Mean Global Longitudinal Strain Research Articles

Inter-Vendor differences in speckle tracking strain - A ten year follow-up on the Strain Standardization Task Force Inter-Vendor Comparison Study

Abstract Background Global longitudinal strain (GLS) derived from two-dimensional speckle-tracking echocardiography is feasible and accurate. Nonetheless, in 2013, the Inter-Vendor Comparison Study showed significant differences of measurement results among vendors. In order to make tracking-based strain imaging a clinically accepted and useful parameter, it is of outmost importance to have interchangeable and accurate measurement results from all vendors. Purpose To investigate if the efforts of the EACVI/ASE/Industry Task Force to Standardize Deformation Imaging have led to a reduction of inter-vendor differences during the past ten years. Methods In an unique setting, in one single room, 372 echocardiographic examinations were performed in sixty-two subjects (50 male, age 56.1 ± 16.98) with a wide range of left ventricular (LV) function (ejection fraction from 30% to 64%) using ultrasound systems from six manufacturers. Each subject was scanned consecutively on all machines by the same assigned experienced sonographer. For each subject two image sets of LV apical views were acquired in order to assess reproducibility in a true test-retest setting. We assessed mean GLS (GLSAV) as average peak systolic global strain from the three apical views on five vendor-specific and five vendor-independent software solutions. We measured endocardial and mid-/full-wall GLS. Since there is no gold standard method to measure GLS, we compared GLSAV of each vendor to the average of the GLS values only from vendors that provide tracking software solutions (SWS) for clinical use. Results For both endocardial (Figure 1) and mid-/full-wall (Figure 2) GLS measurements from clinical SWS were comparable and within a very narrow range (mean GLS of vendors 17.25 ± 0.3% and 15.36 ± 0.3% respectively). The maximum absolute difference between all SWS was 4.1% and 4.9% strain units for endocardial and mid-/full-wall GLS respectively. GLSAV of each software versus the mean of clinical SWS showed significant correlation for most of the companies (r² >0.8, p<0.001). Test-retest variability of GLS measurements expressed as relative mean error was good and lower than for LV ejection fraction (6.3% on average for mean GLS and 7% for LV ejection fraction, p>0.05). Conclusions Our data show a substantial inter-vendor bias in GLS measurements. Nevertheless, in contrast to the situation ten years ago, companies that provide tracking software solutions for clinical use provide now very similar GLS values. In addition, most companies do now allow mid-/full-wall tracking. Our data indicate that the efforts of the strain standardization task force have been fruitful. A continuing effort is needed until all software providers adhere to the task force consensus recommendations.Figure 1Figure 2

The impact of cardiovascular risk factors on longitudinal changes in cardiac structure and function in an older population of hypertensive patients

Abstract Background Hypertension is associated with cardiac structural and functional changes, with left ventricular hypertrophy and diastolic dysfunction as strong predictors of adverse cardiac events. Limited data exist on how cardiovascular (CV) risk factors accelerate left ventricular (LV) mass and diastolic dysfunction over time in older hypertensive patients. Purpose To investigate the association between CV risk factors and accelerated deterioration of LV mass, left atrial volume (LAV), global longitudinal strain (GLS), and tissue Doppler E/e’ ratio in an older population of hypertensive patients. Methods Post-hoc analysis of a randomized clinical trial that investigated whether atrial fibrillation screening, using an implantable loop recorder, and subsequent initiation of anticoagulation, could prevent stroke in high-risk individuals. Only individuals with hypertension who had transthoracic echocardiography performed on two occasions, with a median of 5 years between echocardiograms, were included in this sub-study (n = 570). Multivariable linear regression analysis was performed to investigate the association between risk factors and changes in LV mass, LAV, GLS and E/e’. ß-values were calculated per 1 SD change for all variables. Results Mean age was 74±3 years, and 55% were men. Mean body mass index (BMI) was 27.8±4.3 kg/m2, 26% had diabetes, 58% used statins, 12% had a history of ischemic heart disease, and 4% had heart failure. The median use of antihypertensive drugs was 2 (IQR: 1,2), mean systolic blood pressure was 148.6±18.2 mmHg. During a median follow-up of 5 years, the mean increase in LV mass was 6.5±38.3g. Male sex (ß 0.24, p < 0.001) and increasing BMI (ß 0.29, p <0.001) were significantly associated with an accelerated increase in LV mass (Fig. 1). The mean increase in LAV was 14.6±15.7ml. Diabetes (ß -0.16, p = 0.006) and high sensitivity C-reactive protein (hsCRP) (ß 0.14, p = 0.007) were significantly associated with changes in LAV (Fig. 2). The absolute decline in mean GLS was 0.27%. Increasing age (ß -0.09, p = 0.027), heart failure (ß -0.10, p = 0.020), ischemic heart disease (ß -0.16, p < 0.001), hsCRP (ß -0.12, p = 0.003) and s-creatinine (ß -0.09, p = 0.033) were all significantly associated with an accelerated decline in GLS (Fig. 1). E/e’ declined with an average 0.96±2.89. Increasing age (ß 0.12, p = 0.001), female sex (ß 0.09, p = 0.049), and increasing systolic blood pressure (ß 0.13, p = 0.004) were associated with an increase in E/e’ (Fig. 2). Conclusion Male sex and increasing BMI were independently associated with an accelerated increase in LV mass. Diabetes was independently associated with LAV decline, while hsCRP was significantly associated with increasing LAV. Increasing age, heart failure, ischemic heart disease, hsCRP, and s-creatinine were independently associated with an accelerated decline in GLS. Increasing age, systolic blood pressure and female sex were independently associated with increasing E/e’.

Subclinical left ventricular dysfunction in rheumatoid arthritis: findings from the prospective Porto-RA cohort.

Patients with rheumatoid arthritis (RA) have an increased risk of cardiac dysfunction and heart failure (HF) due to a pro-inflammatory state. Detecting cardiac dysfunction in RA is challenging as these patients often present preserved ejection fraction (EF) but may have subclinical ventricular dysfunction. Echocardiographic strain analysis is a promising tool for early detection of subclinical left ventricular systolic dysfunction (LVSD). This study assesses the prognostic role of strain analysis in RA. Prospective study of 277 RA patients without known heart disease and preserved EF, categorized by left ventricular global longitudinal strain (GLS): normal GLS (≤ -18%) vs. subclinical LVSD (> -18%). Primary outcome was a composite of myocardial infarction, HF hospitalization, stroke, or cardiovascular death (MACE). Mean age was 57years, 79% female. Although mean GLS was within normal (-20 ± 3%), subclinical LVSD was observed in 24% of patients (n = 67) and was positively correlated with older age (OR 1.54 per 10years; p < 0.001) and comorbid conditions, such as dyslipidemia (OR 2.27; p = 0.004), obesity (OR 2.29; p = 0.015), and chronic kidney disease (OR 8.39; p = 0.012). Subclinical LVSD was independently associated with a 3.9-fold higher risk of MACE (p = 0.003) and a 3.4-fold higher risk of HF hospitalization/cardiovascular death (p = 0.041). A GLS threshold of > -18.5% provided optimal sensitivity (78%) and specificity (74%) in identifying patients at elevated MACE risk (AUC = 0.78; p < 0.001). Subclinical LVSD, identified by reduced GLS, was strongly associated with adverse cardiovascular events in RA. Whether these findings have therapeutic implications is worth exploring in clinical trials.

The role of Cardiotrophin-1 and echocardiography in early detection of subclinical diabetic cardiomyopathy in children and adolescents with type 1 diabetes mellitus.

To assess the role of Cardiotrophin-1 (CT-1) and echocardiography in early detection of subclinical Diabetic Cardiomyopathy (DCM) in children with type 1 Diabetes Mellitus (T1D). This case-control study included two groups of children and adolescents aged between 7 and 18. Group (1) included forty patients with T1D (duration > 5 years) regularly followed at the children's hospital of Cairo University, and Group (2) included forty age and sex-matched healthy subjects as a control group. The serum level of CT-1 was measured, and conventional echocardiography, tissue Doppler imaging (TDI), and 2D speckle tracking echocardiography were performed. The level of CT-1 in the cases ranged from 11 to 1039.4 pg/ml with a median (IQR) of 19.4 (16.60-25.7) pg/ml, while its level in the control group ranged from 10.8 to 162.6 pg/ml with a median (IQR) of 20.2 (16.2-24.8) pg/ml. CT-1 levels showed no statistically significant difference between cases and controls. Patients had significantly higher mean left ventricle E/E' ratio (p<0.001), lower mean 2D global longitudinal strain (GLS) of the left ventricle (LV) (p<0.001), and lower mean GLS of the right ventricle (RV) (p<0.001) compared to controls. Ofpatients with diabetes, 75 % had LV diastolic dysfunction, 85 % had RV diastolic dysfunction, 97.5 % had LV systolic dysfunction, and 100 % had RV systolic dysfunction. Non-conventional echocardiography is important for early perception of subclinical DCM in patients with T1D. CT-1 was not specific for early detection of DCM.

Evaluation of changes in cardiac longitudinal strain rate in patients with systemic sclerosis undergoing iloprost treatment: an observational study.

Systemic Sclerosis (SSc) is characterized by widespread microangiopathy and fibrosis of skin and visceral organs. Left ventricle involvement is usually subclinical, characterized by systolic and/or diastolic dysfunction. The global longitudinal strain (GLS), a validated and reliable technique for the measurement of ventricular longitudinal deformation by means of echocardiography, may detect subclinical systolic dysfunction of SSc myocardium. The improvement of myocardial perfusion by means of intravenous Iloprost administration could ameliorate the contractility of SSc heart. Therefore, we aimed to evaluate GLS in a series of SSc patients prior and after Iloprost infusion. Fifteen consecutive SSc patients (age: 54 ± 11 years; 12 females) treated with Iloprost because of the presence/history of digital ulcers underwent echocardiography, including GLS technique. This evaluation was conducted immediately before Iloprost administration and at the end of the 6-h infusion session. Significant improvement in the mean GLS was observed after Iloprost administration (from -13.5 ± 2.5 to -15 ± 3.3; p= 0.011). The echocardiographic data obtained from the four-chamber view showed the best quality for GLS analysis and showed a highly significant improvement of the strain after Iloprost administration (from -13.4 ± 2.2 to -15.6 ± 3; p= 0.001). The degree of GLS improvement did not correlate with any SSc parameters. Iloprost administration improved GLS, suggesting that the increase of myocardial perfusion allowed, at least in part, a correction of left ventricular systolic dysfunction. Further studies are needed to confirm these findings, further exploring the mid/long-term effects of Iloprost on myocardial contraction.

Echocardiographic Functional Outcomes Following Regional Nodal Irradiation for Breast Cancer Using Volumetric Modulated Arc Therapy

Regional nodal irradiation (RNI) for breast cancer yields improvements in disease outcomes, yet comprehensive target coverage often increases cardiac radiation therapy (RT) dose. Volumetric modulated arc therapy (VMAT) may mitigate high-dose cardiac exposure, although it often increases the volume of low-dose exposure. The cardiac implications of this dosimetric configuration (in contrast to historic 3D conformal techniques) remain uncertain. Eligible patients receiving adjuvant RNI using VMAT for locoregional breast cancer were prospectively enrolled in an IRB-approved study. Echocardiograms were performed prior to RT, at the conclusion of RT, and 6 months following RT. Echocardiographic parameters were measured by a single reader and measures were compared pre- and post-RT via the signed-rank test. Changes in echocardiographic parameters over time were compared to mean and max heart doses via the Spearman correlation test. Among 19 evaluable patients (median age 38 years), 89% (n = 17) received doxorubicin and 37% (n = 7) received trastuzumab/pertuzumab combination therapy. All patients received VMAT-based whole-breast/chest wall and RNI. The average mean heart dose was 456 cGy (range, 187-697 cGy) and the average max heart dose was 3001 cGy (1560-4793 cGy). Among salient echocardiographic parameters, no significant decrement in cardiac function was observed when comparing pre-RT to 6 months post-RT: mean left ventricular ejection fraction (LVEF) was 61.8% (SD 4.4%) pre-RT and 62.7% (SD 3.8%) 6 months post-RT (P = .493); mean global longitudinal strain (GLS) was -19.3% (SD 2.2%) pre-RT and -19.6% (SD 1.8%) 6 months post-RT (P = .627). No individual patient exhibited reduced LVEF or sustained decrement in GLS. No correlations were observed for changes in LVEF or GLS when compared to mean or maximum heart doses (P > .1 for all). VMAT for left-sided RNI yielded no significant early decrement in echocardiographic parameters of cardiac function, including LVEF and GLS, within this limited cohort. No patient exhibited significant LVEF changes, and none exhibited sustained decrements in GLS. VMAT may be a reasonable approach to cardiac avoidance in patients requiring RNI, including those receiving anthracyclines and HER2-directed therapy. Larger cohorts with longer follow-ups will be needed to validate these findings.

Artificial intelligence-derived left ventricular strain in echocardiography in patients treated with chemotherapy

Global longitudinal strain (GLS) is an echocardiographic measure to detect chemotherapy-related cardiovascular dysfunction. However, its limited availability and the needed expertise may restrict its generalization. Artificial intelligence (AI)-based GLS might overcome these challenges. Our aims are to explore the agreements between AI-based GLS and conventional GLS, and to assess whether the agreements were influenced by expertise levels, cardiac remodeling and cardiovascular diseases/risks. Echocardiographic images in the apical four-chamber view of left ventricle were retrospectively analyzed based on AI-based GLS in patients treated with chemotherapy, and correlation between AI-based GLS (Caas Qardia, Pie Medical Imaging) and conventional GLS (Vivid E9/VividE95, GE Healthcare) were assessed. The agreement between unexperienced physicians (“GLS beginner”) and experienced echocardiographer were also assessed. Among 94 patients (mean age 69 ± 12 years, 73% female), mean left ventricular ejection fraction was 64 ± 6%, 14% of patients had left ventricular hypertrophy, and 21% had left atrial enlargement. Mean GLS was − 15.9 ± 3.4% and − 19.0 ± 3.7% for the AI and conventional method, respectively. There was a moderate correlation between these methods (rho = 0.74; p < 0.01), and bias was − 3.1% (95% limits of agreement: -8.1 to 2.0). The reproducibility between GLS beginner and an experienced echocardiographer was numerically better in the AI method than the conventional method (inter-observer agreement = 0.82 vs. 0.68). The agreements were consistent across abnormal cardiac structure and function categories (p-for-interaction > 0.10). In patients treated with chemotherapy. AI-based GLS was moderately correlated with conventional GLS and provided a numerically better reproducibility compared with conventional GLS, regardless of different levels of expertise.

Left ventricular function assessment in Kawasaki disease by two-dimensional global longitudinal systolic strain with automated function imaging.

Kawasaki disease is an acute febrile vasculitis of childhood mainly affecting children under 4 years of age. In the acute stage of the disease, heart function decreases and gradually returns to normal after treatment. However, subendocardial involvement may persist, which cannot be assessed by M-mode echocardiography. Strain echocardiography is a recently developed technique to assess subendocardial involvement of myocardial deformation. We aimed to study the stratified strain of left ventricular function in a Kawasaki patient at least 6 months after the acute stage of the disease with special conditions for entering the study using two-dimensional speckle-tracking imaging. Between September 2020 and October 2022, 27 healthy children and 27 children with a history of Kawasaki disease more than 6 months ago were evaluated using two-dimensional global longitudinal peak systolic strain with automated function imaging technology. The mean age of patients was 5.6 years. With M-mode echocardiography, ejection fraction of each group was in the normal range. Mean (± standard deviation) global longitudinal peak strain in four-chamber view of girls with Kawasaki disease was - 23.74 ± 2.77, and that in boys with Kawasaki disease was - 20.93 ± 2.06 (P value = 0.008). GLPS (global longitudinal peak strain) was compared as an overall average and as in a separate segment, which showed significant difference in two comparisons. In our study, a decrease in the function of some cardiac segments is reported. Global longitudinal peak strain in four-chamber view was significantly lower in boys. Comparing different segments, a difference in global left ventricular long-axis strain was found between the two groups. On the other hand, there was a major difference between the two groups in the basal inferolateral, basal anterolateral, and mid-inferolateral, which receives blood from Left Circumflex artery. Using stain echocardiography to detect continued subendocardial involvement in asymptomatic children with a history of Kawasaki disease for a better understanding of the condition, effective management and follow-up is recommended.

Synergistic Effect of Transmyocardial Revascularization and Platelet-Rich Plasma on Improving Cardiac Function After Coronary Artery Bypass Grafting.

Background Coronary artery disease (CAD) is a global health burden, contributing to mortality and morbidity. A proportion of patients with CAD suffer from diffuse CAD, where conventional revascularization techniques such as percutaneous coronary intervention and coronary artery bypass grafting (CABG) may be insufficient to adequately restore myocardial perfusion. Transmyocardial revascularization (TMR) uses a laser to create microscopic channels in the myocardium, inducing inflammation, angiogenesis, and neovascularization to improve perfusion to ischemic regions. Platelet-rich plasma (PRP) is an autologous concentrate of platelets that contains a myriad of growth factors and bioactive proteins, which have been shown to promote tissue regeneration and wound healing. The combination of TMR and PRP therapies has been proposed to synergistically enhance myocardial revascularization and functional recovery in patients with advanced CAD undergoing surgical revascularization. Methods This study evaluated the efficacy of combining TMR and PRP with CABG in improving cardiac function in diffuse CAD patients. Fifty-two patients were randomized to CABG alone (n = 16), CABG+TMR (n = 17), CABG+PRP (n = 10), and CABG+TMR+PRP (n = 9). TMR was performed using a holmium:YAG laser to create 10 channels in the inferolateral left ventricular wall. PRP was prepared from autologous whole blood and injected into the myocardium adjacent to the TMR channels. Cardiac function was assessed using speckle-tracking echocardiography preoperatively, postoperatively, and at one-year follow-up. Adverse events, including post-operative atrial fibrillation, acute kidney injury, and readmissions, were also recorded. Statistical analyses were performed to compare outcomes between the treatment groups. Results The CABG+TMR+PRP group showed significantly improved global longitudinal strain (GLS) at one year compared to CABG alone (mean GLS -15.96 vs -12.09, p = 0.02). Post-operative left ventricular ejection fraction trended higher in the TMR+PRP group (57.78%) vs other groups, but not significantly. Post-operative atrial fibrillation was higher in the TMR+PRP group (67% vs 25%, p = 0.04), potentially reflecting increased inflammation. No significant differences were observed in other adverse events. Conclusions The results of this study suggest a synergistic benefit of combining TMR and PRP therapies as an adjunct to CABG in patients with diffuse CAD. The significant improvement in GLS at one year in the TMR+PRP group compared to CABG alone indicates enhanced myocardial remodeling and functional recovery, which may translate to improved long-term outcomes. The higher incidence of postoperative atrial fibrillation in the TMR+PRP group warrants further investigation but may reflect the heightened inflammatory response necessary for angiogenesis and tissue regeneration. Prospective, randomized controlled trials with larger sample sizes and longer follow-up periods are needed to validate these findings and optimize treatment protocols. Nonetheless, concomitant TMR+PRP therapy represents a promising approach to augmenting myocardial revascularization and recovery in patients with advanced CAD undergoing surgical revascularization.

Left ventricular diastolic function and cardiotoxic chemotherapy

BackgroundLeft ventricular ejection fraction falls when the myocardium has already lost a significant portion of its functional capacity. There are conflicting data on whether diastolic dysfunction precedes systolic dysfunction after cardiotoxic chemotherapy. We aimed to study systolic and diastolic dysfunction after cardiotoxic chemotherapy and whether diastolic dysfunction can predict subsequent risk of systolic dysfunction. It was an observational prospective cohort study, and patients receiving cardiotoxic chemotherapy were included. Baseline, demographic, and clinical details were recorded. Echocardiographic measurements of left ventricular systolic function, global longitudinal strain, and diastolic function were noted at baseline, three months, and 6 months.ResultsWe included eighty patients. The mean age of the patients was 54.92 ± 7.6 years, predominantly females (80%). The mean left ventricular ejection fraction fell from 64.92 ± 1.96 to 60.97 ± 4.94 at 6 months. Low ejection fraction was seen in 8 (10%) patients at 6 months. The mean global longitudinal strain (GLS) at baseline was − 18.81 ± 0.797 and fell to − 17.65 ± 2.057 at 6 months, with 12 (15%) patients having low GLS (< − 18). Grade 1 diastolic dysfunction was seen in 22 (27.5%) patients, and grade 2 diastolic dysfunction was seen in 3 (3.8%) patients at 6 months. There was a significant decrease in E/A ratio (inflow early diastolic velocity/Inflow late diastolic velocity), mitral tissue Doppler velocity, and an increase in isovolumic relaxation time, mitral valve deceleration time, and E/e′ (inflow early diastolic velocity/tissue Doppler mitral annular velocity), at three months and 6 months. Ejection fraction at 6 months was significantly and negatively correlated with diastolic dysfunction at three months (r = − 0.595, p = 0.02).ConclusionsCardiotoxic chemotherapy is associated with early diastolic dysfunction. Early diastolic dysfunction predicts subsequent left ventricular systolic dysfunction.

Combined Efficacy of Global Longitudinal Strain and Epicardial Fat Thickness Measurement in Assessing Coronary Artery Disease Severity

ABSTRACT Context: More positive global longitudinal strain (GLS) and higher epicardial fat thickness (EFT) correlate with coronary artery disease (CAD) severity. Aim: The aim of the study was to assess the combined efficacy of GLS and EFT measurement in predicting severity of CAD measured by coronary angiography. Study and Design: Prospective, observational study conducted in Government Medical College, Kottayam, Kerala, for 2 years. One thousand patients with ≥50% coronary stenosis were grouped as cases and 500 patients who had normal coronaries or &lt;50% stenosis were taken as controls. Subjects and Methods: EFT and GLS were measured by transthoracic echo and the severity of CAD was by Gensini scoring. Statistical Analysis Used: Mean and standard deviation used for quantitative data and group differences were compared with Student’s t-test. Results: We observed a mean EFT of 7.2 mm ± 1.6 mm and mean GLS of–13.24 ± 1.6 among cases compared to a mean EFT of 3.4 mm ± 0.8 mm and mean GLS of–19.2 ± 1.2 in the controls with P &lt; 0.001. The cutoff values of EFT and GLS for predicting significant CAD were 4.85 mm and 14.9 with a sensitivity of 96% and specificity of 88%. Conclusion: Combined use of GLS and EFT measurement is less costly and very well correlates with CAD severity.

Cardiomyopathy discovered during pregnancy: Insights from speckle tracking echocardiography in a cohort of pregnant patients.

Heart failure (HF) is considered the leading cause of cardiac-related morbidity and mortality during pregnancy. Peripartum cardiomyopathy (PPCM) presents diagnostic challenges, often mirroring dilated cardiomyopathy (DCM). The aim of the study is to evaluate echocardiographic features, including global and segmental longitudinal strain values, in pregnant women with a history of newly diagnosed left ventricular systolic dysfunction (LVSD) in the third trimester of pregnancy. This cross-sectional study, conducted in two referral cardio-obstetric clinics in Isfahan, Iran, enrolled pregnant women with newly diagnosed LV systolic dysfunction in the third trimester of pregnancy. A multidisciplinary pregnancy heart team assessed the patients. Reevaluation of patients and advanced echocardiographic investigation, including speckle tracking echocardiography (STE), were performed at least six months after delivery. The study included 26 pregnant women. Baseline characteristics revealed varying NYHA functional classes and etiologies, including DCM or non-dilated LV cardiomyopathy and PPCM. Undiagnosed DCM with exacerbation during pregnancy or non-dilated LV cardiomyopathy were the most probable causes for LV systolic dysfunction (65.4%). In five cases, peripartum cardiomyopathy was more relevant. The mean global longitudinal strain (GLS) was -16.94% and -13.95% in PPCM and DCM, respectively. Significantly different regional longitudinal strain numbers among different LV segments in PPCM were observed (P=.042), whereas the segmental strain in DCM patients did not differ. When LVSD is discovered late in pregnancy, it is not easy for the authors to differentiate between peripartum cardiomyopathy and other cardiomyopathies. Advanced echocardiographic techniques, particularly GLS analysis, may be valuable in differentiating between these conditions.

Echocardiography Coupled with Strain Method in the Screening for Cardiac Involvement in Rheumatoid Arthritis.

In this study, the usefulness of transthoracic echocardiography (TTE) in systematic screening was assessed for various cardiac abnormalities in patients with rheumatoid arthritis (RA). We performed a comparative cross-sectional study from July 2020 to February 2021. Each patient underwent a TTE coupled with the strain technique. Seventy-two RA patients and 72 controls were included. Abnormalities detected by TTE were more frequent in RA patients (80.6% vs. 36.1%; p < 0.01), and they were asymptomatic in 65.5% of cases. Valvular involvement was found in 45.8% of RA patients, with a significant difference (p < 0.01). Left ventricular diastolic dysfunction was also more frequent in the RA group (36.1% vs. 13.9%; p < 0.01). Left ventricular systolic dysfunction was absent in our study, but subclinical left ventricular myocardial damage assessed by Global Longitudinal Strain (GLS) method was found in 37.5% of RA patients and 16.6% of controls (p < 0.01). The mean GLS in RA patients was -17.8 ± 2.9 (-22 to -10.7) vs. -19.4 ± 1.9 (-24.7 to -15.7) in controls. Left ventricular hypertrophy was detected in 22.2% of RA patients and in 6.9% of controls (p < 0.01). Pericardial effusion and pulmonary arterial hypertension were present only in the RA group (2.8% of cases). We found a significant relationship between echocardiographic damage and disease activity (p < 0.01), number of painful joints (p < 0.01), functional impact (HAQ) (p = 0.01), CRP level (p < 0.01) and the use and dose of Corticosteroids (p = 0.02; p = 0.01). Echocardiographic damage in RA is frequent and often asymptomatic, hence there has been an increased interest in systematic screening in order to improve the quality of life and vital prognosis of patients. Early management of RA can reduce the risk of occurrence of cardiac involvement.

Abnormal Global Longitudinal Strain Correlates with Amyloidogenic Light Chain-Induced Cardiac Dysfunction via Direct Myocardial Toxicity in Patients without Significant Amyloid Fibril Deposition

Introduction: Patients with advanced cardiac AL have high early mortality despite receiving effective plasma cell-directed therapies. Cardiac dysfunction is caused by direct myocardial toxicity from amyloidogenic light chains (LCs) and architectural distortion from amyloid fibril deposition. Diagnosis before significant fibril-induced cardiac dysfunction is critical for improving outcomes. While measuring cardiac biomarkers is standard for risk stratification of patients with newly diagnosed AL, serum concentrations can be impacted by fluid shifts and renal impairment, suggesting a need for complementary biomarkers. Our transcriptomic analysis highlighted dysregulation of myocardial contractility in cardiac cells exposed to amyloidogenic LCs, leading us to hypothesize that there could be clinically measurable differences in cardiac contractility (Ghosh et al., 2023). Global longitudinal strain (GLS) is a sensitive echocardiographic measure of myocardial contractility and may predict survival independent of serum cardiac biomarkers. Since LC-induced cardiac dysfunction via direct myocardial toxic effects is reversible with plasma cell-directed therapy and may represent an early cardiac insult in patients with cardiac AL, we identified and evaluated patients with LC-induced cardiac dysfunction and no clinical or echocardiographic evidence of significant cardiac amyloid fibril deposition to determine clinical features potentially associated with early cardiac AL. Methods: We analyzed the demographic, clinical, and echocardiographic features of patients with non-cardiac biopsy-proven AL amyloidosis and LC-induced cardiac dysfunction seen at the Boston University Amyloidosis Center between January 1, 2011 and March 31, 2023. Direct LC-induced cardiac dysfunction was defined as: (1) elevated cardiac biomarkers (BNP &amp;gt;176 pg/mL or NT-proBNP &amp;gt;899 pg/mL or troponin I &amp;gt;0.033 ng/mL, per institutional reference ranges); (2) normal echocardiographic interventricular septal thickness (&amp;lt;11 mm in males and &amp;lt;10 mm in females); (3) estimated glomerular filtration rate &amp;gt;60 mL/min/1.73m 2; (4) absence of late gadolinium enhancement on cardiac magnetic resonance imaging (if performed); and (5) negative endomyocardial biopsy (if performed). Echocardiographic variables, including left ventricular ejection fraction (LVEF) and GLS, were collected from the electronic health record or post-processed manually using TomTec 2D CPA. All statistical analyses were performed using GraphPad Prism version 8©. Overall survival (OS) was evaluated using the Kaplan-Meier estimator and log rank tests. Results: Twenty-nine patients met our criteria for direct LC-induced cardiac dysfunction. Median age at diagnosis was 65 years (range: 46-83), and 55% of patients (n=16) were male ( Table 1). LC isotype was lambda in 69% (n=20) and kappa in 31% (n=9) of patients. The difference in free light chains (dFLC) was &amp;gt;50 mg/L in 62% (n=18) of patients at diagnosis.Additionally, 76% (n=22) of patients met criteria for Boston University stage II cardiac disease with mildly elevated cardiac biomarkers (median BNP 237 pg/mL, median troponin I 0.053 ng/mL). Among 16 patients for whom a GLS measurement was available, 81% (13/16) had an abnormal GLS (normal &amp;lt; -18%). Median and mean GLS were -15.5% (-7 to -21.7) and -15.3% ± 4.5, respectively ( Figure 1). Median OS was 5.2 years for the entire cohort. Conclusion: We found that a subset of patients with AL amyloidosis demonstrate cardiac dysfunction without substantial clinical or echocardiographic evidence of amyloid deposition; this we postulate to be the result of direct myocardial toxic effects by amyloidogenic LCs. Early cardiac biomarker stage and abnormal GLS were commonly associated with LC-induced cardiac dysfunctionin these patients.

Multi-dimensional evaluation in patients with aortic stenosis who are candidates for cardiac surgery

Abstract Introduction In patients with severe aortic stenosis (AS), the presence of left ventricular systolic dysfunction is one of the main predictors of adverse events after valve replacement surgery (SAVR). However, more and more patients are being referred for surgery early on and have preserved systolic function at the time of surgery. Within this category, global longitudinal strain (GLS) has been proposed as a marker of ventricular remodeling after cardiac surgery. Objectives Our study aims to identify the variation of GLS in patients undergoing SAVR and any differences compared to classes of diastolic dysfunction. Materials and methods From June 2020 to October 2022, we analyzed 100 patients with AS with an indication for cardiac surgery treatment admitted to the cardiac surgery department of our AOU. All patients underwent an echocardiogram immediately before surgery and in the early postoperative period (mean 7 days); 52 of them were enrolled for follow-up and repeated an echocardiogram at least 3 months after surgery. In all cases, the GLS of the left ventricle was calculated and patients were divided into four classes by the degree of diastolic dysfunction (0-III) according to the most recent international guidelines; moreover, patients were divided into 2 groups: group A for grades 0-1 of diastolic dysfunction and Group B for grades 2-3. The data were analyzed with SPSS 28 software. Analysis of variance was performed with a t-test and ANOVA test. Results In the final analysis, 100 patients with AS were included, with a mean age of 70.8±8.27, of whom 43 were women (43%) and 57 were men (57%). In 20 patients (20%) ischaemic heart disease with an indication for coronary revascularization was also present. The mean preoperative ejection fraction was 58.98±9.5%. The mean GLS values before surgery were 15.13±4.56% with a reduction immediately post-cardiac surgery of 12.26±3.67%, p&amp;lt;0.0001. GLS values were comparable within the various classes of diastolic dysfunction at preoperative examination (p=0.579) and immediately postoperative (p=0.286). At follow-up, analysis was repeated for 52 patients: an improvement in mean GLS was found: 16.09±3.64%, p&amp;lt;0.0001. The mean GLS in the two groups at follow-up was statistically different: 17.38±3.35% in group A vs 13.44±3.63% in group B, p&amp;lt;0.0001. Conclusions In our case series, patients with severe aortic stenosis undergoing SAVR show a significant early reduction in GLS regardless of the degree of diastolic dysfunction, while after at least 3 months of follow-up, they show a great recovery, significantly better in patients with Grades 0 or 1 diastolic dysfunction.GLS at the 3 times

Ventriculoarterial coupling as estimated by the PWV/GLS ratio correlates with disease severity in liver cirrhosis patients

Abstract Introduction Liver cirrhosis is characterized by vasodilation, reduced peripheral resistances and increased cardiac output. Recently, a novel parameter based on the ratio of carotid-femoral pulse wave velocity (PWV) to the absolute value of global longitudinal strain (GLS), has been proposed to estimate the relationship between left ventricle and aortic function (ventriculoarterial coupling- VAC). Purpose This study aimed to investigate the potential correlation between VAC, as estimated by the PWV/GLS ratio, and disease severity in patients with liver cirrhosis. Methods A total of 65 cirrhotic patients (mean age 59.1±8.3 years, 48 (73.8%) males) without cardiovascular disease were included in this study. PWV was calculated by dividing the estimated distance difference between the femoral and carotid arteries by the pulse transit time measured with a validated noninvasive device (simultaneous measurement with two transducers). Echocardiography was performed to determine GLS, which was calculated semi-automatically using dedicated software. Disease severity was assessed using the Model for End-Stage Liver Disease (MELD) score. Results The mean PWV was 7.8 ± 1.6 m/s, mean GLS was 21.1 ± 2.7%, and mean PWV/GLS ratio was 0.38 ± 0.11. Spearman’s correlation analysis showed that both PWV and GLS were significantly correlated with MELD score (rho=-0.330, p=0.007 and rho=0.276, p=0.026, respectively), indicating that patients with higher disease severity had lower PWV and higher absolute GLS values. There was also a negative correlation between PWV and GLS (rho=-0.377, p=0.002). PWV/GLS ratio was negatively correlated with MELD score (rho=-0.354, p=0.004). In addition to MELD score, PWV/GLS ratio was significantly associated with age (rho=0.281, p=0.023) and systolic blood pressure (SBP) (rho=0.445, p&amp;lt;0.001). A non-significant association with stroke volume (SV) was also observed (rho=-0.207, p=0.099), suggesting that cirrhotic patients with reduced afterload and increased cardiac output had lower values of the ventriculoarterial coupling index. Multivariate linear models confirmed the robustness of the association between PWV/GLS ratio and disease severity even after accounting for age, SBP, and SV (p=0.047). Conclusions Our findings suggest that the PWV/GLS ratio is reduced in cirrhotic patients with more severe disease. This association remains significant even after controlling for age, systolic blood pressure, and stroke volume, indicating that PWV/GLS ratio may serve as an early marker of cardiovascular dysfunction in patients with liver cirrhosis.Figure 1Table 1

Cardiac damage extent in patient with isolated severe aortic stenosis referred to surgical aortic valve replacement: is it reversible after surgery?

Abstract Background Aortic stenosis (AS) may lead to progressive and adverse cardiac remodeling. A recently-proposed staging classification regarding extravalvular cardiac damage in AS patients undergoing aortic valve intervention was shown to have significant prognosis implications. However, cardiac damage evolution and reversibility after intervention remain unknown. Aims to assess extravalvular cardiac damage evolution after surgical aortic valve replacement (SAVR) in patients with isolated severe AS. Methodology we performed a single-center, prospective cohort study enrolling consecutive patients with severe aortic stenosis undergoing SAVR. Those with previous cardiomyopathy or concomitant severe valve dysfunction beyond AS were excluded. All patients performed transthoracic echocardiogram (TTE) and cardiac magnetic resonance (CMR) within 3 months before SAVR as well as at the 3rd to 6th post-operative month. Patients were classified according to the extent of cardiac damage into 4 groups: stage 0: no damage; stage 1: left ventricle (LV) hypertrophy (indexed LV mass &amp;gt;95 g/m2 [women] or &amp;gt;115 g/m2 [men]), LV diastolic (E/e′ &amp;gt; 14) or systolic (ejection fraction &amp;lt;50%) dysfunction; stage 2: dilated left atrium (&amp;gt;34mL/m2) or atrial fibrillation; stage 3: pulmonary hypertension (systolic pulmonary artery pressure ≥60mmHg); stage 4: significant right ventricle (RV) dysfunction. Global longitudinal strain (GLS) was also assessed to further characterize the extent of LV damage – a GLS &amp;gt; -14.7% was considered abnormal. Due to the impact of on-pump cardiac surgery on RV systolic longitudinal function, RV ejection fraction assessed by CMR (&amp;lt;45%) was used to define significant post-operative RV dysfunction. Results A total of 67 patients were included (mean age 71 ± 8 years; 50% male; mean valvular transaortic gradient 60 ± 19 mmHg; mean indexed aortic valve area 0.4 ± 0.01 cm2/m2; mean LV ejection fraction by TTE 58 ± 9%). Overall, a significant number of patients still showed sign of structural cardiac damage after surgery – 14 vs. 10 on stage 1, 44 vs. 39 on stage 2, 1 vs. 1 on stage 3 and 4 vs. 4 on stage 4 after AVR- figure 1. However, a statistically significant improvement in the number of patients at stage 0 after surgery (4 vs. 11, paired McNemar test p=0.016) was observed, as well as a significant improvement in GLS (mean GLS pre and post AVR -14.8 ± 3.6% vs. -16.6 ± 3.3%, respectively; 45 vs. 21% patients with abnormal GLS before and after AVR, p=0.001). Conclusion Extravalvular cardiac damage is common in a selected cohort of severe AS and potentially reversible after SAVR. A significant improvement in GLS, although not a part of the previously established staging system, was observed after AVR. Whether or not these findings may correlate with long-term patient prognosis or if additional favorable cardiac remodeling is seen on a longer-term follow-up remains to be determined.

Longitudinal Strain Patterns in Stress (Takotsubo) Cardiomyopathy: Evidence of Global Myocardial Injury and Incomplete Recovery

BackgroundStress cardiomyopathy develops after abrupt sympathetic stimulation, likely from catecholamine-induced myocardial toxicity. The evolution of myocardial strain during and following an episode have not been previously characterized. We aimed to determine whether pre-existing contractile abnormalities may explain the observed regional dysfunction during an acute episode, and to investigate the persistence of strain abnormalities after clinical recovery. MethodsWe identified patients who were diagnosed with stress cardiomyopathy and had an echocardiogram performed prior to their episode, during their episode, and within 1 year after. Diagnosis was confirmed based on the absence of obstructive coronary lesions. Left ventricular (LV) longitudinal strain was calculated using speckle-tracking software and compared between baseline, episode, and follow-up echocardiograms. ResultsLV strain analysis was performed on 23 patients. LV ejection fraction was 64±8.7% at baseline, 45±12% during the episode, and 59±10% after a median follow-up of 46 days. LV global longitudinal strain was 24±4.7% at baseline, 11±4.9% during the episode, and 19±4.6% after follow-up. Mean ejection fraction (p<0.01) and global longitudinal strain (p<0.001) remained below baseline levels at follow-up. Longitudinal strain was reduced (<18%) in 80±23% of myocardial segments during an episode and 41±21% of myocardial segments at follow-up. During the acute episode, 35±6% of the abnormal segments were in the base, outside of the region of ballooning. ConclusionsOur findings suggests that stress cardiomyopathy is associated with global rather than regional myocardial injury, and that contractile abnormalities persist after clinical improvement. These findings challenge prior understanding of stress cardiomyopathy and may guide future pathophysiologic understanding of this complex disease.

Abstract 16308: Comparison of Myocardial Mechanics Post Mitral Valve Repair With Leaflet Preservation vs. Leaflet Resection: A Sub-Analysis of the Randomized CAMRA CardioLink-2 Trial

Introduction: Prior studies comparing leaflet resection vs. leaflet preservation for surgical repair of mitral regurgitation (MR) caused by prolapse focus predominantly on measurement of left ventricular ejection fraction. This study aims to evaluate subclinical differences in myocardial mechanics pre- mitral valve (MV) repair, immediately after, and 1-year post-repair, as well as compare differences between leaflet resection and preservation strategies. Methods: 104 patients were randomly assigned to the resection or preservation group for surgical treatment of posterior leaflet prolapse in the Canadian Mitral Research Alliance CardioLink-2 study. Speckle-tracking echocardiography was performed at baseline (pre-repair), immediately post-repair, and 1 year post-repair. Global longitudinal strain (GLS) was compared at the three timepoints, as well as between leaflet preservation and resection groups using descriptive statistics. Results: The mean age of the participants was 65 ± 10 years, and 83% were male. The mean GLS pre-MV repair was -19.6 ± 5.4, and did not differ between the leaflet resection and leaflet preservation groups. The mean GLS dropped to -12.8 ± 4.7 immediately post-repair (p= 0.001 compared to pre-repair). The GLS immediately post-repair was slightly lower in the leaflet resection vs. preservation group (-11.8 ± 4.9 vs. -14.2 ± 3.3, p=0.04). At 1 year post-repair, the mean GLS improved to -16 ± 4, but remained below pre-repair values (p=0.001 compared to immediate post-repair, p=0.03 compared to pre-repair values). At 1-year follow-up, there were no differences in GLS between the leaflet resection and preservation groups. Conclusion: The leaflet preservation and resection techniques for surgical repair of MR have similar effects on myocardial mechanics 1-year post-repair. MV repair is associated with an immediate reduction in myocardial strain, with only partial recovery in the first year post-MV repair. Further studies are needed to determine whether myocardial strain continues to improve beyond the first year post-repair to baseline levels.

Speckle tracking echocardiography-derived left ventricular global longitudinal strain in ex-thalassaemics.

Long term survivors of haematopoietic stem cell transplantation (HSCT) for β-thalassemia major are designated "ex-thalassaemics". Whether ex-thalassaemics continue to harbour residual myocardial dysfunction and thereby stand the risk of heart failure-related morbidity and mortality is unknown. The aim of this study was to assess the prevalence and predictors of subclinical left ventricular (LV) dysfunction in an apparently normal ex-thalassaemic population. We conducted a single centre cross-sectional study among 62 ex-thalassaemic patients, who had undergone HSCT for β-thalassaemia major at our centre. The primary outcome variable was LV systolic dysfunction, as assessed by 1) LV global longitudinal strain (GLS) derived by 2D speckle tracking echocardiography and 2) LV ejection fraction (EF) derived by 2D Simpsons Biplane method. Among the 62 patients included in the study, 7 [11.3%] were found to have LV systolic dysfunction, all of which were subclinical. Of these, 4 [6.5%] had abnormal GLS and LVEF, 2 [3.2%] had abnormal GLS with normal LVEF, and 1 [1.6%] had abnormal LVEF with low normal mean GLS. There were no statistically significant predictors of LV dysfunction in this cohort. There was a high prevalence of subclinical myocardial dysfunction in the ex-thalassaemic population reiterating the need for close follow up of these patients. 2D Speckle tracking echocardiography-derived LV global longitudinal strain is an effective tool in detecting subclinical myocardial dysfunction in this cohort.