Two-dimensional Echocardiographic Examination Research Articles

The Usefulness of the TAPSE/sPAP Ratio for Predicting Survival in Medically Treated Chronic Thromboembolic Pulmonary Hypertension.

The ventriculoarterial uncoupling has been linked with unfavorable results as measured noninvasively by tricuspid annular plane systolic excursion divided by systolic pulmonary artery pressure (TAPSE/sPAP). However, its prognostic importance in chronic thromboembolic pulmonary hypertension (CTEPH) is limited. Thus, we determine the effect of the TAPSE/sPAP ratio on outcomes and predictors of all-cause mortality in these patients. We analyzed 56 subjects with medically treated CTEPH. Two-dimensional echocardiographic examination and right heart catheterization findings were recorded from the hospital database. Baseline New York Heart Association functional class (NYHA-FC), 6-min walk distance (6MWD), and brain natriuretic peptide (BNP) test results were recorded. The median age was 65.5 years. Over a median follow-up time of 27 months, 29 (51.8%) patients died. BNP values were higher (P = 0.008), 6MWD values were lower (P = 0.004), and NHYA-FC (P = 0.0001) was worse in the non-survivor group. TAPSE (P = 0.0001) and TAPSE/sPAP ratio (P = 0.001) were significantly lower and pulmonary vascular resistance (PVR) was higher in the non-survivor group (P = 0.03). The best cut-off value for the TAPSE/sPAP ratio for predicting mortality was 0.20 mm/mmHg and the survival rates were significantly lower in the TAPSE/sPAP ratio ≤0.20 group (log-rank P = 0.012). 6MWD (P = 0.005), NHYA-FC III-IV (P = 0.0001), TAPSE/sPAP ratio ≤0.20 (P = 0.017), PVR (P = 0.008), and TAPSE/sPAP ratio ≤0.20 combined with NYHA-FC III-IV (P = 0.0001) were significant determinants and TAPSE/sPAP ratio ≤0.20 combined with NYHA-FC III-IV was the only independent predictor of mortality (P = 0.003). Medically treated CTEPH patients with a TAPSE/sPAP ratio ≤0.20 had lower survival rates. TAPSE/sPAP ratio≤0.20 combined with NYHA-FC III-IV was the independent predictor of poor prognosis.

Abstract 14755: Left Ventricular Three-Dimensional Speckle Tracking Echocardiography Predicts Adverse Clinical Outcomes in Heart Transplant Patients

Background: The prognostic value of 3D-GLS in HT recipients has not been evaluated. This study explored the long-term prognostic significance of 3D-GLS in HT recipients. Methods: The study comprised 296 consecutive patients who underwent HT between January 2015 and December 2019 at Union Hospital in Wuhan, China. All subjects underwent comprehensive transthoracic two-dimensional (2D) and 3D echocardiographic examinations. Patients were followed until January 1st, 2022. Major adverse cardiac events (MACE) were defined as a composite of heart failure hospitalization, re-transplantation and death. Results: After a median follow-up of 3.3 years, 53 HT patients experienced MACE. Patients with MACE displayed significantly impaired 2D-GLS and 3D-GLS compared with those without MACE. Kaplan-Meier analysis showed that the risk of MACE increased significantly with worsening tertiles of 2DGLS and 3DGLS (both log-rank p < 0.001). Area under the curve for 3D-GLS was larger than that in 2D-GLS for MACE prediction. On multivariate Cox proportional hazards regression, 2D-GLS and 3D-GLS were independently associated with the MACE after adjustment for diabetes, history of rejection, hemoglobin, brain natriuretic peptide (BNP), and LV ejection fraction. In addition, 3D-GLS provided incremental prognostic value over 2D-GLS. Continuous net reclassification improvement analysis showed an improvement of + 23.3% was noted in the accuracy of classification between 3D-GLS and 2D-GLS. Conclusion: In heart transplant recipients, 3D-GLS is an independently predictor of MACE. These findings support the potential of 3D-GLS to identify higher risk HT patients.

Two-dimensional speckle tracking echocardiography, a powerful method for the evaluation of anthracyclines induced left ventricular insufficiency.

Anthracyclines have been one of the most important therapeutic methods in breast cancer therapy for decades. However, serious long-term toxicities, especially cardiotoxicity limits the continuous usage of anthracyclines, hence affects long term prognosis. Early detection of myocardial dysfunction during treatment is critical but challenging. Two-dimensional speckle tracking echocardiography (2D-STE) is a non-Doppler technique that can assess deformation and strain by tracking displacement of acoustic markers in the myocardium. This study aims to compare the sensitivity and precision between 2D-STE and traditional echocardiography on monitoring the left ventricular function in patients with breast cancer after anthracyclines therapy, which is the key indicator for evaluating myocardial changes. Thirty-three patients with breast cancer were recruited from February 2019 to December 2019. All patients were treated with 4 cycles anthracycline. 2D-STE and conventional echocardiography were performed on each patient. Two-dimensional echocardiographic examination was used to collect data interventricular septum diameter (IVSD), end-diastolic left ventricular posterior wall diameter (LVPWD), left ventricular end-diastolic diameter (LVEDD) and left ventricular systole on the parasternal left ventricular long axis view. The final diameter (left ventricular end-systolic diameter [LVESD]) and the left ventricular short axis shortening rate (LVFS) was measured by M-type. The two-plane Simpson’s method was used to measure left ventricular end-diastolic volume (LVEDV) and end-systolic volume (left ventricular end-systolic volume [LVESV]) to obtain left ventricular ejection fraction (LVEF). Two-dimensional speckle tracking imaging technical indicator includes left ventricular global longitudinal strain (LVGLS), subendocardial myocardial longitudinal strain (LVGLS-Endo) and epicardial myocardial longitudinal strain (LVGLS-Epi). The correlation between 2-dimensional speckle tracking imaging and conventional ultrasound parameters were analyzed. Compared with baseline (T0), the systolic function parameter LVEF was significantly changed after four cycle chemotherapy (T4) (P < .05). However, the conventional echocardiographic parameters including IVSD, LVPWD, LVEDD, LVESD, LVEDV, and LVESV were not statistically significant (P > .05). Meanwhile, the two-dimensional strain parameters LVGLS, LVGLS-Endo, and LVGLS-Epi were statistically significant after T2 and T4 cycle chemotherapy (P < .01).The two-dimensional strain parameter GLS has higher accuracy and sensitivity for monitoring left ventricular insufficiency caused by anthracycline therapy when compared with traditional echocardiography.

Early Impairment of Right Ventricular Functions in Patients with Moderate Asthma and the Role of Isovolumic Acceleration

Introduction: Asthma is a common chronic lung disease that affects people all over the world. Pulmonary hypertension and right ventricular (RV) dysfunction are possible complications that may develop in the advanced stages of asthma. However, the number of studies investigating asthma and its implications on new RV parameters are very rare. This study aims to evaluate the RV functions in patients with moderate asthma before the development of pulmonary hypertension. Patients and Methods: Forty-one patients with moderate asthma and 40 healthy individuals were enrolled in this case-control study. All participants underwent a detailed two-dimensional echocardiographic examination. RV functions were measured through RV isovolumic acceleration (IVA) index in addition to conventional parameters. RV IVA, a tissue doppler derived parameter, was calculated as the ratio between maximum isovolumic myocardial velocity during isovolumic contraction and the time interval from the onset of this wave to the time at its maximum velocity. Results: There were no significant differences between the two groups in terms of baseline clinical characteristics, laboratory findings and echocardiographic parameters measuring left ventricular functions (p&gt; 0.05). In asthmatic patients, RV isovolumic relaxation time and RV myocardial performance index were higher (p= 0.027 and p&lt;0.001 respectively), while RV fractional area change, tricuspid annular plane systolic excursion (TAPSE) and RV IVA values were all lower (p&lt;0.001). RV IVA was found to be inversely proportional to asthma duration. TAPSE [β= 0.632, 95% CI= (0.121) - (0.225), p&lt;0.001] and pulmonary artery systolic pressure [β= -0.188, 95% CI= (-0.057) - (-0.003), p= 0.032] were shown as independent predictors of RV IVA. Conclusion: Asthma is an important disease that may result in subclinical RV dysfunction even before the development of pulmonary hypertension. RV IVA, an easily obtained and load-independent parameter, may be a useful and reliable index that sensitively analyzes subtle deteriorations in the contractile function of RV in asthmatic patients. RV IVA may also correlate with asthma duration.

Lack of right ventricular hypertrophy is associated with right heart failure in patients with left ventricular failure.

Presence of right heart failure (RHF) is associated with a worse prognosis in patients with left ventricular failure (LVF). While the cause of RHF secondary to LVF is multifactorial, an increased right ventricular (RV) afterload is believed as the major cause of RHF. However, data are scarce on the adaptive responses of the RV in patients with LVF. Our aim was to understand the relationship of right ventricular hypertrophy (RVH) with RHF and RV systolic and diastolic properties in patients with LVF. 55 patients with a left ventricular ejection fraction of 40% or less were included in the present study. A comprehensive two-dimensional transthoracic echocardiographic examination was done to all participants. 12 patients (21.8%) had RHF, and patients with RHF had a significantly lower right ventricular free wall thickness (RVFWT) as compared to patients without RHF (5.3 ± 1.7mm vs. 6.6 ± 0.9mm, p = 0.02) and the difference remained statistically significant after adjusting for confounders (Δx̅:1.34mm, p = 0.002). RVFWT had a statistically significant correlation with tricuspid annular plane systolic excursion (r = 0.479, p < 0.001) and tricuspid annular lateral systolic velocity (r = 0.360, p = 0.007), but not with the indices of the RV diastolic function. None of the patients with concentric RVH had RHF, while 22.2% of patients with eccentric RVH and 66.7% of patients without RVH had RHF (p < 0.01 as compared to patients with concentric RVH). In patients with left ventricular systolic dysfunction, absence of RVH was associated with worse RV systolic performance and a significantly higher incidence of RHF.

Triglyceride glucose index reflects the unfavorable changes of left ventricular diastolic functions and structure in uncomplicated newly diagnosed hypertensive patients

ABSTRACT Introduction Left ventricular (LV) diastolic dysfunction and structural abnormalities are common cardiac changes in hypertension (HTN), and several factors other than high blood pressure (BP) may play a role in these changes. The aim of this study was to reveal the relationship between triglyceride glucose (TyG) index, a novel parameter for insulin resistance (IR), with LV diastolic function and structure in hypertensive patients. Material and method A total of 119 newly diagnosed, untrated hypertensive patients free of diabetes and/or cardiovascular complications were included in this study. IR was estimated with the TyG index calculated from ln [fasting TG (mg/dL) × fasting blood glucose (mg/dL)/2]. Two-dimensional and Doppler echocardiographic examinations were performed to assess LV diastolic functions and structure. Results Based on median TyG index, 51 patients was assigned as group I (<8.7) and 68 patients as group II (>8.7). In patients with high TyG index, left atrial volume index (LAVi) (p < .001) LV mass index (LVMI) (p = .016), E/e’ ratio (p < .001) increased, and e’ velocity (p < .001) and E/A ratio (p = .028) decreased. There was a statistically significant correlation between TyG index and these parameters (all p > .05). Stepwise multiple regression analysis demonstrated that the relationship of TyG index with LV diastolic function and structure was independent of potential confounders (all p < .001). Conclusion This study suggest that a high TyG index is related to LV diastolic functional impairment and structure abnormality in newly diagnosed hypertensive patients in the absence of diabetes or CVD.

156 Rivaroxaban in very elderly patients with atrial fibrillation

Abstract Aims The incidence of atrial fibrillation (AF) increases with age. The risk of stroke is increased 4- to 5-fold in old patients with AF. In the Framingham Study, 23.5% of strokes in patients aged 80 and older were attributable to AF. Advanced age is also associated with a progressive increase in the risk of major bleeding in subjects ≥85 years, particularly if treated by oral anticoagulants (OAC). Only 20% of patients &amp;gt;75 years were included in randomized controlled trials (RCTs) involving OACs in AF, due to the high risk of falls and bleeding, especially intracranial haemorrhage (ICH). The management of anticoagulation in the very elderly represents a challenging issue because they are at high thromboembolic risk, and also at high haemorrhagic risk. The aim of our study was to describe the use and tolerability of rivaroxaban in very old patients with heart failure with reduced ejection fraction. The average age of enrolled patients is 76.0 ± 8.4 years with a significant prevalence of the elderly (16.0% with age ≥85 years with a slight male prevalence). Methods We analysed retrospective data from 50 patients from June 2016 to June 2018 and taking rivaroxaban 20 mg. The average age of enrolled patients was 76 ± 8.2 years and 40% were females. The inclusion criteria were patients with at least one episode of documented AF of any duration in the preceding 12 months. The average CHA2DS2-VASc of these subjects is 3.2 ± 1.4, while the haemorrhagic risk expressed by the HAS-BLED appears more contained (2.7 ± 1.1). The risk profile of these patients was complex as documented by an older age, by a CHA2DS2-VASc higher and by the prevalence of comorbidities such as heart failure, valvular disease, peripheral vasculopathy and diabetes mellitus. Follow-up, characterized by clinical examination and blood analysis, was performed at 3, 6, and 12 months. The AF patients were followed for the effectiveness outcome of thromboembolism (ischaemic stroke and/or systemic embolism) and bleeding outcomes (composite of major bleeding, gastrointestinal bleeding, and intracranial Haemorrhage), as well as bleeding requiring hospitalization. A secondary safety endpoint was total minor bleedings. Standard two-dimensional transthoracic echocardiographic examination was performed. Left ventricular end-diastolic volume, end-systolic volume, and ejection fraction (LVEF) were measured using the modified Simpson’s rule from the apical view. Results During follow-up, we observed no major bleedings, strokes, or cardiovascular deaths. Only two minor haemorrhages (one epistaxis and one haematuria, none of which required blood transfusion or hospital admission) observed with no differences observed in LVEF or left atrial dimension at echocardiography, body mass index, and the thrombotic and haemorrhagic risk profile. Conclusions Such data confirm that the new oral anticoagulants, and in particular rivaroxaban, are considered safe even in the most population frail and above all elderly, allowing for enlargement the use of anticoagulant therapy. Results are expected of long-term follow-up to confirm the benefits of that therapeutic choice.

Left Ventricular Rotational Abnormalities in Treated Hypopituitarism: Insights From the Three-Dimensional Speckle-Tracking Echocardiographic MAGYAR-Path Study.

Introduction: Hypopituitarism is a rare, often underdiagnosed, complex hormonal disease caused by the decreased secretion of one or more hormones in the pituitary gland. The present study was designed to assess left ventricular (LV) rotational mechanics in patients with treated hypopituitarism. It was also aimed to find possible differences in these parameters according to the origin of hypopituitarism (congenital vs. acquired).Methods: The present prospective study involved 35 treated patients with hypopituitarism; however, 4 patients had to be excluded due to inferior image quality. The mean age of the remaining 31 cases was 56.3 ± 13.2 years (18 males). The control group consisted of 29 age- and sex-matched healthy volunteers (mean age: 55.3 ± 4.8 years, 14 males). In all cases a complete two-dimensional echocardiography examination was performed followed by three-dimensional speckle-tracking echocardiography.Results: No significant differences could be found in LV volumes between the controls and patients with hypopituitarism and hypopituitary subgroups. LV apical rotation (8.1 ± 5.1° vs. 10.6 ± 3.5°, p < 0.05) and LV twist (11.9 ± 5.3° vs. 15.1 ± 3.8°, p < 0.05) were impaired in the hypopituitary group with normally directed LV rotational mechanics as compared to the healthy controls. However, 13% of patients showed a near absence of LV twist called LV “rigid body rotation” (LV-RBR). There were no significant differences regarding LV apical and basal rotations and twist between acquired and congenital hypopituitary subgroups.Conclusions: Impaired LV apical rotation and twist could be demonstrated in hypopituitarism regardless of its origin. In the present study with small number of patients with hypopituitarism, LV-RBR was present in 13% of cases.

Strain generation and right ventricular systolic function: The sum of all its parts.

Speckle-tracking echocardiography (STE) has provided a reliable means to enhance characterization and quantification of global right ventricular (RV) systolic function. The use of Automated Functional Imaging (AFI) software has been previously used to quantify RV longitudinal peak global strain (PGS) values during two-dimensional (2D) transthoracic echocardiographic examinations. However, there is a paucity of data regarding relative strain contribution of each individual regional segments when compared with global strain assessment. Consequently, our goal was to use AFI STE to examine the strain contribution of each regional segment when assessing RV function. A retrospective analysis was performed on 107 patients that met our study criteria to correlate 2D TTE measures of RV systolic function to both RV AFI STE longitudinal peak global strain (PGS) and each individual regional RV free wall (RVFw) and inter-ventricular septum (IS) strain values. We found that TTE variables of RV systolic function only correlated with PGS (RVFAC; P<.0001, TAPSE; P<.0001, and TA TDI S'; P<.0001) but none of the six individual regional AFI strain values. When PGS was not included in the multivariate analysis, only the mid RVFw and mid IS strain regions correlated with measures of RV systolic function. Regional differences do exist with regards to strain generation along the RVFw and IS. These differences could be physiologically and anatomically explained based on our current understanding of RV muscle fiber arrangement. Further research is now needed to better characterize RV function in different clinical entities.

The influence of left ventricular geometry on myocardial work in essential hypertension.

We sought to investigate echocardiography-derived myocardial work in hypertensive patients with different left ventricular (LV) geometric patterns. This cross-sectional study included 211 hypertensive patients (74 with normal LV geometry, 53 with concentric remodeling, 46 with eccentric LV hypertrophy (LVH) and 38 with concentric LVH) who underwent complete two-dimensional echocardiographic examination including two-dimensional speckle-tracking echocardiography. Pressure-strain curve was used to determine parameters of myocardial work. Our findings showed that multidirectional LV strain was lower in patients with eccentric and concentric LVH than in those with normal LV geometry and concentric remodeling. Global myocardial work index and global constructive work were higher in patients with eccentric and concentric LVH than in those with normal LV geometry and concentric remodeling. Global wasted work and global efficacy work were similar between groups with different LV geometry. E/e' and LV mass index were associated with global myocardial work index and global constructive work independently of clinical and echocardiographic parameters. In conclusion, myocardial work was higher in patients with eccentric and concentric LVH than in patients with normal LV geometry and concentric remodeling. Increased blood pressure in patients with concentric LVH in comparison with other LV geometric patterns has significant impact on the final result. LV geometry has significant impact on myocardial work in hypertensive patients.

Association between myocardial work and functional capacity in patients with arterial hypertension: an echocardiographic study

Purpose The aim of this study was to examine myocardial performance using pressure-strain loops in hypertensive patients with different level of blood pressure control. Material and methods This cross-sectional study included 204 subjects (45 controls, 70 patients with well-controlled hypertension, 58 patients with uncontrolled hypertension and 31 patients with resistant hypertension) who underwent complete two-dimensional echocardiographic examination including two-dimensional speckle-tracking echocardiography. Pressure-strain curve was used to determine global myocardial work, constructive work, wasted work and work efficiency in all study participants. Results Left ventricular (LV) longitudinal strain gradually reduced from controls throughout well-controlled hypertensive patients, to patients with uncontrolled and resistant hypertension. Global myocardial work was higher in patients with uncontrolled and resistant hypertension than in controls and well-controlled hypertension. Constructive work was also higher in all hypertensive patients than in controls. Global wasted work and work efficiency were similar between different groups. Global myocardial work index was associated with peak oxygen consumption independently of sex, age, body mass index (BMI), LV structural and functional parameters in all hypertensive participants. Conclusions Myocardial work was significantly deteriorated in patients with uncontrolled and resistant arterial hypertension compared to controls and well-controlled hypertensive patients. Global myocardial work was associated with functional capacity independent of clinical and echocardiographic parameters.

Prognostic potential of layer-specific global longitudinal strain in patients with non-ST-segment elevated acute coronary syndrome and preserved left ventricular ejection fraction.

This study sought to investigate the prognostic potential of layer-specific global longitudinal strain (GLS) in predicting cardiac events among non-ST-segment elevated acute coronary syndrome (NSTE-ACS) patients with preserved LVEF. In this prospective study, we enrolled 160 consecutive NSTE-ACS patients with preserved LVEF (≥ 50%) who underwent successful percutaneous coronary intervention (PCI). Transthoracic two-dimensional echocardiography examinations were performed within 48h of admission (before PCI). Cardiac events were defined as all-cause death, re-infarction, and hospitalization for heart failure. During a median follow-up of 30.2months, 23 patients (14.4%) developed cardiac events. GLS for all three myocardial layers were reduced in patients with adverse outcome (all P < 0.001). Yet GLSendo (area under curves = 0.85) and GLSmid (area under curves = 0.83) showed relatively higher predictive power than GLSepi when identifying patients with cardiac events. The best cut-off value of GLSendo was - 20.8%, with a diagnostic sensitivity and specificity of 87% and 71% respectively. A significant increase in the risk of cardiac events development was shown among patients with impaired layer GLS (log-rank test, P < 0.001). In conclusion, NSTE-ACS patients with preserved LVEF, layer GLS assessed before PCI all had good abilities to predict cardiac events, which might provide more prognostic information against conventional echocardiographic risk factors.

Myocardial work in hypertensive patients with and without diabetes: An echocardiographic study.

We aimed to investigate myocardial performance using pressure-strain loops in hypertensive patients with and without type 2 diabetes mellitus (DM). This cross-sectional study included 165 subjects (55 controls, 60 hypertensive patients without DM, and 50 hypertensive patients with DM) who underwent complete two-dimensional echocardiographic examination (2DE) including two-dimensional speckle-tracking echocardiography. Pressure-strain curve was used to determine global myocardial work index, constructive work, wasted work, and work efficiency in all study participants. Left ventricular (LV) longitudinal and circumferential strains gradually reduced from controls throughout hypertensive subjects to patients with DM and hypertension. Global myocardial work index gradually increased from controls, throughout hypertensive patients to subjects with hypertension and DM (1887±289 vs 2073±311 vs 2144±345mmHg%, P=.001). Constructive work increased in the same direction (2040±319 vs 2197±344 vs 2355±379mmHg%, P<.001). Work efficiency and wasted work did not differ between three observed groups. Glycosylated hemoglobin and systolic blood pressure were associated with global myocardial work and constructive work independently of age, body mass index, LV structural and functional parameters in all hypertensive participants. In conclusion, pressure-strain curve showed that myocardial work was significantly affected by hypertension and diabetes. Diabetes demonstrated an additional negative effect on myocardial work in hypertensive patients.

Left Ventricular Pressure-Strain–Derived Myocardial Work at Rest and during Exercise in Patients with Cardiac Amyloidosis

Left ventricular pressure-strain-derived myocardial work index (LVMWI) is a novel, noninvasive method for left ventricular (LV) function evaluation in relation to LV pressure dynamics. LV global longitudinal strain (LVGLS) has proven benefit for diagnosis and risk stratification in patients with cardiac amyloidosis (CA), but LVGLS does not adjust for loading conditions. The aim of the present study was to characterize LVMWI at rest and during exercise in patients with CA. A total of 155 subjects were retrospectively included. These subjects comprised 100 patients with CA and 55 healthy control subjects. All patients had previously undergone comprehensive two-dimensional echocardiographic examinations at rest. Furthermore, a subgroup 27 patients with CA and 41 control subjects was examined using semisupine exercise stress echocardiography. Patients with CA had significantly lower LVGLS, LVMWI, and LV myocardial work efficiency (LVMWE) than control subjects (P<.0001 for all). The reduction in LV myocardial performance was more pronounced in the basal segments, which led to significant alterations in the average apical-to-basal segmental ratios between patients with CA and control subjects (LVGLS, 2.6 [1.9 to 4.1] vs 1.3 [1.2 to 1.5]; LVMWI, 2.6 [1.7 to 3.8] vs 1.3 [1.1 to 1.5]; LVMWE, 1.1 [1.0 to 1.3] vs 1.0 [1.0 to 1.1]; P<.0001 for all). The average increase in LVMWI from rest to peak exercise was 1,974mm Hg% (95% CI, 1,699 to 2,250mm Hg%; P<.0001) in control subjects and 496mm Hg% (95% CI, 156 to 835mm Hg%; P<.01) in patients with CA. The absolute numeric LVGLS increase was 5.6% (95% CI, 3.9% to 7.3%; P<.0001) in control subjects and only 1.2% (95% CI, -0.9% to 3.3%; P=.26) in patients with CA (between groups, P<.0001) from rest to peak exercise. The LVMWI increase in patients with CA was mediated by improvement in the apical segments (P<.0001), whereas there was no significant LVMWI alterations in the midventricular or basal segments. LVMWE remained stable during exercise in control subjects (Δ -0.6%; 95% CI, -2.5% to 1.2%; P=.50) but decreased significantly in patients with CA (Δ -2.5%; 95% CI, -4.8% to -0.2%; P<.05). Patients with CA have significantly reduced magnitude of LVMWI compared with healthy control subjects. With exercise, the differences are even more pronounced. Even though LVMWI increased with exercise, LVMWE decreased, suggesting inefficient myocardial energy exploitation in patients with CA.

The association between 24-h blood pressure patterns and left ventricular mechanics.

We sought to investigate left ventricular (LV) mechanics in the recently diagnosed hypertensive patients with different 24-h blood pressure (BP) patterns (dipping, nondipping, extreme dipping and reverse dipping). The current cross-sectional study included 209 hypertensive patients who underwent 24-h ambulatory BP monitoring and comprehensive two-dimensional echocardiographic examination including multilayer strain analysis. There was no difference in 24-h and daytime BP values between four groups. Night-time BP significantly and gradually increased from extreme dippers, across dippers and nondippers, to reverse dippers. LV global longitudinal and circumferential strains were greater in dippers and extreme dippers than in nondippers and reverse dippers. This was also found for endocardial and epicardial LV longitudinal and circumferential strains. Multivariate logistic regression analysis demonstrated that nondipping and reverse dipping patterns were associated with reduced LV longitudinal strain [odds ratio (OR) 1.71 (95% confidence interval (CI): 1.10-5.61) and OR 2.50 (95% CI: 1.31-6.82), respectively] independently of age, sex, 24-h SBP, LV mass index and E/è. Only the reverse dipping BP pattern was independently of clinical and echocardiographic parameters related with reduced LV circumferential strain [OR 1.90 (95% CI: 1.10-4.80)]. Nondipping and reverse dipping BP patterns had stronger impact on LV mechanics compared with patients with dipping and extreme dipping BP patterns in hypertensive population. LV functional and mechanical remodeling deteriorated from extreme dippers and dippers, to nondippers and reverse dippers.

Evaluation of right ventricle functions might be a method for early recognizing cardiotoxicity in hematopoietic stem cell transplantation

Objective: We aimed to investigate whether right ventricular (RV) functional assessment by echocardiography may help in the early diagnosis of hematopoietic stem cell transplantation (HSCT)-induced cardiotoxicity. Methods: Our study population comprised 41 autologous multiple myeloma, 25 autologous Hodgkin's lymphoma, 20 autologous and 19 allogeneic non-Hodgkin's lymphoma, 10 allogeneic acute myeloid leukemia, 12 allogeneic myelodysplastic syndrome, and 10 allogeneic aplastic anemia patients. Conventional two-dimensional echocardiographic and tissue Doppler imaging examination of the patients were performed before and after HSCT. Post-HSCT values were compared with pre-HSCT values. Results: The mean age of the patients was 46.51 ± 16.24 years, and the mean hospital length of stay and the mean leukocyte engraftment time were 30 and 11 days, respectively. The number of female and male patients was 60 (43.8%) and 77 (56.2%), respectively. There were no significant differences in echocardiographic parameters including left ventricular end-diastolic diameter, left ventricular end-systolic diameter, left ventricular ejection fraction, RV, right atrium, pulmonary artery pressure, pulmonary velocity, Pulmonary acceleration time (PAT)/ pulmonary ejection time (PET), PAT, E, A wave velocity, E/A ratio, and DT and A' velocity before and after HSCT. Compared to pretransplant values, posttransplant values of the E' velocity, S' velocity, E'/A' ratio, and tricuspid annular plane systolic excursion showed a statistically significant decrease (0.15 ± 0.34 vs. 0.12 ± 0.04, P = 0.032; 0.19 ± 0.06 vs. 0.09 ± 0.04, P

Risk in atrial fibrillation: left atrial function matters

Risk in atrial fibrillation: left atrial function matters

Combined effects of growth hormone and testosterone replacement treatment in heart failure.

AimsAlthough preliminary studies have demonstrated safety and effectiveness of single replacement therapy for growth hormone deficiency or testosterone deficiency in heart failure (HF), no data are available regarding the combined treatment with both GH and T in this setting. Thus, the aim of the present hypothesis generating pilot study was to evaluate the effectiveness and safety of multiple hormonal replacement therapies in chronic HF.Methods and resultsFive stable HF with reduced ejection fraction patients, with a concomitant diagnosis of growth hormone deficiency and testosterone deficiency, on top of guideline‐based HF treatment underwent 1 year of GH replacement therapy by subcutaneous injections of somatotropin at a dose of 0.012 mg/kg every second day. After 12 months, a T replacement treatment was added at a dosage of 1000 mg every 3 months. Each patient underwent a complete M‐mode, two‐dimensional, and Doppler echocardiographic examination, and an incremental symptom‐limited cardiopulmonary exercise test on a bicycle ergometer at baseline (BL), after 1 year of GH treatment (V1), and after 1 year of combined GH + T treatments (V2). One‐year of GH treatment resulted in a significant improvement in left ventricular ejection fraction (+5.4%, P < 0.01), New York Heart Association functional class (P < 0.05), and peak oxygen consumption (VO2 peak) (+19.3%, P < 0.01), and in a significant reduction in NT‐proBNP levels (−35.1%, P < 0.01). Notably, one additional year of combined GH and T replacement therapy induced a further increase in VO2 peak (+27.7%, final delta change + 52.44%, P < 0.01), as well as a significant improvement in muscular strength, as assessed by handgrip dynamometry (+17.5%, final delta change + 25.8%, P < 0.01). These beneficial effects were paralleled with an improvement of the overall clinical status (as assessed by New York Heart Association class). Of note, neither adverse effects nor cardiovascular events were reported during the follow‐up period.ConclusionsOur preliminary data suggest for the first time that combined replacement therapy with GH and T could be considered safe and therapeutic in HF patients with multiple hormone deficiencies, supporting the hypothesis that multiple hormone deficiencies syndrome can be considered as a novel and promising therapeutic target in HF. Further studies with a more robust design and larger population are needed.

Do reverse dippers have the highest risk of right ventricular remodeling?

We aimed to evaluate right ventricular (RV) deformation in recently diagnosed untreated hypertensive patients with different 24-h blood pressure (BP) patterns (dipping, nondipping, extreme dipping and reverse dipping). This cross-sectional study involved 190 untreated hypertensive patients who underwent 24-h ambulatory BP monitoring and a detailed two-dimensional echocardiographic examination, including the assessment of layer-specific strain. We found that 24-h and daytime BP values did not differ between the four groups. Nighttime BP significantly and gradually increased from extreme dippers across dippers and nondippers to reverse dippers. RV structure and systolic and diastolic function did not significantly differ among the four groups. However, RV global and RV free wall longitudinal strains were significantly lower in nondippers and reverse dippers than in dippers and extreme dippers. The endocardial and epicardial RV longitudinal strains of the whole RV and free wall RV were the lowest in reverse dippers and highest in extreme dippers. Multivariate logistic regression analysis demonstrated that only reverse dipping patterns were associated with reduced RV global longitudinal strain [OR 2.9 (95% CI: 1.5-8.2)], independent of age, sex, 24-h systolic BP, LV mass index, RV wall thickness and E/e't. Similarly, the reverse dipping pattern was associated with reduced RV free wall longitudinal strain, independently of the mentioned parameters [OR 3.8 (95% CI: 1.8-8.5)]. In conclusion, in the hypertensive population, the reverse dipping BP pattern had an adverse effect on RV deformation. RV remodeling progressively deteriorated from extreme dippers to reverse dippers, but only the reverse dipping BP pattern was independently associated with the reduction in RV longitudinal strain.

Incremental value of right parasternal transthoracic echocardiographic examination over the left parasternal approach in assessing ascending aorta size: Additional benefit of three-dimensional echocardiography.

The ascending aorta (AA) has not been well studied using two-dimensional right parasternal transthoracic echocardiographic examination (2DRPE). The aim of the present study was to assess the incremental value of 2DRPE over two-dimensional left parasternal transthoracic echocardiographic examination (2DLPE) in evaluating the size of AA in adult patients (pts) and, secondly, to determine whether live/real time three-dimensional (3D) RPE provided any additional benefit over 2DRPE. The AA was successfully imaged by 2DLPE, 2DRPE, and 3D RPE in 87 of 141 (61.7%) pts which comprised of two groups of consecutive pts separated by an interval of 2 weeks. The maximum length of AA visualized by 2DRPE (4.98 ± 0.89) was larger than 2DLPE in 76/87(87%) pts (P < 0.001). Both the maximum systolic AA inner luminal width and leading edge-to-leading edge width by 2DRPE were greater than 2DLPE (P < 0.001). Similar to other noninvasive imaging modalities where mid-AA width is taken at level of right pulmonary artery, mid-AA width could also be taken at this level by 2DRPE in 79/87(91%) pts since this landmark was visualized during 2DRPE. However, this vessel could be visualized in only 2/87 (2%) pts with 2DLPE. 3DRPE conferred additional benefit over 2DRPE. The maximal AA length by 3DRPE was larger than 2DRPE in 60/87(69%) pts, and the maximal inner lumen and leading edge to leading edge widths were larger in 54/87(62%) and 66/87(76%) pts, respectively. Our preliminary study demonstrates significant incremental value of 2DRPE over 2DLPE in the assessment of AA. 3DRPE confers an additional advantage over 2DRPE.