Tissue Doppler Imaging Measurements Research Articles

A new protocol for a single-stage combined cardiopulmonary and echocardiography exercise test: a pilot study

Abstract Aims The value of cardiopulmonary exercise testing (CPET) and exercise stress echocardiography (ESE) in managing cardiac disease is well known, but no standard CPET–ESE protocol is currently recommended. This pilot study aims to compare feasibility and cardiac function responses between a new high-intensity single-stage combined test (CPET–hiESE) and a standard maximal ESE (smESE). Methods and results After screening and maximal CPET, all volunteers (n = 21) underwent three ESE modalities: (i) based on the gas exchange threshold (hiESE–GET, 40% of peak-GET, 6 min), (ii) based on heart rate (HR) (hiESE–HR, 80% of peak HR, 6 min), and (iii) smESE (85% of predicted peak HR for age, 3 min). Speckle tracking echocardiography (STE) and tissue Doppler imaging (TDI) were measured at each step. There was superior image quality and data completeness for the right ventricle strain for both hiESE modalities compared with smESE (71.4 and 76.2 vs. 42.9%, P = 0.07). Left ventricular STE data completeness was similar for all three conditions. Despite systematically higher HR, work rate and levels of exertion in the smESE compared with hiESE, STE and TDI parameters were not systematically different. Concordance correlation coefficients ranged from 0.56 to 0.88, lowest for strain rate parameters and mean difference from −0.34 to 1.53, highest for TDI measurements. Conclusion The novel CPET–hiESE protocol allowed for better data completeness, at lower levels of exertion compared with smESE, without systematically different cardiac reserve measurements in healthy participants. This single-stage protocol can be individualized to clinical populations, which would provide practical advantages to standard testing.

Usefulness of Tissue Doppler Imaging for the Evaluation of Pulmonary Hypertension in Canine Heartworm Disease

Background: Dirofilaria immitis is a nematode that produces proliferative pulmonary endarteritis in dogs due to direct contact of the adult parasites with the intima layer of the pulmonary arteries, leading to irreversible severe structural damage and sustained pulmonary hypertension (PH), which can produce severe cardiorespiratory disorders. The purpose of this study was to assess the diagnostic value of the echocardiography tissue Doppler imaging (TDI) in determining the presence of PH in dogs with heartworm disease. Methods: There were 116 heartworm-infected dogs with PH and 33 healthy dogs included in the study. Based on the right pulmonary artery distensibility index (RPADi) < 29.5%, PH was present in 47.4% of infected dogs. Additionally, the animals were evaluated using other standard alternative echocardiographic measures to estimate PH. Moreover, a total of eight echocardiographic measurements were analysed using the TDI to determine its usefulness in diagnosing PH (E′, A′, S, E′:A′, global TDI, HRI-IVCT, HRI-IVRT, R-TEI). Results: The TDI measurements showed significant differences between dogs with and without PH, demonstrating a positive correlation with respect to the RPADi. In addition, cut-off values for the detection of PH with excellent sensitivity and specificity were found for E′:A′, global TDI, HRI-IVCT, HRI-IVRT and R-TEI. Conclusions: The TDI mode may be useful as an adjunct diagnostic method for the determination of PH in dogs with Dirofilaria immitis.

Right ventricular strain by speckle tracking echocardiography in patients with systemic scleroderma and absence of pulmonary hypertension

Abstract Funding Acknowledgements Type of funding sources: None. Introduction In patients with scleroderma the morphological remodeling and alteration of right ventricular (RV) function begins even before the setting of pulmonary artery hypertension (PAH). These alterations are associated with worse outcomes and high mortality rate as 30% of deaths are attributed to cardiovascular causes followed by respiratory causes (17%). Purpose Early detection of RV dysfunction is possible using advanced imaging techniques and can lead to specific therapeutic management before installation of PAH and clinical signs and symptoms of heart failure . Purpose of this study is to evaluate new indices, based on speckle tracking echocardiography, for identification of subclinical RV systolic failure. Methods Thirty (30) scleroderma patients without any signs or symptoms of PAH and forty (40) healthy subjects were included in the present study. Two-dimensional echocardiography (2DE) and two-dimensional speckle-tracking echocardiography (2DSTE) were performed. All the usual 2DE, Doppler and tissue Doppler imaging measurements were obtained for the evaluation of RV function. Moreover, TAPSE, maximum systolic myocardial velocity from TDI of lateral tricuspid valve annulus (SRV), auto RV global longitudinal strain (aRVGLS) and auto RV free wall longitudinal strain (aRVFWLS) by 2DSTE were measured. aRVGLS and aRVFWLS are new indices, with appropriate RV function echo logistics in new technology echo systems, independent from known manual measurements. Results In scleroderma patients significantly higher systolic pulmonary artery pressure was recorded, although it remained within normal limits in both groups (24.6+-5.4mmHg vs 19.2+-5.9 mmHg) . Scleroderma patients had significant decreased RV systolic function with significantly lower TAPSE and SRV. Both aRVGLS and aRVFWLS were also lower in scleroderma patients compared to the control group (−18.6+-2.7 vs −23.1+-2.3 % and −25.4+-3.1 vs −26.4+-2.2 % respectively). aRVGLS was the best significant predictor of early RV systolic impairment in patients with scleroderma.The difference in aRVFWLS was not significant. Conclusions Scleroderma is a severe systematic disease associated with high mortality rates. RV remodeling, dysfunction, and progressive pulmonary artery hypertension are among the most important internal organ manifestations of this disease. Early detection of RV dysfunction before installation of pulmonary hypertension is possible by 2DSTE, and may be helpful to guide further therapy in these patients.

Role of P Wave Duration and Tissue Doppler Imaging as Predictive Indicators for Paroxysmal Atrial Fibrillation in Hypertensive Patients

Background: Atrial fibrillation (AF) is the most prevalent chronic arrhythmia in the heart. AF accounts for one-third of rhythm disorder hospitalizations. AF increases profoundly the risk of stroke, heart failure, and death. This study used P-wave and transthoracic echocardiography with tissue Doppler imaging (TDI) to determine paroxysmal AF predictors in hypertensive individuals.
 Methods: This case control study was performed on 100 hypertensive adult patients. They were classified into two equal group: Group I included hypertensive patients diagnosed to have paroxysmal AF. Group II (control group) included hypertensive patients with normal sinus rhythm. All subjects were subjected to electrocardiographic and conventional and tissue Doppler Imaging measurements.
 Results: Pmax had significantly increased in PAF patients compared to sinus rhythm patients. PAL, PAR, PAI, LR, LI and IR had significantly increased in PAF patients compared to sinus rhythm patients. In Multivariate logistic regression analysis, Pmax, PAL, PAI, PAR, LR, LI and IR were found to be independent predictors for PAF. Therefore, Pmax, PAL PAI, PAR, LR, LI and IR were found to be significant predictors for PAF. Best cut-off values for Pmax, PAL, PAI, PAR, LR, LI and IR were: (118, 81, 61, 49.9, 34, 20 and 16 ms) with sensitivity (76, 96, 96, 88, 82, 86 and 77.5 ), specificity (84, 100, 98, 92, 78, 82 and 76) and the AUC of (0.850, 0.979, 0.987, 0.961, 0.836, 0.891 and 0.798) respectively.
 Conclusions: Electrocardiographic P-wave analysis and echocardiographic TDI may identify hypertension patients at risk for paroxysmal AF, since the combination of Pmax and TDI may help in predicting the development of AF in hypertensive individuals.

Automated right ventricular strain by speckle tracking echocardiography in patients with systemic scleroderma

Abstract Introduction In patients with scleroderma the morphological remodeling and alteration of right ventricular (RV) function begins even before the setting of pulmonary artery hypertension (PAH). These alterations are associated with worse outcomes and high mortality. Purpose Early detection of RV dysfunction is possible using advanced imaging techniques and can lead to specific therapeutic measures before installation of PAH. Purpose of this study is to evaluate new indices, based on speckle tracking technology, for identification of subclinical RV systolic failure. Methods Twenty-five (25) scleroderma patients without any signs or symptoms of PAH and twenty-five (25) healthy subjects were included in the present study. Two-dimensional echocardiography (2DE) and two-dimensional speckle-tracking echocardiography (2DSTE) were performed. All the usual 2DE, Doppler and tissue Doppler imaging measurements were obtained for the evaluation of RV function. Moreover, TAPSE, maximum systolic myocardial velocity from TDI of lateral tricuspid valve annulus (SRV), auto RV global longitudinal strain (aRVGLS) and auto RV free wall longitudinal strain (aRVFWLS) by 2DSTE were measured. aRVGLS is a new index, with appropriate RV function echo logistics in new technology echo systems, independent from known manual measurements. Results In scleroderma patients significantly higher systolic pulmonary artery pressure was recorded, although it remained within normal limits in both groups. Scleroderma patients had significant decreased RV systolic function with significantly lower TAPSE and SRV. Both aRVGLS and aRVFWLS were also significantly lower in scleroderma patients compared to the control group. aRVGLS was the best predictor of early RV systolic impairment in patients with scleroderma. Conclusions Scleroderma is a severe systematic disease associated with high mortality rates. RV remodeling, dysfunction, and progressive pulmonary artery hypertension are among the most important internal organ manifestations of this disease. Early detection of RV dysfunction is possible by 2DSTE, and may be helpful to guide further therapy in these patients. Funding Acknowledgement Type of funding sources: None.

Changes in myocardial tissue velocities over a decade: the Copenhagen City Heart study

Abstract Background The aim of the present study was to investigate the impact of cardiovascular risk factors – age, sex, hypertension, hypercholesterolemia, diabetes, smoking and obesity on Tissue Doppler imaging (TDI) measures of systolic and diastolic tissue velocities in the general population over a 10-year period. Identifying risk factors that are associated with changes in TDI velocities could lead to an improved understanding of the pathophysiology of the deteriorating heart and enable early preventive actions and strategies. Methods The study included 1128 members from the general population who participated in both the 4th and 5th Copenhagen City Heart Study. At both examination rounds, the participants underwent echocardiography. The examinations were 10 years apart. Conventional echocardiographic measures of cardiac structure and function and measures of TDI myocardial tissue velocities were obtained. Results Average change in s', e' and a' were −0.4±1.1 cm/s, −0.9±1.7 cm/s and 0.5±1.7 cm/s, respectively. After multivariable adjustments, older age (P<0.001) and higher systolic blood pressure (BP) (P=0.029) were found to be associated with a decrease in s' at follow-up. Male sex (P<0.001) was found to be associated with an increase in s'. Older age (P<0.001) and greater number of smoking pack-years (P=0.004) were associated with a decrease in e' at follow-up after multivariable adjustments. In addition, greater BMI (P=0.004) was significantly associated with a decrease in a'. Higher diastolic BP (P=0.004) and male sex (P=0.004) were associated with an increase in a'. Conclusion In the general population, overall systolic and diastolic function declined over a 10-year period. Both systolic and diastolic function as assessed by myocardial TDI velocities were affected by multiple conventional cardiovascular risk factors. Funding Acknowledgement Type of funding sources: None.

Do type 1 diabetic children have echocardiographic signs of subclinical cardiac dysfunction?

Background Diabetes mellitus is a major illness in which cardiac problems play a significant role in patient mortality.Objectives We aimed to evaluate whether children with diabetes mellitus type 1 have early echocardiographic signs of subclinical cardiac dysfunction and whether their sex, metabolic control, and duration of diabetes have an effect.Patients and methods A case–control study was performed from January 2022 to November 2022 that included 29 children and adolescents with type 1 diabetes aged from 4 to 15 years. A control group of 15 healthy children was also included. They were recruited from the pediatric endocrinology clinic, Al-Fayoum University Children’s Hospital, Al-Fayoum University, Egypt. Conventional echocardiographic study and tissue Doppler imaging measurements were done.Results With glycated hemoglobin levels less than 7%, the study group of diabetic children had inadequate glycemic control. There was a statistically significant low mean of fractional shortening and high mean of left ventricular septal wall thickness in diastole among diabetic children in comparison with controls, with P values of 0.04 and 0.038, respectively, but still within normal range.Conclusion Children with diabetes have poor glycemic control and scanty echocardiographic evidence of subclinical cardiac dysfunctions. According to the study, cardiac dysfunction in children with diabetes is uncommon. For the early identification of any potential cardiac dysfunctions, distant periodic cardiac examination using both conventional and tissue Doppler echocardiography is advised.

Subclinical systolic and diastolic myocardial dysfunction in polyphasic polymyositis/dermatomyositis: a 2-year longitudinal study

BackgroundCardiac involvement in patients with idiopathic inflammatory myopathies (IIM) is associated with increased morbidity and mortality risk; however, little is known about the progression of cardiac dysfunction and long-term data are scarce. In the present work, we intended to prospectively study echocardiographic parameters in patients with IIM for 2 years.MethodsTwenty-eight IIM patients (41.9±1.6 years) without cardiovascular symptoms were enrolled. Patients with monophasic/polyphasic disease patterns were studied separately and compared to age-matched healthy individuals. Conventional echocardiographic and tissue Doppler imaging (TDI) parameters of systolic [LV: ejection fraction (EF), mitral annulus systolic movement (MAPSE), lateral s′) and diastolic left (mitral inflow velocities, lateral anulus velocities: e′, a′, E/e′) and right ventricular function (fractional area change: FAC, tricuspid annulus plane systolic excursion: TAPSE) were measured at the time of the diagnosis and 2 years later.ResultsSubclinical LV systolic dysfunction is characterized by reduced lateral s′ (10.4 vs. 6.4 cm/s, p<0.05), EF (62.6±0.6%, vs. 51.7±0.7%) and MAPSE (18.5±0.6 vs. 14.5±0.6 mm) could be observed in IIM patients with polyphasic disease course 2 years after diagnosis compared to controls. Furthermore, diastolic LV function showed a marked deterioration to grade I diastolic dysfunction at 2 years in the polyphasic group (lateral e′: 12.9 ±0.6, vs. 7.4±0.3 cm/s; lateral a′: 10.7±0.3, vs. 17.3±0.8 cm/s; p<0.05) supported by larger left atrium (32.1±0.6 vs. 37.8±0.6 mm; p<0.05]. TDI measurements confirmed subclinical RV systolic dysfunction in polyphasic patients 2 years after diagnosis (FAC: 45.6±1.8%, vs. 32.7±1.4%; TAPSE: 22.7±0.5, vs. 18.1±0.3 mm; p<0.05). Similar, but not significant tendencies could be detected in patients with monophasic disease patterns. Polyphasic patients showed significantly (p<0.05) worse results compared to monophasic patients regarding EF (51.7±0.7% vs. 58.1±0.6%), lateral s′ (6.4±0.4 cm/sec vs. 8.6±0.4 cm/s,), left atrium (37.8±0.6 mm vs. 33.3±0.8 mm), FAC (32.7±1.4% vs. 41.0±1.6%) and TAPSE (18.1±0.3 mm vs. 21.3±0.7 mm).ConclusionsSignificant subclinical cardiac dysfunction could be detected in IIM patients with polyphasic disease course 2 years after diagnosis, which identifies them as a high-risk population. TDI is a useful method to detect echocardiographic abnormalities in IIM complementing conventional echocardiography and can recognize the high cardiac risk.

Early Left Ventricular Diastolic Dysfunction, Reduced Baroreflex Sensitivity, and Cardiac Autonomic Imbalance in Anabolic-Androgenic Steroid Users.

The effects of androgen anabolic steroids (AAS) use on athletes’ cardiac autonomic activity in terms of baroreflex sensitivity (BRS), and heart rate variability (HRV) have not yet been adequately studied. Furthermore, there is no information to describe the possible relationship between the structural and functional cardiac remodeling and the cardiac autonomic nervous system changes caused by AAS abuse. Thus, we aimed to study the effects of long-term AAS abuse on cardiac autonomic efficacy and cardiac adaptations in strength-trained athletes. In total, 80 strength-trained athletes (weightlifters and bodybuilders) participated in the study. Notably, 40 of them using AAS according to their state formed group A, 40 nonuser strength-trained athletes comprised group B, and 40 healthy nonathletes (group C) were used as controls. All subjects underwent a head-up tilt test using the 30 min protocol to evaluate the baroreflex sensitivity and short HRV modulation. Furthermore, all athletes undertook standard echocardiography, a cardiac tissue Doppler imaging (TDI) study, and a maximal spiroergometric test on a treadmill to estimate their maximum oxygen consumption (VO2max). The tilt test results showed that group A presented a significantly lower BRS and baroreflex effectiveness index than group B by 13.8% and 10.7%, respectively (p < 0.05). Regarding short-term HRV analysis, a significant increase was observed in sympathetic activity in AAS users. Moreover, athletes of group A showed increased left ventricular (LV) mass index (LVMI) by 8.9% (p < 0.05), compared to group B. However, no difference was found in LV ejection fraction between the groups. TDI measurements indicated that AAS users had decreased septal and lateral peak E’ by 38.0% (p < 0.05) and 32.1% (p < 0.05), respectively, and increased E/E’ by 32.0% (p < 0.05), compared to group B. This LV diastolic function alteration was correlated with the year of AAS abuse. A significant correlation was established between BRS depression and LV diastolic impairment in AAS users. Cardiopulmonary test results showed that AAS users had significantly higher time to exhaustion by 11.0 % (p < 0.05) and VO2max by 15.1% (p < 0.05), compared to controls. A significant correlation was found between VO2max and LVMI in AAS users. The results of the present study indicated that long-term AAS use in strength-trained athletes led to altered cardiovascular autonomic modulations, which were associated with indices of early LV diastolic dysfunction.

Left Ventricle Phenotyping Utilizing Tissue Doppler Imaging in Premature Infants with Varying Severity of Bronchopulmonary Dysplasia.

Bronchopulmonary dysplasia (BPD) is characterized by alveolar-capillary simplification and is associated with pulmonary hypertension (PH) in preterm infants. The contribution of left ventricle (LV) disease towards this severe BPD-PH phenotype is not well established. We aimed to describe the longitudinal trajectory of the LV function as measured by tissue Doppler imaging (TDI) and its association with BPD-PH. We retrospectively assessed prospectively acquired clinical and echocardiographic data from 77 preterm infants born between 2011 and 2013. We characterized the LV function by measuring systolic and diastolic myocardial velocities (s’, e’, a’), isovolumetric relaxation time (IVRT), and myocardial performance index with TDI at three time periods from 32 and 36 weeks, postmenstrual age through one year of age. We also measured post systolic motion (PSM), a marker of myocardial dysfunction that results from asynchronous movement of the ventricular walls, and not previously described in preterm infants. Patients were stratified into groups according to BPD severity and the presence of PH and compared over time. Conventional TDI measures of the LV function were similar between groups, but the septal PSM was significantly prolonged over the first year of age in patients with BPD-PH. PSM provides a novel objective way to assess the hemodynamic impact of lung and pulmonary vascular disease severity on LV function in preterm infants with BPD and PH.

The effect of Celiac disease on cardiac functions and aortic elasticity parameters in children.

We aimed to investigate the effect of Celiac disease on myocardial functions and aortic elasticity parameters. Thirty children with Celiac disease and 30 healthy children were enrolled in the study. Both the groups were similar in terms of age and gender. Cardiac functions of all children in the patients and control group were evaluated using conventional transthoracic echocardiography and tissue Doppler imaging. Aortic strain, distensibility, and stiffness index were calculated by M-mode echocardiography. The demographic findings, height, weight, and body mass index of cases were similar among two groups. No statistical difference was found between E wave velocity for conventional transthoracic echocardiography and tissue Doppler imaging measurements of the mitral valve; early diastolic flow peak velocity, A wave velocity; late diastolic flow peak velocity; and E/A ratio. Isovolumetric relaxation time and isovolumetric contraction time ratios were statistically different between the groups (p = 0.000, p = 0.000, p = 0.000). The myocardial performance index calculated according to the pulse Doppler measurement results was found to be statistically different between the groups (p = 0.000). There was no statistical difference between the groups in terms of aortic strain, distensibility, and stiffness index. In this study, both conventional transthoracic echocardiography and tissue Doppler imaging revealed the affection of the myocardial functions during systole and diastole in children with Celiac disease. Therefore, early follow-up and routine cardiac evaluation of celiac patients may be appropriate due to the increased risk of cardiac affection.

Early changes in myocyte contractility and cardiac function in streptozotocin-induced type 1 diabetes in rats

Diabetes can elicit direct deleterious effects on the myocardium, independent of coronary artery disease or hypertension. These cardiac disturbances are termed diabetic cardiomyopathy showing increased risk of heart failure with or without reduced ejection fraction. Presently, there is no specific treatment for this type of cardiomyopathy and in the case of type I diabetes, it may start in early childhood independent of glycemic control. We hypothesized that alterations in isolated myocyte contractility and cardiac function are present in the early stages of experimental diabetes in rats before overt changes in myocardium structure occur. Diabetes was induced by single-dose injection of streptozotocin (STZ) in rats with data collected from control and diabetic animals 3 weeks after injection. Left ventricle myocyte contractility was measured by single-cell length variation under electrical stimulation. Cardiac function and morphology were studied by high-resolution echocardiography with pulsed-wave tissue Doppler imaging (TDI) measurements and three-lead surface electrocardiogram. Triglycerides, cholesterol and liver enzyme levels were measured from plasma samples obtained from both groups. Myocardial collagen content and perivascular fibrosis of atria and ventricle were studied by histological analysis after picrosirius red staining. Diabetes resulted in altered contractility of isolated cardiac myocytes with increased contraction and relaxation time intervals. Echocardiography showed left atrium dilation, increased end-diastolic LV and posterior wall thickness, with reduced longitudinal systolic peak velocity (S’) of the septum mitral annulus at the apical four-chamber view obtained by TDI. Triglycerides, aspartate aminotransferase and alkaline phosphatase were elevated in diabetic animals. Intertitial collagen content was higher in atria of both groups and did not differ among control and diabetic animals. Perivascular intramyocardial arterioles collagen did not differ between groups. These results suggest that alterations in cardiac function are present in the early phase in this model of diabetes type 1 and occur before overt changes in myocardium structure appear as evaluated by intersticial collagen deposition and perivascular fibrosis of intramyocardial arterioles.

Rapid, Single-View Speckle-Tracking-Based Method for Examining Left Ventricular Systolic and Diastolic Function in Point of Care Ultrasound.

A rapid, reliable quantitative assessment of left ventricular systolic and diastolic function is important for patient treatment in urgent and dynamic settings. Quantification of annular velocities based on a single 2-dimensional image loop, rather than on Doppler velocities, could be useful in point-of-care or focused cardiac ultrasound. We hypothesized that novel speckle-tracking-based mitral annular velocities would correlate with reference standard tissue Doppler imaging (TDI) velocities in a focused cardiac ultrasound-esque setting. Two echocardiographers each performed transthoracic echocardiographic measurements before and after induction of anesthesia in supine patients undergoing cardiac surgery. Speckle-tracking echocardiography (STE)-based systolic (S'STE ) and diastolic (E'STE and A'STE ) velocities were compared to TDI and global longitudinal strain/strain rate. We also compared mitral annular displacement by speckle tracking with M-mode imaging. Twenty-five patients were included and examined in both preinduction and postinduction states. Speckle-tracking-based velocities correlated with TDI measurements in both states (S', r = 0.73 and 0.76; E', r = 0.87 and 0.65; and A', r = 0.65 and 0.73), showing a mean bias of 25% to 30% of the reference standard measurement. The correlation of S'STE with strain and the strain rate (S-wave) and E'STE with the strain rate (E-wave) was good in awake, spontaneously breathing patients but was less strong in the ventilated state. Similarly, displacement by speckle tracking correlated with M-mode measurements in both states (r = 0.91 and 0.84). Measurements required medians of 31 and 34 seconds; reproducibility was acceptable for S'STE and E'STE . Speckle-tracking-based mitral annular velocities and displacement correlate well with conventional measures as well as with deformation imaging. They may be clinically useful in rapidly assessing both systolic and diastolic function from a single 2-dimensional image loop.

P858 Cardiovascular toxicity induced by immunotherapy and tyrosine kinase inhibitors

Abstract Background in the recent years, survival of cancer patients increased enormously through the use of new anticancer drugs such as molecular target drugs (tyrosine kinase inhibitors- TKIs, immunotherapy). Immunotherapy includes anti-BRAF and anti-MEK drugs (although evidences are scarce, these drugs seem to be capable of causing cardiovascular toxicity too); TKIs includes inhibitors of VEGF, VEGFR and other kinases. Purpose to assess cardiovascular toxic effects of TKIs and immunotherapy, to identify early signs of cardiac and vascular toxicity using speckle tracking echocardiography and arterial stiffness measurement. Methods a prospective study was carried out evaluating 45 patients treated with immunotherapy or TKIs. Population was divided into 2 groups: Group A (17 patients with melanoma treated with anti- BRAF and anti-MEK) and Group B (28 patients with solid cancer treated with TKIs-anti VEGF). Cardiological evaluation including electrocardiogram, conventional echocardiogram with tissue Doppler imaging (TDI) and left ventricular global longitudinal strain (GLS) measurement and carotid ultrasound scan was carried out before starting therapy and at a follow-up time of 6 and 12 months. Cardiovascular events such as heart failure, arterial hypertension, arrhythmias, Qtc interval prolongation, stroke, arterial and venous thrombosis were assessed during follow-up. Results mean follow-up was 7 months for anti-BRAF and 13 months for TKI. Neither cardiovascular adverse events nor significant reductions in LVEF or other echocardiographic parameters during follow-up were observed in Group A: we did not observe significant changes in GLS (-18,4 [RI -19,9 a -15,8] vs. -18,3 [RI -18,9 a -16,1] or in vascular parameters (PWV 7,3 ± 1,4 vs. 6,7 ± 1,5, β mean wave 8,5 [RI 6,3-12] vs. 7,4 [RI 4,9-9,4]; α mean wave 6,8 [RI 3,1-6,2] vs. 9,6 [RI 2,4-4,6]). As regards Group B, new onset of arterial hypertension in 35% of population but no significant changes in LVEF or other echocardiographic parameters including GLS ( -18,6 ± 2,3 vs. -18,3 ± 3,3) were observed. Significant changes were furthermore found in vascular parameters with increased arterial stiffness during follow-up (PWV 7,82 ± 1,23 vs. 10,02 ± 2,73; p = 0,04, β mean wave 5,33 ± 1,98 vs. 8,43 ± 3,03; p = 0,02, α mean wave 10,79 ± 4,03 vs.16,82 ± 6,38; p = 0,03). Conclusions according to the literature data, immunotherapy seems to have a safe cardiovascular profile. Anti-VEGF drugs seem to predominantly cause vascular damage, early identifiable through arterial stiffness measurement.

P2735Ventricular function in a large cohort of healthy, term newborns assessed by tissue doppler imaging and speckle tracking echocardiography; establishment of normal values and z-scores

Abstract Background There is a paucity of published data presenting reference values for ventricular function in newborns. Purpose This study was conducted to establish echocardiographic normal data and z-scores for ventricular functional parameters in newborns assessed by Tissue Doppler Imaging (TDI) and Speckle Tracking Echocardiography (STE). Methods We included healthy, term newborns from a prospective, population-based study of newborns, who had a comprehensive, systematic echocardiographic (TTE) examination performed within 14 days of birth. Only newborns without any signs of structural or functional cardiac abnormalities were included. Measurements were obtained according to guidelines. Body surface area (BSA) was calculated using the Haycock formula. Z-score models according to birthweight and BSA at time of TTE were developed for TDI and STE parameters. Results Four hundred newborns (53% male) with gestational age of (median (IQR)) 40.3 (39.4, 41.1) weeks were included. Age, weight, and BSA at TTE were (mean±SD) 11±3 days, 3.7±0.5 kg, and 0.23±0.02m2, resp. Ejection fraction was 67±4%. TDI and STE measurements of ventricular function are presented as mean±SD (Table). Global longitudinal strain was calculated as the average of all left ventricular segmental strain values from apical 4-, 2-, and 3-chamber views. Results for selected parameters according to BSA are illustrated (Figure). TDI and STE of ventricular function Parameter View and modality Value Unit Mitral annulus septal wall e' Apical 4-chamber Tissue Doppler 5.7±0.8 cm/s Mitral annulus septal wall a' Apical 4-chamber Tissue Doppler 5.9±1.0 cm/s Mitral annulus septal wall s' Apical 4-chamber Tissue Doppler 4.6±0.6 cm/s Mitral annulus lateral wall e' Apical 4-chamber Tissue Doppler 6.9±1.0 cm/s Mitral annulus lateral wall a' Apical 4-chamber Tissue Doppler 6.0±1.1 cm/s Mitral annulus lateral wall s' Apical 4-chamber Tissue Doppler 4.8±0.6 cm/s Left ventricular longitudinal strain, 4-chamber Apical 4-chamber 2D 19±2 % Left ventricular longitudinal strain, 2-chamber Apical 2-chamber 2D 20±2 % Left ventricular longitudinal strain, 3-chamber Apical 3-chamber 2D 19±2 % Left ventricular global strain 19±2 % Right ventricular longitudinal strain, free wall Apical 4-chamber 2D 23±4 % Percentile charts Conclusion Normal data for TDI and STE assessment of ventricular function in 400 healthy, term newborns ispresented. An online z-score calculator will be available. Normal data is necessary for the evaluation of pathological changes, and these results contribute substantially to a field where available data is limited. Acknowledgement/Funding Danish Heart Association, Danish Children's Heart Foundation, Candy's Found., Toyota Found., Herlev-Gentofte Hospital Research Found., Gangsted Found.

P4440Assessment of left atrial function in patients with systemic lupus erythematosus with and without neuropsychiatric manifestations: association with cardiovascular events

Abstract Introduction Cardiac involvement in Systemic Lupus Erythematosus (SLE) may lead to left ventricular (LV) hypertrophy with possible impairment of LV diastolic function and left atrial (LA) function, particularly in patients with severe forms of SLE with neuropsychiatric manifestations (NPSLE) and can also be associated with cardiovascular outcome. Purpose We evaluated the prevalence of LV diastolic dysfunction and LA dysfunction in a large cohort of SLE patients including also NPSLE patients, and their association with the occurrence of cardiovascular events (cerebrovascular accidents, lung-embolism, coronary revascularisation, heart failure hospitalisations and development of supraventricular arrhythmias). Methods A total of 102 SLE patients (87% female, 42±15 years) were included, of which 43 (42%) with NPSLE according to a multidisciplinary team assessment. All patients fulfilled the American College of Rheumatology (ACR 1997) and Systemic Lupus Erythematosus International Collaborating Clinics (SLICC 2012) classification criteria for SLE. Echocardiography was performed at the first visit: LV diastolic function was assessed according to current recommendations and including Tissue Doppler Imaging measures; LA volume (LAVI) was also measured and LA function was assessed by LA reservoir strain using 2D speckle tracking imaging. Results In the SLE patients, mean LV mass index was 82±32 g/m2, 29% of patients showed an e'septal &lt;10, 7% an E/e'&gt;14, 16% a LAVI&gt;34 ml/m2 and 5% a tricuspid velocity &gt;2.8m/s. When applying the currently recommended multiparametric approach, only 4% of SLE patients showed LV diastolic dysfunction. In NPSLE patients, the prevalence of LV diastolic dysfunction was not significantly higher (5%). However, an impaired LA reservoir strain (based on the median value of 25%) was observed in 54% of the total SLE population and in 77% of NPSLE patients suggesting higher sensitivity of this parameter to detect impaired LA function and LV diastolic function. During a median follow up of 11 years (Interquartile range: 4–19 years), 43 (42%) patients developed a cardiovascular event. Kaplan-Meier curve analysis showed that SLE patients with impaired LA strain &lt;25% experienced higher cumulative rates of cardiovascular events, as compared to SLE patients with LA strain≥25% (Chi-square 4.350; Log rank p=0.037). At the uni- and multivariate Cox-regression models, LA strain showed significant association with cardiovascular events (hazard ratio [HR]:0.944; 95% confidence interval [CI]: 0.893–0.997; p=0.039) together with age (HR: 1.030; 95% CI: 1.002–1.059; p=0.039) after correcting for LV mass index and LV diastolic dysfunction. LA reservoir strain Conclusions LA dysfunction as assessed by LA reservoir strain is significantly impaired in SLE and particularly in NPSLE patients and improve detection of myocardial involvement in these patients. Furthermore, LA reservoir strain is independently associated with the development of cardiovascular events.

Echocardiography Imaging of Cardiotoxicity.

Heart disease is the most important cause of non-cancer death for patients with cancer. Addressing the cardiotoxic effects of anticancer therapies to prevent increased cardiovascular risk in this population is crucial. Echocardiography plays a big role in monitoring cardiotoxicity induced by cancer treatment. Many emerging modalities, including tissue Doppler imaging measures, speckle tracking imaging, and three-dimensional echocardiography, may provide improved sensitivity and specificity to detect cancer treatment-induced cardiotoxicity. Additional research is critical to define the value of both conventional and novel indices in guiding the clinical management of cancer treatment-induced cardiotoxicity.

Intervendor Discordance of Fetal and Neonatal Myocardial Tissue Doppler and Speckle-Tracking Measurements

Fetal and neonatal studies report a wide range of cardiac parameters derived by pulsed-wave Doppler tissue imaging (DTI) and two-dimensional speckle-tracking echocardiographic (STE) imaging. The use of different ultrasound systems and their vendor-specific software compromises the ability to compare echocardiographic findings among various studies. The aim of this study was to evaluate intervendor reproducibility as well as intra- and interobserver repeatability of DTI and STE measurements in normal-term fetuses and neonates. A prospective study was conducted of term fetuses (n=196) from uncomplicated pregnancies assessed days before the onset of labor and a few hours after birth. Fetal and neonatal DTI and STE parameters were obtained and analyzed using vendor-specific software on three ultrasound systems: Toshiba Aplio MX versus GE Vivid E9 and GE Vivid E9 versus Philips EPIQ. A reproducibility study in fetuses and neonates (n=118) was performed by systematic scanning with head-to-head comparison. DTI reproducibility showed moderate to good correlation, with good agreement for fetuses and neonates on Toshiba versus GE (intraclass correlation coefficient [ICC]=0.4-0.8). Correlation of DTI measurements on GE versus Philips was poor to moderate for fetuses (ICC=0.1-0.6) and moderate to good for neonates (ICC=0.5-0.8), with wider limits of agreement. Fetal and neonatal STE parameters revealed very poor correlation (ICC=0.1-0.3) and agreement among ultrasound vendors. Intra- and interobserver repeatability demonstrated good to excellent correlation of all fetal and neonatal DTI and STE measurements, with good agreement irrespective of the ultrasound platform used. These findings demonstrate reliable assessment of fetal and neonatal DTI and STE measurements when performed on the same ultrasound platform, whereas ultrasound machines and software from different vendors give significantly divergent estimates of DTI and STE parameters in fetuses and neonates. These intervendor discrepancies have significant clinical and research implications and should be considered when interpreting and comparing study findings, establishing reference standards, or performing systematic reviews.

Qualitative Assessment of Color M-Mode Signals in the Evaluation of Left Ventricular Diastolic Function: A Proof of Concept Study

Although the most recent American Society of Echocardiography guidelines are a major step forward in echocardiographic evaluation of diastolic function, the ability to differentiate between normal and abnormal function remains challenging. The authors aimed to determine whether qualitative assessments of color M-mode flow displays could be a useful parameter in the evaluation of left ventricular (LV) diastolic dysfunction. Retrospective observational study. Tertiary care level hospital. The study comprised echocardiographic data from 105 consecutive patients. None. Patients were allocated into the following 3 groups according to the LV diastolic function based on current American Society of Echocardiography recommendation guidelines for LV diastolic dysfunction classification: group I-normal function (n = 40); group II-early relaxation abnormalities (grade I) (n = 50), and group III-elevated LV pressures (grade II) (n = 15). Patients with normal diastolic function were younger (45 ± 14 y) than those with diastolic dysfunction (group II: 64 ± 10 y and group III: 56 ± 15 y) (p < 0.05). Volumetric echocardiographic parameters and mitral inflow and mitral annulus tissue Doppler imaging measures were significantly different among the 3 studied groups (p < 0.05). Interestingly, qualitative assessment of color M-mode flows displayed distinctive signals based on the left ventricle filling properties. Intraobserver and interobserver variability to determine the reliability of these signals were robust (weighted kappa 0.84 ± 0.11 and 0.65 ± 0.13, respectively). Qualitative assessment of color M-mode flow displays offers simple and reliable information of potential usefulness in the evaluation of LV diastolic function.

Diaphragm sniff ultrasound: Normal values, relationship with sniff nasal pressure and accuracy for predicting respiratory involvement in patients with neuromuscular disorders

BackgroundIn patients with neuromuscular disorders, assessment of respiratory function relies on forced vital capacity (FVC) measurements. Providing complementary respiratory outcomes may be useful for clinical trials. Diaphragm sniff ultrasound (US) is a noninvasive technique that can assess diaphragm function that may be affected in patients with neuromuscular disorders.PurposeWe aimed to provide normal values of sniff diaphragm ultrasound, to assess the relationship between sniff diaphragm US, vital capacity (VC) and sniff nasal pressure. Additionally, we aimed to evaluate the diagnostic accuracy of sniff diaphragm US for predicting restrictive pulmonary insufficiency.Materials and methodsWe included patients with neuromuscular disorders that had been tested with a sniff diaphragm US and functional respiratory tests. Healthy subjects were also included to obtain normal diaphragm sniff ultrasound. We performed diaphragm tissue Doppler imaging (TDI) and time movement (TM) diaphragm echography combined with sniff maneuver.ResultsA total of 89 patients with neuromuscular diseases and 27 healthy subjects were included in our study. In patients, the median age was 32 years [25; 50] and the median FVC was 34% of predicted [18; 55]. Sniff diaphragm motion using TM ultrasound was significantly associated with sniff nasal pressure, both for the right hemidiaphragm (r = 0.6 p <0.0001) and the left hemidiaphragm (r = 0.63 p = 0.0008). Right sniff peak TDI velocity was also significantly associated with FVC (r = 0.72, p<0.0001) and with sniff nasal pressure (r = 0.66 p<0.0001). Sniff diaphragm ultrasound using either TM mode or TDI displayed significant accuracy for predicting FVC<60% with an area under curve (AUC) reaching 0.93 (p<0.0001) for the right sniff diaphragm ultrasound in TM mode and 0.86 (p<0.001) for right peak diaphragm TDI velocity.ConclusionSniff diaphragm TM and TDI measures were significantly associated with sniff nasal pressure. Sniff diaphragm TM and TDI had a high level of accuracy to reveal respiratory involvement in patients with neuromuscular disorders. This technique is useful to assess and follow up diaphragm function in patients with neuromuscular disorders. It may be used as a respiratory outcome for clinical trials.