Subtle Left Ventricular Systolic Dysfunction Research Articles

Antioxidant Genetic Variants Modify Echocardiography Indices in Long COVID.

Although disturbance of redox homeostasis might be responsible for COVID-19 cardiac complications, this molecular mechanism has not been addressed yet. We have proposed modifying the effects of antioxidant proteins polymorphisms (superoxide dismutase 2 (SOD2), glutathione peroxidase 1 (GPX1), glutathione peroxidase 3 (GPX3) and nuclear factor erythroid 2-related factor 2, (Nrf2)) in individual susceptibility towards the development of cardiac manifestations of long COVID-19. The presence of subclinical cardiac dysfunction was assessed via echocardiography and cardiac magnetic resonance imaging in 174 convalescent COVID-19 patients. SOD2, GPX1, GPX3 and Nrf2 polymorphisms were determined via the appropriate PCR methods. No significant association of the investigated polymorphisms with the risk of arrhythmia development was found. However, the carriers of variant GPX1*T, GPX3*C or Nrf2*A alleles were more than twice less prone for dyspnea development in comparison with the carriers of the referent ones. These findings were even more potentiated in the carriers of any two variant alleles of these genes (OR = 0.273, and p = 0.016). The variant GPX alleles were significantly associated with left atrial and right ventricular echocardiographic parameters, specifically LAVI, RFAC and RV-EF (p = 0.025, p = 0.009, and p = 0.007, respectively). Based on the relation between the variant SOD2*T allele and higher levels of LV echocardiographic parameters, EDD, LVMI and GLS, as well as troponin T (p = 0.038), it can be proposed that recovered COVID-19 patients, who are the carriers of this genetic variant, might have subtle left ventricular systolic dysfunction. No significant association between the investigated polymorphisms and cardiac disfunction was observed when cardiac magnetic resonance imaging was performed. Our results on the association between antioxidant genetic variants and long COVID cardiological manifestations highlight the involvement of genetic propensity in both acute and long COVID clinical manifestations.

Part 2: The Clinical Applications of Left Ventricular Myocardial Strain

There is an increasing prevalence of cardiovascular disease and heart failure. Indices of left ventricular (LV) systolic function such as LV ejection fraction used to identify those at risk of adverse cardiac events such as heart failure may not be truly representative of LV systolic function in certain cardiac diseases. Given that LV ejection fraction reduction may represent more advanced irreversible stages of disease, measures of myocardial strain have emerged as a feasible and robust instrument for the early identification of heart disease and subtle LV systolic dysfunction. The purpose of this review was to provide an overview of emerging clinical applications of LV global longitudinal strain in valvular and cardiomyopathic diseases and coronavirus disease 2019.

Part 1: The Clinical Applications of Left Ventricular Myocardial Strain.

There is an increasing prevalence of cardiovascular disease and heart failure. Indices of left ventricular (LV) systolic function such as LV ejection fraction used to identify those at risk of adverse cardiac events such as heart failure may not be truly representative of LV systolic function in certain cardiac diseases. Given that LV ejection fraction reduction may represent more advanced irreversible stages of disease, measures of myocardial strain have emerged as a feasible and robust instrument for the early identification of heart disease and subtle LV systolic dysfunction. The purpose of this review was to provide an overview of myocardial strain concepts and emerging clinical applications of global longitudinal strain in cardio-oncology.

Cardiovascular complications of Cushings syndrome: Impact on morbidity and mortality.

Cardiovascular complications of Cushings syndrome: Impact on morbidity and mortality.

Impaired Left Ventricular Circumferential Midwall Systolic Performance Appears Linked to Depressed Preload, but Not Intrinsic Contractile Dysfunction or Excessive Afterload, in Paradoxical Low-Flow/Low-Gradient Severe Aortic Stenosis.

Paradoxical low-flow/low-gradient aortic stenosis (P-LFLG-AS) occurs in about one-third of patients with severe AS and preserved left ventricular (LV) ejection fraction (EF). Our aim was to differentiate between altered LV loading conditions and contractility as determinants of subtle LV systolic dysfunction in P-LFLG-AS. We retrospectively analyzed medical records of patients with isolated severe degenerative AS and preserved EF (30 subjects with P-LFLG-AS and 30 patients with normal-flow/high-gradient severe AS (NFHG-AS)), without relevant coexistent diseases (e.g., diabetes, coronary artery disease and chronic kidney disease) or any abnormalities which could account for a low-flow state. Patients with P-LFLG-AS and NFHG-AS did not differ in aortic valve area index and most clinical characteristics. Compared to NFHG-AS, subjects with P-LFLG-AS exhibited smaller LV end-diastolic diameter (LVd) (44 ± 5 vs. 54 ± 5 mm, p < 0.001) (consistent with lower LV preload) with pronounced concentric remodeling, higher valvulo-arterial impedance (3.8 ± 1.1 vs. 2.2 ± 0.5 mmHg per mL/m2, p < 0.001) and diminished systemic arterial compliance (0.45 ± 0.11 vs. 0.76 ± 0.23 mL/m2 per mmHg, p < 0.001), while circumferential end-systolic LV midwall stress (cESS), an estimate of afterload at the LV level, was similar in P-LFLG-AS and NFHG-AS (175 ± 83 vs. 198 ± 69 hPa, p = 0.3). LV midwall fractional shortening (mwFS) was depressed in P-LFLG-AS vs. NFHG-AS (12.3 ± 3.5 vs. 14.7 ± 2.9%, p = 0.006) despite similar EF (61 ± 6 vs. 59 ± 8%, p = 0.4). By multiple regression, the presence of P-LFLG-AS remained a significant predictor of lower mwFS compared to NFHG-AS upon adjustment for cESS (β ± SEM: −2.35 ± 0.67, p < 0.001); however, the significance was lost after further correction for LVd (β = −1.10 ± 0.85, p = 0.21). In conclusion, the association of P-LFLG-AS with a lower cESS-adjusted mwFS, an index of afterload-corrected LV circumferential systolic function at the midwall level, appears secondary to a smaller LV end-diastolic cavity size according to the Frank–Starling law. Thus, low LV preload, not intrinsic contractile dysfunction or excessive afterload, may account for impaired LV circumferential midwall systolic performance in P-LFLG-AS.

Global longitudinal strain detects subtle left ventricular systolic dysfunction in Duchenne muscular dystrophy patients and carriers

BackgroundWith the continuous improvement of the respiratory care of Duchenne muscular dystrophy patients, cardiac manifestations (heart failure and arrhythmias) become the leading causes of morbidity and mortality. Early identification of cardiac muscle affection is crucial to start anti-failure drugs that reverse remodeling and improve prognosis. This study aimed to detect subtle cardiac changes in Duchenne muscular dystrophy patients and carriers using electrocardiography and echocardiography.ResultsThis study included genetically diagnosed Duchenne muscular dystrophy patients (28 males) and carriers (25 females) and compared them to healthy gender-matched control groups. All study participants underwent clinical assessment, 12-lead electrocardiography, and global longitudinal strain augmented echocardiography. In the current study, Duchenne muscular dystrophy patients had higher heart rates, smaller left ventricular internal diameters, left atrial diameter, lower ejection fraction, and worse left ventricular global longitudinal strain in comparison with the control group. The global longitudinal strain inversely correlated with the age of Duchenne muscular dystrophy patients. The number of exon mutations did not affect electrocardiography and echocardiographic findings. Exon mutations 45–47 and 51–54 were significantly associated with an ejection fraction less than 60%. Duchenne muscular dystrophy carriers had smaller left ventricular wall diameters, left ventricular end-diastolic diameter, left atrial diameter, and worse left ventricular global longitudinal strain in comparison with the control group.ConclusionsLeft ventricular global longitudinal strain could detect subtle left ventricular systolic dysfunction in Duchenne muscular dystrophy patients and carriers before the decline of left ventricular ejection fraction.

Subtle cardiac dysfunction in lymphoma patients receiving low to moderate dose chemotherapy

Left ventricular (LV) global peak systolic longitudinal strain (GLS) is a sensitive measurement for detecting subtle LV systolic dysfunction and a powerful prognostic predictor. However, the clinical implication of LV GLS in lymphoma patients receiving cancer therapy remains unknown. We prospectively enrolled 74 lymphoma patients (57.9 ± 17.0 years old, 57% male). We performed echocardiographic studies after the 3rd and 6th cycles and 1 year after chemotherapy and a cardiopulmonary exercise test upon completion of 3 cycles of anticancer therapy. Cancer therapy-related cardiac dysfunction (CTRCD) was defined as a ≥ 15% relative reduction in GLS value from baseline. The primary outcome was a composite of all-cause mortality and heart failure events. Thirty-six patients (49%) had CTRCD (LV GLS: baseline vs. after 3rd cycle of therapy: 20.1 ± 2.6 vs. 17.5 ± 2.3%, p < 0.001). CTRCD was detected after the 3rd cycle of anticancer therapy. CTRCD patients had impaired exercise capacity (minute oxygen consumption/kg, CTRCD vs. CTRCD (-): 13.9 ± 3.1 vs. 17.0 ± 3.9 ml/kg/min, p = 0.02). More primary outcome events occurred in the CTRCD group (hazard ratio 3.21; 95% confidence interval 1.04–9.97; p = 0.03). LV GLS could detect subtle but clinically significant cardiac dysfunction in lymphoma patients in the early stage of anticancer therapy. CTRCD may be associated with not only a reduced exercise capacity but also a worse prognosis.

Evidence of subtle left ventricular systolic dysfunction in cryptogenic stroke in the young.

Ischemic stroke in young patients often remains cryptogenic, that is, no underlying reason can be found. Some of these strokes may originate in the heart. Left ventricular (LV) dynamic volumetry and strain analysis are relatively new and promising methods for evaluating LV function. In this pilot study, we recruited 30 young (18-50years) patients with cryptogenic ischemic stroke and 30 age- and sex-matched controls from the SECRETO study (NCT01934725). The LV systolic function was assessed by LV volumetry (ejection fraction, peak emptying rate, and time to peak emptying rate). The longitudinal systolic function was assessed by speckle tracking strain and strain rate imaging, and by tissue velocity imaging derived MAD (mitral annular displacement) and septal S'. Stroke patients had less vigorous global longitudinal strain (median -18.9, interquartile range 3.3), compared to healthy controls (median -20.0, interquartile range 2.8), P=.010. There was no statistically significant differences in septal S', MAD, global longitudinal strain rate, or dynamic volumetry-derived parameters between the two groups. Young cryptogenic stroke patients have subtly altered systolic function compared to healthy controls, found merely with longitudinal strain analysis. This infers that the heart may play a role in the pathogenesis of cryptogenic ischemic stroke.

Association Between Subclinical Left Ventricular Myocardial Systolic Dysfunction Detected by Strain and Strain‑Rate Imaging and Liver Steatosis and Fibrosis Detected by Elastography and Controlled Attenuation Parameter in Patients with Metabolic Syndrome.

PurposeThe components of metabolic syndrome (MS) are risk factors for developing both cardiovascular disease (CVD) and non-alcoholic fatty liver disease (NAFLD). Strain (SI) and strain‑rate imaging (SRI) are able to recognize early changes in cardiac function. Vibration-controlled transient elastography (VCTE) and controlled attenuation parameter (CAP) detect and quantify liver fibrosis and steatosis. We aimed to assess whether there is any correlation between liver fibrosis and steatosis and left ventricular (LV) dysfunction in MS patients.Patients and MethodsA total of 150 adults with MS were registered in the study. They were compared with a control group of 150 age- and sex-matched adults without MS. After the classic echocardiographic assessment of LV function, two-dimensional speckle echocardiography (2D-STE) was used to evaluate LV peak systolic strain (S) and peak systolic strain rate (SR), while liver steatosis and fibrosis were evaluated by VCTE and CAP.ResultsLV diastolic dysfunction was significantly more frequent among the patients with MS. We found significant differences between the two groups regarding the presence of subtle LV systolic dysfunction, detected by reduced values of S and SR. The risk for LV diastolic dysfunction was 3.6 times higher in MS with severe steatosis and 8 times higher in patients with severe fibrosis, P<0.0001. The risk for LV systolic dysfunction was double in MS with severe steatosis and 1.7 times higher in MS with severe fibrosis, P<0.0001.ConclusionIn MS patients with normal LV ejection fraction, conventional echocardiography parameters identified diastolic LV dysfunction, while SI and SRI identified subtle impairment of systolic LV dysfunction. The presence of hepatic steatosis and fibrosis increases significantly the risk for cardiac dysfunction in MS patients (P<0.0001).

Effect of pericardial incision on left ventricular morphology and systolic function in patients during coronary artery bypass grafting

BackgroundAccurate assessment of left ventricular (LV) systolic function is important after coronary artery bypass grafting (CABG). LV ejection fraction (LVEF) is conventionally used to evaluate LV systolic function; deformation parameters can be used to detect subtle LV systolic dysfunction. It is unclear whether an incised pericardium without sutures during CABG could affect LV morphology and function. We investigated the effect of pericardial incision on LV morphology and systolic function during CABG.MethodsIntraoperative transesophageal echocardiography was performed in 27 patients during elective off-pump beating heart CABG 5 min before and after pericardial incision. LV longitudinal and mid-cavity transversal diameters, sphericity index, volumes, and LVEF were measured. LV global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and twist obtained by two-dimensional speckle tracking echocardiography were measured simultaneously.ResultsLV mid-cavity transversal diameter increased, while the LV sphericity index decreased (P < 0.001) immediately after pericardial incision. The GLS, GCS, and twist significantly decreased, while the GRS notably increased (P < 0.001). The LV volumes and LVEF remained unchanged.ConclusionsPericardial incision immediately transformed LV morphology from an ellipsoid to sphere, with decreased longitudinal and circumferential strain and twist, and increased radial strain, while LVEF remained unchanged. This should be considered when evaluating LV systolic function in patients after CABG.

P775 Assessment of left ventricular function in patients with atrial fibrillation using real time triplain speckle tracking in comparison with 2D speckle tracking

Abstract Background Atrial fibrillation (AF) is one of the most common cardiovascular diseases in the world, can cause many structural and functional cardiac abnormalities, one of them is left ventricular (LV) systolic dysfunction which may not be detected by conventional echocardiographic parameters (CEP) and need to use a modality of real time triplain (3P) speckle tracking strain for early detection and improvement of prognosis Purpose Assessment of LV systolic function in AF patients with normal ejection fraction (EF) using 3P speckle-tracking strain and its role as early predictor of subclinical dysfunction Methods A case-control study was conducted at Baghdad Heart Center, Baghdad Medical City since July 2017 to July 2018, including patients with AF and control group. The CEP (EF, diastolic function, mitral annular plane systolic excursion) and speckle tracking longitudinal strain were done for the patients by 3P in comparison with two dimension (2D) Results The study included two groups. First group: 100 patients with AF, mean age (48 ± 12.2) ranging between (25-81), (48%) men, (52%) women. Second group: 100 control patients with mean age (46.4 ± 13.1) ranging between (20-84), (58%) men, (42%) women. 3P method showed more easy and accurate in comparison with 2D method in patients with AF. Applying cut off value of (-17.5%), it was found that 71% of AF patients had undetected LV systolic dysfunction even with preserved EF. Global longitudinal strain was reduced significantly in those with AF group and reduced mitral annular plane systolic excursion Conclusion(s) Real time triplain speckle tracking can be dependable which is easy, useful, and more accurate in comparison with 2D method in assessment of LV function in patients with AF. 3P method is a useful tool in the early detection of subtle LV systolic dysfunction in AF patients with preserved EF and in whom more aggressive interventions could have a significant impact on prognosis. 3P vs 2D in Patients with AF and Control Average GLS by 3P % Average GLS by 2D % p-value No. Mean± SD No. Mean± SD AF group EF &amp;lt; 52 % 29 -11.23± 3.89 29 -12.05± 3.84 0.01 EF ≥53 % 71 -13.30± 2.55 71 -14.20± 2.64 0.001 Control group EF &amp;lt; 52 % 2 -21.15± 4.45 2 -20.20± 1.84 0.6 EF ≥53 % 98 -19.14± 1.49 98 -19.91± 1.66 0.001 3P, real time triplain; 2D, two dimension; AF, atrial fibrillation; GLS, global longitudinal strain; SD, standard deviation; EF, ejection fraction

P2741Predictors of subtle left ventricular systolic dysfunction after treatment of coarctation of the aorta

Abstract Background With the advent of the term “Heart Failure with Preserved Ejection Fraction - HFpEF”, more and more evidence has emerged supporting the importance of Speckle Tracking Echocardiography in measurement of Left ventricular (LV) Strain to assess subtle myocardial systolic dysfunction in such patients. Aim: To assess Global Longitudinal stain (GLS) of the LV in patients with Coarctation of the Aorta (CoA) after surgical or percutaneous treatment and predict the variables affecting the occurrence of subtle myocardial dysfunction in these patients. Patients and methods This was a cross sectional observational study that included 77 patients who presented to Ain Shams University hospital for follow up post treatment of Coarctation of the Aorta. All of these patients underwent intervention (surgical or catheter based) in the period between January 2005 and December 2017 and aged between 15 and 40 years at the time of the study. The patients underwent a detailed transthoracic echocardiogram, including Speckle Tracking using Phillips Q Lab version 7.1 software. All patients had normal systolic functions as measured by LV ejection fraction using Modified Simpsons' method. Correlations between variables were studied using “Independent paired T test and Chi square test”. Results The mean follow up duration was 13.19±3 years. The least accepted GLS value using the Phillips Q Lab version 7.1 software was −16.4%. Accordingly, the study group was divided into two groups (Normal GLS and Abnormal GLS). Nineteen patients had a low GLS, representing 24% of the study population. There was no age nor sex predilection between the two groups. Age at first intervention correlated positively with GLS (p=0.01), meaning that earlier intervention lead to better LV strain as the GLS is a negative value. Patients with Bicuspid Aortic Valve and those having Left ventricular Hypertrophy had significantly lower GLS (p=0.001). Patients with continuous abdominal Aortic flow had significantly lower GLS as compared to patients with pulsatile flow (p=0.005) (see figure). The occurrence of complications, e.g. stent fracture or recoarctation caused a significant reduction in GLS (p=0.012). Type of intervention, Order of interventions and age at second and third interventions did not significantly affect the GLS. CoA dimensions by MSCT and presence of Hypertension both before and after treatment did not affect the GLS. Effect of Aortic flow on GLS Conclusions Although most patients post CoA repair have normal LV ejection fraction, a good proportion of them have impaired LV global longitudinal strain and are thus prone to HFpEF. Earlier age at intervention, absence of complications and LV hypertrophy, as well as presence of pulsatile Abdominal Aortic flow lead to better LV performance as measured by GLS. LV strain derived from Speckle Tracking Echocardiography should be an integral part of follow up of CoA patients after repair. Acknowledgement/Funding None

Subclinical Systolic Myocardial Dysfunction in Diabetic Patients by 2-Dimensional Speckle Tracking

Background: Diabetic cardiomyopathy became a subject of great interest and the evidence for this entity is rapidly emerging as the incidence of heart failure is increasing in those patients even with no hypertension or coronary artery disease (CAD). Objective: The current study was aimed at early detection of subtle left ventricular systolic dysfunction by speckle tracking echocardiography in patients with Diabetes Mellitus with and without hypertension. Patients and methods: This study included a total of 100 asymptomatic poorly controlled diabetic patients with or without hypertension and no structural heart disease and 25 age-matched apparently healthy control subjects attending at Cardiology department, Al-Azhar University Hospital in Damietta. The included subjects were divided into three groups; Group I (control) consisted of 25 apparently healthy subjects, Group II (diabetic normotensive group) consisted of 64 patients and Group III (diabetic hypertensive) consisted of 36 patients. The following were done for all: resting ECG, HbA1c, conventional echo assessment and finally strain imaging with measurement of LV-GLS and LV-GCS. Results: There was a significant inverse correlation between the duration diabetes, BMI and LV-GLS. On the other hand, there was no significant correlation between hypertension or HbA1c and echocardiographic parameters including conventional and strain methods. Patients with higher BMI had more decrease in LV circumferential strain while patients with longer periods of DM and higher values of BMI had a decrease on both global LV longitudinal and circumferential strains. Conclusion: It could be concluded that assessment of left ventricular (LV) systolic function in patients with diabetes mellitus by speckle tracking echocardiographic modalities can detect subtle LV dysfunction earlier than conventional echocardiographic measures.

Early Detection of Left Ventricular Systolic Dysfunction in Asymptomatic Patients with Chronic Aortic Regurgitation by two Dimensional Speckle Tracking Echocardiography

Background: Early detection of subclinical left ventricular (LV) systolic dysfunction is crucial and could influence patients' prognosis by aiding the clinician to candidate patients for better management.&#x0D; Objective: To detect early LV systolic dysfunction in asymptomatic patient with chronic aortic regurgitation by two dimensional speckle tracking echocardiography.&#x0D; Methods: Sixty one asymptomatic patients with chronic aortic regurgitation, with no ischemic heart diseases (by coronary angiography) or conductive heart diseases, no diabetes mellitus, no hypertension, and no other valvular heart diseases (group 1) and fifty age and sex-matched healthy subjects (group 2) were enrolled into the study. Group (1) was further classified into 3 sub-groups according to 4 chosen parameters from the published guidelines of American Society of Echocardiography (ASE) into: Mild AR, Moderate AR, and Severe AR.&#x0D; All patients and controls underwent echocardiographic examination including conventional echocardiography, tissue Doppler study and Two Dimensional (2-D) Speckle Tracking Echocardiography.&#x0D; Results: GLS showed the highest sensitivity and specificity in detection of subtle LV systolic dysfunction in moderate AR. In moderate AR,a cut off value of &gt; (-19.62) has sensitivity and specificity of 91.3% and 95.5% respectively, with Positive Predictive Value (PPV) and Negative Predictive Value ( NPV ) of 87.5% and 96.9% respectively, Area under curve (AUC) of 0.981. In all types of AR, GLS had higher NPV than PPV which makes it a powerful screening tool for early detection of subtle LV systolic dysfunction.&#x0D; Conclusion: Global Longitudinal strain measured by 2-D speckle tracking echocardiography is an excellent tool for early detection of subtle LV systolic dysfunction in asymptomatic patients with chronic AR&#x0D;

Evaluation of Subtle Left Ventricular Systolic Dysfunction by Longitudinal Systolic Strain in Patients with Human Immunodeficiency Virus.

Although left ventricular systolic dysfunction (LVSD) is a major cause of morbidity in human immunodeficiency virus (HIV)-infected patients, there is limited data on cardiac functions of these patients. Compared to the conventional echocardiography, the global longitudinal strain (GLS) can detect subclinical myocardial dysfunction at an earlier stage. In our study, we aimed to evaluate left ventricular systolic functions using the GLS in HIV-infected patients and to investigate the effect of cluster of differentiation 4 T-cell values on LVSD. This prospective, case-control study included a total of 65 HIV-infected patients and 48 healthy volunteers. Conventional and strain echocardiography were performed on all participants. In HIV-infected patients, CD4 T-cell counts and HIV-ribonucleic acid (HIV-RNA) values were measured. The median CD4 T-cell count was 529.65 cells/mm3 in the HIV-infected patients and median duration of living with HIV was 16.25 (range: 2 to 120) months. Baseline characteristics and left ventricular ejection fraction values were similar in both groups. However, there was a significant difference in the low-density lipoprotein cholesterol, triglycerides, interventricular septum, left ventricular posterior wall, and GLS between the groups (p = 0.013, p = 0.005, 0.041, p = 0.013, and p = 0.003, respectively). There was a positive correlation between GLS and CD4 levels (r = 0.463, p < 0.001). Our study results suggest that reduced CD4 T-cell counts in HIV-infected patients may cause myocardial dysfunction and GLS can be useful to show subtle LVSD asymptomatic cases.

Assessment of left ventricular systolic function by tissue Doppler imaging in controlled versus uncontrolled type 2 diabetic patients.

AimTo detect and quantify early subtle left ventricular (LV) systolic dysfunction using Tissue Doppler Imaging in type 2 diabetic patients with apparently normal LV ejection fraction.MethodsNinety age and sex matched subjects were enrolled in the study, sixty of them were suffering from type 2 diabetes mellitus (DM) whom were divided according to HbAlc into 2 groups, 30 uncontrolled diabetic patients with HbAlc > 8% and 30 controlled diabetic patients with HbAlc < 8% and a third group of 30 normal subjects served as controls. We excluded patients with inadequate Doppler signal, all structural heart diseases, systemic disorders with cardiac involvement and patients with false positive HbAlc. Assessment of diastolic function was done by Pulsed Doppler through mitral flow and by propagation flow velocity. Assessment of left ventricular systolic function was done by conventional echocardiography by 2D Simpson method and by Tissue Doppler Imaging (TDI) through detection of mitral annular peak systolic velocities.ResultsLeft ventricular diastolic function was compared between the studied groups and showed that the mean peak early mitral inflow velocity E wave and the color M-mode flow propagation velocity of early diastolic flow (Vp) were significantly lower, and the mean peak late mitral inflow velocity A wave was significantly higher in uncontrolled diabetics versus controlled diabetic patients and control group with highly significant statistical difference (p < 0.001). Assessment of global systolic function by conventional Simpson’s modified biplane method didn’t show significant difference between uncontrolled diabetic patients, controlled diabetic patients and normal individuals. However, evaluation of systolic function by Tissue Doppler Imaging showed that the mean peak longitudinal systolic velocity was significantly decreased in uncontrolled diabetic patients when compared to controlled diabetic patients and normal individuals, with highly significant statistical difference (p < 0.001). A cut-off value for systolic dysfunction detected by TDI in uncontrolled diabetic patients was calculated. The peak systolic velocities < 7 cm/s for medial mitral annulus and < 8.2 cm/s for lateral mitral annulus indicated systolic dysfunction in diabetic patients with sensitivity and specificity of 96% and 67% respectively for medial mitral annulus while 98% and 71% respectively for lateral annulus.ConclusionTDI is a simple and effective method for detection of subtle LV systolic dysfunction in type 2 uncontrolled diabetic patients.

SY12-1 - Role of Echocardiographic Strain Imaging for Patients With Heart Failure

The risk stratification of patients with heart failure (HF) can be performed using echocardiographic parameters such as left ventricular (LV) ejection fraction (LVEF). Since LVEF reflects merely the change in LV volume but does not take into consideration ultrastructural changes that may occur at the myocardial level and that may impair LV systolic performance. Thus, LVEF may not truly represent LV systolic function in specific cardiac diseases or when subtle LV systolic dysfunction is present. Two-dimensional speckle-tracking is a post-processing computer algorithm that uses the routine grayscale digital images, and enables assessment of myocardial strain, thereby providing detailed information on global and regional active LV deformation. Global longitudinal strain (GLS), which was defined as the average peak strain of 18 segments from standard apical views, provides the best evidence on the diagnostic and prognostic implications, and the ability of GLS to predict cardiovascular outcome may be superior to LVEF. This presentation reviews the strengths of echocardiographic speckle-tracking strain imaging, especially GLS, and its current potential for clinical use in patients with HF.

Atrial fibrillation per se was a major determinant of global left ventricular longitudinal systolic strain.

Atrial fibrillation (AF) may cause systolic abnormality via inadequate diastolic filling and tachycardia-induced cardiomyopathy. Global longitudinal strain (GLS) is a very sensitive method for detecting subtle left ventricular systolic dysfunction. Hence, this study aimed to evaluate whether AF patients had a more impaired GLS, AF was a major determinant of GLS, and determine the major correlates of GLS in AF patients.The study included 137 patients with persistent AF and left ventricular ejection fraction (LVEF) above 50% and 137 non-AF patients matched according to age, gender, and LVEF. Comprehensive echocardiography with GLS assessment was performed for all cases.Compared with non-AF patients, AF patients had a more impaired GLS, a larger left atrial volume index, higher transmitral E wave velocity (E), and early diastolic mitral velocity (Ea) (all P < 0.001) but comparable E/Ea. After adjustment for baseline and echocardiographic characteristics, the presence of AF remained significantly associated with impaired GLS (β = 0.533, P < 0.001). In addition, multivariate analysis of AF patients indicated that faster heart rates and decreased E, Ea, and LVEF were associated with more impaired GLS.This study demonstrated that AF patients had a more impaired GLS than non-AF patients, although LVEF was comparable between the 2 groups. AF was a major determinant of GLS even after adjustment for relevant clinical and echocardiographic parameters.

The mechanism of reduced longitudinal left ventricular systolic function in hypertensive patients with normal ejection fraction.

MacIver and Townsend's hypothesis predicts, based on a mathematical model of left ventricular contraction, that preserved absolute radial wall thickening (radWT) due to left ventricular hypertrophy is responsible for the normal ejection fraction in patients with heart failure with preserved ejection fraction (HFPEF). We tested the validity of this hypothesis by detailed echocardiography including evaluation of ventricular myocardial strain (S) using speckle tracking imaging in at least 60-year-old 18 controls and 94 hypertensive patients with normal ejection fraction. Echocardiography revealed no left ventricular diastolic dysfunction in 38 out of 94 (40%) patients with hypertension (HTDD-negative group), and 56 out of 94 (60%) patients had diastolic dysfunction (HTDD-positive groups). The absolute values of global longitudinal left ventricular peak systolic S were significantly reduced in both patient groups (P < 0.05 for HTDD-negative, P < 0.01 for HTDD-positive groups) vs. the controls. There were no significant between-groups differences in circumferential and radial peak left ventricular systolic Ss, radWT and ejection fraction. Left ventricular mass (LVM) (P < 0.001), LVM/BMI (P < 0.01) increased in the HTDD-positive group and ejection fraction/LVM/BMI decreased in both patient groups (P < 0.01 for HTDD-negative, P < 0.001 for HTDD-positive groups) vs. the controls. LVM increased, ejection fraction/LVM/BMI decreased in the HTDD-positive group vs. the HTDD-negative group (P < 0.05 and P < 0.01, respectively). We demonstrated decreased longitudinal left ventricular systolic function and showed that preserved ejection fraction was due to preserved absolute radWT and not due to increased radial or circumferential systolic function in patients with hypertension and normal ejection fraction, a potential HFPEF precursor condition. Instead of ejection fraction, rather ejection fraction/LVM/BMI might be used to detect subtle left ventricular systolic dysfunction in hypertension and HFPEF.

Myocardial deformation imaging unmasks subtle left ventricular systolic dysfunction in asymptomatic and treatment-naïve HIV patients.

Patients infected by the human immunodeficiency virus (HIV) and receiving highly active antiretroviral therapy have a higher incidence of cardiovascular disease than healthy subjects, but little is known about cardiac function in asymptomatic and treatment-naïve patients. We sought to study cardiac function in asymptomatic HIV-infected, treatment-naïve patients. We studied 41 HIV-infected and treatment-naïve patients and 20 age- and sex-matched healthy controls. Patients with cardiac symptoms, history of cardiac disease or NT-proBNP >100pg/mL were excluded. We addressed cardiac function using standard echocardiography along with tissue Doppler (TDI) measurements, including strain/strain rate assessment. Standard echocardiographic parameters did not differ between groups, except for transmitral E wave velocity (64.8±14cm/s in HIV vs 76.1±10cm/s in controls, p=0.002). In contrast, TDI mitral and tricuspid annulus s velocity and all strain/strain rate measurements were significantly lower in HIV patients: s lateral, 10.2±2.4/11.3±0.7, p=0.011; s septal, 8.1±1.6/8.7±0.8, p=0.045; s tricuspid, 13.4±2.3/14.9±1.3, p=0.002; strain/strain rate, septal (strain/strain rate, 15.1±5.7/-0.9±0.3, 25.3±1.7/-1.9±0.2, p<0.001), anterior (16.7±3/-1.0±0.1, 26.7±1.7/-1.9±0.2, p<0.001), lateral (16.0±6/-1.0±0.1, 27.5±1.8/-2.2±0.3, p<0.001) and posterior (15.2±5.8/-1.0±0.2, 26.2±1.8/-2.2±0.3, p<0.001) left ventricular wall. HIV infection itself is accompanied by subclinical systolic dysfunction, not apparent to standard echocardiography that can be unmasked though using sensitive echocardiographic techniques.