Peak Systolic Strain Research Articles

P5250Diastolic strain rate ratio as determined on MRI on detecting left ventricle stiffness and predict heart failure in post-STEMI patients

Abstract Background ST-elevation myocardial infarction (STEMI) Patients suffered from progressive heart failure, for which progressive and aggravated Left ventricle stiffness was one of the major culprit. Myocardial deformation in the early diastole is largely affected by the left ventricle compliance which could partly reflect chamber stiffness and potentially predict left ventricular remodeling for post-STEMI patients. Purpose To determine the value of diastolic strain rate in detecting left ventricle stiffness and early heart failure in post-STEMI patients. Methods A number of 52 (M/F: 46/6, age: 54.27 [46.8–62.3]yrs) patients with STEMI three months ago were prospectively recruited from 2016 to 2017. Follow-up was done until 2018. The primary end points were the symptoms of heart failure (NYHA II-IV). Consent was acquired from each patient and 3.0 T MRI was arranged. Imaging analysis was performed on Cvi 42 (V5.9.3 Canada). Peak radial strain (PS) and strain rate (SR) were extracted both from 2D short- and long-axis cine images, while peak circumferential parameters only from the short axis slices and longitudinal the long axis slices. The diastolic strain rate ratios (DSRRs) were calculated as the peak early diastolic SR divided by the peak late diastolic SR, which were derived from the two peak points on the corresponding curve of time-to-SR curve in the diastole (Figure 1a). Receiver-operating characteristics curve analysis and Logistic regression test were done for statistical analysis on R project and P<0.05 was considered as significant. Results Three patients were excluded due to unsatisfied cine images. Among the 52 patients, none of the patients died or had congestive heart failure. 23/52 (44.2%) patients complained of heart failure symptoms at the one-year follow-up. No significant difference was found in LVEF and three directional peak strain values or systolic peak strain rates between the patients with and without heart failure. Patients with symptoms had lower Longitudinal PS (P=0.049), early diastolic radial SR (P=0.01798), longitudinal SR (P=0.0042), and decreased DSRR in all directions (Figure 1b). Multivariate Logistic regression test showed that only DSRR in the radial direction on the short axis (DSRR-SR) was the independent predictor of the heart failure symptoms (6.59; range, 6.71–3.68; P=0.026). ROC analysis demonstrated that the DSRR-SR of 2.35 had sensitivity 91.3% and specificity 58.6% for the prediction of heart failure (Figure 1c). Figure 1 Conclusion DSRR especially DSRR-SR was more sensitive to left ventricle stiffness change and help predict the progression of heart failure for Post-STEMI patients. Further studies were needed to verify the its association with other cardiovascular clinical events. Acknowledgement/Funding the National Natural Science Foundation of China (81600299,81471721, 81471722, 81771887, and 81771897,);

P2740Quantitative assessment of the entire right ventricle from one acoustic window: an attractive approach in patients with congenital heart disease

Abstract Background Right ventricular (RV) function is recognized as a prognostic factor in congenital heart disease (CHD). The accuracy of established parameters as tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RVFAC) and tissue Doppler imaging (TDI S') are limited as the parameters reflect only a limited region of the RV. We previously introduced a novel four-view approach with different RV walls visualized in their long axis from one apical view using 2D-transthoracic echocardiographic (TTE) iRotate mode. Aims To extensive evaluate the entire RV function using iRotate echocardiography in a whole spectrum of CHD patients with abnormally loaded RV; both feasibility and RV echocardiographic parameters as comparison with healthy subjects is evaluated. Methods and results One hundred and forty-two CHD patients with abnormally loaded RV and 89 healthy subjects were included. All subjects underwent complete TTE with evaluation of TAPSE, TDI S' and peak systolic global longitudinal RV strain (RV-GLS) from the RV walls using the four-view iRotate model. The feasibility of TAPSE and RV S' ranged between 94% and 100%. The feasibility of RV-GLS in CHD was 98%, 69%, 87% and 72% respectively in the lateral, anterior, inferior and inferior coronal view walls. With the exception of RV S' in the inferior coronal view, all parameters were significantly lower in the CHD vs healthy subjects (p<0.001) (Table). i-Rotate RV wall GLS (%) RV wall GLS (%) Measurement Feasibility Congenital (n=142) Controls (n=89) P-value Lateral 97.9 −17.6±5.0 −25.4±4.5 <0.001 Anterior 69.0 −15.9±4.9* −24.2±4.5 <0.001 Inferior 88.7 −17.2±4.7 −23.3±4.4 <0.001 Inferior coronal view 72.5 −15.1±4.5* ** −20.8±5.2 <0.001 Data expressed as mean ± SD or %. p<0.05 for *Lateral vs Anterior and vs Inferior CV; **Inferior vs Inferior CV. Conclusion The feasibility of all RV parameters in the four-axis iRotate model is excellent in CHD and represents a reproducible, easily applicable and complete RV assessment in daily practice. RV function is significantly decreased in the CHD group using both load dependent and independent parameters. Complete RV strain analysis reveals regional differences in patients with CHD.

P1023Upstream therapy with spironolactone in patients with atrial fibrillation may reduce the burden of diffuse myocardial fibrosis and arrhythmia

Abstract Background The pathophysiology of atrial fibrillation (AF) involves a continuum of structural, hemodynamic, and electrophysical remodeling that coexist in a complex interplay, often involving increased diffuse myocardial fibrosis. Purpose To examine whether low dose spironolactone can reduce the extent of diffuse fibrosis in the left atrium (LA) and left ventricle (LV), evaluated using post-contrast T1 myocardial relaxation time (T1 time) and myocardial strain derived from cardiac magnetic resonance imaging (CMR), in patients with paroxysmal and persistent AF. Methods CMR sub-study population of 100 individuals from INSPIRE-AF, an investigator-initiated, randomized, controlled, double-blind study (NCT02764619). Study participants with paroxysmal (n=49) and persistent (n=51) non-valvular AF and LV ejection fraction ≥45% were randomized to spironolactone 25 mg once daily (SPL-group, n=49) or placebo (PL-group, n=51) in addition to standard treatment. CMR scans were conducted at inclusion and after 12 months of treatment. LA and LV measures, including volumes, ejection fraction, and peak systolic longitudinal strain were assessed using cine CMR feature tracking. T1 times were estimated using a previously validated modified look-locker inversion-recovery sequence. Commercially available software (Circle, Calgary, Canada) was used. All participants were followed for recurrences of AF, and all recurrences were documented with a standard 12-lead electrocardiogram. The associations between changes in mean volume, strain, and T1 times were examined using multivariable linear regression, adjusted for baseline age, sex, and AF type. Results LV post-contrast T1 time increased significantly in the SPL group (mean increase in SPL=1,97 ms [95% CI: 0,169; 3,323] vs. PL=0,21 ms [95% CI: −0,67; 1,11], p=0,027 for difference). However, the mean change of post-contrast LA T1 time did not differ between groups. LV peak longitudinal strain was also significantly improved in the SPL group (mean decrease in SPL: 19,82% [95% CI: −0,85; 40,48] vs. PL: 14,15% [95% CI: −36,21; 7,92], p=0,047). Similarly, LA stroke volume corrected for body surface area increased in the SPL-group (mean SPL: 34,33 ml/m2 [95% CI: −2,17; 42,62] vs. PL: 8,46 ml/m2 [95% CI: −20,13; 5,94], p=0,013). All changes remained significant after adjusting for age, sex and systolic blood pressure. No difference was found in arrhythmia burden between groups (P=0,89). Conclusion Low dose spironolactone may reduce the burden of diffuse myocardial fibrosis in AF. However, there was no reduction in the burden of arrhythmia. Acknowledgement/Funding Region of Southern Denmark, University of Southern Denmark, Danish Heart Association

P1470Myocardial dysfunction index: a novel myocardial strain parameter for diagnosing myocardial ischemia

Abstract Background and purpose Peak systolic strain (ε-sys) derived from speckle tracking echocardiography (STE) is a useful parameter for assessing regional contractile dysfunction during acute ischemia. However, low ε-sys does not always indicate myocardial ischemia because of its relatively large variation in segmental normal ranges and intervendor differences. Therefore, comparison of strain before and after an ischemic event and demonstration of a decrease in ε-sys should be necessary to confirm myocardial ischemia, which is not always possible in clinical situations. It is well known that early systolic lengthening (ESL) and post-systolic shortening (PSS) occur during acute ischemia. We hypothesized that ESL and PSS would correlate with the decrease in ε-sys and integrated analysis of ESL and PSS could be useful to diagnose the presence of myocardial ischemia. Methods 2D short-axis or 3D full-volume images were acquired by Artida at baseline, during flow-limiting stenosis (mean 50±20% flow reduction), and during complete occlusion of the left circumflex coronary artery in 22 dogs (2D-STE = 12, 3D-STE = 10).Circumferential strain was analyzed in the center of risk area, and the absolute value of peak systolic strain (ε-sys), post-systolic strain index (PSI) as a parameter of PSS, and early systolic strain index (ESI) as a parameter of ESL were measured. A new parameter, myocardial dysfunction index (MDI), which was calculated as follows: (ESL amplitude + PSS amplitude)/maximal strain amplitude during the cardiac cycle, was also calculated. The difference in ε-sys between at baseline and during ischemia (Δε-sys) was measured and the diagnostic accuracy for estimating Δε-sys < −3% was assessed by the receiver operating characteristics (ROC) curve analysis. Results During ischemia, ε-sys decreased from 19±3 to 12±6% and MDI increased from 2±4 to 27±30%. MDI was significantly correlated with Δε-sys (2D-STE: r=−0.80, 3D-STE: r=−0.83, p<0.01, respectively) (Figure). The area under the curve (AUC) of MDI for estimating Δε-sys < −3% tended to be larger than those of ESI and PSI (MDI: 0.9, ESI: 0.73, PSI: 0.85). Figure 1 Conclusions The novel parameter, MDI was correlated with the decrease in ε-sys during acute ischemia. Integrated analysis of ESL and PSS may be useful for diagnosing the presence of myocardial ischemia.

P1492Is early repolarization pattern only an ion channel disease?

Abstract Background Early repolarization pattern (ERP) has been generally described as a benign electrocardiographic (ECG) sign despite it is associated with the development of malign ventricular arrhythmias. Although the pathophysiological mechanism of malign ventricular arrhythmias in ERP has been explained only electrophysiologically, whether the presence of structural changes in myocardium has not been known yet. Purpose We hypothesized that ERP is not only an ion channel disease. The structural changes in myocardium begin in individuals with ERP sign on 12 lead surface ECG even if a young person. The aim of the present study was to determine myocardial dysfunction due to early decaying in myocardial structure in individuals with ERP sign by the use of 2D- speckle tracking echocardiography (STE). Method We prospectively included 99 individuals who admitted to our clinic between 01.04.2018 and 01.09.2018. 48 individuals had ERP. 12 lead surface ECG was taken from all individuals at admission, all individual's ECG were further analysed for presence of ERP and ERP was divided into three groups which were defined as presence of ST elevation, J wave and QRS slurring. 2D-STE (Philips Epiq 7C Ultrasound System for Cardiology (Andover, USA)) was performed in all individuals. All strain echocardiographic recordings were further analysed off- line by the use of associated software. Results ERP had significantly lower left ventricular (LV) global longitudinal strain (GLS), circumferential peak systolic strain rate (CPSSr) in basal segments of LV and left ventricular ejection fraction compared to controls. In addition, LV diastolic function especially in LV basal segments were significantly impaired in individuals with ERP when assessed by circumferential peak diastolic strain rate (CPDSr) compared to controls. GCS, LV- longitudinal peak systolic Sr (LPSSr) and LV- longitudinal peak diastolic Sr (LPDSr) in all of the apical chambers were similar between two groups (Table 1). There was not a relationship between type of ERP and all of these parameters including GLS, GCS, LPSSr, CPSSr, LPDSr, CPDSr. Finally, ST elevation pattern had higher GCS value while QRS slurring pattern had higher GLS value (Figure 1). Figure 1 and Table 1 Conclusion Our study firstly demonstrated ERP can be combined of structural and electrical heart disease. LV-GLS can be more closely associated with ERP than LV-GCS. In addition, the either of impaired of circumferential systolic and diastolic function in LV basal segments can be detected in individuals with ERP.

P1685Risk factors and earliest signs of heart damage in young adults with hypertension

Abstract Background It is well known that the risk of cardiovascular complications becomes higher even in high normal BP ranges. High normal BP is usually asymptomatic in young age. It is important to establish the main risk factors and the initial signs of cardiac dysfunction at early stages of arterial hypertension (AH) formation. Objective To assess the prevalence of leading risk factors and to investigate the global longitudinal strain rate of left ventricle (LV) by speckle tracking (STE) method in young men with high normal pressure. Methods The study involved 80 patients aged 22 (20; 25) years. The first group (I) included 55 subjects with high normal office BP values (130–139/85–89 mm Hg), the second group (II) consisted of 25 subjects with office BP less than 130/85 mm Hg. Anthropometric and blood biochemical parameters were tested in all subjects. The heart status was assessed according to transthoracic echocardiography-data. The test was performed on an expert class apparatus General Electric Vivid 7 in the B and M mode by the pulse wave and color flow Doppler. LV functional status was assessed by STE with GLPS analysis. STE data was obtained in B-mode from three apical positions with a frame rate of 80–90 per minute. longitudinal peak systolic strain (LPSS) in basal, midwall and apical segments as well as a LV walls was assessed in the compared groups. The parameters tested are presented as median, interquartile range, average and standard deviation. Results Both groups were comparable in age. Smoking (25.9% and 28.6%, p=0.54) and total cholesterol (48,1% and 45,5%; p=0,11) were highly prevalent in groups I and II. Overweight is registered significantly more frequently in subjects with high BP (41.5% and 14.3 respectively, p=0.0009). Family history of premature cardiovascular disease, heart rate, diabetes, uric acid were comparable in both groups. The GLPS value was significantly lower in the group with high normal BP than in the reference group: −19,1 (−17,71; −20,2) and −20,9 (−20,6; −22,4) (p=0,0014). The decrease of LPSS at the basal and midwall segments was recorded more often in subjects with high normal BP (p=0.0008 and p=0.0003, respectively). LPSS in all LV walls was significantly lower in group I. LPSS in anteroseptal wall was 18.7±3.4 and 21.1±4.1, p=0.029; in anterior wall it was 19.8±2.9 and 22.3±3.0, p=0.006; in lateral wall it was 18.7±3.3 and 20.9±1.9, p=0.004; in inferolateral wall it was 18.7±3.3 and 21.1±3.2, p=0.017), in inferior was (19.8±3,1 and 22.3±2.2, p=0,002), in inferoseptal was (17.2±3.4 and 19.8±1.6, p=0.0007) in groups I and II, respectively. The nature of revealed changes in the subjects with high blood pressure requires further targeted investigation. Conclusion The multisegment GLPS decrease may be the earliest marker of myocardial dysfunction in the initial stages of hypertension. The contribution of overweight is evident in the persistent BP increase.

P6318Survival rate in patients with the identification of predictors for antibody mediated rejection

Abstract Introduction Antibody mediated rejection (AMR) is still an important issue in heart transplantation (HT). The standard methods of diagnosis and treatment remain controversial, whereas immunosuppressive therapy is mainly used to prevent cellular rejection. Purpose To determine predictors of AMR using the routine investigations in clinical practice. Methods During 7 years we conducted a single center study of 181 HT recipients. Patients were divided into 5 groups based on AMR and detected anti-HLA, such as DSA and non-DSA antibodies. Recipients underwent immunology screening and HLA antibodies tests, DSA; 2D-speckle-tracking echocardiography using the Kruskal-Wallis and Wilcoxon signed-rank tests; Spearman correlation, the table of critical values for the Pearson correlation. Kaplan-Meier curves were used to estimate the survival rate. Roc-analysis was used to measure the diagnostic accuracy. Statistical analysis was performed with the STATISTICA 10 (Tibco, USA). Results The study demonstrated the lowest survival in patients with anti-HLA antibodies, such as anti-HLA and non-DSA antibodies versus recipients without anti-HLA de novo. Survival in patients with DSA is 40%, and in patients without DSA is 68%. It should be noted that comparing of survival in patients with HLA identified in different post-transplant period showed that patients with HLA-antibodies identified in late post-transplant period had worse survival (50%) than recipients who developed antibodies in the early post-transplant period (75%). On the second stage of the study we conducted 2D-speckle-tracking echocardiography. At first we estimated 2D-STE parameters for the selected groups of patients in the first period of our study, and then during AMR and the late period of the study. AMR effectively reduces the parameters of deformation and mechanics, GLPS LV,%i = −9,94±1,37, RadS LV,% 19,36±3,66, Cir SLV,% −17,83±4,89, ROT APEX°,4,51±1,46, ROT BASE°, −4,75±2,12, ROT MID° 1,94±1,41, TWIST,% 8,90±1,85, RV-FWS,% −15,89±0,89. The possible criteria for diagnosis of AMR include global peak systolic strain, sensitivity (S) 86,2%, specificity (Sp) 90,4%, radial systolic strain, S 75,8%, Sp 84,5% circular systolic strain, S 78,6%, Sp 84,4%; left ventricular twist S 66,7%, Sp 94,2% (p<0,001). Conclusions There is a correlation between changes and parameters of 2D-speckle-tracking echocardiography. DSA limits the survival and increases the risk for AMR.

Reproducibility of Combined Acquisition and Measurement of Left Ventricular Longitudinal Peak Segmental Strain in Relation to the Severity of Left Ventricular Dysfunction

Whether left ventricular (LV) longitudinal peak systolic segmental strain (LPSS) has sufficient reproducibility to be used in clinical practice (e.g., in patient follow-up) remains unclear. The aim of this study was to assess the reproducibility of combined acquisition and measurements of LPSS across the spectrum of LV ejection fraction (LVEF). In this prospective study, 72 subjects (mean age, 63±14years; 65% men) were included in four equal groups: group 1, LVEF≥50%, healthy; group 2, LVEF≥50%, presence of cardiovascular disease and/or risk factors; group 3, LVEF 30%-49%; and group 4, LVEF≤29%. Two observers performed four sets of image acquisitions and measurements (three during the same session, one after a median of 1day) to account for intraobserver, interobserver, and test-retest reproducibility of combined acquisition and measurements. LPSS was measured in each of the 17 LV segments. On average, the intraobserver and test-retest intraclass correlation coefficients and mean absolute differences of repeated acquisition and measurement of LPSS were similar across groups. However, interobserver intraclass correlation coefficients and mean absolute differences decreased in group 4 compared with groups 1 to 3. The intraobserver, test-retest, and interobserver coefficients of variation of all LV segments became worse as LVEF decreased, especially in group 4, in which LPSS was not reproducible in most segments. Reproducibility of LPSS in basal LV segments was worse compared with apical segments. The average measurement uncertainty (defined as the 95% limits of agreement of repeated acquisition and measurements) of LPSS in a test-retest scenario was ±8.9%, ±11.8%, ±10.7%, and ±9.0% in groups 1, 2, 3, and 4, respectively. The clinical applicability of LPSS is hindered by suboptimal reproducibility, even if a single observer repeats both acquisition and measurements. Changes in LPSS during patient follow-up should be interpreted with caution.

Left Atrial Function with MRI Enables Prediction of Cardiovascular Events after Myocardial Infarction: Insights from the AIDA STEMI and TATORT NSTEMI Trials.

Background The role of left atrial (LA) performance in acute myocardial infarction (AMI) remains controversial. Cardiac MRI myocardial feature tracking (hereafter, MRI-FT) is a method used to quantify myocardial function that enables reliable assessment of atrial function. Purpose To assess the relationship between LA function assessed with MRI-FT and major adverse cardiovascular events (MACE) after AMI. Materials and Methods This secondary analysis of two prospective multicenter cardiac MRI studies (AIDA STEMI [NCT00712101] and TATORT NSTEMI [NCT01612312]) included 1235 study participants with ST-elevation myocardial infarction (n = 795) or non-ST-elevation myocardial infarction (n = 440) between July 2008 and June 2013. All study participants underwent primary percutaneous coronary intervention. MRI-FT analyses were performed in a core laboratory by researchers blinded to clinical status to determine LA performance using LA reservoir function peak systolic strain (εs), LA conduit strain (εe), and LA booster pump function active strain (εa). The relationship of LA performance to a MACE within 12 months after AMI was evaluated by using Cox proportional hazards models and area under the receiver operating characteristic curve (AUC). Results Study participants with MACE had worse LA performance parameters compared with study participants without MACE (εs = 21.2% vs 16.2%, εe = 8.8% vs 6.9%, εa = 11.8% vs 10%; P < .001 for all). All atrial parameters were strongly associated with MACE (hazard ratio [HR], εs = 0.9, εe = 0.88, εa = 0.89; P < .001 for all). For εs, a cutoff of 18.8% was identified as the only independent atrial parameter with which to predict MACE after accounting for confounders and established prognostic markers in adjusted analysis (HR, 0.95; P = .02). The εs yielded incremental prognostic value above left ventricular ejection fraction, global longitudinal strain, microvascular obstruction, and infarct size (AUC comparisons, P < .04 for all). Conclusion Feature tracking of cardiac MRI to derive left atrial peak reservoir strain provided incremental prognostic value for major adverse cardiovascular events prediction versus established cardiac risk factors after acute myocardial infarction. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Almeida in this issue.

Speckle tracking derived reference values of myocardial deformation and impact of cardiovascular risk factors - Results from the population-based STAAB cohort study.

AimsWe aimed to provide reference values for speckle-tracking derived systolic and diastolic myocardial deformation markers, and to determine their relation with age, sex, and cardiovascular risk factors.Methods and resultsThe Characteristics and Course of Heart Failure STAges A/B and Determinants of Progression (STAAB) cohort study recruited a representative sample of the population of Würzburg, Germany, aged 30–79 years. In a sample of 1818 participants (52% female, mean age 54±12 years) global longitudinal peak systolic strain (GL-PSS, n = 1218), systolic (GL-SSR, n = 1506), and early (GL-EDSR, n = 1506) and late diastolic strain rates (GL-LDSR, n = 1500) were derived from 2D speckle tracking analysis. From a subgroup of 323 individuals without any cardiovascular risk factor, sex- and age-specific reference values were computed. GL-PSS, GL-SSR, and GL-EDSR were associated with sex, GL-EDSR decreased and GL-LDSR increased with age. In the total sample, dyslipidemia was associated with altered GL-PSS, GL-SSR, and GL-EDSR in women but not in men, whereas obesity was associated with less favorable GL-PSS and GL-EDSR in either sex. Hypertension impacted more adversely on systolic and diastolic myocardial deformation in women compared to men (all p<0.01).ConclusionThe female myocardium appeared more vulnerable to high blood pressure and dyslipidemia when compared to men, while obesity was associated with adverse myocardial deformation in either sex. The reference values for echocardiographic myocardial deformation provided for a non-diseased population and their here reported associations with cardiovascular risk factors will inform future observational and intervention studies regarding i) effect sizes and power calculation, ii) cross-study comparisons, and iii) categorization of myocardial deformation in specific patient groups.

Evaluation of the impact of percutaneous coronary intervention of chronic total occlusion on regional myocardial function using strain echocardiography

BackgroundSuccessful revascularization of chronic total occlusions has been associated with potential effects on left ventricular (LV) function. Strain and strain rate are more sensitive measures of LV mechanics than LV ejection fraction (LVEF). This study was conducted to investigate the impact of revascularization of chronic total occlusion (CTO) on LV function using tissue Doppler (TDI) strain echocardiography.ResultsThis study included 60 patients divided into two main groups: the percutaneous coronary intervention (PCI) group including patients who had a successful PCI of CTO on left anterior descending (LAD) artery and was presented for elective PCI with symptomatic angina and/or positive functional ischemic study. They included 18 males with a mean age of 57 ± 5 years. The optimum medical treatment (OMT) group, including 30 patients, had non-revascularized CTO-LAD and was kept on OMT alone; 20 of them were males with a mean age of 58 ± 4 years. In the PCI group, there was a significant improvement in all the TDI strain parameters of the LAD territory segments. Six months after PCI, the peak systolic strain rate improved from − 0.65 ± 0.21 to 1.05 ± 0.31 1/s (p value < 0.01), the peak systolic strain improved from 6.54 ± 2.48 to 11.51 ± 3.33% ( p value < 0.001 ), and the end systolic strain improved from 7.88 ± 2.77 to 10.51 ± 3.14% (p value < 0.01 ). There was no significant improvement in the mean LVEF (60.70 ± 8.33 vs 61.91 ± 8.16% (p value = 0.6)). In the OMT group, there was no improvement in all the strain parameters and there was no change in the mean LVEF. In the PCI group, there was a significant improvement in the angina class (p value = 0.03) while, in the OMT group, there was no significant improvement (p value = 0.835).ConclusionsSuccessful PCI for CTO improved regional LV myocardial function assessed by TDI strain echocardiography. This improvement was associated with improvement in the angina class.

Unmasking right ventricular dysfunction in chronic rheumatic mitral regurgitation.

Right ventricular (RV) systolic function is an important predictor of mortality but has been poorly studied in chronic rheumatic mitral regurgitation (CRMR). We studied RV systolic function using speckle-tracking echocardiography (STE) in patients with CRMR. Seventy-seven patients with CRMR and 40 healthy controls were enrolled in a cross-sectional study at Chris Hani Baragwanath Hospital between January and October 2014. RV peak systolic strain (PSS) and left ventricular (LV) global longitudinal strain (GLS) were measured using Philips Qlab 9 STE software. RVPSS was lower in CRMR patients compared to the controls ( -16.8 ± 4.5 vs -19.2 ± 3.4%, p = 0.003) with no difference in conventional RV systolic function parameters (p = 0.39). RVPSS was lower in severe CRMR compared to moderate CRMR patients ( -14.3 ± 4.23 vs -18 ± 4.18%, p < 0.0001). CRMR patients with LV systolic dysfunction had a greater reduction in RVPSS and LVGLS compared to those with preserved LV systolic function (p = 0.001). LVGLS and significant tricuspid regurgitation (TR) were independent predictors of RVPSS (p < 0.001). In CRMR patients, RVPSS was a more sensitive marker for detecting earlier RV systolic dysfunction than traditional RV functional parameters.

Pediatric malignancies: Is the prechemotherapy left ventricular function normal?

We compared the left ventricular (LV) systolic function in children with cancer before initiation of chemotherapy with matched controls using speckle tracking echocardiography. In this retrospective study, we analyzed the echocardiograms of 89 cancer patients before the initiation of chemotherapy and 82 age- (8.4±5.2 vs. 8.9±3.9years, P=.4) and gender-matched (64% vs. 67%, males, P=.4) healthy controls. Peak systolic LV longitudinal strain (LS) was significantly lower in cancer patients in apical two (-19.8±3.0 vs. -23.5±4.0, P<.001), three (-19.4±3.2 vs. -23.4±4.0, P<.001), and four-chamber views (-19.7±3.4 vs. -22.5±3.0, P<.001) compared to controls, as was global longitudinal strain (GLS) (-19.8±2.7 vs. -23.4±3.2, P<.001). The prechemotherapy group also had a higher E/e' ratio compared to controls at the septal (9.3±3.9 vs. 7.9±1.7, P=.005) and lateral annulus (7.9±3.3 vs. 5.9±1.4, P<.001) of the mitral valve. The LV ejection fraction was lower in cancer patients compared to controls (63.5±4.9 vs. 66.8±4.1, P<.001), although still within normal limits. There were no differences in LV myocardial performance index (0.30±0.05 vs. 0.30±0.09, P<.65) and shortening fraction (35.8±5.2 vs. 36.1±6.1, P<0.75) between the two groups. Subgroup analysis showed no difference in LV GLS between patients with solid tumors (n=56) and blood cancers (n=33) (GLS -19.2±2.9 vs. 19.5±2.4, P>0.05). Our data demonstrating abnormalities in LV GLS in pediatric cancer patients even prior to initiation of chemotherapy are novel and perplexing. Further longitudinal follow-up is required to assess the implications of this abnormal LV function in these patients.

Assessment of Myocardial Ischemic Memory Using Three-Dimensional Speckle-Tracking Echocardiography: A Novel Integrated Analysis of Early Systolic Lengthening and Postsystolic Shortening

Persistence of subtle abnormal myocardial deformation such as postsystolic shortening (PSS) after transient ischemia can be used to diagnose a history of myocardial ischemia (myocardial ischemic memory). Furthermore, early systolic lengthening (ESL) has recently attracted attention as another marker of myocardial ischemia. However, it is unclear whether the persistence of such abnormal deformation can be detected by three-dimensional (3D) speckle-tracking echocardiography, which has relatively low spatial and temporal resolution compared with two-dimensional echocardiography. The aim of this study was to evaluate the diagnostic accuracy of myocardial ischemic memory and its spatial extent using 3D speckle-tracking echocardiography. The left circumflex coronary artery was occluded for 2min, followed by reperfusion, in 33 dogs. Their hemodynamic and 3D echocardiographic data were chronologically acquired. Peak systolic strain, early systolic strain index as a parameter of ESL, postsystolic strain index as a parameter of PSS, and myocardial dysfunction index as a combined parameter of ESL and PSS were analyzed in all left ventricular segments. At the center of the risk area, early systolic strain index and postsystolic strain index significantly increased until 20min after reperfusion compared with baseline, although peak systolic strain recovered by 20min. Myocardial dysfunction index significantly increased for >20min after reperfusion and allowed better diagnostic accuracy of ischemic memory than the other parameters. In the 147 risk segments, abnormal values of myocardial dysfunction index remained in 49 segments (33%) at 20min after reperfusion, whereas abnormal peak systolic strain was observed in only 13 segments (9%). ESL and PSS persisted after transient ischemia and could be detected by 3D speckle-tracking echocardiography. Integrated analysis of ESL and PSS provided higher diagnostic accuracy of ischemic memory. This method may be useful for detecting transient ischemic insults in patients after the disappearance of anginal attack.

Longitudinal evaluation of myocardial function in preterm infants with respiratory distress syndrome

Preterm births and respiratory distress syndrome (RDS) are associated with pulmonary vascular disease and altered myocardial function. We serially assessed up to 1year of age the effects of RDS on global and regional myocardial function of preterm infants, compared to preterm and term controls using conventional echocardiography parameters, tissue Doppler velocities and deformation analysis. A total of 120 infants (30 preterm [PT] with RDS, 30 PT controls without RDS, and 60 term controls) underwent conventional and tissue Doppler echocardiography within 72hours of birth, at corrected term age for the preterm infants, at 1month corrected, and at 1year corrected age. At birth, compared to preterm and term controls, the PT-RDS group had decreased right ventricular (RV) long-axis function, systolic velocity, peak systolic strain, shorter pulmonary arterial acceleration time (PAAT), and lower ratio of PAAT to RV ejection time (PAAT:RVET). Preterm infants had left ventricular (LV) diastolic dysfunction at birth (lower early diastolic myocardial velocity, mitral E velocity, and mitral E:A ratio), and reduced long-axis systolic velocities and shortening. Differences between groups disappeared by 1month corrected age, except PAAT:RVET which remained lower in the PT-RDS group. At 1year, RV function was normal in PT-RDS apart from systolic strain rate, and LV function was normal apart from lower stroke volume and shortening, relative to body weight. PT-RDS had lower left and right ventricular systolic and diastolic function at birth which improved over time, suggesting postnatal maturation of cardiac function and resolution of lung disease.

Subclinical myocardial disease in patients with primary hyperoxaluria and preserved left ventricular ejection fraction: a two-dimensional speckle-tracking imaging study.

Primary hyperoxaluria (PH) is characterized by progressive chronic kidney disease (CKD) and systemic oxalate deposition. Myocardial dysfunction might be present early in the course of the disease. However, this hypothesis has not yet been tested in the PH population. Therefore, we aimed to determine whether strain imaging using two-dimensional speckle tracking echocardiography (2D-STE) might detect subclinical myocardial disease in otherwise asymptomatic PH patients. Prospective study of pediatric and adolescent PH patients with preserved LV ejection fraction (LV EF) and without renal replacement therapy. Subjects underwent conventional echocardiography and 2D-STE. Global (GLS) and segmental peak systolic LV longitudinal strain (LS) measurements were obtained. Data were compared with age- and gender-matched controls, and Z-scores were calculated as appropriate. Fifteen PH patients (age 14.1 ± 5.9years; 13/15 in CKD stages 1-2) were studied. Although LV EF was preserved (63 ± 6%) in patients, GLS was significantly impaired (GLS - 17.1 ± 2.2% vs - 22.4 ± 1.9%, p < 0.001). This was mainly due to decreased LS values in the apical segments (p < 0.05). Echocardiographic indices of ventricular wall thickness were significantly increased in patients compared to controls (all p < 0.03). GLS correlated significantly with Z-scores of diastolic interventricular wall thickness (r = - 0.57, p = 0.025) and moderately with serum creatinine levels (r = 0.53, p = 0.044). No correlation was found between GLS and blood pressure measurements. Subclinical myocardial disease is already present early in the course of disease in PH patients with preserved LV EF and some degree of renal dysfunction, but without overt systemic oxalosis. Current recommendations to screen only PH patients with advanced CKD for cardiac disease should be revised accordingly.

Frequency of Coronary Microvascular Dysfunction and Diffuse Myocardial Fibrosis (Measured by Cardiovascular Magnetic Resonance) in Patients With Heart Failure and Preserved Left Ventricular Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is frequently accompanied by co-morbidities and a systemic proinflammatory state, resulting in coronary microvascular dysfunction (CMD), as well as myocardial fibrosis. The purpose of this study is to examine the relation between myocardial perfusion reserve (MPR) and diffuse myocardial fibrosis in patients with HFpEF using cardiovascular magnetic resonance. A single center study was performed in 19 patients with clinical HFpEF and 15 healthy control subjects who underwent quantitative first-pass perfusion imaging to calculate global MPR. T1 mapping was used to assess fibrosis and to calculate extracellular volume. Spiral cine displacement encoded stimulated echo was used to calculate myocardial strain. Comprehensive 2D echocardiograms with speckle tracking, cardiopulmonary exercise testing, and brain natriuretic peptide levels were also obtained. In patients with HFpEF, mean left ventricular EF was 61% ± 9% and left ventricular mass index 45 ± 12 g/m2. Compared with controls, HFpEF patients had reduced global MPR (2.29 ± 0.64 vs 3.38 ± 0.76, p = 0.002) and VO2 max (16.5 ± 6.8 vs 30.9 ± 7.7 ml/kg min, p <0.001) whereas extracellular volume (0.29 ± 0.04 vs 0.25 ± 0.04, p = 0.02), pulmonary artery systolic pressure (35.4 ± 13.7 vs 22.3 ± 5.4 mm Hg, p = 0.004), and average E/e' (15.0 ± 7.6 vs 8.6 ± 2.0, p = 0.005) were increased. Displacement encoded stimulated echo peak systolic circumferential strain (p = 0.60) as well as echocardiographic derived global longitudinal strain (p = 0.07) were similar between both groups. The prevalence of CMD, defined as global MPR <2.5, in the HFpEF group was 69%. In conclusion, HFpEF patients have a high prevalence of CMD and diffuse fibrosis. These parameters may be useful clinical end points for future therapeutic trials.

Left Atrial Strain to Identify Diastolic Dysfunction in Children with Cardiomyopathies

Background: Left ventricular (LV) diastolic dysfunction (DD) carries worse prognosis in childhood. 2-dimensional (2-D) left atrial (LA) strain accurately categorizes DD in adults but its role in children is unknown. Thus, the aim of this study is to investigate whether LA strain and strain rate could diagnose and classify DD in children with dilated (CMD), hypertrophic (HCM) and restrictive (RCM) cardiomyopathies (CM). Methods and Results: The study includes 136 children (aged 8.8 ± 6 years): 44 with DCM, 40 with HCM, 7 with RCM and 45 healthy controls (CTRL). They underwent standard echocardiographic examination and 2-D speckle-tracking analyses (LV longitudinal peak systolic strain (LS), LA peak systolic strain and strain rate). No significant differences in mitral E/A and pulmonary S/D ratios were observed among the four groups. Although E/E’ and indexed left atrial volumes were found to be significantly higher in HCM, DCM and RCM compared to CTRL (p < 0.001), they showed no significant difference among the three CM groups. LV LS values were significantly reduced in CM vs CTRL (p < 0.001) and in DCM vs HCM (p < 0.01), with no other differences between the remaining groups. LA peak systolic strain and strain rate values showed a steady and significant decrease with worsening of DD. Receiver Operating Characteristics (ROC) curves showed area under the curve of 0.976 (p < 0.001) for LA strain and 0.946 (p < 0.001) for LA strain rate, to distinguish CTRL from CMs. Conclusions: LA strain and strain rate could be a promising tool to better understand and classify DD in children with cardiomyopathies, opening the way to its clinical use.

Left Ventricular Systolic Myocardial Function in Ankylosing Spondylitis.

Subclinical left ventricular (LV) myocardial dysfunction is associated with an increased risk of cardiovascular disease (CVD), but it is not known whether subclinical LV myocardial dysfunction is present in patients with ankylosing spondylitis (AS) independent of CVD risk factors. Conventional and speckle tracking echocardiography were performed in 106 patients with AS (mean ± SD age 48 ± 12 years; 59% men) and 106 matched controls (mean ± SD age 51 ± 12 years; 59% men). LV systolic myocardial function was assessed by peak systolic global longitudinal strain (GLS). CVD risk factors were similarly distributed in patients with AS and controls, but more controls received statin therapy (P = 0.05). GLS was significantly lower in patients with AS compared to controls (mean ± SD -17.7 ± 2.5% versus -18.4 ± 2.3%; P = 0.03). In univariable linear regression analyses in the total study population, lower GLS was associated with having AS, male sex, higher body mass index, higher LV mass index, and lower LV ejection fraction (all P < 0.05). Having AS retained an independent association with lower GLS when adjusted for these factors in multivariable analyses (β = 0.16, P = 0.02). In patients with AS, lower GLS was independently associated with larger aortic root diameter in multivariable analyses (β = 0.24, P = 0.02), while no association with AS disease activity, disease duration, or use of antirheumatic medication was observed. Patients with AS had lower GLS compared with controls, independent of confounders. In AS patients, lower GLS was associated with larger aortic root diameter. Prospective studies should test whether lower GLS contributes to the observed higher CVD risk in patients with AS.

Quantification of regional right ventricular strain in healthy rats using 3D spiral cine dense MRI

Statistical data from clinical studies suggests that right ventricular (RV) circumferential strain (Ecc) and longitudinal strain (Ell) are significant biomarkers for many cardiovascular diseases. However, a detailed and regional characterization of these strains in the RV is very limited. In the current study, RV images were obtained with 3D spiral cine DENSE MRI in healthy rats. An algorithm for surface growing was proposed in order to fit irregular topology. Specifically, a new custom plugin for the DENSEanalysis program, called 3D DENSE Plugin for Crescent Organ, was developed for surface reconstruction and precise segmentation of organs with sharp curvature, such as the murine RV. The RV free wall (RVFW) was divided into three longitudinal thirds (i.e., basal, middle, and apical) with each one partitioned into circumferential fourths (i.e., anterior, anteriorlateral, inferiorlateral and inferior). Peak systolic strains were quantified for each segment and comparisons were performed statistically. The inclusion of a new plugin was able to generate global values for Ecc and Ell that are in good agreement with previous findings using MRI. Despite no regional variation found in the peak Ecc, the peak Ell exhibited regional variation at the anterior side of the RV, which is potentially due to differences in biventricular torsion at the RV insertion point and fiber architecture. These results provide fundamental insights into the regional contractile function of the RV in healthy rat and could act as a normative baseline for future studies on regional changes induced by disease or treatment.