Lower Left Ventricular Global Longitudinal Strain Research Articles

Sex-specific impact of diabetes mellitus on left ventricular systolic function and prognosis in heart failure

We aimed to investigate the sex differences in associations of diabetes mellitus (DM) with echocardiographic phenotypes and clinical outcomes of heart failure (HF). We studied 4,180 patients admitted for acute HF between 2009 and 2016 (median follow-up, 31.7 months) whose left ventricular global longitudinal strain (LV-GLS) data were available. Patients were compared by sex and DM. Structural equation model (SEM) analysis was performed to evaluate the moderating effects of two causal paths, via ischemic heart disease (IHD) and LV-GLS, linking DM with mortality. Compared to non-diabetic women, diabetic women had significantly lower LV-GLS (11.3% versus 10.1%, p < 0.001), but the difference was attenuated within men (9.7% versus 9.2%, p = 0.014) (p-for-interaction by sex = 0.018). In Cox analyses, DM was an independent predictor for higher mortality in both sexes (women: adjusted hazard ratio [HR] 1.35, 95% confidence interval [CI] 1.15–1.59 versus men: HR 1.24, 95% CI 1.07–1.44, p-for-interaction by sex = 0.699). Restricted cubic spline curves showed that LV-GLS consistently declined, and mortality increased in women with worsening hyperglycemia, but these trends were not evident in men. In SEM analysis, the main driver from DM to mortality differed by sex; men had a stronger effect via IHD than LV-GLS, whereas LV-GLS was the only predominant path in women.

Left and right ventricular longitudinal strains are associated with poor outcome in COVID-19: a systematic review and meta-analysis

BackgroundThis systematic review and meta-analysis aimed to assess whether ventricular longitudinal strain can be used as a prognostication tool in patients with coronavirus disease 2019 (COVID-19).MethodsSystematic literature searches of PubMed, Embase, and EuropePMC databases were performed on 16 November 2020. Left ventricular global longitudinal strain (LV-GLS) refers to LV contraction measurement using the speckle tracking-based method refers to the mean of strain values of the RV free wall (three segments) measured using echocardiography. The main outcome was poor outcome, defined as a composite of mortality and severe COVID-19.ResultsSeven studies comprising of 612 patients were included in meta-analysis. Six studies have mortality as their outcome, and 1 study has severity as their outcome. Patients with poor outcome have lower LV-GLS (SMD 1.15 (0.57, 1.72), p < 0.001; I2 70.4%). Each 1% decrease in LV-GLS was associated with 1.4x increased risk of poor outcome (OR 1.37 (1.12, 1.67), p = 0.002; I2 48.8%). Patients with poor outcome have lower RV-LS (SMD 1.18 (0.91, 1.45), p < 0.001; I2 0%). Each 1% decrease in RV-LS was associated with 1.3x increased risk of poor outcome (OR 1.25 (1.15, 1.35), p < 0.001; I2 11.8%). Subgroup analysis showed that for every 1% decrease in LV-GLS and RV-LS is increased mortality with OR of 1.30 (1.12, 1.50) and OR of 1.24 (1.14, 1.35), respectively.ConclusionThis study shows that lower LV-GLS and RV-LS measurements were associated with poor outcome in patients with COVID-19.Trial registrationPROSPERO CRD42020221144

Left Ventricular Myocardial Work in Patients with Severe Aortic Stenosis

Left ventricular myocardial work (LVMW) is a novel method to assess left ventricular (LV) function using pressure-strain loops that takes into consideration LV afterload. The estimation of LV afterload in patients with severe aortic stenosis (AS) may be challenging, and no study so far has investigated LVMW in this setting. The aim of this study was to develop a method to calculate LVMW in patients with severe AS and to analyze its relationship with heart failure symptoms. Indices of LVMW were calculated in 120 patients with severe AS who underwent transcatheter aortic valve replacement and invasive LV and aortic pressure measurements. LV systolic pressure was also derived by adding the mean aortic valve gradient to the aortic systolic pressure. LV global longitudinal strain and echocardiography-derived LV systolic pressure were then incorporated to construct pressure-strain loops of the left ventricle. An excellent correlation was observed between LVMW indices calculated using the invasive and echocardiography-derived LV systolic pressure. Patients in New York Heart Association functional class III or IV (n=97 [73%]) had lower LV global longitudinal strain, LV global work index, LV global constructive work, and right ventricular free wall strain compared with those in New York Heart Association functional class I or II. In contrast to LV global longitudinal strain, LV global work index (odds ratio per 100mm Hg% increase, 0.91; 95% CI, 0.85-0.98; P=.012) and LV global constructive work showed independent associations with New York Heart Association functional class III or IV heart failure symptoms. The calculation of echocardiography-based LVMW indices is feasible in patients with severe AS. In particular, LV global work index and global constructive work showed independent associations with heart failure symptoms and may provide additional information on myocardial remodeling and function in patients with severe AS.

Prognostic utility of routine assessment of left ventricular global longitudinal strain and peak atrial reservoir strain in stable heart disease patients

Abstract Background Left ventricular ejection fraction above 40% is a poor predictor of cardiac outcomes. Strain imaging seems to add incremental prognostic value in various heart conditions. Purpose The aim of the study is to investigate whether assessment of both left ventricular global longitudinal strain (LVGLS) and peak atrial reservoir strain (PARS) in routine daily practice is useful in predicting cardiac events. Methods We prospectively enrolled 300 patients (212 men, mean age 64.8±10.9 years old) with stable cardiac disease, referred for echocardiographic examination and eligible for strain imaging. Conventional and speckle tracking 2D rest echocardiography were performed and clinical variables were recorded. We excluded patients with acute coronary syndromes, severe valvular disease, cardiomyopathies, arrhythmia and class IV NYHA. Results During a median follow up of 30 months, there were 111 cardiac events (CE) recorded including: 7 cardiac deaths (CD), 25 acute coronary syndromes (ACS), 45 hospitalisations for worsening heart failure (WHF), 23 episodes of atrial fibrillation (AF), 11 stroke (S). Average EF, LVGLS and PARS in patients with CE were significantly lower than in patients without CE (55.8±8.4%, −17.3±3.9% and 16.3±9.8% vs. 60.4±8.4%, −20.1±3.7% and 28.4±8.2%; p&amp;lt;0.05, p&amp;lt;0.01, p&amp;lt;0.01). In univariate analysis, lower LVGLS, respectively lower PARS were associated with a higher risk of cardiac events [Hazard Ratio (HR)1.26; 95% CI (confidence interval): 1.08–1.34; p&amp;lt;0.01 per 1% decrease, respectively HR 1.38; 95% CI: 1.16–1.42; p&amp;lt;0.01 per 1% decrease]. On multivariate analysis this association was independent after adjustment for age, gender, hypertension, diabetes, ejection fraction, left atrial indexed volume. Lower LVGLS was a better predictor of a composite of ACS and CD (HR 1.38 per 1% decrease 95% CI: 1.16–1.48; p&amp;lt;0.01). Lower PARS had a stronger association with AF, S and WHF (HR 1.49 per 1% decrease 95% CI: 1.19–1.58; p&amp;lt;0.01). In a model defined by depressed LVGLS (more positive than −18%) adding lower PALS, with a cut off point of 20%, significantly improved prediction of CE (C-statistic increased from 0.68 to 0.83, p&amp;lt;0.001). Conclusions Left ventricular global longitudinal strain and peak atrial reservoir strain are independent predictors of cardiac events patients with stable heart disease. Acute coronary syndromes and death were better predicted by depressed LVGLS and onset of atrial fibrillation, stroke and worsening heart failure were better predicted by lower PARS. Routine assessment of both parameters improves significantly prediction of cardiac events and helps clinical decision making. Funding Acknowledgement Type of funding source: None

Right ventricular myocardial work in patients with HFrEF

Abstract Background Right ventricular myocardial work (RVMW) is a novel method of non-invasively quantifying right ventricular (RV) systolic function. Through the use of speckle tracking echocardiography-derived RV pressure-strain loops, RVMW provides a quantitative evaluation of afterload-dependent RV systolic function. Purpose To investigate RVMW in patients with heart failure and reduced ejection fraction (HFrEF) and compare to that of patients without cardiovascular disease (CVD) and a structurally and functionally normal heart. Methods Noninvasive analysis of RVMW was performed in 23 HFrEF patients and 23 patients without cardiovascular or structural heart disease. The novel indices of RV global constructive work (RVGCW), RV global work index (RVGWI), RV wasted work (RVWW) and RV global work efficiency (RVGWE) were analysed utilizing proprietary software originally developed for the assessment of left ventricular myocardial work by speckle tracking echocardiography. Parameters of RVMW were then compared between the two patient groups. Results The HFrEF group had lower left ventricular (LV) ejection fraction (18.7% [±6.7] vs 60.1% [±4.6], p&amp;lt;0.0001), LV global longitudinal strain (−3.6% [±1.6] vs −20.4% [±2.1), p&amp;lt;0.0001) and RV global longitudinal strain (−10.0% [±4.2] vs −22.0% [±3.1], p&amp;lt;0.0001) when compared to those with no CVD. Estimated pulmonary artery systolic pressure (42.5mm Hg [±12] vs 22.5mm Hg [±3.7], p&amp;lt;0.0001) and estimated right atrial pressure (8mm Hg (5 to 15) vs 5mm Hg (5 to 5), p&amp;lt;0.0001) were significantly higher in the HFrEF group. RVGWI (259.7mmHg% [±135.0] vs 385.3mmHg% [±103.1], p=0.001), RVGWW (83.7mmHg% [±58.6] vs 14.5mmHg% [8.5 to 20.5], p&amp;lt;0.0001) and RVGWE (77.2% [11.4] vs 95.5% [93.5 to 97], p&amp;lt;0.0001) were significantly lower in the HFrEF group when compared to those without CVD. There was no statistically significant difference in RVGCW between the two groups (353.5mmHg% [±118.4] vs 417.2 [±102.1], p=0.057). Conclusion The novel parameters of RVGWI, RVGWW and RVGWE were significantly reduced in patients with HFrEF when compared to those without CVD. Further exploration of the clinical role and prognostic value of these afterload dependent parameters of RV systolic function is warranted. Funding Acknowledgement Type of funding source: None

Ventricular and atrial functions assessed by speckle-tracking echocardiography in patients with human immunodeficiency virus.

Antiretroviral therapy (ART) has dramatically changed the clinical manifestation of human immunodeficiency virus (HIV) associated cardiomyopathy from severe left ventricular (LV) systolic dysfunction to a pattern of subclinical cardiac dysfunction. The aim of this study was to evaluate by speckle tracking echocardiography (STE) LV, right ventricular (RV), and biatrial functions in HIV-infected patients under different ART combinations. We consecutively included 128 HIV-infected patients (mean age 44.2 ± 10.1 years, 110 males) and 100 controls (mean age 42.1 ± 9.4 years, 83 males). Ventricular and atrial functions were assessed by both conventional and STE. Although there was not any significant difference in conventional echocardiographic variables, HIV-infected patients had significantly lower LV global longitudinal strain (GLS), RV GLS, left atrial (LA) reservoir and conduit strain, and right atrial conduit strain. HIV patients receiving integrase strand transfer inhibitors and protease inhibitors (PI) had significantly lower LV GLS and LA conduit strain, while patients receiving non-nucleoside reverse transcriptase inhibitors and PI had significantly lower RV GLS than controls. CD4 count at the time of echocardiography was strongly correlated with LV GLS (r = .619, P < .001) and RV GLS (r = .606, P < .001). Biventricular and atrial functions are subclinically impaired in HIV-infected patients. ART regimen may also affect myocardial functions.

P1514 Increased myocardial oxygen demand is associated with impaired left ventricular strain in patients with morbid obesity referred for bariatric surgery

Abstract Background Obesity predisposes for left ventricular (LV) hypertrophy and systolic dysfunction. Higher myocardial oxygen demand in LV hypertrophy is associated with higher risk for cardiovascular events, while the association with LV systolic function has been less explored. Purpose To assess the association of myocardial oxygen demand with LV systolic function in morbidly obese subjects without known heart disease. Methods Clinical and echocardiographic data from 110 obese subjects referred for gastric bypass surgery (mean age 42 ± 11 years, 74% women, mean body mass index [BMI] 41.9 ± 4.8 kg/m², 33% with hypertension, 15% with diabetes) in the prospective FatWest (Bariatric Surgery on the West Coast of Norway) study was used. LV function was assessed by ejection fraction (EF) by Simpson"s biplane method and endocardial global longitudinal strain (GLS) by 2D vector velocity imaging using a 16-segment model (Image Arena 4.6, Tomtec, Unterschleissheim, Germany). Myocardial oxygen demand was estimated from LV mass - wall stress - heart rate product according to a previously validated formula. Results Myocardial oxygen demand was higher in men (1884 vs. 1579 x 10³ g x kdyne/cm² x bpm, p &amp;lt; 0.05), and associated with higher BMI (r = 0.24) and pulse pressure (r = 0.28), and with lower EF (r = -0.22) and lower GLS (r = 0.26, all p &amp;lt; 0.05). In multiple regression analysis, higher myocardial oxygen demand was associated with lower LV GLS (Beta = 0.21, p &amp;lt; 0.05) independent of age, gender, BMI, pulse pressure, diabetes, and EF (Table). Conclusion In obese patients without known heart disease referred for bariatric surgery, higher myocardial oxygen demand was associated with lower LV systolic function measured by GLS independent of confounders. Covariates of lower GLS in multivariable Variable β correlation coefficient p LV mass - wall stress - heart rate product (g x kdyne/cm&amp;sup2; x bpm x 10&amp;sup3;) 0.21 0.04 Age (years) -0.12 0.22 Gender 0.34 &amp;lt;0.01 BMI (kg/m&amp;sup2;) 0.25 &amp;lt;0.01 Pulse pressure (mmHg) -0.04 0.71 Diabetes -0.17 0.09 LV EF (%) -0.01 0.90

Severe Aortic Valve Stenosis: Symptoms, Biochemical Markers, and Global Longitudinal Strain.

Background:According to the actual guidelines regarding severe aortic valve stenosis (AS), symptoms are the most important trigger for aortic valve replacement (AVR). However, the objective analysis of cardiological clinic can be confused, considering the aging population this disease affects and the comorbidities.Objectives:Looking for an objective marker of disease, useful for scheduling the correct AVR, we researched the relation between some biochemical markers of left ventricular (LV) dysfunction and its global longitudinal strain.Materials and Methods:We analyzed 74 consecutive patients (82 ± 4 years) with severe AS. We identified 61 patients with symptoms (angina, dyspnea, and syncope) and 13 asymptomatic patients. The clinical and echocardiographic parameters were compared between these two groups. LV ejection fraction (LVEF), LV global longitudinal strain (LVGLS), NT-pro-B-type brain natriuretic peptide (BNP), troponin T (TNT), creatine kinase-MB (CPK-MB), and myoglobin were determined at the time of evaluation.Results:Compared with the asymptomatic group, patients in the symptomatic group had a lower LVGLS (P = 0.002) and an increased pro-BNP (P = 0.0002). LVGLS showed a good correlation with pro-BNP as a marker of myocardial damage, with a linear increase of pro-BNP in patients with a linear decrease of LVGLS (r = 0.43). Despite the normal value of LVEF > 50% in asymptomatic patients, some of them (46%) have an early dysfunction of LVGLS. No other statistically significant difference emerged from the biochemical analysis, in TNT (P = 0.29), CPK-MB (P = 0.36), and myoglobin (P = 0.38).Conclusions:Pro-BNP and LVGLS can be considered an objective marker of clinical severity of AS disease, useful for management and scheduling of AVR, especially in asymptomatic patients.

Left Ventricular Morphology and Function as a Determinant of Pulmonary Hypertension in Patients with Severe Aortic Stenosis: Cardiovascular Magnetic Resonance Imaging Study.

Background and Objectives: The influence of cardiac magnetic resonance (CMR) derived left ventricular (LV) parameters on the prognosis of patients with aortic stenosis (AS) was analyzed in several studies. However, the data on the relations between the LV parameters and the development of pulmonary hypertension (PH) in severe AS is lacking. Our objectives were to evaluate the CMR-derived changes of the LV size, morphology, and function in patients with isolated severe AS and PH, and to investigate the prognostic impact of these parameters on elevated systolic pulmonary artery pressure (sPAP). Materials and Methods: Thirty patients with isolated severe AS (aortic valve area ≤1 cm2) underwent a 2D-echocardiography (2D echo) and CMR before aortic valve replacement. Indices of the LV mass and volumes and ejection fraction were analyzed by CMR. The LV global longitudinal (LV LGS) and circumferential strain (LV CS) were calculated using CMR feature tracking (CMR-FT) software (Medis Suite QStrain 2.0, Medis Medical Imaging Systems B.V., Leiden, The Netherlands). The LV fibrosis expansion was assessed using a late gadolinium enhancement sequence. PH was defined as having an estimated sPAP of ≥45 mm Hg. The statistical analysis as performed using SPSS version 23.0 (SPSS, Chicago, IL, USA) Results: 30 patients with severe AS were included in the study, 23% with severe isolated AS had PH (mean sPAP 55 ± 6.6 mm Hg). More severe LV anatomical and functional abnormalities were observed in patients with PH when compared with patients without PH—a higher LV end-diastolic volume index (EDVi) (140 [120.0–160.0] vs. 90.0 mL/m² [82.5–103.0], p = 0.04), larger LV fibrosis area (7.8 [5.6–8.0] vs. 1.3% [1.2–1.5], p = 0.005), as well as lower LV global longitudinal strain (GLS; −14.0 [−14.9–(−8.9)] vs. −21.1% [−23.4–(−17.8)], p = 0.004). By receiver–operating characteristic (ROC) curve analysis, LV EDVi > 107.7 mL/m² (Area Under the Curve (AUC) 95.7%), LV GLS < −15.5% (AUC 86.3%), and LV fibrosis area >5% (AUC 89.3) were found to be robust predictors of PH in severe AS patients. Conclusions: In patients with severe aortic stenosis, a larger end-diastolic LV volume, impaired LV global longitudinal strain, and larger LV fibrosis extent can predict the development of pulmonary hypertension.

Impaired left ventricular mechanics and functional reserve are associated with reduced exercise capacity in patients with hypertrophic cardiomyopathy.

Reduced metabolic equivalents (METs) are an indicator of exercise intolerance, which predicts poor prognosis in hypertrophic cardiomyopathy (HCM) patients. We sought to evaluate the changes in left ventricular (LV) mechanics and functional reserves, as well as their association with functional capacity in HCM patients. Seventy HCM patients and thirty controls were included in this study. LV mechanics were evaluated at rest and during exercise by echocardiography and two-dimensional speckle-tracking imaging to obtain parameters of functional reserve, LV global longitudinal strain (LVGLS), strain rate (SR), and circumferential strain. Hypertrophic cardiomyopathy (HCM) patients had lower LVGLS, systolic SR, early and late diastolic SR at rest and during exercise, and reduced absolute and relative systolic and diastolic reserve compared to controls. LV circumferential strain was significantly higher at rest but lower during exercise in HCM patients. Exercise capacity was markedly reduced in HCM patients, and peak exercise LVGLS (LVGLS-exe) significantly correlated with exercise capacity. Multivariate regression analyses showed that LVGLS-exe, LV filling pressure during exercise (E/e'-exe), and LV mass index (LVMI) were independent predictors of exercise capacity. Moreover, LVGLS-exe displayed incremental predictive value over E/e'-exe and LVMI for exercise intolerance. Receiver operating characteristic curve analysis showed LVGLS-exe had optimal accuracy for predicting exercise intolerance in HCM patients. Hypertrophic cardiomyopathy (HCM) patients have reduced LV mechanics at rest and during exercise and impaired mechanical reserve. LVGLS-exe is associated with exercise capacity and is an optimal predictive value for reduced exercise capacity in HCM patients.

Assessment of right ventricular function by free wall longitudinal strain in organic mitral regurgitation

Organic mitral regurgitation (MR) is a frequent heart valve disease which influences ventricular functions and impacts cardiovascular outcome. Right Ventricular Free Wall Longitudinal Strain (RVLS) is a good prognosticator in heart failure. Hence, we aimed to study its determinants in organic MR. One hundred ninety-two patients (60 ± 15 years, 125 males) with mild to severe chronic organic MR were prospectively enrolled and underwent a comprehensive echocardiography with RVLS assessment. RV ejection fraction (EF) was also measured by cardiac magnetic resonance (CMR) imaging ( n = 128) or radionuclide angiography ( n = 6) in 134 patients (70%) Patients were stratified into 2 groups according to RVLS ≤ −26% (normal function) or > −26% (RV dysfunction). Patients with RV dysfunction exhibited a more severe condition with greater MR (SOR MR: 0.46 ± 0.25 cm 2 versus 0.38 ± 0.22 cm 2 , P = 0.023), were more symptomatic (NYHA 2.0 ± 0.9 versus 1.5 ± 0.6, P < 0.0001), had a lower left ventricular global longitudinal strain (LVGLS) (−19.6 ± 3.9% versus −21.5 ± 2.8%, P = 0.0001) and a lower RV EF by CMR/radionuclide Imaging (45.8 ± 10% versus 50.2 ± 7%, P = 0.0037). RVLS correlated with TAPSE ( r = −0.40, P < 0.0001), RV Fractional shortening ( r = −0.38, P < 0.0001), TEI index ( r = 0.3, P < 0.0001) and tricuspid annular systolic velocity ( r = −0.27, P < 0.0001). In addition, RVLS correlated only weakly ( r = −0.40, P < 0.0001) with RV EF. In multivariate analysis, pathophysiological determinants of RVLS were rhythm ( β = −0.26, P < 0.0001), pulmonary vascular resistance (Abbas formula, β = 0.26, P < 0.0001), LVGLS ( β = 0.19, P = 0.01) and LV end-systolic volume ( β = 0.15, P = 0.028). RVLS correlates with classical echocardiographic parameters of RV function. RVLS is influenced by pulmonary vasculature resistance (ventriculo-arterial coupling) and LV function (RV to LV interdependence), in agreement with previous findings. As a simple parameter, RVLS could be added to the routine assessment of RV function in organic MR.

Time course of left atrial reverse remodelling after mitral valve surgery and the impact of left ventricular global longitudinal strain in patients with chronic severe mitral regurgitation.

We aimed to investigate the time course of left atrial (LA) reverse remodelling (LARR) after mitral valve (MV) surgery in patients with chronic severe mitral regurgitation (MR) and examine the impact of left ventricular (LV) mechanical function on LARR. A total of 140 patients (73 males, age 54 ± 16 years) with chronic severe MR undergoing MV surgery were analysed. All patients underwent two-dimensional, Doppler and speckle-tracking echocardiography before and after surgery (1 week, 6 months and 12 months). There was a significant decrease in LA volume from 137.8 ± 85.5 to 89.7 ± 54.6 ml (-32.1 ± 16.7%, P < 0.001) at 1 week after surgery. LA volume further decreased to 77.4 ± 52.4 ml (-9.9 ± 13.4%, P < 0.001) at 6 months but increased to 79.7 ± 62.4 ml (3.6 ± 11.9%, P = 0.002) at 12 months after surgery. Patients with good LARR (a reduction of ≥25% in LA volume) showed lower LV global longitudinal strain (LV-GLS) than those with poor LARR (P = 0.032). In simple correlation, age (r = 0.19, P = 0.026), preoperative LA volume (r = -0.28, P = 0.001) and preoperative LV-GLS (r = 0.28, P = 0.001) showed significant correlations with the % change in LA volume, whereas no correlations were observed with preoperative LV ejection fraction, global circumferential and radial strain. In multivariate analyses, preoperative LV-GLS (β = 0.24, P = 0.014) was an independent determinant for early LARR along with age and preoperative LA volume. The majority of LARR after MV surgery occurred during the early postoperative period. LV-GLS, age and LA volume at surgery determined the degree of early LARR after MV surgery in patients with chronic severe MR.

Noninvasive Detection of Cardiac Allograft Vasculopathy by Stress Exercise Echocardiographic Assessment of Myocardial Deformation

The aim of this study was to evaluate the value of noninvasive assessment of cardiac allograft vasculopathy (CAV) in heart-transplanted patients by exercise stress myocardial deformation and coronary flow reserve (CFR) assessment. Fifty-eight heart-transplanted patients underwent semisupine exercise echocardiography with assessment of left ventricular (LV) longitudinal myocardial deformation. CAV was assessed by coronary angiography and noninvasive CFR by (15)O-H2O positron emission tomographic imaging and Doppler echocardiography. Patients were divided into three groups on the basis of angiographic CAV: no CAV (n=21), mild CAV (n=19), and severe CAV (n=18). Patients with severe CAV had significantly lower LV global longitudinal strain (GLS) at rest (no CAV, -16±2%; mild CAV, -15±2%; severe CAV, -12±4%; P<.001), failed to increase LV GLS during exercise (no CAV, -5.7±2.0%; mild CAV, -3.3±2.9%; severe CAV, -0.2±2.8%; P<.0001), and had significantly lower echocardiographic coronary flow velocity reserve (CFVR) (no CAV, 3.2±0.4; mild CAV, 2.7±0.7; severe CAV, 1.8±0.5; P<.0001) and PET CFR (no CAV, 3.4±0.9; mild CAV, 3.1±0.9; severe CAV, 1.9±0.8; P<.0001). Furthermore, patients with mild CAV had significantly lower exercise LV GLS and echocardiographic CFVR than patients with no CAV. Exercise LV GLS, echocardiographic CFVR, and PET CFR were significantly correlated with the presence of severe CAV in a logistic regression model (LV GLS odds ratio, 0.71; 95% CI, 0.60-0.84; P<.0001; echocardiographic CFVR odds ratio: 0.06; 95% CI, 0.01-0.23; PET CFR odds ratio, 0.17; 95% CI, 0.07-0.46). This relation remained significant after adjustment for symptoms and time since transplantation. Noninvasive assessment of LV longitudinal myocardial deformation during exercise is feasible and strongly associated with the presence and degree of CAV. Exercise stress myocardial deformation analysis, echocardiographic CFVR, or PET CFR may serve as a noninvasive model for the detection of CAV.

Impact of long-axis function on cardiac surgical outcomes in patients with radiation-associated heart disease

BackgroundMalignancy-associated thoracic radiation leads to radiation-associated cardiac disease (RACD) that often necessitates cardiac surgery. Myocardial dysfunction is common in patients with RACD. We sought to determine the predictive value of global left ventricular ejection fraction and long-axis function left ventricular global longitudinal strain (LV-GLS) in such patients. MethodsWe studied 163 patients (age, 63 ± 14 years; 74% women) who had RACD and underwent cardiac surgery (20% had reoperations) between 2000 and 2003. In addition to standard echocardiography, LV-GLS (%) was derived from the average of 18 segments in 3 apical views of the left ventricle, using velocity vector imaging. Standard clinical and demographic parameters were recorded. All-cause mortality was recorded. ResultsThe mean duration between cardiac surgery and the last chest radiation was 18 ± 12 years. The median European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 8, and 88 patients died over 6.6 ± 4 years. A total of 52% of patients had ≥II+ mitral regurgitation; 23% of patients had severe aortic stenosis; and 39% of patients had ≥II+ tricuspid regurgitation. The mean left ventricular ejection fraction was 54% ± 13%, and the mean LV-GLS was −12.9% ± 4%. In a Cox proportional survival analysis, lower LV-GLS was predictive of mortality in univariable analysis (hazard ratio, 1.07 (95% confidence interval, 1.01-1.14); P = .006); however, after adjustment for other variables, the association became nonsignificant. In patients with a EuroSCORE <median, abnormal LV-GLS (<−14.5%) was associated with significantly higher mortality (48%), compared with those with normal LV-GLS (32%). ConclusionsIn patients who have RACD and undergo cardiac surgery, LV-GLS does not sufficiently discriminate and is not independently predictive of long-term outcomes. However, in patients with a low EuroSCORE, abnormal LV-GLS was associated with higher mortality, compared with those with normal LV-GLS.