Left Ventricular Longitudinal Strain Research Articles

Cardiac function evaluation in children with spinal muscular atrophy: A case-control study.

Spinal muscular atrophy (SMA) is an autosomal recessive disorder characterized by degeneration of lower motor neurons, resulting in progressive muscle weakness and atrophy. However, little is known regarding the cardiac function of children with SMA. We recruited SMA patients younger than 18 years of age from January 1, 2022, to April 1, 2022, in the First Affiliated Hospital of Sun Yat-sen University. All patients underwent a comprehensive cardiac evaluation before treatment, including history taking, physical examination, blood tests of cardiac biomarkers, assessment of echocardiography and electrocardiogram. Age/gender-matched healthy volunteers were recruited as controls. A total of 36 SMA patients (26 with SMA type 2 and 10 with SMA type 3) and 40 controls were enrolled in the study. No patient was clinically diagnosed with heart failure. Blood tests showed elevated values of creatine kinase isoenzyme M and isoenzyme B (CK-MB) mass and high-sensitivity cardiac troponin T (hs-cTnT) in spinal muscular atrophy (SMA) patients. Regarding echocardiographic parameters, SMA children were detected with lower global left and right ventricular longitudinal strain, abnormal diastolic filling velocities of trans-mitral and trans-tricuspid flow. The results revealed no clinical heart dysfunction in SMA patients, but subclinical ventricular dysfunction was seen in SMA children including the diastolic function and myocardial performance. Some patients presented with elevated heart rate and abnormal echogenicity of aortic valve or wall. Among these SMA patients, seven patients (19.4%) had scoliosis. The Cobb's angles showed a significant negative correlation with LVEDd/BSA, but no correlation with other parameters, suggesting that mild scoliosis did not lead to significant cardiac dysfunction. Our findings warrant increased attention to the cardiac status and highlight the need to investigate cardiac interventions in SMA children.

Diagnostic capabilities of instrumental methods for studying early cardiovascular adverse events in patients with lymphoproliferative disorders, quality and safety issues

Aim. To study the possibilities of instrumental research methods in relation to the earliest detection of cardiovascular events in oncohematological patients receiving antitumor immunochemotherapy, as well as to deter­mine the requirements for documenting adverse events.Material and methods. For the study, 63 patients were prospectively selected with a diagnosis of indolent non-Hodgkin lymphoma, who were indicated for antitumor immunochemotherapy. The patients were examined in three stages (before treatment, after 3 and 6 cycles of therapy) and divided into 2 groups by simple randomization. Cardiovascular toxicity in the main group of patients was assessed using 3D transthoracic echocardiography, analysis of left ventricular (LV) global longitudinal systolic strain and electrocardiography. The control group underwent a standard 3D echocardiography with analysis of LV ejection fraction. Clinical manifestations of cardiovascular events were assessed in all patients during treatment.Results. According to the study, significant changes were obtained in LV ejection fraction on the third visit — a decrease from 58,9±1,07 to 48,1±0,73% (p<0,05) and from 57,7±1,13 to 49,4±0,58% (p<0,05) in patients of the main and control groups and global longitudinal LV strain from |21,1±1,18 to |14,0±1,61 |% (p<0,05) in patients of the main group. A mixed clinical phenotype of cardiovascular toxicity was the most common among all patients. An integrated approach to the early diagnosis of cardiovascular events makes it possible to identify a larger percentage of patients with subclinical myocardial dysfunction.Conclusion. The long period of latent cardiovascular toxicity emphasizes the need for early verification of cardiovascular complications of antitumor therapy and expansion of the established paraclinical diagnostic minimum. In addition, taking into account the accumulated experience, recommendations are presented for the preparation of medical documentation in order to ensure the safety and quality of care.

Association between left ventricular systolic function parameters and myocardial injury, organ failure and mortality in patients with septic shock

BackgroundLeft ventricular ejection fraction (LVEF) is inconsistently associated with poor outcomes in patients with sepsis. Newer parameters such as LV longitudinal strain (LVLS), mitral annular plane systolic excursion (MAPSE) and LV longitudinal wall fractional shortening (LV-LWFS) may be more sensitive indicators of LV dysfunction, but are sparsely investigated. Our objective was to evaluate the association between five traditional and novel echocardiographic parameters of LV systolic function (LVEF, peak tissue Doppler velocity at the mitral valve (s´), LVLS, MAPSE and LV-LWFS) and outcomes in patients admitted to the Intensive Care Unit (ICU) with septic shock.MethodsA total of 152 patients admitted to the ICU with septic shock from two data repositories were included. Transthoracic echocardiograms were performed within 24 h of ICU admission. The primary outcome was myocardial injury, defined as high-sensitivity troponin T ≥ 45 ng/L on ICU admission. Secondary outcomes were organ support-free days (OSFD) and 30-day mortality. We also tested for the prognostic value of the systolic function parameters using multivariable analysis.ResultsLVLS, MAPSE and LV-LWFS, but not LVEF and s´, differed between patients with and without myocardial injury. After adjustment for age, pre-existing cardiac disease, Simplified Acute Physiology (SAPS3) score, Sequential Organ Failure Assessment (SOFA) score, plasma creatinine and presence of right ventricular dysfunction, only MAPSE and LV-LWFS were independently associated with myocardial injury. None of the systolic function parameters were associated with OSFD or 30-day mortality.ConclusionsMAPSE and LV-LWFS are independently associated with myocardial injury and outperform LVEF, s´ and LVLS. Whether these parameters are associated with clinical outcomes such as the need for organ support and short-term mortality is still unclear.Trial registration NCT01747187 and NCT04695119.

Biventricular interaction and aortic function in adult patients with repaired tetralogy of Fallot: a two-dimensional-three-dimensional speckle-tracking echocardiographic study.

In patients late after correction of tetralogy of Fallot (TOF), the combined effects of pre-operative hypertrophy and hypoxia, ventricular interdependence, acquired post-operative lesions such as pulmonary or aortic regurgitation, and congenital vasculopathy may result in impaired right ventricular (RV) and left ventricular (LV) function. The aim of the present study was to investigate the interventricular interactions in repaired TOF (rTOF) and the impact of aortic function on biventricular performance using two-dimensional (2D-STE) and three-dimensional speckle-tracking echocardiography (3D-STE). Twenty-five adult patients with rTOF and 25 age- and gender-matched healthy controls were studied. LV and RV volumes were determined by 3D-STE and cardiac magnetic resonance. LV and RV longitudinal strains (LVLS and RVLS) and LV and RV area strains (LVAS and RVAS) and LV twist/rotation were calculated by 3D-STE. Ascending aorta circumferential strain (AAo-CS) was obtained using 2D-STE. LV 3D-STE parameters were decreased in rTOF patients compared with controls even in patients with normal ejection fraction. AAo-CS was decreased (6.7 ± 1.9 vs. 10.1 ± 2.6, P = 0.003) in rTOF patients compared with controls even in the presence of normal aortic dimensions and correlated with AAo diameter (r = -0.69, P = 0.0001), LV twist (r = 0.54, P = 0.004), LVAS (r = -0.56, P = 0.003), and RVLS (r = -0.39, P = 0.036). LVAS and AAo-CS were associated with disease severity (peak oxygen consumption and arrhythmia occurrence). Significant improvement in global χ 2 value was noted with RV 3D-STE parameters + LVAS + AAo-CS compared with RV dysfunction alone for detecting exercise capacity impairment (from 77.1 to 84.4 to 91.2, P = 0.003). Speckle-tracking echocardiography revealed subtle LV and AAo dysfunction in adults with rTOF. A correlation was observed between LV and RV strain changes and between AAo strain impairment and LV/RV dysfunction. LV and AAo changes had an incremental value in evaluating disease severity.

Clinical characteristics and assessment of structural and functional myocardium changes in patients with nonspecific connective tissue disorder

Early non-invasive diagnosis of structural changes in the heart plays an important role in optimizing approaches to preventing dangerous rhythm disorders at a young age.Aim: To study the phenotypic features of nonspecifi c connective tissue disorder (NCTD) in relation to the myocardial strain and the level of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with cardiac arrhythmias and NCTD.Results. There was an association between a local longitudinal left ventricular (LV) strain and pectus excavatum (r1 = 0.234, p = 0.008), joint hypermobility syndrome (r1 = 0.406, p = 0.026), spinal scoliosis (r1 = 0.266, p = 0.003), mitral valve prolapse (MVP) (r1 = 0.519, p = 0.003), diagnostic threshold of NCTD (r1 = 0.395, p = 0.031) in patients with arrhythmias and NCTD;there was an inverse weak to moderate association of body mass index (BMI) and myocardial strain in a number of LV segments. There was a signifi cant relationship between NT-proBNP and diagnostic threshold of NCTD (r1 = 0.496, p = 0.001), mitral valve prolapse (r1 = 0.469, p = 0.002).Conclusion. Chest deformity, spinal scoliosis, joint hypermobility, mitral valve prolapse and BMI decrease in patients with arrhythmic syndrome and NCTD are associated with the myocardial strain and NT-proBNP level that can be used for the early identifi cation of myocardial remodeling in this patient cohort.

Anthracycline-induced cardiotoxicity on regional myocardial work and left ventricular mechanical dispersion in adolescents and young adults in post-lymphoma remission.

Myocardial work (MW) is a new echocardiographic tool with a high sensitivity to detect early and subtle alterations of myocardial function. We aimed to evaluate the late effects of anthracyclines by assessing the global and segmental MW and intraventricular mechanical dispersion from speckle tracking echocardiography in childhood lymphoma survivors (CLS). Thirty-one young adults including CLS and age-matched healthy controls were enrolled. All underwent echocardiography including an evaluation of left ventricular (LV) morphology and regional function. We assessed LV longitudinal (differentiating sub-endocardial and sub-epicardial layers), circumferential strains and twist, global and regional MW index (MWI). LV mechanical dispersion was assessed from the time dispersion of LV longitudinal strain, from myocardial wasted work (MWW) and myocardial work efficiency (MWE). The longitudinal strains both at the level of the sub-endocardium and sub-epicardium were reduced in CLS compared to controls. The global MWI was also decreased (1668 ± 266 vs 1870 ± 264%.mmHg in CLS patients and controls, respectively, p < 0.05), especially on the apical segments. An increase of LV intraventricular mechanical dispersion was observed in CLS. MWW and MWE remained unchanged compared to controls. Our results strongly support that cardiac remodeling is observed in CLS, characterized by a decrease in MW and an increase in LV mechanical dispersion. The apex is specifically altered, but its clinical significance remains uncertain. MW as a complement to strain seems interesting in cancer survivors to detect myocardial dysfunction at early stage and adapt their follow-up.

Association of Thyroid Dysfunction in Individuals ≥ 65 Years of Age With Subclinical Cardiac Abnormalities.

The relationship between thyroid dysfunction and measures of myocardial disease in older individuals remains to be defined. To evaluate the impact of thyroid dysfunction on structure and function of the left heart chambers and blood markers of cardiac disease. Cross-sectional analysis of the Cardiovascular Health Study, a community-based cohort of older individuals recruited from 4 urban areas in the United States. Of 3163 participants studied, 2477 were euthyroid, 465 had subclinical hypothyroidism (SCH), 47 overt hypothyroidism (OH), 45 endogenous (endo) subclinical hyperthyroidism (endo-SCT), and 129 had exogenous (exo) SCT due to thyroid hormone supplementation. Participants underwent clinical evaluation, blood sampling and biomarker measurement, 2-dimensional and speckle tracking echocardiography for assessment of left heart myocardial deformation, circulating biomarkers of diastolic overload (NT-proBNP), fibrosis (sST2, gal-3), and cardiomyocyte injury (hs-cTnT). SCH was associated with higher NT-proBNP (beta = 0.17, P = .004), whereas OH was associated with higher hs-cTnT (beta = 0.29, P = .005). There were also suggestive associations of SCH with higher sST2, as well as endo-SCT with higher gal-3 and lower (worse) left atrial reservoir strain. Left ventricular longitudinal strain and end diastolic strain rate did not differ significantly from euthyroid participants in SCH, OH, or exo-SCT. In this free-living elderly cohort, subclinical and overt hypothyroidism were associated with abnormalities of blood biomarkers consistent with diastolic overload and myocardial necrosis respectively, whereas subclinical hyperthyroidism tended to be associated with myocardial fibrosis and decreased left atrial strain. Our findings could represent stage B heart failure and illuminate distinct aspects of the pathobiology of heart disease related to thyroid gland dysfunction with potential clinical implications.

Early left ventricular microvascular dysfunction in diabetic pigs: a longitudinal quantitative myocardial perfusion CMR study

BackgroundMicrovascular pathology is one of the main characteristics of diabetic cardiomyopathy; however, the early longitudinal course of diabetic microvascular dysfunction remains uncertain. This study aimed to investigate the early dynamic changes in left ventricular (LV) microvascular function in diabetic pig model using the cardiac magnetic resonance (CMR)-derived quantitative perfusion technique.MethodsTwelve pigs with streptozotocin-induced diabetes mellitus (DM) were included in this study, and longitudinal CMR scanning was performed before and 2, 6, 10, and 16 months after diabetic modeling. CMR-derived semiquantitative parameters (upslope, maximal signal intensity, perfusion index, and myocardial perfusion reserve index [MPRI]) and fully quantitative perfusion parameters (myocardial blood flow [MBF] and myocardial perfusion reserve [MPR]) were analyzed to evaluate longitudinal changes in LV myocardial microvascular function. Pearson correlation was used to analyze the relationship between LV structure and function and myocardial perfusion function.ResultsWith the progression of DM duration, the upslope at rest showed a gradually increasing trend (P = 0.029); however, the upslope at stress and MBF did not change significantly (P > 0.05). Regarding perfusion reserve function, both MPRI and MPR showed a decreasing trend with the progression of disease duration (MPRI, P = 0.001; MPR, P = 0.042), with high consistency (r = 0.551, P < 0.001). Furthermore, LV MPR is moderately associated with LV longitudinal strain (r = − 0.353, P = 0.022), LV remodeling index (r = − 0.312, P = 0.033), fasting blood glucose (r = − 0.313, P = 0.043), and HbA1c (r = − 0.309, P = 0.046). Microscopically, pathological results showed that collagen volume fraction increased gradually, whereas no significant decrease in microvascular density was observed with the progression of DM duration.ConclusionsMyocardial microvascular reserve function decreased gradually in the early stage of DM, which is related to both structural (but not reduced microvascular density) and functional abnormalities of microvessels, and is associated with increased blood glucose, reduced LV deformation, and myocardial remodeling.

Tafamidis improves myocardial longitudinal strain in A97S transthyretin cardiac amyloidosis.

Transthyretin cardiomyopathy (ATTR-CM) is a debilitating disease that has received much attention since the emergence of novel treatments. The Transthyretin Cardiomyopathy Clinical Trial showed that tafamidis, a transthyretin tetramer stabilizer, effectively reduced the declines in functional capacity and quality of life. However, Ala97Ser (A97S) hereditary ATTR-CM is underrepresented in major ATTR-CM tafamidis trials. We aim to investigate the change in global longitudinal strain (GLS) of A97S ATTR-CM patients after 12 months of tafamidis treatment. We retrospectively analysed a prospective cohort of patients with A97S ATTR-CM who received tafamidis meglumine (61 mg/day) at the National Taiwan University Hospital. Echocardiography with speckle tracking strain analysis was performed at baseline and 12 months after treatment. In all, 20 patients were included in the cohort. The baseline left ventricular ejection fraction (LVEF) and interventricular septum (IVS) thickness were 59.20 ± 13.23% and 15.10 ± 3.43 mm, respectively. After 12 months of tafamidis treatment, the LVEF and IVS were 61.83 ± 15.60% (p = 0.244) and 14.59 ± 3.03 mm (p = 0.623), respectively. GLS significantly improved from -12.70 ± 3.31% to -13.72 ± 3.17% (p = 0.048), and longitudinal strain (LS) in apical and middle segments significantly improved from -16.05 ± 4.82% to -17.95 ± 3.48% (p = 0.039) and -11.89 ± 4.38% to -13.58 ± 3.12% (p = 0.039), respectively. Subgroup analysis showed that patients with LVEF < 50% had a better treatment response and improvement in GLS. The patients with an IVS ⩾ 13 mm had an improvement in two-chamber LS from -10.92 ± 4.25% to -13.15 ± 3.87% (p = 0.042) and an improvement in apical left ventricular LS from -15.30 ± 5.35% to -17.82 ± 3.99% (p = 0.031). Tafamidis significantly improved GLS, and particularly apical and middle LS in A97S ATTR-CM patients.

Impact of maternal bariatric surgery on offspring perinatal cardiac function: A prospective study.

To assess perinatal cardiac function in offspring of women with previous bariatric surgery and examine its association with maternal glucose control. Prospective study. Maternity unit, UK. Fifty-four fetuses/neonates; 29 of post-bariatric surgery women and 25 of women without surgery. Prospective, longitudinal observational study of pregnant women with and without previous bariatric surgery, matched for early pregnancy body mass index. Cardiac function of all offspring was assessed by two-dimensional conventional, spectral tissue Doppler and speckle-tracking echocardiography at 35-37 weeks of gestation and at 5-7 weeks of age. Maternal glycated haemoglobin (HbA1c) was measured at 27-30 weeks of gestation. Maternal demographics and fetal/infant cardiac function indices were compared between the groups. Correlation coefficient (r) is reported. Fetal/infant cardiac function indices. Compared with no-bariatric neonates, offspring of post-bariatric women were smaller at birth (birthweight centiles: 64.96 ± 36.41 versus 40.17 ± 27.99; p = 0.007). There were no significant differences in fetal/infant cardiac function indices and perinatal cardiac changes, between groups. There was a positive correlation between maternal HbA1c and fetal left ventricular (LV) longitudinal strain (r = 0.33) and LV longitudinal strain rate (r = 0.29), suggesting an inverse relation between HbA1c and fetal LV systolic function, but this was mainly seen in offspring of women with no previous bariatric surgery (r = 0.56 and r = 0.50, respectively). Maternal bariatric surgery does not appear to inadvertently affect the offspring cardiac performance. We found an inverse correlation between maternal HbA1c levels and fetal LV systolic function but this was mainly seen in the no-bariatric pregnancies.

THE POSSIBILITY OF PREDICTING LEFT VENTRICULAR DYSFUNCTION IN THE EARLY POSTOPERATIVE PERIOD IN CHILDREN WITH VENTRICULAR SEPTAL DEFECT

Highlights The article reflects data of an original study on the diagnosis of early postoperative dysfunction in children under 1 year of age after correction of a ventricular septal defect. The relationship between troponin I and conventional echocardiographic parameters, left ventricular longitudinal strain (S, % LV), and parameters reflecting central hemodynamics was assessed. The predictive ability of S, % LV in predicting a decrease in cardiac index after surgery was revealed. AbstractAim. To evaluate the possibility of predicting left ventricular (LV) dysfunction in the early postoperative period in children with ventricular septal defect (VSD).Methods. The study included 204 children under 1 year of age with non-restrictive perimembranous VSD. All parameters were evaluated before surgery, 6 hours, 24 hours and 10 days after surgery. 125 healthy children were enrolled as the control group.Results. 6 hours after surgery, there was a statistically significant decrease in LV ejection fraction (EF) (Me 55 [K3 60–K1 45] %, p = 0.0001), stroke index (SI) of LV outflow tract (LVOT) (12, 07 [16.38–8.24] mL/m2, p = 0.0001), and cardiac index (CI) (1.52 [2.08–1.07] L/min/m2, p = 0.0001). Arterial elasticity (AE) increased (21.4 [32.4–15.79] mm Hg/mL, p = 0.002), indicating a significant increase in afterload. Arterial compliance (AC) decreased (0.058 [0.081-0.038] mL/mm Hg, p = 0.0001), whereas ventricular-arterial coupling (VAC) value significantly increased (2 [2.54–1.67], p = 0.009). There was a dependence between LVOT SI and age (Rs = 0.45, p = 0.03), a moderate relationship between LVOT SI and VAC (Rs = –0.59, p = 0.001), a pronounced relationship between LVOT SI and AC (Rs = 0, 93, p = 0.02), pronounced relationship between LVOT SI and AE (Rs = –0.94, p = 0.03), moderate correlation between VAC and SI (Rs = –0.44, p = 0.04), weak relationship between VAC and patient age (Rs = –0.28, p = 0.03). Longitudinal deformity before surgery (b = 0.028; F = 3.9; p = 0.006) and VSD size (b = -0.08; F = 3.4; p = 0.029) were significantly associated with LV SI dynamics 6 hours after surgery. Dependence equation was as follows: 2.8 – 0.08 * VSD + 0.028 * S. A predictive ability to reduce CI 6 hours after surgery was revealed: longitudinal strain (S), % with a threshold “–” 14.3% (sensitivity 96.2%, specificity 81.6%, AUC 0.92, p&lt;0, 00001) and VSD diameter with a threshold of 8 mm (sensitivity 75%, specificity 52%, AUC 0.69, p&lt;0.0001).Conclusion. In the early postoperative period, there is a decrease in systolic and LV pump function. High AE rates are associated with a decrease in AC and an increase in VAC. Preoperative predictors of SI decrease are as follows: S, %&gt; “–” 14.3 and VSD size &gt; 8 mm.

Left ventricular longitudinal strain in patients with undifferentiated connective tissue disease and arrhythmia

Aim. To evaluate the left ventricular longitudinal strain in patients with arrhythmia and undifferentiated connective tissue disease (UCTD).Material and methods. This cross-sectional comparative study included young patients with arrhythmia and UCTD (43 men and 84 women; mean age, 30,82±8,17 years (group 1, n=127)). The control group included volunteers with single phenotypic characteristics of UCTD, comparable in age and sex (9 men and 21 women, mean age, 34,13±6,87 years (group 2, n=30)). A standard clinical examination, 72-hour electrocardiographic monitoring, and speckle-tracking echocardiography were performed.Results. Patients of group 1 were characterized by lower global systolic longitudinal myocardial strain compared to the control group: -22,96% [-24,56%; -21,50%] in group 1 vs -24,73% [-25,25%; -23,84%] in group 2 (p=0,016). A local decrease in longitudinal myocardial strain (in two or more segments) was noted in 62,2% of patients in group 1 and 13,3% of patients in group 2 (p=0,025). In group 1, a relationship was revealed between class I premature ventricular contractions (PVCs) and a longitudinal strain decrease in the medial anterior (r1=0,253, p=0,004) and apical anterior (r1=0,253, p=0,004) segments, as well as between class V PVCs and strain decrease in the basal lower (r1=0,215, p=0,021) and middle anterior (r1=0,211, p=0,023) segments. In addition, there was a moderate correlation between mitral valve prolapse (MVP) and a decrease in longitudinal systolic strain in the basal inferolateral (r1=0,405, p=0,041) and basal anterior (r1=0,519, p=0,003) segments.Conclusion. Local decrease in left ventricular longitudinal systolic strain in association with arrhythmia and MVP in patients with UCTD makes it possible to recommend speckle-tracking echocardiography for early non-invasive assessment of myocardial remodeling in this cohort of patients.

Evolution and prognostic value of left ventricular deformation and myocardial work parameters in transthyretin amyloid cardiomyopathy.

Wild-type transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly recognized condition. It remains challenging to estimate the extent of disease and the prognosis for most patients. Myocardial work is a sensitive echocardiographic approach that improves the characterization of myocardial damage. We investigate the parameters of myocardial deformation and work in ATTR-CM patients and their changes over time. We analysed clinical, electrocardiographic, biological, and echocardiographic characteristics in 113 patients [median age 82 (77-85), 90.4% male] diagnosed with wild-type ATTR-CM based on international consensus at a single centre. We compared the data at baseline and 18-month follow-up. Thirty-four patients died and 12 were hospitalized for heart failure at a median follow-up of 935 days (interquartile range 691-1159 days). Left ventricular end-diastolic diameter, left atrial strain during reservoir phase (LASRES), left ventricular longitudinal strain, global work index (GWI), global constructive work significantly decreased from baseline to 18 months, while left ventricular wall thickness increased. Left ventricular ejection fraction, right ventricular free wall strain (FWS), global wasted work (GWW), and global work efficiency did not alter significantly. Strain parameters were identified as prognostic on baseline evaluation using a multivariate analysis: GWI, GWW, FWS, and LASRES. They were significantly associated with the risk of death and hospitalization for heart failure. Multi-chamber strain assessment may improve the surveillance of patients with ATTR-CM, and myocardial work parameters may improve clinical risk stratification in this population.

Subclinical left ventricular dysfunction demonstrated by strain imaging echocardiography in moderate to severe COVID-19 patients (Delta variant, single center study)

Abstract Background Cardiovascular complications in acute coronavirus disease 2019 (COVID-19) are well established and are the main contributors to morbidity and mortality. The echocardiographic investigation in these patients upon hospitalisation for COVID-19 infection, however, is relatively constrained due to the high contagiousness risk. Recent studies (1,2) have shown the subclinical myocardial dysfunction defined by left ventricular longitudinal strain (LV-GLS) but these studies were limited the number of patients. Numerous moderate to severe COVID-19 patients in our hospital were subjected to echocardiographic examination during admission in the delta variant period (full screening protocol). Therefore, this beneficial data ought to be made available to the public health. Objectives This study aims to demonstrate the prevalence of subclinical left ventricular (LV) dysfunction by strain imaging echocardiography, defined as LV-GLS, and its correlation to cardiac and inflammatory biomarkers in COVID-19 patients during admission in the delta variant era. Methods Retrospective historical review was performed from the track-care system. Post-processing analysis of strain imaging by speckle tracking echocardiography (STE) using Tomtec imaging system, COVID-19 patients who admitted in the intermediate care unit or intensive care unit and obtaining echocardiographic study during hospital stay with optimal echocardiographic imaging to provide STE (according to EACVI/ASE 2015 consensus)³ during April 2021 to March 2022, were enrolled into the study. LV-GLS &amp;gt; -18% was defined as subclinical LV dysfunction. We described the number and percentage of patients who had decreased left ventricular ejection fraction (LVEF) and expressed it in relation to the decreased LV-GLS and normal LV-GLS (Table 1). The correlation between LV-GLS and biomarkers (troponin-I, C-reactive protein, and interleukin-6) was analysed by Pearson correlation. Results Initially, 247 patients with COVID-19 confirmed by RT-PCR and having an echocardiogram were enrolled, but only 176 patients with adequate echocardiographic imaging (44.3% female) and a mean age of 69.1 ± 16.8 were analysed by an experienced cardiologist. Of 24 patients (13.6%) had decreased LVEF and all of patients in this group had decreased LV-GLS (-9.28% ±.3.7%). 98 of 152 patients (64.5%) in normal LVEF group had decreased LV-GLS (-14.1% ±.3.1%). The correlation between LV-GLS and biomarkers revealed only troponin-I had statistically significant correlation with LV-GLS (r = 0.52, p &amp;lt; 0.001), but C-reactive protein and interleukin-6 were not exhibited significant correlation with LV-GLS (r = 0.11, p = 0.17 and r = 0.09, p= 0.38, respectively). Conclusions Subclinical LV dysfunction as demonstrated by LV-GLS was not uncommon in patients with moderate to severe COVID-19 infection (delta variant era), especially if the patients had elevated cardiac troponin levels.Proportion of decreased LV-GLS in COVIDImpaired LV-GLS and troponin I level

Epicardial fat is associated with adverse ventricular remodeling and diastolic dysfunction in women with ischemia but no obstructive coronary artery disease

Abstract Background Epicardial fat is a metabolically active adipose tissue depot located between the myocardium and visceral pericardium. Increased epicardial fat is associated with the development of atherosclerosis and obstructive coronary artery disease (CAD). However, information regarding relations between epicardial fat—which covers 80% of the heart surface—and cardiac function, is limited. Purpose To evaluate relations between epicardial fat and cardiac morphology and function in all four chambers of the heart. Methods To accomplish our objective, we studied 113 participants from the Women’s Ischemia Syndrome Evaluation cohort who underwent invasive measurement of left ventricular end-diastolic pressure and coronary reactivity, and comprehensive rest-stress cardiac magnetic resonance imaging (cMRI) per standardized protocols. Epicardial fat area was measured from a single high resolution steady-state free precession cine cMRI in the horizontal long axis plane (Figure 1A). Left ventricular (LV) mass, bi-ventricular volumes, and ejection fractions, were assessed using a stack of short axis cine images covering both ventricles (Figure 1B). LV concentricity was defined as the mass-to-end-diastolic volume ratio. Strain and strain rate were assessed in all four chambers by feature tracking (Figure 1C). Left atrial (LA) volume was assessed using three orthogonal long-axis cines, while right atrial (RA) area was assessed using a single horizontal long axis cine (Figure 1D). Participants were stratified by the median epicardial fat area, defined as "Low" epicardial fat (&amp;lt;13 cm2, n=48) and "High" epicardial fat (≥13 cm2, n=65). Results Participant characteristics are reported in Table 1. Notably, the majority (58%) had "High" epicardial fat and body mass index (BMI) was greater in the "High" epicardial fat group. After adjusting for BMI, however, bi-ventricular stroke index remained lower in the "High" epicardial fat group, as did bi-atrial ejection fraction (fractional area change, RA). Moreover, compared to the "Low" epicardial fat group, LV concentricity and LA booster strain were higher in the "High" epicardial fat group (Figure E-F), while LV longitudinal strain and LV early circumferential diastolic strain rate were lower (Figure G-H). No other major differences were observed between groups, including coronary reactivity or myocardial perfusion reserve. Conclusions Together, these data suggest that higher BMI is associated with increased epicardial fat that is related to adverse cardiac remodeling, along with systolic and diastolic dysfunction, across multiple cardiac chambers. Further studies would be useful to define specific mechanism contributing to these observations.Figure 1Table 1

The influence of symptom-to-reperfusion-time on left ventricular strain and extent of infarction in patients with STEMI: a 3-dimensional view on the wavefront phenomenon

Abstract Aims Data on the relationship between time-to-reperfusion and left ventricular (LV) function and infarct characteristics after ST-segment elevation myocardial infarction (STEMI) are inconsistent and not completely understood. Therefore, we examined the association between the symptom-to-reperfusion-time and cardiovascular magnetic resonance (CMR) derived global strain parameters and infarct extent in STEMI patients. Methods and results The study included 108 STEMI patients who underwent successful primary percutaneous coronary intervention (PPCI). Patients were categorized according to the median symptom-to-reperfusion-time: shorter (&amp;lt;160min, n=54) and longer times (&amp;gt;160min, n=54). CMR was performed 2-7 days after PPCI and at 1-month. CMR cine imaging was performed for functional assessment and late gadolinium enhancement (LGE) to evaluate infarct extent. Myocardial feature-tracking was used for global LV strain analysis. Mean transmural extent score was quantified per patient as the average of infarct percentages for all segments containing hyperenhanced tissue. Baseline clinical and angiographic characteristics were comparable between the groups. Patients with shorter reperfusion time had more favorable baseline and follow-up LV circumferential and radial strain (p=0.049, p=0.01, p=0.047, p&amp;lt;0.01, respectively), while LV longitudinal strain appeared comparable for both baseline and follow-up (p&amp;gt;0.05 for both, Figure 1). Mean transmural extent score at follow-up was lower in patients with shorter reperfusion time (p&amp;lt;0.01). In multivariable regression analysis including all 3 strain directions, baseline LV circumferential strain was independently associated with mean transmural extent score at follow-up (β=1.89, p&amp;lt;0.001). Conclusion In STEMI patients, time-to-reperfusion was significantly associated with smaller extent of infarction and better LV circumferential and radial strain but not with longitudinal strain. Moreover, infarct transmurality and residual LV circumferential strain are closely linked.Comparison of BL and FU global LV strainGraphical abstract

Comparative study of the effects of left ventricular and biventricular pacing on indices of cardiac function and clinical status of heart failure patients: preliminary results of READAPT study

Abstract Nonresponse to cardiac resynchronization therapy (CRT) has been related with right ventricular dysfunction. Preferential left ventricular pacing (pLVP) can overcome iatrogenic right ventricular dysfunction by achieving left ventricle resynchronization and by allowing for intrinsic activation of the right side, with ramifications extending beyond cardiac output and atrial fibrillation occurrence. Moreover, the AdaptivCRT® algorithm also automatically adjusts interventricular (V-V) delay every minute, optimizing it by means of comparing relative activation delay between right and left ventricles (electrically – driven optimization). In the present study we evaluated the effects of a pLVP algorithm on 50 heart failure patients (all Caucasians, 49% male; 66 +/- 8 years old; 46% ischemic cardiomyopathy; 41% diabetics; NYHA II-III) following randomization to standard biventricular pacing and pLVP, on echocardiographic and cardiopulmonary exercise test indices of functional status, as well as a self-reported quality of life questionnaire. Device programming was based on echocardiography-evaluated maximization of stroke volume and subsequent interventricular and atrioventricular delay adjustments delegated to the device. The follow-up consisted of 6 and 12-months visits; after the 1rst month of optimizing maximum CRT response. Results Significant comparative effects of LVP over optimized CRT were noted regarding RV systolic velocity in TDI even from 6-months from baseline (6% increase, p=0.01); while end-systolic diameter of left ventricle was increased by 4% in 6-months in CRT group (p=0.01), while no significant difference was observed in LVP group. At 12 months endsystolic volume was significantly decreased (16%, p=0.01) and left ventricular systolic longitudinal strain was improved in 12 months in LVP group compared to CRT group (p- for interaction =0.001). Additionally, in cardiorespiratory exercise test LVP group showed improved inotropic reserve compared to CRT group according to maximum SBP achieved (20% increase, p&amp;lt;0.01 for interaction); while all other cardiorespiratory indices shoed borderline significant changes at 12 -months. Minnesota score was significantly reduced in LV-P group by 70% at 6-months; whereas no significant change was observed in CRT group (p for interaction &amp;lt;0.01). Conclusions In the preliminary findings of READAPT study, it seems that LV pacing optimized by a standardized echocardiographic protocol in patients with preserved AV conduction, LBBB, can achieve a higher percentage of synchronized LV pacing associated with improved patient quality of life; right ventricular function and endsystolic volume at 6 and 12-months of follow-up, over echo-optimized CRT pacing.

Regional left ventricular longitudinal strain and heart failure in a low-risk community

Abstract Background Global longitudinal strain is a well-established prognosticator of heart failure (HF) in the general population. The prognostic values of regional left ventricular (LV) longitudinal strain of the basal, mid and apical regions remain unexplored in the general population. Purpose The purpose of this study was to investigate the relationship between regional LV strain and incident HF in the general population. Methods This prospective cohort study included randomly selected citizens from a major metropolitan area. All participants were examined with echocardiography. The outcome was incident HF. Participants were excluded if regional LV strain was not assessable in all 3 LV regions or if they had atrial fibrillation or HF at baseline. A multivariable Cox regression model adjusted for sex, age, smoking status, heart rate, systolic blood pressure, history of ischemic heart disease, hypertension, diabetes, LV mass index, LV ejection fraction and E/e’ was used. Results A total of 3,952 individuals were included. Mean age was 56±18 years and 43% were male. Mean basal, mid, and apical LV strain was 16.4±2.6%, 19.5±2.6 and 22.8±3.6% respectively. Median follow-up was 5.4 years (IQR: 4.4; 6.3) and 99 developed HF. In multivariable Cox regressions models, only decreasing LV basal strain was associated with future HF (HR = 1.18, 95%CI (1.06; 1.32), P = 0.003, per 1% decrease) (Figure 1). Additionally, LV basal strain provided incremental prognostic information regarding future HF to the Atherosclerosis Risk in Communities HF risk score (continuous net reclassification index = 0.468, 95% CI (0.155; 0.687)). Conclusion In individuals from the general population, basal LV strain entailed incremental prognostic information regarding the risk of incident HF.Basal strain and incident HF

Value of left ventricular longitudinal strain in predicting overt heart failure in patients with Chagas disease and preserved left ventricular ejection fraction

Abstract Introduction Speckle-tracking echocardiography (STE) is an established tool to detect early myocardial contractile impairment. In Chagas disease patients, STE may be helpful to identify subtle myocardial damage with the potential of progression to heart failure. Purpose This study aimed to assess the value of STE in predicting heart failure in Chagas disease patients with preserved left ventricular ejection fraction (LVEF). Methods Patients with Chagas disease living in endemic area who had preserved LVEF (&amp;gt;50%) were selected for the study. Clinical evaluation, B-type natriuretic peptide (NT-ProBNP), electrocardiogram (ECG), and echocardiogram were performed at enrollment in 2015 to 2016 and in the follow-up visit between 2018 and 2019. Global longitudinal strain (GLS) derived from STE was analyzed offline. Peak GLS was calculated as the mean value from 18 segments of the left ventricle (Figure 1). The outcome was development of heart failure defined by elevation of NT-ProBNP levels, categorized according to age-specific cut-points for heart failure at the second evaluation. Patients with abnormal NT-ProBNP at baseline or those who died between the 2 visits were not included. Results A total of 692 were enrolled, mean age was 58 ± 12 years and 495 (72%) were women. Mean LVEF at baseline and follow-up visits were 63.4 ± 4.6% and 59.8 ± 11.2% (p&amp;lt;0.001). The median [IQR] time between visit 1 and visit 2 was 5.4 [4.5 - 5.8] years. Among patients alive and attending the second visit, 48 patients (7%) developed overt heart failure with overall incidence rate of 14.1 events per 1000 patient-years (95% CI 10.4-18.6). On multivariable analysis, independent predictors of new-onset heart failure were male sex (OR 2.30, 95% CI 1.02-5.18), age (OR 1.04, 95% CI 1.01-1.07), QRS duration (OR 1.03, 95% CI 1.01-1.04), left atrial (LA) volume indexed (OR 1.05, 95% CI 1.01-1.09), and GLS (OR 0.90, 95% CI 0.81-0.98). LVEF did not remain in the model. The C-statistic of the final model was 0.80 (95% CI 71-88) showing a good discrimination. Conclusions In a cohort of patients with Chagas disease from remote areas with preserved ejection fraction, GLS was an important predictor of progression to overt heart failure, after adjustment for sex, age, QRS duration and LA volume. GLS was associated with further increased NT-ProBNP levels, which is useful to guide heart failure management, irrespective of systolic dysfunction.

Mechanisms of adaptation to high intensity exercise in hypertrophic cardiomyopathy

Abstract Background Many individuals with hypertrophic cardiomyopathy (HCM) demonstrate exercise limitation. For a proportion this may be related to their overall cardiorespiratory fitness influenced by physical activity habits, body mechanics, or habitus. In others there is evidence of central and/or peripheral pathophysiology. However, some individuals with HCM demonstrate favourable adaptation to exercise. In the SAFE-HCM study, participants who underwent 12 weeks of high intensity exercise showed significant improvement in exercise indices including peak VO2, VO2/kg at anaerobic threshold (AT), time to AT, and overall exercise time compared to a usual care group. Purpose There have been no studies investigating the mechanistic adaptation(s) to exercise in HCM. This sub-study aimed to identify whether the observed improvements in exercise indices were attributable to central or peripheral adaptation. Methods Eighty patients with HCM (45.7±8.6 years) underwent baseline clinical, quality of life and psychological assessment. Individuals were randomised to a 12-week high intensity exercise programme (n=40) or usual care (n=40). Baseline evaluation was repeated at 12 weeks. The Fick equation (oxygen uptake (VO2) = cardiac output (CO) X (arterial-venous oxygen content (a-vO2 difference)) was used to assess whether central and/or peripheral adaptation was responsible for observed improvements. 2D speckle tracking imaging was utilised to calculate left ventricular longitudinal strain from the apical 2-, 3- and 4 chamber views (EchoPAC, V202, GE Healthcare). Results 12-weeks of high intensity exercise training produced a statistically significant increase in CO (1.1±0.4 L/min, CI (0.2,2.0), p=0.016) compared with the usual care group. There was no difference in the change in a-vO2 difference between groups (p=0.682) suggesting central adaptation to high intensity exercise. This was driven by an increase in stroke volume (SV) (6.1±3.0ml, CI (0.1,12.2), p=0.047) rather than an increase in heart rate (0.6±3.6 bpm, CI (-6.6,7.7), p=0.874). However, there was no change in resting myocardial deformation to account for the observed improvement in CO. Analysis of strain data demonstrated no difference in resting regional 4Ch (-0.7±0.6, CI (-1.9, 0.5), p=0.270) 3Ch (-1.1±0.9, CI (-2.8, 0.6), p=0.201), 2Ch (-1.3±0.9, CI (-3.1, 0.5), p=0.162) or average global longitudinal strain (0.9±0.6, CI (-2.2,0.3), p=0.144) between groups at 12 weeks. Conclusion Favourable central adaptations, predominantly driven by an increase in SV, enable improvements in exercise capacity following a high intensity exercise programme. Further studies are required to understand the physiological processes underlying this adaptation including assessment of myocardial deformation at peak exercise