Left Ventricular Systolic Dyssynchrony Research Articles

Potential Underestimation of Left Ventricular Mechanical Dyssynchrony in Dyssynchrony and Outcomes Assessment.

Left ventricular (LV) mechanical dyssynchrony (LVMD) is fundamental to the progression of heart failure and ventricular remodeling. The status of LVMD in different patterns of bundle branch blocks (BBB) is unclear. In this study, we analyzed the relationship between LVMD and left ventricular systolic dysfunction using real-time three-dimensional echocardiography (RT-3DE). RT-3DE and conventional two-dimensional echocardiography were performed on 68 patients with left bundle branch block (LBBB group), 106 patients with right bundle branch block (RBBB group), and 103 patients without BBB (Normal group). The RT-3DE data sets provided time-volume analysis for global and segmental LV volumes. The LV systolic dyssynchrony index (LVSDI) was calculated using the standard deviation (SD) and maximal difference (Dif) of time to minimum segmental volume (tmsv) for LV segments adjusted by the R-R interval. LVMD was considered if the LVSDI (Tmsv-16-SD) was greater than or equal to 5%. LVSDI is negatively and significantly correlated with left ventricular ejection fraction (LVEF), but not with BBB or QRS duration. The proportion of LVMD in the LBBB, RBBB, and Normal group was 30.88%, 28.30%, and 25.24%, respectively, and there was no significant difference. In dilated cardiomyopathy, LVMD is more closely related to LVEF reduction than QRS morphology and duration.

Association of epicardial fat volume with subclinical myocardial damage in patients with type 2 diabetes mellitus.

In type 2 diabetes mellitus (T2DM) patients, left ventricular systolic dyssynchrony (LVSD) with normal left ventricular ejection fraction (LVEF) and normal myocardial perfusion could referred to as subclinical myocardial damage, which is difficult to diagnose at an early stage. Epicardial adipose tissue, a distinctive heart-specific visceral fat, is closely related to various cardiovascular diseases. The objective of this study was to investigate the correlation between epicardial fat volume (EFV) and subclinical myocardial damage in T2DM patients. This retrospective cross-sectional study included 117 T2DM patients with normal myocardial perfusion by single photon emission computed tomography-computed tomography (SPECT-CT) and normal LVEF by echocardiography. The study was conducted from January 2018 to December 2022. Patient data were collected through electronic medical records including basic patient information, medical history, laboratory tests, and medication data. The EFV was quantified through a non-contrast CT scan. Quantitative indicators of LVSD including phase standard deviation (PSD) and phase histogram bandwidth (PBW) were obtained through phase analysis of the gated rest myocardial perfusion imaging (MPI). Additionally, 83 healthy individuals at the same time were selected to gain the reference threshold of LVSD indicators (13.1° for PSD and 37.6° for PBW). Univariate and multivariable logistic regression models were performed to analyze factors influencing LVSD. A generalized additive model (GAM) was applied to explore the relationship between EFV and LVSD. The receiver operating characteristic (ROC) curve was used to analyze the diagnostic value of EFV for LVSD. Among all patients, 32 (27.4%) patients had LVSD. Compared with the non-LVSD group, the body mass index (BMI) and EFV were higher in the LVSD group (25.83±2.66 vs. 23.94±3.13 kg/m2; 142.41±44.17 vs. 108.01±38.24 cm3, respectively, both P<0.05). Multivariate regression analysis revealed that EFV was independently associated with LVSD [odds ratio (OR) =1.19; 95% confidence interval (CI): 1.06-1.34; P=0.003]. Age, BMI, incidence of hypertension, and LVSD were increased with tertiles of EFV (all P<0.05). The GAM indicated a linear association between EFV and LVSD. The ROC curve analysis concluded that the area under the curve (AUC) of EFV for predicting subclinical myocardial damage in T2DM patients was 0.732 (95% CI: 0.633-0.831, P<0.001), with the optimal threshold of 122.26 cm3, sensitivity of 71.9%, and specificity of 69.4%. EFV is an independent risk factor for LVSD in T2DM patients with normal LVEF and normal MPI, which could potentially serve as a novel imaging marker and a potential therapeutic target for subclinical myocardial damage.

Left ventricular systolic dyssynchrony: a novel imaging marker for early assessment of myocardial damage in Chinese type 2 diabetes mellitus patients with normal left ventricular ejection fraction and normal myocardial perfusion

ObjectivesMyocardial damage is the important cause of heart failure (HF) in type 2 diabetes mellitus (T2DM), which is difficult to early diagnose, especially in T2DM with normal left ventricular ejection fraction (LVEF) and normal myocardial perfusion. The goal was to evaluate myocardial damage in T2DM with normal LVEF and normal myocardial perfusion by detecting left ventricular systolic dyssynchrony (LVSD), and find out the risk factors associated with LVSD. MethodsThis study included 95 T2DM with normal LVEF, normal myocardial perfusion. 69 consecutive individuals without T2DM and CAD were enrolled as the control group with age-, sex- and BMI-matched. All participants underwent stress/rest 99mtechnetium-sestamibi (99mTc-MIBI) gated myocardial perfusion imaging (GMPI) and two-dimensional echocardiography within 1 week. Clinical data including age, gender, BMI, duration of diabetes, chronic diabetic complications, glycated haemoglobin A1c (HbA1c), fast blood glucose (FBG) and Brain Natriuretic Peptide (BNP) were collected from medical records. Left ventricular synchrony parameters were acquired, including phase standard deviation (PSD) and phase histogram bandwidth (PBW) by rest GMPI. ResultsPSD and PBW in T2DM group were significantly higher than control group (P < .05). LVSD was detected in 20 (21%) T2DM patients. Compared to non-LVSD T2DM group, LVSD T2DM group had higher BMI, higher prevalence of BNP ≥ 35 pg/mL and chronic diabetic complications (P < .05). BNP ≥ 35 pg/mL had mild positive association with LVSD (r = 0.318, P = .004). In multivariate logistic regression, chronic diabetic complications and high BMI (> 23.4 kg/m2) were independent risk factors of LVSD (OR 5.64, 95% CI 1.58-20.16, P = .008; OR 6.77, 95% CI 1.59-28.89, P = .010). ConclusionsLVSD existed in T2DM patients with normal LVEF and normal myocardial perfusion. Chronic diabetic complications and high BMI (> 23.4 kg/m2) were the independent risk factors of LVSD. LVSD based on GMPI can be the novel imaging marker to early assess myocardial damage in T2DM patients.

Three-dimensional echocardiographic assessment of left ventricular geometric changes following acute myocardial infarction

Acute ST-segment elevation myocardial infarction (STEMI) is associated with left ventricular (LV) structural and functional consequences. We aimed to elucidate LV geometric changes following STEMI using three-dimensional (3D) echocardiography (3DE) and to assess their functional implications using two-dimensional (2D) speckle tracking echocardiography (STE). The study included 71 patients with STEMI who underwent baseline and 6-month follow-up 2D- and 3DE. Measured parameters included LV dimensions, biplane volumes, wall motion assessment, 2D LV global longitudinal strain (GLS), and 3D LV volumes, sphericity index and systolic dyssynchrony index. According to 3DE, LV geometric changes were classified as, adverse remodeling, reverse remodeling, and minimal LV volumetric changes. The occurrence of in-hospital and follow-up major adverse cardiovascular events (MACE) was assessed among the study population. The incidence of developing adverse remodeling was 25.4% while that of reverse remodeling was 36.6%. Adverse remodeling patients had significantly higher in-hospital MACE. Reverse remodeling was associated with significantly improved GLS, that was less evident in those with minimal LV geometric changes, and non-significant improvement for adverse remodeling group. LV baseline 2D GLS significantly correlated with follow-up 3D volumes among both reverse and adverse remodeling groups. Female gender and higher absolute GLS change upon follow-up were significantly associated with reverse remodeling. ROC-derived cutoff for adverse remodeling reallocated a substantial number of patients from the minimal change group to the adverse remodeling. Following acute STEMI, two-dimensional GLS was associated with and potentially predictive of changes in LV volumes as detected by three-dimensional echocardiography.

Subclinical hypothyroidism and its relationship with therapy failure in patients underwent cardiac resynchronization therapy.

Cardiac resynchronization therapy (CRT) is used in patients with heart failure (HF), an important problem in cardiology practice, with reduced left ventricular systolic dysfunctions and left ventricular dyssynchrony to improve morbidity and mortality. Thyroid diseases have undeniable effects on cardiac functions. So, we aimed to evaluate the effect of subclinical hypothyroidism on CRT response in HF patients in this study. After the exclusion, 386 consecutive patients who received first-time CRT-defibrillator (CRT-D) or CRT-pacemaker (CRT-P) were retrospectively included. Known overt hypothyroidism or hyperthyroidism patients were excluded. The response of CRT was defined as a relative increase (≥15%) or absolute increase (≥10%) in left ventricular ejection fraction (LVEF) from implantation to one-year after follow-up. Diabetes mellitus, atrial fibrillation and coronary artery disease ratios were similar between responder vs. non-responder groups. Thyroid stimulating hormone (TSH) levels were higher (p <0.005) in non-responder group. Responder group had higher baseline LVEF (p <0.001), and follow-up LVEF (p <0.001) and longer baseline QRS interval (p =0.004), but similar post-implant QRS interval duration (p >0.005) with non-responder group. Baseline QRS interval (p =0.002), baseline LVEF (p <0.001) and the presence of subclinical hypothyroidism (SCH) (p =0.001) were independent predictors of CRT response. Adding SCH as a risk factor to our baseline risk modelling has an independent prognostic impact to predict non-responder patients (p =0.01). Presence of the SCH may be an important predictor of non-response in patients undergoing CRT. Evaluating the risk factors associated with non-response to CRT may be logical in identifying patients who obtain maximum benefit from CRT treatment.

Cardiac magnetic resonance imaging in patients with left bundle branch block: Patterns of dyssynchrony and implications for late gadolinium enhancement imaging.

Left bundle branch block (LBBB) is a ventricular conduction delay with high prevalence. Aim of our study is to identify possible recurring patterns of artefacts in late gadolinium enhancement (LGE) imaging in patients with LBBB who undergo cardiac magnetic resonance imaging (MRI) and to define parameters of mechanical dyssynchrony associated with artefacts in LGE images. Fifty-five patients with LBBB and 62 controls were retrospectively included. Inversion time (TI) scout and LGE images were reviewed for artefacts. Dyssynchrony was identified using cardiac MRI by determining left ventricular systolic dyssynchrony indices (global, septal segments, and free wall segments) derived from strain analysis and features of mechanical dyssynchrony (apical rocking and septal flash). Thirty-seven patients (67%) with LBBB exhibited inhomogeneous myocardial nulling in TI scout images. Among them 25 (68%) patients also showed recurring artefact patterns in the septum or free wall on LGE images and artefacts also persisted in 18 (72%) of those cases when utilising phase sensitive inversion recovery. Only the systolic dyssynchrony index of septal segments allowed differentiation of patient subgroups (artefact/no artefact) and healthy controls (given as median, median ± interquartile range); LBBB with artefact: 10.44% (0.44-20.44%); LBBB without artefact: 6.82% (-2.18-15.83%); controls: 4.38% (1.38-7.38%); p < 0.05 with an area under the curve of 0.863 (81% sensitivity, 89% specificity). Septal flash and apical rocking were more frequent in the LBBB with artefact group than in the LBBB without artefact group (70 and 62% versus 33 and 17%; p < 0.05). Patients with LBBB show recurring artefact patterns in LGE imaging. Use of strain analysis and evaluation of mechanical dyssynchrony may predict the occurrence of such artefacts already during the examination and counteract misinterpretation.

Optimization of biventricular cardiac resynchronization improves cardiac power and atrial kinetics in patients with systolic heart failure with often hospitalizations for decompensation

Abstract Cardiac resynchronization therapy (CRT) reduces symptoms and improves left ventricular function in patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony. In this work the biochemical, clinical and echocardiographic outcome of optimizing CRT (optCRT) function by the optimal VTI value of left ventricular outflow track. Methods 80 NYHA III patients (68±10 years; 75% men; 53% ischemic cardiomyopathy-ICM), under optimal tolerated medical therapy, with standard BVP indication, having been implanted with a CRT system. Echocardiographic measurements, including aortoventricular coupling (VAC) calculation, 6-min-walking-test and quality of life (MLHF questionnaire) were measured at baseline, 6 months on optCRT. Cardiac power (CP) was calculated according the equation: CP=Cardiac Output x Mean Aortic Pressure/451. Results End-systolic volume of left ventricle was reduced (p=0.001) in both ischemic and non-ICM; while max left atrial volume was reduced only in non-ICM patients (72.1±32 to 65.8±30, p=0.04). Global longitudinal strain was improved in non ICM patients (p=0.015). Systolic strain of right ventricle was improved in non-ICM (9.4±2.2 to 10.7±2.3 vs. 8.7±3 to 8.9±3.2, p=0.03 for non-ICM); while left atrial function and the ratio E to E TDI of mitral annulus were not improved in either group. Non-ICM patients improved VAC (baseline: 1,36±0,3; CRT: 1.11±0.2; p=0.01) and CP (baseline 660±160 to 782±260, p=0.001); while no significant improvement was detected to ICM patients. 6-min-walk test was improved up to 30% (p=0.05). NtproBNP levels were decreased only in non-ICM patients (1759±1060.9 to 1015±650 vs. 2063,8±1800 to 1950.7±2342, p=0.001). MLHFQ improved in non-ICM patients (p=0.015); while non-significant improvement was detected in ICM patients. Conclusion Optimization of cardiac resynchronization therapy based on stroke volume maximization benefits quality of life and exercise tolerance, mainly in non-ICM. GLPS and aorto-ventricular coupling was improved in non-ischemic patients, reflecting the better adaptation of CRT in this population. Thus, CRT optimization by echocardiographic evaluation may be useful in improve clinical status and quality of life in CRT non-responder patients. Funding Acknowledgement Type of funding sources: None.

Longitudinal evaluation of diastolic dyssynchrony by SPECT gated myocardial perfusion imaging early after acute myocardial infarction and the relationship with left ventricular remodeling progression in a swine model

BackgroundLeft ventricular diastolic dyssynchrony (LVDD), a dyssynchronous relaxation pattern, has been known to develop after myocardial damage. We aimed to evaluate the dynamic changes in LVDD in the early stage of acute myocardial infarction (AMI) by phase analysis of 99mtechnetium methoxyisobutylisonitrile (99mTc-MIBI) single-photon emission computed tomography (SPECT) gated myocardial perfusion imaging (GMPI) and explore its relationship with the progression of left ventricular remodeling (LVR). MethodsThe left anterior descending coronary arteries of 16 Bama miniature swine were occluded with a balloon to build AMI models. Animals were imaged by SPECT GMPI before AMI and at 1 day, 1 week and 4 weeks after AMI, and quantitative analysis was performed to determine the extent of left ventricle (LV) perfusion defects, left ventricular systolic dyssynchrony (LVSD) and the LVDD parameters: phase histogram bandwidth (PBW) and phase standard deviation (PSD). Echocardiography was simultaneously applied to evaluate left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular ejection fraction (LVEF), and the LVDD parameters: Te-12-diff and Te-12-SD. Myocardial injury markers were measured, and 12-lead ECGs were performed. The degree of LVR progression was defined as ΔLVESV (%) = (LVESVAMI4weeks − LVESVAMI1day)/LVESVAMI1day. ResultsThirteen swine completed the study. LVDD parameters changed dynamically at different time points after AMI. LVDD occurred as early as 1 day after AMI, peaked at 1 week, and trended toward a partial recovery at 4 weeks. Phase analysis on SPECT GMPI showed a significant correlation with tissue Doppler imaging for the assessment of LVDD during the longitudinal evaluation (r = 0.569 to 0.787, both P <0.05). During the univariate and multivariate regression analyses, the LVDD parameters PBW and PSD as of 1 day after AMI were significantly associated with the progression of LVR, respectively (PBW, β = 0.004, 95% CI 0.001 to 0.007, P = 0.024; PSD, β = 0.008, 95% CI 0.000 to 0.017, P = 0.049). Adjusted smooth curve fitting and threshold effect analysis indicated PBW and PSD break-point values of 142° and 60.4°, respectively, to predict the progression of LVR after AMI. ConclusionsPhase analysis of SPECT GMPI can accurately and reliably characterize LVDD. LVDD occurred on the first day after AMI, reached its peak at 1 week, and partially recovered at 4 weeks after AMI. LVDD as evaluated by phase analysis of SPECT GMPI early after AMI was significantly associated with the progression of LVR. The early assessment of LVDD after AMI may provide helpful information for predicting the progression of LVR in the future.

Epicardial Adipose Tissue Measured From Computed Tomography Predicts Cardiac Resynchronization Therapy Response in Patients With Non-ischemic Systolic Heart Failure.

Background: Epicardial adipose tissue (EAT) has been linked with the pathogenesis of heart failure (HF). Limited data have been reported about the clinical value of EAT for cardiac resynchronization therapy (CRT) in non-ischemic systolic HF. We aimed to explore the values of EAT measured from CT to predict the response to CRT in patients with non-ischemic systolic HF.Methods: Forty-one patients with CRT were consecutively recruited for our study. All patients received both gated resting Single Photon Emission CT (SPECT) myocardial perfusion imaging (MPI) and dual-source multi-detector row CT scans. EAT thickness was assessed on both the parasternal short and horizontal long-axis views. The area of EAT was calculated at the left main coronary artery level. Left ventricular systolic mechanical dyssynchrony (LVMD) was measured by phase standard deviation (PSD) and phase histogram bandwidth (PBW). The definition of CRT response was an improvement of 5% in left ventricular ejection fraction (LVEF) at 6 months after CRT implantation.Results: After 6 months of follow-up, 58.5% (24 of 41) of patients responded to CRT. A greater total perfusion deficit (TPD) was observed in the left ventricle, and a narrower QRS complex was observed in the nonresponse group than in the response group (p < 0.05). Meanwhile, the systolic PSD and systolic PBW were statistically greater in the CRT group with no response than in the response group (p < 0.05). Meanwhile, the baseline QRS duration, TPD, systolic PSD, systolic PBW, EAT thicknesses of the left ventricular (LV) apex, right atrioventricular (AV) groove, and left AV groove were all significantly related to the CRT response in the univariate logistic regression analysis. Furthermore, the QRS duration and EAT thicknesses of the right AV groove and left AV groove were independent predictors of CRT response in the multivariate logistic regression analysis.Conclusions: The EAT thickness of the left AV groove in patients with non-ischemic systolic HF is associated with the TPD of LV and LV systolic dyssynchrony. The EAT thickness of the AV groove has a good predictive value for the CRT response in patients with non-ischemic systolic HF.

Left ventricular systolic and diastolic dyssynchrony to improve cardiac resynchronization therapy response in heart failure patients with dilated cardiomyopathy

BackgroundThe systolic and diastolic dyssynchrony is physiologically related, but measure different left ventricular mechanisms. Left ventricular systolic mechanical dyssynchrony (systolic LVMD) has shown significant clinical values in improving cardiac resynchronization therapy (CRT) response in the heart failure patients with dilated cardiomyopathy (DCM). Our recent study demonstrated that LV diastolic dyssynchrony (diastolic LVMD) parameters have important prognostic values for DCM patients. However, there are a limited number of studies about the clinical value of diastolic LVMD for CRT. This study aims to explore the predictive values of both systolic LVMD and diastolic LVMD for CRT in DCM patients. MethodsEighty-four consecutive CRT patients with both DCM and complete left bundle branch block (CLBBB) who received gated resting SPECT MPI at baseline were included in the present study. The phase analysis technique was applied on resting gated short-axis SPECT MPI images to measure systolic LVMD and diastolic LVMD, characterized by phase standard deviation (PSD) and phase histogram bandwidth (PBW). CRT response was defined as ≥ 5% improvement of LVEF at 6-month follow-up. Variables with P < 0.10 in the univariate analysis were included in the multivariate cox analysis. ResultsDuring the follow-up period, 59.5% (50 of 84) patients were CRT responders. The univariate cox regression analysis showed that at baseline QRS duration, non-sustained ventricular tachycardia (NS-VT), systolic PSD, systolic PBW, diastolic PSD, diastolic PBW, scar burden and LV lead in the scarred myocardium were statistically significantly associated with CRT response. The multivariate cox regression analysis showed that QRS duration, NS-VT, systolic PSD, systolic PBW, diastolic PSD, and diastolic PBW were independent predictive factors for CRT response. Furthermore, the rate of CRT response was 94.4% (17 of 18) in patients whose LV lead was in the segments with both the first three late contraction and the first three late relaxation; by contrast, the rate of CRT response was only 6.7% (1 of 15, P < 0.000) in patients whose LV lead was in the segments with neither the first three late contraction nor the first three late relaxation. ConclusionBoth systolic LVMD and diastolic LVMD from gated SPECT MPI have important predictive values for CRT response in DCM patients. Pacing at LV segments with both late contraction and late relaxation has potential to increase the CRT response.

Left ventricular systolic dyssynchrony index and endothelial dysfunction parameters as subclinical predictors of cardiovascular involvement in patients with beta‐thalassemia major

Cardiovascular iron load is the leading cause of morbidity and mortality in beta-thalassemia major (β-TM). However, many patients remain asymptomatic until the late stage. In this cross-sectional study, we investigated the role of three-dimensional (3D) echocardiography and endothelial dysfunction parameters in asymptomatic β-TM patients, and the relationship between these parameters and cardiac magnetic resonance imaging (MRI) T2* value. A total of 51 asymptomatic β-TM patients receiving regular blood transfusions were divided into two groups based on cardiac MRI-T2* values (MRI-T2*<20ms and ≥20ms), which MRI-T2*<20ms determines myocardial iron load and evaluated by two-dimensional (2D) and 3D-echocardiography including endothelial dysfunction parameters. The relationships between ferritin levels, 2D and 3D-echocardiography measurements, endothelial dysfunction parameters, and cardiac MRI-T2* values were investigated. All left ventricle ejection fraction (LVEF) obtained by 2D-echocardiography were normal (≥50%). LVEF-3D (53.25±2.33 vs. 58.81+1.02), SDI12 (6.53±0.56 vs. 2.85+0.48), and SDI16 (7.65±0.75 vs. 3.26+0.49) were significantly different and negatively correlated between groups with MRI-T2*<20ms and ≥20ms, respectively. Flow-mediated dilatation (FMD) (6.08%±0.34% vs. 14.46%±1.12), aortic strain (7.79%±2.19% vs. 12.76%±4.19), ferritin levels were significantly different and negatively correlated between groups with MRI-T2*<20ms and ≥20ms, respectively. Higher ferritin, SDI12/16 were significant independent predictors of MR-T2*<20ms. SDI16>5.5, SDI12>4.3 predicted MRI-T2*<20ms with a sensitivity of 92%, specificity of 81% (AUC 0.85, P<.001), and sensitivity of 92%, specificity of 78% (AUC 0.83, P<.001), respectively. SDI12/16 calculated by 3D-echocardiography may be a promising predictors of cardiovascular iron load and, decreased LVEF-3D, FMD, and aortic strain might be good indicators of subclinical cardiovascular involvement of β-TM.

Assessment of Atypical Cardiovascular Risk Factors Using Single Photon Emission Computed Tomography in Mexican Women

Ischemic heart disease (IHD) is a health care problem in women that increases morbimortality, particularly in developing countries. There is limited information regarding atypical risk factors associated with IHD in Mexican women. To explore risk factors in women that could contribute to IHD and myocardial dysfunction using the single photon emission computed tomography (SPECT) myocardial perfusion study (MPS). We designed a cross-sectional study in which we evaluated atypical and typical risk factors using a clinical questionnaire. We performed a SPECT-MPS to evaluate the presence of ischemia/infarction, decreased left ventricular ejection fraction, systolic dyssynchrony and diastolic function by peak filling rate and time to peak filling rate. 172 women were included, 64 with IHD. Adverse events during pregnancy (premature birth and miscarriage), rheumatoid arthritis, gynecological conditions (menopause and age of first menstruation) and low educational level, together with previously known typical risk factors were associated with infarction or ischemia and ventricular dysfunction. Potential associated factors for systolic dyssynchrony were rheumatoid arthritis (OR: 2.90, 95% CI: 0.95-8.66, p = 0.054) and history of premature birth (OR: 0.13, 95% CI: 0.01-0.66, p <0.01). Although those women with arterial hypertension and smoking shown an increased risk for dyssynchrony, these factors were not statistically significant. Low-educational level (OR 2.16, 95% CI 1.1-4.18, p = 0.019) was associated with decreased peak filling rate. The presence of atypical risk factors in women could lead to decreased myocardial function, particularly in women at risk of developing IHD.

Evaluation of cardiac function and systolic dyssynchrony of fetuses exposed to maternal autoimmune diseases using speckle tracking echocardiography

ObjectivesTo compare cardiac function and systolic dyssynchrony of fetuses not exposed to and those exposed to maternal autoimmune antibodies using two-dimensional speckle tracking echocardiography (2DSTE).MethodsAn observational study of 52 fetuses, 18 from mothers with autoimmune antibodies (anti-SSA/Ro60, anti-Ro52 or/and anti-SSB/La) and 34 from healthy mothers without antibodies, was conducted. Maternal baseline characteristics, fetoplacental Doppler parameters, and conventional echocardiographic data were prospectively collected. Systolic global and regional longitudinal strain of left and right ventricle (LV and RV) and the time to peak strain of regional myocardium were measured using 2DSTE. We also calculated the differences in time to peak strain between the LV free wall and RV free wall (two-chamber dyssynchrony, 2C-DYS) and the LV dyssynchrony between the septum and LV free wall (one-chamber dyssynchrony, 1C-DYS).ResultsThere were no significant differences in conventional systolic and diastolic functional parameters for the LV and RV. No effect modification was demonstrated in a myocardial deformation analysis. However, 1C-DYS was significantly more prolonged in the maternal autoimmune disease group (19.50 [8.00 to 29.25] vs. 28.50 [13.50 to 39.25], P = 0.042).ConclusionsLV systolic mechanical dyssynchrony in fetuses of mothers with autoimmune antibodies suggests in-utero subclinical damage of the cardiac conduction system.Key points• The left ventricular systolic dyssynchrony was significantly more prolonged in the maternal autoimmune disease (AD) fetuses.• Subclinical damage to the left ventricular conduction system of the fetal heart in maternal AD was observed.• Systolic and diastolic functional of the left and right ventricle were preserved in fetuses exposed to maternal autoimmune disease.

Transthoracic implantation of dual-chamber pacemaker for synchronous treatment of cardiac dysfunction due to idiopathic complete left bundle branch block in children

Objective: To investigate the efficacy and feasibility of transthoracic implantation of permanent left atrial and left ventricular dual-chamber pacemaker for synchronous treatment of cardiac dysfunction due to idiopathic complete left bundle branch block (CLBBB) in children. Methods: The clinical data of five children with cardiac dysfunction due to idiopathic CLBBB and accepting implantation of permanent left atrial and left ventricular epicardial dual chamber pacemaker from January 2015 to July 2019 at the Pediatric Cardiologic Department of the First Hospital of Tsinghua University were analyzed retrospectively. The effects of pacemaker implantation on patients' cardiac function and cardiac synchrony were evaluated by echocardiogram. Results: Among 5 patients, 2 were males and 3 females. At the time of pacemaker implantation, the age of these patients was 0.5-5.7 years, the left ventricle ejection fraction (LVEF) was 29%-46%, the left ventricle end stage of diastolic diameter was 30-53 mm and the mean Z score was 4.0-34.0. Pacemaker was successfully implanted for all the patients. After the implantation, medications that can suppress atrioventricular node conduction were used and sensed atrioventricular delay (SAV) parameters were modulated until patients' QRS duration became shortest and the percentage of left ventricular pacing increased to and maintained at 97% to 100%. Patients' QRS duration was 120-160 ms before implantation and 90-120 ms after implantation. Patients' cardiac function began to improve 1 day to 1 month after implantation. Patients' cardiac function normalized after a mean of 1-12 months. LVEF increased from 29%-46% to 55%-67%. During the follow-up, interventricular mechanical delay, septal-to-posterior wall motion delay, and left ventricular systolic dyssynchrony index decreased significantly: IVMD decreased from 31-62 ms to 26-50 ms; SPWMD decreased from 40-63 ms to 10-50 ms and Ts-SD decreased from 34.3-50.3 ms to 16.3-31.4 ms. The global longitudinal strain of left ventricle decreased from -7.7%--13.8% to -13.5%--20.3%. Conclusion: Cardiac dysfunction due to CLBBB in children can be treated with transthoracic implantation of permanent epicardial left atrial and left ventricular dual chamber pacemaker which can substitute three chamber pacemaker to achieve the effects of synchronous therapy that lead to reversion and normalization of cardiac function.

Prognostic value of left-ventricular systolic and diastolic dyssynchrony measured from gated SPECT MPI in patients with dilated cardiomyopathy

BackgroundLeft-ventricular systolic dyssynchrony (LVSD) has been an important prognostic factor in the patients with dilated cardiomyopathy (DCM). However, the association between the LV diastolic dyssynchrony (LVDD) and clinical outcome is not well established. This study aims to evaluate the prognostic values of both systolic and diastolic dyssynchrony in patients with DCM. MethodsFifty-two patients with DCM were enrolled and divided into two groups according to cardiac deaths from the follow-up data. The phase-analysis technique was applied on resting gated short-axis SPECT MPI images to measure LV systolic and diastolic dyssynchrony, including phase standard deviation (PSD), phase histogram bandwidth (PBW), and phase entropy (PE). Variables with P < 0.10 in the univariate analysis were included in the multivariate cox analysis. ResultsDuring the follow-up period (2.9 ± 1.7 years), 18 (34.6%) cardiac deaths were observed. Compared with survivors, patients with cardiac death had lower LVEF (P = 0.011), and more severe LV systolic and diastolic dyssynchrony. The univariate cox regression analysis showed that hypertension, NT-proBNP, LVEF, systolic PSD, systolic PE, and diastolic PBW were statistically significantly associated with cardiac death. The multivariate cox regression analysis showed that systolic PE and diastolic PE were independent predictive factors for cardiac death. Furthermore, the receiver operating characteristic (ROC) analysis, when applied into the combination of systolic PE and diastolic PE for predicting cardiac death, had an area under curve (AUC) of 0.766, a sensitivity of 0.765, and a specificity of 0.722. ConclusionsBoth the LVSD and LVDD parameters from SPECT MPI have important prognostic values for DCM patients. Both systolic PE and diastolic PE are independent prognostic factors for cardiac death.

Phase analysis of gated myocardial perfusion imaging for early diagnosis of cardiotoxicity caused by anthracyclines in patients with diffuse large B-cell lymphoma

Objective To evaluate the left ventricular systolic synchrony and investigate the early diagnostic value of left ventricular systolic dyssynchrony on cardiotoxicity caused by anthracyclines in patients with diffuse large B-cell lymphoma (DLBCL). Methods Thirty-two patients (22 males, 10 females, age: 22-73(54.4±14.2) years) from June 2016 to January 2019 with confirmed DLBCL and normal gated myocardial perfusion imaging (GMPI) before anthracyclines chemotherapy were enrolled prospectively. GMPI was performed after 6 cycles or more of chemotherapy. Changes of myocardial markers, electrocardiogram (ECG) indicators, left ventricular function indicators including left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), peak filling rate (PFR), summed motion score (SMS) and summed thickening score (STS) as well as left ventricular systolic synchrony indicators including phase bandwidth (BW), phase standard deviation (SD) and entropy before and after anthracyclines chemotherapy were analyzed. Paired t test, Wilcoxon signed rank test and χ2 test were used for data analysis. Results Compared with pre-chemotherapy, the left ventricular systolic synchrony indicators were significantly higher than those before chemotherapy (BW: (42.81±11.37)° vs (29.28±8.68)°; SD: (11.65±4.64)° vs (8.79±3.14)°; entropy: (39.84±5.51)% vs (36.19±5.94)%; t values: -9.132 to -3.173, all P 0.05). Of 32 patients, 13 patients (40.62%) had left ventricular systolic dyssynchrony, and the rate of chemotherapy-induced left ventricular systolic dyssynchrony was significantly higher than that of left ventricular dysfunction (15.62%, 5/32; χ2=4.947, P=0.025). All 5 patients with left ventricular dysfunction caused by chemotherapy had left ventricular systolic dyssynchrony. The LVEF of the chemotherapy-induced left ventricular systolic dyssynchrony group was significantly lower than that of the left ventricular systolic synchronization group ((54.54±9.25)% vs (66.79±7.65)%; t=4.087, P<0.01). Conclusion Left ventricular systolic dyssynchrony can be appeared in DLBCL patients after chemotherapy and is significantly earlier than left ventricular dysfunction, which can be an early indicator of cardiotoxicity caused by anthracycline chemotherapy. Key words: Lymphoma, large B cell, diffuse; Drug therapy, combination; Anthracyclines; Ventricular function, left; Myocardial perfusion imaging

Reproducibility of Left Ventricular Dyssynchrony Indices by Three-Dimensional Speckle-Tracking Echocardiography: The Impact of Sub-optimal Image Quality.

Background: 3D speckle-tracking echocardiography (3D-STE) is a novel method to quantify left ventricular (LV) mechanical dyssynchrony. 3D-STE is influenced by image quality, but studies on the magnitude of its effect on 3D-STE derived LV systolic dyssynchrony indices (SDIs) and their test-retest reproducibility are limited.Methods: 3D-STE was performed in two groups, each comprising 18 healthy volunteers with good echocardiographic windows. In study 1, optimal and inferior-quality images, by intentionally poor echocardiographic technique, were acquired. In study 2, sub-optimal quality images were acquired by impairing ultrasound propagation using neoprene rubber sheets (thickness 2, 3, and 4 mm) mimicking mildly, moderately, and severely impaired images, respectively. Measures (normalized to cardiac cycle duration) were volume- and strain-based SDIs defined as the standard deviation of time to minimum segmental values, and volume- and strain-derived dispersion indices. For both studies test-retest reproducibility was assessed.Results: Test-retest reproducibility was better for most indices when restricting the analysis to good quality images; nevertheless, only volume-, circumferential strain-, and principal tangential strain-derived LV dyssynchrony indices achieved fair to good reliability. There was no evidence of systematic bias due to sub-optimal quality image. Volume-, circumferential strain-, and principal tangential strain-derived SDIs correlated closely. Radial strain- and longitudinal strain-SDI correlated moderately or weakly with volume-SDI, respectively.Conclusions: Sub-optimal image quality compromised the reliability of 3D-STE derived dyssynchrony indices but did not introduce systematic bias in healthy individuals. Even with optimal quality images, only 3D-STE indices based on volume, circumferential strain and principal tangential strain showed acceptable test-retest reliability.

Left ventricular systolic dysfunction potentially contributes to the symptoms in heart failure with preserved ejection fraction.

Left ventricular diastolic dysfunction (LVDD) is considered a key factor associated with heart failure (HF) symptoms in patients with preserved ejection fraction (HFpEF). However, LV systolic performance, including LV systolic function and synchrony, has not been well characterized in these patients. The aims of this study were to assess to investigate the underlying relationship and differences between subclinical LVDD and HFpEF. Eighty-six patients with LVDD were recruited (58 with HFpEF and 28 with subclinical LVDD). Systolic left ventricular (LV) longitudinal strain (LS), systolic longitudinal strain rate (LSrS), early diastolic longitudinal strain rate (LSrE), and late diastolic longitudinal strain rate (LSrA) were measured using speckle tracking echocardiography. LV diastolic and systolic dyssynchrony (Te-SD and Ts-SD) were calculated. Forty age- and sex-matched healthy individuals were enrolled as a control group. LV global LS and LSrS were decreased in patients with HFpEF than in normal controls and subclinical LVDD patients (P<.05). Te-SD and Ts-SD were significantly more prolonged in subclinical LVDD and HFpEF patients than in the control group (P<.05). Reduced LS was associated with HF symptoms in LVDD patients, and a cutoff value of -18% for LS could differentiate HFpEF from subclinical LVDD with 73% sensitivity and 69% specificity. LV systolic function and mechanical dyssynchrony were impaired in HFpEF patients. Deteriorated LV longitudinal systolic function was likely correlated with the symptoms of HFpEF.

Assessment of Left Ventricular Mechanical Dyssynchrony in Left Bundle Branch Block Patients with and Without Heart Failure by Tissue Doppler Imaging

Introduction: Large number of patients with heart failure (HF) have left bundle branch block (LBBB). Most precise method for identification of intraventricular dyssynchrony is tissue Doppler imaging (TDI). Purpose of this research was to compare left ventricular (LV) mechanical dyssynchrony in LBBB patients with and without HF and to compare various methods of LV systolic dyssynchrony assessment by TDI. Materials and Methods: One hundred and sixteen patients with a diagnosis of LBBB were included in the study. All patients underwent conventional two-dimensional echocardiography for global LV function assessment. LV systolic dyssynchrony was measured by opposing wall delay, maximum delay, and Yu index. LBBB patients were grouped into four classes according to their LV function and the presence or absence of HF, normal LV function without HF (Group A), normal LV function with HF (Group B), LV dysfunction with HF (Group C), and LV dysfunction without HF (Group D). Results: LV systolic dyssynchrony was significantly higher (P &lt;0.001) in Group C and D as compared to Group A and B. LV systolic dyssynchrony was significant higher in Group C and D as compared to Group A and B by using opposing wall delay (P &lt;0.001), Yu index (P &lt;0.001), and maximum delay (P &lt;0.001) imaging criteria. Mean Yu index (P &lt;0.001) and mean maximum delay (P &lt;0.001) were significantly higher in Group C and D as compared to Group A and B. Conclusions: LV systolic dyssynchrony was more common in LBBB patients with LV dysfunction than those with normal LV function, irrespective of the presence or absence of HF.

Impact of Left Bundle Branch Block on Left Atrial Dyssynchrony and Its Relationship to Left Ventricular Diastolic Function in Patients with Heart Failure and Dilated Cardiomyopathy.

Background and ObjectivesThe impact of left bundle branch block (LBBB) on left atrial (LA) dyssynchrony in heart failure (HF) patients with non-ischemic dilated cardiomyopathy (DCM) has not been clearly elucidated.MethodsEighty consecutive symptomatic HF patients with non-ischemic DCM (left ventricular ejection fraction, LVEF<35%) were included. LBBB was defined on electrocardiography. Left ventricular (LV) systolic and diastolic dyssynchrony index and LA dyssynchrony index were obtained by color-coded tissue Doppler imaging.ResultsThere was no significant difference in LV size, LVEF, LV global longitudinal strain, peak atrial longitudinal strain and LA volume between patients with LBBB (n=38) and no LBBB (n=42). There was a significant difference in LV systolic dyssynchrony index (p=0.014) and there was a mild difference in LV diastolic synchronicity index (p=0.045) between patients with LBBB and no LBBB. However, there was no difference in LA dyssynchrony index between the 2 groups (p=0.60). LA dyssynchrony index was not related to LV systolic and diastolic dyssynchrony indexes, but it was related to the deceleration time of mitral early diastolic velocity (E), the ratio of E to mitral annular early diastolic velocity (E/e′) and LA volume. E/e′ was most related to LA dyssynchrony index (r2=0.325, p=0.002).ConclusionsLBBB influences both LV systolic and diastolic dyssynchrony, but not LA dyssynchrony. LA dyssynchrony was related to LV diastolic function regardless of the presence of LBBB in in patients with non-ischemic DCM.