LV GLS Research Articles

Ferric carboxymaltose reduces the burden of arrhythmic events in heart failure with reduced ejection fraction: the role of the non-invasive arrhythmic biomarkers

BackgroundTreating iron deficiency (ID) with ferric carboxymaltose (FCM) in patients with heart failure with reduced ejection fraction (HFrEF) enhances morbidity, quality of life (QoL), and exercise capacity. MethodsThis single center, prospective follow-up study aims to assess FCM's impact on arrhythmic events and non-invasive markers in HFrEF patients with cardiac implantable electronic devices (CIEDs) and ID. Symptomatic HFrEF patients with ID and CIEDs scheduled for IV FCM were followed for 12-months. Arrhythmic activity was evaluated from CIEDs and non-invasive markers from Holter recordings pre- and post-FCM. Ventricular tachycardia/ventricular fibrillation (VT/VF) episodes, non-sustained VT (nsVT), late potentials (LPs), Microvolt T-wave alternans (MTWA), heart rate variability, turbulence (HRT) QTc, and premature ventricular contractions (PVCs, number and Lown and Wolf classification) were assessed. Left ventricular EF (LVEF), global longitudinal strain (LV GLS), QoL (KCCQ, EQ-5D-5L), six-minute walking distance (6MWD), peak oxygen consumption, and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels were also recorded. ResultsNinety-six patients in optimal medical treatment participated (median age 71.9 [12.3] years, 83% male). Post-FCM treatment, VT/VF (P=0.043) and nsVT (P<0.001) frequency decreased significantly. The Lown and Wolf classification improved (P=0.002) and predicted VT/VF episodes better than other markers (AUC 0.737, P=.001). MTWA, LPs and HRT improved statistically significantly post-FCM. Hospitalization rates and NT-proBNP levels decreased, while LVEF, LV GLS, 6MWD, QoL and peak VO2 improved statistically significantly (P<0.001). ConclusionsOur study provides real-world evidence that IV FCM led to statistically significant reduction in ventricular arrhythmic episodes, as well as an improvement in non-invasive arrhythmic markers.

Association between impaired left ventricular global longitudinal strain and B-type natriuretic peptide in obstructive hypertrophic cardiomyopathy

Abstract Background Left ventricular global longitudinal strain (LV-GLS) is considered valuable in explaining impaired left ventricular contractility in hypertrophic cardiomyopathy (HCM) with preserved ejection fraction and is associated with worse outcome. Elevated B-type natriuretic peptide (BNP) is a biomarker of increased LV wall stretch and a risk factor of heart failure, mortality, and other adverse cardiovascular events. However, relationship between GLS and BNP has not received sufficient attention in the obstructive variant of HCM. Purpose This study aimed to determine the association between echocardiographic LV-GLS and plasma BNP in patients with hypertrophic obstructive cardiomyopathy (HOCM). Methods A total of 145 consecutive patients (32% females) with symptomatic HOCM were enrolled in the retrospective study. HOCM was defined with a maximum end-diastolic wall thickness ≥15mm without other etiologies for LV hypertrophy, and peak LV outflow tract (LVOT) gradient ≥30mmHg. The echocardiographic parameters regarding LV geometry, loading conditions, and GLS were evaluated according to guidelines. Patients were divided into two groups according to absolute GLS values (greater or lower than median LV-GLS). Patient baseline clinical data, echocardiographic parameters, and BNP were compared. Univariate and multivariable regression analysis were applied to identify the independent determinator of LV-GLS. Results The median value of LV-GLS of this study cohort was -13.4%. Eighty-one patients (47.6±13.4 years-old) had a |GLS|≥13.4% and 64 individuals (48.7±12.6 years-old) had a |GLS|&amp;lt;13.4%. No differences were found in age, gender, physical examinations, LVEF, cardiovascular comorbidities, or active medications between the two groups, except for body mass index (BMI). Patients with |GLS|≥13.4% had statistically lower BMI (24.58±2.42 vs. 26.00±3.12kg/m², p=0.030). BNP was found significantly elevated in patients with |GLS|&amp;lt;13.4% when compared with individuals with |GLS|≥13.4% {median (IQR); 550.05 (214.50, 899.35) vs. 182.40 (78.90, 479.90)pg/mL, p=0.004}. In univariate regression analysis, decreased |GLS| was associated with male gender, maximum and mean LV wall thickness, peak LVOT gradient, reduced mitral annular e’ velocity, elevated BNP and cardiac troponin I. In multivariable regression analysis, GLS was found independently associated with mean LV wall thickness and BNP. Conclusions In patients with symptomatic HOCM with preserved ejection fraction, impaired LV-GLS was found to be associated with plasma BNP and mean LV wall thickness, independent of gender, age, loading conditions, LVEF, or LVOT gradient. Reduced GLS may be a more sensitive surrogate in assessing increased myocardial wall tension or stretch, rather than LV contractility in these patients. Therefore, the interpretation of GLS in HOCM should shift away from systolic interest toward emphasizing its potential value in risk stratification of diastolic heart failure with preserved LVEF.Figure 1

The importance of heart rate on left ventricular global longitudinal strain in echocardiography: novel insights facilitated by automated deep learning methods

Abstract Background Heart rate (HR) is assumed to influence echocardiographic measurements. Consequently, HR needs to be considered for accurate assessment of cardiac function. Despite left ventricular global longitudinal strain (LV GLS) being recognised as a valuable measure of cardiac function, its normal reference ranges remain confined to patients within a limited range of resting HR. So far, time-consuming manual analyses and high measurement variability have precluded comprehensive assessment of the interplay between HR and LV GLS. Using fully automated GLS measurements provided by novel deep learning (DL) methods, it is now possible to evaluate changes in LV GLS across a wide range of HR. Purpose To improve echocardiographic assessments across a wide range of HR intervals, we aimed to study the influence of controlled HR variations on LV GLS using programmable pacemakers and fully automated DL measurements. Methods Participants with sinus node dysfunction and implanted programmable pacemakers were enrolled. Echocardiographic acquisitions were obtained at baseline HR and during stepwise increments by 10 beats/min, targeting a range from 50 to 140 beats/min. Recordings of cine-loops including 10 cardiac cycles were obtained for the four-chamber, two-chamber, and apical long axis view. LV GLS was measured for all cycles using a fully automated DL method developed by our group, and presented as mean of the three standard apical views for all patients at each HR level. A linear mixed model was used for construction of an overall trendline based on the estimated fixed effects across all 50 patients, stating patient number as the random effect. The correlation between HR and LV GLS was evaluated by a likelihood ratio test. Results Fifty patients were included, 52% females, mean age 68 years (27 to 88 years). All patients had preserved atrioventricular conduction. Resting HR ranged from 50 to 87 beats/min (mean 64 beats/min). At baseline echocardiographic acquisition, most participants were within normal ranges for LV volumes, systolic and diastolic function. A total of about 13,000 cardiac cycles were automatically analysed by the DL method. The overall trend demonstrated a linear relation between increasing HR and decreasing absolute LV GLS (Figure 1). Across HR increments from 50 to 140 beats/min, there was a 32% (22%–42%) reduction in absolute LV GLS, declining from -17.1% to -11.7%. The strong correlation between changes in HR and LV GLS was further supported by a highly significant likelihood ratio test (p-value &amp;lt;0.001). Conclusions There was a reduction of absolute LV GLS with increasing HR. These findings emphasize the importance of integrating HR considerations into clinical echocardiography practice. Moreover, the results highlight that DL methods can unlock substantially richer insights from individual patient data, offering a new pathway towards more personalized and precise cardiac diagnostics.Figure 1

Donor-derived cell-free DNA versus left ventricular global longitudinal strain in noninvasive detection of heart allograft injury

Abstract Introduction Invasive endomyocardial biopsy (EMB) is still considered the gold standard method for monitoring heart transplant (HTx) rejection. However, it is associated with potentially serious complications, and its histopathologic interpretation has high interobserver variability. Thus, noninvasive methods for surveillance of the transplanted organ remains of great interest. The noninvasive donor-derived cell-free DNA is a marker of graft injury which can indicate acute rejection, even before the histopathological diagnosis of rejection detected by EMB. The assay has a high negative predictive value for acute rejection. Left ventricular global longitudinal strain (LV GLS) is an emerging marker of subclinical myocardial injury which plays a crucial role in the evaluation of several cardiac diseases; however, its role in HTx injury has so far been poorly investigated. Purpose We aimed to investigate the efficacy of a local laboratory-run dd-cfDNA assay-based heart transplant rejection surveillance programme, and the prognostic and discriminatory performance of LV GLS for subsequent heart allograft injury. Methods HTx recipients without a history of allograft rejection requiring intensification of immunosuppressive therapy were transitioned from our EMB-based surveillance protocol to dd-cfDNA-based rejection surveillance. We assessed the percentage of dd-cfDNA to total cell-free DNA. Injury cut-off was defined by a dd-cfDNA level ≥0.20%, while the severe injury threshold was at ≥0.35%. LV ejection fraction was calculated using 2D Simpson’s method. To derive LV GLS, we analyzed apical 4-chamber, 2-chamber, and long-axis images by 2D speckle tracking echocardiography. Results A total of 244 dd-cfDNA samples were analyzed from 46 patients in fifteen runs performed monthly between October 2022 and December 2023. The dd-cfDNA fraction remained below the injury cut-off in most patients (81%). There were no missed rejection episodes. 88% of routine EMBs that would have otherwise been performed were safely avoided. Eighteen for-cause EMBs were performed based on dd-cfDNA levels suggesting injury. One EMB verified moderate cellular rejection (ISHLT grade 2R) that required steroid pulse therapy. Two EMBs proved mild cellular rejection, one EMB confirmed mild antibody-mediated rejection, while one EMB proved mixed rejection. Thirteen EMBs found no rejection. Mean LVEF was preserved (57.6%±7.6%). Mean LV GLS was -15.1%±2.5% in the whole cohort, while -15.6%±4.7% in recipients with HTx rejection on indication EMB. There was no significant correlation between dd-cfDNA and LV GLS (n=159). Conclusion The noninvasive dd-cfDNA assay is effective in ruling out acute rejection and safely decreases the necessity of invasive surveillance EMBs after HTx. LV GLS is less sensitive in comparison with the dd-cfDNA assay for detection of myocardial injury in the early stages of graft rejection in HTx recipients at low risk for rejection.

Prognostic impact of left ventricular myocardial work in patients undergoing surgery for primary mitral regurgitation

Abstract Background Although left ventricular ejection fraction (LVEF) is widely used as a parameter for the assessment of LV systolic function, LVEF can overestimate LV systolic function in patients with severe mitral regurgitation (MR) due to its high load-dependency. Echocardiography-based, left ventricular myocardial work (LVMW) can assess LV function by incorporating LV afterload. Purpose This study aims to evaluate the prognostic value of LVMW indices in patients with primary MR undergoing mitral valve surgery. Methods Individuals who underwent mitral valve surgery for severe primary MR were included. All patients underwent transthoracic echocardiography before surgery. LVMW was derived from a vendor-specific package which integrates LV global longitudinal strain with sphygmomanometric blood pressure to construct pressure-strain loops during the cardiac cycle. (Figure 1) For the LVMW indices, previously-established normal values were used as thresholds. The primary endpoint was all-cause mortality after mitral valve surgery. Results A total of 309 patients (mean age 63 ± 12 years, 68% male) with severe, primary MR who underwent surgery, were included. The mean LV global work index (LVGWI) was 1977 ± 537 mmHg% and 132 (43%) patients had impaired LVGWI (≤ 1900 mmHg%). During a median follow-up of 5.0 years (interquartile range, 2.5-8.9), 27 (8.7%) patients died after mitral valve surgery. Patients with impaired LVGWI or LV GLS (≤ 20%) had lower survival rates compared to the group with preserved LVGWI (p &amp;lt;0.01) or LVGLS (p = 0.02), whereas there was no significant difference in the survival rate between patients with LVEF ≤ 60% and &amp;gt; 60%. (Figure 2) Furthermore, LVGWI ≤ 1900 mmHg% demonstrated incremental prognostic value over LVGLS (p = 0.049) for all-cause mortality. Conclusions In patients with severe, primary MR who underwent surgery, impaired pre-operative LVGWI was associated with a higher mortality risk. In addition, impaired LVGWI had incremental prognostic value over LVGLS. Based on these findings, LVMW is a promising parameter for predicting postoperative outcome and determining the optimal timing of valve surgery in patients with severe, primary MR.Fig1.Echo-derived Myocardial workFig2.Kaplan-Meier curves

Association of visceral adipose tissue with echocardiographic abnormalities in type 2 diabetes patients

Abstract Introduction Ectopic deposition of adipose tissue, particularly visceral adipose tissue (VAT) has been identified as a significant contributor to cardiometabolic complications among individuals with type 2 diabetes (T2D). An increase in VAT has been suggested to cause cardiac dysfunction, which may lead to echocardiographic abnormalities such as alterations in speckle-tracking and left ventricular ejection fraction (LVEF). However, this relationship has not been fully elucidated. Purpose This study aims to determine the association between VAT and echocardiographic abnormalities in patients with T2D. Methods A cross-sectional study in a tertiary hospital which included 195 individuals with T2D, the diagnosis of autoimmune diabetes was excluded. VAT was measured using electrical bioimpedance (BIA), and cardiac function was determined using echocardiography. A Spearman rank correlation analysis was conducted to evaluate the association between VAT and echocardiographic parameters, with significance set at p &amp;lt; 0.05. Results Within our cohort, the median age was 57 years, with 37% men. Based on the third quartile (P75) cutoff (5 liters for men, 3.75 liters for women), the population was categorized into P1-75 and P75-100 (Table). There were significant differences in LVEF (61% in P1-75 vs. 58% in P75-100, p = 0.041), left ventricular global longitudinal strain (LV GLS) (P1-75: -20.3%, P75-100: -19.2%, p = 0.012), and conduit phase of left atrial strain (LAScd) (P1-75: 25%, P75-100: 20%, p = 0.046). Positive correlations (Figure) were observed between VAT and indexed LV mass (r = 0.171, p = 0.020), basal diameter of the right ventricle (r = 0.308, p = 0.001), and LV GLS (r = 0.197, p = 0.006). Additionally, negative correlations were observed between VAT and LVEF (r = -0.342, p = &amp;lt;0.001) and right ventricular fractional area change (r = - 0.227, p= 0.001). Conclusion Increased VAT was associated with cardiac dysfunction, as indicated by altered LV GLS and LAScd. This study underscores the relevance of VAT in influencing both functional and structural changes in the left and right ventricles. It also highlights the significance of monitoring VAT for comprehensive cardiovascular risk assessment in T2D patients.Clinical demographics tableScatter plots with correlation graphs

A study to assess the ability of the HFA-ICOS risk stratification tool to predict cancer therapy-related cardiac dysfunction for patients receiving anthracycline chemotherapy

Abstract Introduction The use of anthracycline chemotherapy is complicated by the risk of developing cancer therapy-related cardiac dysfunction (CTRCD). The Heart Failure Association (HFA) and International Cardio-Oncology Society (ICOS) have jointly published a novel cardiovascular risk stratification tool for patients receiving anthracycline chemotherapy which categorises patients according to their risk of CTRCD (1). The risk tool has not yet been validated for use in the United Kingdom. Purpose In this study, we test the ability of the HFA-ICOS risk stratification tool to predict CTRCD for patients receiving anthracycline chemotherapy. Methods A retrospective study of patients ≥18 years who received anthracycline chemotherapy between January 2019 to January 2023 at two cardio-oncology centres in the United Kingdom. Patients were eligible if they had ≥1 follow up echocardiogram after the end of anthracycline treatment. Patients receiving HER-2 targeted therapies were excluded. Patients were classified into low/medium/high/very-high risk categories using the HFA/ICOS tool. The prevalence of CTRCD was assessed during the follow up period; a minimum of 6 months after the end of chemotherapy. Results 288 patients met eligibility criteria for the study. 59 patients (20%) were treated for leukaemia, 104 (36%) lymphoma, 63 (22%) sarcoma and 49 (17%) breast cancer. The mean age was 49±18yrs, with 56% females. The mean cumulative dose of doxorubicin (or equivalent) was 235±104mg/m2. Using the HFA/ICOS tool, 50% of patients were deemed low risk, 31% medium risk, 16% high risk and 3% very high risk at baseline. Using guideline recommended CTRCD definitions, there was an overall incidence of 9% of symptomatic CTRCD and 22% of asymptomatic CTRCD (Table 1). The incidence of symptomatic CTRCD significantly increased as the baseline risk of CTRCD increased. 20% of patients deemed high or very-high risk at baseline subsequently developed symptomatic CTRCD (Fig 1). Furthermore, patients at high or very-high risk were 4.4 times more likely to develop symptomatic CTRCD than patients who were low risk (OR 4.4, 95% CI 1.7-11.6, p=0.003). There was no association with baseline risk and the development of asymptomatic CTRCD. The incidence of mild asymptomatic CTRCD may be underestimated due to the lack of routine surveillance with cardiac biomarkers and left ventricular global longitudinal strain (LV GLS) imaging for asymptomatic disease during the study period. Conclusion The novel HFA/ICOS risk stratification tool is useful in predicting patients who will develop symptomatic CTRCD in a contemporary UK setting.

Effect of renal dialysis session on novel echocardiographic parameters of left and right ventricle in patients with end-stage renal disease

Abstract Introduction Chronic heart disease is among the leading causes of end-stage renal disease (ESR). On the other hand, patients with ESR undergoing dialysis demonstrate often subclinically impaired left and/or right ventricular function according to small studies, and higher prevalence of chronic heart disease. However, data regarding the effect of renal dialysis on novel echocardiographic parameters among renal dialysis patients remain limited.The purpose of our study, was to study the effect of renal dialysis on novel echocardiographic parameters of left and right ventricle. Methods All 50 patients (14 females) of mean age 62.9 years undergoing renal dialysis in our kidney unit regularly were included in our study. Blood pressure, heart rate and weight measurements and heart echocardiogram with measurement of LV GLS, RV GLS, RV FWS, LA ResS, E/e’ ratio, Right Ventricular Systolic pressure (PASP) and inferior vena cava (IVC) diameter, before and after renal dialysis session, were carried out. Results Mean values of body weight (79,9 vs 77,6 kg), heart rate (74,2 vs 73,5 bpm) and blood pressure (131,5/80,6 vs 123,5/76,9 mmHg) were as expected statistically significant reduced after renal dialysis (p&amp;lt;0,001). Values of PASP (36,1 vs 27,8 mmHg), E/e’ ratio (14 vs 12,5) and IVC diameter (1,6 vs 1,3 cm), were statistically significant reduced after renal dialysis (p&amp;lt;0,001). Furthermore, values of RV GLS (-19,3 vs -20,3 %), RV FWS (-21,2 vs -22,6 %) and LA ResS (29,6 vs 30,7%), were statistically significant improved after renal dialysis session (p &amp;lt;0,001), while LV GLS depicted a minor improvement (-17,9% vs 18,2%) not statistically significant. Conclusion In conclusion, renal dialysis session had a beneficial effect on novel echocardiographic parameters of left and right ventricle (RV GLS, RV FWS, LA ResS) due to improvement of hemodynamic parameters (blood pressure, heart rate, PASP and IVC diameter) and intravascular volume reduction. Larger clinical studies should be organized to further investigate the effect of renal dialysis on those parameters and the underlying mechanisms in the chronic setting of hemodialysis.

Ventricular-arterial coupling as assessed by the PWV/GLS ratio in the general population: reference values, correlates and predictive value

Abstract Purpose Ventricular-arterial coupling (VAC) reflects global cardiovascular efficiency. We may assess VAC state non-invasively by combining the non-invasive gold standards for arterial stiffness (carotid-femoral pulse wave velocity or PWV) and left ventricular systolic function (LV global longitudinal strain or GLS). To gain insight in the clinical value of the PWV to GLS ratio, we conducted a general population study to determine its reference values, clinical correlates and predictive value. Methods We measured PWV by applanation tonometry and GLS by echocardiography in 1026 individuals (mean age 50.3 years; 52% women). We derived age- and sex-specific reference values for PWV/GLS from a low-risk subsample. Clinical correlates of PWV/GLS were determined by stepwise regression. We calculated multivariable-adjusted hazard ratios (HR) for incident cardiovascular (CV) events (median follow-up time: 10.1 years). Results Upper limits of normality for PWV/GLS varied with sex and age, ranging from 0.41 m/sec% in young women up to 0.64 m/sec% in older men. Higher PWV/GLS correlated with male sex and higher age, heart rate, pulse pressure, mean arterial pressure and left ventricular mass (P&amp;lt;0.05 for all). On a continuous scale, only GLS was a significant predictor of CV events after adjustment (HR per 1% decrease: 1.24; P=0.0030). A PWV/GLS ratio above the median (&amp;gt;0.37 m/sec%) did predict future CV events after adjustment (HR versus below median: 2.02; P=0.0067). However, abnormal PWV/GLS defined by reference limits or by cutoffs from literature did not independently predict CV events (P≥0.31 for all). Conclusion Age- and sex-specific reference values for PWV/GLS were reported. PWV/GLS relates to age, sex and blood pressure. In contrast to GLS, PWV/GLS does not hold value for CV event prediction in the community.

Risks factors of adverse clinical outcomes in asymptomatic mitral regurgitation patients with preserved ejection fraction: a systematic review and meta-analysis.

Indication for mitral valve (MV) surgery in asymptomatic mitral regurgitation (MR) patients with preserved ejection fraction (EF) remains unclear. This study aims to identify risk factors of adverse clinical outcomes in asymptomatic MR patients with preserved EF for early indication of MV surgery. 3 databases were systematically searched to include studies with asymptomatic MR patients with preserved EF. Risk factors of adverse clinical outcomes (composite outcome of MACE and MV surgery indication), mortality, and left ventricular dysfunction (LVD) are pooled with a meta-analysis of random effect model. A total of 39 observational studies with 9135 asymptomatic moderate to severe MR patients are included. We identified 21 statistically significant risk factors for adverse outcomes. Increased natriuretic peptide, presence of atrial fibrillation, LV GLS > 20%, LVEDD > 35mm, LVESD > 22mm, and LAVI > 55ml/mm2, ERO > 55mm2, and regurgitation volume > 60ml (HR 2.21, 2.07, 4.23, 2.98, 4.05, 1.84, 4.02, 3.30, respectively; p-value < 0.05; I2 0-87%) are associated with greater risk of adverse clinical outcome. Risk factors associated with postoperative LVD are the increase of LVEDD, LVESD, and RVSP. Risk factors associated with mortality are increasing STS score and LV GLS. Several clinical parameters and risk factors can be used to stratify asymptomatic MR patients with preserved ejection fraction who could benefit from early indication for MV surgery.

Cardiac Function and Structure before and after Mild SARS-CoV-2 Infection in Elite Athletes Using Biventricular and Left Atrial Strain.

Myocardial involvement has been observed in athletes following SARS-CoV-2 infection. It is unclear if these changes are due to myocardial damage per se or to an interruption in training. The aim of this study was to assess cardiac function and structure in elite athletes before and after infection (INFAt) and compare them to a group of healthy controls (CON). Transthoracic echocardiography was performed in 32 elite athletes, including 16 INFAt (median 21.0 (19.3-21.5) years, 10 male) before (t0) and 52 days after (t1) mild SARS-CoV-2 infection and 16 sex-, age- and sports type-matched CON. Left and right ventricular global longitudinal strain (LV/RV GLS), RV free wall longitudinal strain (RV FWS) and left atrial strain (LAS) were assessed by an investigator blinded to patient history. INFAt showed no significant changes in echocardiographic parameters between t0 and t1, including LV GLS (-21.8% vs. -21.7%, p = 0.649) and RV GLS (-29.1% vs. -28.7%, p = 0.626). A significant increase was observed in LA reservoir strain (LASr) (35.7% vs. 47.8%, p = 0.012). Compared to CON, INFAt at t1 had significantly higher RV FWS (-33.0% vs. -28.2%, p = 0.011), LASr (47.8% vs. 30.5%, p < 0.001) and LA contraction strain (-12.8% vs. -4.9%, p = 0.050) values. In elite athletes, mild SARS-CoV-2 infection does not significantly impact LV function when compared to their pre-SARS-CoV-2 status and to healthy controls. However, subtle changes in RV and LA strain may indicate temporary or training-related adaptions. Further research is needed, particularly focusing on athletes with more severe infections or prolonged symptoms.

Speckle-tracking echocardiography as screening tool for myocardial fibrosis and Iron overload in transfusion-dependent beta-thalassemia

BackgroundTransfusion-dependent beta thalassemia (TDT) is a genetic disorder characterized by low haemoglobin levels, often leading to myocardial iron overload (MIO) and myocardial fibrosis (MF). Cardiac Magnetic Resonance (CMR) represents the gold standard for MIO and MF assessment, although its limited availability and high costs pose challenges. Left Ventricular Global Longitudinal Strain (LV GLS) measured by Speckle Tracking Echocardiography (STE) could offer a valuable alternative. MethodsA monocentric diagnostic accuracy study was conducted to compare the performance of LV GLS with CMR using T2* for evaluating MIO and late gadolinium enhancement (LGE) for detecting MF. Between January 2022 and January 2023, 44 consecutive patients with TDT were enrolled. For each participant was performed LV GLS with STE, including CMR with T2* technique and LGE sequences. ResultsCMR identified MIO in 8 patients (18 %) and MF in 5 (11 %). LV GLS STE was normal in patients without MIO (−20.6 ± 3.1 %) or MF (−20.6 ± 2.8 %), significantly differing from those with MIO (−18.2 ± 2.1 %, p = 0.043) and MF (−16.4 ± 1.7 %, p = 0.002). ROC analysis indicated an optimal LV GLS STE cutoff of −19.8 % for MIO (AUC = 0.76, 95 % CI: 0.59–0.93, p = 0.054) with an overall diagnostic accuracy of 64 % and an optimal cutoff of −18.3 % for MF (AUC = 0.93, 95 % CI: 0.85–1.00, p = 0.009) with an accuracy of 86 %. ConclusionsThe findings of this pilot study indicate that LV GLS with STE, may be a cost-effective screening tool for the early detection of MIO and MF in TDT patients.

Hypertension and Left Ventricular Strain in Pediatric Chronic Kidney Disease.

Left ventricular global longitudinal strain (LV GLS) on echocardiography is a sensitive yet clinically significant marker of myocardial dysfunction. Reduced LV GLS is prevalent in adults with chronic kidney disease and hypertension and is associated with adverse cardiovascular outcomes. It may be a biomarker of chronic kidney disease-associated myocardial dysfunction in children, but data are limited. Our objective was to describe LV GLS in the CKiD study (Chronic Kidney Disease in Children) and to examine the association between blood pressure (BP) and reduced LV GLS. A single apical 4-chamber view was used to estimate LV GLS. Our main analyses examined the association of clinic BP with the absolute value of LV GLS and LV GLS dichotomized at 16. Sensitivity analyses using 24-hour ambulatory BP monitoring data were also performed. Generalized estimating equations were used to account for within-person correlation and to estimate robust SEs for 95% CIs. Covariates in adjusted models included: age, sex, race, estimated glomerular filtration rate, urine protein, hemoglobin, left ventricular hypertrophy, and the use of renin-angiotensin system inhibitors. LV GLS was measured in 962 person-visits. A total of 77 assessments had an LV GLS <16. In adjusted models, both clinic systolic BP (odds ratio, 1.02 [95% CI, 1.01-1.03]) and diastolic BP (odds ratio, 1.02 [95% CI, 1.00-1.03]) percentiles were associated with LV GLS <16. Having awake or nighttime diastolic BP hypertension on ambulatory BP monitoring was significantly associated with a lower absolute value of LV GLS. Office systolic and diastolic hypertension was associated with diminished LV GLS. Only diastolic hypertension detected on ambulatory BP monitoring was associated with lower LV GLS.

Use of strain imaging to detect subtle myocardial involvement in post COVID-19 patients: An Indian perspective

BackgroundThe study assessed Global longitudinal strain imaging (GLS) to detect subtle myocardial dysfunction among patients clinically recovered from COVID-19. MethodsAll patients (n = 101 76 % males, mean age 55.45 ± 11.14 years), and controls (n = 30), underwent clinical assessment and echocardiography, including GLS assessment. ResultsThe prevalence of diabetes mellitus, hypertension and dyslipidemia was comparable amongst patients and controls. The average GLS was significantly lesser in post COVID patients (−16.21 ± 1.96 vs −18.49 ± 1.64 respectively, p = 0.004) and significantly higher proportion of post COVID patients had GLS > -18 % (43 % vs 22.58 % respectively, p = 0.001) as compared to controls. The RV free wall longitudinal strain (RVFLS) was also lower in the patient group (22.35 ± 4.69 vs 24.19 ± 4.11, p = 0.004) and 21.7 % post COVID-19 patients had pathological RV FWLS (> −20 %) vs controls (6.6 %).Average GLS was significantly lesser in severe post COVID patients (viz −14.25 ± 1.92 vs −16.63 ± 1.61 vs −17.63 ± 1.91, p < 0.0001, respectively among severe, moderate and mild COVID-19 patients. On performing regression analysis, severity of COVID-19 (OR 7.762) was a significant predictor of impaired GLS. ConclusionDespite normal global LVEF, post COVID-19 recovered patients had significantly lower LV GLS and RV FWLS with severe COVID-19 infection, regardless of having a clinical recovery. This study reiterates the importance of speckle tracking echocardiography as an important imaging modality for detection of subclinical myocardial dysfunction in the post COVID-19 recovered patients.

Impact of smoking on procedural outcomes and all-cause mortality following acute myocardial infarction: A misleading early-stage pseudoparadox with ultimately reduced survival

BackgroundSmoking has conflicting results on outcomes following acute myocardial infarction (AMI). We evaluated the independent influence of smoking status on patient outcomes. MethodsWe included patients with AMI undergoing invasive coronary angiography with available self-reported smoking status. The incidence of death of any cause was evaluated during a median follow-up of 1.14 years (range 0.36–3.40 years). Association between smoking status and long-term mortality was evaluated using multivariable adjusted Cox regression analysis. ResultsFrom 1612 AMI patients (aged 65.7 ± 13.3 years, 72.1 % male), 378 patients (23.4 %) were current-smokers, 311 (19.3 %) ex-smokers, and 923 (57.3 %) non-smokers. Compared with non-smokers, current-smokers were younger (68.5 ± 13.0 vs. 58.6 ± 12.5, p < 0.0001) and more frequently presented with STEMI (21.6 % vs. 35,4 %, p < 0.0001), while ex-smokers with similar frequency of STEMI-manifestation as non-smokers (22.5 %, p = 0.79) constituted an intermediate-group in terms of age (65.8 ± 11,6 years). Although smoking status was not significantly associated with long-term survival in unadjusted-analysis, active-smokers had 56 % higher long-term mortality than non-smokers when adjusting for age, gender, medications and other traditional risk factors, whereas ex-smokers possessed comparable survival probability (current-smokers: 1.56[1.14–2.14], p = 0.006, ex-smokers 1.16[0.84–1.59], p = 0.37). Current-smokers had unadjusted lower NT-proBNP and modestly higher absolute in-hospital left ventricular global longitudinal strain (LV GLS) values that did not differ among groups after the same adjustments (NT-proBNP: −0.08[-0.31; 0.15], p = 0.5, LV GLS: 0.65[-0.26; 1.55], p = 0.16). ConclusionActive smoking is associated with increased adjusted long-term mortality, earlier onset and more frequent manifestation as STEMI, compared to non-smoking. Comparable adjusted results for LV GLS and NT-proBNP between groups support the presence of the pseudoparadox.

Left ventricular reverse remodeling after combined ARNI and SGLT2 therapy in heart failure patients with reduced or mildly reduced ejection fraction

BackgroundCardiac remodeling is an adverse phenomenon linked to heart failure (HF) progression. Cardiac remodeling could represent the real therapeutic goal in the treatment of patients with HF and reduced ejection fraction (HFrEF), being potentially reversed through different pharmacotherapies. Currently, there are well-established drugs such as ACEi/ARBs and β-blockers with anti-remodeling effects. More recently, ARNI effects on cardiac remodeling were also demonstrated; additional potential benefits of gliflozins remain non clearly demonstrated. Aim of studyTo evaluate possible changes in cardiac remodeling in patients with HFrEF/HFmrEF in treatment with ARNI or ARNI plus SGLT2i and the potential benefit on cardiac remodeling of adding SGLT2i to ARNI. MethodsBetween June 2021 and August 2023, 100 consecutive patients with HFrEF/HFmrEF underwent conventional and advanced echocardiography (TDI, 2DSTE): patients were therefore divided into three groups according to therapy with neither ARNI nor SGLT2i, just ARNI or both. After 3 months, all patients underwent echocardiographic follow-up. ResultsAfter a 3 months of therapy, significant improvements were observed for LVEF, LVEDD, LVEDV, LVESV, LV mass, E/e’, LV GLS, TAPSE (ANOVA p< 0.01 in all cases), RV S’ velocity (ANOVA p< 0.001).The trend in favor of additional treatment with SGTL2i over ARNI remained statistically significant even after multivariable analysis (p< 0.001 for LVEF, LVEDD; p< 0.01 for LV GLS, TAPSE, TRVS; p< 0.05 for LV mass). ConclusionsSGLT2i therapy when added to the standard treatment for HFrEF and HFmrEF is associated with an improved biventricular function and ventricular dimensions at follow-up.

Effects of SGLT2 Inhibitors on Cardiac Mechanics in Hispanic and Black Diabetic Patients.

Background: Clinical trials demonstrating improved cardiovascular outcomes with SGLT2 inhibitors have often had limited representation from Black and Hispanic populations. While the mechanisms of action are not well known, ethnicity- or gender-based receptor physiology may render SGLT2 inhibitors a better agent in certain populations over others. Methods: A medical records query yielded diabetic patients initiated on SGLT2 inhibitors between 2013 and 2020. Patients with coronary artery disease, cardiac arrhythmias, and heart failure were excluded. Transthoracic echocardiographic studies (TTE) before and after starting SGLT2 inhibitors were analyzed, and post-processing left ventricular global longitudinal strain (LV GLS) analysis was also performed on each echocardiographic study. Univariate outliers and patients with missing data were excluded. Results: Among 94 patients with TTE (mean age 60.7 years; 68% Hispanics, 22.3% Blacks; median follow up of 7 months), there were significant improvements in the mean LV GLS (-15.3 vs. -16.5; p = 0.01), LV mass (LVM) (198.4 ± 59.6 g vs. 187.05 ± 50.6 g; p = 0.04), and LV mass index (LVMI) (100.6 ± 26.6 g/m2 vs. 94.3 ± 25.4 g/m2; p = 0.03) before and after initiating SGLT2 inhibitors but no significant change in the ratio (MV E/E') of peak early diastolic mitral flow velocity (E) and spectral pulsed-wave Doppler-derived early diastolic velocity from the septal mitral annulus (E') (12.5 ± 5.7 vs. 12.7 ± 4.8; p = 0.38). Changes in HbA1c (r2 = 0.82; p = 0.026), LVM (r2 = 0.20; p = 0.04), and LVMI (r2 = 0.20; p = 0.04) were found to be independently associated with changes in values of LV GLS on follow-up echocardiograms, when compared to the pre-medication LV GLS number. Conclusion: Non-White diabetic patients receiving SGLT2 inhibitors against a backdrop of other cardioprotective medications demonstrate significant improvements in LV remodeling and LV GLS, driven in part by an improvement in glycemic control. Large, prospective studies are needed to explore the differences in the therapeutic actions of SGLT2 inhibitors among different populations.

Comparison of a semi-automatic strain analysis of left heart with manual myocardial tracing in speckle-tracking echocardiography

Purpose. To compare a semi-automatic strain analysis of the left ventricle and left atrium with a manual method in speckle-tracking echocardiography.Materials and methods. A strain of left ventricle and left atrium was assessed in 110 patients by two methods: manual (Q-Analysis) and semi-automatic (AutoStrain). The following parameters were evaluated: LV global longitudinal strain (LV GLS), LA longitudinal strain during the reservoir phase (LASr), LA longitudinal strain during the conduit phase (LAScd), and LA longitudinal strain during the contraction phase (LASct).Results. The ROI correction was carried out significantly more often with the semi-automatic method of measuring LV GLS than with manual (40.1% vs. 16.4%, p &lt; 0.05). There were significant differences in LV GLS average values, LASr values, and LAScd values obtained by the semi-automatic and manual methods. LV GLS average values obtained by the semi-automatic method were lower (18.8 ± 2.8% vs. 20.0 ± 3.1%, p &lt; 0.001), and the values of LASr and LAScd obtained by the semi-automatic method were higher (LASr 31.6 ± 9.8% vs. 30.3 ± 10.8%, p = 0.038; LAScd 17.1 ± 7.1% vs. 15.4 ± 6.8%, p &lt; 0.001) than in manual. Semi-automatic method takes more time for LV strain analysis and less time for LA strain analysis than manual method.Conclusion. The semi-automatic method of LV and LA strain evaluation showed higher reproducibility compared with the manual method. With the semi-automatic method, the values of the LV GLS were lower, and the correction of ROI was required more often and took more time than with manual. The semi-automatic method of LA strain evaluation was characterized by higher values in the reservoir and conduit phases and required less time compared to the manual method. The LA longitudinal strain in the reservoir phase showed the highest values of reproducibility compared to other LA strain paremeters.

Impact of SGLT2 inhibition on markers of reverse cardiac remodelling in heart failure: Systematic review and meta-analysis.

Several landmark randomized-controlled trials (RCTs) have demonstrated the efficacy of sodium-glucose co-transport 2 (SGLT2) inhibitors in reducing all-cause mortality, cardiovascular (CV) mortality and heart failure (HF) hospitalizations. Much interest surrounds their mechanism of action and whether they have direct effects on reverse cardiac remodelling. Therefore, we conducted a meta-analysis of placebo controlled RCTs evaluating the impact of SGLT2 inhibition on imaging derived markers of reverse cardiac remodelling in patients with HF. We performed a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement and Cochrane Collaboration. Data interrogation of each major database including PubMed, EMBASE, MEDLINE and Cochrane Library was performed. RCTs evaluating HF patients >18years comparing SGLT2 inhibitor versus placebo-control were included. Outcome measures included left ventricular end-diastolic volume and volume index (LVEDV/LVEDVi), left ventricular end-systolic volume and volume index (LVSDV/LVSDVi), left ventricular ejection fraction (LVEF), left ventricular mass index (LVMi), left atrial volume index (LAVi) and left ventricular global longitudinal strain (LV GLS). Studies with an HF with preserved ejection fraction population were excluded from analysis of parameters, which would be significantly affected by baseline LVEF, such as volumes and LVEF. The mean difference and standard error were extracted from each study and a random effects model used pool the mean difference and standard error across studies. A pre-specified sub-group analysis was performed to stratify results according to imaging modality used (cardiac magnetic resonance imaging and echocardiography). This study is registered on PROSPERO: CRD42023482722. Seven randomized, placebo-controlled trials in patients with HF comprising a total population of 657 patients were included. Overall LVEF of included studies ranged from 29±8.0% to 55.5±4.2%. In studies included in analysis of HFrEF parameters, baseline LVEF ranged from 29±8% to 45.5±12%. Pooled data demonstrated SGLT2 inhibition, compared with placebo control, resulted in significant improvements in mean difference of LVEDV [-11.62ml (95% confidence interval, CI -17.90 to -5.25; z=3.67, P=0.0004)], LVEDVi [-6.08ml (95% CI -9.96 to -2.20; z=3.07; P=0.002)], LVESV [-12.47ml (95% CI -19.12 to -5.82; z=3.68; P=0.0002)], LVESVi [-6.02ml (95% CI -10.34 to -1.70; z=2.73; P=0.006)], LVM [-9.77g (95% CI -17.65 to -1.89; z=2.43; P=0.02)], LVMi (-3.52g [95% CI -7.04 to 0.01; z=1.96; P=0.05)] and LVEF [+2.54mL (95% CI 1.10 to 3.98; z=3.62; P=0.0005)]. No significant difference in GLS (n=327) [+0.42% (95%CI -0.19 to 1.02; P=0.18)] or LAVi [-3.25ml (95% CI -8.20 to 1.69; z=1.29; P=0.20)] was noted. This meta-analysis provides additional data and insight into the effects of SGLT2 inhibition on reverse cardiac remodelling in patients with HF. Compared with placebo control, we found that treatment with a SGLT2 inhibitor produced significant improvements in several markers of reverse cardiac remodelling.

Role of Speckle Tracking Echocardiography in the Assessment of Subclinical Left Ventricular Dysfunction in Post COVID-19 Patients

Background: The utilization of two-dimensional speckle-tracking echocardiography (2-D STE) serves as a precise measurable technique for conducting an assessment of both global and localized cardiac performance, exhibiting remarkable sensitivity. Its utility is particularly noteworthy in the early identification of cardiac impairments that are not clinically evident. This study’s objective was to investigate the effectiveness of STE in identifying latent left ventricular dysfunction among individuals who have recuperated from COVID-19. Methods: This study was conducted at a single center; this analytical cross-sectional analysis involved 100 individuals over the age of 18. The study comprised two cohorts: one with 50 post COVID-19 patients, confirmed through a positive PCR test within a month of diagnosis, and a control group of 50 healthy subjects be compatible for age, sex, and risk factors. Subsequently, the post COVID-19 patients were stratified based on high-sensitivity troponin levels into two subgroups: Group I included those exhibiting signs of myocardial damage, while Group II consisted of patients showing no evidence of myocardial injury. Results: Elderly individuals, a greater prevalence of hypertension (HTN), raised levels of D-dimer and, serum C-reactive protein (CRP) along with increased Left ventricular end-diastolic volume (LVEDV) and diminished Left ventricular global longitudinal strain (LVGLS) over a one-month observation period, were all significantly linked to myocardial injury, as indicated by a p-value &lt; 0.05. The LVGLS was a reliable indicator of cardiac injuries in COVID-19 survivors, with an AUC of 0.947 and a CI ranging from 0.886 to 1.00 (P &lt; 0.001), particularly at a threshold of ≤ -20%, where it achieved 87.2% sensitivity and 100% specificity. Approximately 35 patients exhibited an LVGLS below this threshold. Furthermore, D-dimer and CRP levels post COVID-19 were notably elevated in those with cardiac injuries in comparison with those not, a difference that was statistically significant (P &lt; 0.05). Furthermore, during the follow-up after one month period, post COVID-19 CRP levels, LVEDV, and LVGLS remained significantly higher in patients with myocardial injury in comparison with those didn’t have myocardial injury (p &lt; 0.05). Conclusions: LV GLS is acknowledged as a noteworthy, autonomous predictor of outcome for myocardial injury in individuals diagnosed with COVID-19. This metric offers preliminary insights into the infection’s severity, potentially aiding in the early intervention and management strategies for affected patients.