Longitudinal Strain Analysis Research Articles

Association of arterial hemodynamics with left ventricular systolic function in hypertensive patients: A longitudinal study

BACKGROUND Left ventricular (LV) systolic impairment, particularly in the longitudinal direction, is considered an early and sensitive marker of hypertensive heart disease and increased cardiovascular risk. The evidence indicates that aortic stiffness and central hemodynamic factors are important determinants of LV performance, mediating the interaction between the heart and vascular load. Despite the existence of cross-sectional analyses linking central blood pressure (BP) parameters with LV mechanics, no longitudinal data are available which include serial measurements in the course of antihypertensive treatment. OBJECTIVES To investigate the associations between changes in LV longitudinal and circumferential function with alterations in arterial hemodynamics and ventricular-arterial coupling (VAC) in patients with uncomplicated hypertension during a 12-month follow-up. MATERIAL AND METHODS In this retrospective study, 216 patients (age 64.3 ±7.6 years) underwent echocardiography including left ventricular longitudinal (GLS) and circumferential strain (GCS) analysis, brachial BP measurements, VAC (combining echocardiography and brachial BP), and arterial hemodynamics using radial tonometry at baseline and after 12 months of antihypertensive therapy. Patients were grouped into 2 subsets: with improvement in GLS (n = 103) and with deterioration in GLS (n = 113). RESULTS No significant differences were observed in the majority of cardiovascular, demographic or clinical characteristics between the groups. The subset with improvement in GLS demonstrated more favorable changes over follow-up in pulse wave velocity (p = 0.03), central augmentation pressure (p = 0.01) and ventricular-arterial coupling (p = 0.04) compared to patients showing deterioration in GLS. In the multivariable analysis, independent determinants of changes in GLS were: GLS at baseline (-0.48; p < 0.001), changes from baseline to follow-up in central augmentation pressure (-0.29; p = 0.002) and ventricular-arterial coupling (-0.25; p = 0.004). Independent determinants of analogous changes in GCS were: GCS at baseline (-0.46; p < 0.001) and changes in central augmentation pressure (-0.22; p = 0.02). CONCLUSIONS Left ventricular longitudinal and circumferential functional remodeling over time in hypertensive patients is associated with arterial hemodynamics and ventricular-arterial coupling.

Speckle-Tracking Global Longitudinal and Regional Strain Analysis in Neonates with Coarctation of Aorta: A Case-Control Study.

Our objectives are to compare speckle-tracking peak global longitudinal (pGLS) and regional strain values in neonates with coarctation of aorta (CoA) and control groups. Echocardiographic parameters measured by speckle-tracking were studied in a retrospective single-center study. A comparison of pGLS and segmental deformation between neonates with CoA and control group was performed using a three-way mixed ANOVA model. There was a significant difference in the means of segmental strain values between CoA and control group at the apical (p = 0.018) and basal segments (p = 0.031) of the interventricular septum and at the apical segment (p = 0.026) of the left ventricle (LV). After correcting for multiple comparisons, the results had a tendency toward statistical significance (adjusted-p < 0.10). There was significant difference in the mean values of pGLS [F(1, 39) = 7.61, p = 0.009, adjusted p = 0.018] between the studied groups. The results of ROC analysis showed that a cut-off value of −16.60% for pGLS provided an estimated sensitivity of 92.31% (95% CI: [63.97, 99.81]) and 71.43% specificity (95% CI: [51.33, 86.78]) for the diagnosis of CoA in neonates (AUC = 0.794, 95% CI: [0.66, 0.93]). pGLS can be regarded as a feasible and reproducible parameter reflecting LV dysfunction in newborns with CoA when compared to newborns with a false-positive diagnosis.

RATE VS RHYTHM CONTROL IN A PATIENT WITH PULMONARY ARTERIAL HYPERTENSION AND ATRIAL FLUTTER: USE OF DIRECT HEMODYNAMIC MEASUREMENTS

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Atrial arrhythmias in patients with pulmonary arterial hypertension (PAH) are generally felt to be poorly tolerated hemodynamically [1]. Although this observation has driven expert recommendations to attempt rhythm control first, there is no high-quality evidence to support this approach in rate-controlled arrhythmias. We present a case in which management in a patient with PAH and rate-controlled atrial flutter was informed by invasive hemodynamic measurements performed before and after cardioversion. CASE PRESENTATION: A 45-year-old female with history of PAH, treated with subcutaneous treprostinil and macitentan, and atrial flutter, was admitted for decompensated right heart failure and rate-controlled atrial flutter. Atrial flutter was recurrent after prior cardioversion, prompting consideration of ablation.As the patient was rate-controlled and given the potential risk of anesthesia and an invasive procedure, we measured hemodynamics before and immediately after electrical cardioversion. Hemodynamics are summarized in Table 1. Initial hemodynamics showed significant pulmonary hypertension, with evidence of both pre-capillary and post-capillary components and a reduced cardiac index. Cardioversion to sinus rhythm did not result in a significant change in hemodynamics. Given no hemodynamic improvement with restoration of sinus rhythm, ablation was not pursued. DISCUSSION: Attempting rhythm control in patients with rate-controlled atrial arrhythmias and PAH is the currently accepted practice, although the evidence to support this approach is insufficient. Improvement in cardiac function in heart failure with reduced ejection fraction can be seen immediately after electrical cardioversion, with significant improvement in stroke volume, even in rate-controlled populations[2]. In our case, hemodynamic measurements showed no improvement in cardiac performance or pulmonary pressures after cardioversion. This suggests that some patients with PAH and rate-controlled atrial arrhythmias merit an assessment of the potential benefit of a rhythm control strategy. Understanding the benefit of rhythm-control is particularly important in patients with PAH given the high-risk nature of anti-arrhythmic medications and cardiac ablation. Patients with PAH more often have atypical ablative targets leading to longer procedures, time under anesthesia, and more detrimental consequences if an iatrogenic ASD occurs[1]. CONCLUSIONS: While a rhythm control strategy may be beneficial for some PAH patients, hemodynamic evaluation may help inform the management strategy for rate-controlled atrial arrhythmias in this population. REFERENCE #1: Wanamaker, B., et al., Atrial Arrhythmias in Pulmonary Hypertension: Pathogenesis, Prognosis and Management. Arrhythm Electrophysiol Rev, 2018. 7(1): p. 43-48. REFERENCE #2: Fumagalli, S., et al., External Cardioversion of Atrial Fibrillation Causes an Early Improvement of Cardiac Performance: A Longitudinal Strain Analysis Study. J Cardiovasc Echogr, 2014. 24(1): p. 10-17. DISCLOSURES: No relevant relationships by Hana Bakalli, source=Web Response No relevant relationships by Aron Bender, source=Web Response No relevant relationships by Jessica Channick, source=Web Response Advisory Committee Member relationship with Actelion Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee Consultant relationship with Actelion Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Arena Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Bayer Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee No relevant relationships by Sonia Jasuja, source=Web Response No relevant relationships by Rajan Saggar, source=Web Response No relevant relationships by Alexander Sherman, source=Web Response

Usefulness of strain cardiac magnetic resonance for the exposure of mild left ventricular systolic abnormalities in pectus excavatum

BackgroundSystolic dysfunction in pectus excavatum (PEX) is usually very subtle and mainly focused on the right ventricle (RV), leading to normal or unremarkable cardiac imaging findings unless involving exercise stress. ObjectivesWe evaluated systolic function in PEX using longitudinal strain cardiac magnetic resonance (CMR), a validated parameter for the assessment of the systolic deformation of subendocardial fibers. MethodsThis prospective registry comprised consecutive patients with PEX who were referred to CMR to define treatment strategies or to establish surgical candidacy. We also included a control group of 15 healthy volunteers without chest wall abnormalities. Using dedicated software, we evaluated the endocardial global longitudinal strain (GLS) of both ventricles and the endocardial global circumferential strain (GCS) of the left ventricle (LV). ResultsA total of 50 patients with PEX comprised the study population, with a mean age of 19.9 ± 8.0 years. The right ventricular ejection fraction (RVEF) of patients with PEX was significantly lower compared to the control group both at end-expiration (59.5 ± 6.8 vs. 64.7 ± 4.7%, p = 0.008) and end-inspiration (56.7 ± 7.2%, vs. 62.7 ± 4.4, p = 0.004); as well as the pulmonary stroke distance (12.6 ± 2.5, vs. 15.0 ± 2.0 cm, p = 0.001). The LV volumetric analysis revealed no differences between PEX and the control group (p > 0.05 for all) regardless of the respiratory cycle, with a mean expiratory LV ejection fraction (LVEF) of 61.4 ± 6.0%. In contrast, the GLS of the LV was significantly lower in PEX compared to controls (-21.2 ± 3.2 vs. -23.7 ± 3.0%, p = 0.010), whereas GCS was similar either at expiration (-28.5 ± 4.0%, vs. -29.5 ± 2.8, p = 0.38) or inspiration (-29.3 ± 4.1%, vs.-28.9 ± 2.3, p = 0.73). ConclusionsIn this study, we demonstrated that longitudinal strain analysis might enable the detection of very subtle left ventricular systolic function abnormalities in patients with PEX, that are commonly overlooked using the conventional assessment. Level of evidenceII

Improved Analytical Method for Longitudinal Strain Analysis of Buried Pipelines Subjected to Thaw Slumping Load

Thawing landslide is a common geological disaster in permafrost regions, which seriously threatens the structural safety of oil and gas pipelines crossing permafrost regions. Most of the analytical methods have been used to calculate the longitudinal stress of buried pipelines. These analytical methods are subjected to slope-thaw slumping load, and the elastic characteristic of the soil in a nonlinear interaction behavior is ignored. Also, these methods have not considered the real boundary at both ends of the slope. This study set out to introduce an improved analytical method to accurately analyze the longitudinal strain characteristics of buried pipelines subjected to slope-thaw slumping load. In this regard, an iterative algorithm was based on an ideal elastoplastic model in the pipeline-soil interaction. Based on field monitoring and previous finite element results, the accuracy of the proposed method was validated. Besides, a parametric analysis was conducted to study the effects of wall thickness, internal pressure, ultimate soil resistance, and slope angle on the maximum longitudinal strain of the pipeline. The results from the compression section showed that the pipeline is more likely to yield, indicating an actual situation in engineering. Moreover, the maximum longitudinal tensile and compression strain of pipelines decrease with increasing the wall thickness, internal pressure, ultimate resistance of soil, and slope angle. Finally, based on the pipeline limit state equations in CSA Z662-2007 and CRES which considered the critical compression factor comprehensively, the critical slumping displacements for both tensile and compressive strain failures were derived for reference. The research results attach great significance to the safety of pipeline under slope.

Perioperative Two-Dimensional Left Ventricular Global Longitudinal Strain in Coronary Artery Bypass Surgery: A Prospective Observational Pilot Study

There are limited data on perioperative left ventricular strain. The authors aimed to describe the entire perioperative course of two-dimensional left ventricular global longitudinal strain in patients undergoing coronary artery bypass graft (CABG) surgery and compare to common parameters of LV function assessment. Prospective observational study. Single university hospital. Forty patients scheduled for isolated on-pump CABG surgery with preserved left and right ventricular function with an unremarkable, complication-free perioperative course. Two-dimensional strain analysis and standard echocardiographic assessment of left ventricular function were performed pre- (T1) and postoperatively (T4) by transthoracic echocardiography (TTE) and intraoperatively pre- (T2) and poststernotomy (T3) by transesophageal echocardiography (TEE). Echocardiography was performed under stable hemodynamics and predefined fluid management, in sinus rhythm without any vasoactive support. Analysis of two-dimensional LV global longitudinal strain (2D-LV GLS) was performed using Tomtec 2D Cardiac Performance Analysis software. Philips QLAB 10.8 was used to analyze left ventricular ejection fraction (LV EF) and tissue velocity of the lateral mitral annulus (LV S ́). There were no significant differences (median with interquartile range [IQR]) after induction of anesthesia in values of LV EF and 2D-LV GLS (T1 v T2; 59% [IQR, 52 to 64] v 56% [IQR, 51.75 to 63] and -15.2 [IQR, -18.05 to -13.08] v -15.6 [IQR, -17.65 to -13.88]; both not significant [ns]), while LV S´ declined (T1 v T2, 7 cm/s [IQR, 5.25 to 8] v 5.25 cm/s [IQR, 4.6 to 6.83]; p < 0.001). Bland-Altman analysis for this comparison of 2D-LV GLS (T1 v T2) showed that bias was not significant between both techniques; however, there were limits of agreement. After sternotomy (T2 v T3) neither LV EF nor 2D-LV GLS or LV S´ declined. 2D-LV GLS deteriorated significantly after CABG (T1 v T4; -15.2 [IQR, -18.05 to -13.08] v -11.3 [IQR, -15.8 to -9.78]; p < 0.001). In contrast, LV EF and LV S´ did not change significantly in the perioperative interval (T1 v T4; 59% [IQR, 52 to 64] v 56% [IQR, 51.5 to 64.25] and 7 cm/s [IQR, 5.25 to 8] v 7 cm/s [IQR, 6 to 8]; both ns). Values of 2D-LV GLS did not differ in awake, spontaneously breathing patients assessed by TTE and in anesthetized and ventilated patients with stable hemodynamics measured by TEE. 2D-LV GLS did not change after sternotomy; however, it declined significantly after on-pump CABG, while LV EF and LV S´ remained unchanged.

Echocardiographic Longitudinal Strain Analysis in Heart Failure: Real Usefulness for Clinical Management Beyond Diagnostic Value and Prognostic Correlations? A Comprehensive Review.

Heart failure (HF) is a highly prevalent clinical syndrome characterized by considerable phenotypic heterogeneity. The traditional classification based on left ventricular ejection fraction (LVEF) is widely accepted by the guidelines and represents the grounds for patient enrollment in clinical trials, even though it shows several limitations. Ejection fraction (EF) is affected by preload, afterload, and contractility, it being problematic to express LV function in several conditions, such as HF with preserved EF (HFpEF), valvular heart disease, and subclinical HF, and in athletes. Over the last two decades, developments in diagnostic techniques have provided useful tools to overcome EF limitations. Strain imaging analysis (particularly global longitudinal strain (GLS)) has emerged as a useful echocardiographic technique in patients with HF, as it is able to simultaneously supply information on both systolic and diastolic functions, depending on cardiac anatomy and physiology/pathophysiology. The use of GLS has proved helpful in terms of diagnostic performance and prognostic value in several HF studies. Universally accepted cutoff values and variability across vendors remain an area to be fully explored, hence limiting routine application of this technique in clinical practice. In the present review, the current role of GLS in the diagnosis and management of patients with HF will be discussed. We describe, by critical analysis of the pros and cons, various clinical settings in HF, and how the appropriate use and interpretation of GLS can provide important clues.

High-sensitivity cardiac troponin T determines all-cause mortality in cancer patients: a single-centre cohort study.

AimsCardio‐oncology is a growing interdisciplinary field which aims to improve cardiological care for cancer patients in order to reduce morbidity and mortality. The impact of cardiac biomarkers, echocardiographic parameters, and cardiological assessment regarding risk stratification is still unclear. We aimed to identify potential parameters that allow an early risk stratification of cancer patients.Methods and resultsIn this cohort study, we evaluated 930 patients that were admitted to the cardio‐oncology outpatient clinic of the University Hospital Heidelberg from January 2016 to January 2019. We performed echocardiography, including Global Longitudinal Strain (GLS) analysis and measured cardiac biomarkers including N‐terminal pro brain‐type natriuretic peptide (NT‐proBNP) and high‐sensitivity cardiac troponin T levels (hs‐cTnT). Most patients were suffering from breast cancer (n = 450, 48.4%), upper gastrointestinal carcinoma (n = 99, 10.6%) or multiple myeloma (n = 51, 5.5%). At the initial visit, we observed 86.7% of patients having a preserved left ventricular ejection fraction (LVEF >50%). At the second follow up, still 78.9% of patients showed a preserved LVEF. Echocardiographic parameters or elevation of NT‐proBNP did not significantly correlate with all‐cause mortality (ACM) (logistic regression LVEF <50%: P = 0.46, NT‐proBNP: P = 0.16) and failed to identify high‐risk patients. In contrast, hs‐cTnT above the median (≥7 ng/L) was an independent marker to determine ACM (multivariant logistic regression, OR: 2.21, P = 0.0038) among all included patients. In particular, hs‐cTnT levels before start of a chemotherapy were predictive for ACM.ConclusionsBased on our non‐selected cohort of cardio‐oncological patients, hs‐cTnT was able to identify patients with high mortality by using a low cutoff of 7 ng/L. We conclude that measurement of hs‐cTnT is an important tool to stratify the risk for mortality of cancer patients before starting chemotherapy.

CMR-based T1-mapping offers superior diagnostic value compared to longitudinal strain-based assessment of relative apical sparing in cardiac amyloidosis

Cardiac amyloidosis (CA) is an infiltrative disease. In the present study, we compared the diagnostic accuracy of cardiovascular magnetic resonance (CMR)-based T1-mapping and subsequent extracellular volume fraction (ECV) measurement and longitudinal strain analysis in the same patients with (a) biopsy-proven cardiac amyloidosis (CA) and (b) hypertrophic cardiomyopathy (HCM). N = 30 patients with CA, N = 20 patients with HCM and N = 15 healthy control patients without relevant cardiac disease underwent dedicated CMR studies. The CMR protocol included standard sequences for cine-imaging, native and post-contrast T1-mapping and late-gadolinium-enhancement. ECV measurements were based on pre- and post-contrast T1-mapping images. Feature-tracking analysis was used to calculate 3D left ventricular longitudinal strain (LV-LS) in basal, mid and apical short-axis cine-images and to assess the presence of relative apical sparing. Receiver-operating-characteristic analysis revealed an area-under-the-curve regarding the differentiation of CA from HCM of 0.984 for native T1-mapping (p < 0.001), of 0.985 for ECV (p < 0.001) and only 0.740 for the “apical-to-(basal + midventricular)”-ratio of LV-LS (p = 0.012). A multivariable logistical regression analysis showed that ECV was the only statistically significant predictor of CA when compared to the parameter LV-LS or to the parameter “apical-to-(basal + midventricular)” LV-RLS-ratio. Native T1-mapping and ECV measurement are both superior to longitudinal strain measurement (with assessment of relative apical sparing) regarding the appropriate diagnosis of CA.

Early Echocardiographic and Cardiac MRI Findings in Multisystem Inflammatory Syndrome in Children.

Multisystem Inflammatory Syndrome in Children (MIS-C) is a known severe condition affecting children previously exposed to SARS-CoV-2. The aim of our study was to describe the early cardiac abnormalities in patients with MIS-C, evaluated by speckle tracking echocardiography (STE) and cardiac MRI (CMR). Clinical, laboratory and microbiological data were measured for all patients. All children underwent standard transthoracic echocardiography, STE with analysis of left ventricle global longitudinal strain (GLS). Seventeen (75%) of the children were evaluated with CMR. Twenty-three patients (13M, 10F) were recruited, mean age was 8.1 ± 4 years. Cardiovascular symptoms were present in 10 (43.5%). Nine children (39.1%) shared Kawasaki Disease-like symptoms. Four patients (17.4%) needed ICU admission. In-hospital survival was 100%. TnI was elevated in 15 (65.2%) and BNP in 20 (86.9%) patients. The median time to STE evaluation was 8 days and to CMR was 18 days after fever onset. Mean LVEF was 59 ± 10%. Coronary dilation was observed in six (26.1%) patients. STE showed a reduced mean LVGLS (−17 ± 4.3%). LGE with a non-ischemic pattern was evident in six out of seventeen patients (35.2%). The elevation of myocardial necrosis markers, the reduction of LVGLS and the presence of LGE on CMR in about a quarter of MIS-C patients supports the hypothesis of a post-viral immune-mediated myocarditis-like pathogenesis.

Scintigraphic and echocardiographic evaluation of patients with cardiac transthyretin amyloidosis and first-degree relatives

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Pfizer Research Grant (ID#57165999) Background Misfolding of transthyretin (TTR) is the source of two distinct forms of amyloidosis (ATTR): acquired or wild-type (ATTRwt) and hereditary (ATTRm), which is transmitted in an autosomal dominant inheritance with a variable penetrance. Types of transthyretin (TTR) gene mutations display genetic and ethnic variability. Purpose The aim of this prospective study was to assess the TTR gene variants, echocardiographic parameters and regional left ventricle 99mTc-DPD uptake among patients with ATTR and first-degree relatives. Methods We present data based on evaluation of first 25 patients (13 (52%) females), including 10 (40%) index patients with ATTR (age 66.4 ± 13 years) and 15 (60%) first-degree relatives who were studied between June 2020 and February 2021. Analysis included clinical data, free light chain blood immunoglobulins and urine immunofixation, transthoracic echocardiography (TTE) with global longitudinal strain (GLS) analysis, single-photon emission computed tomography (SPECT) with 3,3-disphono-1,2-propanodicarboxylic acid (DPD), genetic testing by an amplicon-based next-generation TTR sequencing approach, and in selected cases cardiac or soft tissue biopsy. Results Overall, 6 index patients were diagnosed with ATTRm and 4 with ATTRwt presenting mixed, cardiac or neuropathic phenotype. There were detected following types of TTR variants - Phe53Leu, Ala101Val, Glu112Lys, Glu109Lys. Nine out of 10 index patients were diagnosed with amyloid cardiomyopathy (CA) with grade 2-3 tracer uptake in SPECT and symptomatic heart failure (NYHA 2.2 ± 1.1; NT-proBNP value 2224 ± 2799 pg/ml). In both ATTRm and ATTRwt there were patients presenting with either focal or diffuse tracer pattern evaluated by SPECT technique. In TTE there was marked left ventricle (LV) hypertrophy with maximum wall thickness of 22 ± 5 mm and LV mass value index value of 382 ± 111 g/m2. All patients with CA had abnormal global longitudinal strain (GLS, -14.5 ± 5%) and diastolic dysfunction (EA 1.56 ± 0.76, E/E’ 16 ± 11). None of relatives expressed tracer uptake in scintigraphy. Overall, 5 first-degree relatives were diagnosed with Phe53Leu variant, among them two patients presented with decreased GLS value. Conclusions Patients with ATTR presented in TTE with LV hypertrophy, decreased GLS value, diastolic dysfunction and grade 2-3 in scintigraphy with either focal or diffuse tracer uptake in SPECT technique. None of first-degree relatives expressed increased tracer uptake in scintigraphy. However, some of relatives who were diagnosed with pathogenic TTR variant presented with decreased GLS value.

Myocardial strain analysis as a non-invasive screening test in the diagnosis of stable coronary artery disease

BackgroundCoronary artery disease (CAD) is one of the most prevalent diseases around the world; however, finding the best noninvasive, low-cost, and more easily accessible test for its screening has been a challenge for several years. Eighty-nine patients suspected of stable CAD underwent 2D-speckle-tracking echocardiography (2DSTE) at resting position and offline longitudinal myocardial strain analysis, followed by coronary angiography. The correlation of the global longitudinal strain (GLS) and territorial longitudinal strain (TLS) with significant CAD (70% and more stenosis in at least one coronary artery) was then evaluated.ResultsThe statistical analysis showed a significant correlation between low GLS and significant CAD (P=0.0001). The results also showed a significant correlation between low TLS and significant CAD in the left and right coronary artery territories. The optimal cut-off point of GLS for the detection of significant CAD was −19.25, with a sensitivity of 76.5% and specificity of 76.6%.ConclusionThis study confirmed the usefulness of 2DSTE myocardial strain analysis in diagnosis of CAD for detecting the affected coronary arteries using GLS and SLS.

Absence of cardiac damage induced by long-term intensive endurance exercise training: A cardiac magnetic resonance and exercise echocardiography analysis in masters athletes

ObjectivesIt is under debate whether the long-term practice of intensive endurance exercise induces chronic cardiac damage such as myocardial fibrosis and ventricle contractile dysfunction. Multimodality analysis was performed to evaluate myocardial damage induced by long term intensive endurance training in master athletes. MethodsThirty-three asymptomatic endurance master athletes (47 ± 6 year-old, 9,6 ± 1,7 h training/week for 26 ± 6 years), were compared to 18 sedentary controls (49 ± 7 year-old). They underwent a CMR protocol including 4 chambers morphological and late gadolinium-enhancement (LGE) analysis, left (LV) and right ventricular (RV) T1 mapping and calculation of cardiac extracellular volume (ECV). A maximal exercise echocardiography with left and right ventricular longitudinal global strain (LGS) analysis was performed. Cardiac biomarkers of fibrosis (high sensitive cardiac Troponin T, N-Terminal pro brain natriuretic peptide, N-terminal propeptide of procollagen type I and N-terminal propeptide of procollagen type III) were analysed. ResultsAthletes had larger left and right atrial volume, LV and RV end diastolic volume and increased LV and RV mass compared to controls. LGE was not found in athletes. Native T1 values of LV and RV were not significantly different in athletes compared with controls. ECV was normal in both groups (21,5%± 1,6% [18.3 – 23%] in athletes, 22%± 2,2% [18.5 – 27%] in controls). LV and RV peak exercise LGS values were higher in athletes. Cardiac biomarkers levels were normal. ConclusionDespite significant physiological cardiac remodelling, consistent with previous descriptions of athlete's heart, there was no evidence of myocardial fibrosis or exercise left or right ventricular dysfunction or cardiac fibrosis in endurance athletes. Our results are not supporting the hypothesis of deleterious cardiac effects induced by long term and intensive endurance exercise training.

The impact of chronic alcohol overuse on heart function and prognosis: layer-specific longitudinal strain and mid-term outcome analysis.

The exact effects of alcohol drinking on cardiac function are not clear. This study aimed to determine the relationship between consumed amount of alcohol, myocardial injury, and prognosis. Myocardial function and cardiac outcomes were examined in subjects with chronic alcoholism by classical and strain echocardiographic parameters, including global (GLS) and layer-specific longitudinal strain of the endocardial (GLSendo) and epicardial (GLSepi) layer. One group of 65 alcohol-overusers (ALC), median (IQR, interquartile range) age 44 (38-51) years, was compared with 30 controls (CG). Median (IQR) alcohol dose (in alcohol units, 1 AU = 1 g of ethanol) per week was 30 (12-51) AU in ALC and 0 in CG; P <0.001, and the mean (SD, standard deviation) drinking period was 16 (9) years. ALC patients demonstrated higher left ventricular (LV) mass and impaired diastolic function. The ALC group demonstrated lower median (IQR) LV ejection fraction (EF): 52% (37%-57%) vs 60% (55%-63%) (P <0.001); GLS: 17% (9%-20%) vs 19% (18%-21%) (P = 0.01); absolute layer-specific strain values. GLSendo <19% and GLSepi <15% predicted worsened mid-term prognosis, as did elevated N-terminal brain natriuretic peptide (NT-proBNP) and lower EF and GLS. Long-term alcohol overuse, even with a rather low reported median (IQR) dose of 4 (2-7) AU per day resulted in LV hypertrophy, diastolic and systolic dysfunction. Diminished GLS <18%, endocardial <19% and epicardial <15% layer strain predicted combined endpoints but did not significantly improve the prognostic power of tested models, based on NT-proBNP and EF in follow-up.

Improvement of left ventricular systolic performance during sacubitril/valsartan in a cohort of patients with heart failure and reduced ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Sacubitril/valsartan is a well-established therapeutic option for patients with heart failure with reduced ejection fraction (HFrEF). While it was clearly demonstrated to improve patients’ clinical conditions, its potential role in inducing left ventricle (LV) reverse remodeling is still under investigation. Purpose to evaluate clinical and echocardiographic effect of sacubitril/valsartan on a cohort of patients with HFrEF after six months of therapy. Methods 36 patients with HFrEF eligible to start a therapy with sacubitril/valsartan were enrolled. A standard and advanced echocardiographic evaluation was performed before starting the therapy and after six months of follow up (FU). Off-line analysis of left ventricle global longitudinal strain (GLS), longitudinal strain of the free wall of the right ventricle (RVFWSL) and left atrial strain (LAS) was conducted. Clinical and biochemical parameters were evaluated as well. Results At six months of FU NYHA class improved in the vast majority of patients (NYHA class III at baseline vs FU: 56% vs 5%, p 0.001). We observed a significant reduction in LV end-diastolic (99.62 ± 33.24 vs 91.54 ± 33.36, p 0.043) and end-systolic (69.99 ± 26.01 vs 58.68 ± 25.7, p 0.001) volumes and an improvement of LV ejection fraction (30.4 ± 5.02 vs 37.3 ± 6.4, p &amp;lt; 0.001). After six months of therapy, GLS significantly improved (-9.71 ± 2.87 vs -13.04 ± 3.14, p &amp;lt; 0.001). No differences in left and right atrial volumes (respectively 56.6 ± 29 vs 54 ± 30, p 0.349; 54.7 ± 23.7 vs 48.3 ± 19, p 0.157), RVFWSL (-16,5 ± 5,4 vs -16,8 ± 1,5) and LAS (14 ± 6 vs 19 ± 8, p 0.197) were found at FU. Conclusion Left ventricular function evaluated with standard and advanced echocardiographic parameters improved after six months of therapy with sacubitril/valsartan in HFrEF patients. Reduction in LV volumes was found as well. Echo Analysis Baseline Echo Analysis (n= 36) 6 Months FU Echo Analysis (n= 36) p LVEDVi, mL/m2 99, 62 ± 33,24 91,54 ± 33,36 0,043 LVESVi, mL/m2 69,99 ± 26,01 58,68 ± 25,7 0,001 LVEF, % 30,4 ± 5, 02 37,3 ± 6,4 &amp;lt; 0,001 E/E’ average 12,16 ± 3,74 9,71 ± 1,33 0,023 LS Endo Average ,% -9,71 ± 2,87 -13,04 ± 3,14 &amp;lt; 0,001 LVEF left ventricular ejection fraction, LVEDVi: left ventricular end diastolic volume indexed, LVESVi: left ventricular end systolic volume indexed; LS: longitudinal strain

Aortic root longitudinal strain by speckle-tracking echocardiography predicts progressive aortic root dilation in Marfan syndrome patients

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Science, Innovation and Universities; Instituto de Salud Carlos III Introduction In Marfan syndrome (MFS) patients reduced longitudinal strain of the ascending aorta (AAo) as measured by applying feature-tracking on cine cardiac magnetic resonance (CMR) images predicts aortic root dilation and aortic events during the follow-up. Speckle-tracking is well established for cardiac deformation assessment but proximal aorta applications are challenging due to limited wall thickness and substantial cardiac motion. Moreover, echocardiography is widely used in the clinical assessment aortic diseases. Purpose We aimed to test a speckle-tracking tool for root longitudinal strain analysis in terms of comparison with CMR-derived AAo longitudinal strain and reproducibility and as predictor of dilation in MFS patients. Methods Thirty-five MFS patients diagnosed by original GHENT criteria, with maximum aortic root diameter of 45 mm and free from previous aortic dissection or cardiac/aortic surgery and non-severe aortic regurgitation were consecutive enrolled and followed-up. CMR and echocardiography were performed less than 2 months apart. Baseline and final aortic root diameter were measured on CMR images. To quantify aortic root cyclic elongation by echocardiography, two regions of interests were manually created covering both walls in a parasternal long-axis view and tracked along the cardiac cycle (Figure 1). Longitudinal strain was computed as the average of maximum increase in relative distance of several sub-regions covering both walls. CMR-derived AAo longitudinal strain was available in 29 patients. Intra-observer reproducibility was tested in 15 patients via intraclass correlation coefficient (ICC) for single-rater absolute agreement. Results Aortic root longitudinal strain by echocardiography was mildly related to CMR-derived AAo longitudinal strain (R = 0.27) and was larger compared to CMR-derived values (16.2 ± 6.0 vs 11.3 ± 4.3). Reproducibility was high, with ICC of 0.811, R = 0.802, p &amp;lt; 0.001. After a mean follow up of 76 ± 13 months, aortic root diameter grew in 20 patients with a rate of 0.29± 0.24 mm/year. Overall mean growth-rate was 0.87 ± 0.33 mm/year. In multivariable analysis corrected for age and baseline aortic root diameter, baseline longitudinal strain by echocardiography was independently and inversely related to progressive dilation (p = 0.033). Conclusions The measurement of aortic root longitudinal strain by speckle-tracking echocardiography is feasible. Aortic root longitudinal strain is an independent predictor of progressive dilation in MFS patients. This may permit the improvement of risk-stratification in aortic diseases in large scale studies. Abstract Figure 1

Regional strain pattern and correlation with cardiac magnetic resonance imaging in fabry disease

Background:Cardiovascular disease is the most common cause of death among Fabry disease patients, who carry significantly increased risk for heart failure and sudden cardiac death. Echocardiographic strain imaging and cardiac MRI are important clinical tools for early detection of cardiomyopathy before onset of systolic or diastolic dysfunction. However, studies on these imaging modalities are limited among Fabry patients.Aim and Objective:To evaluate echocardiographic strain pattern and correlation with cardiac MRI in Fabry disease.Materials and Methods:We performed a detailed analysis of global longitudinal strain and correlation with cardiac MRI finding in 9 patients diagnosed with Fabry disease.Results:Despite normal left ventricular ejection fraction, basal and mid inferior segments are more likely to demonstrate strain abnormalities compared to other regions. Additionally, increased interventricular septal and left ventricular posterior wall thickness are correlated with greater strain abnormalities. Finally, MRI evidence of fibrosis and infiltration are detected among most patients with strain abnormalities, but in some cases, strain imaging were able to detect early evidence of cardiomyopathy even before MRI was fully able to detect the change. Basal and mid inferoseptal segment strain abnormalities are early signs of developing cardiomyopathy among patients with Fabry disease.Conclusion:Though cardiac MRIs are critical tools for detection of myocardial infiltration and scarring, these findings may not always be detectable in early phases of the disease. Multiple imaging modalities maybe considered in monitoring and evaluation of cardiomyopathy in Fabry disease.

Yeni Tanı Dipper ve Non-dipper Hipertansif Hastalarda Strain Analiz Metoduyla Sol Ventrikül Global Sistolik Fonksiyonlarının Değerlendirilmesi

Objective: Non-dipper hypertension has been associated with enhanced target organ damage and adverse cardiovascular outcomes. The effect of dipper and non-dipper status on cardiac target organ damage has not been comprehensively investigated by two-dimensional (2D) strain echocardiography. We aimed to investigate myocardial deformational strain parameters in dipper and non-dipper untreated hypertensive patients. Material and Methods: We included 42 newly diagnosed hypertensive patients without a previous history of cardiovascular disease and coexisting chronic disease. Study population consisted of two groups of patients, 23 dipper patients and 19 non-dipper patients. Global longitudinal strain (GLS), radial strain and circumferential strain analysis were measured by 2D speckle tracking method. Results: The study population included 42 patients (15 male) with a mean age of 54.5±9 years. The assessment of left ventricular (LV) systolic function by GLS showed decreased values in non-dippers compared with dippers (-18.13±2.07 vs. -13.7±1.95; p=0.001). But no significant intergroup differences were observed in circumferential and radial strain. The analysis showed that night-time mean arterial pressure (MAP), nighttime systolic and diastolic blood pressures, 24-hr systolic blood pressure, dipping rate and nocturnal reduction rate of MAP were the parameters that correlated with GLS. Only dipping rate was independently associated with LV GLS. Conclusion: An isolated non-dipper BP was found to cause impaired LV systolic function detected by myocardial strain.

Preserved Left Atrial Function Following Left Atrial Appendage Closure for Stroke Prevention.

Patients with atrial fibrillation (AF) are at high risk of thromboembolism, with most thrombi forming in the left atrial (LA) appendage. LA appendage closure is an alternative therapy to oral anticoagulation for stroke prevention in AF patients with contraindication to oral anticoagulation. LA function is critical for cardiovascular function, and recent studies suggested a direct relationship between LA function and AF recurrence. Deformation imaging characterizes and quantifies myocardial function. This study aims to investigate the impact of LA appendage closure on LA function in patients with paroxysmal AF. We studied patients with paroxysmal AF who underwent LA appendage closure in a single-center, retrospective study. Twelve patients (CHA2DS2-VASc score, 4.12 ± 1.1; age, 75.9 ± 6.9 years; 7 men and 5 women) were eligible. Echocardiography-derived LA global longitudinal strain analysis, LA diameter, and LA volume index were determined before and after a 6-month follow-up. All patients were in sinus rhythm during echocardiography. The LA global longitudinal strain was unchanged after LA appendage closure (from -18.9 ± 2.8% to -19.6 ± 2.6%; P=.66). No changes were observed for LA size (from 49.1 ± 6.1 mm to 50.5 ± 5.2 mm; P=.45) or for LA volume index (from 51.6 ± 4.6 mL/m² to 52.1 ± 4.1 mL/m²; P=.49), corroborating unaltered LA function after LA appendage closure. LA function is crucial for cardiovascular function and recurrence of AF. Our study provides evidence that LA appendage closure preserves LA function, determined by strain imaging in patients with paroxysmal AF and sinus rhythm during echocardiography.

Myocardial deformation after radiotherapy for breast cancer: A layer-specific and territorial longitudinal strain analysis (BACCARAT study)

Breast cancer (BC) radiotherapy (RT) and the resulting cardiac exposure is associated with early decrease of global longitudinal strain (GLS). Recent software allows multi-layer and segmental analysis of strain, which may be of interest to quantify and locate the impact of cardiac exposure on myocardial function and potentially increase the early detection of radiation-induced cardiotoxicity. To evaluate whether decrease in GLS after BC RT is layer-specific and if it varies according to the left ventricular regional level and the coronary arterial territories. LS was measured at baseline before radiotherapy and 6 months post-radiotherapy. The LS was obtained for each myocardial layer (endocardial, mid-myocardial, epicardial), left ventricular regional level (basal, mid, apical) and coronary artery territory (left anterior descending artery (LAD), circumflex artery, right coronary artery). The study included 64 left sided BC patients. Mean age was 58 ± 4 years, mean doses to the heart, the left ventricle and the LAD were respectively 3.0, 6.7 and 16.4 Gy. Despite unchanged LVEF between baseline and 6 months post-RT (61 ± 7% vs. 60 ± 9%, P = 0.07), decreased GLS was observed for the three layers (endocardial: −20.0 ± 3.2% to −18.8 ± 3.8%; mid-myocardial: −16.0 ± 2.7% to −15.0 ± 3.1%; epicardial: −12.3 ± 2.5% to −11.4 ± 2.8%, all P = 0.02), but only the endocardial layer GLS (GLS-endo) relative change was significant (−4.7%, P = 0.049). Indeed, the GLS-endo was significantly decreased for the most exposed parts of the left ventricle corresponding to the apical level (−26.3 ± 4.0% vs. −24.2 ± 7.1%, P = 0.03) and LAD territory (−22.8 ± 4.0% vs. −21.4 ± 4.8%, P = 0.03). Six months post-RT, GLS decreased predominantly in the endocardial layer of the most exposed part of the left ventricle. For precise evaluation of RT-induced cardiotoxicity and early left ventricular dysfunction, the endocardial layer-based GLS might be the most sensitive parameter.