Left Ventricular Twist In Patients Research Articles

Left ventricular twist in patients with severe aortic stenosis: meaning and evolution after surgery

Abstract Background Structural and functional left ventricular (LV) remodeling is the result of myocardial adaptation to chronic pressure overload in patients with severe aortic stenosis (AS). Changes in LV rotational dynamics are supposed to occur due to increased afterload in order to maintain LV ejection fraction (EF) in this setting. However, data regarding rotational dynamics with AS severity and their evolution after aortic valve replacement (AVR) are scarce. Goal To describe LV twist in patients with severe AS according to LV remodeling and assess its evolution after surgical AVR. Methodology Single center prospective cohort study of patients with classical isolated severe AS referred to surgical AVR. Complete transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) were performed before surgery for both valvular and LV remodeling assessment. TTE was performed at the 3rd to 6th post-operative month. LV twist was defined as the peak difference in systolic rotations of LV apex and base as viewed from the apex and calculated at bidimensional strain in short axis views. LV remodeling was categorized by CMR according to Figure 1. Correlation analysis was performed for indexes of AS severity and LV function. Results A total of 80 patients with classical high flow, high gradient, preserved LV EF (46% male; mean age 71 ± 8 years old; mean aortic valve [AV] gradient 61±17.6mmHg, mean AV area 0.73±0.18cm2 , mean LVEF: 58 ± 9%) were included. LV twist before surgery was 24.5 +/- 9.7% and this was modestly correlated with both LV flow (r = 0.315, p= 0.001) and AV gradients (r = 0.315, p = 0.013). Rotational indexes were no different across distinct types of LV remodeling. After AVR there was a significant decrease in LV twist (24.5 +/- 9.7% vs. 16.5 +/- 8.3%, p<0.001), despite significant improvement in global longitudinal strain (-14.7 ± 3.9% vs -16.1 ± 3.1%, p < 0.001) and maintenance of preserved LVEF (58 ± 9% vs 60 +/- 8%, p = 0.07). Conclusion As LV twist has an inverse relation to GLS after AVR, this may represent a compensatory mechanism for LVEF preservation in patients with severe AS. Rotational mechanics seems to be independent from structural LV remodeling in this setting.

Exaggerated myocardial torsion may contribute to dynamic left ventricular outflow tract obstruction in hypertrophic cardiomyopathy.

Dynamic left ventricular (LV) outflow tract obstruction (LVOTO) is associated with symptoms and increased risk of developing heart failure in hypertrophic cardiomyopathy (HCM). The association of LVOTO and LV twist mechanics has not been well studied in HCM. The aim of the study was to compare the pattern of LV twist in patients with HCM associated with asymmetrical septal hypertrophy with and without LVOTO. Echocardiography (including speckle tracking) was performed in 212 patients with HCM, divided according to the absence (n = 130) or presence (n = 82) of LVOTO (defined as peak pressure gradient ≥30 mmHg either at rest and/or with Valsalva manoeuvre). Patients with LVOTO were older, had smaller LV dimensions, a higher LV ejection fraction (LVEF), a longer anterior mitral valve leaflet length, and a higher early transmitral pulsed wave to septal tissue Doppler velocity ratio (E/E'). A univariate analysis showed that peak twist was significantly higher in patients with LVOTO compared with patients without LVOTO (19.7 ± 7.3 vs. 15.7 ± 6.0, P = 0.00015). Peak twist was similarly enhanced in patients with LVOTO, manifesting only during Valsalva (19.2 ± 5.6, P = 0.007) and patients with resting LVOTO (19.9 ± 8.0, P = 0.00004) compared with patients without LVOTO (15.7 ± 6.0). A stepwise forward logistic regression analysis showed that LVEF, LV end-systolic dimension indexed to body surface area, anterior mitral valve leaflet length, E/E', and peak twist were all independently associated with LVOTO. This study demonstrates that increased peak LV twist is independently associated with LVOTO in patients with HCM. Peak twist was similarly exaggerated in patients with only latent LVOTO, suggesting that it may play a contributory role to LVOTO in HCM.

Differences in left ventricular twisting and different strains in patients with heart failure with preserved ejection fraction versus patients with arterial hypertension

Abstract Patients with advanced arterial hypertension (HPT) without heart failure often have left ventricular (LV) changes similar to hypertensive patients with heart failure with preserved ejection fraction (HFpEF). We assumed that cardiac mechanics may be different in both groups. Methods We study 58 patients (23 female) with HPT and with left ventricular concentric hypertrophy (LVH) as well as negative diastolic stress test and 52 HPT patients (29 female) with HFpEF NYHA II-III 72±5 years. All patients where in sinus rhythm. HPT and HFpEF patients has comparable degree of LV mass index (LVMI 85.3±8.6 g/m2 vs 86.2±8.9 g/m2, P=NS). Incidence of diabetes mellitus, chronic kidney disease or chronic obstructive lung disease was comparable between groups. 43 sex and age matched healthy subjects served as control (C). Comprehensive 2D/3D echocardiography (EchoCG) with offline measurements of longitudinal (LS), circumferential (CS) and radial strain (RS) global values of entire walls and 3 myocardial layers, LV twist (LVT)was performed before and after symptom limited or heart rate of 120 bpm limited diastolic stress test. Results HPT and HFpEF patients had significantly lower absolute values LS, CS, AS, as well as lower values of RS, and LVT compared with controls at rest and after stress test. The values of LS, RS and LVT did not significantly differ at rest in HPT patients and HFpEF patients, but HFpEF patients had lower values of global CS (GCS) due to reduction only in endocardial layer CS (ECS) (LS: 16.4±5.2% vs 16,8±5.9, p=0.07; ECS: 10.9±2,3% vs 17.3±4.1%, p<0.01; GCS: 12.8±3.5% vs 15.1±2.1%, p<0.03; RS: 29.7±10.2% vs 31.1±12.4%, p=0.06; LVT: 2.3±1.4deg vs 2.6±1.7deg, p=0.06). After diastolic stress test patients with HFpEF had significantly lower values of LVT and GCS compared with HPT patients (LVT: 1.8±0.9deg vs 3.4±1.8deg, p<0.001; GCS: 10.4±2.7% vs 17.1±3.4%, p<0.01). We also found greater relative increase (RI) in endocardial LS and LVT in patients with HPT after stress test compared with HFpEF patients, RI of other parameters did not differ between these two groups (RI ELS: 16±2.1% vs 10.5±1,7%, p<0.03; RI LVT 33.3±6,4% vs −21.7±4.1%, p<0.0001). ECS had the diagnostic value to predict HFpEF (area under curve 0.874), RI LVT was the best predictor of HFpEF symptoms (area under curve 0.912) with cut off value 22.3%. Conclusion ECS is reduced in HFpEF patients compared with HPT patients with the same degree of structural abnormalities on conventional EchoCG and is a predictor of HFpEF. HPT patients have more relative improvement in ELS during stress test compared with HFpEF patients. RI LVT was the best predictor of HFpEF symptoms. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): City Hall resources

Evaluation of characteristics of left ventricular twist in patients with liver cirrhosis by two-dimensional speckle tracking imaging

Evaluation of characteristics of left ventricular twist in patients with liver cirrhosis by two-dimensional speckle tracking imaging

Left ventricular twist was decreased in isolated left bundle branch block with preserved ejection fraction.

Objective:Left ventricular (LV) rotation and twist play an important role in LV contraction and relaxation. Left bundle branch block (LBBB) deteriorates both diastolic and systolic functions. We evaluated the LV twist in patients with LBBB and preserved ejection fraction (EF) (>50%) to determine twist as a potential marker for subtle myocardial dysfunction.Methods:This observational cross-sectional study included 34 LBBB patients with preserved EF who were free from ischemic and valvular disease (Group 1) and 36 healthy controls (Group 2). All patients underwent 2-D Doppler and 2-D speckle tracking echocardiography. LV apical, basal rotation, and twist were evaluated in both groups and compared accordingly. In addition, subjects were dichotomized considering the median twist value of the study population. Binary logistic regression analysis was performed to determine the independent variables associated with inframedian twist.Results:Baseline clinical characteristics were similar in LBBB patients and controls. Mean apical rotation (2.5°±1.9° vs. 4.4°±2.9°; p=0.002), basal rotation (-2.9°±2.3° vs. -4.1°±2.7°; p=0.05), and twist (5.4°±3° vs. 8.6°±3.3°; p<0.001) were decreased in group 1. Parameters related to intra- and interventricular mechanical dyssynchrony, such as longitudinal left ventricular dyssynchrony index (LVdys) and preejection interval of LV, interventricular mechanical delay (IVMD), and left posterior wall contractions (SPMWD) were significantly higher in the LBBB group. The median twist value of the studied population was 6.65°. Binary logistic regression analysis showed that only presence of LBBB was independently associated with inframedian twist (OR=6.250; 95% CI: 2.215–17.632; p<0.001).ConclusionThe LBBB might have induced the reduction of LV twist by diminishing the LV rotation before inducing a prominent effect on the left ventricular ejection fraction (LVEF). Therefore, twist may be considered as a marker for subtle LV dysfunction in LBBB with substantially normal EF.

Exercise Training Normalizes Timing of Left Ventricular Untwist Rate, but Not Peak Untwist Rate, in Individuals with Type 2 Diabetes and Diastolic Dysfunction: A Pilot Study

There is limited information regarding the role of left ventricular (LV) twist and the effect of exercise in type 2 diabetes (T2D). The aim of this study was to compare LV twist parameters in patients with T2D versus healthy control subjects and the effects of high-intensity interval exercise (HIIE) and moderate-intensity exercise (MIE) on LV twist in patients with T2D with diastolic dysfunction. This study, which included both prospective and retrospective components, included 47 patients with T2D and diastolic dysfunction and 37 healthy individuals. Patients with T2D were randomized to HIIE (4×4min at 90%-95% of maximal heart rate, three times a week, 120min/wk; n=24) or MIE (210min/wk; n=23) for 12weeks and examined with echocardiography (LV twist by speckle-tracking method) at baseline and posttest. The control subjects received no intervention and were matched according to age, gender, and body mass index to those completing the intervention. In total, 37 subjects completed 12weeks of MIE (n=17) or HIIE (n=20). LV peak untwist rate (UTR) was similar in patients with T2D and control subjects (P˃.05). At baseline, LV peak UTR, relative to total diastolic period, occurred 5.8 percentage points later in patients with T2D compared with control subjects (P=.004). Time to peak UTR was shortened by 6.5 percentage points (P=.002) and 7.7 percentage points (P<.001) after MIE and HIIE, respectively. Time to peak UTR was similar to that in control subjects after exercise interventions. In patients with T2D and diastolic dysfunction, LV peak UTR was similar, but time to peak LV UTR was delayed compared with control subjects. Twelve weeks of endurance exercise normalized the timing of UTR.

Left ventricular twist in left ventricular noncompaction

Left ventricular (LV) twist is an important component of systolic function. The effect of abnormal LV twist on adverse remodelling of the heart in left ventricular noncompaction (LVNC) is unknown. This study used speckle-tracking echocardiography to evaluate LV twist in patients with LVNC and determine whether abnormal LV twist is associated with more adverse LV remodelling. Clinical, echocardiographic, and myocardial deformation characteristics were prospectively compared between 60 subjects diagnosed with LVNC and 59 age-matched healthy controls. Net instantaneous twist was defined as: peak apical rotation minus isochronous basal rotation. Normal rotation during systole was defined based on the 2010 ASE/EAE consensus document. Rigid body rotation (RBR) was determined present if the apex and base moved in the same direction during ejection. Rigid body rotation was found in 32 (53.3%) subjects with LVNC. The 28 subjects with LVNC and normal LV rotation had diminished apical rotation, basal rotation, and net twist compared with normal controls (P < 0.0001). Patients with LVNC and RBR had worse NYHA functional status (P < 0.0001), but similar echocardiographic indices of remodelling, ejection fraction, and strain parameters as those with LVNC and normal LV rotation. Left ventricular twist is diminished in subjects with LVNC and normal LV rotation. Rigid body rotation occurs in 53.3% of subjects with LVNC and is not associated with more adverse remodelling than subjects with LVNC and normal LV rotation.

Normal left ventricular twist in patients with non-compaction cardiomyopathy, or in normal subjects with hypertrabeculation? Reply

We are grateful to Dr Van Dalen for his letter (van Dalen et al ., submitted) dealing with the results and the characteristics of our study population.1 However, an expert reader will certainly recognize that we have carefully followed the proposed inclusion criteria for left ventricular (LV) non-compaction (NC). Indeed, as we reported, all our LVNC patients met the criteria proposed by Jenny et al. (i) absence of coexisting cardiac abnormalities; (ii) NC/C ratio at end-systole >2 and (iii) evidence on colour Doppler of deep perfused intertrabecular recesses.2 As reported by us1 and others,3 the significant correlation between left ventricular ejection fraction (EF) and twist supports the evidence that twist plays a major …

Normal left ventricular twist in patients with non-compaction cardiomyopathy, or in normal subjects with hypertrabeculation?

We read with great interest the article by Pacileo et al. ,1 recently published in the European Journal of Echocardiography. The authors described normal left ventricular (LV) twist in 14 patients with non-compaction cardiomyopathy (NCCM). This finding is in sharp contrast to severely impaired LV twist described in larger series by us2,3 and others.4 Also, an abnormal LV motion pattern called ‘rigid body …

Evaluation of left ventricular twist in patients with myocardial bridge

ObjectiveTo probe into the speckle tracking imaging assessment of the influence on the left ventricular twist by myocardial bridge of the left anterior descending (LAD)coronary artery.Methods21 patients with symptoms with...

81 Dyssynchronous three plane motion and impaired left ventricular twist in patients with heart failure and normal ejection fraction

<h3>Background</h3> The pathophysiology of heart failure with normal ejection fraction (HFNEF) is complex and not fully understood. Recent publications showed a loss of apical rotation and longitudinal function particularly on exercise in these patients. Whether a deterioration of basal rotation and a dyssynchrony of different three plane motions on exercise might contribute to symptoms in these patients is not known. <h3>Method</h3> 72 Patients (age 73±7 years, 48 female) with breathlessness on exertion and normal EF (60±7%) underwent cardiopulmonary exercise test to rule out alternative clinical reasons (VO₂max 18.4±4.9 ml/min/kg). Data were compared to 38 age-matched control subjects (age 71±7 years, 29 female, EF 63±7%) with a normal exercise tolerance (VO₂max 28.6±5.1 ml/min/kg). All underwent full Doppler 2D-echocardiography at rest and on supine exercise. Echo images were analysed off-line. Apical and basal rotation, longitudinal and radial displacement were measured by speckle tracking. Speckle tracking pictures and colour TDI curves were loaded into custom made software. The software interpolated all curves and calculated twist as the difference of rotation at apex and at base. The software offered timing information to calculate SD and time delays for different motions. <h3>Results</h3> As previously described apical rotation was reduced at rest and on exercise Basal rotation was comparable at rest but significantly reduced on exercise in patients. The SD for four different systolic peak motions (basal and apical rotation, longitudinal and radial displacement) was comparable at rest but on exercise controls showed a significantly reduced SD compared to patients showing a greater ability to synchronise motions. Furthermore a ratio of untwist during IVRT and longitudinal extension (Ratio Untwist /Extension in IVRT) showed a significant deeper slope on exercise for patients indicating a loss of synchrony in diastole, too. All results are presented in Abstract 81 table 1. <h3>Conclusion</h3> Patients with HFNEF show a deterioration of basal rotation and a systolic and diastolic three plane dyssynchrony particularly on exercise. This might further contribute to the deterioration of early diastolic suction and therefore decrease stroke volume on exercise. This might be a major contribution to their symptoms.

Relation of Left Ventricular Twist and Global Strain with Right Ventricular Dysfunction in Patients After Operative “Correction” of Tetralogy of Fallot

In patients with corrected tetralogy of Fallot (cToF), left ventricular (LV) dysfunction is closely related to right ventricular (RV) dysfunction, indicating adverse ventricular-ventricular interactions. However, the mechanism that links RV dysfunction to LV dysfunction remains unclear. In this prospective study, 32 patients with cToF and 19 controls were enrolled. With cardiac magnetic resonance imaging, biventricular ejection fractions were assessed. Using 2-dimensional speckle tracking, global and regional RV and LV strains and LV twist were assessed. To detect and characterize ventricular-ventricular interaction, the relation between global and regional RV mechanics and global and regional LV mechanics was assessed. Global RV strain, global LV strain, and LV twist were decreased in patients with cToF. Global RV strain correlated with global LV strain (r = 0.66, p <0.001) and LV twist (r = -0.72, p <0.001), indicating the presence of adverse ventricular-ventricular interaction. Furthermore, close relations were observed between apical RV strain and apical LV strain (r = 0.62, p <0.001) and apical LV rotation (r = -0.67, p <0.001). In conclusion, RV strain was significantly related to LV strain and LV twist in patients with cToF and controls. Furthermore, apical RV strain correlated with apical LV strain and apical LV rotation, indicating adverse apical ventricular-ventricular interactions.

Abstract 6116: Assessment of Global and Regional Left Ventricular Twist in Patients with Anterior Wall Myocardial Infarction Before and After Revascularization by 2-D Speckle Tracking Imaging

Background: Torsion of the left ventricle is related to myocardial architecture and contractility and is being evaluated as a sensitive marker of cardiac performance. New 2-D speckle tracking imaging (STI) may provide a powerful means of assessing LV torsion noninvasively. This study sought to evaluate the global and regional left ventricular twist in patients with anterior wall myocardial infarction (AMI) before and after revascularization by STI. Methods: A total of 50 subjects, including study group (n = 20) who underwent revascularization for AMI as well as 1 month after revascularization, and control group (n = 30) of normal individuals were studied using STI. LV twist was defined as apical rotation relative to the base. The peak LV twist, standard deviation of time to peak twist (Tw-SD) and maximal temporal difference of time to peak twist (Tw-diff) of 6 myocardial regions were measured. Results: Before revascularization, peak LV twist was significantly reduced while Tw-SD and Tw-diff significantly increased in patients with AMI as compared with normal control group ( P &lt;0.001). One month after revascularization, these changes improved compared with pre- revascularization but remained diminished compared with normal controls (Table 1 ). There were significant correlations between LV peak twist and LVEF ( r =0.78, P &lt;0.05), and LVEDD ( r =−0.63, P &lt;0.05) in all subjects. Conclusion: LV twist measures significantly diminished and dys-synchronized in AMI patients prior to revascularization and improved after revascularization. STI measures correlate with EF and have the potential to quantify left ventricular global and segmental dysfunction in patients with AMI. Left ventricular regional and global peak twist, torsion and synchrony measures

Assessment of left ventricular torsion in patients with anterior wall myocardial infarction before and after revascularization using speckle tracking imaging

Rotation of the left ventricular (LV) apex to the base, or LV torsion, is related to myocardial contractility and structure and has recently been recognized as a sensitive indicator of cardiac performance, but it has been difficult to measure. The recent development of 2-dimensional (2D) speckle tracking imaging (STI) may provide a powerful means of assessing LV torsion. This study was conducted to evaluate the global and regional LV twist in patients with anterior wall myocardial infarction (AMI) disease before and after revascularization by STI. 2D STI was performed in 35 AMI patients before and one month after revascularization, as well as in 32 normal controls. Left ventricular global and regional rotations were obtained at basal and apical short-axis levels; LV torsion was defined as apical rotation relative to the base. The time sequences were normalized to the percentage of systolic and diastolic duration. Before revascularization, LV peak regional and global torsion in patients with AMI were significantly reduced as the result of reduced apical and basal rotation relative to those of normal control group (all P < 0.001); most significantly in the anterior and anterior-septal regions (P < 0.001); one month after revascularization, there were significant changes in peak rotation at either the base or apex relative to pre-revascularization values (all P < 0.001). Similarly, peak regional and global LV torsion were increased significantly (all P < 0.001). Global torsion inversely correlated with EDV (r = -0.605, P = 0.028) and ESV (r = -0.638, P = 0.019); and positively correlated with LVEF (r = 0.630, P = 0.021). Tight relations were also found between torsion and LV longitudinal and short axis function. Systolic torsion was decreased in AMI patients. Revascularization therapy can improve the LV function of the AMI patients. STI has a potential to quantify left ventricular global and segment torsion in patients with AMI, and may make the assessment more available in clinical and research cardiology.