Left Ventricular Twist Research Articles

Influence of Ventricular Wringing on the Preservation of Left Ventricular Ejection Fraction in Cardiac Amyloidosis

The purpose of this work was to determine the influence of myocardial wringing on ventricular function in patients with cardiac amyloidosis (CA). Fifteen healthy volunteers (group 1) and 34 patients with CA (17 with left ventricular ejection fractions [LVEFs]≥53% [group 2] and 17 with LVEFs<53% [group 3]) were evaluated using two-dimensional speckle-tracking echocardiography. A control group of mass-matched patients (n=20) with left ventricular (LV) hypertrophy and LVEFs≥53% was also included. Longitudinal strain (LS), circumferential strain, and LV twist and torsion were calculated. Deformation index (DefI), a new parameter of wringing, calculated as twist/LS, that takes into account actions that occur simultaneously during LV systole (i.e., longitudinal shortening and twist), was evaluated. Torsional and wringing parameters were calculated according to LVEF. Lower global values of LS and circumferential strain were observed among patients with CA (LS: group 1, -20.6±2.5%; group 2, -11.6±4.1%; group 3, -9.0±3.1%; circumferential strain: group 1, -22.7±4.9%; group 2, -14.4±8.0%; group 3, -13.6±3.8%; P<.001 for both). Torsion did not vary between group 2 and group 1 (2.5±1.1°/cm vs 2.7±0.8°/cm, P= NS). In contrast, DefI was greater in group 2 than in group 1 (-1.8±0.8°/% vs -1.0±0.3°/%, P<.01). Torsion and DefI were lower in group 3 (1.2±0.7°/cm and -1.1±0.6°/%, respectively, P<.001 for both) than in group 2. DefI was similar in patients with LV hypertrophy (-1.7±0.6°/%, P= NS) and group2. In patients with CA, preservation of LVEF depends on greater ventricular wringing. DefI, a parameter that integrates the twist and the simultaneous longitudinal shortening of the left ventricle, is a more accurate indicator of the efficacy of this mechanism.

Using cardiovascular magnetic resonance to define mechanisms of comorbidity and to measure the effect of biological therapy: the CADERA observational study

Background The VEDERA (Very Early vs. Delayed Etanercept in Rheumatoid Arthritis) randomised controlled trial compared the effect of conventional synthetic disease-modifying anti-rheumatic drug (csDMARD) therapy with biologic DMARD (bDMARD) therapy using the tumour necrosis factor inhibitor etanercept in treatment-naive, early rheumatoid arthritis patients. The CADERA (Coronary Artery Disease Evaluation in Rheumatoid Arthritis) trial was a bolt-on study in which VEDERA patients underwent cardiovascular magnetic resonance imaging to detect preclinical cardiovascular disease at baseline and following treatment. Objectives To evaluate whether or not patients with treatment-naive early rheumatoid arthritis have evidence of cardiovascular disease compared with matched control subjects; whether or not this is modifiable with DMARD therapy; and whether or not bDMARDs confer advantages over csDMARDs. Design The VEDERA patients underwent cardiovascular magnetic resonance imaging at baseline and at 1 and 2 years after treatment. Setting The setting was a tertiary centre rheumatology outpatient clinic and specialist cardiovascular magnetic resonance imaging unit. Participants Eighty-one patients completed all assessments at baseline, 71 completed all assessments at 1 year and 56 completed all assessments at 2 years. Patients had no history of cardiovascular disease, had had rheumatoid arthritis symptoms for ≤ 1 year, were DMARD treatment-naive and had a minimum Disease Activity Score-28 of 3.2. Thirty control subjects without cardiovascular disease were approximately individually matched by age and sex to the first 30 CADERA patients. Patients with a Disease Activity Score-28 of ≥ 2.6 at 48 weeks were considered non-responders. Interventions In the VEDERA trial patients were randomised to group 1, immediate etanercept and methotrexate, or group 2, methotrexate ± additional csDMARD therapy in a treat-to-target approach, with a switch to delayed etanercept and methotrexate in the event of failure to achieve clinical remission at 6 months. Main outcome measures The primary outcome measure was difference in baseline aortic distensibility between control subjects and the early rheumatoid arthritis group and the baseline to year 1 change in aortic distensibility in the early rheumatoid arthritis group. Secondary outcome measures were myocardial perfusion reserve, left ventricular strain and twist, left ventricular ejection fraction and left ventricular mass. Results Baseline aortic distensibility [geometric mean (95% confidence interval)] was significantly reduced in patients (n = 81) compared with control subjects (n = 30) [3.0 × 10–3/mmHg (2.7 × 10–3/mmHg to 3.3 × 10–3/mmHg) vs. 4.4 × 10–3/mmHg (3.7 × 10–3/mmHg to 5.2 × 10–3/mmHg), respectively; p &lt; 0.001]. Aortic distensibility [geometric mean (95% confidence interval)] improved significantly from baseline to year 1 across the whole patient cohort (n = 81, with imputation for missing values) [3.0 × 10–3/mmHg (2.7 × 10–3/mmHg to 3.4 × 10–3/mmHg) vs. 3.6 × 10–3/mmHg (3.1 × 10–3/mmHg to 4.1 × 10–3/mmHg), respectively; p &lt; 0.001]. No significant difference in aortic distensibility improvement between baseline and year 1 was seen in the following comparisons (geometric means): group 1 (n = 40 at baseline) versus group 2 (n = 41 at baseline): 3.8 × 10–3/mmHg versus 3.4 × 10–3/mmHg, p = 0.49; combined groups 1 and 2 non-responders (n = 38) versus combined groups 1 and 2 responders (n = 43): 3.5 × 10–3/mmHg versus 3.6 × 10–3/mmHg, p = 0.87; group 1 non-responders (n = 17) versus group 1 responders (n = 23): 3.6 × 10–3/mmHg versus 3.9 × 10–3/mmHg, p = 0.73. There was a trend towards a 10–30% difference in aortic distensibility between (group 1) responders who received first-line etanercept (n = 23) and (group 2) responders who never received etanercept (n = 13): 3.9 × 10–3/mmHg versus 2.8 × 10–3/mmHg, p = 0.19; ratio 0.7 (95% confidence interval 0.4 to 1.2), p = 0.19; ratio adjusted for baseline aortic distensibility 0.8 (95% confidence interval 0.5 to 1.2), p = 0.29; ratio fully adjusted for baseline characteristics 0.9 (95% confidence interval 0.6 to 1.4), p = 0.56. Conclusions The CADERA establishes evidence of the vascular changes in early rheumatoid arthritis compared with controls and shows improvement of vascular changes with rheumatoid arthritis DMARD therapy. Response to rheumatoid arthritis therapy does not add further to modification of cardiovascular disease but, within the response to either strategy, etanercept/methotrexate may confer greater benefits over standard methotrexate/csDMARD therapy. Trial registration Current Controlled Trials ISRCTN89222125 and ClinicalTrials.gov NCT01295151. Funding This project was funded by the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership, and will be published in full in Efficacy and Mechanism Evaluation; Vol. 8, No. 4. See the NIHR Journals Library website for further project information. Pfizer Inc. (New York, NY, USA) supported the parent study, VEDERA, through an investigator-sponsored research grant reference WS1092499.

Effect of Gestational Diabetes Mellitus on Neonatal Myocardial Function

Background and Aims: Infants born to mothers with gestational diabetes mellitus (GDM) have impaired myocardial performance and are at risk of pulmonary hypertension. We aimed to assess myocardial deformation and left ventricular (LV) rotational mechanics in this population. Methods: We studied 40 infants of mothers with GDM and 40 control infants. Three echocardiograms were carried out over the first 3 days after birth. Results: GDM infants had a lower gestation at birth and a thicker septal wall, a higher LV eccentricity index (indicating septal bowing), and a lower PAATi (indicating higher pulmonary vascular resistance) (all p < 0.05). GDM infants had lower LV strain, systolic and early diastolic strain rates, lower right ventricular (RV) strain, and early diastolic strain rates over the study period (all p < 0.05). By day 3, GDM infants had higher twist, torsion, and higher LV twist and untwist rates (all p < 0.05). GDM status was an independent predictor of LV and RV function and pulmonary vascular resistance (p < 0.01). Conclusion: Infants of mothers with GDM demonstrate important changes in myocardial function in addition to pulmonary vascular resistance that do not resolve by hospital discharge. The observed LV twist increase in GDM infants may be a compensatory mechanism for the lower longitudinal function in this cohort.

Left ventricular rotational mechanics in elite athletes with high dynamic component of their training - a three-dimensional speckle-tracking echocardiographic study

Abstract Funding Acknowledgements Type of funding sources: None. Introduction. In normal circumstances left ventricular (LV) apex and base rotate different directions during cardiac cycle, while LV apex rotates counterclocwise, LV base has a clockwise movement at the same time. This sort of towel-wringing-like movement is called LV twist. Three-dimensional speckle-tracking echocardiography (3DSTE) is a new, promising, easy-to-perform and reproducible modality for the evaluation of LV apical and basal rotations. Although cardiac adaptation is a known feature seen in highly trained athletes, there are conflicting results according to sport activity-related changes in LV rotational mechanics. The present study was designed to test whether differences in LV rotational mechanics could be detected in elite athletes with high dynamic, but different grade of static components of their training by 3DSTE. Methods. The subjects group comprised 80 elite sportmen, which group of athletes was further divided according to the task force classification of the American College of Cardiology considering dynamic and static components of their training. The following groups were created regarding to their physical activity: Group C1 (high dynamic/low static)(n = 13, mean age: 24.0 ± 5.1 years, Group C2 (high dynamic/moderate static)(n = 23, mean age: 24.6 ± 7.7 years) and Group C3 (high dynamic/high static)(n = 34, mean age: 22.8 ± 6.0 years). Their results were compared to 67 age- and gender-matched non-athletic healthy controls (mean age: 24.0 ± 5.1 years, 33 men). 3DSTE was used for the evaluation of LV rotational abnormalities. Results. Increased LV end-diastolic and end-systolic volumes could be detected in Groups C2 and C3 subjects as compared to controls. No changes in LV volumes and rotational mechanics could be detected in Group C1 cases. Reduced LV basal rotation was seen in Group C2 and C3 subjects compared to that of controls (-3.17 ± 2.81 degree and -2.88 ± 1.88 degree vs. -4.31 ± 1.82 degree, p &amp;lt; 0.05 and p &amp;lt; 0.05, respectively). It was accompanied with LV twist reduction in Groups C2 and C3 subjects compared to that of controls (11.3 ± 4.3 degree and 11.5 ± 4.1 degree vs. 14.0 ± 3.4 degree, p &amp;lt; 0.05 and p &amp;lt; 0.05, respectively). None of elite athletes showed absence of LV twist called as LV ‘rigid body rotation’ (LV-RBR). Conclusions. Significant LV basal rotation and twist reduction could be detected in elite athletes with high dynamic and moderate/high static components of their training.

LV twist predicts prognosis in children and adolescents with non-compaction cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Background Left ventricular non-compaction cardiomyopathy (LVNC) is associated with poor clinical outcome in childhood, with heart failure, arrhythmias, and embolic events as main clinical manifestations. LV twist has recently been demonstrated having good predictive value in diagnosing LVNC in young patients. However, how LV twist may influence long-term clinical outcome of LVNC children and adolescents is still unknown. The aim of this study was to analyse a set of echocardiographic parameters to find imaging predictors of worse clinical outcomes in a long-term follow-up of LVNC children and young patients. Methods Children and adolescents, followed from May 2012 to June 2020, were enrolled in a retrospective study. All patients underwent 2-dimensional speckle tracking echocardiography and cardiovascular magnetic resonance imaging (1.5 Tesla) at our Institution’s first evaluation. Death, heart failure hospitalization, aborted sudden cardiac death, ventricular arrhythmias (sustained and non-sustained ventricular tachycardia), and embolisms (i.e. stroke, peripheral arterial embolism and/or pulmonary thromboembolism) were registered and referred to as major adverse cardiovascular events (MACEs). Results Recruited for the study were 47 children (mean age: 11.1± 5; age range: 0–18 years). Twenty-three patients fulfilled the cardiovascular magnetic resonance imaging diagnostic criteria for LVNC (LVNC group), while the remaining 24 did not and were included in the LV hypertrabeculation group (LVHT). They were followed for 4.9 ± 1.0 years, and MACEs were registered. Thirteen children (56% of LVNC, 28% of total) had at least one MACE. Global longitudinal, circumferential and radial strains (GLS, GCS, GRS), LV twist and LVEF resulted being significantly reduced in children with MACEs at follow-up. A multivariable analysis was performed by combining four parameters: LV ejection fraction, GLS, GCS, LV twist. These independent variables were chosen according to univariable analyses and clinical relevance. The results from the analysis demonstrated that LV twist was the only independent predictor (P = 0.033, coeff. B 0.726) of worse clinical outcomes in young patients with LVNC. Conclusions LV twist is a promising tool to stratify and predict prognosis in LVNC young patients. Our findings show the importance of LV twist assessment to detect the severity of LVNC and to plan for early clinical intervention.

Assessment of left ventricular twist by 3D ballistocardiography and seismocardiography compared with 2D STI echocardiography in a context of enhanced inotropism in healthy subjects

Ballistocardiography (BCG) and Seismocardiography (SCG) assess the vibrations produced by cardiac contraction and blood flow, respectively, by means of micro-accelerometers and micro-gyroscopes. From the BCG and SCG signals, maximal velocities (VMax), integral of kinetic energy (iK), and maximal power (PMax) can be computed as scalar parameters, both in linear and rotational dimensions. Standard echocardiography and 2-dimensional speckle tracking imaging echocardiography were performed on 34 healthy volunteers who were infused with increasing doses of dobutamine (5–10–20 μg/kg/min). Linear VMax of BCG predicts the rates of left ventricular (LV) twisting and untwisting (both p < 0.0001). The linear PMax of both SCG and BCG and the linear iK of BCG are the best predictors of the LV ejection fraction (LVEF) (p < 0.0001). This result is further confirmed by mathematical models combining the metrics from SCG and BCG signals with heart rate, in which both linear PMax and iK strongly correlate with LVEF (R = 0.7, p < 0.0001). In this setting of enhanced inotropism, the linear VMax of BCG, rather than the VMax of SCG, is the metric which best explains the LV twist mechanics, in particular the rates of twisting and untwisting. PMax and iK metrics are strongly associated with the LVEF and account for 50% of the variance of the LVEF.

Usefulness of speckle tracking echocardiography and biomarkers for detecting acute cellular rejection after heart transplantation

BackgroundAcute cellular rejection (ACR) is a major complication after heart transplantation. Endomyocardial biopsy (EMB) remains the gold standard for its diagnosis, but it has concerning complications. We evaluated the usefulness of speckle tracking echocardiography (STE) and biomarkers for detecting ACR after heart transplantation.MethodsWe prospectively studied 60 transplant patients with normal left and right ventricular systolic function who underwent EMB for surveillance 6 months after transplantation. Sixty age- and sex-matched healthy individuals constituted the control group. Conventional echocardiographic parameters, left ventricular global longitudinal, radial and circumferential strain (LV-GLS, LV-GRS and LV-GCS, respectively), left ventricular systolic twist (LV-twist) and right ventricular free wall longitudinal strain (RV-FWLS) were analyzed just before the procedure. We also measured biomarkers at the same moment.ResultsAmong the 60 studied patients, 17 (28%) had severe ACR (grade ≥ 2R), and 43 (72%) had no significant ACR (grade 0 – 1R). The absolute values of LV-GLS, LV-twist and RV-FWLS were lower in transplant patients with ACR degree ≥ 2 R than in those without ACR (12.5% ± 2.9% vs 14.8% ± 2.3%, p=0.002; 13.9° ± 4.8° vs 17.1° ± 3.2°, p=0.048; 16.6% ± 2.9% vs 21.4%± 3.2%, p < 0.001; respectively), while no differences were observed between the LV-GRS or LV-GCS. All of these parameters were lower in the transplant group without ACR than in the nontransplant control group, except for the LV-twist. Cardiac troponin I levels were significantly higher in patients with significant ACR than in patients without significant ACR [0.19 ng/mL (0.09–1.31) vs 0.05 ng/mL (0.01–0.18), p=0.007]. The combination of troponin with LV-GLS, RV-FWLS and LV-Twist had an area under curve for the detection of ACR of 0.80 (0.68–0.92), 0.89 (0.81–0.93) and 0.79 (0.66–0.92), respectively.ConclusionHeart transplant patients have altered left ventricular dynamics compared with control individuals. The combination of troponin with strain parameters had higher accuracy for the detection of ACR than the isolated variables and this association might select patients with a higher risk for ACR who will benefit from an EMB procedure in the first year after heart transplantation.

Left Ventricular Twist and Untwist in Patients Undergoing Elective Percutaneous Coronary Intervention.

Background:Left ventricular (LV) twist and untwist plays important roles in physiological adaptation and development of clinically relevant cardiac diseases.Aims:To assess LV twist and untwist in patients undergoing elective percutaneous coronary intervention (PCI) by two-dimensional (2D) speckle tracking echocardiography (STE).Subjects and Methods:Fifty patients who had stable angina pectoris and/or abnormal result from noninvasive stress tests were enrolled after undergoing elective PCI. Conventional and 2D STE were performed before elective PCI and after 3 months.Results:There was no significant systolic improvement in conventional echocardiography. However, there was a significant diastolic improvement after elective PCI as higher E, E/A, e` and lower E/e` (P < 0.034, <0.042, 0.015, and 0.033, respectively). In addition, there was a statistically significant improvement of STE-derived systolic parameters as regard higher global longitudinal strain, peak twist, and torsion (P value 0.009, 0.009, and < 0.001, respectively). Furthermore, there was significant improvement of STE-derived diastolic parameters as higher peak untwist, recoil, and lower time to peak untwist (P value 0.013, 0.001, and 0.004, respectively).Conclusions:LV and untwist parameters were improved before most of conventional echocardiographic parameters in postrevascularization of stable coronary artery disease.

Comparison of left ventricular rotational mechanics between term and extremely premature infants over the first week of age

ObjectiveLeft ventricle (LV) rotational mechanics is an emerging tool to characterise LV function, but warrants further evaluation in neonates. The aim of this study was to compare LV rotational mechanics...

Changes in Left Ventricle Mechanics in Patients with Anderson - Fabry Disease under Enzyme Replacement Therapy

Background: Sixty percent of patients with Fabry disease (FD) have cardiovascular involvement at the time of diagnosis. Among patients with heart failure of all causes, about 50% show normal or preserved left ventricular systolic function. We reported the evolution and echocardiographic findings of five patients with Fabry disease before undergoing enzyme replacement therapy and after 48 months of follow-up. Method: Systolic and diastolic functions were assessed in 5 patients with FD using transthoracic echocar- diography. They were matched with echocardiography performed between 36 to 48 months after treatment was started. Results: At initial evaluation, heart failure symptoms were positive in 3 patients. No history of fainting or cardiac arrhythmia was found on the initial approach. The mean LVEF before ERT was 57.25 ± 3.3. After 48 months of follow-up we observed a significant change increased on the LVEF to 68.7 ± 4.2 (p=0.04). All patients had increased interventricular septum thickness (IVT). The mean relative parietal thickness decreased from 0.63 to 0.59, after 48 months. Patients with mutation c.971T>A were more likely to increase the RPT. If the patient was free of dialysis the RWT tends to decrease. Diastolic function assessment revealed significantly higher E velocities, E wave increase from 73.6 to 81 m sec (p=0.04). But E/A ratio did not change after 48 months of ERT (1 vs. 1.1, p=NS). Two patients had diastolic dysfunction before ERT. After 2 years, four patients have diastolic dysfunction grade II. Before starting enzyme replacement therapy, all strain measures were abnormal. However, it was observed that their measurements did not worsen after ERT was started. The left ventricular twist was assessed, finding a decrease in it with a mean pre-ERT of 10o ± 4 vs. 13.7o ± 2.5 at 48 months (normal value 20 ± 7.3°), this was not significant. Conclusion: After 2 years of follow-up, we found an improvement in LVEF, a decrease in the ventricular septum. We found no progression in diastolic dysfunction. Even though enzyme replacement therapy in Fabry has proven efficacy, there are very few evaluation and monitoring tools to assess its effects at the cardio- vascular level. Systolic function is affected only in the late stages of the disease, although the diastolic function is affected earlier, it does not vary greatly over time once ERT has started. We found that conventional parameters, ven- tricular mass and septum diameter are useful as a baseline evaluation.

Diabetes mellitus deteriorates left ventricular deformation in acromegaly-analysis from the three-dimensional speckle-tracking echocardiographic MAGYAR-Path study.

Acromegaly and diabetes mellitus (DM) separately are associated with cardiovascular alterations and modified left ventricular (LV) deformation, which can be quantitatively assessed by three-dimensional speckle-tracking echocardiography (3DSTE). The present study aimed to assess the relationship between LV deformation and twist in the presence of DM in acromegaly. Thirty-seven acromegaly patients were involved in the study, but due to insufficient image quality 13 have to be excluded from analysis. Therefore, the present study comprised 24 acromegaly patients, from which 5 had DM. Their data was compared to 35 age- and gender matched healthy controls. Complete two-dimensional Doppler echocardiography extended with 3DSTE were performed in all patients and controls. Only non-diabetic acromegaly cases had increased global and mean segmental LV radial strain, diabetic acromegaly patients had similar LV radial strain as compared to that of healthy subjects. Other LV strain parameters did not show any difference between diabetic and non-diabetic acromegaly patients. While LV basal rotation was similar among the groups, LV apical rotation was reduced in both diabetic and non-diabetic patients as compared to healthy subjects. However, diabetic acromegaly patients had tendentiously higher values. The ratio of absence of LV twist called as LV rigid body rotation was similar between the groups examined. Diabetes mellitus deteriorates left ventricular deformation in acromegaly.

Echocardiographic and clinical outcomes of patients undergoing septal myectomy plus anterior mitral leaflet extension for hypertrophic cardiomyopathy.

Septal myectomy is indicated in patients with obstructive hypertrophic cardiomyopathy (HCM) and intractable symptoms. Concomitant mitral valve (MV) surgery is performed for abnormalities contributing to systolic anterior motion (SAM), or for SAM-mediated mitral regurgitation (MR) with or without left ventricular outflow tract (LVOT) obstruction. One MV repair technique is anterior mitral leaflet extension (AMLE) utilizing bovine pericardium, stiffening the leaflet and enhancing coaptation posteriorly. Fifteen HCM patients who underwent combined myectomy-AMLE for LVOT obstruction or moderate-to-severe MR between 2009 and 2020 were analyzed using detailed echocardiography. The mean age was 56.6 years and 67% were female. The average peak systolic LVOT gradient and MR grade measured 73.4 mmHg and 2.3, respectively. Indications for myectomy-AMLE were LVOT obstruction and moderate-to-severe MR in 67%, MR only in 20%, and LVOT obstruction only in 13%. There was no mortality observed, and median follow-up was 1.2 years. Two patients had follow-up grade 1 mitral SAM, one of whom also had mild LVOT obstruction. No recurrent MR was observed in 93%, and mild MR in 7%. Compared with preoperative measures, there was a decrease in follow-up LV ejection fraction (68.2 vs 56.3%, p = 0.02) and maximal septal wall thickness (25.5 vs 21.3 mm, p < 0.001), and an increase in the end-diastolic diameter (21.9 vs 24.8 mm/m2, p = 0.04). There was no change in global longitudinal strain (-12.1 vs -11.6%, p = 0.73) and peak LV twist (7.4 vs 7.3°, p = 0.97). In conclusion, myectomy-AMLE is a viable treatment option for carefully selected symptomatic HCM patients with LVOT obstruction or moderate-to-severe MR.

Evaluation of myocardial function in pregnant women with speckle-tracking echocardiography

Objectives: The speckle-tracking technique calculates the regional rate, the strain and the strain rate from two-dimensional gray-scale visualizations. The aim of this study was to evaluate with speckle-tracking echocardiography the effects of the first, second and third trimesters of pregnancy on cardiac functions. Methods: One hundred five voluntary pregnant and 35 healthy women of reproductive age were included in the study. For echocardiographic evaluations, the 111 highest-quality visualizations were chosen: 24 cases in the first trimester, 31 cases in the second trimester, 32 cases in the third trimester and 24 healthy women as a control group. Global longitudinal, radial, and circumferential strain, and left ventricular (LV) rotation and twist were evaluated by two-dimensional speckle tracking echocardiography. Results: During pregnancy, the diameter, and volume of the left atrium, LV stroke volume, and the heart rate significantly increased beginning in the first trimester (p &amp;lt; 0.0125). The parameters of pulse-Doppler E velocity and tissue Doppler Em velocity significantly increased in the first trimester (p &amp;lt; 0.0125), whereas in the second and third trimester they decreased to control levels. Global longitudinal strain was significantly decreased in the third trimester of the pregnancy (p &amp;lt; 0.0125). Basal and apical LV rotation and twist were significantly increased in the third trimester of pregnancy (p &amp;lt; 0.0125). LV apical and basal reverse rotation rate were significantly increased in the first trimester of pregnancy (p &amp;lt; 0.0125). Conclusions: In the third trimester global longitudinal strain decreased whereas LV rotation and twist increased. Speckle-tracking echocardiography may be used to evaluate the effects of pregnancy and that provide further data on cardiac functions.

Circumferential deformation in diagnosis and risk assessment of patients with left ventricular non-compaction

Abstract Introduction Echocardiography-based deformation analysis is used for studying left ventricular (LV) mechanics and have an emerging role in the diagnosis of cardiomyopathies. Left ventricular non-compaction (LVNC) is a rare cardiomyopathy characterised by a two-layered LV myocardium with prominent trabeculae separated by deep recesses perfused from the LV cavity. Left ventricular hypertrabeculation (LVHT) may be difficult to differentiate from LVNC. In this study, we aim to develop a diagnostic algorithm based on the circumferential deformation (CD) of LVNC, LVHT and controls; and find their associations with LVNC outcomes. Methods We compared 45 LVNC patients, 45 LVHT individuals, and 45 matched healthy controls. LVNC was diagnosed according to current echocardiographic criteria. LVHT was defined as presence of three or more trabeculae in the LV apex visualised in both parasternal short axis and apical views. Controls had a normal echocardiographic examination and no evidence of cardiovascular disease. Strain analysis was performed using TomTec Image-Arena (version 4.6). Results Receiver observer characteristics curve (ROC) analyses revealed that GCS &amp;lt;22.3% differentiated LVNC from control or LVHT. In individuals with global circumferential strain (GCS) below 22.3%, an apical peak circumferential strain (PCS) cut-off value of 18.4% differentiated LVNC [&amp;lt;18.4%] and LVHT [≥18.4%] (fig. 1). An independent echocardiographer (Table 1) performed blind validation of diagnosis on 32 subjects from each group. Combined endpoint of cardiovascular events in LVNC (CVE) is described in figure 2. Multi-variate regression analyses have shown that GCS was associated with 11-fold increased risk of CVE independent of LVEF and NC:C ratio, while global longitudinal strain (GLS) displayed only 2-fold increased risk. Regional basal and apical peak circumferential or longitudinal strain, left ventricular twist, basal-apical rotation ratio have shown significant associations (Fig. 3). Conclusions A diagnostic algorithm with GCS and aPCS (threshold value 18.4%) differentiates LVNC from LVHT and control with very high sensitivity and specificity independent of additional echocardiographic or clinical information. Circumferential strain derived parameters exhibit a very strong association with outcomes independent of LVEF and NC:C ratio. Absence of CVE in LVHT provides further evidence on the distinct nature of LVNC and LVHT. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): 2018 research grant from the Swiss Heart Foundation

Left ventricular rotational abnormalities in adult patients with corrected tetralogy of Fallot following different surgical procedures – a three-dimensional speckle-tracking echocardiographic study

Abstract Introduction Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Abnormal aortic dimensions and elasticity parameters have been long described for corrected TOF (cTOF) together with left ventricular (LV) rotational abnormalities. The present study focuses on investigating LV rotational mechanics in cTOF, and possible correlation of these parameters with aortic elastic properties. It was also aimed to be examined whether different surgical strategies has any effect on the results. Methods The study involved 26 adult cTOF patients, from which 14 had palliative surgery first [Blaloc-Taussig (n=10), Waterstone-Cooley (n=2) shunts, or Brock procedure (n=2)] (mean age at the repair: 7.3±10.2 years) and a late total correction (mean age at the repair: 10.0±13.3 years) (pcTOF), while the early total correction was the treatment of choice in 12 patients (mean age at the repair: 4.2±3.2 years) (etrTOF). Their results were compared to that of 37 age- and gender-matched healthy adults. Routine transthoracic two-dimensional Doppler echocardiography extended with assessment of aortic elastic properties and three-dimensional speckle-tracking echocardiography (3DSTE) was performed in all cTOF patients and controls. Results Sixteen out of 26 cTOF patients showed normally directed LV rotational mechanics, while apical and basal LV rotations were in the same clockwise and counterclockwise directions in 7 and 3 cTOF cases, respectively (38%). This sort of LV movement is called as LV rigid body rotation (RBR). The ratio of LV-RBR between etrTOF and pcTOF patients did not differ significantly (33% vs. 43%, p=0.70). Significantly reduced LV apical rotation (5.2±3.7 degree vs. 10.2±4.5 degree, p&amp;lt;0.05) and twist (9.0±3.3 degree vs. 14.6±4.9 degree, p&amp;lt;0.05) could be demonstrated in cTOF patients with normally directed LV rotational mechanics with preserved LV basal rotation regardless of previous procedure. pcTOF patients showed significantly reduced LV apical rotation as compared to that of etrTOF cases (3.2±3.7 degree vs. 7.1±2.5 degree, p&amp;lt;0.05). From the 7 cTOF patients with clockwise LV-RBR, apical and basal LV rotation proved to be −6.8±5.4 degree and −4.9±2.4 degree, respectively with LV apico-basal gradient of 4.3±3.6 degree. The mean LV apical and basal LV rotation of 3 cTOF patients with counterclockwise LV-RBR prove to be −2.1±3.4 degree and 0.2±0.9 degree, respectively with LV apico-basal gradient of 2.5±2.4 degree. Significant correlations could be demonstrated between LV apical rotation and aortic stiffness index (r=−0.55, p=0.03) and aortic distensibility (r=0.52, p=0.04). Conclusions Significant LV rotational abnormalities could be demonstrated in cTOF with the high prevalence of LV-RBR. cTOF patients with early total reconstruction proved to have beneficial results. Abnormal physiologic response of LV rotational mechanics to increased aortic stiffness can be detected in cTOF patients without LV-RBR. Funding Acknowledgement Type of funding source: None

Evidence for abnormal deformational reserve in hypertrophic obstructive cardiomyopathy on exercise: is this a true fingerprint?

Abstract Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by muscle hypertrophy and fibrosis, interfering with force generation and relaxation. Abnormal ventricular (LV) myocardial deformation have been demonstrated in patients with HOCM at rest, but there is lack of data regarding the deformational mechanics in exercise in obstructive HCM. Aims To assess the adaptability of LV deformational behaviour to physical exercise in HOCM patients as compared to healthy controls and to examine if Deformational Imaging (DMI) can provide additional information. Methods 28 obstructive HOCM (age 51.2±14.2yrs; 16 men, LVOT-obstruction 56±19mmHg at rest or on Valsalva maneuver) and 32 control subjects (50.9±6.8 yrs, 19 men from the MAGYAR-PATH Registry) underwent bicycle stress Echo (ESE) with full conventional 2D- and Doppler TTE, 2D- and 3D-Speckle Tracking Analysis (DMI) and 3D-Full Volume assessment both at rest and on submaximal ESE. Results At rest, the HOCM group had lower GLS (−14.6±4.5 vs 18.4±2.6%, p&amp;lt;0.01) but higher CS (−32.9±5.1 vs 28.8±2.3%) and Twist (9.9±2.6 vs 6.1±2.2°) than in control subjects. Exercise induced an increase in all strains in control subjects but less in HOCM (GLS: −21.4±3.5 vs 15.1±3.0% and CS: −33.9±3.6 vs 34.1±4.2% in controls). The increase of LV twist was blunted in HOCM (Δ1.2 vs Δ3.6° in controls). The PSS was more pronounced in HOCM on ESE (46.6±12.0 vs 21.2±9.6%, AUC: 0.71 for predicting HOCM), the UTR was slower (118±2.1 vs 133.1±14.1°/s) and occurred later in HOCM. The MD of Strain increased in HOCM on ESE (Δ85.1 vs Δ8.1ms in controls). The Twist had positive correlation with LVOT-obstruction (R2=0.54, p&amp;lt;0.01) and inverse correlation with UTR (R2=−0.72, p&amp;lt;0.02). The UTR/Twist ratio diminished only in HOCM on exercise (−6.0±0.8 vs −13.1±2.5 1/s). The MD, the PSS on ESE and the UTR/Twist ratio predicted the HOCM deformation phenotype accurately (AUC: 0.72, cut-off 6.0 1/s). Conclusions The HOCM patients had attenuated Strain and Rotational response on exercise implying impaired deformational adaptability with post-systolic shortening and pronounced mechanical dispersion of peak Strain on exercise which was more accurate to identify the HOCM phenotype than other Echo-indices. These findings support evidence for reduced systolic-diastolic coupling efficiency in HOCM patients on exercise which can contribute to the development of exercise-related breathlessness, dynamic LVOT-obstruction and arrhythmias in patients with HOCM. These distinct deformational patterns on exercise can help in the differential diagnosis of patients with LV hypertrophy of unknown aetiology with good sensitivity and specificity and can also aid in the risk stratification workup in HOCM. DMI Predictors for HOCM Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Milton Keynes University Hospital Research Founding

Gender-specific adaptations to 4-months of strength training: Evaluation of left ventricular morphology and myocardial function

With millions of Europeans engaged in fitness club, strength training (ST) represents a widespread physical activity. At heart level, ST induces a concentric myocardial hypertrophy generally associated with a normal resting myocardial function. However, effect of ST have been described in men only, and whether women have similar cardiac responses to ST compared to men remains to be elucidated. To assess the gender-specific adaptations of ST on left ventricular (LV) morphology and myocardial function. Twelve healthy young men (26 ± 4 y) and 12 age-matched women (29 ± 7 y) took part in a supervised 4-months ST program at 70% of their repetition maximum. Resting echocardiographies were performed at the beginning of the training program and after each month. LV morphology, systolic and diastolic functions were assessed using two-dimensional, Doppler and 2D-strain. Myocardial regional function was evaluated from LV longitudinal (LS), circumferential strains (CS), and LV rotations and twist. At baseline, women exhibited lower interventricular septum and lateral wall thicknesses, LV volumes and LV mass compared to men. They exhibited higher LV global LS (GLS) and CS and lower diastolic function (E wave and E′ wave from tissue Doppler). However, no-gender effect of ST were observed on LV morphology. LV mass progressively increased, due to an increase of LV wall thicknesses, of LV end-diastolic volume and of the relative wall thicknesses (after the second month). LV diastolic function increased progressively whereas GLS and longitudinal diastolic strain rates decreased progressively. Apical rotation increased ( P = 0.06) whereas basal rotation remained unchanged. Despite women had specific cardiac morphology and myocardial function compared to men at baseline, no-gender-specific adaptation were observed during 4-months of supervised ST. Women elicit a similar concentric cardiac remodeling compared to men.

Speckle tracking echocardiography and left ventricular twist mechanics: predictive capabilities for noncompaction cardiomyopathy in the first degree relatives.

In non-compaction cardiomyopathy (NCCM), there are several echocardiographic and cardiac magnetic resonance (CMR)-based quantitative diagnostic indices, current criteria mainly placed on morphological features, and none of the diagnostic indices includes left ventricular (LV) function. LV function and hemodynamics could be normal in NCCM patients. Evaluation of left ventricular function at the subclinical stage, strain echocardiographic parameters could be used alternative to standard echocardiographic examinations. The aim of this study to evaluate; NCCM patients, their first-degree relatives, ventricular motion patterns, strain characteristics, and the predictive capabilities of these features for early diagnosis of cardiomyopathy. This cross-sectional, case-control study included 32 NCCM patients, 30 first-degree relatives (father, mother, siblings and children) and 31 healthy volunteers. All patients evaluated with baseline echocardiography, strain measurements, and ventricular wall motion pattern. There were no differences between the groups in terms of age, weight, and body surface area. We observed a statistically significant decrease in ejection fraction (EF), fractional shortening (FS), E/E' and global strain values in patients' relatives compared to healthy volunteers (Patients' relatives: LVEF:60.9 ± 7.2%, FS:0.34 ± 0.07, E/E':7.51 ± 1.83, GLS: - 18.6 ± 3.6, GLSr: - 1.1 ± 0.1, GCS: - 17.1 ± 3.1, GCSr: - 1.2 ± 0.1, GRS:37.1 ± 6.2, GRSr:1.7 ± 0.1; all p values< 0.05). 'Rigid Body Rotation (RBR)' movement pattern was also observed in some of the patient's relative's like in the patients. RBR movement pattern determined patients; EF, longitudinal strain-strain rate, and basal layer rotation values were significantly lower, but radial strain values were higher with the RBR movement pattern (for all values p < 0.05). RBR movement pattern, deterioration of strain parameters, and accompanying echocardiographic features like LVEF, fractional shortening (FS), E/E' in patients' relative groups may contribute to reveal the subclinical status of disease and could be predictive for early diagnosis of cardiomyopathy.

Assessment of Left Ventricular Mechanics in Patients with Severe Aortic Stenosis after Transcatheter Aortic Valve Implantation: 2-D Speckle Tracking Imaging Study.

BackgroundChronic pressure overload secondary to severe aortic stenosis causes impairment of left ventricular myocardial deformation and associated with adverse outcome. The present study aimed to assess the response of myocardial mechanics after transcatheter aortic valve implantation (TAVI).MethodsAssessment of myocardial mechanics by quantification of LV longitudinal, circumferential strain and rotational deformation (apical, basal rotation and twist) by 2-D Speckle-tracking echocardiography at baseline and at midterm follow-up post-TAVI. The patients were divided into 2 groups based on baseline left ventricular ejection fraction. 46 patients had preserved LV EF ≥50% preserved ejection fraction (PEF) and 34 patients had reduced left ventricular ejection (REF) < 50%.Results80 patients with severe AS and high surgical risk were evaluated. At a mean follow-up of 8 ± 3 months after TAVI, left ventricular longitudinal strain (LS) significantly improved in reduced ejection fraction (REF) group from -9.88 ± 3.93% to 11.89 ± 3.15% (P = 0.001). In preserved ejection fraction (PEF) group, longitudinal strain improved from -13.8 ± 3.1% to -15.2 ± 3.3% (P < 0.001). Longitudinal strain rate (LSR) improved significantly in REFgroup, -0.48 ± 0.20sec−1 to -0.62 ± 0.16 sec−1 (P < 0.001) and in PEF group,-0.73 ± 0.19 sec−1 to-0.77 ± 0.16 sec −1 (P < 0.005). In PEF group, LV twist angle was supra-physiological at baseline and decreased after TAVI towards normal values (P = 0.006). In REF group LV twist angle was reduced at baseline with significant increase towards normal value after transcatheter aortic valve implantation (TAVI),P = 0.005. That was attributed to severe LV dysfunction associated with reduction of left ventricular twist at baseline which improved in response to TAVI alongside with improvement of left ventricular systolic function. In reduced ejection fraction (REF) group circumferential strain and strain rate improved significantly after TAVI.ConclusionsMyocardial mechanics of the left ventricle including strain, strain rate and twist are deformed in severe aortic stenosis. TAVI restores myocardial mechanics towards physiological values in patients with preserved and reduced ejection fraction.

Speckle tracking echocardiography in a patient with viral myocarditis and acute myocardial infarction

The present case of a patient with acute myocarditis with preserved left ventricular (LV) ejection fraction at the acute stage illustrates the obvious impairment of circumferential and rotational deformation, which can be documented by speckle tracking echocardiography. Thus, qualitative patterns of LV twist, radial strain, and circumferential layer strain, might be a new approach to detect acute myocarditis. The early diagnosis of acute myocarditis by echocardiography is important because of the considerable risk of cardiovascular morbidity as documented by the occurrence of an acute myocardial infarction presumably induced by inflammatory process in this case.<Learning objective: The compound of myocardial deformations caused by left ventricular subendomyocardial and subepimyocardial fibers may be a crucial diagnostic target in cardiac diseases. The predominant involvement of viral myocarditis of the outer myocardial layers might induce impairment of circumferential and rotational deformation, which can potentially serve as a new diagnostic key by echocardiography. In contrast, left ventricular ejection fraction and longitudinal deformation are often observed within normal ranges in patients with acute myocarditis. Acute myocardial infarction as a major cardiac event in acute stage of myocarditis causes completely different deformation patterns, mainly by the predominant involvement of the inner myocardial layers inducing severe pathologies of territorial longitudinal deformation. Patients with suspected acute myocarditis and abnormal findings of circumferential and rotational deformation should undergo additional diagnostic procedures as cardiac magnetic resonance and myocardial biopsy to confirm the diagnosis.>