Strain Rate Imaging Research Articles

Prognostic value of right atrial strain in patients with isolated severe tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Moderate or severe isolated Tricuspid regurgitation (TR) can lead to right ventricular (RV) dysfunction and adverse outcome. Only few patients with significant TR undergo intervention, and the optimal timing for intervention remains elusive. The right atrium (RA) is the receiving chamber of the tricuspid regurgitant volume. Changes in RA function has been described in chronic severe TR, specifically reduction in right atrial reservoir strain (RARS). The aim of this study was to evaluate the prognostic value of RA function in a cohort of patients with isolated severe TR. Materials and Methods Clinical, laboratory and echocardiographic data from 105 consecutive patients with isolated moderate-severe TR (grade≥+3) were analyzed. RARS was evaluated by two-dimensional speckle-tracking echocardiography using a semi-automated software (TOMTEC, Philips). The cohort was divided into two groups: RARS value above or below 10.9%, according to an optimal threshold obtained by a receiver operating characteristic (ROC) curve. Results and discussion A total of 105 patients (mean age 79Y, 59% female) were included. Compared with patients with higher RARS, patients with RARS≤10.9% had higher rate of atrial fibrillation and worse RV function. Lower RARS was also associated with larger inferior vena cava diameter, abnormal cholestatic liver enzymes and higher rate of diuretic use. During a median follow-up period of 19 months (IQR:8–25), 39 (37%) patients died. Patients with RARS ≤10.9% had significantly lower survival rates compared with patients with RARS>10.9 (60% vs. 20%; P<.001). A multivariable analysis (including age, RV longitudinal strain, systolic pulmonary artery pressure and atrial fibrillation) showed that lower RARS was independently associated with higher all-cause mortality (OR 2.47, 95%CI [1.07–6.06]; P=0.03). Conclusions Impaired RA function assessed by echocardiographic RA reservoir strain is independently associated with all-cause mortality in patients with isolated severe TR. Serial measurement of RARS can potentially aid in optimizing timing for intervention in patients with TR.

Association of strain echocardiography with cardiovascular outcomes in patients with heart failure with preserved ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Speckle Tracking Echocardiography (STE) with measurement of Left Ventricular Global Longitudinal Strain (LVGLS) is an important predictor of morbidity and mortality in Heart Failure with Reduced Ejection Fraction (HFrEF), but its prognostic importance in Heart Failure with Preserved Ejection Fraction (HFpEF) is less clear. The purpose of this meta-analysis is to analyze the association between LVGLS and Major Adverse Cardiac Events (MACE) in HFpEF. Methods A literature search was conducted for studies reporting on STE in patients with HFpEF and the association between LVGLS and MACE. The databases queried were Pubmed, Embase, and Web of Science. The search was not restricted to time or publication status. Results A total of 9 studies with 2,082 total patients met inclusion criteria. Among these, 5 studies with 944 HFpEF patients (300 with future MACE, 644 without future MACE) compared baseline mean LVGLS. Mean follow up duration was 28 months (ranging 12–48 months), mean age was 67 years old, 39.4% were male. LVGLS was significantly reduced in patients who eventually had MACE compared to those without MACE on follow-up (MD −2.09, 95% CI −2.17, −2.01, p < 0.01). 4 studies with 1,138 HFpEF patients (676 with impaired LVGLS below cutoff, 462 with unimpaired LVGLS above cutoff) compared all-cause mortality or heart failure hospitalization. Mean follow up was 35 months, mean age was 71 years old, 38.3% were male, and the average LVGLS cutoff was 14. Impaired LVGLS below cutoff was associated with significantly higher risk of MACE (OR 2.13, 95% CI 1.67, 2.72, p < 0.01). Subgroup analysis demonstrated that impaired LVGLS below cutoff was associated with significantly higher risk of both all-cause mortality (OR 2.11, 95% CI 1.40, 2.97, p < 0.01) and heart failure hospitalization (OR 2.16, 95% CI 1.53, 3.06, p < 0.01). Conclusions STE and measurement of LVGLS may represent a useful clinical tool in risk stratification of HFpEF patients at risk for future mortality and adverse cardiac events.

Prognostic value of strain echocardiography measurements in patients with non-ischemic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Background Speckle tracking echocardiography has been increasingly used in the evaluation of myocardial function. However, the association of reduced strain measurements with cardiovascular outcomes remains unclear in patients with nonischemic cardiomyopathy (NICM). Purpose The purpose of this meta-analysis is to evaluate the prognostic value of speckle tracking echocardiography in patients with NICM. Methods A literature search was conducted for studies reporting on the association of left ventricular global longitudinal strain (LVGLS), left ventricular global circumferential strain (LVGCS), left ventricular global radial strain (LVGRS), and right ventricular global longitudinal strain (RVGLS) on baseline echocardiography with cardiovascular outcomes on long term follow-up in patients with NICM. The primary endpoint was major adverse cardiac events (MACE). Secondary endpoints included left ventricular reverse remodeling (LVRR) and ventricular arrhythmias (VA). The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. Results A total of 17 studies with 2375 participants (640 with adverse outcomes and 1735 without adverse outcomes) met inclusion criteria. Mean follow-up duration was 33 months. Mean ejection fraction was 30%. Baseline LVGLS, LVGCS, LVGRS, and RVGLS were significantly lower in NICM patients who subsequently experienced MACE on follow-up compared to patients without MACE (SMD −0.57, 95% CI −0.82, −0.32; p<0.01; SMD −0.54, 95% CI −0.75, −0.33; p<0.01; SMD −0.51, 95% CI −0.7, −0.32; p<0.01; SMD −0.46, 95% CI −0.75, −0.18; p<0.01). Baseline LVGLS was significantly higher in patients who experienced LVRR on follow-up compared to patients without LVRR (SMD 0.36, 95% CI 0.05–0.68; p = 0.02). Baseline LVGLS was significantly lower in NICM patients who experienced VA on follow-up (SMD −1.19, 95% CI −2.12, −0.26, p = 0.01). Conclusions Speckle tracking echocardiography may represent a useful clinical tool for risk stratification of NICM patients at risk for adverse cardiac events and poor treatment response.

Three-dimensional left ventricular strain analysis in Fabry disease: correlation with heart failure severity, myocardial scar and impact on long-term prognosis

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Charles University Research program “Cooperatio - Cardiovascular Science”. Introduction Fabry disease (FD) is a multisystemic lysosomal storage disorder caused by a defect in the gene coding the alpha-galactosidase A enzyme. Cardiac involvement typically manifests as a phenocopy of hypertrophic cardiomyopathy. Three-dimensional echocardiography can analyze myocardial deformation of the left ventricle (LV) in both circumferential and longitudinal dimensions. Purpose We assessed 3D echocardiographic strain of the LV in FD patients in relation to heart failure severity, the presence of cardiovascular magnetic resonance (CMR) scar and long-term prognosis. Methods 3D echocardiography was feasible in 75/99 FD patients. Baseline natriuretic peptides and CMR late gadolinium enhancement were assessed together with long term outcome (death, heart failure decompensation or cardiovascular hospitalization) over a median follow-up of 3.1 years. Results The average age was 47 ± 14 years, 44% of patients were male and 51% expressed hypertrophy or concentric remodeling of the LV. Average LV ejection fraction (EF) was 65 ± 6%. A stronger correlation was observed for NTproBNP levels with 3D global longitudinal strain (GLS) (r = 0.49, p < 0.0001) than with 3D global circumferential strain (GCS) (r = 0.38, p < 0.001). LV EF by 3D weakly correlated with NTproBNP levels (r = 0.25, p = 0.036). Individuals with posterolateral scar on CMR had significantly lower local 3D circumferential strain at corresponding region (p = 0.008). 3D GLS was associated with long-term outcome (adjusted HR 0.84, CI 0.75, 0.95, p = 0.004) while 3D GCS was not (HR 0.94, CI 0.85 – 1.10, p = 0.284). 3D LV EF was not associated with long-term outcome. Conclusion 3D GLS is strongly associated with both heart failure severity measured as natriuretic peptides levels and long-term prognosis. Only borderline association of 3D GCS with HF severity and no association with prognosis was observed. Decreased local 3D CS reflects typical posterolateral scarring in FD. Where feasible, 3D-strain echocardiography can be used for comprehensive mechanical assessment of the LV in FD patients.

Prognostic value of right ventricular function in patients with severe tricuspid regurgitation undergoing tricuspid valve intervention

Abstract Funding Acknowledgements Type of funding sources: None. Background Indications and optimal timing of intervention for severe tricuspid regurgitation (TR) remain controversial due to insufficient evidence. Right ventricular (RV) function assessment, a key factor of preoperative evaluation, remains challenging due to limitations of conventional echocardiographic indexes, particularly with concomitant severe TR. Right ventricular free wall longitudinal strain (RVFWLS) is able to evaluate intrinsic systolic function and to identify RV dysfunction at early stage compared to conventional echocardiographic indices. Purpose to analyze the prognostic implications of pre-operative RV dysfunction, evaluated through conventional and speckle-tracking echocardiography, in patients with severe TR undergoing tricuspid valve intervention. Methods In this single-center retrospective study, we enrolled consecutive patients with severe TR who underwent surgical or transcatheter tricuspid valve intervention (TTVI) between November 2016 and July 2021. The primary endpoint was all-cause mortality. For a secondary exploratory analysis, to compare outcomes of operated versus conservatively treated patients, we enrolled consecutive patients with severe TR who underwent echocardiographic evaluation in the same time period and who undergo conservative management. Results Study population included 100 patients: 78 patients underwent isolated TV surgical intervention and 22 TTVI. ROC curve analysis showed RVFWLS as the best echocardiographic parameter to predict all-cause mortality (AUC: 0.726, IC 0.57–0.88 P = 0.006). Estimated 4-years survival was significantly lower in patients with RV dysfunction (defined as an absolute value of RVFWLS ≤ 21%, cutoff derived from ROC analysis with sensitivity 60% and specificity 87%) compared to patients with normal RV function: 70.0% vs 93.9% p = 0.002 (Figure 1). Independent prognostic role of RVFWLS was confirmed at multivariable analysis adjusted for significative clinical and echocardiographic variables (OR 0.88, 95% CI 0.80–0.98; P = 0.016). At secondary exploratory analysis, patients treated conservatively had a worst estimated 4-year survival compared to operated patients (59.6% vs 84.0%, p = 0.001). Stratifying this population according to the presence of RV dysfunction, in the group with lower RVFWLS values there were no significative differences in overall survival between operated and conservatively-treated patients (Figure 2). Conclusions Preoperative RV dysfunction defined by echocardiographic strain analysis is independently associated with outcomes after TV intervention. RVFWLS could be useful for indication and timing of intervention for severe TR.

Trends in the clinical use of speckle tracking strain imaging: insights from a worldwide EACVI survey

Abstract Funding Acknowledgements Type of funding sources: None. Background Strain imaging has emerged as a sensitive measure of myocardial function and an early marker of myocardial involvement in different diseases. Purpose and Methods To evaluate the use of speckle tracking strain imaging in clinical practice, an open access online survey was conducted by the EACVI according to published criteria(1). The survey explored the feasibility, appropriate use and clinical implementation of echocardiographic strain imaging. Health care providers in cardiology from all levels of health care centres were encouraged to participate in this global survey. Results In all, 431 respondents from 77 countries participated. Most respondents worked within the cardiology and cardiothoracic departments (95%). Participants from tertiary centres (46%), and private clinics or public hospitals (54%) were also represented. Fifty eight percent of the participants were senior experienced echocardiographers, 40% were trained in strain imaging at an expert centre, 37% via research in strain imaging, 33% via the EACVI e-learning platform or hands-on courses and 29% via national teaching courses. Only 16% reported having no training. Despite almost universal access (98%) to speckle tracking strain quantification, only 39% performed and reported strain results frequently (more than half of their reports) and the majority (61%) reported it either infrequently (25–50% reports) or very rarely (<25% reports). The most common reason (65%) for not using the technology despite having access to it was related to post-processing difficulty. Strain quantification was used mainly to assess the left ventricle (LV)(99%), less frequently the right ventricle (RV)(57%), the left atrium (46%) and rarely the right atrium (8%). Eighty-six percent of users assessed LV global longitudinal strain (GLS) from the 3 apical views, with 88% preferring automated algorithms with manual correction to define the regions of interest. The most common clinical conditions where LV strain assessment was considered useful clinically included chemotoxicity (88%) amyloidosis (87%), hypertrophic cardiomyopathy (73%), heart failure with preserved ejection fraction (68%), ischaemic heart disease (63%) and the early phase of dilated cardiomyopathy (59%, Figure 1). Just over half of the respondents quantified RV strain in pulmonary hypertension. Finally, the key areas of improvements identified by the respondents included higher reproducibility of the results (48%) and the ability to readily compare strain values across vendors (42%) (Figure 2). Conclusion Strain imaging is now widely available and many imagers have been trained in its use. Although strain imaging is used in line with the scientific evidence, it is still underutilised in clinical practice. Improved reproducibility and interchangeability of results across vendors may increase the uptake of this technique.

Three-dimensional echocardiographic left ventricular strain analysis in Fabry disease: correlation with heart failure severity, myocardial scar, and impact on long-term prognosis.

Fabry disease (FD) is a multisystemic lysosomal storage disorder caused by a defect in the alpha-galactosidase A gene that manifests as a phenocopy of hypertrophic cardiomyopathy. We assessed the echocardiographic 3D left ventricular (LV) strain of patients with FD in relation to heart failure severity using natriuretic peptides, the presence of a cardiovascular magnetic resonance (CMR) late gadolinium enhancement scar, and long-term prognosis. 3D echocardiography was feasible in 75/99 patients with FD [aged 47 ± 14 years, 44% males, LV ejection fraction (EF) 65 ± 6% and 51% with hypertrophy or concentric remodelling of the LV]. Long-term prognosis (death, heart failure decompensation, or cardiovascular hospitalization) was assessed over a median follow-up of 3.1 years. A stronger correlation was observed for N-terminal pro-brain natriuretic peptide levels with 3D LV global longitudinal strain (GLS, r = -0.49, P < 0.0001) than with 3D LV global circumferential strain (GCS, r = -0.38, P < 0.001) or 3D LVEF (r = -0.25, P = 0.036). Individuals with posterolateral scar on CMR had lower posterolateral 3D circumferential strain (CS; P = 0.009). 3D LV-GLS was associated with long-term prognosis [adjusted hazard ratio 0.85 (confidence interval 0.75-0.95), P = 0.004], while 3D LV-GCS and 3D LVEF were not (P = 0.284 and P = 0.324). 3D LV-GLS is associated with both heart failure severity measured by natriuretic peptide levels and long-term prognosis. Decreased posterolateral 3D CS reflects typical posterolateral scarring in FD. Where feasible, 3D-strain echocardiography can be used for a comprehensive mechanical assessment of the LV in patients with FD.

Early assessment of cardiomyopathy in Duchenne patients by means of longitudinal strain echocardiography.

The diagnosis of Duchenne-linked cardiomyopathy may be challenging. Conventional echocardiographic measurements typically show deterioration beyond the second decade. Global longitudinal strain has been proposed as an earlier marker than left ventricular ejection fraction. A prospective, observational, cross-sectional, case-control study was carried out. Both Duchenne patients and control subjects underwent transthoracic echocardiogram in order to assess left ventricle function. Bayesian linear regression was the main tool for inference. Age effects were parameterised by means of a spline function because of its simplicity to characterise continuous variables and smooth contributions. The posterior distribution of the marginal age effects was used to assess the earliest age of deterioration of each marker. Sixteen Duchenne patients and twenty-two healthy male subjects were enrolled. On overage, cardiac function measures were found for ejection fraction and longitudinal strain among different groups. Age effects on global longitudinal strain are more reliably found at ages of 6 and above, while ejection fraction starts to deteriorate at an older age. Progressive left ventricular dysfunction in Duchenne patients is one of the key issues and starts at an early age with subtle symptoms. This cross-sectional study provides supporting evidence that global longitudinal strain is an earlier marker of disease progression than ejection fraction in Duchenne patients.

ASSESSMENT OF LEFT ATRIAL FUNCTION IN INDIVIDUALS WITH RESISTANT HYPERTENSION BY ADVANCED ECHOCARDIOGRAPHY

Objective: Resistant hypertension is a challenging phenotype within the hypertension (HTN) spectrum, requiring careful assessment and follow-up. Evaluation of left atrial function may be clinically informative, but is commonly neglected. Strain and three-dimensional echocardiography (3D ECHO) may be useful complementary tools for assessing atrial function among hypertensive patients. Design and method: 96 eligible adult patients were categorized into three groups: resistant hypertensive (RH), controlled hypertensive (CH), and normotensive (N), and underwent advanced echocardiography techniques to identify specific morphofunctional changes in the left atrium (LA) throughout different HTN phenotypes. Results: As shown in Figure 1, LA reservoir strain was significantly lower among RH than N and CH patients (p &lt; 0.001). Accordingly, LA conduit strain showed a gradient through the groups: higher among N, followed by CH and RH (p = 0.015). LA contraction strain was higher among CH than N and RH (p = 0.02). Maximum indexed, pre-A, and minimum atrial volumes obtained by 3D ECHO showed differences between N and the others (p &lt; 0.001), but not between CH and RH. N showed higher fraction of passive emptying of the LA than the others (p = 0.02), with no difference between CH and RH. Total emptying of the LA only differed between the extreme groups N and RH, being lower in the latter, while active emptying of the LA showed no difference between the groups (p = 0.82). Conclusions: Advanced echocardiography measures, especially LA strain, proved to be early markers of atrial myocardial damage in both RH and CH. We demonstrated for the first time that morphofunctional changes in the LA due to resistant hypertension may occur concomitantly and even independently from those observed in the left ventricle.

SAFETY AND FEASIBILITY OF HYPOXIA EXPOSURE IN PATIENTS WITH PRIOR MYOCARDIAL INFARCTION

Objective: In mice, normobaric hypoxia exposure corresponding to 8,000 m altitude after myocardial infarction reactivated cardiomyocyte proliferation and improved left ventricular ejection fraction (LVEF). Translating these findings to patients might be limited by hypoxia-induced pulmonary hypertension and myocardial ischemia. Design and method: We conducted a feasibility and safety study at the: envihab facility in 4 patients who had experienced myocardial infarction with fully revascularized LAD-stenosis as culprit lesion 37-104 months prior study entry. Their peak VO2 ranged from 32 - 43 ml/kg/min. The study comprised a two-days baseline, 19 days normobaric hypoxia, and two-days recovery. We gradually lowered atmospheric oxygen to 0.118 FIO2, which is equivalent to 4500 m, and maintained that level for 4.5 days. We obtained transthoracic echocardiography, magnetic resonance imaging, and determined Troponin I, NTproBNP at baseline, during 0.118 FIO2, and recovery. Results: Except for symptoms of acute mountain sickness, hypoxia was well tolerated as severe adverse reactions did not occur and pulmonary hypertension rapidly abated during recovery. During the last 10 days of hypoxia, peripheral oxygen saturation was continuously &lt;90%. LVEF was 50.7±11.0 % (mean±SD) baseline, 57.6±11.2% at 0.118 FIO2, and 57.3±11.2% during recovery. Furthermore, echocardiographic LV global longitudinal strain was -15.28±5.4% at baseline and -17.28±7.56 % in recovery. Magnetic resonance imaging confirmed these findings. NTproBNP diminished (baseline: 203±209 pg/ml, 0.118 FIO2: 122±101/pg/ml, recovery: 85±66 pg/ml) and Troponin I concentrations remained in the reference range throughout the study. In the patient with the largest LVEF increase following hypoxia, an additional 12 weeks follow-up measurement showed stable improvements in LVEF (baseline: 36%, recovery: 48%, 12 weeks follow-up: 47%), left ventricular strain, NTproBNP, and exertional dyspnea. Conclusions: Our study provides evidence regarding safety and potential of hypoxia exposure after myocardial infarction and lays the foundation for future studies assessing hypoxia-influences on cardiac regeneration. However, our findings have to be interpreted with caution given the small sample size and the selected patient population.

Left atrial strain is associated with atrial fibrillation recurrence after catheter ablation: Data from the ISOLATION registry

Abstract Funding Acknowledgements Type of funding sources: None. Background Catheter ablation (CA) has been established as an effective therapeutic option to achieve rhythm control in patients with atrial fibrillation (AF). However, AF recurrence occurs in approximately 45% of the patients undergoing CA. The association between AF recurrence after CA and left atrial (LA) strain, which is a surrogate marker of LA mechanical dysfunction already appearing before the enlargement of the LA, remains less clear. Aim The purpose of this study was to evaluate the association between LA function assessed by strain echocardiography and AF recurrence after CA. Methods This sub-study of ISOLATION (NCT04342312), involved consecutive patients with paroxysmal or persistent AF scheduled for first cryoballoon or radiofrequency CA. Clinical characteristics and echocardiography examination were collected at baseline visit before CA. Patients were followed for 12 months. Follow-up consisted of outpatient visits and heart rhythm monitoring (48 day Holter, 12-lead electrocardiogram, 7 day photoplethysmography-based rhythm app) at 3, 6, and 12 months. Results We analyzed 312 patients (median age 65, 36% women). More than half (52%; n=162) underwent radiofrequency CA and 84 (27 %) had AF recurrence within one year follow-up. No statistically significant differences in baseline characteristic were observed between patients with and without recurrent AF, expect higher prevalence of persistent AF prior to CA in patients with recurrence of AF (75% vs. 46%, p&amp;lt;0.001). LA reservoir strain (22 [14-33]% vs 29 [19-37]%, p=0.002), LA conduit strain (15 [9.6-19]% vs 17 [12-22]%, p=0.038) and LA contraction strain (7.5 [2.2-15]% vs 12 [5.8-16]%, p&amp;lt;0.001), were significantly lower, and mildly-to-severe LA dilatation (≥39mm in women and ≥41–in men) was more frequently observed (77% vs 64%, p=0.039) in patients with (vs without) recurrence of AF. Based on multiple logistic regression, LA contraction strain was an independent predictor for AF recurrence (OR 0.94, 95%CI 0.90-0.98) in all study group. LA contraction strain of ≤9.4% had a sensitivity of 61% and specificity of 58% for recurrence of AF after CA. In the group with normal LA (&amp;lt;39mm in women and &amp;lt;41–in men), LA reservoir strain was significantly associated with the risk for recurrence of AF (OR 0.94 [0.90–0.99]). Overall, LA reservoir strain of ≤29% in this group had a negative predictive value of 90% and sensitivity of 74% for recurrence of AF after CA (Figure 1). AF type was not predictive in this subgroup. In the group with mildly-to-severe enlarged LA, AF type remained strongly predictive for recurrence of AF (OR 3.38[1.82-6.25]), whereas LA strains did not. Conclusions LA function assessed by LA strain is associated with AF recurrence after CA, even in patients with non-dilated LA. Whether integration of results derived from systematic preprocedural LA strain analysis into patients’ selection strategies may help to identify patients profiting from CA required further study.

Right ventricle adaptation to high intensity training assessed by cardiac magnetic resonance in olympic athletes

Abstract Funding Acknowledgements Type of funding sources: None. Background Several determinants affect cardiac remodelling in athletes, including sport discipline, body size and sex. Recently, interest in myocardial deformation (MD) imaging as reliable functional index is growing. Available MD data are usually derived by echocardiography and mostly related to the evaluation of the left ventricle. Data on right ventricle (RV) deformation assessed by CMR are lacking and, currently, specific reference values in athletes have not been explored. Purpose To assess RV deformation in a cohort of Olympic athletes and to evaluate possible inter-individual differences related to type of sport and sex. Methods A cohort of Olympic athletes with unremarkable cardiovascular pre-participation screening tests was enrolled. A group of sedentary individuals was also enrolled for comparison. All subjects underwent CMR without contrast. Cine-images were post-processed to assess RV volume, ejection fraction (EF) and MD by computing global longitudinal strain (GLS) by feature-tracking software. Athletes were divided in subgroups based on sex, ESC sport classification and RV enlargement (RVEDV/LVEDV&amp;gt;1 or ≤1). Results 265 Olympic athletes (15% skill, 19% power, 25% mixed, 41% endurance; 58% male) and 21 sedentary controls were enrolled. Endurance athletes showed the greatest RV remodeling in terms of volumes (Table). No differences in RV-EF were found comparing athletes of different sport categories, but between athletes and sedentary controls. Median value of RV-GLS of the whole athletic cohort was -23 (-21, -25). There were no significant differences among the different sport disciplines other than endurance vs. sedentary controls for RV-GLS. Female athletes showed higher values of RV-GLS when compared with males. When examined with regard to presence of RV enlargement, no differences were observed (Figure). Conclusion Endurance athletes showed the greatest right ventricle remodelling in terms of RV volumes and function. Specifically, they showed the highest values of RV volumes and the lowest values of RV-GLS of the entire athlete’s population, but still within the normal range. Female athletes had higher RV-GLS values when compared with males. No difference was observed between athletes with dilated RV compared to non-dilated RV.

Correction of dyssynchrony by conduction system pacing: results of LEVEL-AT trial

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Catalan Society of Cardiology; Asociación del Ritmo Cardiaco (Spanish Society of Cardiology). Background Correction of dyssynchrony measured with echo strain, in conduction system pacing (CSP) vs biventricular pacing (BIVP) has not been reported. Objectives Our purpose was to compare echocardiographic dyssynchrony correction and strain improvement during follow-up between CSP and BIVP. Methods A treatment received analysis was performed in patients (n=29 CSP; BIVP 40). Patients were evaluated at baseline (ON and OFF programming) and at 6 and 12 months. All echocardiograms were completed by operators blinded to the type of device implanted. Intraventricular (septal flash), interventricular (difference between left and right ventricular outflow times), and auriculoventricular (diastolic filling time) dyssynchrony, as well as strain parameters (septal rebound, global longitudinal strain (GLS), and Risum pattern (typical left bundle branch block contraction pattern)) were analyzed. Results 32% (22/69) were women; baseline LVEF was 27.5% (7% SD) and left ventricular end-systolic volume (LVESV) 138ml (77ml SD) without differences between groups. At the 12-month follow-up, there were no differences in CSP vs. BIVP in LVEF (45.8% (10% SD) vs. 42.7% (12% SD), p=0.25) and LVESV (81.5 ml (41 ml SD) vs. 101.7 ml (56 ml SD), p=0.08). Longitudinal analyses showed that the improvement of all echocardiographic dyssynchrony parameters over time was similar between groups (p&amp;lt;0.001) (Table 1 and Fig 1A). GLS acute correction significantly correlated with LVEF and LVESV at the 12-month follow-up (Fig 1B). Conclusions CSP and BIVP provided a similar dyssynchrony and strain correction over time. Acute strain correction predicted ventricular remodeling at 12 months follow-up.

Left atrial strain significance in prediction of early atrial fibrillation recurrence after cardioversion and ablation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The fibrosis of the LA, which is characteristic of AF, causes mechanical dysfunction of the LA and may also be present in patients without LA enlargement. LA strain represents a surrogate marker of this mechanical dysfunction. Early detection of LA dysfunction may be crucial in identifying patients who are more likely to experience AF recurrence following cardioversion and ablation. Before cardioversion and ablation, the probability of AF recurrence might be predicted, which could lead to better patient selection, an individualized therapeutic strategy with reduced risk and focused follow-up. Purpose The aim of this study was to evaluate the additional predictive value of LA function assessed by using strain echocardiography for early AF recurrence after cardioversion and ablation. Methods 94 patients diagnosed with symptomatic persistent atrial fibrillation (EHRA symptom score ≥3 (mean age 59.4 ± 12.2 years, 58% male, 42%female), preserved LV ejection fraction were prospectively analyzed. In 39 (41,5%) patients pharmacological cardioversion was done after saturation with antiarhythmic drugs,in 27 (28,7%) patients planed electrical cardioversion was done after medical saturation with antiarrhythmic drugs and failure of pharmacological cardioversion, and in 28 (29,8%) patients planed RF ablation was performed. Complete echocardiography evaluation including strain and volume index LA was performed before cardioversion and ablation. The rhythm evaluation was done in the first month after cardioversion and RF ablation (35±5 days). The primary endpoint was persistent AF recurrence. Results 29 (30,8%) patients had AF recurrence in the overall study population, independently of duration of AF or method of rhythm control. Peak atrial longitudinal strain (PALS) ≤15% had the highest incremental predictive value for AF recurrence (HR =8.42, 95% CI: 3.17–25.12, p &amp;lt; 0.001). In patients with non-dilated LA, PALS≤15% remained an independent predictor of AF recurrence (HR = 5.32, 95% CI: 1.77–17.42, p = 0.005). Conclusion This study shown that, in addition to LA dilatation, LA function as determined by PALS can provide a prognostic value for early AF recurrence after cardioversion or ablation. PALS also predicted AF recurrence in patients with nondilated LA. These findings highlight the additional prognostic usefulness of LA strain and recommend its implementation in the systematic assessment of AF patients prior to the choice of rhythm/rate control.

Influence of hypertension on systolic and diastolic left ventricular function including segmental strain and strain rate.

Left ventricular (LV) systolic and diastolic functions are important cardiovascular risk predictors in patients with hypertension. However, data on segmental, layer-specific strain, and diastolic strain rates in these patients are limited. The aim of this study was to investigate segmental two-dimensional strain rate imaging (SRI)-derived parameters to characterize LV systolic and diastolic function in hypertensive individuals compared with that in normotensive individuals. The study sample comprised 1194 participants from the population-based Know Your Heart study in Arkhangelsk and Novosibirsk, Russia, and 1013 individuals from the Seventh Tromsø Study in Norway. The study population was divided into four subgroups: (A) healthy individuals with normal blood pressure (BP), (B) individuals on antihypertensive medication with normal BP, (C) individuals with systolic BP 140-159mmHg and/or diastolic BP>90mm HG, and (D) individuals with systolic BP ≥160mmHg. In addition to conventional echocardiographic parameters, global and segmental layer-specific strains and strain rates in early diastole and atrial contraction (SR E, SR A) were extracted. The strain and SR (S/SR) analysis included only segments without strain curve artifacts. With increasing BP, the systolic and diastolic global and segmental S/SR gradually decreased. SR E, a marker of impaired relaxation, showed the most distinctive differences between the groups. In normotensive controls and the three hypertension groups, all segmental parameters displayed apico-basal gradients, with the lowest S/SR in the basal septal and highest in apical segments. Only SR A did not differ between the segmental groups but increased gradually with increasing BP. End-systolic strain showed incremental epi-towards endocardial gradients, irrespective of the study group. Arterial hypertension reduces global and segmental systolic and diastolic left ventricular S/SR parameters. Impaired relaxation determined by SR E is the dominant factor of diastolic dysfunction, whereas end-diastolic compliance (by SR A) does not seem to be influenced by different degrees of hypertension. Segmental strain, SR E and SR A provide new insights into the LV cardio mechanics in hypertensive hearts.

Echocardiographic Strain to Predict Need for Transplant or Mortality in Fontan Patients with Hypoplastic Left Heart Syndrome.

Despite recent advances, hypoplastic left heart syndrome (HLHS) patients subsequent to the Fontan still have significant morbidity and mortality. Some require heart transplant due to systemic ventricular dysfunction. Limited data exist on timing for transplant referral. This study aims to correlate systemic ventricular strain by echocardiography to transplant-free survival. HLHS patients who had Fontan palliation at our institution were included. Patients were divided into: 1) Required transplant or experienced mortality (composite end point); 2) Did not require transplant or survived. For those who experienced the composite endpoint, the last echocardiogram prior to the composite outcome was used, while for those who did not experience the composite endpoint the last echocardiogram obtained was used. Several qualitative and quantitative parameters were analyzed with focus on strain parameters. Ninety-five patients with HLHS Fontan palliation were identified. Sixty-six had adequate images and eight (12%) experienced transplant or mortality. These patients had greater myocardial performance index by flow Doppler (0.72 versus 0.53, p = 0.01), higher systolic/diastolic duration ratio (1.51 versus 1.13, p = 0.02), lower fractional area change (17.65 versus 33.99, p < 0.01), lower global longitudinal strain (GLS) (-8.63 versus -17.99, p < 0.01), lower global longitudinal strain rate (GLSR) (-0.51 versus -0.93, p < 0.01), lower global circumferential strain (GCS) (-6.68 versus -18.25, p < 0.01), and lower (GCSR) global circumferential strain rate (-0.45 versus -1.01, p < 0.01). ROC analysis demonstrated predictive value for GLS -7.6 (71% sensitive, 97% specific, AUC 81%), GLSR -0.58 (71% sensitive, 88% specific, AUC 82%), GCS -10.0 (86% sensitive, 91% specific, AUC 82%), and GCSR -0.85 (100% sensitive, 71% specific, AUC 90%). GLS and GCS can help predict transplant-free survival in patients with hypoplastic left heart syndrome having undergone Fontan palliation. Higher strain values (closer to zero) may be a helpful tool in determining when transplant evaluation is warranted in these patients.

Global longitudinal strain at 3 months after therapy can predict late cardiotoxicity in breast cancer.

Cancer therapy-related cardiovascular toxicity (CTR-CVT) is a major contributor to poor prognosis in breast cancer (BC) patients undergoing chemotherapy. Left ventricular global longitudinal strain (LV GLS) has predictive value for CTR-CVT, while few researchers take into account late-onset CTR-CVT. This study sought to provide a guide for the prediction of late-onset CTR-CVT in primary BC over the 2 years follow-up via strain and contrast-enhanced echocardiography. Anthracycline and anthracycline + targeted medication groups were created from 111 patients with stage I-III primary BC who were prospectively included. The left ventricular diastolic function, LV global long-axis strain (GLS); left ventricular ejection fraction by contrast-enhanced echocardiography (c-LVEF), and electrocardiograms were collected at baseline, 3, 6, 12, and 24 months after the start of cancer treatment. The high-sensitivity troponin-T and NT-pro BNP at baseline and 3 months after chemotherapy were measured. (1) LV GLS decreased in BC patients over time. (2) After 12 months' follow-up, the LV GLS in the anthracycline+ targeted group was lower than in the anthracycline group. After 24 months' follow-up, the GLS and c-LVEF in the anthracycline + targeted group declined while the E/e' increased. (3) Decreased LVEF (56%) and arrhythmia (38%) are the common causes of CTR-CVT. Lower LVEF was a major factor in late-onset CTR-CVT. (4) Combination of LV GLS and c-LVEF at 3 months were used as predictors for CTR-CVT and exhibited a higher AUC than either one alone (AUC = 0.929, 95% CI: 0.863-0.970). LV GLS at 3 months can predict the late-onset CTR-CVT (AUC = 0.745, p < 0.001), and the cut-off is 20.32%. As time went on, the systolic and diastolic dysfunction of BC patients get worsened. The combination of LV GLS and c-LVEF is better in the prediction of CTR-CVT. Only the LV GLS at 3 months can predict the late-onset CTR-CVT.

Global longitudinal strain analysis application for prediction of left ventricular dysfunction in breast cancer under sequential therapy

Transthoracic echocardiography (TEE) plays a major role in the baseline assessment and follow-up of cardio-oncology patients. While left ventricular ejection fraction (LVEF) still has its place in cardiac monitoring, new modalities like myocardial deformation imaging with speckle tracking strain analysis has been validated for early detection of subclinical LV dysfunction. We conducted a longitudinal prospective study including all the breast cancer patients treated with anthracyclines and trastuzumab from January 2017 to March 2022. All patients underwent baseline TEE, and were followed-up every 3 months after that, with GLS assessment whenever it was possible. We evaluated the frequency of GLS drop and its correlation to LVEF reduction. Out of a total of 1583 patients, 677 had available LV GLS assessment. Among them, 83 (12.3%) decreased their GLS during follow-up, 67% of which had no concomitant drop in LVEF. In these patients, impaired LV GLS values were noted at 3 months after chemotherapy and at 6, and 12 months compared with baseline (−22.3 ± 1.8% at baseline, −18.1 ± 2.3% at 3 months, −17.7 ± 2.1% at 6 months, and −16.9 ± 2.1% at 12 months). LV GLS at 3 months was strongly correlated to cardiotoxicity (LVEF < 50%) at 12 months (P < 0.05). A cut-off LV GLS value of −16.9% was then retained to identify LVEF alteration at the end of follow-up. Finally, our study found that GLS at 3 months and 6 months had a prognostic value, since the lower GLS was, the poorest the patient's clinical outcome was, with further development of symptomatic heart failure. Our study demonstrates that myocardial deformation analysis enables detection of early and progressive subclinical cardiac dysfunction, and GLS at 3 months was positively correlated to LVEF drop at 12 months.

Optimizing Arteriovenous Fistula Care in Kidney Transplant Recipients: A Complex Task.

Optimizing Arteriovenous Fistula Care in Kidney Transplant Recipients: A Complex Task.

Myocardial Deformation Imaging Using Echocardiography: A Disruptive Innovation

Myocardial Deformation Imaging Using Echocardiography: A Disruptive Innovation