Peak Global Strain Research Articles

Very early stage left ventricular endocardial dysfunction of patients with hypereosinophilic syndrome.

Cardiac involvement in hypereosinophilic syndrome (HES) patients entails significant morbidity and mortality. Left ventricular (LV) endocardial damage is important for the development of cardiac involvement in HES patients. However very early stage LV endocardial damage, such as prior to the first stage of an acute necrotic stage, remains uncertain. We studied 32 HES patients, all with normal conventional echocardiographic findings. Global radial and circumferential strain (GRS and GCS) were determined for each peak global strain curve from the mid-LV short-axis view, and global longitudinal strain (GLS) was averaged each peak global strain curve from standard apical views by means of two-dimensional speckle-tracking method. Thirty-one age-, gender-, LV ejection fraction-matched normal subjects were studied for comparison. GRS and GRS were similar for HES patients and normal controls, but GLS for HES patients was significantly lower than that for normal controls (16.2 ± 3.3 % vs 19.3 ± 2.9 %, p < 0.001). Furthermore, receiver operating characteristic curve analysis identified GLS ≤17.0 % as the best predictor of LV endocardial dysfunction with a sensitivity of 66 %, specificity of 78 %, and area under the curve of 0.781 (p = 0.0001). In conclusions, LV endocardial dysfunction pre-existed even in HES patients without apparent cardiac involvement. GLS as assessed with the two-dimensional speckle-tracking method is a promising tool for the better management of very early stage of HES patients.

Myocardial strain can be measured from first trimester fetal echocardiography using velocity vector imaging.

Alterations in myocardial strain can identify cardiac dysfunction and can be measured in the mid-gestation fetus. This study evaluates feasibility of strain measurements in early fetuses and establishes normal early fetal strain values. Normal fetal echocardiograms were reviewed for image adequacy for strain measurements in 12- to 14-week gestation fetuses. Two readers performed independent strain measurements. Values were compared with data from 40 normal second trimester fetuses. Strain evaluation could be attempted in 36 of 53 (68%) of first trimester echocardiograms (mean gestation 13.4 weeks); excessive motion or inadequate imaging planes precluded tracking analysis in the remainder. Strain measurements were feasible in 19 of 53 fetuses (36%, or 53% of those in whom tracking was attempted). Peak systolic global longitudinal left ventricular (RV) and right ventricular (LV) strain were similar (LV = -13.9 ± 5.7%, RV = -14.4 ± 5.5%, p = 0.7). RV strain was higher in first trimester fetuses compared with second trimester normals (p = 0.003). Intraobserver and interobserver agreement were moderate to strong for peak global LV and RV strain but poor for regional basal and mid-septal segments. Strain measurements were feasible in one-third of retrospectively assessed early fetal echocardiograms. Global longitudinal strain may be higher in earlier than mid-gestation fetuses. © 2016 John Wiley & Sons, Ltd.

Three-Dimensional Speckle Tracking Imaging for Assessing Left Atrial Function in Hypertensive Patients With Paroxysmal Atrial Fibrillation.

Hypertension (HT) is known to be the most prevalent risk factor for paroxysmal atrial fibrillation (PAF), however, its mechanisms have not been fully clarified. Our aim was to investigate the differences in left atrial (LA) function between healthy subjects, and hypertensive patients without PAF (HT-PAF(-)) and with PAF (HT-PAF(+)) using 3-dimensional (3D) speckle tracking imaging (STI). A total of 144 subjects were enrolled: 44 HT-PAF(+) (27 males; mean age 69 ± 10 years), 50 HT-PAF(-) (31 males; mean age 63 ± 11 years), and 50 controls (31 males; mean age 51 ± 14 years). All subjects were in sinus rhythm during the examination. LA volume, LA emptying fraction (LAEF), and LA wall strain were analyzed by 3D area tracking imaging. The maximal value of the global strain curve was defined as the peak global strain. The standard deviation of the time from the R-wave on the electrocardiogram to peak positive values of the segmental strain curves corrected by the R-R' interval in 6 mid LA segments (TP-SD) was calculated to assess LA dyssynchrony. LAEF and peak global strain were lower in HT-PAF(+) than in HT-PAF(-) (P < 0.01) and in the control (P < 0.01). Moreover, TP-SD was higher in HT-PAF(+) than in HT-PAF(-) (P < 0.05) and in the control (P < 0.01). Multivariate analysis revealed LA volume index, peak global strain, and TP-SD were independent determinants of HT-PAF(+). The presence of PAF is associated with diminished LA compliance and advanced mechanical dyssynchrony, as well as LA geometric deformation.

Left ventricular extracellular volume is associated with loss of exercise tolerance in children after Tetralogy of Fallot repair, but not with ventricular dysfunction

Background Diffuse myocardial fibrosis is associated with heart failure and ventricular dysfunction in many diseases. The aim of this study was to relate cardiac magnetic resonance (CMR) measures of diffuse myocardial fibrosis to cardiomechanics and exercise tolerance. Methods In 25 patients (age 13.6±2.5 years, 14 male) after surgical repair of Tetralogy of Fallot (ToF), T1 measurements were performed at a mid and basal ventricular level in short axis before and 15 minutes after the application of 0.1 mmol/kg gadobenate dimeglumine in the interventricular septum (IVS), left ventricular (LV) lateral wall, complete LV myocardium and diaphragmatic portion of the right ventricle (RV). The extracellular volume (ECV) was calculated from native and post-contrast T1 times of myocardium and blood and the hematocrit. Peak circumferential (LV), longitudinal (RV) and radial (RV) strain as well as the standard deviation of the time to peak strain of different segments (SDpeak) were measured using CMR feature tracking. The correlation of native T1 times and ECV with strain parameters was tested using Pearson’s coefficient. Native T1 times and ECV were correlated to exercise test results. Results The mean pulmonary regurgitation fraction was 36±16% and RV enddiastolic volumes were enlarged (EV-EDV 155±52 ml/m 2 ) with near-normal ejection fraction (RVEF 47±8%). LV measures were unremarkable. (Native T1 times and ECV did not differ significantly between different parts of the LV (native T1 time: IVS 1001±52 ms, LV lateral wall 978±55ms, entire LV 982±39ms; ECV: IVS 25±4%, LV lateral wall 23±5%, entire LV 24 ±3%) and between males and females, but were higher in the RV as compared to the LV (RV native T1 times 1021±69ms (vs. entire LV p<0.05), ECV 29±6% (vs. entire LV p<0.005)). There was no correlation of LV or RV native T1 times and ECV with peak segmental and global strain (global LV peak circumferential strain -22.2 ±4.6%, RV radial and longitudinal strain of the RV free wall 28.6±18.8% and -11.5±5%) nor with SDpeak (LV 49 ±30ms or 6.4±3.8% of RR-interval). Exercise test results, available in 11 patients, correlated negatively with ECV of the entire LV (V02 max. r=-0.62, p<0.05, Peak workload r=-0.63, p<0.05). Conclusions In patients after ToF repair, CMR measures of diffuse myocardial fibrosis are associated with exercise intolerance but not with LV or RV dysfunction.

Assessment of global left ventricular strain by three-dimensional speckle tracking imaging in patients with chronic renal failure

Objective To evaluate global left ventricular(LV) strain of patients with chronic renal failure(CRF) by three-dimensional speckle tracking imaging(3D-STI) and discuss the possible association between global peak strain and ejection fraction of LV.Methods The study includes 22 patients in the renal failure period,25 patients with uremia (pre-dialysis),and 20 healthy controls.Global peak longitudinal strain (GPSL),global peak area strain(GPSA) and global peak radial strain(GPSR) were measured by 3D-STI.Then possible association between GPSL,GPSA,GPSR and LVEF were discussed by the Pearson correlation analysis.Results The GPSL,GPSA,GPSR were statistically different in the control group,patients in the renal failure period and patients with uremia.There were significant differences between groups(F =13.28,4.65,4.68,P ＜ 0.01) as following,all of GPSL,GPSA,GPSR were lower in uremia group compared with control group [q =7.48(GPSL),4.19(GPSA),4.72(GPSR),P ＜0.01],GPSL was lower in renal failure group compared with control group [q =4.9 (GPSL),P ＜0.01].The Pearson correlation analysis revealed GPSL,GPSA,GPSR were strongly associated with LVEF(r =-0.679,-0.781,0.719,P ＜0.01).Conclusions In patients with CRF,the global peak strain can reveal the systolic function of left ventricle and the global peak longitudinal strain can recognize systolic dysfunction more sensitively. Key words: Echocardiography, three-dimensional; Kidney failure, chronic ; Ventricular function, left; Speckle tracking imaging

Abstract 13480: Utility of Combined Assessment of Exercise Oscillatory Breathing and Global Circumferential Strain to Predict Cardiac Events in Heart Failure Patients

Background: The occurrence of cardiopulmonary exercise testing-derived exercise oscillatory breathing (EOB) is a predictor of survival in heart failure (HF) patients. Whereas, it was recently reported that global circumferential strain (GCS) as assessed by two-dimensional speckle-tracking imaging reflects intrinsic left ventricular (LV) myocardial function and is a powerful predictor of cardiovascular events, and thus appears to be a better predictive parameter than global LV function, including LV ejection fraction (EF). The objectives of our study were to test the hypothesis that a combined assessment of EOB and GCS can further enhance the ability of the method to predict cardiac events in HF patients. Methods: A total of 86 HF patients with LVEF of 44±11% underwent cardiopulmonary exercise testing and echocardiography. GCS was determined as the peak global speckle-tracking strain from mid-LV short-axis view, and GCS of &lt;10.7% was predefined as significant LV myocardial dysfunction for HF patients. EOB definition was based on the criteria as previously reported. Long-term unfavorable outcome events were pre-specified as primary end points of hospitalization for deteriorating HF over 2.0 years. Results: Overall, patients with EOB (n=35) were associates with unfavorable clinical events compared with those without EOB (n=49) (2% vs. 18%, p=0.04). Of 35 patients with EOB, there were 10 patients with EOB and GCS10.7%. The prevalence of unfavorable clinical events of patients with EOB and GCS10.7% (70% vs. 4%, p&lt;0.001). Conclusions: The combined approach of EOB and GCS leads to more accurate prediction of unfavorable cardiac events than using individual parameters in HF patients. The study presented here offers new insights into management of HF patients.

Detailed evaluation of right atrial dysfunction in patients with corrected tetralogy of Fallot by three-dimensional speckle tracking echocardiography

Cardiologia CROATICA The goal: Three-dimensional (3D) speckle tracking echocardiography (STE) could encompass the benefits of STE and 3D echocardiography allowing to see the heart as it is: a 3D organ. In the recent studies, alterations in ventricular deformations could be demonstrated in adult patients with corrected tetralogy of Fallot (cTOF) by 3DSTE. The present study was designed to assess 3DSTE-derived right atrial (RA) volumetric and strain parameters in cTOF. Patients and Methods: A total of 17 cTOF patients were involved into the present study. Their results were compared to 18 ageand gender-matched healthy controls. All subjects have undergone complete 2-dimensional Doppler echocardiographic and 3DSTE measurements. Results: Significantly increased RA volumes respecting heart cycle could be detected in cTOF patients. Total and passive atrial emptying fractions proved to be significantly decreased in patients with cTOF (26.4 ± 12.4% vs. 39.1 ± 8.8%, p=0.001 and 11.2 ± 6.8% vs. 19.8 ± 9.0%, p=0.003, respectively). Global and mean segmental peak longitudinal (17.0 ± 10.9% vs. 30.8 ± 11.2%, p=0.0008 and 20.6 ± 10.7% vs. 34.4 ± 10. 5%, p=0.0005) and area strains (20.2 ± 18.8% vs. 41.0 ± 19.8%, p=0.003 and 28.1 ± 19.8% vs. 49.1 ± 19.7%, p=0.004) and global radial peak strain (9.5 ± 5.6% vs. 15.0 ± 10.0%, p=0.05) proved to be reduced in cTOF patients as compared to controls. Global pre-atrial contraction circumferential strain was significantly decreased in cTOF patients (3.9 ± 6.9% vs. 10.8 ± 11.0%, p=0.03). Conclusions: Complex evaluation of RA dysfunction could be allowed by 3DSTE including volumetric and strain analysis.

Can serum tenascin-c be used as a marker of inflammation in patients with dilated cardiomyopathy?

Tenascin-C (TN-C), an extracellular matrix glycoprotein, is specifically expressed at high levels during embryonic development, but not in the adult heart. TN-C reappears at sites of inflammatory tissue remodeling or wound healing under various pathologic conditions, such as acute myocardial infarction, acute myocarditis,and some cases of cardiomyopathy. Therefore, the expression of TN-C might be useful for detecting the clinical characteristics of, and ventricular remodeling in, dilated cardiomyopathy (DCM). To evaluate the role of TN-C as a sensitive marker for active inflammation in children with newly onset DCM This case controlled study included 24 patients aged from 6 to 72 months with a mean age 45.19 ± 11.03 compared to 20 age and sex matched healthy children. The subjects were divided into 3 groups. Group 1: included twelve patients with acute onset DCM, (less than 6 months duration) ,Group 2: included twelve patients with established chronic DCM, (more than 6 months duration) and Group 3: twenty (20) healthy age and sex matched children served as control group: all studied patients were subjected to full medical history ,thorough clinical examination. Serum Tenascin-C , chest X-ray and echocardiography using conventional parameters as M-mode, 2D, CW Doppler and 2D speckle tracking technique. The 2D Speckle Tracking data showed that the patients group had lower Global peak Strain Longitudinal Apical long axis( G SL ap lax), G peak SL apical 4 chamber(a4c), G peak SL apical 2 chamber(a2c) and G peak SL average with highly statistical significant difference using T -test. Moreover the global echocariographic assessment showed that acute cases had lower G peak SL ap lax, G peak SL ap4c, G peak SL a2c, G peak SL avg, than the chronic cases with a highly statistically significant difference ( P < 0.001). These data confirm furthermore the global affection of the acute DCM cases than the chronic cases.Our study showed highly significant statistical elevation of serum Tenascin-c among DCM patients than in controls ( P value <0.001). It also showed that acute cases had statistically significant higher serum levels of Tenascin-c than chronic cases ( P value <0.001). This indicates that serum Tenascin-C level is elevated in cases of acute dilated cardiomyopathy and is decreased significantly in chronic DCM. And showed that circulating tenascin-C is generally associated with the severity of left ventricular dysfunction. Serum-Tenascin Level was significantly increased in patients with idiopathic dilated cardiomyopathies. This increase was noted in acute and chronic cases, with significant difference between both being higher in the acute cases, and associated with the severity of heart failure and the LV dysfunction as detected by 2D speckle tracking echocardiography.

Assessment of right ventricular function by three-dimensional speckle tracking in uremic patients underwent peritoneal dialysis

Objective To assess right ventricular(RV) function in patients with uremia underwent peritoneal dialysis using three-dimensional speckle tracking imaging.Methods 69 uremic patients with normal left ventricular ejection fraction and right ventricular ejection fraction values underwent peritoneal dialysis were divided into two groups according to pulmonary artery systolic pressure (PASP).Group A consisted of 36 patients with PASP≤40 mmHg(1 mmHg =0.133 kPa).Group B contained 33 patients with PASP＞40 mmHg.A healthy control group including 31 subjects was designated group N.RV dynamic three-dimensional model was obtained from the apical four-chamber view,afterwards the images were stored and analyzed on EchoPAC workstation.RV global longitudinal peak systolic strain (GLS),global circumferential peak systolic strain(GCS) and global radial peak systolic strain(GRS) from each group were measured and compared.Results RV GLS were significantly decreased in uremic patients group A and B compared with group N (P ＜0.05).RV GLS were even lower in group B compared with group A(P ＜ 0.05).No significant difference was found in RV GRS,GCS among group A,group B and group N(P ＞ 0.05).Conclusions Even RV systolic function is still at a normal level in patients with uremic peritoneal dialysis,but its longitudinal myocardial deformation capacity has been as early as RV systolic function decline,and early in the radial,circumferential direction of the global deformation capacity.The application of three-dimensional speckle tracking technology can accurately detect subclinical RV dysfunction,providing the basis for early clinical intervention. Key words: Echocardiography; Uremia; Peritoneal dialysis; Ventricular function, right; Speckle tracking imaging

Impaired global and segmental myocardial deformation assessed by two-dimensional speckle tracking echocardiography in patients with vitamin B12 deficiency

Contrary effects of vitamin B12 deficiency have been shown on the cardiovascular system. Aim of our study was to analyze left ventricular (LV) myocardial deformation, by using the two dimensional (2D) speckle tracking echocardiography (STE) in patients with vitamin B12 deficiency and normal LV ejection fraction. Twenty-five patients with vitamin B12 deficiency (B12 levels < 200 pg/mL; mean age: 29.6 ± 8.2 years, 15 female), and 27 healthy controls (B12 levels > 200 pg/mL; mean age: 30.1 ± 6.9 years, 13 female) were included in the study. 2D echocardiography images were transferred to a workstation for further offline analysis. Longitudinal peak systolic (LPSS) and global strain (LGS) was obtained from 4 chamber and apical long axis (APLAX) views. Standard echocardiographic parameters and tissue Doppler imaging (TDI) velocities were compared between the groups. All LPSS values in the patient group except for apical 4C septal wall longitudinal strain were significantly decreased than those in the control group. There was a positive correlation between B12 levels and strain values except apical 4C septal wall strain values. We found that in patients with vitamin B12 deficiency, global and segmental myocardial deformation was impaired and this impairment was correlated with the levels of vitamin B12.

Left Ventricular Endocardial Dysfunction in Patients with Preserved Ejection Fraction after Receiving Anthracycline

Anthracycline chemotherapy generates progressive dose-dependent left ventricular (LV) dysfunction associated with a poor prognosis. Early detection of minor LV myocardial dysfunction caused by the cardiotoxicity of anthracycline is thus important for predicting global LV dysfunction. Fifty patients with preserved ejection fraction (all ≥55%) after receiving anthracycline chemotherapy were recruited for this study. Two-dimensional speckle tracking was used to assess global radial and circumferential strains from mid-LV short-axis views and global longitudinal strain from the apical four- and two-chamber view as peak global strain curves. Three-dimensional (3D) radial, circumferential, and longitudinal myocardial function was quantified as a peak global strain curve using 3D speckle tracking from all 16 LV segments. 3D speckle tracking imaging was used to evaluate LV endocardial area change ratio (area strain) quantified as peak global area strain curve (3D-GAS) to determine LV endocardial function. Twenty age-, gender-, and EF-matched normal volunteers were studied for comparisons. Only 3D-GAS and peak 3D global circumferential strains of the anthracycline group were significantly worse than those of the control group (-43.3 ± 3.1 vs. -45.8 ± 4.3% and -31.6 ± 3.5% vs. -34.4 ± 4.2%, respectively; P = 0.008, P = 0.004) even though global LV systolic and diastolic functions were similar. 3D-GAS correlated significantly with the cumulative doxorubicin dose (r = 0.316, P = 0.026). It was noteworthy that multivariate analysis showed only 3D-GAS (β = 0.323, P = 0.025) was independently associated with cumulative doxorubicin dose. Three-dimensional speckle tracking area strain was found useful for early detection of minor LV endocardial dysfunction associated with the use of anthracycline, and may thus prove to be clinically useful for predicting global LV dysfunction.

Left ventricular systolic strain of the cardiac allograft evaluated with three-dimensional speckle tracking echocardiography

Three-dimensional speckle tracking echocardiography was employed to evaluate the changes of left ventricular systolic strain in 23 heart transplant recipients at 1st, 3rd, 6th and 12th month after heart transplantation, and 23 healthy subjects served as controls. The three-dimensional full-volume echocardiographic images of left ventricle were recorded and then were analyzed using EchoPAC software. The strain curves and peak systolic strain values for each segment and overall left ventricular wall were obtained. Left ventricular global peak longitudinal strain (GPSL), global peak radial strain (GPSR), global peak circumferential strain (GPSC) and global peak area strain (GPSA) were measured and then statistically analyzed. There were no significant differences in left ventricular ejection fraction (LVEF) and cardiac output (CO) between heart transplant recipients and controls. The GPSL in heart transplant recipients at 1st month after surgery was significantly lower than that in controls, but close to the normal value at 3rd month after surgery and later. The GPSC, GPSA and GPSR were significantly lower in heart transplant recipients at 1st, 3rd, 6th and 12th month after surgery than those in controls. It is suggested that three-dimensional speckle tracking echocardiography can be used for monitoring changes of left ventricular systolic strains and evaluating left ventricular systolic function in cardiac allograft.

Longitudinal follow-up of ventricular performance in healthy neonates

BackgroundSpecific follow-up of newly introduced echocardiographic parameters in healthy neonates and infants is limited. AimTo prospectively describe follow-up of left ventricular (LV) tissue Doppler imaging (TDI) and speckle tracking strain parameters in healthy subjects up to two months after birth. DesignThis is a longitudinal follow-up study. SubjectsTwenty-eight (10 male) healthy newborns were included and underwent transthoracic echocardiography 1–3days, 3weeks and 6–7weeks after birth. Outcome measuresIn each echocardiogram, parameters describing cardiac growth, including LV mass (LVM), were assessed. Additionally, TDI derived peak systolic velocity (S′) and peak early (E′) and late (A′) diastolic velocities were assessed in the basal LV free wall and interventricular septum (IVS). Finally LV longitudinal, radial and circumferential global peak strain parameters were assessed using speckle tracking strain imaging. ResultsLVM significantly increased during follow-up (7.6±2.4 versus 12.4±3.2g, p=0.002). Similarly at 1–3days versus 6–7weeks after birth, an increase in LV and IVS systolic (LV S′ 4.1±1.5 versus 6.3±1.5cm/s, p=0.001; IVS S′ 3.6±0.9 versus 6.4±1.3cm/s, p<0.001) and diastolic (LV E′ 6.1±2.2 versus 9.7±2.9cm/s, p=0.002; IVS E′ 5.1±1.4 versus 10.7±3.3cm/s, p<0.001) TDI parameters was observed. In contrast, global peak longitudinal, radial and circumferential strain parameters did not significantly change during follow-up. ConclusionsA significant increase in LV systolic and diastolic TDI parameters was observed up to two months after birth. Yet this increase may be (cardiac) growth-dependent. No significant changes were observed in speckle tracking strain derived global peak strain parameters; this may render the technique particularly valuable in evaluation of LV systolic performance during periods of significant growth, such as the neonatal period.

Changes in Fetal Left and Right Ventricular Strain Mechanics during Normal Pregnancy

The aim of this study was to detect normal changes in fetal two-dimensional speckle-tracking echocardiography-derived values for global and regional longitudinal left and right ventricular strain, strain rate, and time to peak (T2P) global strain during pregnancy. Forty-four healthy fetuses were examined prospectively during the second-trimester and third-trimester ultrasound examinations (20-24 and 30-34 weeks, respectively). Clips with high frame rates (mean, 120 frames/sec) of two-dimensional (B-mode) grayscale images of apical or basal four-chamber views of both ventricles were used for offline analyses of global and regional walls and segments (basal, mid, and apical) of myocardial strain and strain rate as well as T2P global strain in the longitudinal direction. There were statistically significant decreases in global and regional strain of the right ventricle between the second and third trimesters. No statistically significant changes were observed in global and regional strain of the left ventricle. Global and regional strain rates of both ventricles decreased in a similar way during pregnancy. The mean T2P longitudinal left ventricular global strain (adjusted for heart rate) increased mildly during fetal life. Whereas T2P longitudinal strain of the left ventricle at 20 to 24 weeks was statistically significantly shorter than that of the right ventricle, no difference in T2P longitudinal strain was found at 30 to 34 weeks of gestation between both ventricles. The establishment of these changes between the second-trimester and third-trimester two-dimensional speckle-tracking echocardiography-derived reference values is a mandatory prerequisite for its use in evaluating (pathologic) changes in both ventricular functions during pregnancy.

Risk stratification of patients with non-ST-elevation acute coronary syndromes by assessing global longitudinal strain

Noninvasive detection of left main/three-vessel diseases (LM/3VD) among patients with non-ST-elevation acute coronary syndromes (NSTEACS) has been difficult using echocardiography. However, two-dimensional (2D) strain/strain-rate analysis is more sensitive in quantitatively assessing contractile abnormality. Accordingly, we aimed to clarify the usefulness of 2D strain/strain-rate analysis for risk stratification of NSTEACS. A total of 50 patients with NSTEACS underwent echocardiography and coronary angiography. We evaluated global longitudinal peak strain (global PS), peak systolic strain rate (global SSR), early diastolic global peak strain rate (global ESR), time from aortic valve closure to peak strain (TAVC-global PS), and global ESR (TAVC-global ESR) in apical four-, two-, and three-chamber views. Patients were divided into two groups according to coronary angiographic findings, the high-risk group (n = 15) with either of left main or three-vessel disease, and the low-risk group (n = 35). There were no significant differences in global SSR and global ESR between the two groups. The amplitude of global PS was significantly reduced in high-risk patients with LM/3VD in comparison with low-risk patients (-17.5 ± 2.4% vs -19.8 ± 2.7%, P = 0.007, respectively). TAVC-global PS and TAVC-global ESR were significantly prolonged in high-risk patients with LM/3VD in comparison with low-risk patients (15.3 ± 25.7 ms vs -36.8 ± 32.7 ms, P < 0.0001 and 162.8 ± 32.7 ms vs 135.7 ± 41.5 ms, P < 0.03, respectively). Receiver-operating characteristic analysis demonstrated that TAVC-global PS most strongly detected high-risk patients with sensitivity of 100% and specificity of 74.3% (area under the curve = 0.938, 95 % confidence interval 0.832-0.986, P = 0.0001). Temporal analysis of 2D strain appeared to be useful in detecting high-risk patients with LM/3VD among patients with NSTEACS.

Assessment of Intraventricular Time Differences in Healthy Children Using Two-Dimensional Speckle-Tracking Echocardiography

Parameters describing intraventricular time differences are increasingly assessed in both adults and children. However, to appreciate the implications of these parameters in children, knowledge of the applicability of adult techniques in children is essential. Hence, the aim of this study was to assess the applicability of speckle-tracking strain-derived parameters in children, paying special attention to age and heart rate dependency. One hundred eighty-three healthy subjects (aged 0-19 years) were included. Left ventricular global peak strain, time to global peak strain, and parameters describing intraventricular time differences were assessed using speckle-tracking strain imaging in the apical two-chamber, three-chamber, and four-chamber views (longitudinal strain) and the parasternal short-axis view (radial and circumferential strain). Parameters describing intraventricular time differences included the standard deviation of time to peak strain and differences in time to peak strain between two specified segments. Age and heart rate dependency were evaluated using regression analysis, and intraobserver and interobserver variability were tested. Acquisition and analysis of longitudinal six-segment time-strain curves was successful in 94.8% of subjects and radial and circumferential time-strain curves in 89.5%. No clinically significant linear relation was observed between age or heart rate and parameters describing intraventricular time differences. The coefficient of variation of time to global peak strain parameters was <10, while it was >10 for parameters describing intraventricular time differences. The feasibility of speckle-tracking strain analysis in children is relatively good. Furthermore, no linear relation was observed between age or heart rate and parameters describing intraventricular time differences. However, the limited reproducibility of some parameters describing intraventricular time differences will confine their applicability in clinical practice.

Can Serum Tenascin-C Be Used as a Marker of Inflammation in Patients with Dilated Cardiomyopathy?

Background. Tenascin-C (TN-C) is an extracellular matrix glycoprotein that appears at sites of inflammation in cardiac pathologies. Aim of the Work. To evaluate the role of TN-C as a marker for active inflammation in children with dilated cardiomyopathy (DCM). Subjects and Methods. 24 consecutive patients with primary nonfamilial DCM aged 6–72 months (mean 45.19 ± 11.03) were divided into group I, twelve patients with acute onset DCM (<6 months duration), and group II, twelve patients with chronic DCM (>6 months duration), and compared to 20 healthy age- and sex-matched controls. Investigations included estimation of serum TN-C and echocardiographic evaluation using M-mode and 2D speckle tracking echocardiography (STE). Results. Serum TN-C showed a higher significant statistical elevation among patients than controls (P < 0.001) and in group I than group II (P < 0.001). EF was significantly decreased, and LVEDD and EDV increased in patients than controls and in GI than GII. STE showed a statistically significant difference in global peak strain longitudinal (GPSL) average in patients than controls (P < 0.05) and between GI and GII (P < 0.001). STE wall motion scoring showed normokinesia (33.5%), hypokinesia (8.33%), and akinesia (50%) in GI and hypokinesia (100%) in GII. There was a statistically significant positive correlation between serum TN-C and GPSL average. Conclusions. Increased serum TN-C can be used as a marker of inflammation in DCM and is associated with the severity of heart failure and LV dysfunction as detected by STE.

Abstract 19809: Intrinsic Right Ventricle Dysfunction is a Major Cause of Post LVAD Mortality

Background: Right ventricular (RV) dysfunction after left ventricular assistant device (LVAD) confers significant challenges for post-device managements and increases mortality. The purpose of this study was to test the hypothesis that intrinsic RV myocardial dysfunction measured by 2-D echocardiography speckle tracking imaging prior to LVAD implantation is the most common cause of post-LVAD failure. Methods: Thirty-nine patients who underwent Heartmate II LVAD placement from 2010 to 2011, and 10 age-matched controls were studied. Pre- and post-operative clinical, and echocardiographic data were prospectively collected for LVAD database. RV longitudinal myocardial velocity, strain, and strain rate were measured retrospectively using an off-line speckle-tracking analysis software. Results: Of the 39 LVAD recipients, 24 patients developed acute RV failure immediately post LVAD implantation, among which 13 patients recovered from RV dysfunction after LVAD adjustment and medical management, while 11 patients with intrinsic RV dysfunction as identified by significantly lower global RV peak myocardial velocity, strain, and strain rate prior to LVAD (p&lt;0.05), eventually required RVAD and/or death despite optimal medical therapy. Intrinsic RV myocardial dysfunction often cannot be completely improved by LVAD implantation alone and may be exaggerated by septal shifting caused by emptying or decompressing LV, thus, worsening severe or deteriorating RV dysfunction which eventually requires RVAD or leads to death. Eight of 11 patients including all 7 RVAD patients died within 6 months from LVAD implantation had a peak longitudinal systolic RV global strain of -3% or lower (absolute value). Twenty-four of 27 (88%) patients with the global RV strain higher than -3% (absolute value) survived without RVAD (p&lt;0.05). Conclusions: Poor intrinsic RV myocardial function is often worsened in LVAD patients and is a leading cause for a high LVAD mortality.

Abstract 9794: Load Dependency of Right Ventricular Performance is a Major Factor to be Considered in Decision Making Prior to Ventricular Assist Device Implantation

Background Left ventricular assist devices (LVADs) provide better quality of life than biventricular devices (BVADs), but it is a challenge to evaluate right ventricular (RV) function and to predict its time-course after LV support. Severe RV failure after LVAD implantation appeared related to pre-operative RV geometry and tricuspid regurgitation (TR) which are highly load sensitive parameters. We assessed the impact of load dependency on RV performance before and after LVAD implantation aiming to improve pre-operative decision making. Methods We evaluated our patients who received a LVAD after 1/2006. RV anatomic and functional parameters collected prospectively before LVAD implantation and invasively collected data on pulmonary hemodynamics were tested for relationship with post-implant RV function and patient outcome. Echocardiography including tissue Doppler and 2D strain imaging was used to evaluate RV size, geometry and function. Results After LVAD implantation 45 (9.5%) of 475 evaluated patients showed worsening of RV function which necessitated a mechanical support also for the RV. Whereas RVEF was similar in patients with and without stable post-operative RV function there were significant differences in pre-operative long/short axis (L/S) ratio, tricuspid annulus peak systolic velocity (TAPSm) peak global strain rate (RVSSr),RV/right atrial pressure gradient (ΔP-RV/RA) and pulmonary arterial pressure (PAP) between the two patient groups (p &lt; 0.05). The highest predictive values (up to 93.5%) for RV failure after LVAD insertion were found for pre-operative L/S ≥ 0.6, TAPSm &lt; 8cm/s, and peak RVSSr &lt; 0.7/s in patients with maximum ΔP-RV/RA &lt; 35mmHg. L/S, TAPSm and RVSSr also showed high predictive values for RV failure in patients with preoperative TR &gt; grade II and PAP &lt; 50mmHg. L/S &lt; 0.6, TAPSm ≥ 8cm/s, and peak RVSSr ≥ 0.7/s in patients with maximum ΔP-RV/RA ≥ 35mmHg showed high predictive values (≥ 92%) for postoperative freedom from RV failure. Conclusion RV geometry and velocity of contraction before LVAD implantation are highly predictive for postoperative RV function if preoperative PAP and TR are also considered. RV L/S ratio, TAPSm and RVSSr, in connection with maximum ΔP-RV/RA, can improve decision making before VAD implantation.

Myocardial Deformation Analysis by Echocardiographic Strain Imaging Allows Detection of Patients with Post-Transplant Coronary Stenoses in the Absence of Visible Wall Motion Alterations

Background: Non-invasive detection of transplant coronary artery disease (TxCAD) for timing of angiographies is a major goal. However, because diffuse distal coronary narrowing is a major determinant of left ventricular (LV) dysfunction in Tx,CAD, wall motion alterations induced by coronary stenoses are less evident. Because echocardiographic speckle-tracking derived strain imaging reveals alterations in wall motion and myocardial deformation not detectable by conventional echocardiography and allows the distinction between active and passive wall motion, we assessed its reliability to distinguish patients with angiographic TxCAD from those without the disease. Methods: Between 1/2005 and 6/2007, all heart-transplanted patients underwent 2D-strain analyses before routine coronary angiographies. LV radial, circumferential and longitudinal strain and strain-rate were calculated from parasternal and apical views, respectively. Dyssynchrony and dyssynergy indexes were also calculated from strain curves. In patients without visible wall motion alteration and with normal LV ejection fraction, 2D-strain parameters and indexes were tested for relationships to angiographic findings. Results: All 2D-strain and strain-rate parameters were significantly lower in patients with angiographic TxCAD. Except for global peak strain, all systolic parameters showed high negative predictive values for focal epicardial coronary stenoses. However, high positive predictive values for focal coronary stenoses were found only for dyssynchrony and dyssynergy indexes. The systolic dyssynchrony and endsystolic dyssynergy indexes showed the highest positive and negative predictive values for focal stenoses (>50% narrowing). Thus, at certain cut-off values, these indexes showed positive and negative predictive values of 90-95% and 91-98%, respectively. Conclusions: 2D-strain imaging appeared to be reliable not only for prediction of angiographic TxCAD (with and without focal stenoses), but also for differentiation between TxCAD with and without focal proximal coronary stenoses. The high predictive values of systolic strain dyssynchrony and dyssynergy indexes recommend 2D-strain as a non-invasive tool with the potential to facilitate early detection of stenoses and to enable angiographies to be timed, sparing patients frequent routine angiographies.