Strain Rate Imaging Research Articles

Blood pressure in the early 40s impacts left atrial function by speckle-tracking strain two decades later: data from the ACE 1950 Study

Abstract Background With higher age, the left atrial (LA) wall stiffens, giving rise to impaired reservoir function and a compensatory increase in contractile function. The exposure of systemic blood pressures (BP) through life on the left heart chambers may be an explanation, but long-term follow-up studies are lacking. LA phasic function can be quantified by echocardiographic speckle-tracking strain analysis and provide prognostic information in cardiovascular disease. Purpose To explore the impact of BP in the early 40s on LA function assessed by strain two decades later. Methods A total of 3,706 individuals born in 1950 and residing in Akershus County, Norway, were included in the Akershus Cardiac Examination (ACE) 1950 Study. Baseline examinations were conducted between 2012-2015 and included echocardiography. Of those with available echocardiographic LA strain analyses, 2,399 participants had demographic and clinical data available from the Age 40 Program, a cardiovascular health survey performed when the participants were 40 years old. We assessed the impact of BP at age 40 on LA strain two decades later. Differences in LA reservoir (LASr) and contractile strain (LASct) between systolic (<120, 120-140 and >140mmHg) and diastolic (<70, 70-90, and >90mmHg) BP groups were assessed by ANOVA. Linear regression analyses were performed using BPs as continuous variables. Results Mean age of the 2,399 participants was 40.1±0.3 years at the time of the Age 40 program, and 63.9±0.6 years at the time of the ACE 1950 baseline examination. At age 40, 20.8% of participants had BP ≥140/ ≥90mmHg or used antihypertensive medication. Mean LASr was 35.1±9.2%, while mean LASct was 17.7±5.6%. LASr did not differ significantly between groups of systolic or diastolic BP. LASct, however, showed a statistically significant increase from lower to higher groups of both systolic and diastolic BP (Figure). In linear regression analyses, no associations were found between BPs and LASr, but systolic and diastolic BPs were both significantly associated with LASct (Table). The associations between BPs and LASct remained significant after adjustment for sex, BMI, daily smoking, resting heart rate and hypertension at age 40 (Table). Conclusions Higher systolic and diastolic BP in the early forties were associated with increased LA contractile function two decades later, but no significant changes in LA reservoir function were detected. This indicates contractile function as an early marker of subtle LA dysfunction.Figure.Table.

Fully automated measurements of echocardiographic mechanical dispersion using deep learning: enhanced prediction of ventricular arrhythmias in a large heart failure cohort

Abstract Background Assessment of left ventricular (LV) myocardial deformation by strain echocardiography has shown improved prognostic value over LV ejection fraction (LVEF). Mechanical dispersion (MD) by strain reflects deformation heterogeneity. Also, MD is a marker of ventricular arrhythmia (VA) that improves risk prediction independently of LVEF in patients with heart failure. However, to analyze MD is time consuming and operator-dependent, and clinical use remains limited. Purpose We aimed to investigate the performance of a novel deep learning (DL) based method for fully automated measurements of MD and evaluate its prognostic utility in patients with heart failure compared to a conventional speckle tracking application. Methods In this prospective multicenter follow up study, the IMPROVE study, we consecutively included patients with recently diagnosed heart failure of all cause with LVEF ≤ 40%. Echocardiograms, ECG, blood samples and clinical data were acquired during index hospitalization. All patients were treated according to contemporary guidelines with optimal medical therapy and revascularization if necessary. Two experienced cardiologists recorded all echocardiograms using Vivid E9 or E95 scanners. We obtained data regarding sudden cardiac death, ventricular arrhythmia and appropriate shock from the ICD from medical records and ICD recordings. The primary endpoint was sudden cardiac death or ventricular arrhythmia (SCD/VA) during follow-up. The prognostic value of DL-based and reference MD measurements was assessed through survival statistics. Results We included 492 patients (mean ± SD 73 ± 13 years old, 32% females). Follow-up time was median (IQR) 5 (3) years. The incidence of SCD/VA was 9% (n=45). Patients with MD ≥70ms had increased risk of SCD/VA both by DL-based and reference measurements (both p <0.001). Furthermore, automated MD measurements using DL had higher prognostic value (HR 4.3) compared to manual reference measurements (HR 3.1) (p <0.001). Conclusion Fully automated measurements of MD using a novel DL method was fast, feasible, and improved prediction of SCD/VA in patients with heart failure and reduced LVEF. The integration of DL measurements may facilitate the clinical implementation of MD assessment and improve risk prediction in echocardiography.

Serial changes in left atrial strain in symptomatic obstructive hypertrophic cardiomyopathy treated with mavacamten: insights from VALOR-HCM trial

Abstract Background In severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM), the VALOR-HCM phase 3 randomized, double-blind, placebo-controlled clinical trial demonstrated that mavacamten, a cardiac myosin inhibitor, reduces the eligibility for septal reduction therapy with sustained improvement in left ventricular (LV) outflow tract gradients and symptoms. Mavacamten also resulted in favorable cardiac remodeling, including improvement in left atrial volume index (LAVI), LV diastolic function, and biomarkers (NT-proBNP and troponin T). However, the impact of mavacamten on LA function is not known. Objective We sought to assess serial changes in LA strain measures in patients enrolled in the VALOR-HCM trial. Methods VALOR-HCM included 112 symptomatic obstructive HCM patients (mean age 60 years, 51% male). Patients assigned to mavacamten at baseline (n=56) continued therapy for 56 weeks and those assigned to placebo crossed over to mavacamten (n=52) from week 16-56 (40-week exposure). Echocardiographic LA strain assessment was performed according to the current American and European guideline recommendations, using a vendor-neutral post processing software. For assessment of LA strain components (reservoir, conduit, and contraction), the non-foreshortened apical 4-chamber view was utilized. The zero reference was set at end-diastole. Results Serial changes in LAVI and all components of mean LA strain from baseline to week 56 are shown in the Figure. At baseline, LAVI and all mean LA strain values were worse than reported normal mean thresholds. There was a continued and significant improvement in all 3 LA strain values, from baseline to week 56, along with a significant reduction in LAVI. Improvement in LAVI was seen earlier than improvements in LA strain. There was a significant inverse correlation between change in mean LAVI and LA reservoir strain from baseline to week 56 (r= -0.42, p<0.001). Conclusions In the VALOR-HCM trial, average LAVI and baseline LA strain values were significantly worse than reported normal thresholds. Treatment with mavacamten resulted in an improvement in LAVI and LA strain values from baseline through week 56 suggesting a sustained favorable impact on cardiac remodeling. The advantageous cardiac remodeling associated with long-term treatment with mavacamten may in turn have a favorable impact on the observed high burden of atrial tachyarrhythmias in HCM.Serial changes in LA strain in VALOR-HCM

Speckle tracking echocardiography as a predictor of location of ablation sites in candidates to catheter ablation for recurrent ventricular tachycardia

Abstract Background Preoperative imaging is essential before a ventricular tachycardia (VT) ablation procedure, to improve operative outcomes and reduce procedural times. Although MRI is the gold standard, it has several limitations, including patient compliance, possible presence of non-MRI-compatible devices, and long acquisition time. Speckle tracking echocardiography (STE) is a reliable and appealing technique that quantifies regional and global myocardial deformation, as well as layer-specific (endo-, mid- and epicardial) longitudinal strain, without MRI limitations. Purpose This study aimed to evaluate the efficacy of STE in predicting VT ablation sites. Methods In this study, we compared the bull’s eye segmentation of the left ventricle, global and layer-specific, obtained with STE (TomTec Arena), to investigate whether echocardiography can predict the areas of scar and late potential, as identified by electroanatomic mapping (EnSite X mapping, HD Grid mapping catheter, Abbott). Strain analysis and electroanatomic mapping data were matched segment-by-segment to obtain pairs of endocardial strain and bipolar substrate maps, as well as pairs of midmyocardial/epicardial strain and unipolar substrate maps. Results Twenty-three consecutive patients with an indication for catheter ablation for recurrent VT were enrolled. All patients were being treated with beta-blockers, 52% were taking amiodarone, and only 2 patients were on mexiletine. A total of 1170 pairs of bull’s eye segments were available for analysis. A binary logistic mixed-effects model was used to predict the presence of electroanatomical scar based on strain echocardiography data, to account for interpatient variability. The study findings highlighted a close correlation between the bipolar map and endocardial strain values, and between the unipolar map and midmyocardial strain values. Progressively higher (less negative) values of endocardial strain proved predictive of bipolar electroanatomical scar, with an increase in the odds ratio of bipolar electroanatomical scar equal to 6.2% (95% confidence interval 2.5%-10%) for each unit increase in strain values. Similarly, progressively higher values of midmyocardial strain were predictive of unipolar electroanatomical scar, with an increase in the odds ratio of unipolar electroanatomical scar equal to 6.2% (95% confidence interval 1.2%-11.4%) for each unit increase in strain values. Conclusions The data from our study showed an anatomical correspondence between the areas of low potential identified by electroanatomical mapping and the areas of anomalous longitudinal strain. In particular, the endocardial strain correlates with the bipolar map, and the meso-epicardial strain correlates with the unipolar map. These data may prove useful in the appropriate planning of the procedure in patients with an indication for catheter ablation in the context of recurrent VT.

Three-dimensional deformation imaging to detect myocardial scar

Abstract Introduction Myocardial scar or fibrosis has significant implications in patient management and prognosis. Currently, cardiovascular magnetic resonance (CMR) is the reference technique for detection and quantification of scar though other imaging modalities have been proven to be useful as well. Purpose This study aims to investigate the usefulness of 3D strain echocardiography to identify myocardial scar in patients with ischaemic and non-ischaemic myocardial fibrosis using late gadolinium enhancement (LGE) CMR as a reference. Methods 149 individuals with ischaemic (89), non-ischaemic scar (26) and no scar (34) on LGE CMR underwent 3D transthoracic echocardiography. The 3D data sets were processed with the 4D LV analysis tool by TOMTEC Imaging Systems GmbH, Germany. The longitudinal, circumferential, radial, and principal tangential strain were calculated. Using a 16 LV-segment model the areas of LGE were assessed on CMR images, and a correlation between 3D strain values and LGE was investigated. Results A multivariate binary logistic regression model was built with the conditional backward elimination method using LGE as the dependent variable. The predictors made a significant contribution to the model (Wald test: 49.985, p<0.001). The Cox & Snell R-square was 0.141, and Nagelkerke R-square was 0.232, suggesting that the final model explains 14.1% or 23.2% of LGE variability. By logistic regression analysis, less negative peak principal tangential strain (P-PTS), peak circumferential strain (P-SC), and end-systolic circumferential strain (ES-CS) increased the odds, whereas increased peak radial strain (P-RS) decreased the likelihood of LGE (Table 1). The LGE extent was calculated as the average LGE transmurality of all 16 segments and was used as the dependent variable in linear regression models. The LGE extent was significantly correlated with all strain indices (Table 2). By stepwise linear regression analysis, P-PTS (B=0.029, 95%CI:0.019-0.040, P<0.001) outperformed the remaining strain variables in terms of linear association with LGE extent. Association between strain indices and the presence or absence of myocardial fibrosis in each of the 16 segments was tested by point biserial correlation (Table 3). PTS and CS indices were associated with myocardial fibrosis in 10/16 segments; RS indices were associated with LGE in 9/16 segments, and LS was not related to the presence of LGE in 15/16 segments. Septal (basal-mid-apical) and mid/apical anterior and inferior segmental strain showed more consistent associations with corresponding myocardial fibrosis. Conclusion 3D strain echocardiography is a promising and easily accessible technique, that can be used to identify areas of myocardial scar as it correlates well with LGE in many LV segments. Echocardiography is a bedside and widely available technique, and it could be used in patients with contraindications or no access to CMR or myocardial perfusion scan.Table 3

Arrhythmogenic right ventricular cardiomyopathy: the importance of biventricular strain in risk-stratification

Abstract Background Despite Arrhythmogenic right ventricular cardiomyopathy (ARVC) being a predominant right ventricle (RV) disease, concomitant left ventricle (LV) involvement has been recognized. ARVC diagnosis is made through the RV-centric 2010 Task Force Criteria (TFC), but previous studies already suggested the use of echocardiographic strain measures to better depict RV and LV dysfunction in these patients. No data however is available on the additional value of combining biventricular strain in ARVC for risk stratification. Purpose To assess the prognostic value of measuring both LV global longitudinal strain (GLS) and RV free wall strain (FWLS) analysis in patients with ARVC. Methods A total of 204 patients who met the TFC for the ARVC spectrum were included. Patients were categorized based on a cut-off of -18% for strain impairment in both ventricles. The end-point was a composite of all-cause mortality, arrhythmic events, ICD therapy and heart failure events. Results Patients (age 41 ± 17 years, 55% males) were divided into impaired (n=33), discordant (either RV or LV impaired, n=70), and normal (n=101) strain groups (Fig. 1A). Definite and borderline ARVC were diagnosed in 78% and 39%, respectively, at the time of first available echocardiography. During a follow-up of 87 [24-136] months, 60 (29%) experienced the combined outcome, and a significant difference in event-free survival was observed (p<0.001) between the 3 groups (Fig. 1B). In the multivariate analysis (Fig. 2), the strain grouping remained associated with outcome (p=0.040) after adjusting for age, gender, history of syncope and definite ARVC diagnosis, which were also significantly associated with the endpoint at the univariate analysis. A sub-analysis including only definite and borderline ARVC patients confirmed that the strain grouping was an independent predictor of the composite endpoint (p=0.027). Conclusion Biventricular involvement by strain analysis has additional prognostic value in ARVC patients and outcome is worse for those with both RV and LV involvement.Strain groups and Kaplan Meier curvesMultivariate analysis

Subclinical myocardial disfunction detected by left ventricle myocardial work impairment in patients with long standing human inmmunodeficiency virus infection

Abstract Heart failure is a known complication in patients living with human inmmunodeficiency virus (HVI) infection. Detection of subclinical disfunction is nowadays possible by echocardiographic strain techniques. Myocardial work is a novel technique based on global longitudinal strain (GLS) that measures global work efficiency of left ventricle (GWE) and would allow early detection of subclinical myocardial damage. Methods We performed a cross sectional echocardiographic study of patients with long standing HIV infection, and no previous cardiopathy, assessing GLS of left ventricle (LV), left atrium (LA) and free wall of right ventricle (RV-FW GLS). We identified patients with subclinical disfunction expressed by an impaired GWE , and studied its determinants by lineal regression. Results 110 patients, 78.2% male, median age 53.3 (51.2-55.4) were included. Time from diagnosis was 20.5 (18.6-22.3) years. Myocardial work strain analysis showed an impaired GWE: 91.9% (90.9-92.9);p<0.001) and a GW index of 1840.8 mmHg%(1758.7-1922.9):p<0.001. The rest of deformation parameters laid into normal range: LV GLS was -19.5% (-19.0- -20.0) GLS dispersion 55.1 (50.1-60.1), LA GLS (reservoir) 32.8% (31.2-34.5), and RV free wall GLS -22.3% (-21.4 - -23.2). By univariate analysis, determinants of impaired GWE were age, Score2 risk, time from HIV diagnosis, QRS Interval duration, long QTc Interval, LV ejection fraction (LVEF),diastolic disfunction by doppler tissue imaging, CD4 count nadir, initial and maximun viral load, and exposure to didanosine treatment. After adjustment by cardiovascular risk and diastolic function (Ea velocity by tissue Doppler) , GWE impaired depended on duration of infection (Beta 0.3;95%CI:0.04-0.56;p=0.023), initial viral load (Beta -1.1;95%CI:-2.1- -0.02;p=0.046) and exposure to stavudine (Beta -6.3;95%IC: -11.5- -1.1;p=0.019). Conclusions Subclinical myocardial disfunction is prevalent in long standing HIV infection. Global work efficiency is a very sensitive parameter for detection, even in patients with normal GLS values, and it was related to duration of infection, initial viral load, and exposure to stavudine in our patients.Determinants of Global Work Efficiency

Usefulness of Native T1 in Cardiac Magnetic Resonance Imaging and Echocardiographic Strain Parameters for Detecting Early Cardiac Involvement in Fabry Cardiomyopathy.

Non-invasive diagnosis of disease stage in Fabry cardiomyopathy with multimodality imaging is pivotal when deciding on the appropriate time to initiate enzyme replacement therapy. However, this approach has not been well established. We enrolled 14 patients with Fabry disease. All patients were evaluated using echocardiography and contrast cardiac magnetic resonance (CMR), and were divided into either an early-stage group without left ventricular hypertrophy (LVH; wall thickness >12 mm) or late gadolinium enhancement (LGE; n=7; median age 37 years; 4 female), or an advanced-stage group with LVH and/or LGE (n=7; median age 66 years; 7 female). Strain data from echocardiography and T1 mapping on CMR were compared between the groups. In the advanced-stage group, all strain data were impaired. In the early-stage group, localized longitudinal strain in the basal posterolateral segment was already reduced but both localized and global circumferential strain remained preserved. On CMR analysis, global and localized native T1 shortening were observed in the early-stage group, but were pseudo-normalized in the advanced-stage group. In logistic regression analysis, localized circumferential strain had significant diagnostic value for differentiating between early- and advanced stage (P=0.037) and significantly improved the predictive power of the model containing localized native T1 in CMR. A combination of localized native T1 in CMR and echocardiographic strain parameters could be useful for staging Fabry cardiomyopathy.

Changes in echocardiographic parameters after hemodialysis session in a North African pediatric population with end-stage renal disease and without known heart disease.

Children undergoing long-term hemodialysis (HD) face a reduction in life expectancy mostly due to cardiovascular mortality. Effects of HD on cardiac function have not been fully elucidated in pediatric population. This study aimed to assess HD session impact on cardiac function in pediatric patients using conventional and strain echocardiography. We performed a prospective, comparative study of echocardiographic parameters before and after single HD session in a chronic HD pediatric population. We enrolled between the 1st and 30th September 2023, all consecutive patients with end-stage renal disease (ESRD) aged up to 18 years old on maintenance HD three times weekly for at least three months. All patients underwent conventional and left ventricular (LV) longitudinal strain echocardiography in a window of 30-60 minutes before and after HD. 23 patients, 14.8 ± 2.1 years old and 47.8% male, were enrolled. Reductions in body weight and blood pressure were observed after HD, whereas heart rate increased. Significant decrease in LV and left atrial diameters and volumes after HD session were observed. Mitral peak E velocity, as well as average E/e' were significantly lower after HD. Although LV ejection fraction was unchanged, global longitudinal strain for LV was significantly reduced after dialysis (-17.3 ± 3.0% vs. -14.9 ± 2.4%, p=4.10-8). Patent deterioration in LV systolic function following HD was identified by speckle tracking echocardiography (STE). STE has the potential to unmask early myocardial dysfunction even when there is no evident alteration in conventional systolic function parameters in children with ESRD.

Assessment of Biventricular Systolic and Diastolic Function Using Conventional and Strain Echocardiography in Children with Sickle Cell Disease Surviving 1-year After Hematopoietic Stem Cell Transplant.

Hematopoietic stem cell transplant (HSCT) is a potentially curative therapy for children with sickle cell disease (SCD). The effects of HSCT on ventricular function are not well characterized in children with SCD. Echocardiograms from children with SCD who underwent HSCT between 2007 and 2017 were retrospectively analyzed before and 1-year after HSCT. Left ventricular (LV) volumes, mass, and ejection fraction were calculated by the 5/6 area*length method. LV end-diastolic and systolic dimensions, septal, and posterior wall thickness, and fractional shortening were measured by M-mode. Mitral and tricuspid inflow Dopplers (E and A waves) as well as mitral, tricuspid, and septal tissue Dopplers (E', A') were assessed. E/A, E'/A' and E/E' ratios were calculated. Biventricular strain imaging was performed using speckle-tracking echocardiography. Peak global systolic longitudinal and circumferential LV strain, and global longitudinal right ventricular strain, as well as early and late diastolic strain rate, were measured on LV apical 4-chamber, LV short-axis mid-papillary, and RV apical views, respectively. Forty-seven children (9.7 ± 5.5years, 60% male) met inclusion criteria. Pre-HSCT, subjects had mild LV dilation with normal LV systolic function by conventional measure of ejection fraction and fractional shortening. There was a significant reduction in LV volume, mass, and ejection fraction after HSCT, but measurements remained within normal range. LV longitudinal and circumferential strain were normal pre-HSCT and showed no significant change post-HSCT. RV strain decreased after HSCT, but the absolute change was small, and mean values were normal both pre- and post-HSCT. Conventional measures of diastolic function were all normal pre-HSCT. Post-HSCT there was a reduction in select parameters, but all parameters remained within normal range. Early and late diastolic strain rate parameters showed no significant change from pre- to post-HSCT. At one-year after HSCT in children with SCD conventional measures of systolic and diastolic function are within normal limits. Except for a small decrease in RV systolic strain with values remaining within normal limits, systolic strain and diastolic strain rate values did not significantly change 1-year after HSCT.

Comparing Echocardiographic Strain Imaging in Cardiac Amyloid and End-Stage Renal Disease Patients.

Diagnosing cardiac amyloidosis (CA) is difficult due to nonspecific clinical symptoms and echocardiographic findings. Prior studies have suggested that apical sparing strain patterns may be diagnostically useful. With increasing strain usage, it remains unclear how specific this pattern is to diagnose CA. We analyzed strain patterns between CA and end-stage renal disease (ESRD) patient populations. Patients with ESRD proven negative for CA (n=19) were compared to CA patients with CKD stage 3 or less (n=25). The ESRD cohort was stratified based on time on dialysis. Echocardiographic longitudinal strain (LS) parameters were collected, including regional and global LS, echocardiographic, and demographic parameters. Relative apical LS was calculated using the following equation: average apical LS/(average mid LS+average basal LS). No significant differences were found regarding regional strain or relative apical strain. Our study showed a sensitivity of 80% and specificity of 42% when using a relative apical strain ratio of >1. All groups demonstrated an apical sparing strain pattern visually on the bulls-eye plot. ESRD demonstrates significant overlapping findings across various imaging modalities compared to CA. We demonstrated that relative apical sparing strain is nonspecific for CA among patients with ESRD. Our study calls into question the clinical value of relative apical-sparing stain patterns in identifying CA in an ESRD population and suggests that diagnostic evaluation should be driven by strong clinical suspicion and other imaging and demographic variables.

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

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

Coronary artery calcium score and other risk factors in patients at moderate and high risk of cancer therapy-related cardiovascular toxicity

BackgroundThe presence and burden of coronary artery calcium (CAC) is a strong predictor of cardiovascular events. Current guidelines of the European Society of Cardiology (ESC) for cardio-oncology do not recommend the use of the CAC score to determine the status of risk in cancer patients. The aim of this study is to evaluate the presence and burden of CAC on cardiac tomography and the distribution of the cardiovascular toxicity risk factors in patients with moderate and high baseline risk of cancer therapy-related cardiovascular toxicity.MethodsThe study prospectively included cancer patients, diagnosed and qualified for systemic treatment with anthracycline chemotherapy. Clinical data and blood samples were collected from all patients. Additionally, the echocardiography and coronary computed tomography (CCTA) with the calculation of the coronary artery calcium (CAC) score were performed.ResultsA total of 80 patients (mean age 60.5 years, 75 female) were included in the study. The majority of patients (62, 77.5%) had breast cancer, 11 (13.8%) were diagnosed with sarcoma, and 7 (8.8%) with lymphoma. There were 42 (52.5%) patients classified as having moderate (MR) and 38 (47.5%) as having high risk (HR) of cancer therapy-related cardiovascular toxicity according to current ESC guidelines. In comparison with moderate risk, high risk patients were older and more likely to have hypertension, hyperlipidaemia and chronic kidney disease. The mean coronary artery calcium score was significantly higher in the HR group (150.4 vs. 24.8; p = 0.000). Furthermore, cardiac biomarkers were also higher in high-risk patients (p = 0.000). In echocardiographic parameters global longitudinal strain (GLS) was lower (p = 0.012), and diastolic dysfunction was more common in the HR group. However, the left ventricle ejection fraction (LVEF) was similar in the MR and HR groups.ConclusionsIn patients at high and moderate risk for cancer therapy-related cardiovascular toxicity, cardiovascular toxicity risk factors were common and more prevalent in the high-risk group. The coronary artery calcium score was also significantly higher in the high-risk group. Assessing the presence and burden of coronary artery calcium is an attractive option to assess additional cardiovascular risk in cancer patients.

Optimizing revascularization timing in late-presenting STEMI patients: insights from post systolic index analysis

Recent issue surrounding the need of urgent PCI for stable, late-presenting patients with ST-elevation myocardial infarction is debatable. Research indicates limited mortality benefits with reduced total ischemic time. Exploring post-systolic index (PSI) through strain echocardiography reveals its potential in assessing left ventricular recovery. We compare PSI values in late presenter STEMI patients undergoing PCI. From June to September 2023, a prospective study focused on stable late presenter STEMI patients undergoing PCI. Total ischemic time was classified as ≤ 24 hours (early intervention) and &gt; 24 hours (late intervention). Echocardiography performed thrice: before PCI, 24 hours after PCI, and 30 days after PCI, followed by comparative analysis of PSI values. A total of 43 patients with mean age of 58 ± 7.9 years, predominantly male (74.4%). There were no significant difference in PSI values 24 hours after PCI between groups [22.5 % vs 22.0 %, p = 0.644]. At the 30-day follow-up, the result showed no difference between the two groups [13.0 % vs 13.3 %, p = 0.356]. PSI values before and after PCI showed a significant decrease (31,0 % and 23,2 % and 33,2 % vs 24,9 %, p &lt; 0,001), as well as at the 30-day follow-up (31,0 % vs 13,2 % and 33,2 % vs 15,9 %, p &lt; 0,001). Our findings suggest that both early and late interventions demonstrated similar beneficial outcomes in terms of myocardial recovery. Intervention in late presenter STEMI has been proven beneficial whether performed early or late.

Routine Ankle-Brachial Index (ABI) measurement: a window into atherosclerosis and early left ventricular dysfunction in patients diagnosed with cancer

BackgroundCancer therapy is considered to cause accelerated ischemia. Ankle-Brachial Index (ABI) measurement is an inexpensive, simple, available test for the early diagnosis of peripheral artery disease (PAD); however, it is not performed routinely. We aimed to evaluate the role of routine ABI measurement for the diagnosis of PAD among patients diagnosed with cancer and whether it correlates with left ventricular (LV) dysfunction.MethodsA retrospective, single-center study including patients diagnosed with cancer at Tel Aviv Sourasky Medical Center. The cohort included patients performing routine ABI and LV global longitudinal strain (GLS) echocardiography. The primary endpoint was the prevalence of PAD and whether it correlates with LV dysfunction, defined by LV GLS absolute value < 19%. The secondary composite endpoint evaluated the association between reduced ABI to LV dysfunction and all-cause mortality.ResultsAmong 226 patients, PAD was diagnosed in 14 patients (6%). We revealed a positive correlation between ABI and LV GLS (r = 0.22, p < 0.01) with a reduced mean ABI score among patients with reduced LV GLS. A reduced mean ABI was observed among the positive composite endpoint group; however, it was not statistically significant (p = 0.35).ConclusionsWe report, for the first time to our knowledge, the routine use of ABI testing among patients diagnosed with cancer. ABI showed a significant correlation to LV GLS, implying a potential tool in the early diagnosis of atherosclerosis and cardiotoxicity. Considering its low cost and availability, future prospective trials are needed to integrate its role in routine assessment.

Assessment of left ventricular myocardial systolic dysfunction in premature ovarian insufficiency patients using echocardiographic layer-specific myocardial strain imaging

BackgroundDue to the lack of oestrogen, premature ovarian insufficiency (POI) is an independent risk factor for ischaemic heart disease and overall cardiovascular disease. This study aimed to apply layer-specific myocardial strain for early quantitative evaluation of subclinical left ventricular myocardial systolic function changes in patients with POI.MethodsForty-eight newly diagnosed, untreated patients with POI (POI group) and fifty healthy female subjects matched for age, height and weight (control group) were enrolled. Standard transthoracic echocardiography was used to measure conventional parameters and layer-specific strain parameters.The layer-specific strain parameters included subendomyocardial global longitudinal strain (GLSendo), mid-layer myocardial global longitudinal strain (GLSmid), subepimyocardial global longitudinal strain (GLSepi), subendomyocardial global circumferential strain (GCSendo), mid-layer myocardial global circumferential strain (GCSmid), and subepimyocardial global circumferential strain (GCSepi). ResultsThere were no significant differences in age, body mass index (BMI), blood pressure, or left ventricular ejection fraction (LVEF) between the two groups. The end-diastolic interventricular septal thickness (IVST) was greater in the POI group (8.29 ± 1.32 vs. 7.66 ± 0.82, P = 0.008), and the POI group had lower E, E/A, and lateral e′ (all P < 0.05). As for systolic functions,the POI group had lower GLSendo, GLSmid, GLSepi, GCSendo, GCSmid, and GCSepi (all P < 0.05).The intraobserver and interobserver coefficients of GLSendo, GLSmid, GLSepi, GCSendo, GCSmid, and GCSepi were greater than 0.900. ConclusionsPOI patients with normal LVEF may suffer from subclinical left ventricular myocardial systolic dysfunction. Echocardiography of layer-specific myocardial strain could more sensitively detect subclinical impairment of left ventricular systolic function in POI patients.Graphical abstract

Mavacamten-Associated Temporal Changes in Left Atrial Function in Obstructive HCM: Insights From the VALOR-HCM Trial

BackgroundIn severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM), the VALOR-HCM (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy) trial showed that mavacamten reduced the eligibility for septal reduction therapy with sustained improvement in left ventricular outflow tract gradients. Mavacamten also resulted in favorable cardiac remodeling, including improvement in biomarkers (eg, N-terminal pro–B-type natriuretic peptide and troponin T). However, the impact of mavacamten on left atrial (LA) function is unknown. ObjectivesThe aim of this study was to assess serial changes in LA strain measures in patients enrolled in the VALOR-HCM trial. MethodsVALOR-HCM included 112 symptomatic patients with obstructive HCM (mean age 60 years; 51% male). Patients assigned to receive mavacamten at baseline (n = 56) continued therapy for 56 weeks and those assigned to placebo transitioned to mavacamten (n = 52) from week 16 to week 56. Echocardiographic LA strain (reservoir, conduit, and contraction) was measured by using a vendor-neutral postprocessing software. ResultsAt baseline, the mean LA volume index (LAVI) and LA strain values (conduit, contraction, and reservoir) were 41.3 ± 16.5 mL/m2, −11.8% ± 6.5%, −8.7% ± 5.0%, and 20.5% ± 8.7%, respectively (all worse than reported normal). LAVI significantly improved by −5.6 ± 9.7 mL/m2 from baseline to week 56 (P < 0.001). There was a significant (P < 0.05) improvement in absolute LA strain values from baseline to week 56 (conduit [−1.7% ± 6%], contraction [−1.2% ± 4.5%], and reservoir [2.8% ± 7.7%]). Patients originally receiving placebo had no differences in LA measurements up to week 16. There was no significant improvement in LA strain values (conduit [−0.9% ± 3.8%], contraction [−0.4% ± 3.4%], and reservoir [1.4% ± 6.1%]; all; P = NS) from baseline to week 56 in patients with history of atrial fibrillation. ConclusionsIn VALOR-HCM, mavacamten resulted in an improvement in LAVI and LA strain at week 56, suggesting sustained favorable LA remodeling and improved function, except in the atrial fibrillation subgroup. Whether the advantageous LA remodeling associated with long-term treatment with mavacamten results in a favorable impact on the observed high burden of atrial tachyarrhythmias in HCM remains to be proven. (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy [VALOR-HCM]; NCT04349072)

Evaluation of left ventricular systolic function in opium users by strain echocardiography.

Heart failure is known as a health problem in the world due to its mortality and burdens on the health care system. Studies remain controversial about the effect of opium usage on systolic heart function. Therefore, the aim of this study was to compare systolic left ventricular function in opium users with non-addict people by strain echocardiography and its association with serum apelin level. This case-control study was conducted in 2022 at Shafa Hospital in Kerman, Iran, on 50 opium users who referred to the addiction treatment centres and had no history of other substance usage. The addiction is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and a history of opium consumption for at least 3years. Fifty healthy people (non-opium users) who were matched in terms of age and sex were enrolled as a control group. Demographic information of the participants, including age, gender and amount of opium usage, was recorded by questionnaire. Citrated blood samples were taken from all participants in the study, and serum apelin was measured by the enzyme-linked immunosorbent assay (ELISA) method. They underwent transthoracic echocardiography by an expert cardiologist using the same device (Philips Affiniti 50). Echocardiographic systolic parameters have been recorded and compared between the two groups. In this study, 100 participants, including 50 opium users and 50 non-opium users (as a control group), were investigated. The mean age was 36.4±5.08 in the opium users' group and 34.14±7.2 in the control group. As both groups were matched, there were 8 (16%) women and 42 (84%) men in each of the two groups. The mean amount of ejection fraction (EF) and global longitudinal strain (GLS) were significantly lower in opium users than in the control group (P<0.001). The results also demonstrated that the serum level of apelin in the addicted persons was lower when compared with the non-addicted persons (3.4 vs. 9.7; P<0.001). Evaluation of systolic left ventricular function in opium users by strain echocardiography showed that opium affects the systolic function of the heart, as observed by a significant reduction in EF and GLS. So opium usage can be considered a risk factor for heart failure and needs more attention in preventive cardiology.

Echocardiographic strain imaging in the pediatric heart: clinical value and utility in decision making.

Speckle tracking echocardiography (STE)-derived measures of myocardial mechanics, referred to herewithin as strain measurements, directly assess myocardial contractility and provide a nuanced assessment of ventricular function. This review provides an overview of strain measurements and their current clinical value and utility in decision making in pediatric cardiology. Strain measurements are advancing understanding of how cardiac dysfunction occurs in children with acquired and congenital heart disease (CHD). Global strain measurements can detect early changes in cardiac function and are reliable methods of serially monitoring systolic function in children. Global strain measurements are increasingly reported in echocardiographic assessment of ventricular function alongside ejection fraction. Research is increasingly focused on how strain measurements can help improve clinical management, risk stratification, and prognostic insight. Although more research is needed, preliminary studies provide hope that there will be clinical benefit for strain in pediatric cardiology management. Strain measurements provide a more detailed assessment of ventricular function than conventional measures of echocardiographic functional assessment. Strain measurements are increasingly being used to advance understanding of normal and abnormal myocardial contractility, to increase sensitivity to detect early cardiac dysfunction, and to improve prognostic management in children with acquired and CHD.

Fetal Right Heart Strain in Systemic Right Ventricles and Impact on Post-surgical Outcomes.

Patients with hypoplastic left heart syndrome (HLHS) and its variants rely on the right ventricle (RV) to provide cardiac output. Diminished RV systolic function has been associated with poor clinical outcomes in this population. Echocardiographic strain has emerged as a useful method to quantify RV deformation. We aimed to describe fetal strain in the systemic RV and further investigate if there was any correlation with clinical outcomes. We conducted a retrospective, single center study evaluating strain in fetuses with systemic RV. We measured fetal RV global longitudinal strain (GLS) and segmental strain using Tomtec 2D speckle tracking software and compared these findings to controls. Fifty patients with systemic RV were included in the study group with controls matched one to one for each echocardiogram. Ten patients died after first-stage palliation. GLS was reproducible, with interobserver ICC 0.82. There was no statistically significant difference in GLS among different HLHS subtypes. Abnormal GLS did not correlate with worse clinical outcomes. GLS in systemic RVs in the 2nd and 3rd trimester did not vary significantly throughout gestation and did not correlate with clinical outcomes. Risk factors associated with poor outcome were mainly postnatal. Multi-centered studies are needed to determine if these findings hold true in a larger sample size.