Geometry as a Confounder When Assessing Ventricular Systolic Function

Global Circumferential and Radial Strain Among Patients With Immune Checkpoint Inhibitor Myocarditis

BACKGROUND

Global circumferential strain (GCS) and global radial strain (GRS) are reduced with cytotoxic chemotherapy. There are limited data on the effect of immune checkpoint inhibitor (ICI) myocarditis on GCS and GRS.

OBJECTIVES

This study aimed to detail the role of GCS and GRS in ICI myocarditis.

METHODS

In this retrospective study, GCS and GRS from 75 cases of patients with ICI myocarditis and 50 ICI-treated patients without myocarditis (controls) were compared. Pre-ICI GCS and GRS were available for 12 cases and 50 controls. Measurements were performed in a core laboratory blinded to group and time. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiogenic shock, cardiac arrest, complete heart block, and cardiac death.

RESULTS

Cases and controls were similar in age (66 ± 15 years vs 63 ± 12 years; P = 0.20), sex (male: 73% vs 61%; P = 0.20) and cancer type (P = 0.08). Pre-ICI GCS and GRS were also similar (GCS: 22.6% ± 3.4% vs 23.5% ± 3.8%; P = 0.14; GRS: 45.5% ± 6.2% vs 43.6% ± 8.8%; P = 0.24). Overall, 56% (n = 42) of patients with myocarditis presented with preserved left ventricular ejection fraction (LVEF). GCS and GRS were lower in myocarditis compared with on-ICI controls (GCS: 17.5% ± 4.2% vs 23.6% ± 3.0%; P < 0.001; GRS: 28.6% ± 6.7% vs 47.0% ± 7.4%; P < 0.001). Over a median follow-up of 30 days, 28 cardiovascular events occurred. A GCS (HR: 4.9 [95% CI: 1.6-15.0]; P = 0.005) and GRS (HR: 3.9 [95% CI: 1.4-10.8]; P = 0.008) below the median was associated with an increased event rate. In receiver-operating characteristic (ROC) curves, GCS (AUC: 0.80 [95% CI: 0.70-0.91]) and GRS (AUC: 0.76 [95% CI: 0.64-0.88]) showed better performance than cardiac troponin T (cTnT) (AUC: 0.70 [95% CI: 0.58-0.82]), LVEF (AUC: 0.69 [95% CI: 0.56-0.81]), and age (AUC: 0.54 [95% CI: 0.40-0.68]). Net reclassification index and integrated discrimination improvement demonstrated incremental prognostic utility of GRS over LVEF (P = 0.04) and GCS over cTnT (P = 0.002).

CONCLUSIONS

GCS and GRS are lower in ICI myocarditis, and the magnitude of reduction has prognostic significance.

The prognostic value of global myocardium strain by CMR-feature tracking in immune checkpoint inhibitor-associated myocarditis

OBJECTIVES

Immune checkpoint inhibitor (ICI)-associated myocarditis is a potentially fatal complication. Sparse published researches evaluated the prognostic value of cardiovascular magnetic resonance feature tracking (CMR-FT) for ICI-associated myocarditis.

METHODS

In the single-center retrospective study, 52 patients with ICI-associated myocarditis and CMR were included from August 2018 to July 2021. The ICI-associated myocarditis was diagnosed by using the clinical criteria of the European Society of Cardiology guidelines. Major adverse cardiovascular events (MACE) were comprised of cardiovascular death, cardiogenic shock, cardiac arrest, and complete heart block.

RESULTS

During a median follow-up of 171 days, 14 (27%) patients developed MACE. For patients with MACE, the global circumferential strain (GCS), global radial strain (GRS), global longitudinal strain (GLS), and left ventricular ejection fraction (LVEF) were significantly worse and native T1 values and late gadolinium enhancement (LGE) extent were significantly increased, compared with patients without MACE (p < 0.05). The GLS remained the independent factor associated with a higher risk of MACE (hazard ratio (HR): 2.115; 95% confidence interval (CI): 1.379-3.246; p = 0.001) when adjusting for LVEF, LGE extent, age, sex, body mass index, steroid treatment, and prior cardiotoxic chemotherapy or radiation. After adjustment for LVEF, the GLS remained the independent risk factor associated with a higher rate of MACE among patients with a preserved LVEF (HR: 1.358; 95% CI: 1.007-1.830; p = 0.045).

CONCLUSIONS

GLS could provide independent prognostic value over GCS, GRS, traditional CMR features, and clinical features in patients with ICI-associated myocarditis.

KEY POINTS

• The global circumferential strain (GCS), global radial strain (GRS), and global longitudinal strain (GLS) by cardiovascular magnetic resonance feature tracking were significantly impaired in patients with an immune checkpoint inhibitor (ICI)-associated myocarditis. • GLS was still significantly impaired in patients with preserved left ventricular ejection fraction. • The worse GLS was an independent risk factor over GCS, GRS, traditional CMR features, and clinical features for predicting major adverse cardiovascular events in patients with ICI-associated myocarditis.

State of the Art: Quantitative Cardiac MRI in Cardiac Amyloidosis

Cardiac amyloidosis (CA) is characterized by amyloid infiltration in the myocardial extracellular space, causing heart failure. Patients with CA are currently underdiagnosed. Cardiac involvement is significantly associated with the prognosis and treatment decision-making for CA. Early identification and accurate stratification are the crucial first step in patient management. Comprehensive cardiac MRI-based evaluation of the cardiac structure, function, and myocardial tissue characterization assesses cardiac involvement by tracing disease processes. Emerging quantitative tissue characterization techniques have introduced new measures that can identify early staged CA and monitor disease progression or response after treatment. Quantitative cardiac MRI is becoming an instrumental tool in understanding CA, which leads to changes in individualized patient care. This review aimed to discuss the quantitative cardiac MRI-based assessment of CA using established and emerging techniques. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 3.

Long-Term Changes in Cardiac Structure and Function Following Bariatric Surgery

BACKGROUND

Studies with short-term follow-up have demonstrated favorable effects of weight loss (WL) on the heart, but little information is available regarding long-term effects or effects of visceral fat reduction.

OBJECTIVES

The purpose of this study was to evaluate the effects of long-term WL following bariatric surgery on cardiac structure, function, ventricular interaction, and body composition, including epicardial adipose thickness and abdominal visceral adipose tissue (VAT).

METHODS

A total of 213 obese patients underwent echocardiography before and >180 days following bariatric surgery. Abdominal VAT area was measured by computed tomography in 52 of these patients.

RESULTS

After 5.3 years (IQR: 2.9-7.9 years), body mass index (BMI) decreased by 22%, with favorable reductions in blood pressure, fasting glucose, and left ventricular (LV) remodeling in the full sample. In the subgroup of patients with abdominal computed tomography, VAT area decreased by 30%. In all subjects, epicardial adipose thickness was reduced by 14% (both P < 0.0001) in tandem with reductions in ventricular interdependence. LV and right ventricular longitudinal strain improved following WL, but left atrial (LA) strain deteriorated, while LA volume and estimated LA pressures increased. In subgroup analysis, LV wall thickness and strain correlated more strongly with VAT than BMI at baseline, and reductions in LV mass following surgery were correlated with decreases in VAT, but not BMI.

CONCLUSIONS

In this observational study, weight loss following bariatric surgery was associated with epicardial fat reduction, reduced ventricular interaction, LV reverse remodeling, and improved longitudinal biventricular mechanics, but LA myopathy and hemodynamic congestion still progressed. Reduction in visceral fat was associated with favorable cardiac effects, suggesting this might be a key target of WL interventions.

Baseline blood pressure and development of cardiotoxicity in patients treated with anthracyclines: A systematic review

Aims

Anthracyclines, a mainstay of cancer treatment, are associated with significant life-threatening cardiotoxicity. As cancer survivorship improves, there is a growing need to identify patients most at risk and strategies to mitigate anthracycline-associated cardiotoxicity. Elevated baseline blood pressure (bBP) is a possible risk factor for cardiotoxicity. The aim of this systematic review was to summarise the literature and evaluate relationships between bBP and anthracycline-associated cardiotoxicity.

Methods and results

Systematic searches were conducted, limited to English language but without restrictions on study type or country of origin. All studies fulfilled the PRISMA statement and relevant studies reviewed and narratively synthesised. A total of 1330 papers were screened, with 12 included in the qualitative synthesis. Eight papers indicated elevated bBP was associated with significantly higher risk of developing cardiotoxicity. Four papers noted significant relationships between left ventricular ejection fraction (LVEF) decline and elevated bBP. Of the four papers that failed to show an association, one noted increased risk of developing chronic heart failure. A relationship between baseline diastolic and systolic BP and anthracycline-associated cardiotoxicity is also noted.

Conclusions

This study indicates adult patients with elevated bBP have increased vulnerability to anthracycline-associated cardiotoxicity, with those with pre-hypertension or raised systolic versus diastolic pressure potentially an overlooked population. Recommendations for inclusion of bBP, incorporating individual systolic versus diastolic pressures, in cardio-oncology risk prediction models to guide clinical decision-making are thus warranted.

Interstitial Collagen Loss, Myocardial Remodeling, and Function in Primary Mitral Regurgitation

Interstitial collagen loss and cardiomyocyte ultrastructural damage accounts for left ventricular (LV) sphericity and decrease in LV twist and circumferential strain. Normal LV diastolic function belies significantly abnormal left atrial (LA) function and early LV diastolic untwist rate. This underscores the complex interplay of LV and LA myocardial remodeling and function in the pathophysiology of primary mitral regurgitation. In this study, we connect LA function with LV systolic and diastolic myocardial remodeling and function using cardiac magnetic resonance tissue tagging in primary mitral regurgitation.

Global Longitudinal Strain and Biomarkers of Cardiac Damage and Stress as Predictors of Outcomes After Transcatheter Aortic Valve Implantation

Background Global longitudinal strain (GLS) is a sensitive measure of left ventricular function and a risk marker in severe aortic stenosis. We sought to determine whether biomarkers of cardiac damage (cardiac troponin) and stress (NT-proBNP [N-terminal pro-B-type natriuretic peptide]) could complement GLS to identify patients with severe aortic stenosis at highest risk. Methods and Results From a multicenter prospective cohort of patients with symptomatic severe aortic stenosis who underwent transcatheter aortic valve implantation, we measured absolute GLS (aGLS), cardiac troponin, and NT-proBNP at baseline in 499 patients. Left ventricular ejection fraction <50% was observed in 19% and impaired GLS (aGLS <15%) in 38%. Elevations in cardiac troponin and NT-proBNP were present in 79% and 89% of those with impaired GLS, respectively, as compared with 63% and 60% of those with normal GLS, respectively (P<0.001 for each). aGLS <15% was associated with increased mortality in univariable analysis (P=0.009), but, in a model with both biomarkers, aGLS, and clinical covariates included, aGLS was not associated with mortality; elevation in each biomarker was associated with an increased hazard of mortality (adjusted hazard ratio, >2; P≤0.002 for each) when the other biomarker was elevated, but not when the other biomarker was normal (interaction P=0.015). Conclusions Among patients with symptomatic severe aortic stenosis undergoing transcatheter aortic valve implantation, elevations in circulating cardiac troponin and NT-proBNP are more common as GLS worsens. Biomarkers of cardiac damage and stress are independently associated with mortality after transcatheter aortic valve implantation, whereas GLS is not. These findings may have implications for risk stratification of asymptomatic patients to determine optimal timing of valve replacement.

A global case meta-analysis of three-dimensional speckle tracking for evaluating the cardiotoxicity of anthracycline chemotherapy in breast cancer

Background

Anthracycline cardiotoxicity has become one of the most common complications of anthracycline therapy. Regular follow-up of chemotherapy patients with myocardial deformation parameters might be helpful for early diagnosis of myocardial damage and protective intervention. This study aimed to investigate the value of three-dimensional speckle tracking imaging (3D-STI) in diagnosing and predicting potential cardiotoxicity in breast cancer patients undergoing anthracycline therapy through meta-analysis based on global cases collection.

Methods

Relevant case-control studies published prior to November 2021 were extracted to assess cardiotoxicity by 3D-STI in breast cancer patients undergoing chemotherapy. Weighted mean difference (WMD) and 95% confidence interval (CI) were used as pooled statistics. Meta regression and subgroup analysis were employed to identify sources of heterogeneity and publication bias was evaluated by Egger’s test and funnel plot.

Results

A total of 1,515 breast cancer patients from 14 studies were enrolled and followed up for 4 or 6 cycles of chemotherapy. Following chemotherapy, absolute values of Left ventricular ejection fraction (LVEF) WMD = –1.59, 95% CI (–1.99, –1.20); p < 0.001; global longitudinal strain (GLS) WMD = 2.19, 95% CI (1.87, 2.51); p < 0.001; global circumferential strain (GCS) WMD = 1.69, 95% CI (1.11, 2.26); p < 0.001; global radial strain (GRS) WMD = –1.72,95% CI (–2.44, –1.00); p < 0.001, and global area strain (GAS) WMD = 6.25, 95% CI (4.48, 8.02); p < 0.001 were decreased. A medium degree of heterogeneity was shown for values of LVEF (I² = 44.4%, p = 0.037) while values for GLS (I² = 59.0%, p = 0.003), GCS (I² = 81.3%, p < 0.001) and GRS (I² = 57.5%, P = 0.004) showed a large degree of heterogeneity. Egger’s test and funnel plot showed no significant publication bias in GLS, GCS and GAS data (all p > 0.05).

Conclusion

3D-STI has utility for the non-invasive and objective evaluation of changes in left ventricular function in breast cancer patients undergoing chemotherapy with anthracyclines. The current findings have clinical potential for the early evaluation of myocardial injury caused by chemotherapy toxicity.

Feature tracking cardiovascular magnetic resonance reveals recovery of atrial function after acute myocarditis

Follow-up after acute myocarditis is important to detect persisting myocardial dysfunction. However, recovery of atrial function has not been evaluated after acute myocarditis so far. Thirty-five patients with strictly defined acute myocarditis underwent cardiovascular magnetic resonance (CMR, 1.5 T) in the acute stage at baseline (BL) and at 3 months follow-up (FU). The study population included 13 patients with biopsy-proven "cardiomyopathy-like" myocarditis (CLM) and 22 patients with "infarct-like" (ILM) clinical presentation. CMR feature tracking (FT) was performed on conventional cine SSFP sequences. Median LA-GLS increased from 33.2 (14.5; 39.2) at BL to 37.0% (25.2; 44.1, P = 0.0018) at FU in the entire study population. Median LA-GLS also increased from 36.7 (26.5; 42.3) at BL to 41.3% (34.5; 44.8, P = 0.0262) at FU in the ILM subgroup and from 11.3 (6.4; 21.1) at BL to 21.4% (14.2; 30.7, P = 0.0186) at FU in the CLM subgroup. Median RA-GLS significantly increased from BL with 30.8 (22.5; 37.0) to FU with 33.7% (26.8; 45.4, P = 0.0027) in the entire study population. Median RA-GLS also significantly increased from 32.7 (25.8; 41.0) at BL to 35.8% (27.7; 48.0, P = 0.0495) at FU in the ILM subgroup and from 22.8 (13.1; 33.9) at BL to 31.0% (26.0; 40.8, P = 0.0266) at FU in the CLM subgroup. Our findings demonstrate recovery of LA and RA function by CMR-FT strain analyses in patients after acute myocarditis independent from clinical presentation. Monitoring of atrial strain could be an important tool for an individual assessment of healing after acute myocarditis.

Left ventricular assessment with artificial intelligence increases the diagnostic accuracy of stress echocardiography

AIMS

To evaluate whether left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS), automatically calculated by artificial intelligence (AI), increases the diagnostic performance of stress echocardiography (SE) for coronary artery disease (CAD) detection.

METHODS AND RESULTS

SEs from 512 participants who underwent a clinically indicated SE (with or without contrast) for the evaluation of CAD from seven hospitals in the UK and US were studied. Visual wall motion scoring (WMS) was performed to identify inducible ischaemia. In addition, SE images at rest and stress underwent AI contouring for automated calculation of AI-LVEF and AI-GLS (apical two and four chamber images only) with Ultromics EchoGo Core 1.0. Receiver operator characteristic curves and multivariable risk models were used to assess accuracy for identification of participants subsequently found to have CAD on angiography. Participants with significant CAD were more likely to have abnormal WMS, AI-LVEF, and AI-GLS values at rest and stress (all P < 0.001). The areas under the receiver operating characteristics for WMS index, AI-LVEF, and AI-GLS at peak stress were 0.92, 0.86, and 0.82, respectively, with cut-offs of 1.12, 64%, and -17.2%, respectively. Multivariable analysis demonstrated that addition of peak AI-LVEF or peak AI-GLS to WMS significantly improved model discrimination of CAD [C-statistic (bootstrapping 2.5th, 97.5th percentile)] from 0.78 (0.69-0.87) to 0.83 (0.74-0.91) or 0.84 (0.75-0.92), respectively.

CONCLUSION

AI calculation of LVEF and GLS by contouring of contrast-enhanced and unenhanced SEs at rest and stress is feasible and independently improves the identification of obstructive CAD beyond conventional WMSI.

A Holistic View of Advanced Heart Failure

Advanced heart failure (HF) may occur at any level of left ventricular (LV) ejection fraction (LVEF). The latter, which is widely utilized for the evaluation of LV systolic performance and treatment guidance of HF patients, is heavily influenced by LV size and geometry. As the accurate evaluation of ventricular systolic function and size is crucial in patients with advanced HF, the LVEF should be supplemented or even replaced by more specific indices of LV function such as the systolic strain and cardiac power output and size such as the LV diastolic diameters and volumes. Conventional treatment (cause eradication, medications, devices) is often poorly tolerated and fails and advanced treatment (mechanical circulatory support [MCS], heart transplantation [HTx]) is required. The effectiveness of MCS is heavily dependent on heart size, whereas HTx which is effective in the vast majority of the cases is limited by the small donor pool. Expanding the MCS indications to include patients with small ventricles as well as the HTx donor pool are major challenges in the management of advanced HF.

Decongestion improving right heart function ameliorates prognosis after an acute heart failure episode

BACKGROUND

The prognostic role of decongestion-related change of cardiac morphology and in particular right heart function has not been investigated comprehensively in AHF patients.

METHODS AND RESULTS

This prospective observational single-centre study included consecutive patients hospitalized for treatment of AHF with reduced, mildly-reduced or preserved left ventricular ejection fraction (LVEF). Comprehensive transthoracic echocardiography at admission and discharge assessed decongestion-related change of cardiac function and morphology. The combined endpoint of 1 year all-cause mortality and cardiovascular rehospitalization explored the prognostic importance of decongestion-related change. The 176 study participants were 83 years old [74-87] and 54% were men. Fifty one (29%) had rLVEF, 65 (37%) mrLVEF, and 60 (34%) pLVEF. The proportion of de novo or worsening chronic HF was not different between LVEF groups. HF aetiology and cardiovascular risk factors were equally distributed across all groups except for a higher BMI in the pLVEF group. Decongestion equally reduced body weight, heart rate, systolic and diastolic blood pressure, tricuspid regurgitation gradient, and inferior vena cava diameter across all groups (P < 0.004 for all). Decongestion-related increase in TAPSE independent of the LVEF was associated with improvement of right-ventricular-pulmonary artery coupling and a lower incidence of the combined outcome in the Cox proportional hazard risk analysis (unadjusted HR 0.50 95% CI 0.33-0.78, P = 0.002; adjusted HR 0.46 95% CI: 0.33-0.78, P = 0.001).

CONCLUSIONS

Decongestion-related increase in TAPSE and recovery of RV/pulmonary artery coupling was observed across all LVEF groups and associated with a risk reduction for the combined endpoint highlighting the important prognostic role of right heart recovery after an AHF episode.

Echocardiographic Investigation of Low-Flow State in a Hispanic/Latino Population

Objective

To assess the prevalence of low-flow state (LFS) with left ventricular (LV) stroke volume index of less than 35 mL/m² and the demographics, clinical and echocardiographic characteristics associated with LV remodeling and function in a Hispanic/Latino population.

Participants and Methods

The study included 1346 asymptomatic participants from the Hispanic Community Health Study/Study of Latinos with normal LV ejection fraction (≥55%) and no valvular heart disease. LV volume, mass and left atrial volume, LV ejection fraction, global longitudinal strain, and myocardial contraction fraction were measured by echocardiography. The participants were divided into LFS or normal flow state (NFS: stroke volume index ≥35 mL/m²). Demographics, clinical and echocardiographic characteristics, and measures of LV remodeling and function were compared between the LFS and NFS groups.

Results

The prevalence of LFS was 41%. In comparison with NFS, the LFS had lower LV mass index (77.2±0.96 g/m² vs 84.6±0.86 g/m²; P<.001), left atrial volume index (20.6±0.35 mL/m² vs 23.5±0.37 mL/m²; P<.001), global longitudinal strain (−16.8±0.16% vs −17.7±0.17%; P<.001), and myocardial contraction fraction (43.3±0.63% vs 55.7±0.64%; P<.001). There was no significant difference in the relative wall thickness (LFS: 0.40±0.004 vs NFS: 0.40±0.005; P=.57). The LFS group had significantly higher hemoglobin A1c (6.18±0.07% vs 5.97±0.04%; P=.01) than the NFS group.

Conclusion

A high prevalence of LFS associated with echocardiographic characteristics reflecting unfavorable LV remodeling and function was observed in a Hispanic/Latino population. Further studies of the prognostic significance of LFS in a large multiethnic population are warranted.

Impact of myocardial injury on regional left ventricular function in the course of acute myocarditis with preserved ejection fraction: insights from segmental feature tracking strain analysis using cine cardiac MRI

The aim of this study was to provide insights into myocardial adaptation over time in myocyte injury caused by acute myocarditis with preserved ejection fraction. The effect of myocardial injury, as defined by the presence of late gadolinium enhancement (LGE), on the change of left ventricular (LV) segmental strain parameters was evaluated in a longitudinal analysis. Patients with a first episode of acute myocarditis were enrolled retrospectively. Peak radial (PRS), longitudinal (PLS) and circumferential (PCS) LV segmental strain values at baseline and at follow-up were computed using feature tracking cine cardiac magnetic resonance imaging. The change of segmental strain values in LGE positive (LGE+) and LGE negative (LGE-) segments was compared over a course of 89 ± 20 days. In 24 patients, 100 LGE+ segments and 284 LGE- segments were analysed. Between LGE+ and LGE- segments, significant differences were found for the change of segmental PCS (p < 0.001) and segmental PRS (p = 0.006). LGE + segments showed an increase in contractility, indicating recovery, and LGE- segments showed a decrease in contractility, indicating normalisation after a hypercontractile state or impairment of an initially normal contracting segment. No significant difference between LGE+ and LGE- segments was found for the change in segmental PLS. In the course of acute myocarditis with preserved ejection fraction, regional myocardial function adapts inversely in segments with and without LGE. As these effects seem to counterbalance each other, global functional parameters might be of limited use in monitoring functional recovery of these patients.

Cardiovascular Magnetic Resonance Imaging in the Early Detection of Cardiotoxicity Induced by Cancer Therapies

The significant progress in cancer treatment, including chemotherapy, immunotherapy, radiotherapy, and combination therapies, has led to higher long-term survival rates in cancer patients, while the cardiotoxicity caused by cancer treatment has become increasingly prominent. Cardiovascular magnetic resonance (CMR) is a non-invasive comprehensive imaging modality that provides not only anatomical information, but also tissue characteristics and cardiometabolic and energetic assessment, leading to its increased use in the early identification of cardiotoxicity, and is of major importance in improving the survival rate of cancer patients. This review focused on CMR techniques, including myocardial strain analysis, T1 mapping, T2 mapping, and extracellular volume fraction (ECV) calculation in the detection of early myocardial injury induced by cancer therapies. We summarized the existing studies and ongoing clinical trials using CMR for the assessment of subclinical ventricular dysfunction and myocardial changes at the tissue level. The main focus was to explore the potential of clinical and preclinical CMR techniques for continuous non-invasive monitoring of myocardial toxicity associated with cancer therapy.

Specific alterations of regional myocardial work in strength-trained athletes using anabolic steroids compared to athletes with genetic hypertrophic cardiomyopathy

PURPOSE

Strength-trained athletes using anabolic androgenic steroids (AAS) have left ventricular (LV) hypertrophy and myocardial fibrosis that can lead to sudden cardiac death. A similar feature was described in athletes with hypertrophic cardiomyopathy (HCM), which complicates the diagnosis for clinicians. In this context, we aimed to compare the LV function of the 2 populations by measuring global and regional strain and myocardial work using speckle-tracking imaging.

METHODS

Twenty-four strength-trained asymptomatic athletes using AAS (AAS-Athletes), 22 athletes diagnosed with HCM (HCM-Athletes), and 20 healthy control athletes (Ctrl-Athletes) underwent a resting echocardiography to assess LV function. We evaluated LV global and regional strains and myocardial work, with an evaluation of the constructive work (CW), wasted work, and work efficiency (WE).

RESULTS

Compared to Ctrl-Athletes, both AAS-Athletes and HCM-Athletes had a thicker interventricular septum, with majored values in HCM-Athletes. LV strain was reduced in AAS-Athletes and even more in HCM-Athletes. Consequently, global WE was significantly diminished in both AAS and HCM-Athletes (93% ± 2% in Ctrl-Athletes, 90% ± 4% in AAS-Athletes, and 90% ± 5% in HCM-Athletes (mean ± SD); p < 0.05). Constructive work and WE regional analysis showed specific alterations, with the basal septal segments preferentially affected in AAS-Athletes, and both septal and apical segments affected in HCM-Athletes.

CONCLUSION

The regional evaluation of myocardial work reported specific alterations of the major LV hypertrophy induced by the regular use of AAS compared to the LV hypertrophy due to HCM. This finding could help clinicians to differentiate between these 2 forms of pathological hypertrophy.

Advanced Echocardiographic Techniques in Cardio-Oncology: the Role for Early Detection of Cardiotoxicity

PURPOSE OF REVIEW

Implementation of advanced echocardiographic techniques in cardio-oncology is a growing need as they are the cornerstone of early detection of cancer therapy-related cardiovascular toxicity (CTR-CVT).

RECENT FINDINGS

Three-dimensional echocardiography and myocardial deformation techniques have shown more accuracy and reproducibility than classic 2D measurements in detecting cardiovascular adverse effects in patients undergoing anticancer therapies. Application of advanced echo techniques to daily monitoring of patients with cancer helps to identify those at risk of developing CTR-CVT during and after cancer treatment. Furthermore, advanced echo parameters improve early initiation of cardioprotective treatments in order to minimize cardiovascular events and cancer treatment interruption.

Left ventricular active strain energy density is a promising new measure of systolic function

The left ventricular ejection fraction does not accurately predict exercise capacity or symptom severity and has a limited role in predicting prognosis in heart failure. A better method of assessing ventricular performance is needed to aid understanding of the pathophysiological mechanisms and guide management in conditions such as heart failure. In this study, we propose two novel measures to quantify myocardial performance, the global longitudinal active strain energy (GLASE) and its density (GLASED) and compare them to existing measures in normal and diseased left ventricles. GLASED calculates the work done per unit volume of muscle (energy density) by combining information from myocardial strain and wall stress (contractile force per unit cross sectional area). Magnetic resonance images were obtained from 183 individuals forming four cohorts (normal, hypertension, dilated cardiomyopathy, and cardiac amyloidosis). GLASE and GLASED were compared with the standard ejection fraction, the corrected ejection fraction, myocardial strains, stroke work and myocardial forces. Myocardial shortening was decreased in all disease cohorts. Longitudinal stress was normal in hypertension, increased in dilated cardiomyopathy and severely decreased in amyloid heart disease. GLASE was increased in hypertension. GLASED was mildly reduced in hypertension (1.39 ± 0.65 kJ/m3), moderately reduced in dilated cardiomyopathy (0.86 ± 0.45 kJ/m3) and severely reduced in amyloid heart disease (0.42 ± 0.28 kJ/m3) compared to the control cohort (1.94 ± 0.49 kJ/m3). GLASED progressively decreased in the hypertension, dilated cardiomyopathy and cardiac amyloid cohorts indicating that mechanical work done and systolic performance is severely reduced in cardiac amyloid despite the relatively preserved ejection fraction. GLASED provides a new technique for assessing left ventricular myocardial health and contractile function.

The Dynamic Characteristics of Myocardial Contractility and Extracellular Volume in Type 2 Diabetes Mellitus Mice Investigated by 7.0T Cardiac Magnetic Resonance

Type 2 diabetes mellitus (T2DM) is associated with a high prevalence of diastolic dysfunction and congestive heart failure. A potential contributing factor is the accelerated accumulation of diffuse myocardial fibrosis and stiffness. Novel cardiac magnetic resonance (CMR) imaging techniques can identify both myocardial fibrosis and contractility quantitatively. This study aimed to investigate the dynamic characteristics of the myocardial strain and altered extracellular volume (ECV) fraction as determined by 7.0 T CMR in T2DM mice. C57Bl/6J mice were randomly divided into T2DM (fed a high-fat diet) and control (fed a normal diet) groups. They were scanned on 7.0 T MRI every 4 weeks until the end of week 24. The CMR protocol included multi-slice cine imaging to assess left ventricle strain and strain rate, and pre- and post-contrast T1 mapping images to quantify ECV. The ECV in the T2DM mice was significantly higher (p < 0.05) than that in the control group since week 12 with significantly impaired myocardial strain (p < 0.05). A significant linear correlation was established between myocardial strain and ECV (p < 0.001) and left ventricular-ejection fraction and ECV (p = 0.003). The results suggested that CMR feature tracking-derived myocardial strain analysis can assess functional abnormalities that may be associated with ECM alterations in diabetic cardiomyopathy, contributing to the study of diabetic therapy effects.

Echocardiographic Abnormalities in Adults With Anorexia Nervosa

Anorexia nervosa (AN) is a psychiatric disorder that may lead to cardiac complications. The objective of this study was to evaluate global and regional longitudinal strain changes in patients affected by AN as an early marker of myocardial damage. We prospectively enrolled 48 consecutive patients with AN and 44 age-matched and gender-matched healthy controls. In all subjects, we performed echocardiography, including global longitudinal strain (GLS) measurement. A subset of 33 patients with AN had further echocardiographic examinations during the follow-up. Compared with healthy controls, patients with AN had a greater prevalence of pericardial effusion (9 of 48 vs 0 of 44, p = 0.003), a smaller left ventricular mass (63 ± 15 vs 99 ± 30 g, p < 0.001), a lower absolute value of GLS (-18.9 ± 2.8 vs -20.2 ± 1.8%, p = 0.010) and of basal LS (-15.4 ± 6.0 vs -19.4 ± 2.6%, p < 0.001). The bull's eye mapping showed a plot pattern with blue basal areas in 18 of 48 patients with AN versus 1 of 44 controls (p < 0.001). During the follow-up, of 13 patients with blue areas in the first bull's eye mapping, 11 recovered completely, and of 20 patients with a red bull's eye at the first examination, none presented blue areas at the second one. In conclusion, GLS is significantly altered in patients with AN, and a basal blue pattern on bull's eye mapping identifies more severe cases. These changes seem to be reversible.

Serial changes of layer-specific myocardial function according to chemotherapy regimen in patients with breast cancer

Aims

Chemotherapy-induced cardiotoxicity (CIC) is a significant complication, meanwhile myocardial damage might differ depending on chemotherapy agents and their timing. The aim of this study was to evaluate serial changes of layer-specific myocardial function in patients with breast cancer and their differences by the development time of CIC and chemotherapy agent.

Methods and results

A total of 105 consecutive patients with breast cancer (age: 52.3 ± 9.3 years) were enrolled. Chemotherapy-induced cardiotoxicity occurred in 20 (19%) patients during 6 months. Endocardial and midmyocardial functions decreased in patients with or without CIC, with patients with CIC showing greater decreases during follow-up. Global longitudinal strain (GLS) change at 3 months was the most sensitive parameter to detect CIC. When new development of CIC was analysed at 6 months, GLS was reduced earlier than the decrease of left ventricular ejection fraction. In patients with CIC who were treated with anthracycline-based regimen for 3 months, endocardial GLS markedly decreased at 3 months and continued to decrease until 6 months. Patients with CIC who received trastuzumab therapy after anthracycline therapy showed further reduction in endocardial GLS at the 6-month follow-up, which was not shown in patients with CIC who received taxane therapy subsequently.

Conclusion

Myocardial function assessed by strain decreased in all patients with breast cancer receiving chemotherapy. The endocardial layer was the most vulnerable to chemotherapy-induced myocardial damage. Functional impairment was more profound in patients with CIC who received sequential anthracycline-trastuzumab chemotherapy. Thus, early evaluation of left ventricular function might be necessary for all patients with breast cancer to detect CIC.

Effects of Hypertrophic and Dilated Cardiac Geometric Remodeling on Ejection Fraction

Background: Both heart failure (HF) with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) can present a wide variety of cardiac morphologies consequent to cardiac remodeling. We sought to study if geometric changes to the heart during such remodeling will adversely affect the ejection fraction (EF) parameter’s ability to serve as an indicator of heart function, and to identify the mechanism for it.

Methods and Results: A numerical model that simulated the conversion of myocardial strain to stroke volume was developed from two porcine animal models of heart failure. Hypertrophic wall thickening was found to elevate EF, while left ventricle (LV) dilation was found to depress EF when myocardial strain was kept constant, causing EF to inaccurately represent the overall strain function. This was caused by EF being calculated using the endocardial boundary rather than the mid-wall layer. Radial displacement of the endocardial boundary resulted in endocardial strain deviating from the overall LV strain, and this deviation varied with LV geometric changes. This suggested that using the epi- or endo-boundaries to calculate functional parameters was not effective, and explained why EF could be adversely affected by geometric changes. Further, when EF was modified by calculating it at the mid-wall layer instead of at the endocardium, this shortcoming was resolved, and the mid-wall EF could differentiate between healthy and HFpEF subjects in our animal models, while the traditional EF could not.

Conclusion: We presented the mechanism to explain why EF can no longer effectively indicate cardiac function during cardiac geometric changes relevant to HF remodeling, losing the ability to distinguish between hypertrophic diseased hearts from healthy hearts. Measuring EF at the mid-wall location rather than endocardium can avoid the shortcoming and better represent the cardiac strain function.

Feasibility of Coronary CT Angiography-derived Left Ventricular Long-Axis Shortening as an Early Marker of Ventricular Dysfunction in Transcatheter Aortic Valve Replacement

Purpose

To evaluate the value of using left ventricular (LV) long-axis shortening (LAS) derived from coronary CT angiography (CCTA) to predict mortality in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).

Materials and Methods

Patients with severe AS who underwent CCTA for preprocedural TAVR planning between September 2014 and December 2019 were included in this retrospective study. CCTA covered the whole cardiac cycle in 10% increments. Image series reconstructed at end systole and end diastole were used to measure LV-LAS. All-cause mortality within 24 months of follow-up after TAVR was recorded. Cox regression analysis was performed, and hazard ratios (HRs) are presented with 95% CIs. The C index was used to evaluate model performance, and the likelihood ratio χ² test was performed to compare nested models.

Results

The study included 175 patients (median age, 79 years [IQR, 73-85 years]; 92 men). The mortality rate was 22% (38 of 175). When adjusting for predictive clinical confounders, it was found that LV-LAS could be used independently to predict mortality (adjusted HR, 2.83 [95% CI: 1.13, 7.07]; P = .03). In another model using the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM), LV-LAS remained significant (adjusted HR, 3.38 [95 CI: 1.48, 7.72]; P = .004), and its use improved the predictive value of the STS-PROM, increasing the STS-PROM C index from 0.64 to 0.71 (χ² = 29.9 vs 19.7, P = .001). In a subanalysis of patients with a normal LV ejection fraction (LVEF), the significance of LV-LAS persisted (adjusted HR, 3.98 [95 CI: 1.56, 10.17]; P = .004).

Conclusion

LV-LAS can be used independently to predict mortality in patients undergoing TAVR, including those with a normal LVEF.Keywords: CT Angiography, Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR), Cardiac, Outcomes Analysis, Cardiomyopathies, Left Ventricle, Aortic Valve Supplemental material is available for this article. © RSNA, 2022See also the commentary by Everett and Leipsic in this issue.

Highlighting the role of global longitudinal strain assessment in valvular heart disease

Background

Echocardiography has been the choice for imaging modality for valvular heart disease. It is less invasive, widely available, and allows valvular structure visualization. Echocardiographic assessment often also determines the management. Left ventricular ejection fraction is the most commonly used indicator during echocardiography assessment. It shows signs of left ventricular dysfunction in patients with valve disease. However, most of the time, the ongoing process of cardiac damage may already occur even with preserved cardiac function; further deteriorated ejection fraction will show irreversible cardiac damage. There is a need for a more advanced diagnostic tool to detect early cardiac dysfunction, to prevent further damage.

Main body

Advanced echocardiography imaging using strain imaging allows a physician to evaluate cardiac function more precisely. A more sensitive parameter than left ventricular ejection fraction, global longitudinal strain, can evaluate subclinical myocardial dysfunction before the symptoms occur by evaluating complex cardiac mechanisms. Global longitudinal strain evaluation provides the chance for physicians to determine the intervention needed to prevent further deterioration and permanent cardiac dysfunction. Global longitudinal strain is proven to be beneficial in many types of valvular heart diseases, especially in mitral and aortic valve diseases. It has an excellent diagnostic and prognostic value for patients with valve disease. This review aims to present the superiority of global longitudinal strain compared to left ventricular ejection fraction in assessing cardiac function in patients with valvular heart disease. Clinical usage of global longitudinal strain in several valvular heart diseases is also presented in this review.

Conclusions

The superiority of global longitudinal strain to left ventricular ejection fraction relies on the mechanism where other strains would compensate for the deterioration of longitudinal strain, which is more vulnerable to damage, so the cardiac function is preserved. Therefore, examination of longitudinal strain would give the physician early signs of cardiac function impairment, and prompt management can be conducted.

Investigation of Left Ventricular Strain and Its Morphological Basis During Different Stages of Diastolic and Systolic Dysfunction in Spontaneously Hypertensive Rat

BACKGROUND

Myocardial fibrosis plays an important role in the pathogenesis of hypertensive cardiac dysfunction, and myocardial strain could detect early systolic abnormalities when left ventricular ejection fraction (LVEF) is preserved. The aim of this study was to investigate the characteristics of left ventricular multidirectional strain during different stages of heart dysfunction and the possible morphological basis in spontaneously hypertensive rats (SHRs).

METHODS

SHRs and Wistar-Kyoto (WKY) rats were randomly divided into cages and observed for 3-25 months. Echocardiographic measurements, LV + dp/dtmax and left ventricular end-diastolic pressure (LVEDP), and histological collagen volume fraction (CVF) were observed in all rats.

RESULTS

According to LVEF and LVEDP, SHRs were divided into normal cardiac function group (group A), diastolic dysfunction group (group B1), and systolic dysfunction group (group B2). In group A, myocardial strain and CVF showed no difference compared with the control group. In group B1, global longitudinal strain (GLS) and endocardial longitudinal strain (SL-endo) were lower than those in group A CVF-endo was increased (all P < 0.05). In group B2, global and layer-specific strain decreased significantly, along with the increased CVF-endo and CVF-epi (all P < 0.05). The decrease of GLS and SL-endo was moderately correlated with the increase of CVF-endo. The reduction of LVEF was correlated with the decrease of SC-endo (r = 0.65, P < 0.01).

CONCLUSIONS

Pathological myocardial fibrosis associated with hypertension develops from the inner to outer layer of myocardium, which is coincident with the impairment of myocardial deformation, where longitudinal strain is involved firstly and LVEF declines when all directions of strain are reduced.

Serial Assessment of Right Ventricular Deformation in Patients With Hypoplastic Left Heart Syndrome: A Cardiovascular Magnetic Resonance Feature Tracking Study

Background As right ventricular dysfunction is a major cause of adverse outcome in patients with hypoplastic left heart syndrome, the aim was to assess right ventricular function and deformation after Fontan completion by performing 2-dimensional cardiovascular magnetic resonance feature tracking in serial cardiovascular magnetic resonance studies. Methods and Results Cardiovascular magnetic resonance examinations of 108 patients with hypoplastic left heart syndrome (female: 31) were analyzed. Short-axis cine images were used for right ventricular volumetry. Two-dimensional cardiovascular magnetic resonance feature tracking was performed using long-axis and short-axis cine images to measure myocardial global longitudinal, circumferential, and radial strain. All patients had at least 2 cardiovascular magnetic resonance examinations after Fontan completion and 41 patients had 3 examinations. Global strain values and right ventricular ejection fraction decreased from the first to the third examination with a significant decline in global longitudinal strain from the first examination to the second examination (median, first, and third quartile: -18.8%, [-20.5;-16.5] versus -16.9%, [-19.3;-14.7]) and from the first to the third examination in 41 patients (-18.6%, [-20.9;-15.7] versus -15.8%, [-18.7;-12.6]; P-values <0.004). Right ventricular ejection fraction decreased significantly from the first to the third examination (55.4%, [49.8;59.3] versus 50.2%, [45.0;55.9]; P<0.002) and from the second to the third examination (53.8%, [47.2;58.7] versus 50.2%, [45.0;55.9]; P<0.0002). Conclusions Serial assessment of cardiovascular magnetic resonance studies in patients with hypoplastic left heart syndrome after Fontan completion demonstrates a significant reduction in global strain values and right ventricular ejection fraction at follow-up. The significant reduction in global longitudinal strain between the first 2 examinations with non-significant changes in right ventricular ejection fraction suggest that global longitudinal strain measured by 2-dimensional cardiovascular magnetic resonance feature tracking might be a superior technique for the detection of changes in myocardial function.

The Agreement of a Two- and a Three-Dimensional Speckle-Tracking Global Longitudinal Strain

Background: Two-dimensional (2D) and three-dimensional (3D) speckle-tracking echocardiography (STE) enables assessment of myocardial function. Here, we examined the agreement between 2D and 3D STE measurement of a global longitudinal strain (GLS) in patients with normal left ventricle, reduced ejection fraction, and cardiac pacing. Methods: Our analysis included 90 consecutive patients (59% males; average age: 73.2 ± 11.2 years) examined between May 2019−December 2020, with valid 2D and 3D loops for further speckle-tracking strain analysis. Linear regression, Pearson correlation, and a Bland−Altman plot were used to quantify the association between 2D and 3D GLS and related segments, using the 17-segment American Heart Association (AHA) model. Analyses were performed in the entire study group and subgroups. Intra- and inter-observer variability of 2D and 3D GLS measurement was also performed in all participants. Results: We observed a strong correlation between 2D and 3D GLS measurements (R = 0.76, p < 0.001), which was higher in males (R = 0.78, p < 0.001) than females (R = 0.69, p < 0.001). Associated segment correlation was poor (R = 0.2−0.5, p < 0.01). The correlation between 2D and 3D GLS was weaker in individuals with ventricular pacing of >50% (R = 0.62, p < 0.001) than <50% (R = 0.8, p < 0.001), and in patients with LVEF of <35% (R = 0.69, p = 0.002) than >35% (R = 0.72, p < 0.001). Intra-observer variability for 2D and 3D GLS was 2 and 2.3%, respectively. Inter-observer variability for 2D and 3D GLS was 3.8 and 3.6%, respectively Conclusion: Overall 2D and 3D GLS were closely associated but not when analyzed per segment. It seems that GLS comparison is more representative of global shortening than local displacement. Right ventricular pacing and reduced left ventricular ejection fraction were associated with a reduced correlation between 2D and 3D GLS.

Could CMR Tissue-Tracking and Parametric Mapping Distinguish Between Takotsubo Syndrome and Acute Myocarditis? A Pilot Study

RATIONALE AND OBJECTIVE

Takotsubo syndrome (TS) is a transient and often misdiagnosed form of left ventricular dysfunction. Acute myocarditis (AM) is usually included in TS differential diagnosis. The aim of this study is to assess the role of cardiac magnetic resonance imaging coupled with tissue-tracking technique (CMR-TT) and parametric mappings analysis in discriminating between TS and AM.

MATERIALS AND METHODS

We retrospectively enrolled three groups: patients with TS (n = 12), patients with AM (n = 14), and 10 healthy controls. All the patients had a comprehensive CMR examination, including the assessment of global and segmental longitudinal strain, circumferential strain, radial strain (RS), and parametric mapping.

RESULTS

The analysis of variance was used to compare the different groups. In TS patients, basal RS, global T1 mapping, global T2 mapping, mid T2 mapping, apical T1 and T2 mapping were statistically significantly different compared with the other groups. MANCOVA analysis confirmed that the association between myocardial strain data and parametric mapping was independent on age and sex. Apical T1 and T2 mapping proved to have a good performance in differentiating TS from AM (area under the curves of 0.908 and 0.879, respectively).

CONCLUSION

Basal RS and apical tissue mapping analysis are the most advanced CMR-derived parameters in making a differential diagnosis between TS and AM.

Prognostic value of myocardial work and global longitudinal strain in patients with heart failure and functional mitral regurgitation

In patients with heart failure and functional mitral regurgitation (FMR), the assessment of left ventricular (LV) function is important for risk stratification and decision making. As LV ejection fraction (LVEF) might not be an optimal metric for LV systolic performance in this population, alternatives such as global longitudinal strain (GLS) and global myocardial work index (GWI) have been proposed. In the present study, we investigated the prognostic value of GLS and GWI and compared these measures to other LV systolic performance parameters. A prospective and consecutive cohort of 181 patients (median age 72 years, 76% male) with LVEF < 50% and FMR underwent comprehensive echocardiographic examination including speckle tracking echocardiography and grading of FMR severity. During a median follow-up of 42 months, 72 cardiovascular (CV) events occurred. In univariate analysis, LVEF, GLS, GWI, mitral S', LV outflow tract time velocity integral, forward LVEF and LV ejection time were associated with CV events. After multivariate adjustment only GLS (hazard ratio (HR) = 0.884, p = 0.015) and GWI (HR = 0.927, p = 0.034) remained independently associated with CV events. There was no difference in the incremental prognostic value of GWI compared to GLS (delta -2 log likelihood = 0.8; p = 0.37). In this cohort of heart failure patients with FMR, GLS and GWI were independently associated with cardiovascular events, whereas other systolic performance parameters were not. However, GWI did not outperform GLS, and further research is required to determine the value of these strain-based measures in clinical practice.

Myocardial strain to identify benefit from beta-blockers in patients with heart failure with reduced ejection fraction

AIMS

Not all patients with heart failure with reduced ejection fraction (HFrEF) benefit equally from beta-blockers. Previous studies suggest that myocardial strain that reflects myocardial deformation may have a better prognostic value than the left ventricular ejection fraction. We aimed to evaluate the differential effect of beta-blockers according to the global longitudinal strain (GLS) in patients with HFrEF.

METHODS AND RESULTS

Of the 4312 patients in the Strain for Risk Assessment and Therapeutic Strategies in Patients with Acute Heart Failure registry, we included 2126 HFrEF patients whose data on beta-blocker use and GLS were available. Patients were categorized into two groups: one group of patients had GLS ≥ 10%, and the other group had GLS < 10%. The primary outcome was 5 year all-cause mortality according to beta-blocker use. Of the 2126 patients with HFrEF, 526 (24.7%) and 1600 (75.3%) patients had GLS ≥ 10% and <10%, respectively. Overall, 1399 patients (65.8%) received beta-blockers, and 864 (40.6%) patients died during the 5 year follow-up. Beta-blocker use was associated with improved survival in patients with GLS < 10% in both the inverse probability treatment-weighted (hazard ratio 0.70, 95% confidence interval 0.59-0.83, P < 0.001) and Cox regression analyses (hazard ratio 0.69, 95% confidence interval 0.59-0.81; P < 0.001). However, beta-blocker use was not associated with better survival in patients with GLS ≥ 10% in the inverse probability treatment-weighted and Cox regression analyses (both P > 0.05).

CONCLUSIONS

Beta-blocker use appears to be associated with improved survival in patients with HFrEF and GLS < 10%, but this is not the case in patients with GLS ≥ 10%. Therefore, GLS may be used to identify patients who have attenuated benefits from beta-blockers in HFrEF.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT03513653 (https://clinicaltrials.gov/ct2/show/NCT03513653).

Advances in Multimodality Cardiovascular Imaging in the Diagnosis of Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a syndrome defined by the presence of heart failure symptoms and increased levels of circulating natriuretic peptide (NP) in patients with preserved left ventricular ejection fraction and various degrees of diastolic dysfunction (DD). HFpEF is a complex condition that encompasses a wide range of different etiologies. Cardiovascular imaging plays a pivotal role in diagnosing HFpEF, in identifying specific underlying etiologies, in prognostic stratification, and in therapeutic individualization. Echocardiography is the first line imaging modality with its wide availability; it has high spatial and temporal resolution and can reliably assess systolic and diastolic function. Cardiovascular magnetic resonance (CMR) is the gold standard for cardiac morphology and function assessment, and has superior contrast resolution to look in depth into tissue changes and help to identify specific HFpEF etiologies. Differently, the most important role of nuclear imaging [i.e., planar scintigraphy and/or single photon emission CT (SPECT)] consists in the screening and diagnosis of cardiac transthyretin amyloidosis (ATTR) in patients with HFpEF. Cardiac CT can accurately evaluate coronary artery disease both from an anatomical and functional point of view, but tissue characterization methods have also been developed. The aim of this review is to critically summarize the current uses and future perspectives of echocardiography, nuclear imaging, CT, and CMR in patients with HFpEF.

Evaluation of Asymmetric Dimethylarginine Serum Level and Left Ventricular Function by 2D Speckle Tracking Echocardiography in Children on Regular Hemodialysis

Cardiovascular disease is the leading cause of morbidity and mortality in children with chronic kidney disease. Asymmetric dimethylarginine (ADMA) is thought to be related to chronic kidney disease patients' adverse cardiovascular effects. Our study is to assess ADMA concentrations in children on hemodialysis (HD) as a marker of cardiovascular risk and detect the relation to the left ventricular (LV) function by traditional and speckled tracking echo. Forty children with end-stage renal disease on regular HD were enrolled in the study and selected from the nephrology HD unit of Al-Zahraa Hospital, Al-Azhar University. Another group of 40 healthy children matches age and sex with the patient's group as a control. ADMA serum level, traditional echo, and tissue Doppler imaging spackled tracking were performed to assess: LV functions for both groups in the same line with the routine laboratory investigations. Moreover, bioimpedance was assessed after the HD session. Children on regular HD have a significantly higher (ADMA) serum level compared to their controls; the median is (72.5 ng/mL) and (25 ng/mL), respectively (P = 0.001) and a significant increase in high-sensitivity C-reactive protein and the median is (3.6 ng/mL) and (2.5 ng/mL), respectively (P = 0.001). Moreover, conventional echo detects 27 (67.5%) patients out of 40 had an impaired LV function; meanwhile, 33 (82.5%) had a global LV strain (LV GLS) detected by 2D (Speckle echo), a negative correlation between LV ejection fraction with serum (urea, cholesterol, and triglyceride) and a positive correlation between ADMA and LV systolic diameter. LV GLS (Speckle echo) is negatively correlated with LV end-diastolic diameter, LV end-systolic diameter and positively correlated with LV inter ventricular septum in diastole and reduced average systolic velocity (ml). The sensitivity and specificity of (ADMA), high-sensitivity C-reactive protein (hs-CRP), traditional, and Speckle echo for early left ventricular (LV) dysfunction were 92.50, 92, and 67.50, 97 and 67.50, 90.00, and 80.00, 92, respectively. An ADMA emerges as a sensitive and specific marker for early LV dysfunction in children on hemodialysis (HD); drugs targeting ADMA isessential in the future direction after clinical approval, to avoid early LV changes, furthermore (Speckle echo) is superior to the traditional echo for early detection of LV changes in chronic kidney disease (CKD) children.

Reconsidering the ejection fraction centric view of pharmacologic treatment for heart failure

For the past two decades, heart failure (HF) has been classified into two phenotypes based on ejection fraction (EF). Inhibitors of the RAAS, neprilysin, , and beta-blockers represent foundational treatments for patients with a reduced EF (<40%) but have not been considered effective in patients with preserved EF (≥40%). However, re-examination of the clinical trial evidence has cast considerable doubt about the utility of an EF threshold of 40% as the main decision tool for HF treatment. In CHARM, candesartan reduced the risk of cardiovascular death or HF hospitalization by 24% up to an EF of 50%, with attenuation of the effect on HF hospitalization in patients with EF >55-60%. In RALES and TOPCAT, spironolactone reduced the risk of cardiovascular death or HF hospitalization by 28% up to an EF of 50%, with attenuation of the effect on HF hospitalization in patients with EF >55-60%. In PARADIGM-HF and PARAGON-HF, sacubitril/valsartan reduced total HF hospitalizations by 20% up to an EF of 55-60%, with an attenuated effect in patients with the highest EF. In the EMPEROR trials, empagliflozin reduced the risk of total HF hospitalizations by approximately 30% in patients with EF ranging from <25% to 60%, with an attenuated effect in patients with EF >60-65%. Since patients with an EF >60% represent only 10-15% of all HF patients, we propose that foundational HF treatments should be applied to patients across broad range of EF.

One step closer to myocardial physiology: From PV loop analysis to state-of-the-art myocardial imaging

Recent advances in cardiac imaging have revitalized the assessment of fundamental physiological concepts. In the field of cardiac physiology, invasive measurements with pressure-volume (PV) loops have served as the gold standard methodology for the characterization of left ventricular (LV) function. From PV loop data, fundamental aspects of LV chamber function are derived such as work, efficiency, stiffness and contractility. However, the parametrization of these aspects is limited because of the need for invasive procedures. Through the utilization of recent advances in echocardiography, magnetic resonance imaging and positron emission tomography, it has become increasingly feasible to quantify these fundamental aspects of LV function non-invasively. Importantly, state-of-the-art imaging technology enables direct assessment of myocardial performance, thereby extending functional assessment from the net function of the LV chamber, as is done with PV loops, to the myocardium itself. With a strong coupling to underlying myocardial physiology, imaging measurements of myocardial work, efficiency, stiffness and contractility could represent the next generation of functional parameters. The purpose of this review is to discuss how the new imaging parameters of myocardial work, efficiency, stiffness and contractility can bring cardiac physiologists, researchers and clinicians alike one step closer to underlying myocardial physiology.

Long Term Prognostic Value of Contractile Reserve Assessed by Global Longitudinal Strain in Patients with Asymptomatic Severe Aortic Stenosis

Background. Left ventricle (LV) global longitudinal strain (GLS) at rest has shown prognostic value in patients (pts) with severe aortic stenosis (SAS). Contractile reserve (CR) during exercise stress echo (ESE) estimated via GLS (CR-GLS) could better stratify the asymptomatic patients who could benefit from early intervention. Aims. To determine the long-term prognostic value of CR-GLS in patients with asymptomatic SAS with an ESE without inducible ischemia. Additionally, to compare the prognostic value of CR assessed via ejection fraction (CR-EF) and CR-GLS. Methods. In a prospective, single-center, observational study between 2013 and 2019, 101 pts with asymptomatic SAS and preserved left ventricular ejection fraction (LVEF) > 55% were enrolled. CR was considered present with an exercise-rest increase in LVEF (Simpson’s rule) ≥ 5 points and > 2 absolute points in GLS. Patients were assigned to 2 groups (G): G1: 56 patients with CR-GLS present; and G2: 45 patients CR-GLS absent. All patients were followed up. Results. G2 Patients were older, with lower exercise capability, less aortic valve area (AVA), a higher peak aortic gradient, and less LVEF (71.5% ± 5.9 vs. 66.8% ± 7.9; p = 0.002) and GLS (%) at exercise (G1: −22.2 ± 2.8 vs. G2: −18.45 ± 2.4; p = 0.001). During mean follow-up of 46.6 ± 3.4 months, events occurred in 45 pts., with higher incidence in G2 (G2 = 57.8% vs. G1 = 42.2%, p < 0.01). At Cox regression analysis, CR-GLS was an independent predictor of major cardiovascular events (HR: 1.98, 95% CI 1.09–3.58, p = 0.025). Event-free survival was lower for patients with CR-GLS absent (log rank test p = 0.022). CR-EF was not outcome predictive (log rank test p 0.095). Conclusions: In patients with asymptomatic SAS, the absence of CR-GLS during ESE is associated with worse prognosis. Additionally, CR-GLS was a better predictor of events than CR-EF.

Multimodality imaging in patients with heart failure and preserved ejection fraction: an expert consensus document of the European Association of Cardiovascular Imaging

Nearly half of all patients with heart failure (HF) have a normal left ventricular (LV) ejection fraction (EF) and the condition is termed heart failure with preserved ejection fraction (HFpEF). It is assumed that in these patients HF is due primarily to LV diastolic dysfunction. The prognosis in HFpEF is almost as severe as in HF with reduced EF (HFrEF). In contrast to HFrEF where drugs and devices are proven to reduce mortality, in HFpEF there has been limited therapy available with documented effects on prognosis. This may reflect that HFpEF encompasses a wide range of different pathological processes, which multimodality imaging is well placed to differentiate. Progress in developing therapies for HFpEF has been hampered by a lack of uniform diagnostic criteria. The present expert consensus document from the European Association of Cardiovascular Imaging (EACVI) provides recommendations regarding how to determine elevated LV filling pressure in the setting of suspected HFpEF and how to use multimodality imaging to determine specific aetiologies in patients with HFpEF.

Insights Into Myocardial Oxygenation and Cardiovascular Magnetic Resonance Tissue Biomarkers in Heart Failure With Preserved Ejection Fraction

BACKGROUND

The pathophysiology of heart failure with preserved ejection fraction is not well understood, but evidence strongly suggests involvement of microvascular dysfunction. We studied the myocardial oxygenation reserve as a direct marker of coronary vascular function and its relation to myocardial deformation and tissue characteristics by cardiovascular magnetic resonance (CMR).

METHODS

In a dual-center case-control study, patients with heart failure and preserved ejection fraction (>50%) and healthy controls older than 50 years underwent quantitative CMR for ventricular volumes and functional assessment with feature tracking, as well as tissue characterization (T1, T2, extracellular volume). Coronary vascular function was measured by oxygenation-sensitive (OS)-CMR of the myocardial oxygenation response to a vasoactive breathing maneuver.

RESULTS

Twenty-nine patients completed the CMR exam. Compared with cutoffs derived from 12 control subjects, circumferential peak strain was attenuated in 97% of patients. Native T1 was elevated in 93%, extracellular volume was elevated in 83%. Sixty-six percent of patients revealed either regional or global myocardial edema, defined by an increased myocardial T2. An attenuated global myocardial oxygenation reserve (<4.4%) was observed in 96% of the patients (1.7±3.9% versus 9.1±5.3% in controls, P<0.001). This was correlated with septal wall thickness (r=-0.54, P=0.003), edema (myocardial T2; β=-0.26% oxygenation-sensitive/ms [95% CI, -0.49 to -0.03], P=0.029), and reduced diastolic strain rate (β=1.50% oxygenation-sensitive/s^-1 [95% CI, 0.06-2.90], P=0.042).

CONCLUSIONS

In patients with clinical heart failure with preserved ejection fraction, vascular dysfunction as measured by an attenuated myocardial oxygenation reserve is associated with myocardial edema, a thicker septum, and diastolic dysfunction. A quantitative comprehensive CMR exam including oxygenation-sensitive-CMR allows for comprehensive imaging-based phenotyping of heart failure with preserved ejection fraction.

Cardiac geometry, function and mechanics in left ventricular non-compaction cardiomyopathy with preserved ejection fraction

BACKGROUND

Left ventricular non-compaction (LVNC) cardiomyopathy in adults has primarily been studied with a phenotypic expression of low ejection fraction (EF) and dilated cardiomyopathy; however, data on LVNC with preserved EF is scarce. The present study aimed to evaluate cardiac geometry and mechanics in LVNC patients with preserved EF.

METHODS

A retrospective cohort study of patients diagnosed with LVNC and a preserved EF between 2008 and 2019 was performed. LVNC was defined according to the presence of established transthoracic 2D echocardiographic (TTE) criteria as follows: (1) prominent LV trabeculations with deep recesses; (2) bi-layered myocardial appearance; and, (3) systolic non-compacted:compacted ratio≥ 2. Subjects were matched 1:1 to controls without LVNC referred for routine TTE. Geometric, functional and mechanics parameters were analyzed in the two cohorts using 2D and speckle-tracking TTE.

RESULTS

Seventeen patients with LVNC and preserved EF were identified. Compared with controls, patients with LVNC had similar LV systolic function and chamber dimensions, but a larger mass and relative wall thickness, and more abnormal LV geometry (76% vs. 18%, p = 0.002), LA remodeling, and pulmonary hypertension. Global longitudinal strain was significantly decreased (-15.4 ± 3.2 vs. -18.9 ± 2.8%, p =  < 0.01) and the prevalence of rigid body rotation was significantly increased (57% vs. 14%, p = 0.05) in the LVNC population. The peak twist values were comparable in both cohorts.

CONCLUSIONS

Impaired LV geometry and longitudinal mechanics, as well as increased myocardial stiffness as expressed by rigid body rotation, characterize LVNC with preserved EF when compared with controls.

Prognostic Value of Global Longitudinal Strain in Patients With Heart Failure With Improved Ejection Fraction

OBJECTIVES

The authors sought to determine whether global longitudinal strain (GLS) is independently associated with the natural history of patients with heart failure (HF) with improved ejection fraction (HFimpEF).

BACKGROUND

Left ventricular (LV) ejection fraction (EF) often improves in patients with reduced EF. The clinical course of patients with HFimpEF, however, is quite variable. GLS, a sensitive indicator of LV systolic function, could help predict risk of future events in this population.

METHODS

Retrospective analysis of HF patients with LVEF >40% on index echocardiogram who had LVEF <40% on initial study and improvement of ≥10%. GLS was assessed by 2-dimensional speckle-tracking software on index echocardiography. Primary outcome was time to first occurrence of cardiovascular mortality or HF hospitalization/emergency treatment.

RESULTS

Of the 289 patients with HFimpEF, median absolute values of GLS (aGLS) and LVEF from index echocardiography were 12.7% (IQR: 10.8%-14.7%) and 52% (IQR: 46%-58%), respectively. Over 53 months following index echocardiography, the primary endpoint occurred less frequently in patients with aGLS above the median than below it (21% vs 34%; P = 0.014); HR of 0.51; 95% CI: 0.33-0.81; P = 0.004. When assessed as a continuous variable, each 1% increase in aGLS on index echocardiogram was associated with a lower likelihood of the composite endpoint; HR of 0.86; 95% CI: 0.79-0.93; P < 0.001, an association that persisted after multivariable adjustment; HR 0.90; 95% CI: 0.82-0.97; P = 0.01. Lower aGLS was associated with increased likelihood of deterioration in LVEF.

CONCLUSIONS

In patients with HFimpEF, GLS is a strong predictor for future HF events and deterioration in cardiac function.

Heart failure with mid-range or mildly reduced ejection fraction

Left ventricular ejection fraction (EF) remains the major parameter for diagnosis, phenotyping, prognosis and treatment decisions in heart failure. The 2016 ESC heart failure guidelines introduced a third EF category for an EF of 40-49%, defined as heart failure with mid-range EF (HFmrEF). This category has been largely unexplored compared with heart failure with reduced EF (HFrEF; defined as EF <40% in this Review) and heart failure with preserved EF (HFpEF; defined as EF ≥50%). The prevalence of HFmrEF within the overall population of patients with HF is 10-25%. HFmrEF seems to be an intermediate clinical entity between HFrEF and HFpEF in some respects, but more similar to HFrEF in others, in particular with regard to the high prevalence of ischaemic heart disease in these patients. HFmrEF is milder than HFrEF, and the risk of cardiovascular events is lower in patients with HFmrEF or HFpEF than in those with HFrEF. By contrast, the risk of non-cardiovascular adverse events is similar or greater in patients with HFmrEF or HFpEF than in those with HFrEF. Evidence from post hoc and subgroup analyses of randomized clinical trials and a trial of an SGLT1-SGLT2 inhibitor suggests that drugs that are effective in patients with HFrEF might also be effective in patients with HFmrEF. Although the EF is a continuous measure with considerable variability, in this comprehensive Review we suggest that HFmrEF is a useful categorization of patients with HF and shares the most important clinical features with HFrEF, which supports the renaming of HFmrEF to HF with mildly reduced EF.

Longitudinal CMR assessment of cardiac global longitudinal strain and hemodynamic forces in a mouse model of heart failure

To longitudinally assess left ventricle (LV) global longitudinal strain (GLS) and hemodynamic forces during the early stages of cardiac dysfunction in a mouse model of heart failure with preserved ejection fraction (HFpEF). Cardiac MRI measurements were performed in control mice (n = 6), and db/db mice (n = 7), whereby animals were scanned four times between the age of 11-15 weeks. After the first scan, the db/db animals received a doxycycline intervention to accelerate progression of HFpEF. Systolic function was evaluated based on a series of prospectively ECG-triggered short-axis CINE images acquired from base to apex. Cardiac GLS and hemodynamic forces values were evaluated based on high frame rate retrospectively gated 2-, 3-, and 4-chamber long-axis CINE images. Ejection fraction (EF) was not different between control and db/db animals, despite that cardiac output, as well as end systolic and end diastolic volume were significantly higher in control animals. Whereas GLS parameters were not significantly different between groups, hemodynamic force root mean square (RMS) values, as well as average hemodynamic forces and the ratio between hemodynamic forces in the inferolateral-anteroseptal and apical-basal direction were lower in db/db mice compared to controls. More importantly, hemodynamic forces parameters showed a significant interaction effect between time and group. Our results indicated that hemodynamic forces parameters were the only functional outcome measure that showed distinct temporal differences between groups. As such, changes in hemodynamic forces reflect early alterations in cardiac function which can be of added value in (pre)clinical research on HFpEF.

How to standardize measurement of global longitudinal strain

Global longitudinal strain (GLS) is a robust and sensitive marker of left-ventricular systolic function, reflecting longitudinal shortening of the ventricle. A growing body of evidence indicates its superiority in identifying subclinical, early alterations in cardiac function compared to traditional markers, such as ejection fraction. Therefore, there is a growing demand to assess GLS in clinical settings, but limited availability on how to obtain GLS accurately and appropriately in the current literature. This review summarizes key aspects of GLS measurement, including image acquisition, post-processing, and training/experience needed to facilitate the clinical implication with standardization.

Longitudinal Assessment of Global and Regional Left Ventricular Strain in Patients with Multisystem Inflammatory Syndrome in Children (MIS-C)

Multisystem inflammatory syndrome in children (MIS-C) is one of the most significant sequela of coronavirus disease 2019 (COVID-19) in children. Emerging literature has described myocardial dysfunction in MIS-C patients using traditional and two-dimensional speckle tracking echocardiography in the acute phase. However, data regarding persistence of subclinical myocardial injury after recovery is limited. We aimed to detect these changes with deformation imaging, hypothesizing that left ventricular global longitudinal (GLS) and circumferential strain (GCS) would remain impaired in the chronic phase despite normalization of ventricular function parameters assessed by two-dimensional echocardiography. A retrospective, single-institution review of 22 patients with MIS-C was performed. Fractional shortening, GLS, and GCS, along with regional longitudinal (RLS) and circumferential strain (RCS) were compared across the acute, subacute, and chronic timepoints (presentation, 14-42, and > 42 days, respectively). Mean GLS improved from - 18.4% in the acute phase to - 20.1% in the chronic phase (p = 0.4). Mean GCS improved from - 19.4% in the acute phase to - 23.5% in the chronic phase (p = 0.03). RCS and RLS were impaired in the acute phase and showed a trend towards recovery by the chronic phase, with the exception of the basal anterolateral segment. In our longitudinal study of MIS-C patients, GLS and GCS were lower in the acute phase, corroborating with left ventricular dysfunction by traditional measures. Additionally, as function globally recovers, GLS and GCS also normalize. However, some regional segments continue to have decreased strain values which may be an important subclinical marker for future adverse events.