Ventricular Dysfunction In Asymptomatic Patients Research Articles

Global longitudinal strain to predict left ventricular dysfunction in asymptomatic patients with severe mitral valve regurgitation: literature review.

The optimal treatment strategy for asymptomatic patients with severe mitral valve regurgitation (MR) and preserved left ventricular (LV) function is challenging. This manuscript reviews the available literature on the value of left ventricular global longitudinal strain (LV-GLS) in predicting LV dysfunction after mitral valve surgery in these patients and discusses its current place in the treatment strategy. Studies were identified from Cochrane Library, SCOPUS, PubMed and Web of Science up to February 2018. The domain used was MR. The determinant was LV-GLS; other methods of deformation imaging were excluded. The examined outcome was LV dysfunction after surgery. A total of 144 articles were retrieved, of which 11 publications met the inclusion criteria, including a total of 2415 patients. Ten studies showed a significant correlation between preoperative LV-GLS and LV dysfunction postoperatively; one study reported a negative correlation. These studies suggest that LV-GLS is a predictor of LV dysfunction after surgery in asymptomatic patients with chronic MR. Hence, incorporation of LV-GLS for clinical decision-making in these patients might be of additional value. Further research is needed to confirm the role of LV-GLS in postoperative patients, and additionally in asymptomatic MR patients during a ‘watchful waiting’ strategy.

Dobutamine stress echocardiography unmasks early left ventricular dysfunction in asymptomatic patients with uncomplicated Type 2 diabetes: A comprehensive 2D speckle-tracking imaging Study

Discrepancies are present in the literature on resting myocardial mechanics in patients with uncomplicated type 2 diabetes mellitus (T2DM). Data are noticeably sparse regarding circumferential function and torsional mechanics. Resting deformation imaging may not be sensitive enough to detect subtle dysfunctions. The aim of this study was thus to comprehensively evaluate myocardial mechanics in patients with T2DM at rest and to investigate whether dobutamine stress echocardiography could unmask functional alterations that would remain otherwise subtle at rest. Forty-four patients with T2DM and 35 healthy control subjects of similar age and sex were prospectively recruited. After conventional echocardiography, myocardial mechanics was evaluated at rest and during low-dose dobutamine stress echocardiography (target heart rate, 110 beats/min). Patients with T2DM presented with altered global diastolic function but preserved systolic function. Deformation imaging indexes were similar between groups at rest, but significant differences were noticed under dobutamine infusion ( Table 1 ). Multivariate analysis identified epicardial fat, dyslipidemia, and fasting glycaemia as significant contributors to the changes from rest to dobutamine. These findings demonstrate the usefulness of dobutamine stress echocardiography in establishing impairments in myocardial mechanics in patients with uncomplicated T2DM. Systemic metabolic disturbances and epicardial fat act as the main contributors to the blunted response to dobutamine stress in these patients.

Dobutamine Stress Echocardiography Unmasks Early Left Ventricular Dysfunction in Asymptomatic Patients with Uncomplicated Type 2 Diabetes: A Comprehensive Two-Dimensional Speckle-Tracking Imaging Study

Discrepancies are present in the literature on resting myocardial mechanics in patients with uncomplicated type 2 diabetes mellitus (T2DM). Data are noticeably sparse regarding circumferential function and torsional mechanics. Resting deformation imaging may not be sensitive enough to detect subtle dysfunctions. The aim of this study was thus to comprehensively evaluate myocardial mechanics in patients with T2DM at rest and to investigate whether dobutamine stress echocardiography could unmask functional alterations that would remain otherwise subtle at rest. Forty-four patients with T2DM and 35 healthy control subjects of similar age and sex were prospectively recruited. After conventional echocardiography, myocardial mechanics was evaluated at rest and during low-dose dobutamine stress echocardiography (target heart rate, 110 beats/min). Patients with T2DM presented with altered global diastolic function but preserved systolic function. Deformation imaging indexes were similar between groups at rest, but significant differences were noticed under dobutamine infusion for longitudinal strain (-21.2±2.4% vs -24.2±2.5%, P<.001), circumferential strain (apex, -32.3±5.3% vs -36.3±5.3%, P=.002; papillary muscle, -25.6±3.2% vs -28.0±3.6%, P=.001; base, -23.2±3.6% vs -25.3±3.8%, P=.03), apical (11.2±4.4° vs 14.1±6.3°, P=.020) and basal (-12.2±3.3° vs -14.3±3.9°, P=.021) rotation, and twist (21.9±5.9° vs 26.8±8.3°, P=.007). Multivariate analysis identified epicardial fat, dyslipidemia, and fasting glycaemia as significant contributors to the changes from rest to dobutamine. These findings demonstrate the usefulness of dobutamine stress echocardiography in establishing impairments in myocardial mechanics in patients with uncomplicated T2DM. Systemic metabolic disturbances and epicardial fat act as the main contributors to the blunted response to dobutamine stress in these patients.

Feasibility of exercise stress echocardiography and myocardial response in patients with repaired congenital heart disease

Exercise stress echocardiography (ESE) can unmask ventricular dysfunction in asymptomatic patients with congenital heart disease (CHD), but its acquisition and interpretation is often challenging, and the method has not been validated in CHD. This study aimed to evaluate the feasibility of ESE using Doppler imaging and to assess myocardial response to exercise in patients with biventricular (BiV) and univentricular (UniV) circulation after CHD repair. In this single-center prospective study, we recruited 55 participants (17 females), median age 14 years (8-22 years). Our analysis categorized participants in these three groups: with structurally normal hearts as controls (n=21), with BiV circulation (n=20) and with UniV circulation (n=14). We acquired ESE images of the systemic ventricle including pulsed-wave flow and spectral tissue Doppler imaging (TDI) of lateral free wall before and immediately after standard, symptom-limited exercise tests on an electronically braked cycle ergometer. During ESE we obtained inflow E-wave and TDI systolic (S') and early diastolic (E') velocities in 93% to 100% of participants at rest and in 90% to 100% of participants post exercise. Feasibility to obtain Doppler imaging parameter was the same across study groups. The myocardial response to exercise was increase in heart rate (HR), S' and inflow E-wave velocity in all participants. Patients with BiV circulation had preserved ventricular function at rest. While patients with UniV circulation had low S', E', and E-wave velocities at rest in comparison to controls and to BiV group (all P<.001), both patients with BiV and UniV circulation showed significant increases in HR, S' velocity and inflow E-wave velocity post exercise, with magnitudes of these increases higher in controls than in the BiV and UniV group. The S' and E' velocities were strongly associated with lower percent predicted peak oxygen consumption VO2 (rs=0.614 and rs=0.64, respectively, both P<.001). ESE with Doppler imaging is a practical noninvasive diagnostic method and sufficiently robust for the assessment of morphologic LV/systemic ventricles under exercise in patients after biventricular and univentricular CHD repair. Although patients with BiV and UniV circulation had both preserved myocardial response to exercise, the magnitude of this response was the lowest in patients with UniV circulation.

Association of left atrial reservoir function with left atrial structural remodeling related to left ventricular dysfunction in asymptomatic patients with hypertension: evaluation by two-dimensional speckle-tracking echocardiography

Left atrial (LA) structural and functional abnormalities are vital steps on the pathway toward heart failure with preserved ejection fraction in asymptomatic patients. The purpose of this study was to assess the relationship of LA function, particularly reservoir function, with LA structural remodeling related to the left ventricular (LV) dysfunction in asymptomatic patients with hypertension (HT) using conventional, tissue Doppler, and 2-D speckle-tracking echocardiography. Fifty age-matched healthy individuals and 140 patients with HT, including 75 with LA volume index (LAVI) < 29 ml/m2 (normal LA group) and 65 with LAVI ≥ 29 ml/m2 (large LA group), were enrolled. We defined peak early diastolic transmitral flow velocity/peak early diastolic mitral annular motion velocity (E/e′)/peak systolic LA strain (S-LAs) as LA diastolic stiffness. The LV mass index, relative LV wall thickness, peak atrial systolic transmitral flow velocity, LA total, active, and passive emptying volume indexes, and E/e′/S-LAs were greatest, and S-LAs, peak early diastolic LA strain, peak systolic LV longitudinal strain and circumferential strain rate, and peak early diastolic LV radial strain rate were lower in the large LA group compared with control and/or normal LA group. Multivariate linear regression analysis revealed that aging, LA remodeling, and LV systolic and diastolic dysfunction are defined as strong predictors related to increased LA diastolic stiffness in the large LA group. HT alters LA dynamics significantly, with resultant increased LA volume and diastolic stiffness related to LV diastolic and systolic dysfunction, even in asymptomatic patients. Earlier treatment with reninangiotensin system inhibitors may improve abnormal LA-LV interaction in this patient population.

Contribution of obesity to left atrial and left ventricular dysfunction in asymptomatic patients with hypertension: A two-dimensional speckle-tracking echocardiographic study

Hypertension and obesity each are well known to result in heart failure with preserved ejection fraction. Therefore, it is clinically important to clarify the mechanisms of further deterioration of left atrial (LA)-left ventricular (LV) interaction in asymptomatic patients with obesity in the presence of hypertension. Data on conventional and two-dimensional speckle-tracking echocardiography (2DSTE) were obtained from 134 asymptomatic hypertensive patients. The study sample was divided into two groups: non-obese (n = 80; body mass index [BMI] <25 kg/m2] and obese (n = 54; BMI ≥25 kg/m2). The end-diastolic LV diameter, ratio of early transmitral flow to mitral annular motion velocity (E/e’), peak systolic LV circumferential strain rate, and E/e’/peak systolic LA strain (S-LAs) were greater in the obese group. Among the significantly correlated variables with BMI and E/e’/S-LAs in univariate analyses, multivariate analyses revealed that BMI is independently associated with end-diastolic LV diameter and peak systolic LV radial strain in all hypertensive patients, and that age, systolic blood pressure, relative LV wall thickness, peak systolic mitral annular motion velocity (s’), peak systolic LV radial strain, and peak early diastolic LV longitudinal strain rate are identified as independent predictors related to E/e’/S-LAs in the obese patients, whereas only s’ contributes to the E/e’/S-LAs in the non-obese patients. Impaired LA-LV interaction was accelerated with obesity in the presence of hypertension. Assessment of the LA and LV function using 2DSTE provided additional information to the negative effects of cardiovascular risk factors on the LA and LV function in patients without clinical symptoms.

Early predictors of alterations in left atrial structure and function related to left ventricular dysfunction in asymptomatic patients with hypertension

Our aim was to investigate the relationships between left atrial (LA) structural and functional changes and left ventricular (LV) dysfunction related to LV pressure overload in asymptomatic patients with hypertension. One hundred and twenty-six asymptomatic patients with hypertension and LV ejection fraction (EF) ≥60% were studied. Conventional, pulsed and tissue Doppler, and two-dimensional speckle-tracking echocardiography (2DSTE) were performed to seek the independent determinants for alterations in LA structure and function. LA volume index (LAVI) correlated with age, body mass index (BMI), end-diastolic ventricular septal thickness (VSth), end-diastolic LV posterior wall thickness, relative LV wall thickness (RWT), LV mass index, peak A velocity of transmitral flow, E/e’, and peak systolic and early diastolic LA strains and strain rates. Peak LA strain during ventricular systole (S-LAs) correlated with age, BMI, heart rate (HR), end-systolic LV diameter, LAVI, VSth, RWT, LVEF, e’, E/e’, peak systolic LV radial strain, and peak early diastolic LV longitudinal strain rate. Multivariate regression analyses indicated that LV mass index, peak A velocity, E/e’, and S-LAs are defined as strong predictors related to LAVI, and that BMI, HR, LAVI, and peak systolic LV radial strain are defined as strong predictors related to S-LAs. In conclusion, 2DSTE demonstrated that alterations in LA structure and function are mainly associated with LV diastolic and systolic dysfunction, respectively, in preclinical patients with hypertension.

Alpha-lipoic acid improves subclinical left ventricular dysfunction in asymptomatic patients with type 1 diabetes.

Oxidative stress plays an important role in the development of diabetic cardiomyopathy. Alpha-lipoic acid (ALA) is a powerful antioxidant that may have a protective role in diabetic cardiac dysfunction. We investigated the possible beneficial effect of alpha-lipoic acid on diabetic left ventricular (LV) dysfunction in children and adolescents with asymptomatic type 1 diabetes (T1D). Thirty T1D patients (aged 10-14) were randomized to receive insulin treatment (n = 15) or insulin plus alpha-lipoic acid 300 mg twice daily (n = 15) for four months. Age and sex matched healthy controls (n = 15) were also included. Patients were evaluated with conventional 2-dimensional echocardiographic examination (2D), pulsed tissue Doppler (PTD), and 2-dimensional longitudinal strain echocardiography (2DS) before and after therapy. Glutathione, malondialdhyde (MDA), nitric oxide (NO), tumor necrosis factor-alpha (TNF-alpha), Fas ligand (Fas-L), matrix metalloproteinase 2 (MMP-2), and troponin-I were determined and correlated to echocardiographic parameters. Diabetic patients had significantly lower levels of glutathione and significantly higher MDA, NO, TNF-alpha, Fas-L, MMP-2, and troponin-I levels than control subjects. The expression of transforming growth factor beta (TGF-beta) mRNA in peripheral blood mononuclear cells was also increased in diabetic patients. Significant correlations of mitral e'/a' ratio and left ventricular global peak systolic strain with glutathione, MDA, NO, TNF-alpha, and Fas-L were observed in diabetic patients. Alpha-lipoic acid significantly increased glutathione level and significantly decreased MDA, NO, TNF-alpha, Fas-L, MMP-2, troponin-I levels, and TGF-beta gene expression. Moreover, alpha-lipoic acid significantly increased mitral e'/a' ratio and left ventricular global peak systolic strain in diabetic patients. These findings suggest that alpha-lipoic acid may have a role in preventing the development of diabetic cardiomyopathy in type 1 diabetes.

Myocardial Systolic Velocities and Deformation Assessed by Speckle Tracking for Early Detection of Left Ventricular Dysfunction in Asymptomatic Patients with Severe Primary Mitral Regurgitation

In asymptomatic patients with severe primary mitral regurgitation (PMR), early detection of left ventricular (LV) dysfunction indicates the optimal timing of mitral valve surgery; however, normal ejection fraction (EF) and end-systolic diameter (ESD) can mask significant LV impairment. We studied 28 asymptomatic patients (59 ± 13 years, 18 male) with severe PMR, EF > 60%, and ESD < 45 mm, and 10 age-matched healthy subjects. All underwent echocardiography with tissue velocity imaging to assess LV geometry, EF, and longitudinal systolic function; and two-dimensional speckle tracking to assess longitudinal strain (LS) and longitudinal strain rate (LSR), and radial strain (RS) and radial strain rate (RSR). Patients were reevaluated 14 days after successful mitral valve repair and divided in: IA, with a postoperative EF reduction >10% (13 patients) and IB, with an EF reduction <10% (15 patients). Patients with PMR had longitudinal dysfunction and decreased radial systolic deformation, by comparison with controls, although EF and ESD were similar. Subgroup IA had significantly lower S(TVI) , LS, and RS than IB (7.3 ± 0.9 vs 10.8 ± 1.5 m/s; -16.0 ± 4.2% vs -21.7 ± 2.1%; and 37.4 ± 2.5% vs 41.6 ± 2.4%; all p < 0.001) although preoperative LV mass index, LV diameters, and EF were similar. Multiple stepwise regression analysis showed that S(TVI) and the combination of S(TVI) and LS represent the main independent predictors for a postoperative EF reduction >10% (r(2) = 0.52, p < 0.001; and r(2) = 0.70, p < 0.001, respectively). Myocardial systolic velocities as well as radial and longitudinal LV deformation assessed by speckle tracking can detect subclinical LV dysfunction and predict impaired postoperative LV function in asymptomatic patients with severe PMR.

Relation of subclinical left and right ventricular dysfunctions measured by computed tomography angiography with the severity of coronary artery disease

Ventricular dysfunction in asymptomatic patients is directly linked to the eventual development of symptomatic congestive heart failure. This study investigates whether subclinical left ventricular (LV) and right ventricular (RV) dysfunctions measured by computed tomography angiography is associated with the severity of coronary artery disease (CAD). We studied 1608 consecutive patients with suspected CAD (age 62 ± 10 years, 64% male), who underwent coronary artery calcium (CAC) scanning and computed tomography angiography. RV and LV volumes at end systole and end diastole were measured, and stroke volume and ejection fraction were calculated using the Simpson method and piecewise smooth subdivision surface (PSSS) method. Analysis by Simpson was performed on short axis and apical four-chamber views. Axial images were used to measure RV and LV volumes by the PSSS method. CAD was defined as normal, nonobstructive, and obstructive (0% stenosis, luminal stenosis 1-49 and 50%+, respectively). There was a strong agreement between PSSS and Simpson method RV ejection fraction (RVEF) and LV ejection fraction (LVEF) measurement. RVEF and LVEF decreased proportionally from CAC 0 to CAC 100+, also from normal-to-diseased coronaries (P=0.001). After adjustment for cardiovascular risk factors, the mean LVEF and RVEF decreased 2.8 and 2.4%, respectively in CAC 100+ compared with CAC 0. Similarly, LVEF and RVEF decreased significantly in nonobstructive CAD (-3.5 and -3.1%, respectively) and obstructive CAD (-5.9 and -4.5%, respectively) compared with normal coronaries, respectively (P<0.05). The relative risk of each 5% decrease in LVEF and RVEF was 1.33 and 1.29 for nonobstructive CAD and 1.54 and 1.33 for obstructive CAD, respectively. The presence and severity of coronary atherosclerosis is significantly associated with subclinical RV and LV dysfunctions.

Left ventricular dysfunction in asymptomatic patients with systemic lupus erythematosus

Left ventricular dysfunction in asymptomatic patients with systemic lupus erythematosus

Prognostic implication of valvular lesion and left ventricular size in asymptomatic patients with chronic organic mitral regurgitation and normal left ventricular performance

To date, few studies have evaluated asymptomatic patients with organic mitral regurgitation (MR). The goal of the present study was to assess the presence of independent predictive factors for progression of symptoms and/or left ventricular dysfunction (SLVSD) in this population. We prospectively evaluated 128 consecutive patients (mean age 60 +/- 8 years, 68% men; ejection fraction 66 +/- 3%) who were asymptomatic, with severe organic MR. Mean follow-up was 29 +/- 12 months. The combined end point was SLVSD. Clinical and echocardiographic variables were evaluated. Follow-up data were also estimated considering the annualized rate (?) of the echocardiographic indices. Thirty-seven patients (29%) had SLVSD during follow-up. Cox regression model identified the effective regurgitant orifice area (EROA) >55 mm2 (risk ratio 6.3, 95% CI 2.3-8.1, P < .001) and end-systolic diameter >22 mm/m2 (risk ratio 4.5, 95% CI, 1.8-9.4, P < .02) as the only independent predictors of SLVSD. When the follow-up data were added, the ?EROA (>15 mm2/y) was independently associated with the end point. In asymptomatic patients with organic MR, the EROA and the end-systolic diameter are independent predictors of SLVSD and allow a better risk stratification in this group of patients. ANALYTICAL SUMMARY: The goal of this study was to determine the presence of independent predictors of symptomatic progression, and/or left ventricular dysfunction in asymptomatic patients with severe mitral regurgitation. We prospectively evaluated 128 consecutive patients (mean age 60 +/- 8 years, 68% male; ejection fraction 66 +/- 3%). During follow-up (mean 29 +/- 12 months). The end point occurred in 37 patients (29%). Multivariate analysis using Cox model identified the effective regurgitant orifice area (EROA) >55 mm2 (RR: 6.3; 95% CI: 2.3-8.1; P < .001) and an end-systolic diameter (ESD) >22 mm/m2 (RR: 4.5; 95%CI: 1.8-9.4; P < .02) as the only independent predictors of the end point. When the follow-up data were added, the annualized change rate of the EROA (>15 mm2/year) was independently associated with the end point. In asymptomatic patients with organic mitral regurgitation, the EROA and ESD at study entry were independent predictors of the combined end point and allowed a better risk stratification in this group of patients.

Subclinical left ventricular dysfunction in asymptomatic patients with Type II diabetes mellitus, related to serum lipids and glycated haemoglobin.

The aim of the present study was to measure regional ventricular function at rest and during stress in order to assess if patients with Type II diabetes have subclinical myocardial dysfunction and if it is related to risk factors. Seventy subjects (35 patients with Type II diabetes with no symptoms, signs or history of heart disease, and 35 age- and sex-matched healthy controls) had echocardiography at rest and during dobutamine stress. Myocardial velocities were measured off-line from digital loops of colour tissue Doppler. Subendocardial function was assessed from the mean longitudinal velocities of four basal segments (apical views) and radial function from the velocities of the basal posterior wall (parasternal view). Systolic functional reserve was calculated as the increase in velocity from baseline. Longitudinal peak systolic velocity was lower in patients with diabetes, at rest (5.6 +/- 1.4 compared with 6.5 +/- 1.1 cm/s) and at peak stress (10.9 +/- 2.8 compared with 14.3 +/- 2.1 cm/s) (both P <0.01). Functional reserve was impaired in patients with diabetes (+5.4 +/- 2.0 compared with +7.7 +/- 1.7 cm/s; P <0.01). Radial systolic velocity was higher in patients with diabetes (5.4 +/- 1.3 compared with 4.7 +/- 1.4 cm/s; P <0.05). Resting longitudinal systolic function correlated inversely with low-density lipoprotein-cholesterol ( r =-0.53), glycated haemoglobin ( r =-0.48), age ( r =-0.41) and diastolic blood pressure ( r =-0.38) (all P < 0.05). Peak stress systolic velocity correlated inversely with glycated haemoglobin ( r =-0.46) and age ( r =-0.44) (both P < 0.01). In conclusion, patients with Type II diabetes and no clinical heart disease have impaired subendocardial function of the left ventricle at rest and peak stress, which is related to glycated haemoglobin and serum low-density lipoprotein-cholesterol.

Value of the electrocardiogram in detecting left ventricular dysfunction in asymptomatic patients with aortic regurgitation

This study demonstrates the value of the electrocardiogram at rest, but preferably with effort, to detect LV dysfunction in patients with AR. We suggest that the R 6:S 2 time relation is useful in evaluation of AR and in follow-up of patients. When the test becomes abnormal, LV dysfunction is present. Further studies are needed in order to confirm this simple test, to correlate the findings with other investigative techniques, and to investigate reversibility of LV dysfunction after surgical management.