatient CR program effectively decreased aortic afterload and improved LV diastolic and systolic dysfunction in patients with AMI and preserved or mildly reduced EF.

Evaluation of Left Ventricular Function in Patients With Severe Aortic Stenosis Utilizing Automated Cardiac Motion Quantitation Techniques

ObjectiveThe objective of this study is to explore the patterns of alteration in left ventricular systolic function among patients with severe aortic stenosis (SAS) through the application of automatic myocardial motion quantification (aCMQ) techniques. Furthermore, we seek to ascertain dependable quantitative markers for the assessment of impaired left ventricular function in patients with SAS and an ejection fraction (EF) ≥ 60%. MethodsSeventy patients who underwent echocardiography and received a diagnosis of severe aortic stenosis (SAS) in the hospital from November 2021 to August 2022 were selected for the SAS group and categorized into three subgroups based on ejection fraction (EF)—SAS group with EF ≥ 60%, SAS group with EF ranging from 50% to 59%, and SAS group with EF < 50%. Concurrently, 30 healthy individuals were recruited at the hospital during the same timeframe to serve as the control group. Participants from both groups underwent standard transthoracic echocardiography to assess conventional echocardiographic parameters. Dynamic images were examined using automatic myocardial motion quantification (aCMQ) software to derive longitudinal peak strain (LPS) parameters, which were then subjected to statistical analysis. ResultsIn comparison to the control group participants, the measurements of ascending aorta diameter (AoD), left atrium diameter (LAD), interventricular septal end diastolic thickness (IVSd), left ventricular posterior wall end diastolic thickness (LVPWd), peak systolic velocity (Vmax), and mean pressure gradient (MPG) were significantly higher in the SAS groups (p < 0.05). When compared to participants in the SAS group with an EF ≥ 60%, the values of IVSd, LVPWd, Vmax, and MPG in the SAS group with EF ranging from 50% to 59% were significantly elevated (p < 0.05). Similarly, left ventricular end-diastolic diameter (LVEDD), the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity (E/e'), and the ratio of early to late diastolic mitral inflow velocities (E/A) in the SAS group with EF < 50% were significantly elevated (p < 0.05). The absolute values of longitudinal peak strain (LPS) in the SAS groups were significantly lower in comparison to those in the control group (p < 0.05). Furthermore, all measurements of left ventricular global longitudinal systolic peak strain (GLPS) showed a positive correlation with MPG, a moderate negative correlation with aortic valve area index (AVAI), and a moderate positive correlation with E/A. ConclusionsPatients with SAS and an EF < 50% exhibited the most profound impairment in left ventricular myocardial function. Utilizing the aCMQ technique enables the precise and quantitative evaluation of the severity of impaired left ventricular systolic function in patients within the SAS group with an EF ≥ 60%.

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.

Comparing the impact of left bundle branch area pacing and traditional left ventricular pacing on right heart function following dual-chamber pacemaker implantation

Objective: To compare the effects of left bundle branch area pacing (LBBaP) versus traditional right ventricular pacing (RVP) on left ventricular function in patients after dual-chamber pacemaker implantation. Methods: A retrospective cohort study was conducted on patients who underwent dual-chamber pacemaker implantation from March 2017 to April 2021 in Beijing Anzhen Hospital. The patients were divided into the LBBaP group and RVP group based on the placement of the ventricular lead. Follow-up was conducted until March 2022, comparing baseline and follow-up echocardiographic parameters, pacing parameters, and the incidence and timing of complications between the two groups. The complications included ventricular electrode perforation, dislocation, pericardial effusion, tricuspid valve perforation, etc. Results: A total of 163 patients aged (68.3±13.5) years were included, including 82 (50.3%) men, with 80 patients in the LBBaP group and 83 in the RVP group. Baseline left ventricular end-diastolic diameter ((50.49±4.95) mm vs. (47.43±8.15) mm, P=0.01) and left atrium (LA) ((33.14±5.94) mm vs. (30.18±3.92) mm, P=0.001) in the LBBaP group were significantly higher than those in the RVP group. Follow-up LA diameter ((37.10±6.70) mm vs. (40.10±8.90) mm, P=0.016) showed a statistically significant difference in the LBBaP group compared to the RVP group. There was no statistically significant difference between the two groups in baseline QRS duration(P=0.490). Postoperative QRS duration in the LBBaP group was significantly lower ((110.69±24.01) ms vs. (139.65±29.85) ms, P<0.010). Intraoperative threshold in the LBBaP group was significantly higher ((0.83±0.32) V/0.48 ms vs. (0.71±0.23) V/0.48 ms, P=0.004), while impedance was lower ((754.53±205.59) Ω vs. (905.41±302.75) Ω, P<0.01). Comparing with the RVP group, postoperative ventricular pacing ratio (VP) ((87.39±20.92) % vs. (79.49±25.76) %, P=0.034), threshold ((0.90±0.38) V/0.48 ms vs. (0.69±0.27) V/0.48 ms, P<0.01) in the LBBaP group were higher, and impedance ((507.45±77.37) Ω vs. (620.52±197.29) Ω, P<0.01) in the LBBaP group was lower. Postoperative follow-up period was 5 to 51 months, with a median follow-up time of 17 months. No statistically significant difference in overall complications between the LBBaP and RVP groups was found (13.8% (11/80) vs. 7.2% (6/83), P>0.05). The median time to occurrence of complications after surgery was significantly earlier in the LBBaP group (29.74 (95%CI 27.21-32.26) months vs. 46.17 (95%CI 42.48-49.86) months, P=0.030). Conclusion: LBBaP demonstrates more stable pacing parameters, substantial improvement in clinical left ventricular function, with a relatively higher threshold compared to traditional RVP, and complications occurs relatively early.

Echocardiographic Myocardial Work: A Novel Method to Assess Left Ventricular Function in Patients with Coronary Artery Disease and Diabetes Mellitus.

Myocardial ischemia caused by coronary artery disease (CAD) and the presence of metabolic abnormalities and microvascular impairments detected in patients with diabetes mellitus (DM) are a common cause of left ventricular (LV) dysfunction. Transthoracic echocardiography is the most-used, non-invasive imaging method for the assessment of myocardial contractility. The accurate evaluation of LV function is crucial for identifying patients who are at high risk or may have worse outcomes. Myocardial work (MW) is emerging as an alternative tool for the evaluation of LV systolic function, providing additional information on cardiac performance when compared to conventional parameters such as left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) because it incorporates deformation and load into its analysis. The potential of MW in various conditions is promising and it has gained increased attention. However, larger studies are necessary to further investigate its role and application before giving an answer to the question of whether it can have widespread implementation into clinical practice. The aim of this review is to summarize the actual knowledge of MW for the analysis of LV dysfunction caused by myocardial ischemia and hyperglycemia.

Application of Speckle Tracking Echocardiography for Evaluating Ventricular Function after Transcatheter Pulmonary Valve Replacement.

Pulmonary regurgitation usually leads to right heart dilatation and eventually right heart dysfunction, which is associated with a poor prognosis. Transcatheter pulmonary valve replacement is a developing treatment for pulmonary valve dysfunction that can take the place of traditional surgery and make up for the shortcomings of a large injury. Echocardiography plays a significant role in assessing ventricular function; however, conventional echocardiographic parameters have several limitations. Speckle tracking echocardiography has been regarded as a more accurate tool for quantifying cardiac function than conventional echocardiography. Therefore, the aim of this review was to summarize the application of speckle tracking echocardiography for evaluating right and left ventricular functions in patients after transcatheter pulmonary valve replacement.

Estimation of left ventricular functions in patients with subclinical hypothyroidism: a meta-analysis.

To evaluate left ventricular (LV) function in patients with subclinical hypothyroidism (ScH) compared to healthy individuals and to provide clinical hints for practitioners. PubMed, Embase, Cochrane Library, and Web of Science were systematically searched in this meta-analysis. Studies evaluating LV function in ScH patients were included. Standardized mean difference (SMD) and the 95% confidence intervals (CIs) were calculated as effect size. Heterogeneity and risks of bias of included studies were assessed. A total of 9 studies were identified as eligible. The SMD for fractional shortening (FS, %) was -0.21 (95% CI: -0.60, 0.17; z = -1.08, p = 0.2788). The pooled SMD for systemic vascular resistance (SVR, dynes/sec·cm-5) was -0.41 (95% CI: -1.31, 0.49; z = -0.89, p = 0.3744). The pooled SMD for early diastolic mitral flow velocity/late diastolic mitral flow velocity (E/A) ratio was -0.74 (95% CI: -1.09, -0.39; z = -4.13, p < 0.001). The pooled SMD for ejection fraction (EF, %) was -0.35 (95% CI: -0.59, -0.12; z = -2.95, p = 0.0032). ScH patients had significantly worse LV function parameters than healthy controls. These changes in LV function may be involved in the management of ScH.

Correlation of ventricular pacing burden and left ventricular function in patients with heart failure with reduced ejection fraction.

Pacemaker-induced cardiomyopathy is a well described phenomenon in patients with preserved ejection fraction at the time of permanent pacemaker implant. One of the identified risk factors for pacemaker-induced cardiomyopathy is the degree of ventricular pacing burden. However, it is unclear how a high right ventricular pacing burden affects patients with depressed left ventricular function at the time of pacemaker implantation. We sought to assess the relationship between right ventricular pacing and change in left ventricular function over time. We conducted an analysis of all patients who had received either a single or dual lead cardiac implantable electronic devices, excluding biventricular devices, and had a prior transthoracic echocardiogram demonstrating an ejection fraction of less than 50%. The primary end-point was the correlation between the percentage of ventricular pacing and the change in LV ejection fraction. Fifty eight patients with preceding heart failure had pacemakers implanted and had follow up echocardiograms. There was no correlation between the degree of ventricular pacing and the absolute change in LV function (r = .04, p = .979). None of the previously identified risk factors for pacemaker induced cardiomyopathy were predictive of a significant fall in ejection fraction. The degree of RV pacing and other established risk factors for pacemaker-induced cardiomyopathy in patients with normal left ventricular function at the time of implantation do not appear to carry the same risk in patients with pre-existing heart failure who receive either single or dual lead pacemakers.

Relationship of Adiponectin and High-Sensitivity CReactive Protein with Left Ventricular Dysfunction among Patients Undergoing Coronary Angiography

Background: Decreased levels of adiponectin (APN) and elevated levels of high-sensitivity C-reactive protein (hs-CRP) have been found as predictors of left ventricular dysfunction and cardiovascular events. Therefore, this study aimed to assess the relationship of APN and hs-CRP with the severity of left ventricular dysfunction among Egyptian patients undergoing coronary angiography (CAG).&#x0D; Methods: A cross-sectional study was conducted among 100 Egyptian patients who underwent clinically indicated CAG at Suez Canal University Hospital in Ismailia - Egypt, from May 2009 to December 2010. The left ventricular ejection fraction (LVEF) scoring system was used to assess left ventricular function based on echocardiographic findings. Pearson correlation was used to determine the relationship of APN and hs-CRP levels with echocardiographic LVEF score, and analysis of variance (ANOVA) was used to compare clinical and biochemical parameters among patients according to left ventricular function at P-value &lt;0.05.&#x0D; Results: The mean hs-CRP level had a significant weak negative correlation with the mean HDL-cholesterol level (r = -0.222; P = 0.048), while the mean APN level had a significant weak negative correlation with BMI (r = -0.269; P = 0.007) but a significant weak positive correlation with the mean hs-CRP level (r = 0.215; P = 0.031) and a significant moderate positive correlation with the mean HDL-cholesterol level (r = 0.302; P = 0.002). Left ventricular function in patients undergoing CAG was normal in 34 (34%), mildly impaired in 41 (41%) patients and moderately impaired in 25 (25%), with significantly different mean hs-CRP levels among the three groups (P = 0.025) that increased from normal to moderately impaired left ventricular function. However, there was no statistically significant difference in left ventricular function according to the mean level of APN.&#x0D; Conclusion: The hs-CRP level is negatively correlated with HDL-cholesterol, while APN is negatively correlated with BMI and hs-CRP but positively correlated with HDL-cholesterol in Egyptian patients undergoing CAG. The hs- CRP level correlates with the severity of left ventricular dysfunction. However, left ventricular function does not appear to correlate with APN levels.

Left ventricular afterload reduction by transcatheter aortic valve implantation acutely alleviates right ventricular pacing-induced left ventricular dysfunction in patients with aortic stenosis

Abstract Introduction In patients with left bundle branch block (LBBB) cardiac function has been found to be particularly sensitive to alterations in left ventricular (LV) afterload. Nevertheless, whether the detrimental hemodynamic effect of right ventricular pacing (RVP)-induced electromechanical dyssynchrony on LV function is also associated with afterload dependency, has not been investigated yet. Purpose Hence, in the current study we sought to examine the acute effect of RVP on LV function in patients with aortic stenosis (AS) before (with elevated afterload) and after (without elevated afterload) transcatheter aortic valve implantation (TAVI). Methods Patients with a previously implanted permanent pacemaker (PM) and significant AS referred for TAVI at our heart and vascular center university were screened for this observational study. Only those patients who had an intrinsic, regular, narrow QRS or right bundle branch block (RBBB) morphology rhythm were included. From 2022 March to 2023 February, nine patients with a DDD PM (with sick sinus syndrome and maintained AV conduction) and four patients with a VVI PM (with atrial fibrillation and complete AV block but stable junctional escape rhythm) were enrolled. Following TAVI, four patients were excluded due to the development of new-onset persistent LBBB. Transthoracic conventional and advanced echocardiography and non-invasive blood pressure monitoring were performed immediately before TAVI and on the second postoperative day. The measurements were carried out during intrinsic QRS rhythm and during frequency-matched RVP as well. Global longitudinal strain was determined by speckle-tracking echocardiography, then using LV pressure curves estimated from systolic blood pressure and mean aortic gradient, global myocardial work index (GMWI) was calculated to assess LV contractility. Results Mean aortic gradient was decreased after TAVI (40.2±3.6 vs. 6.7±1.3mmHg before vs. after TAVI, P&amp;lt;0.001) indicating successful reduction of LV afterload. Compared to the intrinsic QRS rhythm, RVP decreased GMWI before TAVI (GMWI: 1967±206 vs. 1240±174mmHg% intrinsic QRS vs. RVP, P&amp;lt;0.001) and after TAVI (GMWI: 1399±149 vs. 1020±121mmHg% intrinsic QRS vs. RVP, P=0.019) as well. Nevertheless, the extent of RVP-induced LV contractility impairment (expressed as ΔGMWI) was significantly alleviated after pressure unloading therapy (ΔGMWI: -37.1±6.6 vs. -24.5±7.8% before TAVI vs. after TAVI, P=0.024). Conclusion Our preliminary results indicate that RVP-induced LV dysfunction is afterload dependent. Hence, in patients with AS and a high percentage of RVP, TAVI might entail substantial functional improvement.

Frontiers in conduction system pacing: treatment of long PR in patients with heart failure.

Patients with heart failure who have a prolonged PR interval are at a greater risk of adverse clinical outcomes than those with a normal PR interval. Potential mechanisms of harm relating to prolonged PR intervals include reduced ventricular filling and also the potential progression to a higher degree heart block. There has, however, been relatively little work specifically focusing on isolated PR prolongation as a therapeutic target. Secondary analyses of trials of biventricular pacing in heart failure have suggested that PR prolongation is both a prognostic marker and a promising treatment target. However, while biventricular pacing offers an improved activation pattern, it is nonetheless less physiological than native conduction in patients with a narrow QRS duration, and thus, may not be the ideal option for achieving therapeutic shortening of atrioventricular delay. Conduction system pacing aims to preserve physiological ventricular activation and may therefore be the ideal method for ventricular pacing in patients with isolated PR prolongation. Acute haemodynamic experiments and the recently reported His-optimized pacing evaluated for heart failure (HOPE HF) Randomised Controlled Trial demonstrates the potential benefits of physiological ventricular pacing on patient symptoms and left ventricular function in patients with heart failure.

Clinical outcomes of left bundle branch area pacing compared with biventricular pacing in patients with heart failure requiring cardiac resynchronization therapy: systematic review and meta-analysis

Abstract Background Biventricular pacing (BVP) is recommended from the most recent ESC guidelines as the first line pacing strategy in patients with heart failure (HF) that require cardiac resynchronization therapy (CRT). (1) Many studies have shown its beneficial effects regarding morbidity and mortality in this population. (2, 3) However, 10% of patients cannot be treated by BVP due to unsuitable coronary sinus vein, while 30-40% are non-responders to BVP and experience no benefit from this treatment.(4) Left bundle branch area pacing (LBBAP) is a new pacing modality (5) that can achieve narrow QRS and improve left ventricular function in patients with HF, by engaging the intrinsic conduction pathway of the heart. Also, it appears to have better results in electrical and mechanical synchrony compared with BVP. Purpose We conducted a systematic review and meta-analysis to compare the two pacing modalities in terms of hard clinical outcomes, in patients with heart failure that require CRT. Methods Medline, Embase, Cochrane Central Register of Controlled Trials and Web of Science databases were systematically searched for studies comparing LBBAP with BVP for CRT in patients with HF. Outcomes of interest were all-cause mortality, Heart Failure Hospitalizations (HFH) and New York Heart Association (NYHA) class improvement. Two independent investigators identified studies, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias 2 tool for randomized clinical trials and the Newcastle-Ottawa-Scale for observational studies. Pairwise meta-analysis was conducted using random and fixed effects models. Risk Ratios (RRs) and weighted mean difference (WMD) with 95% confidence intervals (CIs) were used to report dichotomous and continuous variables respectively. Heterogeneity was assessed with the I² statistic. Results In total, 764 studies were retrieved and finally 9 trials with 992 individuals (365 in LBBAP and 627 in BVP group) were included in the analysis. The mean follow-up duration was 13 ± 5.82 months and the average procedural success rate in the LBBAP group was 89.8%. The baseline characteristics were similar between the two groups. Pooled analysis showed that the two methods had no difference in terms of all-cause mortality (RR:0.87 CI 95%:0.38 to 2.02; I²=0%; p=0.750, Figure 1) with 8 (2.4%) vs 17 (2.9%) events occurring in LBBAP and BVP group respectively. However, LBBAP was found to have significantly lower risk for HFH (RR:0.58 CI 95%:0.38 to 0.91; I²=0%; p=0.020, Figure 2A) and to achieve more improvement in NYHA class compared with BVP (WMD: -0.40, CI 95%: -0.68 to -0.12; I²=72%; p=0.005; Figure 2B). Conclusions To the best of our knowledge this is the first meta-analysis that assesses exclusively the clinical outcomes of LBBAP compared to BVP in such an important number of patients. LBBAP presents better outcomes in HFH and NYHA class improvement, but it has no difference in all-cause mortality in comparison with BVP.Figure 1.All-cause mortalityFigure 2.A.HFH B.NYHA class improvement

Abstract 12947: Restoration of Sinus Rhythm Significantly Improves Left Ventricular Function in Patients With Very Low Ejection Fraction

Introduction: Left ventricular (LV) dysfunction is a common sequelae of supraventricular tachycardia, especially atrial fibrillation (AF). We evaluated the impact of restoration of sinus rhythm following successful catheter ablation on LV function in AF patients with ejection fraction of ≤20%. Methods: Consecutive AF patients with LVEF ≤20% undergoing their first catheter ablation were included in the study. All received isolation of pulmonary veins, left atrial posterior wall and superior vena cava. Additionally, non-PV triggers were ablated at the operator’s discretion. Echocardiogram was performed at baseline and 6 months post-ablation to measure the LVEF. Arrhythmia-monitoring was performed at 1, 3 and 6 months with event recorders, 12-lead ECG and 7-day Holter monitoring. Results: A total of 63 patients undergoing catheter ablation for AF were included (age: 62.5 ± 9.9 years, male: 82.5%). Majority of the patients had LVEF of ≤15% (n=48, 76%); remaining 15 patients had LVEF of 16-20%. Mean LA diameter was 4.94 ± 0.57 cm and 82.5% of patients had non-paroxysmal type of AF. Median duration of AF was 27 months. Follow-up echocardiogram at 6 months of follow-up detected significant improvement in LVEF [Mean difference: 15.2 ± 11.7% (p &lt; 0.001)]. All patients were arrhythmia-free at that time point: 47 (74.6%) off-drugs and 16 (25.4%) patients on previously ineffective anti-arrhythmic drugs. Conclusion: Restoration of sinus rhythm following successful catheter ablation was associated with significant improvement in LVEF in patients with severe LV dysfunction

Abstract 12142: Treadmill Exercise Stress Echocardiography Exposes Impaired Left Ventricular Function in Patients Recovering From Hospitalization for COVID-19 versus Historical Controls

Usual clinical testing rarely reveals persisting cardiac abnormalities in patients after hospitalization for Covid-19. Such testing may overlook residual changes responsible for increased adverse cardiac events seen post-discharge. To further elucidate patients’ long-term status, we performed exercise stress echocardiography (ESE) in 15 patients age 30-63 without myocarditis 3 to 31 months after hospital discharge. We compared patient outcomes to published data in healthy controls (HC) exercising according to the same protocol. Patients’ treadmill exercise (Bruce protocol), averaging 8.2 min, was halted by dyspnea or fatigue. Baselines before stress averaged the same in recovering patients (RP) and HC except for heart rate (HR): 81±13 bpm for RP and 63±8 for HC (p&lt;0.0001). Peak stress values in RP were compared with HC: Stress revealed significantly lower LVEF and raised E/e’ soon after peak effort in RP compared with HC performing the same exercise. Thus, when stressed, patients with no known cardiac impairment before or during Covid-19 hospitalization showed modest but consistently diminished systolic contractile function and diastolic LV compliance during recovery compared to HC. Peak HR during stress was significantly elevated in RP vs. HC; peak SBP also trended higher. Average systolic pulmonary artery pressures among RP remained normal. Our measurements during ESE uniquely identified residual abnormality in cardiac contractile function not evident in the unstressed condition. This finding exposes a previously-unrecognized residual influence of Covid-19 that may relate to underlying autonomic dysfunction, microvascular disease, or diffuse interstitial changes after subclinical myocarditis and may have long-term implications for clinical management and later prognosis.

Switch to gliflozins and biventricular function improvement in patients with chronic heart failure and diabetes mellitus.

SGLT2 inhibitors have been shown to reduce hospitalisation in patients with chronic heart failure (CHF). The cardioprotective mechanisms of gliflozins however have not been fully elucidated. The aim of this study was therefore to evaluate the effect of SGLT2 inhibitors on right and left ventricular function in patients with diabetes and HF. Seventy-eight patients with diabetes and CHF were enroled in the study and followed up; 38 started treatment with SGLT2i, while the remaining 40 continued their previous antidiabetic therapy. All patients underwent conventional, TDI and strain echocardiography in an ambulatory setting, at the beginning and after 3 months of therapy with SGLT2i. After 3 months of therapy with SGLT2i, echocardiographic parameters assessing both left and right ventricular dimensions and function were found as significantly improved in patients switching to SGLT2i than control group: LVEF (45 ± 9% vs. 40 ± 8%, p < 0.001), LVEDD (54 ± 6.5 vs. 56 ± 6.5 mm, p < 0.01), GLS (-13 ± 4% vs. -10 ± 3%, p < 0.001), TAPSE (21 ± 3 vs. 19 ± 3 mm, p < 0.001), RV S' (12.9 ± 2.5 vs 11.0 ± 1.9 cm/sec, p < 0.001)and PAsP (24 ± 8 vs. 31 ± 9 mmHg, p < 0.001). Also mitral (1.0 ± 0.5 vs. 1.3 ± 0.5, p < 0.01) and tricuspid regurgitation (1.0 ± 0.5 vs. 1.3 ± 0.5, p < 0.01) improved after SGLT2i therapy. Changes were not statistically significant in patients not treated with SGLT2i (p n.s. in all cases). In a real-world scenario, treatment with SGLT2i in patients with CHF and diabetes is associated with an improvement in both left and right ventricular function assessed at echocardiography. These data may explain potential anti-remodelling effects of gliflozins.

TCT-623 Effects of Complete Revascularization in Relation to Left Ventricular Function in Patients With STEMI and Multivessel Disease: Data from the COMPLETE Randomized trial

TCT-623 Effects of Complete Revascularization in Relation to Left Ventricular Function in Patients With STEMI and Multivessel Disease: Data from the COMPLETE Randomized trial

Effect of Empagliflozin and Pioglitazone on left ventricular function in patients with type two diabetes and nonalcoholic fatty liver disease without established cardiovascular disease: a randomized single-blind clinical trial

BackgroundNonalcoholic fatty liver disease (NAFLD) is a complex metabolic disorder that increases the risk for cardiovascular disease in patients with type 2 diabetes mellitus (T2DM). Global longitudinal strain (GLS) is an indicator of left ventricular (LV) mechanics and can detect subclinical myocardial dysfunction. We compared the effects of pioglitazone and empagliflozin on GLS in patients with T2DM and NAFLD without established atherosclerotic cardiovascular disease.MethodsThis study was a 24-week randomized, single-blind, and parallel-group (1: 1 ratio) clinical trial. Seventy-three participants with T2DM (being treated with metformin) and NAFLD but without established atherosclerotic cardiovascular disease (ASCVD) were randomized to empagliflozin or pioglitazone. Liver steatosis and fibrosis were measured using transient elastography, and GLS was measured by echocardiography. The primary endpoint was the change in GLS from baseline to week 24. Secondary end points include changes in controlled attenuation parameter (CAP) and Liver stiffness measure (LSM).ResultsIn this study, GLS improved by 1.56 ± 2.34% (P < 0.01) in the pioglitazone group and 1.06 ± 1.83% (P < 0.01) in the empagliflozin group without a significant difference between the two groups (P = 0.31). At baseline, GLS was inversely associated with the severity of liver fibrosis: r = − 0.311, P = 0.007. LSM in the pioglitazone and empagliflozin group [(-0.73 ± 1.59) and (-1.11 ± 1.33)] kpa (P < 0.01) decreased significantly. It was without substantial difference between the two groups (P = 0.26). Empagliflozin and pioglitazone both improved controlled attenuation parameter. The improvement was more critical in the empagliflozin group: -48.22 + 35.02 dB/m vs. -25.67 + 41.50 dB/m, P = 0.01.ConclusionSubclinical cardiac dysfunction is highly important in patients with T2DM and with NAFLD. Empagliflozin and Pioglitazone improve LV mechanics and fibrosis in patients without established ASCVD. This has a prognostic importance on cardiovascular outcomes in high-risk patients with T2DM. Moreover, empagliflozin ameliorates liver steatosis more effectively them pioglitazone. This study can serve as a start point hypothesis for the future. Further studies are needed to explore the concept in larger populations.Trial registration: This trial was registered in the Iranian Registry of Clinical Trials (IRCT): “A Comparison between the Effect of Empagliflozin and Pioglitazone on Echocardiographic Indices in Patients with Type 2 Diabetes Mellitus and Nonalcoholic Fatty Liver Disease” IRCT20190122042450N5, 29 November 2020. https://www.irct.ir/search/result?query=IRCT20190122042450N5.

Assessment of left ventricular function in patients with type 2 diabetes mellitus by non-invasive myocardial work.

Diabetes mellitus (DM) is a chronic disease that poses a serious risk of cardiovascular diseases. Therefore, early detection of impaired cardiac function with non-invasive myocardial imaging is critical for improving the prognosis of patients with DM. This study aimed to assess the left ventricular (LV) function in patients with type 2 diabetes mellitus (T2DM) by non-invasive myocardial work technique. In all, 67 patients with T2DM and 28 healthy controls were included and divided into a DM group and a control group. Two-dimensional dynamic images of apical three-chamber view, apical two-chamber view, and apical four-chamber view were collected from all subjects, consisting of at least three cardiac cycles. LV myocardial strain parameters, including global longitudinal strain (GLS) and peak strain dispersion (PSD), as well as myocardial work parameters, including global constructive work (GCW), global wasted work (GWW), global work index (GWI), and global work efficiency (GWE), were obtained and analyzed. A total of 15 subjects were randomly selected to assess intra-observer and inter-observer consistency of myocardial work parameters and strain parameters, which showed excellent results (intra-class correlation coefficients: 0.856 - 0.983, P<0.001). Compared with the control group, the DM group showed significantly higher PSD (37.59 ± 17.18 ms vs. 27.72 ± 13.52 ms, P<0.05) and GWW (63.98 ± 43.63 mmHg% vs. 39.28 ± 25.67 mmHg%, P<0.05), and lower GWE (96.38 ± 2.02% vs. 97.72 ± 0.98%, P<0.001). Furthermore, the PSD was positively correlated with GWW (r = 0.565, P<0.001) and negatively correlated with GWE (r = -0.569, P<0.001). Uncoordinated LV myocardial strain, higher GWW, and lower GWE in patients with T2DM may serve as indicators for the early assessment of cardiac impairment in T2DM.

Role of collateral circulation in the recovery of left ventricular function after recanalization of chronic coronary total occlusion

Aim. To obtain extended data on the impact of collateral circulation on the recovery of left ventricular (LV) function after recanalization of chronic coronary total occlusion (CTO), especially in patients with reduced left ventricle ejection fraction (LVEF).Material and methods. This single-center, prospective, non-randomized study included 20 patients with single-vessel CTO with reduced LVEF (&lt;50%), confirmed by magnetic resonance imaging (MRI), who underwent successful recanalization. All patients were divided into 2 groups depending on the severity of collateral circulation. After 1, 3 and 6 months, MRI was repeated to assess LV function recovery.Results. All patients had prior myocardial infarction, while in 70% of cases — in the area of the occluded artery. A previous attempt to recanalize CTO was noted in 30%. The mean baseline LVEF according to echocardiography was 38,80±6,72%. The most common target vessel was the right coronary artery (n=17, 85%), followed by the circumflex and anterior descending arteries — 1 (5%) and 2 (10%) patients, respectively. In the group with high collateral circulation, the initial LVEF according to MRI was higher compared to the group with mild collateral circulation (35,8±7,33% vs 30,7±8,82%, p=0,17). After 6 months, MRI showed significant changes in end-diastolic volume (from 226±71,1 ml to 203±55,2 ml) and LV endsystolic volume (from 153±72,8 ml to 118±57,6 ml), as well as mean increase in LVEF by 3,3%, 4,8% and 5,2% at 1, 3 and 6 months, respectively (p=0,01 compared with baseline). The predictors of LVEF recovery in multivariate regression analysis were the initial LVEF according to MRI, and the filling rate of distal CTO bed on coronary angiography (R2=0,63).Conclusion. Successful percutaneous coronary intervention with CTO improves LV function in patients with ischemic cardiomyopathy, regardless of the degree of collateral circulation. LV function recovery generally occurs within 3 months after revascularization.

Evaluation of left ventricular function in patients with coronary slow flow: A systematic review and meta-analysis.

Coronary slow flow (CSF) is an angiographic finding defined as delayed distal vessel perfusion without severe stenosis of the epicardial coronary arteries. However, definite alterations in left ventricular (LV) function in patients with CSF remains inconsistent. This study aimed to clarify the changes in LV function in patients with CSF and explore the factors that may influence LV function. PubMed, Embase, and Cochrane Library databases were systematically searched. Standardized mean differences and 95% confidence intervals (CI) for the LV function parameters were calculated. Subgroup analysis, meta-regression analysis, and correlation analysis were performed to explore the factors influencing LV function. Twenty-two studies (1101 patients with CSF) were included after searching three databases. In patients with CSF, LV ejection function in patients with CSF was marginally lower (61.8%; 95% CI: 61.0%, 62.7%), global longitudinal strain was decreased (-18.2%; 95% CI: -16.7%, -19.7%). Furthermore, left atrial diameter, left atrial volume index, and E/e' were significantly increased, while E/A and e' were significantly decreased. The mean thrombolysis in myocardial infarction frame count (TFC) was linearly associated with LV function; the larger the mean TFC, the greater the impairment of LV function. Left ventricular systolic and diastolic functions were impaired in patients with CSF, and this impairment was aggravated with increasing mean TFC.