Ventricular Longitudinal Function Research Articles

The relationship between coronary microvascular dysfunction and left ventricular longitudinal systolic function in patients with diabetes mellitus

Abstract Background Coronary microvascular dysfunction (CMD) often accompanies diabetes mellitus (DM), leading to myocardial ischemia despite normal or mildly narrowed coronary arteries (<50% stenosis). CMD causes myocardial hypoperfusion, resulting in impaired systolic function. Coronary flow reserve (CFR) serves as a marker of microvascular function, particularly in the absence of significant epicardial coronary stenosis. Myocardial contrast echocardiography (MCE) is a key tool for clinically assessing CFR. Global longitudinal strain (GLS) derived from two-dimensional speckle tracking echocardiography (2D-STE) offers early insights into left ventricular systolic dysfunction during subclinical stages but is underexplored in diabetic CMD patients. Objective This study aimed to assess myocardial microcirculatory dysfunction in diabetic patients using stress myocardial ultrasound enhancement imaging, investigate its relationship with left ventricular longitudinal systolic function, and evaluate the utility of 2D-STE in assessing left ventricular systolic function in CMD patients. The findings provide insights for early detection and prevention of left ventricular longitudinal systolic dysfunction in diabetic patients with myocardial microcirculatorydysfunction. Methods Seventy type 2 diabetic patients who underwent coronary CT or angiography within the past three months without obstructive coronary artery disease were included. Clinical data, biochemical parameters, and blood glucose levels were collected. Left ventricular longitudinal strain indices were obtained using 2D-STE, and microvascular function was assessed based on CFR measured via transthoracic stress MCE. Patients were categorized into CMD (CFR<2) and control (CFR≧2) groups, with clinical and echocardiographic parameters compared. Strain parameters included GLS at rest, GLS under stress, and ∆GLS. Correlations between these indices and CFR were analyzed. Results 1. Seventy patients, with 41 males (41.4%) and 58 females (58.6%), averaging 56.14±10.84 years, were included. The mean BMI was 25.53±3.40. Among them, 23 patients were smokers (32.8%), 41 had hypertension (58.6%), and 36 had hyperlipidemia (51.4%). 2. Patients in the CMD group had significantly shorter diabetes duration (6.59±2.18 years vs. 8.13±2.17 years) and lower glycosylated hemoglobin (7.99±1.52% vs. 8.78±1.55%) (P<0.05). No significant differences were observed in other parameters. 3. GLS and ∆GLS differed significantly between groups, while other echocardiographic parameters did not. 4. Logistic regression analysis identified GLS as an independent predictor of CMD in diabetic patients under stress. Conclusions 1. Diabetic patients with CMD exhibit lower GLS and ∆GLS under stress, indicating early reductions in left ventricular systolic function reserve. 2. 2D-STE can detect early left ventricular systolic impairment in diabetic patients.MCE quantitative analysisGLS in normal and CMD group

First report of the clinical characteristics and outcomes of cardiac amyloidosis in Saudi Arabia.

Cardiac amyloidosis (CA) is a potentially fatal multisystemic disease that remains significantly underdiagnosed, particularly in the Middle East. This study aims to evaluate the prevalence and clinical characteristics of CA in a high-risk population at a tertiary centre in Saudi Arabia. This cross-sectional, retrospective, single-centre study was conducted at a tertiary hospital in Riyadh, Saudi Arabia. We reviewed the medical records of heart failure patients seen between August 2018 and July 2022 who exhibited red flags for CA and subsequently underwent CA screening. Red flags that prompted the workup included at least two of the following factors: the presence of unilateral or bilateral carpal tunnel syndrome, a family history of transthyretin amyloid (ATTR) amyloidosis and specific electrocardiographic features (relative/absolute low QRS voltage, pseudoinfarct pattern and atrioventricular/interventricular conduction abnormalities). Echocardiographic red flags included mainly increased wall thickness (≥12mm), significant diastolic dysfunction, reduced left ventricular (LV) longitudinal function, right ventricular (RV) dysfunction and elevated right atrial (RA)/pulmonary artery (PA) pressure. Cardiac magnetic resonance (CMR) red flags included aspects similar to those in an echocardiogram as well as a subendocardial or transmural late gadolinium enhancement (LGE) pattern. These patients were assessed for CA through technetium-99m pyrophosphate ([99mTc]Tc-PYP) bone scintigraphy, serum and urine protein electrophoresis with immunofixation and a serum-free light chain assay. A total of 177 patients were screened, of which 21.0 (11.9%) patients were diagnosed with transthyretin amyloid CA (ATTR-CA) and 13 (7.3%) patients were diagnosed with light chain CA (AL-CA). Compared with patients with negative/equivocal [99mTc]Tc-PYP scans (grades 0-1), patients with positive [99mTc]Tc-PYP scans (grades 2-3) were older (78.0 vs. 68.0years, P<0.001), had higher levels of troponin (P=0.003) and N-terminal pro-brain natriuretic peptide (NT-proBNP) (P<0.001), had a higher LV mass index (P<0.001), displayed a more depressed global longitudinal strain (GLS) (P<0.001) with a greater prevalence of a relative apical sparing pattern (P<0.001) and demonstrated a higher incidence of first-degree atrioventricular block (P=0.008) and low voltage patterns on electrocardiography (P<0.001). Patients with ATTR-CA and AL-CA were more likely to have a subendocardial or transmural LGE pattern on CMR (P<0.001) and had a significantly lower overall survival (P<0.001) when compared with other heart failure aetiologies. This is the first study to describe the clinical characteristics and outcomes of CA in the Middle East and Saudi Arabia. The prevalence of CA among screened heart failure patients here aligns with major international studies, suggesting significant underdiagnosis in the region. Therefore, larger multicentric studies and regional screening programmes are urgently needed to accurately characterize the epidemiology and outcomes of CA in the Middle East.

Inversion of Left Ventricular Axial Shortening: In Silico Proof of Concept for Treatment of HFpEF.

Left ventricular (LV) longitudinal function is mechanically coupled to the elasticity of the ascending aorta (AA). The pathophysiologic link between a stiff AA and reduced longitudinal strain and the subsequent deterioration in longitudinal LV systolic function is likely relevant in heart failure with preserved ejection fraction (HFpEF). The proposed therapeutic effect of freeing the LV apex and allowing for LV inverse longitudinal shortening was studied in silico utilizing the Living Left Heart Human Model (Dassault Systémes Simulia Corporation). LV function was evaluated in a model with (A) an elastic AA, (B) a stiff AA, and (C) a stiff AA with a free LV apex. The cardiac model simulation demonstrated that freeing the apex caused inverse LV longitudinal shortening that could abolish the deleterious mechanical effect of a stiff AA on LV function. A stiff AA and impairment of the LV longitudinal strain are common in patients with HFpEF. The hypothesis-generating model strongly suggests that freeing the apex and inverse longitudinal shortening may improve LV function in HFpEF patients with a stiff AA.

Efficacy of mitral annular velocity as an alternative marker of left ventricular global longitudinal strain to detect the risk of cancer therapy-related cardiac disorders.

Left ventricular longitudinal function can be rapidly evaluated by measuring S' and mitral annular plane systolic excursion (MAPSE) using tissue Doppler imaging. Even when the image quality is poor and the left ventricular endocardium is not visible, S' and MAPSE can be measured if the mitral annulus is visible. However, the utility of S' and MAPSE in diagnosing cancer therapy-related cardiac dysfunction (CTRCD) remains unclear. This study aimed to examine the diagnostic performance of S' and MAPSE and determine appropriate cutoff values. We retrospectively enrolled 279 breast cancer patients who underwent pre- or postoperative chemotherapy with anthracyclines and trastuzumab from April 2020 to November 2022. We compared echocardiographic data before chemotherapy, 6 months after chemotherapy initiation, and 1 year later. CTRCD was defined as a decrease in left ventricular ejection fraction below 50%, with a decrease of ≥10% from baseline or a relative decrease in left ventricular global longitudinal strain (LVGLS) of ≥15%. A total of 256 participants were included in this study, with a mean age of 50.2±11 years. Fifty-six individuals (22%) developed CTRCD within 1 year after starting chemotherapy. The cutoff value for septal S' was 6.85cm/s (AUC=.81, p<.001; sensitivity 74%; specificity 73%), and for MAPSE was 11.7mm (AUC=.65, p=.02; sensitivity 79%; specificity 45%). None of the cases with septal S' exceeding 6.85cm/s had an LVGLS of ≤15%. Septal S' is a useful indicator for diagnosing CTRCD. Septal S' decreased at the same time or earlier than the decrease in LVGLS. The septal S' demonstrated higher diagnostic ability for CTRCD compared to LVGLS.

Quantifying fetal heart health in gestational diabetes: a new approach with fetal heart quantification technology.

This study aimed to assess the impact of gestational diabetes mellitus (GDM) on fetal heart structure and function using a technique called fetal heart quantification (Fetal HQ), with a focus on mitochondrial dynamics, which employs advanced imaging technology for comprehensive analysis. A total of 180 fetuses with normal heart structures, aged 24-40weeks of gestation, were examined. A 2-3s cine loop in the standard four-chamber oblique view was captured and analyzed using the speckle-tracking technique with Fetal HQ. Various echocardiographic parameters were evaluated, including four-chamber view (4CV), global spherical index (GSI), global longitudinal strain (GLS), 24-segment spherical index (SI), ventricular fractional area change (FAC), cardiac output (CO), and stroke volume (SV). These parameters were compared between the GDM group and the control group during two gestational periods: 24+0 to 28+0 weeks and 28+1 to 40+1 weeks. Statistical analysis was performed using independent samples t-tests and Mann-Whitney U tests to identify significant differences. Twenty fetuses from mothers with GDM and 40 from the control group were recruited at 24+0 to 28+0 weeks. At 28+1 to 40+1 weeks, 40 fetuses from mothers with GDM and 80 from the control group were recruited. The fetal left ventricular global longitudinal function was similar between the GDM and control groups. However, compared to the controls, right ventricular function in the GDM group was lower only at 28+1 to 40+1 weeks. In the GDM group, the global spherical index (GSI) was lower than in the control group at 28+1 to 40+1 weeks (1.175 vs. 1.22; p = 0.001). There were significant decreases in ventricular FAC (38.74% vs. 42.83%; p < 0.0001) and 4CV GLS for the right ventricle (-22.27% vs. -26.31%; p = 0.005) at 28+1 to 40+1 weeks. Our findings suggest that GDM is associated with decreased right ventricular function in the fetal heart, particularly during the later stages of pregnancy (28+1 to 40+1 weeks), compared to fetuses from healthy pregnancies. The Fetal HQ technique represents a valuable tool for evaluating the structure and function of fetal hearts affected by GDM during the advanced stages of pregnancy.

LV systolic function assessment in conventional cardiac pacing: a simple and forgotten parameter - MAPSE

Abstract Background Mitral annular plane systolic excursion (MAPSE) was a widely used M-mode echocardiographic marker of left ventricular longitudinal systolic function. On the other hand, right ventricle (RV) apical pacing is associated with left ventricle (LV) dysfunction development due to dysynchronous activation, while non-apical pacing may provide a more physiological LV activation. The aim of this study is to ascertain the clinical usefulness of MAPSE in the assessment of LV contractile function in patients with permanent RV pacing. Methods Consecutive patients with indication for permanent cardiac pacing (with ventricular pacing percentages over 20% - Vp&amp;gt;20%) were retrospectively enrolled from 2019 to 2023. All patients were assessed by echocardiography with MAPSE, left ventricule ejection fraction (LVEF) and diastolic filling patterns being measured at the time of implant and at subsequent follow-ups. Results 359 patients (age range 41-80yo; mean age=60,5yo) were included, 244 men and 115 women, 173 implanted with single-chamber devices and 186 dual-chamber. 259 patients were paced from the RVA (right ventricle apex) and 62 had septal lead positioning. The mean follow-up period was 18±2 months. The results showed that a MAPSE cut off value of ≤10 mm was associated with a LVEF&amp;lt;42±2%, while MAPSE values &amp;gt;10mm were associated with LVEF&amp;gt;45±3% (p&amp;lt;0.01). RV septal pacing was associated with a higher average MAPSE value (14,28 mm) than RVA pacing (13,47). Conclusions MAPSE seems to corelate well with LVEF in RV conventional pacing. Younger patients with preserved LVEF and less than grade II diastolic dysfunction were not associated with a significant decrese in MAPSE value. However, older patients with HFmrEF and RVA pacing seem to have a more substantial reduction in MAPSE value, suggesting that non-apical or conduction system pacing might be beneficial in this subgroup. MAPSE seems to be a quick and reliable echocardiographic marker of LV systolic function in patients with permanent cardiac pacing. It may be used as an early predictive marker for heart failure in conventional RV paced patients.

Left Ventricular Longitudinal Myocardial Function of Heart Failure Patients With Transition From Reduced to Preserved Ejection Fraction and of Those With Preserved Ejection Fraction.

Background: Left ventricular (LV) longitudinal myocardial function is associated with the outcomes of heart failure (HF) patients. HF with improved ejection fraction (EF), known as HFimpEF, which is defined as current LVEF >40% but any previously documented LVEF ≤40%, has favorable outcomes compared with HF with preserved EF (HFpEF). However, LV longitudinal myocardial function in patients with previously reduced LVEF (<50%) but improved LVEF to within the normal range (≥50%) (HFnorEF) and its association with cardiovascular events remain unclear. Methods and Results: We studied 70 patients with HFpEF and 65 with HFnorEF. LV longitudinal myocardial function was assessed as global longitudinal strain (GLS). The primary endpoint was defined as cardiovascular death or HF hospitalization during follow-up of 5.6±3.1 years. The GLS of HFpEF patients was significantly lower than that of HFnorEF patients (13.6±3.5% vs. 14.8±2.2%, P=0.02) even when the LVEF was similar. Multivariate Cox proportional hazards analysis showed that GLS was independently associated with cardiovascular events. Furthermore, of the entire study population, patients with GLS >15.0% had fewer cardiovascular events than those without (log-rank P=0.014) among all the patients. Conclusions: LV longitudinal myocardial dysfunction was more frequently observed in patients with HFpEF than in those with HFnorEF, even when LVEF was similar, and was independently associated with cardiovascular events for HF patients with current LVEF ≥50%.

Left and right ventricular longitudinal systolic function following aortic valve replacement in the PARTNER 2 trial and registry.

Evaluation of left and right ventricular (RV) longitudinal systolic function may enhance risk stratification following aortic valve replacement (AVR). The study objective was to evaluate the changes in left and RV longitudinal systolic function and RV-pulmonary artery (RV-PA) coupling from baseline to 30 days and 1 year after AVR. Left ventricular (LV) longitudinal strain (LS), tricuspid annulus plane systolic excursion (TAPSE), and RV-PA coupling were evaluated in patients from the PARTNER 2A surgical AVR (SAVR) arm (n = 985) and from the PARTNER 2 SAPIEN 3 registry (n = 719). TAPSE and RV-PA coupling decreased significantly following SAVR, but remained stable following TAVR. Lower LV LS, TAPSE, or RV-PA coupling at baseline was associated with increased risk of the composite of death, hospitalization, and stroke at 5 years [adjusted hazard ratios (HRs) for LV LS < 15%: 1.24, 95% confidence interval (CI) 1.05-1.45, P = 0.001; TAPSE < 14 mm: 1.44, 95% CI 1.21-1.73, P < 0.001; RV-PA coupling < 0.55 mm/mmHg: 1.32, 95% CI 1.07-1.63, P = 0.011]. Reduced TAPSE at baseline was the most powerful predictor of the composite endpoint at 5 years. Patients with LV ejection fraction <50% at baseline had increased risk of the primary endpoint with SAVR (HR: 1.34, 95% CI 1.08-1.68, P = 0.009) but not with TAVR (HR: 1.12, 95% CI 0.88-1.42). Lower RV-PA coupling at 30 days showed the strongest association with cardiac mortality. SAVR but not TAVR was associated with a marked deterioration in RV longitudinal systolic function and RV-PA coupling. Lower TAPSE and RV-PA coupling at 30 days were associated with inferior clinical outcomes at 5 years. In patients with LVEF < 50%, TAVR was associated with superior 5-year outcomes.

Longitudinal analysis of systemic ventricular function and atrioventricular valve function after the Norwood procedure.

To evaluate longitudinal systemic ventricular function and atrioventricular valve regurgitation in patients after the neonatal Norwood procedure. Serial postoperative echocardiographic images before Fontan completion were assessed in neonates who underwent the Norwood procedure between 2001 and 2020. Ventricular function and atrioventricular valve regurgitation were compared between patients with modified Blalock-Taussig shunt and right ventricle to pulmonary artery conduit. A total of 335 patients were identified including 273 hypoplastic left heart syndrome and 62 of its variants. Median age at Norwood was 8 (7-12) days. Modified Blalock-Taussig shunt was performed in 171 patients and the right ventricle to pulmonary artery conduit in 164 patients. Longitudinal ventricular function and atrioventricular valve regurgitation were evaluated using a total of 4352 echocardiograms. After the Norwood procedure, ventricular function was initially worse (1-30 days) but thereafter better (30 days to stage II) in the right ventricle to pulmonary artery conduit group (P < 0.001). After stage II, the ventricular function was inferior in the right ventricle to the pulmonary artery conduit group (P < 0.001). Atrioventricular valve regurgitation between the Norwood procedure and stage II was more frequent in the modified Blalock-Taussig shunt group (P < 0.001). After stage II, there was no significant difference in atrioventricular valve regurgitation between the groups (P = 0.171). The effect of shunt type on haemodynamics after the Norwood procedure seems to vary according to the stage of palliation. After the Norwood, the modified Blalock-Taussig shunt is associated with poorer ventricular function and worse atrioventricular valve regurgitation compared to right ventricle to pulmonary artery conduit. Whereas, after stage II, modified Blalock-Taussig shunt is associated with better ventricular function and comparable atrioventricular valve regurgitation, compared to the right ventricle to pulmonary artery conduit.

Right Ventricular Function in Surgical Treatment of Left Heart.

Aim The aim of this study was to evaluate right ventricular (RV) function during left chamber surgery.Material and methods This was a single-site prospective cohort study. The study included 197 patients with valvular pathology of heart left chambers. Mean age of patients was 58 [47; 65] years. Precordial echocardiography was performed preoperatively and within one week after surgery.Results Decreased parameters of the right ventricular (RV) longitudinal function and global contractile function were observed postoperatively in the majority of patients. More noticeable decreases were observed in parameters of the longitudinal function (p&lt;0.001). Analysis of the changes in RV contractility depending on the underlying pathology revealed the greatest changes in the contractile function in the mitral insufficiency group. In the mitral stenosis group, the greatest difference was observed in the tricuspid annular systolic excursion (TAPSE) (p=0.027). In the groups with aortic defects, all parameters of RV contractile function, except for the fractional area change (FAC), showed statistically significant decreases after correction of the underlying defect (p&lt;0.05).Conclusions Surgical intervention for left heart valvulopathy can result in a decrease in RV function unrelated with systolic deficit of the left ventricle. Modern technologies allow multi-vector assessment of the RV contractile function. To assess the RV function, it is advisable to use a combination of parameters that reflect both global and longitudinal function.

Impact of Gore Cardioform Atrial Septal Defect Occluder on Atrial and Ventricular Electromechanics in a Pediatric Population

Transcatheter closure is the first-line treatment for ostium secundum atrial septal defect (ASD). The GORE Cardioform ASD Occluder (GCA) is potentially innovative compared with other self-centering devices. This study aimed to compare the mechanic changes in atrial and ventricular properties before and after GCA implantation. All consecutive patients aged <18years who underwent isolated ASD closure with a single GCA device were enrolled from 2 centers. Echocardiography and electrocardiogram were performed the day before, 24hours, and 6months after ASD closure. Between January 2020 and February 2021, 70 pediatric patients with ASD were enrolled. The mean age was 7.9 ± 3.9years, and the mean defect diameter was 17.1 ± 4.5mm. Global longitudinal strain analysis showed no change in left ventricular longitudinal function (T0 -23.2 ± 2.8%, 24 hours -23.0 ± 2.8%, and 6months -23.5 ± 2.7%). An early and transient reduction in longitudinal strain was detected in the basal septal segments (T0 -19.8 ± 3.3%, 24 hours -18.7 ± 3.6%, and 6months -19.2 ± 3.4%), left atrium (T0 41.4 ± 15.3%, 29.2 ± 1.4%, and 39.0 ± 12.9%), and right ventricle (-27.6 ± 5.4%, -23.6 ± 5.0%, and -27.3 ± 4.6) 24hours after closure, secondary to hemodynamic changes because of flow redirection after ASD closure. Six months after the procedure, only the left atrium showed a mild global longitudinal strain reduction because of the presence of the device within the septum. GCA device had no impact on global and regional ventricular function. Atrial mechanics were preserved, except for the segments covered by the device. This is the first device demonstrating no impact on the left and right ventricular mechanics, irrespective of the device size.

Right ventricular longitudinal strain in transthyretin cardiac amyloidosis (ATTR-CA)

Abstract Transthyretin cardiac amyloidosis (ATTR-CA) is a life-threatening condition characterized by a restrictive phisiology. This condition can be hereditary (ATTRv) or acquired (ATTRwt). Left ventricular global longitudinal strain (LVGLS) measured with speckle-tracking echocardiography (STE) has been well described and it appears to be significantly lower in ATTR-CA than in other hypertrophic phenotypes, presenting with a typical "apical sparing" pattern. Furthermore, LVGLS can predict prognosis among patients with ATTR-CA beyond LVEF. Few studies investigated the role of right ventricular longitudinal strain in ATTR-CA. The aim of this study is to describe right ventricular (RV) involvement in patients with ATTR-CA with the use of STE and to explore its prognostic implications. We retrospectively analyzed echocardiographic images of 221 patients with ATTR-CA evaluated between 1995 and 2019 at our Centre. Since the right ventricular free wall strain (RVFWSL) is the current standard parameter being evaluated when performing STE, we chose it as variable of interest among the others collected. Finally, univariate and multivariate linear regression analyses were used to analyze variables related with clinical events such as heart failure and death. The median age of our cohort was 76,7 years old and they were predominantly males. Among these, most patients had a diagnosis of ATTR-CA wild-type (only 32,1% of study population was affected by ATTRv). At STE, LVGLS was abnormal in both ATTRwt patients (-12%; IQR: -13,75% -10,15%) and ATTRv patients (-12,5%; IQR: -15,5% -10,73%) with no significant difference between groups (p= 0,1715). Furthermore, STE showed impaired right ventricular longitudinal function in both aetiologies, but with a different grade of involvement as the median RVFWLS was -19,8% (IQR: -25,1% -13,9% ) in the ATTRv group and -16,4% in the ATTRwt group (IQR: -21,65% -12,2%) (p=0,043). In our study, a right ventricular apical sparing pattern was not observed. In the univariate analysis, RVFWLS and other parameters such as age, eGFR, tricuspid regurgitation and LVGLS were significantly associated with heart failure, so they were forced into multivariable analysis, but RVFWLS did not show an independent correlation with the endpoint, although a certain trend toward significance could be observed (HR 1,037 95%CI 0.998 - 1.077; p=0,063). Finally, we explored the association between our collected variables and death. At univariate analysis, RVFWLS showed a strong correlation with death (HR 1,034; 95%CI 1.005 - 1.064; p= 0,021), together with NYHA class, eGFR, LVEF and LVGLS. Notably, RVFWLS predicted death at our multivariable regression analysis (HR 1.041 95%CI 1.010 - 1.072; p= 0,008). RVFWLS is an emerging parameter to evaluate RV dysfunction which appears significantly impaired in patients with ATTR-CA. In this setting, it might have not only a diagnostic role, but also a prognostic power, although further data are needed.

Left ventricular longitudinal myocardial function in heart failure patients with transition to preserved ejection fraction from reduced ejection fraction and those with preserved ejection fraction

Abstract Background Left ventricular (LV) longitudinal myocardial dysfunction is considered the first marker of a preclinical form of heart failure (HF) with preserved ejection fraction (HFpEF), and is strongly associated with poor outcomes. LV ejection fraction (LVEF) may improve over time during treatment or follow-up in some patients with HF with reduced ejection fraction (HFrEF). Furthermore, it has been reported that patients with HF with improved EF, known as HFimpEF, which was defined as current LVEF &amp;gt; 40% but any previously documented LVEF ≤ 40%, had favorable outcomes compared to those with HFpEF. However, LV longitudinal myocardial function in patients with previously reduced LVEF who had improved LVEF to normal range (≥ 50%), and its association with cardiovascular events remains unclear. Purpose The purpose of this study was the comparison of LV longitudinal myocardial function in patients with HFpEF and those with previously reduced LVEF who had improved LVEF to normal range (reduced LVEF-HFpEF), and to investigate whether LV longitudinal myocardial function was associated with cardiovascular events. Methods We retrospectively studied 70 patients with HFpEF and 45 patients with reduced LVEF-HFpEF. Reduced LVEF-HFpEF was defined as current LVEF ≥ 50% but any previously documented reduced LVEF &amp;lt; 50% (mean: 34 ± 10%). HFpEF was defined as current and all previous LVEF reports ≥ 50%, and met the HFA-PEFF diagnostic algorithm criteria. LV longitudinal myocardial function was assessed as global longitudinal strain (GLS) by means of two-dimensional speckle-tracking strain. The primary endpoint was defined as cardiovascular death over a median follow-up period of 5.0 (0.5-9.0) years. Results As expected, the Kaplan-Meier curve indicated that patients with reduced LVEF-HFpEF experienced fewer cardiovascular death than those with HFpEF (Figure A). GLS in patients with HFpEF was significantly lower than that in patients with reduced LVEF-HFpEF (13.6 ± 3.5% vs. 14.8 ± 2.2%, P = 0.03) regardless of similar LVEF (55.7 ± 3.3% vs 56.8 ± 5.0%, P = 0.15). An important finding of the multivariate Cox proportional hazards analysis showed that GLS was an independently associated with cardiovascular death (Figure B). Conclusion Impaired LV longitudinal myocardial function was observed in patients with HFpEF compared to those with reduced LVEF-HFpEF regardless of similar LVEF. Moreover, LV longitudinal myocardial function was independently associated with cardiovascular death HF patients with current LVEF ≥ 50%. Our findings may provide new insights for the management of HF patients.FigureAFigureB

Echocardiographic Characteristics of Left and Right Ventricular Longitudinal Function in Patients With a History of Cardiac Surgery

Previous studies have indicated a reduction in right ventricular (RV) longitudinal motion following cardiac surgery. However, the long-term effect of cardiac surgery on longitudinal motion and the involvement of left ventricular (LV) motion remain unclear. Therefore, this study aimed to comprehensively investigate the longitudinal function of the right ventricle and left ventricle in patients who had undergone cardiac surgery. The study included patients who underwent comprehensive transthoracic echocardiography (TTE) with three-dimensional RV data sets. By propensity score matching of clinical and echocardiographic variables, including LV and RV ejection fraction, the echocardiographic parameters were compared between patients with and without a history of cardiac surgery (the surgery and nonsurgery groups, respectively). In this study, the surgery group had significantly lower LV global longitudinal strain values than the nonsurgery group, despite having similar LV ejection fraction. Tricuspid annular plane systolic excursion (TAPSE), tricuspid annular velocity, and RV free wall longitudinal strain were also significantly smaller in the surgery group, whereas the RV ejection fraction was comparable between the 2 groups. Additionally, a subgroup analysis based on the time from previous surgery to TTE (≤1 and >1 year) revealed that TAPSE was reduced in both postoperative phases. In conclusion, LV and RV longitudinal parameters were reduced after cardiac surgery, despite preserved LV and RV global functions. Moreover, TAPSE was reduced even a long time following cardiac surgery. These findings emphasize the need for careful interpretation of biventricular longitudinal motion in patients with a history of cardiac surgery.

Acute Changes in Right Ventricular Function in Pediatric Patients with Pulmonary Valve Stenosis Undergoing Percutaneous Valvuloplasty: A Speckle-Tracking Study.

Pulmonary valve stenosis determines multiple effects on the right ventricular dimension and function. Percutaneous balloon valvuloplasty is the treatment of choice in severe pulmonary valve stenosis in patients of all ages. However, little is known regarding right ventricular function immediate changes after percutaneous balloon dilation. Pediatric patients with isolated pulmonary valve stenosis represent a pure clinical model of chronic RV pressure overload not affected by other confounders or comorbidities. This study seeks to explore right ventricle (RV) mechanics in pediatric patients early after percutaneous balloon pulmonary valvuloplasty (BPV) for valvar pulmonary stenosis (PS). Forty-three pediatric patients (19 males), mean age 3.2 ± 4.9 years old, with severe pulmonary valve stenosis and indication for percutaneous balloon valvuloplasty were recruited. All patients underwent standard transthoracic echocardiography (TTE), and speckle-tracking echocardiography (STE) with an analysis of right ventricle free-wall longitudinal strain (RVFWLS) one day before and one day after the procedure. For each patient, we collected invasive parameters during the interventional procedure before and after BPV. After the procedure, there was an immediate significant reduction in both peak-to-peak transpulmonary gradient (peak-to-peak PG) and ratio between the right ventricle and aortic systolic pressure (RV/AoP) with a drop of ∆29.3 ± 14.67 mmHg and ∆0.43 ± 0.03, respectively. Post-procedural echocardiography showed peak and mean transvalvar pressure gradient drop (∆50 ± 32.23 and ∆31 ± 17.97, respectively). The degree of pulmonary valve regurgitation was mild in 8% of patients before the procedure, affecting 29% of our patients post-BPV (p = 0.007). The analysis of right ventricular mechanics showed a significant improvement of fractional area change (FAC) immediately after BPV (40.11% vs. 44.42%, p = 0.01). On the other hand, right ventricular longitudinal systolic function parameters, TAPSE and global RVFWLS, did not improve significantly after intervention. The segmental analysis of the RVFWLS showed a significant regional increase in the myocardial deformation of the apical segments. Percutaneous BPV represents an efficient and safe procedure to relieve severe pulmonary valve stenosis. The analysis of the right ventricular function on echocardiography demonstrated an immediate global systolic function improvement, while longitudinal systolic function was persistently impaired 24 h after intervention, possibly due to the necessity of a longer recovery time.

Intraoperative Augmented Rotation and Circumferential Strain Compensate for Reduction of Left Ventricular Longitudinal Function After On-Pump CABG Surgery

Left ventricular (LV) longitudinal function is reduced after on-pump coronary artery bypass grafting (CABG), while global LV function often is preserved. There are only limited data on the underlying compensatory mechanism. Therefore, the authors aimed to describe intraoperative changes of LV contractile pattern by myocardial strain analysis. A prospective observational study. At a single university hospital. A total of 30 patients scheduled for isolated on-pump CABG with an uneventful intraoperative course and preoperative preserved LV and RV function, sinus rhythm, without more-than-mild heart valve disease, or elevated pulmonary pressure. Transesophageal echocardiography was performed after induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). Echocardiographic evaluation was performed under stable hemodynamics, in sinus rhythm or atrial pacing, and vasopressor support with norepinephrine ≤0.1 µg/kg/min. EchoPAC v204 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2-dimensional (2D) and 3-dimensional (3D) LV ejection fraction (EF), LV global longitudinal strain (GLS), LV global circumferential strain (GCS), LV global radial strain (GRS), LV apical rotation (aRot), LV basal rotation (bRot), and LV twist. Strain analysis was feasible in all included patients after termination of cardiopulmonary bypass (T2). Although there were no significant differences in the values of conventional echocardiographic parameters during the intraoperative interval, GLS deteriorated significantly after CABG compared to pre-bypass assessment (T1 v T2, -13.4% ± 2.9 v -11.8% ± 2.9; p=0.007). GCS improved significantly after surgery (T1 v T2, -19.4% (IQR -17.1% to -21.2%) v -22.8% (IQR -21.1% to -24.7%); p < 0.001) as well as aRot (T1 v T2, -9.7° (IQR -7.1° to -14.1°) v -14.5° (IQR -12.1° to -17.1°); p < 0.001), bRot (T1 v T2, 5.1° (IQR 3.8°-6.7°) v 7.2° (IQR 5.6°-8.2°); p=0.02), and twist (T1 v T2, 15.8° (IQR 11.7°-19.4°) v 21.6° (IQR 19.2°-25.1°); p < 0.001), while GRS remained unchanged. There were no significant changes in the values of GLS, GCS, GRS, aRot, bRot, or twist, as well as in the values of 2D and 3D LV EF before and after sternal closure (T2 v T3). Beyond evaluation of longitudinal LV strain, measurements of circumferential and radial strain, as well as LV rotation and twist mechanics, were feasible in the intraoperative course of this study. Reduction of longitudinal function after on-pump CABG was compensated intraoperatively by improvement of GCS and rotation in the authors' group of patients. Perioperative assessment of GCS, GRS, as well as rotation and twist, might provide deeper insight into perioperative changes of cardiac mechanics.

Significant dependency of left atrial strain on left ventricular longitudinal motion.

The effects of left ventricular longitudinal function on the left atrial strain, including the left atrial reservoir function, have not been adequately quantified. A total of 124 patients who underwent echocardiography were enrolled in this study. Left atrial strain analysis was performed using two-dimensional speckle tracking echocardiography, and the left atrial volume was derived using the modified Simpson's method. The peak left atrial strain (LAS) and left atrial expansion index (LAEI), as indices of left atrial reservoir function, were measured. The global longitudinal strain (GLS) and mitral annular plane systolic excursion (MAPSE), which are indices of contractile motion toward the left ventricular apex, were also measured. The correlation between LAS and candidate determinants, including left ventricular systolic longitudinal function, was evaluated, and multivariate regression analysis was performed. A significant correlation was found between LAS and left ventricular systolic longitudinal functions, GLS (r = 0.63, p < 0.001), and MAPSE (r = 0.65, p < 0.001). Two models, which were selected by multiple regression analyses for LAS, included GLS or MAPSE as independent determinants. GLS and MAPSE were also the strongest predictors, among other factors. LAS, when determined by evaluating the left atrial reservoir function, was significantly associated with left ventricular function, especially the systolic longitudinal function. Left ventricular function should be considered when assessing left atrial function by LAS.

Biventricular cardiac power reserve in heart failure with preserved ejection fraction.

Cardiac and extracardiac abnormalities play important roles in heart failure with preserved ejection fraction (HFpEF). Biventricular cardiac power output (BCPO) quantifies the total rate of hydraulic work performed by both ventricles, suggesting that it may help to identify patients with HFpEF and more severe cardiac impairments to better individualize treatment. Patients with HFpEF (n = 398) underwent comprehensive echocardiography and invasive cardiopulmonary exercise testing. Patients were categorized as low BCPO reserve (n = 199, < median of 1.57 W) or preserved BCPO reserve (n = 199). As compared to those with preserved BCPO reserve, those with low reserve were older and leaner, with more atrial fibrillation, higher N-terminal pro-B-type natriuretic peptide levels, worse renal function, more impaired left ventricular (LV) global longitudinal strain, worse LV diastolic function and right ventricular longitudinal function. Cardiac filling pressures and pulmonary artery pressures at rest were higher in low BCPO reserve, but central pressures were similar during exercise to those with preserved BCPO reserve. Exertional systemic and pulmonary vascular resistances were higher and exercise capacity was more impaired in those with low BCPO reserve. Reduced BCPO reserve was associated with increased risk for the composite endpoint of heart failure hospitalization or death over 2.9 (interquartile range 0.9-4.5) years of follow-up (hazard ratio 2.77, 95% confidence interval 1.73-4.42, p < 0.0001). Inability to enhance BCPO during exercise is associated with more advanced HFpEF, increased systemic and pulmonary vascular resistance, reduced exercise capacity and increased adverse events in patients with HFpEF. Novel therapies that enhance biventricular reserve merit further investigation for patients with this phenotype.

Association of acute improvement in left ventricular longitudinal function after transcatheter aortic valve implantation with outcomes for severe aortic stenosis and preserved ejection fraction

BackgroundGlobal longitudinal strain (GLS) is reportedly a sensitive marker for early subtle abnormalities in left ventricular (LV) performance of asymptomatic patients with severe aortic stenosis (AS) and preserved LV ejection fraction (LVEF). For symptomatic patients with severe AS and preserved LVEF, however, the association of immediate improvement in GLS after transcatheter aortic valve implantation (TAVI) with long-term outcomes remains uncertain. MethodsThis study concerned 151 symptomatic patients with severe AS and preserved LVEF who had undergone TAVI. Echocardiography was performed before TAVI and 7 (7–9) days after TAVI. GLS was determined by means of a two-dimensional speckle-tracking strain using current guidelines. The primary endpoint was defined as a composite endpoint comprising cardiovascular death or re-hospitalization for HF after TAVI over a median follow-up period of 27.7 (11.9–51.4) months. ResultsMean LVEF and GLS were 65 ± 7 % and 12.8 ± 3.4 %, respectively. The Kaplan-Meier curve indicated that patients with acute improvement in GLS after TAVI experienced fewer cardiovascular events than those without such improvement (log-rank P = 0.02). Multivariate analysis showed that non-acute improvement in GLS after TAVI was independently associated with worse outcomes as well as deterioration of the mean transaortic pressure gradient. ConclusionAssessment of GLS immediately after TAVI is a valuable additional parameter for better management of symptomatic patients with severe AS and preserved LVEF who are scheduled for TAVI.

Systolic function in dogs with pulmonic stenosis of different severities and the effect of balloon valvuloplasty

Introduction/objectivesPulmonic stenosis (PS) is one of the most common congenital heart diseases in dogs leading to right ventricular (RV) pressure overload, myocardial remodeling, and potential RV dysfunction. Our objectives were to investigate the extent of RV systolic dysfunction in canine PS and to examine the immediate influence of balloon valvuloplasty (BV) on systolic function. Animals, materials and methodsThis prospective study evaluated 72 dogs with PS and 86 healthy dogs. Echocardiographic parameters of systolic function included normalized tricuspid annular plane systolic excursion (N-TAPSE), normalized systolic myocardial tissue Doppler velocity of the lateral tricuspid annulus (N-RVFW-S′), fractional area change, and speckle-tracking longitudinal endocardial RV strain. Forty-four dogs underwent BV and were re-examined after surgery. ResultsSystolic function at the basal segment of the RV was significantly lower in the PS group when compared to healthy dogs (mean N-TAPSE 4.29 ± standard deviation 1.18 mm/kg0.285 vs. 5.60 ± 1.29 mm/kg0.285; median N-RVFW-S′ 5.28 [lower-upper 25% quantile 4.35–6.43 cm/s/kg0.186] vs. 7.82 [6.73–8.79 cm/s/kg0.186]; all P<0.001). Global longitudinal RV endocardial strain showed no significant difference between the two groups (−28.50 ± 6.23% vs. 28.61 ± 4.64%; P=0.886), but segmental strain analyses revealed basal hypo- and potential compensatory hyperkinesis of the apical RVFW. Furthermore, BV affected most parameters of systolic function, but not the segmental strain values and N-TAPSE. ConclusionsRight ventricular basal longitudinal systolic function is decreased in dogs with PS in comparison to a healthy cohort. Regional and global function does not necessarily coincide.