Subclinical Dysfunction Research Articles

The comparison of mitral annular plane systolic excursion (MAPSE) and mitral annular systolic velocity (Sm) in determining subclinical left ventricular systolic dysfunction in patients with type 2 diabetes mellitus

Background: Type 2 diabetes mellitus (T2DM) is an independent factor in increasing the risk of heart failure in the absence of coronary heart disease and hypertension. Global longitudinal strain (GLS) as the gold standard in determining subclinical left ventricular (LV) systolic dysfunction is not available on all echocardiographic tools and requires good-quality images. Mitral annular plane systolic excursion (MAPSE) and mitral annular peak systolic velocity (Sm) are simpler, faster, and widely available method that can determine left ventricular systolic dysfunction regardless of image quality. Methods: This study involved 72 asymptomatic T2DM patients, divided into two groups, patients with subclinical left ventricular systolic dysfunction (GLS >-18%) and normal systolic function (GLS ≤-18%). GLS was obtained from the mean of 18 left ventricular segments on the apical 4-chamber, 3-chamber and 2-chamber images. MAPSE was obtained on the septal and lateral sides of the mitral annulus using M-mode on apical 4-chamber view, while Sm was obtained using tissue doppler imaging (TDI). Results: The study included 72 asymptomatic T2DM patients, 34 samples (47.2%) were found with subclinical LV systolic dysfunction. According to receiver operating characteristic (ROC) curve analysis, lateral TDI Sm had the highest area under the curve (AUC), it was 0.85, followed by average TDI Sm was 0.83 and average MAPSE was 0.81. The cut-off value of average TDI Sm <7.425 cm/s had the best sensitivity and specificity, 82.4% and 81.6%, while cut-off value of average MAPSE <13.4 mm had sensitivity of 76.5% and specificity of 73.7%. Conclusion: TDI Sm had better accuracy than MAPSE in determining subclinical LV systolic dysfunction in T2DM patients. However, both of them can be used as alternative diagnostic methods of GLS.

Changes in Left Heart Geometry, Function, and Blood Serum Biomarkers in Patients with Obstructive Sleep Apnea after Treatment with Continuous Positive Airway Pressure.

Background: Cardiovascular remodeling is essential in patients with obstructive sleep apnea (OSA), and continuous positive airway pressure (CPAP) therapy could improve these processes. Two-dimensional (2D) speckle-tracking (ST) echocardiography is a useful method for subclinical biventricular dysfunction diagnosis and thus might help as an earlier treatment for OSA patients. It is still not clear which blood serum biomarkers could be used to assess CPAP treatment efficacy. Objectives: To evaluate left heart geometry, function, deformation parameters, and blood serum biomarker (galectin-3, sST2, endothelin-1) levels in patients with OSA, as well as to assess changes after short-term CPAP treatment. Materials and Methods: Thirty-four patients diagnosed with moderate or severe OSA, as well as thirteen patients as a control group, were included in the study. All the subjects were obese (body mass index (BMI) > 30 kg/m2). Transthoracic 2D ST echocardiography was performed before and after 3 months of treatment with CPAP; for the control group, at baseline only. Peripheral blood samples for the testing of biomarkers were collected at the time of study enrolment before the initiation of CPAP therapy and after 3 months of CPAP treatment (blood samples were taken just for OSA group patients). Results: The left ventricle (LV) end-diastolic diameter and volume, as well as LV ejection fraction (EF), did not differ between groups, but an increased LV end-systolic volume and a reduced LV global longitudinal strain (GLS) were found in the OSA group patients (p = 0.015 and p = 0.035, respectively). Indexed by height, higher LV MMi in OSA patients (p = 0.007) and a higher prevalence of LV diastolic dysfunction (p = 0.023) were found in this group of patients. Although left atrium (LA) volume did not differ between groups, OSA group patients had significantly lower LA reservoir strain (p < 0.001). Conventional RV longitudinal and global function parameters (S′, fractional area change (FAC)) did not differ between groups; however, RV GLS was reduced in OSA patients (p = 0.026). OSA patients had a significantly higher right atrium (RA) diameter and mean pulmonary artery pressure (PAP) (p < 0.05). Galectin-3 and sST2 concentrations significantly decreased after 3 months of CPAP treatment. Conclusions: OSA is associated with the left heart remodeling process—increased LV myocardial mass index, LV diastolic dysfunction, reduced LV and RV longitudinal strain, and reduced LA reservoir function. A short-term, 3-months CPAP treatment improves LV global longitudinal strain and LA reservoir function and positively affects blood serum biomarkers. This new indexing system for LV myocardial mass by height helps to identify myocardial structural changes in obese patients with OSA.

Electrophysiological evidence of subclinical trigeminal dysfunction in patients with COVID-19 and smell impairment: A pilot study.

BackgroundSmell and taste disturbances are among the most frequent neurological symptoms in patients with COVID-19. A concomitant impairment of the trigeminal nerve has been suggested in subjects with olfactory dysfunction, although it has not been confirmed with objective measurement techniques. In this study, we explored the trigeminal function and its correlations with clinical features in COVID-19 patients with impaired smell perception using electrophysiological testing.MethodsWe enrolled 16 consecutive patients with mild COVID-19 and smell impairment and 14 healthy controls (HCs). Olfactory and gustatory symptoms were assessed with self-reported questionnaires. Electrophysiological evaluation of the masseter inhibitory reflex (MIR) and blink reflex (BR) was carried out to test the trigeminal function and its connections within the brainstem.ResultsMasseter inhibitory reflex (MIR) analysis revealed higher latency of ipsilateral and contralateral early silent period in patients when compared with HCs. No significant differences between groups were detected as regards the duration of the early and late silent period. However, several patients showed a prolonged duration of the early silent period. BR evaluation disclosed only an increased amplitude of early components in patients.ConclusionsPatients with COVID-19 and smell impairment show a subclinical trigeminal nerve impairment. Trigeminal alterations mainly involve the oligosynaptic pathway, as a result of either direct viral damage or secondary neuroinflammation of the peripheral trigeminal fibers, whereas the polysynaptic ponto-medullary circuits seem to be spared. The prolonged duration of the early silent period and the increased amplitude of early BR response might reflect a compensatory upregulation of the trigeminal function as a consequence of the olfactory dysfunction.

Characterisation of metabolic phenotype in aortic stenosis: insights from a multi-parametric cardiac magnetic resonance study

Abstract Introduction Left ventricular hypertrophy develops in Aortic stenosis (AS) as a result of increased afterload and is related to perturbations in cardiac fatty acid metabolism with evidence of steatosis and impaired myocardial energetics in severe AS. However, there is wide individual heterogeneity when it comes to degree of hypertrophy and progression to myocardial fibrosis and heart failure in those with same degree of stenosis. Underlying interplay of metabolism and hypertrophy may explain this variability. Purpose We sought to determine if a gradient of myocardial energetic impairment and steatosis exists across the spectrum of AS and precedes irreversible structural remodelling and subclinical LV dysfunction. We investigated metabolic remodelling in AS, focusing on its relationship with stenosis severity, degree of hypertrophy and fibrosis. Methods 74 AS participants including mild AS (n=18), asymptomatic moderate AS (n=38), asymptomatic severe AS (n=18), and healthy volunteers (n=13) underwent assessment of cardiac function, energetics (myocardial phosphocreatine to adenosine triphosphate ratio, PCr/ATP) and myocardial triglyceride content (MTG) using cardiovascular magnetic resonance (CMR) imaging and spectroscopy. Participants were divided into quartile groups based on their LV wall thickness (LVWT) and peak aortic valve gradient (AVG) to study relationship between cardiac metabolism and hemodynamic markers of LV structure and function. Results Baseline CMR characteristics (Fig. 1B-C) show a stepwise deterioration in LV structure and function across both the LVWT and AVG quartile groups (p values significant) with high LV mass index and relatively dilated LV as disease severity increases. Cardiac energetics (PCr/ATP]) were reduced in mild-moderate AS, Q2 (1.43±0.13 vs normal controls, Q1 1.80±0.14, p=0.05, Fig.2A) with a progressive decline with increasing AS severity (severe AS, Q4 PCr/ATP 1.39±0.14, p=0.02 vs controls). MTG was elevated in mild-moderate AS, Q2 (1.52±0.84 vs normal, Q1 1.25±0.70%, p=0.032, Fig. 2B). Whilst all AS groups had evidence of subclinical LV dysfunction with impaired strain parameters, impaired systolic longitudinal strain was related to the degree of energetic impairment (R 0.219, p 0.03). In addition, PCr/ATP was strongly associated with the presence of myocardial fibrosis (p 0.01) strengthening the hypothesis that metabolic changes may play a causative role in disease progression (Fig. 2C). Conclusion A gradient of myocardial energetic deficit and steatosis exists across the spectrum of hypertrophied AS hearts, notably we show in our study that these metabolic changes precede irreversible LV remodelling and subclinical dysfunction. These findings may have value for defining distinct metabolic phenotypes and identifying those most at risk of decompensation. This also opens another avenue for precision metabolic therapy in AS with a potential to intervene and delay or prevent decompensation. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Left ventricular kinetic energy across heart failure subgroups and subclinical diastolic dysfunction

Abstract Background Diastolic dysfunction is a common finding in heart failure with preserved ejection fraction (HFpEF) and is considered a key mechanism for limiting exercise performance. Meanwhile, subclinical diastolic dysfunction (SDD) without heart failure is a growing concern and may be common in the general population [1,5[. The kinetic energy (KE) of intracardiac blood flow reflects the work spent on accelerating blood [3] and may provide a novel window into diastolic filling dynamics [2,4]. Our aim was therefore to quantify left ventricular KE in HFpEF patients and compare with healthy controls, subjects with SDD, and heart failure patients with moderately reduced (HFmrEF) or reduced ejection fraction (HFrEF). Methods We studied 12 healthy controls, 22 healthy subjects with 1–2 echocardiographic criteria of diastolic dysfunction (SDD), 16 HFpEF, 9 HFmrEF, and 16 HFrEF patients. All subjects underwent CMR imaging at 1.5T with acquisition of anatomical cines and 4D flow from a box covering the heart. The LV was delineated over the cardiac cycle and KE inside the segmentation calculated as 0.5 × m × v2, where v is the instantaneous velocity vector magnitude and m is blood mass. Group comparisons of peak and average values were performed using Kruskal-Wallis test with Dunn's uncorrected post hoc test. Significance was assigned at p&amp;lt;0.05. Median values are given. Results Groups were similar with regard to sex, blood pressure, and body surface area. HFpEF (median 72 years) and HFrEF patients (67 years) were significantly older than subjects with SDD (62 years, p=0.001). Examples of KE are shown in Fig. 1. Systolic peak and average KE did not differ between groups (p=0.81 and p=0.54 respectively, Fig. 2). Diastolic peak KE was higher in all groups of heart failure compared to controls (p&amp;lt;0.03 for all) and diastolic average KE was higher in HFmrEF and HFrEF compared to controls (p&amp;lt;0.02). The standard deviation for SDD was wider than in controls (1.6 mJ vs 0.8 mJ for systolic peaks, 2.7 mJ vs 1.1 mJ for diastolic peaks) and more closely resembled the HFpEF group (2.1 mJ in systole, 2.3 mJ in diastole). Conclusions Systolic kinetic energy expenditures are on average similar between controls, subjects with subclinical diastolic dysfunction, and heart failure patients, indicating that cardiac pumping involves approximately the same amount of systolic acceleration for a given afterload. Conversely, diastolic KE was found more dispersed both in heart failure and in asymptomatic individuals with subclinical diastolic dysfunction. Higher peak values of KE were seen in diastole for all types of heart failure including HFpEF, indicating more work is spent filling the ventricle. Measurements of KE in diastole could potentially be a new tool for assessment of heart failure, including early stages of disease development in some individuals with subclinical diastolic dysfunction. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Swedish Heart Lung FoundationRegion of Scania, Sweden

Relevance of subclinical right ventricular dysfunction measured by feature-tracking cardiac magnetic resonance in non-ischemic dilated cardiomyopathy

Abstract Background Right ventricular (RV) dysfunction is associated with worse prognosis in non-ischemic dilated cardiomyopathy (NIDCM). Cardiac magnetic resonance (CMR) is considered the gold standard for RV evaluation. However, scarce data is available with the new feature tracking (FT) technique, which allows strain evaluation from conventional cine sequences. Purpose Our aim is to analyze the prognostic relevance of RV myocardial deformation measured by FT-CMR in NIDCM. Methods Consecutive patients with NIDCM diagnosis and CMR at diagnosis were retrospectively included. Global longitudinal strain of RV free wall (GLS-RVFW) and fractional area change (FAC) were obtained from standard CMR cine sequences with a dedicated FT software. Their association with a composite endpoint (heart failure admission, implantable cardioverter defibrillator in secondary prevention, and death) was evaluated using a logistic regression model. Results FT derived strain was obtained in 98 patients (68±13 years, 71.4% males) with NIDCM, mostly idiopathic (75.5%). Although our cohort showed a severely impaired left ventricular systolic function (LVEF = 29.5±9.6%, 47% with LVEF ≥30%) the RV function was relatively preserved on average (RVEF 52.2±14.6%, 72% with RVEF ≥45%). During a 3.2 [2.2–4] years follow-up 26.5% presented at least one admission for heart failure (HF), 5.1% received an implantable cardioverter defibrillator in secondary prevention, and 8% died. There was no association of RV-FT parameters with prognosis considering the entire study population. However, in patients with LVEF ≥30%, admissions for HF were associated with worse values of GLS-RVFW (−21.6±6.6% vs −31.3±10%; p=0.006) and FAC (32.8±15.8% vs 47.5±13.9%; p&amp;lt;0.001). Similar differences were observed when only patients with RVEF &amp;gt;45% were considered. An GLS-RVFW cut-off point of −19.5% and FAC of 36.5% showed good prognostic performance. Decreased GLS-RVFW or FAC represented an independent predictor for the composite endpoint in patients with LVEF ≥30%. Conclusions In our series of NIDCM decreased values of GLS-RVFW or FAC were able to predict major events independently of RVEF in the subgroup of patients without severe LV dysfunction. Therefore, RV deformation parameters by FT may be early markers of poor prognosis in NIDCM. Funding Acknowledgement Type of funding sources: None.

Early subclinical systolic dysfunction detected by two-dimensional speckle tracking systolic strain in patients with hereditary TTR amyloidosis

Abstract Background Transthyretin Amyloidosis (ATTR) is a rare genetic cause of potentially fatal infiltrative cardiomyopathy. This is the commonest form of inherited restrictive cardiomyopathy. The Transthyretin (TTR) gene is located on chromosome 18q12.1 with autosomal dominant inheritance and variable penetrance. The availability of genetic testing has identified a carrier population without cardiac amyloidosis. 2-dimensional speckle-tracking echocardiography (2D-STE) has been the mainstay of screening and disease surveillance. However, utility of echocardiography for the comprehensive analysis of biventricular strains are not reported in a carrier population without cardiac amyloidosis. We sought to study the global and regional indices of biventricular strain in genotyped cases of ATTR. Purpose To assess whether individuals with a family history of TTR amyloidosis associated with a positive genetic study for transthyretin mutation can develop cardiac abnormalities even before the clinical manifestation of the disease, which may early clarify the cardiovascular risk of this pathology. Methods Patients with genotype TTR positive (TTR+) without cardiovascular symptoms were identified and matched with healthy controls. All patients underwent a full echocardiogram using a standardized protocol: 2D dimensions, tissue Doppler (TDI) and 2D-STE parameters were analyzed. Data are reported as means with standard deviation (±SD) or median with interquartile range [IQR]. Statistics performed were parametric and non-parametric tests, with a p value of &amp;lt;0.05 accepted as significant. In order to identify variables that could be associated with patients TTR genotype positive, an analysis of multiple logistic regression was proposed. Results 31 individuals in TTR+ and 34 controls were studied. Demographic and echocardiography parameters characteristics are detailed in Table. There was no significant difference in chamber dimensions, length, or ejection fraction between groups. Compared with controls, left ventricular (LV) wall thickness and mass index was higher in TTR+ (Table). Average E/e' tended to be higher in TTR+ (table). LV global circumferential and longitudinal strain were significantly lower in TTR+ (−28±4% vs. −21±4%, −25±2% vs. −19±3%, p&amp;lt;0.001 for all). Bull's eyes of the peak Longitudinal Strain are showed in Figure 1. RV strain was also lower in the TTR+ group (−25±5% vs. −18±4%, p&amp;lt;0.005). Additionally, there was a significant reduced in longitudinal strain basal, mid, and apical in TTR+ group (Table). The predictors of positive genetic testing were global longitudinal strain (adjusted odds ratio [95% CI], 2.46 [1.30–4.62]; p=0.005) and average E/e' (2.04; [1.09–3.91]; p=0.025). Conclusion Global and regional biventricular strain is lower in individuals with genetically proven TTR prior to development of cardiac amyloidosis. The impact of these variables as a component of a screening. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Conselho Nacional de Desenvolvimento Científico e Tecnolόgico (CNPq)

Prognostic impact of right ventricular strain in isolated severe tricuspid regurgitation

Abstract Background Right ventricular (RV) systolic function is determinant in the evaluation of patients with severe tricuspid regurgitation (TR). Timely detection of RV dysfunction with conventional 2D echocardiography is challenging. RV strain has emerged as an accurate and sensitive tool for evaluation of RV function with the capability of detecting subclinical RV dysfunction. Purpose This study was aimed to evaluate the prognostic value of RV strain parameters in consecutive stable patients with severe TR. Methods Consecutive patients in stable clinical status with at least severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic following a comprehensive clinical protocol were included. Patients with previous episodes of heart failure or scheduled for TV intervention were excluded. RV systolic function was measured with conventional echocardiographic indices (RV fractional area change [FAC], tricuspid annular plane systolic excursion [TAPSE], DTI S wave [`S]) and with Speckle-tracking echocardiography (STE) derived automatic peak global and free wall longitudinal strain (RV-GLS and RV-FWLS respectively) using the EPIQ system (Philips Medical Systems, Andover, Massachusetts). A combined endpoint of hospital admission due to heart failure (HF) or all-cause mortality was defined. The interobserver variability of RV strain was assessed in 20 randomly selected patients. Results A total of 176 patients were included in this study. Strain parameters detected higher percentage of RV dysfunction compared to conventional indices (figure 1). After a median follow-up of 28 months (IQR: 15–48 months), n=65 patients (37%) reached the combined endpoint. 65 (37%) were admitted for right heart failure and 8% of the population (n=14) died. Cumulative event-free survival was significantly worse in patients with impaired RV-GLS and RV-FWLS. Conventional indices of RV systolic function were not associated with outcomes (p&amp;gt;0.05 for all). In a multivariable analysis (in a model including NYHA class, BNP values, biplane VC, RV end-diastolic area, and RV-FWLS), RV-FWLS was an independent predictors of heart failure and CV mortality (figure 1 and 2; LR χ2: 40.2, p&amp;lt;0.001). Inter-observer agreements for RV strain values were high (intraclass correlation coefficient for RV-GLS and RV-FWLS, r=0.96 and r=0.98 respectively) Conclusion Clinical outcomes demonstrate that RV strain parameters are superior to conventional indices of RV function in patients with isolated ≥ severe TR and absence of previous episodes of heart failure. Among all parameters of RV function, RV-FWLS is the strongest independent predictor of mortality and HF. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto Carlos III

Left and right ventricular function alterations in obstructive sleep apnea patients assessed by 2D speckle tracking echocardiography

Abstract Introduction Obstructive sleep apnea (OSA) is related to increased left ventricular (LV) transmural pressure, blood pressure instability and increased pulmonary artery pressure (PAP) leading to left and right ventricular (RV) dysfunction and heart failure. 2D speckle tracking echocardiography (STE) is useful method for subclinical biventricular dysfunction diagnosis, thus might help to earlier treatment for OSA patients. Purpose The aim of the study was to evaluate changes of biventricular function and mechanics in patients with OSA. Methods We obtained 2D STE from 47 obese patients. 13 patients either did not have OSA, or it was mild (apnea/hypopnea index (AHI) 5–14/hour). OSA group (N=34) consisted of subjects with moderate or severe OSA (AHI ≥15/hour). New indexing for LV myocardial mass and LA volume by height was applied according new guidelines for obese patients. Statistical analyses were performed using the SPSS 27.0 software. The value of p&amp;lt;0.05 was considered as statistically significant. Results BMI did not differ between groups (p=0.108). Control group patients were younger, had higher female ratio, meanwhile arterial hypertension was more prevalent in OSA group (26 (76.5%) vs. 5 (38.5%), p=0.014). New indexing by height for left ventricular myocardial mass revealed higher LV MMi in OSA patients (p=0.007), and higher prevalence of LV diastolic dysfunction (p=0.023) was found in this group of patients. Moreover, LA reservoir function was significantly lower in OSA group compared to controls p&amp;lt;0.001. LV ejection fraction and conventional RV function parameters (s', fractional area change (FAC)) did not differ between groups, however LV and RV global longitudinal strain was reduced in OSA patients (p=0.035 and p=0.026, respectively). OSA patients had significantly higher RA diameter, and mean PAP (p=0.043 and p=0.037, respectively) (Table 1). Conclusions Moderate or severe obstructive sleep apnea is related to reduced biventricular longitudinal strain, more prevalent LV diastolic dysfunction and lower LA reservoir function. New indexing for LV myocardial mass by height helps to identify myocardial structural changes in obese patients with OSA. Funding Acknowledgement Type of funding sources: None.

Ventricular-arterial coupling predicts outcomes in adults with a systemic right ventricle

Abstract Background Patients with a systemic right ventricle (SRV) and biventricular circulation experience high incidence of cardiovascular morbidities and decreased survival [1]. Non-invasive measures of subclinical ventricular dysfunction are needed to appropriately identify patients at increased risk for adverse outcomes. Ventricular-arterial coupling (VAC), the ratio between the effective arterial elastance (Ea) and ventricular end-systolic elastance (Ees), may predict clinical outcomes in patients with SRV [2]. Objectives To assess VAC in adults with SRV and evaluate its correlation with clinical outcomes. Methods Consecutive cardiovascular magnetic resonance (CMR) examinations of adults with D-loop transposition of great arteries (TGA) after atrial switch operation and L-loop TGA performed at Boston Children's Hospital between 2005 and 2019 were analyzed. VAC was calculated as Ea/Ees (Ea = mean arterial blood pressure (MBP)/ventricular stroke volume; Ees = MBP/end-systolic volume). Global myocardial strain was measured by feature tracking analysis on cine steady-state free precession sequences. Cox proportional hazards regression analysis was performed to assess the association of SRV functional parameters with clinical outcomes. The analysis was adjusted for age, sex, and body mass index. The primary outcome was defined as a composite of death, cardiovascular arrest, hospitalizations for heart failure (HF); the secondary outcome as atrial arrhythmias; the tertiary outcome included other causes of cardiovascular hospitalizations (percutaneous or surgical interventions, device implantation, other cardiovascular disease). Cumulative incidence of the study outcomes was estimated using Kaplan-Meier method. Results One hundred sixty-seven adults (mean age 32±10 years, 59% men) with SRV were analyzed. Patients with HF (n=48, 29%) had higher VAC values as compared to those without HF (1.4±0.8 vs. 1.1±0.5, p=0.01). Over a mean follow-up of 6.5±4.2 years, 15 over 139 patients (11%) experienced the primary outcome with an incidence rate of 1.7 per 100 patient-years (95% confidence interval (CI), 1.04–2.85). Higher VAC values were significantly associated with an increased risk of the primary outcome (p for trend = 0.01, Figure 1). VAC was the only functional parameter associated with the primary outcome (hazard ratio (HR) 1.99, 95% CI: 1.06–3.73, p=0.031), secondary outcome (HR 2.33, 95% CI: 1.12–4.82, p=0.023) and tertiary outcome (HR 1.63, 95% CI: 1.09–2.44, p=0.018) in the adjusted analysis (Table 1). Ejection fraction (EF) was not associated with the study outcomes in the adjusted analysis (p&amp;gt;0.05, Table 1) whereas global circumferential and radial strain showed an association limited to the tertiary endpoint (p=0.004, Table 1). Conclusions CMR-derived VAC is associated with adverse outcomes in SRV patients and may improve risk stratification of this unique population. Funding Acknowledgement Type of funding sources: None.

Three dimensional speckle tracking echocardiography in breast cancer patients receiving chemotherapy: incidence and clinical outcomes of subclinical right ventricular systolic dysfunction

Abstract Background The data about the influence of chemotherapy on right ventricular (RV) function and mechanics are scarce and conflicting. Due to the special geometric structure and unique wall motion of the RV, routine techniques for echocardiographic assessment of the RV has challenges. However, 3-dimensional echocardiography (3DE) tracks changes in RV volumes in real time, including the inflow and outflow tracts and the apex throughout the cardiac cycle. 3DE evaluation of RV function and morphology has been compared to cardiac magnetic resonance and is accurate, feasible, and reproducible Methods This study conducted was a retrospective cohort study which included 75 breast cancer patients who underwent chemotherapy at a tertiary hospital from January 2019 to May 2021 to determine clinical outcomes of patients among those who developed an abnormal right ventricular longitudinal free wall strain and global longitudinal strain in terms of all-cause mortality, development of overt right ventricular systolic dysfunction, and adverse cardiovascular events. Results There was a striking statistically significant difference in terms of right ventricular ejection fraction among those who developed an abnormal right ventricular global longitudinal strain at 6 and 12 months post-chemotherapy with a p-value of 0.001 and 0.000 respectively. The difference between the 2 groups of patients in terms of right ventricular global longitudinal strain 6 and 12 months after chemotherapy was also statistically significant (p=0.000). As for the left ventricle, the LV ejection fraction and global longitudinal strain were also statistically significantly different at 12 months post-chemotherapy. Among those who developed an abnormal RV global longitudinal strain, the LV global longitudinal strain was also subsequently lower compared to the normal subgroup at 12 months post-treatment. Conclusion Although the sample size was small, the development of abnormal RV GLS post-chemotherapy was generally associated with subsequent development of overt heart failure, increased all-cause mortality, and CV death. The use of echocardiographic RV GLS surveillance to guide chemotherapy is crucial to enhance clinical outcomes and survival. Funding Acknowledgement Type of funding sources: None.

Prognostic value of left ventricular hemodynamic forces in patients with left ventricular noncompaction

Abstract Introduction Left ventricular noncompaction (LVNC) is a poorly defined entity with LV ejection fraction (LVEF) being the main predictor of major adverse cardiovascular events (MACE). Left ventricular hemodynamic forces (LVHDF) have been recently demonstrated to be promising markers of sub-clinical dysfunction and potential predictors of disease outcome. Purpose To determine in a large cohort of LNVC the LVHDF parameters and its long-term prognostic value. Methods Retrospective, longitudinal, multicentre cohort study including consecutive patients with LVNC from 2000 to 2018. CMR was performed at 1.5T and LVHDF were analyzed with a prototype software (Medis Suite Qstrain). Systolic LVHDF were decomposed into “apex-base” (long-LVHDF) and “lateral-septal” (radial-LVHDF). MACE was defined as a composite of heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and/or all-cause mortality. Results A total of 158 patients were included, age was 53±4.3y and 85 (53.8%) were men. Median LVEF was 44 (IQR 34–55)%, with 61.4% having a LVEF &amp;lt;50%. During a median follow-up of 3.7 (IQR 1.4–5.9) years, MACE occurred in 49 (31%) patients with an unadjusted incidence rate of 8.05 (95% CI 6.0–10.6) events per 100 person-years: 36 HF, 15 VA, 5 SE and 2 deaths. Patients with MACE had significantly worse LVHDF parameters (Table 1). LV-HDF parameters showed no significant variation with age or gender. Spearman coefficient confirmed an inverse correlation between LVEF and long-LVHDF (r=0.478, p&amp;lt;0.0001) and radial-LVHDF (r=0.414, p&amp;lt;0.001). Patients with LVEF &amp;lt;50% (53% vs 78%, p logrank = 0.028) and long-LVHDF &amp;lt;11% (38% vs 84%, p logrank &amp;lt;0.001) had an increased risk of MACE. LVEF (HR 0.97, 95% CI 0.95–0.99, p=0.016), long-LVHDF&amp;lt;11% (HR 5.18, 95% CI 1.1–13.1, p=0.001) and age (HR 1.16, 95% CI 1.06–1.26, p=0.002) were the only variables independently associated with MACE on multivariate analysis. Among patients with LVEF &amp;gt;50%, on univariate regression long-LVHDF &amp;lt;11% (HR 3.32, 95% CI 1.00–11.01, p=0.050) was independently associated with MACE, while LVEF was not (HR 1.04, 95% CI 0.97–1.10, p=0.200). In patients with LVEF &amp;lt;50%, long-LVHDF &amp;lt;11% (HR 7.70, 95% CI 2.40 25.21, p=0.001),and LVEF (HR 0.93,95% CI 0.90–0.95, p&amp;lt;0.001) were independent predictors of outcome on univariate analysis. Conclusions LVHDF in patients LVNC were quantified for the first time, with an adequate correlation with LVEF. Both radial and longitudinal LVHDF were significantly reduced in patients with MACE, however, only misalignment of systolic longitudinal-LVHDF predicted outcomes. In patients with LVEF &amp;gt;50%, reduced longitudinal-LVHDF was associated with prognosis, while LVEF was not, and may serve as an additional tool for risk stratification. Funding Acknowledgement Type of funding sources: None.

Noninvasive Assessment of Left Ventricular Pressure-Volume Relations: Inter- and Intraobserver Variability and Assessment Across Heart Failure Subtypes

A novel method to derive pressure-volume (PV) loops noninvasively from cardiac magnetic resonance images has recently been developed. The aim of this study was to evaluate inter- and intraobserver variability of hemodynamic parameters obtained from noninvasive PV loops in healthy controls, subclinical diastolic dysfunction (SDD), and patients with heart failure with preserved ejection fraction, mildly reduced ejection fraction, and reduced ejection fraction. We included 75 subjects, of whom 15 were healthy controls, 15 subjects with SDD (defined as fulfilling 1 to 2 echocardiographic criteria for diastolic dysfunction), and 15 patients with preserved ejection fraction, 15 with mildly reduced ejection fraction, and 15 with reduced ejection fraction. PV loops were computed using time-resolved left ventricular volumes from cardiac magnetic resonance images and a brachial blood pressure. Inter- and intraobserver variability and intergroup differences of PV loop-derived hemodynamic parameters were assessed. Bias was low and limits of agreement were narrow for all hemodynamic parameters in the inter- and intraobserver comparisons. Interobserver difference for stroke work was 2 ± 9%, potential energy was 4 ± 11%, and maximal ventricular elastance was -4 ± 7%. Intraobserver for stroke work was -1 ± 7%, potential energy was 3 ± 4%, and maximal ventricular elastance was 1 ± 5%. In conclusion, this study presents a fully noninvasive left ventricular PV loop analysis across healthy controls, subjects with SDD, and patients with heart failure with preserved or impaired systolic function. In conclusion, the method for PV loop computation from clinical-standard manual left ventricular segmentation was rapid and robust, bridging the gap between clinical and research settings.

Optimizing pre-donation physiologic evaluation for enhanced recovery after living liver donation - Systematic review and multidisciplinary expert panel recommendations.

While preoperative physiologic evaluation of live liver donors is routinely performed to ensure donor safety and minimize complications, the optimal approach to this evaluation is unknown. We aim to identify predonation physiologic evaluation strategies to improve postoperative short-term outcomes, enhance donor's recovery, and reduce length of stay. We also aim to provide multidisciplinary expert panel recommendations. Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. The systematic review followed PRISMA guidelines, and the recommendations were formulated using GRADE approach and experts' opinion. The search included retrospective or prospective studies, describing outcomes of physiologic evaluation predonation. The outcomes of interest were length of stay, postoperative complications (POC), recovery after donation, and mortality. PROSERO protocol ID CRD42021260662. Of 1386 articles screened, only three retrospective cohort studies met eligibility criteria. Two studies demonstrated no impact of age (<70 years) on POC. Increased body mass index's (BMI) association with POC was present in one study (23.8vs 21.7kg/m2 , OR 1.67 (1.14-2.48), P=.01) and absent in another (<30vs 30-35kg/m2 , P=.61). One study demonstrated decreased risk for postdonation subclinical hepatic dysfunction in donors with higher normal platelet count (PLT). None of the studies noted donor death. Given the scarce data on predonation physiologic testing, the expert panel recommended a battery of tests to guide clinical practice and future investigations. Advancing age (60-69 years) is not a contraindication for liver donation. There is insufficient evidence for a specific predonation BMI cut-off. Abbreviated predonation physiologic testing is recommended in all candidates. Comprehensive testing is recommended in high-risk candidates while considering the pretest probability in various populations (Quality of evidence; Low to Very Low | Grade of Recommendation; Strong).

Role of different echocardiographic modalities in the assessment of microvascular function in women with ischemia and no obstructive coronary arteries.

This review summarizes current knowledge about echocardiographic modalities used to assess microvascular function and left ventricular (LV) systolic function in women with ischemia and no obstructive coronary arteries (INOCA). Although the entire pathophysiological background of this clinical entity still remains elusive, it is primarily linked to microvascular dysfunction which can be assessed by coronary flow velocity reserve. Subtle impairments of LV systolic function in women with INOCA are difficult to assess by interpretation of wall motion abnormalities. LV longitudinal function impairment is considered to be an early marker of subclinical systolic dysfunction and can be assessed by global longitudinal strain quantification.

Comparison of biventricular myocardial strain according to treatment regimens in patients discharged after COVID-19 recovery

Purpose: The effects of different COVID-19 therapeutic strategies on cardiac function are uncertain. Therefore, this study aimed to evaluate the effects of different medical treatments on biventricular function in patients who had recovered from COVID-19.&#x0D; Materials and Methods: Speckle-tracking echocardiography was performed to examine the biventricular myocardial function of patients at follow-up visits after recovery from COVID-19. The patients were divided into two groups based on the medication they used during the active disease: favipiravir (FAV; n = 60) or hydroxychloroquine (HCQ; n = 60). A comparison was made with risk factor–matched controls (n = 41).&#x0D; Results: A total of 161 patients were included in the study. The left ventricular end-diastolic volume, end-systolic volume, end-diastolic diameter, and end-systolic diameter were higher in the HCQ and FAV groups compared to the controls, while the left ventricular ejection fraction was similar between all the groups. The right ventricular diameter was increased, and the systolic pulmonary artery pressure was higher in the HCQ and FAV groups compared to the controls. The left ventricular global longitudinal strain (-18±6.6 vs. -19.7±4.4 vs. -20.4±5, respectively), the right ventricular global longitudinal strain (-19.8±7.5 vs. -22.2±6 vs. -23.4±6.2, respectively), and the right ventricular free wall strain (-16.9±3.6 vs. -18.2±2.4 vs. -19.6±4.7, respectively) were worse in the HCQ group compared to the FAV and control groups.&#x0D; Conclusion: This study found echocardiographic evidence of subclinical cardiac involvement in both the HCQ and FAV groups compared to the controls. However, HCQ treatment was associated with an increased risk of biventricular subclinical systolic dysfunction in COVID-19 survivors compared with FAV treatment.

La cardiomyopathie du Cushing – Cardiac fat in Cushing's syndrome

Cardiovascular disease is the leading cause of death in patients with Cushing's syndrome. Cortisol excess predisposes to well-established cardiovascular risk factors, including hypertension, visceral obesity, dyslipidemia and glucose intolerance, but also exerts direct effects on cardiac structure and function. Increased ventricular mass and subclinical ventricular dysfunction, both potentially reversible after treatment, have been reported in patients with Cushing's syndrome. This increase in ventricular mass contrasts with skeletal muscle atrophy and sarcopenia related to protein wasting induced by hypercortisolism. Cardiac fat might play an important role in the pathogenesis of Cushing's syndrome associated cardiomyopathy. However, in contrast to the general population, in which visceral obesity and diabetes is associated with cardiac steatosis, no increase in intramyocardial lipid content could be found in patients with Cushing's syndrome. Cortisol excess might stimulate beta oxidation and triglyceride consumption and therefore could “protect” cardiomyocytes from ectopic lipid deposition. On the other hand, an accumulation of epicardial and pericardial fat has been observed in Cushing's syndrome. Whereas pericardial fat reflects the thoracic visceral adipose tissue, epicardial fat might be highly susceptible to cortisol, as it decreased following biochemical disease remission in short term follow up. Epicardial fat is directly mixed with the myocardium without being separated by any fascia and shares the same blood supply. It therefore directly exerts paracrine actions on the myocardium and is well known to promote inflammation, microvascular dysfunction and fibrosis. Epicardial fat could play a major role in the pathogenesis of Cushing's syndrome associated cardiomyopathy.

Subclinical sinus node dysfunction in patients with atrial fibrillation-Insight from ultrahigh-resolution mapping of human sinoatrial exits.

Even a short duration of paroxysmal episodes of atrial fibrillation (AF) is associated with sinus node (SN) remodeling and a reduced SN reserve or dysfunction. The number of earliest atrial activation sites (EASs) during sinus rhythm decreases according to the decrease in the SN reserve. We sought to evaluate the EASs during sinus rhythm using an ultrahigh-density mapping system. This study included 35 patients (supraventricular tachycardia [SVT]/paroxysmal atrial fibrillation [PAF]/persistent atrial fibrillation [PsAF] = 5/21/9) who underwent ultrahigh-resolution endocardial mapping of the SN area at rest and during β-stimulation. The number of EASs was determined by the Lumipoint™ algorithm. The number of EASs was greatest in SVT patients both at rest (SVT/PAF/PsAF = 1.4 ± 0.8/1.0 ± 0/1.0 ± 0, p = .04) and during β-stimulation (SVT/PAF/PsAF = 2.6 ± 1.0/1.3 ± 0.6/1.0 ± 0, p < .01). The number significantly increased with β-stimulation as compared to baseline in the PAF patients (p = .02), but not in the PsAF patients. The brain natriuretic peptide (BNP) level was significantly higher in AF than SVT patients (SVT/PAF/PsAF = 12.3 [10.1-14.5]/25.7 [14.8-36.0]/73.4 [57.6-140] pg/ml, p < .01). In the PAF patients, the BNP level was significantly higher in those with unicentric EASs than multicentric EASs during β-stimulation (28.1 [19.1-46.5] vs. 13.1 [9.4-26.9] pg/ml, p = .03), and the optimal cutoff point for the BNP level predicting unicentric EASs was 21.8 pg/ml (sensitivity 82.6%; specificity 85.7%). AF patients have a smaller number of EASs and poorer response to β-stimulation than non-AF patients. An elevated BNP level might predict subclinical SN dysfunction in patients with PAF.

From Structural to Functional Hypertension Mediated Target Organ Damage-A Long Way to Heart Failure with Preserved Ejection Fraction.

Arterial hypertension (AH) is a major risk factor for the development of heart failure (HF) which represents one of the leading causes of mortality and morbidity worldwide. The chronic hemodynamic overload induced by AH is responsible for different types of functional and morphological adaptation of the cardiovascular system, defined as hypertensive mediated target organ damage (HMOD), whose identification is of fundamental importance for diagnostic and prognostic purposes. Among HMODs, left ventricular hypertrophy (LVH), coronary microvascular dysfunction (CMVD), and subclinical systolic dysfunction have been shown to play a role in the pathogenesis of HF and represent promising therapeutic targets. Furthermore, LVH represents a strong predictor of cardiovascular events in hypertensive patients, influencing per se the development of CMVD and systolic dysfunction. Clinical evidence suggests considering LVH as a diagnostic marker for HF with preserved ejection fraction (HFpEF). Several studies have also shown that microalbuminuria, a parameter of abnormal renal function, is implicated in the development of HFpEF and in predicting the prognosis of patients with HF. The present review highlights recent evidence on the main HMOD, focusing in particular on LVH, CMD, subclinical systolic dysfunction, and microalbuminuria leading to HFpEF.

Pulmonary function in patient with ulcerative colitis

Aim: To determine the type and frequency of pulmonary involvement in patients with UC and to determine the distribution of pulmonary dysfunction in patients with UC. Methods: A total of 39 cases of UC, were enrolled consecutively in this study from the Department of Gastroenterology. The age, sex, family history, duration of disease, biochemical parameters (CRP, ESR, blood routine test, etc.), lung function, chest X-ray, diagnoses, and treatments were collected. Patients and controls underwent standard pulmonary function testing. Comparisons of rates among multiple groups were done with Fisher exact test, continuous variables were compared with one-way ANOVA. Results: According to the true love index, the severity of active UC was moderate and severe among 36.7% and 63.3% of subjects respectively. The pulmonary function test “FCV” showed reduced mean FCV among subjects with active UC (2.86±0.77 litres) and inactive UC (3.91±0.62 litres) as compared to controls (4.04±1.14 litres). Among the patients with deranged PFT, 1 (7.6%) had obstructive, 7 (53.8%) had small airway disease and 5 (38.6%) had a restrictive pattern of lung involvement. Conclusion: Subclinical pulmonary dysfunction is frequent in UC and dependent on disease activity. Some alterations were sub-clinical and some of the patients showed troublesome pulmonary symptoms.