Geometry as a Confounder When Assessing Ventricular Systolic Function

Subclinical myocardial dysfunction in coronary slow flow phenomenon: Identification by speckle tracking echocardiography

OBJECTIVE

This study aimed to determine whether STE could help detect subclinical myocardial dysfunction in patients with CSFP.

METHODS

Sixty patients with CSFP confirmed by CAG and 51 controls with normal coronary flow were prospectively enrolled. Coronary angiographic data and conventional and speckle tracking echocardiographic parameters of the LV and RV were obtained for every subject.

RESULTS

Compared with controls, CSFP patients presented with higher BMI and TG levels, but lower HDL-C levels. Conventional echocardiographic parameters of biventricular systolic and diastolic function did not differ between the two groups (all P > 0.05). The GLS of the LV and RV was significantly impaired in CSFP patients compared with that in controls (-19.03% vs -21.42%, P < 0.001 and -19.72% vs -22.96%, P = 0.001, respectively). The myocardial impairment pattern of CSFP patients was homogenous in the RV and heterogeneous in the LV, where only endo- and mid-myocardial layers were affected. LV-GLS and RV-GLS were found to be well correlated with mTFC and HDL-C in CSFP groups (r = 0.463 vs r = 0.439; r = -0.569 vs r = -0.552, all P < 0.05). ROC curve analysis demonstrated that LV-GLS-endo had the highest AUC (0.867, P < 0.001) for predicting subclinical myocardial impairment in CSFP patients.

CONCLUSIONS

Subclinical myocardial systolic dysfunction occurs in both ventricles, and GLS could be an effective method to detect early-stage myocardial impairment in patients with CSFP.

Afterload dependence of right ventricular myocardial deformation: A comparison between tetralogy of Fallot and atrially corrected transposition of the great arteries in adult patients

Background

Prior studies suggested that myocardial deformation is superior to conventional measures for assessing ventricular function. This study aimed to evaluate right ventricular (RV) myocardial deformation in response to increased afterload. Patients with the RV in the systemic position were compared with patients with the RV in the sub-pulmonic position with normal or only slightly elevated systolic right ventricular pressure. Correlations between global longitudinal strain (GLS), radial strain, atrioventricular plane displacement (AVPD), and exercise capacity were evaluated.

Methods

44 patients with congenital heart defect were enrolled in the study. The control group consisted of seven healthy volunteers. All patients underwent cardiovascular magnetic resonance (CMR) and cardiopulmonary exercise testing. We assessed biventricular myocardial function using CMR based feature tracking and compared the results to anatomic volumes.

Results

Strain analysis and displacement measurements were feasible in all participants. RVGLS and RVAVPD were reduced in both study groups compared to the control group (p<0.001). Left ventricular (LV) radial strain was significantly lower in patients with a systemic RV than in those with a subpulmonic RV and lower than in controls (p<0.001). Both LVAVPD and RVAVPD were significantly depressed in patients compared to controls (p<0.05). RVAVPD was more depressed in patients with a high systolic RV pressure than in those with normal RV pressure (p<0.001). RVAVPD did not correlate with exercise capacity in either study group. Exercise capacity in both patient groups was depressed to levels reported in previous studies, and did not correlate with RVGLS.

Conclusions

Both study groups had abnormal myocardial deformation and increased RV volumes. RVGLS in patients was lower than in controls, confirming the effect of increased afterload on myocardial performance.

Alterations in Layer-Specific Left Ventricular Global Longitudinal and Circumferential Strain in Patients With Aortic Stenosis: A Comparison of Aortic Valve Replacement versus Conservative Management Over a 12-Month Period

BACKGROUND

Impairment in left ventricular (LV) systolic strain in aortic stenosis (AS) is well documented. However, alterations in layer-specific LV global longitudinal strain (GLS) and global circumferential strain (GCS) and their recovery following surgical aortic valve replacement (AVR) have not been established. The aim of this study was to examine layer-specific changes in GLS and GCS in patients with AS undergoing AVR and compare these patients with those managed conservatively over 12 months.

METHODS

Eighty-six patients (mean age, 68.8 ± 12 years; 60 men) with AS (19 mild, 15 moderate, and 52 severe) were prospectively recruited. Patients with coronary disease or other significant valvular disease were excluded. Forty patients (46.5%) with severe AS underwent AVR. All patients underwent baseline echocardiography. Patients managed conservatively underwent follow-up echocardiography at 12 months. Patients undergoing AVR underwent follow-up echocardiography at 1 week and 3, 6, and 12 months after AVR.

RESULTS

There was worsening in subendocardial but not subepicardial or transmural GLS even in mild AS (-20.9 ± 1.0% vs -20.6 ± 0.8%, P = .012). In moderate AS, worsening in subendocardial (-19.6 ± 0.9% vs -18.2 ± 1.5%, P = .003), subepicardial (-14.9 ± 1.0% vs -13.8 ± 1.2%, P = .004), and transmural (-17.1 ± 0.9% vs -15.8 ± 1.3%, P = .03) GLS and a trend toward significant worsening in subendocardial GCS (-29.8 ± 5.16% vs -27.5 ± 5%, P = .054) were seen. Conservatively managed patients with severe AS had significant worsening in subendocardial (-16.1 ± 1.6% vs -13.9 ± 2.6%, P = .021), subepicardial (-11.6 ± 1.1% vs -10.1 ± 2.1%, P = .027), and transmural (-13.6 ± 1.3% vs -11.8 ± 2.3%, P = .02) GLS and subendocardial (-24.9 ± 3.6% vs -20.8 ± 4.5%, P = .002) and transmural (-16.9 ± 1.7% vs -14.3 ± 3.5%, P = .04) GCS on follow-up. Patients after AVR demonstrated significant improvement in GLS (from 3 months) and GCS (from 6 months) in both myocardial layers.

CONCLUSIONS

Patients with AS managed conservatively had worsening of GLS over 12 months despite preserved LV ejection fraction, detected earliest in the subendocardial layer. GCS became progressively impaired in moderate and severe AS. Improvement in LV strain after AVR was seen earlier with GLS (from 3 months) than with GCS (from 6 months) in both myocardial layers.

Levosimendan for Perioperative Cardioprotection: Myth or Reality?

BACKGROUND

Levosimendan is a calcium sensitizer drug causing increased contractility in the myocardium and vasodilation in the vascular system. It is mainly used for the therapy of acute decompensated heart failure. Several studies on animals and humans provided evidence of the cardioprotective properties of levosimendan including preconditioning and anti-apoptotic. In view of these favorable effects, levosimendan has been tested in patients undergoing cardiac surgery for the prevention or treatment of low cardiac output syndrome. However, initial positive results from small studies have not been confirmed in three recent large trials.

AIM

To summarize levosimendan mechanisms of action and clinical use and to review available evidence on its perioperative use in a cardiac surgery setting.

METHODS

We searched two electronic medical databases for randomized controlled trials studying levosimendan in cardiac surgery patients, ranging from January 2000 to August 2017. Metaanalyses, consensus documents and retrospective studies were also reviewed.

RESULTS

In the selected interval of time, 54 studies on the use of levosimendan in heart surgery have been performed. Early small size studies and meta-analyses have suggested that perioperative levosimendan infusion could diminish mortality and other adverse outcomes (i.e. intensive care unit stay and need for inotropic support). Instead, three recent large randomized controlled trials (LEVO-CTS, CHEETAH and LICORN) showed no significant survival benefits from levosimendan. However, in LEVO-CTS trial, prophylactic levosimendan administration significantly reduced the incidence of low cardiac output syndrome.

CONCLUSIONS

Based on most recent randomized controlled trials, levosimendan, although effective for the treatment of acute heart failure, can't be recommended as standard therapy for the management of heart surgery patients. Further studies are needed to clarify whether selected subgroups of heart surgery patients may benefit from perioperative levosimendan infusion.

Association of left ventricular myocardial dysfunction with diabetic polyneuropathy

BACKGROUND

The pathogenesis of left ventricular (LV) dysfunction in diabetes has been attracting attention. It has been reported that LV longitudinal systolic myocardial function determined by speckle tracking echocardiography (STE) is associated with diabetic polyneuropathy (DPN). However, the relationship between the severity of peripheral neuropathy and LV myocardial dysfunction is unknown. This study examined the relationship between the severity of DPN and echocardiographic parameters as well as clinical features.

METHODS

The subjects were 166 patients (57 ± 14 years old) with diabetes who had a normal LV ejection fraction (≥ 55%). To assess LV longitudinal systolic function, global longitudinal strain (GLS) was calculated by two-dimensional STE as the average peak strain of 18 LV segments in three standard apical views. A nerve conduction study (NCS) was performed in each subject to assess the severity of neuropathy based on the NCS Baba Classification (Grade 0: no apparent abnormalities-Grade IV: abolition). Three nerves in the lower extremity were examined: tibial nerve (F-wave latency, motor nerve conduction velocity, and amplitude), sural nerve (sensory conduction velocity and amplitude), and peroneal nerve (motor nerve conduction velocity and amplitude).

RESULTS

Of the 166 subjects, 112 subjects (67.5%) were confirmed to have DPN, and all the subjects were divided into two groups according to the presence/absence of DPN. When multivariate analysis was performed using significant factors from univariate logistic regression analysis as explanatory variables, GLS was found to be an independent determinant of DPN (odds ratio: 0.55, p < 0.001). In multivariate analysis of NCS data, F-wave latency was the most important determinant of DPN (odds ratio: 1.43, p < 0.001). There was a significant negative correlation between F-wave latency and GLS (r = - 0.43, p < 0.001). Regarding the relation between GLS and the severity of DPN, GLS was significantly lower in patients with Grade I or higher DPN than in patients without DPN, but showed no significant difference between the grades of neuropathy. In addition, GLS was significantly lower when 2-3 lower extremity nerves were affected by DPN than in patients without DPN.

CONCLUSION

Patients with diabetes may already have subclinical LV myocardial dysfunction when DPN is Grade I. Assessment of LV longitudinal systolic function by GLS may be important in diabetic patients with DPN.

Relationship of Transmural Variations in Myofiber Contractility to Left Ventricular Ejection Fraction: Implications for Modeling Heart Failure Phenotype With Preserved Ejection Fraction

The pathophysiological mechanisms underlying preserved left ventricular (LV) ejection fraction (EF) in patients with heart failure and preserved ejection fraction (HFpEF) remain incompletely understood. We hypothesized that transmural variations in myofiber contractility with existence of subendocardial dysfunction and compensatory increased subepicardial contractility may underlie preservation of LVEF in patients with HFpEF. We quantified alterations in myocardial function in a mathematical model of the human LV that is based on the finite element method. The fiber-reinforced material formulation of the myocardium included passive and active properties. The passive material properties were determined such that the diastolic pressure-volume behavior of the LV was similar to that shown in published clinical studies of pressure-volume curves. To examine changes in active properties, we considered six scenarios: (1) normal properties throughout the LV wall; (2) decreased myocardial contractility in the subendocardium; (3) increased myocardial contractility in the subepicardium; (4) myocardial contractility decreased equally in all layers, (5) myocardial contractility decreased in the midmyocardium and subepicardium, (6) myocardial contractility decreased in the subepicardium. Our results indicate that decreased subendocardial contractility reduced LVEF from 53.2 to 40.5%. Increased contractility in the subepicardium recovered LVEF from 40.5 to 53.2%. Decreased contractility transmurally reduced LVEF and could not be recovered if subepicardial and midmyocardial contractility remained depressed. The computational results simulating the effects of transmural alterations in the ventricular tissue replicate the phenotypic patterns of LV dysfunction observed in clinical practice. In particular, data for LVEF, strain and displacement are consistent with previous clinical observations in patients with HFpEF, and substantiate the hypothesis that increased subepicardial contractility may compensate for subendocardial dysfunction and play a vital role in maintaining LVEF.

Left ventricular systolic function evaluated by strain echocardiography and relationship with mortality in patients with severe sepsis or septic shock: a systematic review and meta-analysis

Background

Sepsis-induced myocardial dysfunction is associated with poor outcomes, but traditional measurements of systolic function such as left ventricular ejection fraction (LVEF) do not directly correlate with prognosis. Global longitudinal strain (GLS) utilizing speckle-tracking echocardiography (STE) could be a better marker of intrinsic left ventricular (LV) function, reflecting myocardial deformation rather than displacement and volume changes. We sought to investigate the prognostic value of GLS in patients with sepsis and/or septic shock.

Methods

We conducted a systematic review (PubMed and Embase up to 26 October 2017) and meta-analysis to investigate the association between GLS and mortality at longest follow up in patients with severe sepsis and/or septic shock. In the primary analysis, we included studies reporting transthoracic echocardiography data on GLS according to mortality. A secondary analysis evaluated the association between LVEF and mortality including data from studies reporting GLS.

Results

We included eight studies in the primary analysis with a total of 794 patients (survival 68%, n = 540). We found a significant association between worse LV function and GLS values and mortality: standard mean difference (SMD) − 0.26; 95% confidence interval (CI) − 0.47, − 0.04; p = 0.02 (low heterogeneity, I² = 43%). No significant association was found between LVEF and mortality in the same population of patients (eight studies; SMD, 0.02; 95% CI − 0.14, 0.17; p = 0.83; no heterogeneity, I² = 3%).

Conclusions

Worse GLS (less negative) values are associated with higher mortality in patients with severe sepsis or septic shock, while such association is not valid for LVEF. More critical care research is warranted to confirm the better ability of STE in demonstrating underlying intrinsic myocardial disease compared to LVEF.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2113-y) contains supplementary material, which is available to authorized users.

Global longitudinal strain measured by speckle tracking identifies subclinical heart involvement in patients with systemic sclerosis

Background Systemic sclerosis is characterised by progressive cutaneous and organ fibrosis. Among all organs, a subclinical heart involvement is difficult to detect through conventional imaging. Design We evaluated whether speckle tracking-derived global longitudinal strain could help detect early subclinical systolic dysfunction in systemic sclerosis patients without overt clinical involvement. Methods A case-control, single-centre study on 52 systemic sclerosis patients and 52 age and gender-matched controls. Patients with structural heart disease, heart failure, atrial fibrillation and pulmonary hypertension were excluded. For every patient, standard echocardiographic and speckle tracking-derived variables for the systolic and diastolic function of the left ventricle and right ventricle were acquired. Results Traditional parameters of left and right systolic function did not differ between systemic sclerosis patients and controls (all P = ns). Left and right ventricular global longitudinal strain was significantly impaired in patients with systemic sclerosis when compared to controls (-19.2% vs. -21.1%; P = 0.009 and -18.2% vs. -22.3%; P = 0.012, respectively). Systemic sclerosis patients had a 2.5-fold increased risk of subclinical left ventricular systolic impairment (odds ratio 2.5, 95% confidence interval 1.1-5.5; P = 0.027) and a 3.3-fold increased risk of subclinical right ventricular systolic impairment when compared to controls (odds ratio 3.3, 95% confidence interval 1.4-7.7; P = 0.004). Alterations in the myocardial deformation pattern of systemic sclerosis patients were homogeneous in the right ventricle and eccentric in the left ventricle. Conclusions While traditional echocardiographic parameters are ineffective in detecting subclinical systolic impairment, reduced global longitudinal strain is common in patients with systemic sclerosis and significant for both ventricles. Global longitudinal strain could become a low-cost, non-invasive and reliable tool in order to detect early cardiac involvement in systemic sclerosis patients.

The relationship between left ventricular structure and function in the elite rugby football league athlete as determined by conventional echocardiography and myocardial strain imaging

AIMS

The aims of this study were to establish the left ventricular (LV) phenotype in rugby football league (RFL) athletes and to mathematically model the association between LV size, strain (ɛ) and ejection fraction (EF).

METHODS AND RESULTS

139 male athletes underwent echocardiographic LV evaluation including ɛ imaging. Non-athletic males were used for comparison. All absolute and scaled structural indices were significantly larger (P < 0.05) in athletes with a predominance for normal LV geometry. EF and global ɛ were similar between groups but strain rates (SR) were significantly lower (P < 0.05) in athletes. Lower apical rotation (P < 0.001) and twist (P = 0.010) were exhibited in athletes.

CONCLUSION

Normal EF is explained by divergent effects of LV internal diastolic dimension (LVIDd) and mean wall thickness (MWT) on LV function. Reductions in SR and twist may be part of normal physiological LV adaptation in RFL athletes.

Speckle-tracking strain assessment of left ventricular dysfunction in synthetic cannabinoid and heroin users

Objective

There is growing evidence regarding the numerous adverse effects of synthetic cannabinoids (SCBs) on the cardiovascular system; however, no studies have shown the cardiovascular effects of opioids using strain echocardiography. This study examines the cardiac structure and function using echocardiographic strain imaging in heroin and synthetic cannabinoid users.

Methods

This double-blind study included patients who were admitted or referred to a rehabilitation center for heroin (n=31) and synthetic cannabinoid users (n=30). Heroin users and synthetic cannabinoid users were compared with healthy volunteers (n=32) using two-dimensional (2D) speckle-tracking (ST) echocardiography.

Results

No differences were found in the baseline characteristics and 2D echocardiography values. The mean global longitudinal strain value was −20.5%±2.4% for SCB users, −22.3%±2.4% for opioid users, and −22.5%±2.2% for healthy volunteers (p=0.024). The mean apical 2-chamber (AP2C) L-strain values were −20.1%±3.1%, −22.4%±3.0%, and −22.3%±2.8% for SCB users, opioid users, and healthy volunteers, respectively (p=0.032). The mean apical 4-chamber (AP4C) L-strain values were −20.7%±2.5% for SCB users, −23.2%±3.2% for opioid users, and −23.8%±3.1% for healthy volunteers (p<0.001).

Conclusion

SCBs are potential causes of subclinical left ventricular dysfunction.

Morphological changes and myocardial function assessed by traditional and novel echocardiographic methods in preadolescent athlete’s heart

Background

Athlete’s heart is a term used to describe the morphological and functional changes in the hearts of athletes. Recent studies suggest that these changes may occur even in preadolescent athletes. This study aims to improve our understanding of the changes occurring in the preadolescent athlete’s heart.

Design and methods

Cardiac morphology and function in 76 preadolescent cross-country skiers (aged 12.1 ± 0.2 years) were compared with 25 age-matched non-competing preadolescents. Echocardiography was performed in all subjects, including 2D speckle-tracking strain echocardiography and 3D echocardiography. All participants underwent cardiopulmonary exercise testing to assess oxygen uptake and exercise capacity.

Results

Athletes had greater indexed VO2 max (62 ± 7 vs. 44 ± 5 mL/kg per min, p < 0.001), indexed left ventricular end-diastolic volume (79 ± 7 vs. 68 ± 7 mL/m2, p < 0.001), left ventricular mass (69 ± 12 vs. 57 ± 13 g/m2, p < 0.001), indexed right ventricular basal diameter (28.3 ± 3.0 vs. 25.4 ± 3.5 mm/m2, p < 0.001) and right atrial area (10.6 ± 1.4 vs. 9.7 ± 1.2 cm2/m2, p < 0.01). There was no difference in left ventricular ejection fraction, global longitudinal strain, and global circumferential strain and right ventricular fractional area change between the groups. Controls had higher right ventricular global longitudinal strain (−28.1 ± 3.5 vs. −31.1 ± 3.3%, p < 0.01). VO2 max was highly correlated to left ventricular end-diastolic volume ( r = 0.76, p < 0.001).

Conclusion

Athletes had greater left ventricular mass and greater left and right ventricular chamber dimensions compared with controls, while left ventricular function did not differ. Interestingly, right ventricular deformation was significantly lower compared with controls. This supports the notion that there is physiological, adaptive remodelling in preadolescent athlete’s heart.

Longitudinal left ventricular function is globally depressed within a week of STEMI

Sixty percent of stroke volume (SV) is generated by atrioventricular plane displacement (AVPD) in a healthy left ventricle (LV). The aims were to determine the effect of ST-elevation myocardial infarction (STEMI) on AVPD and contribution of AVPD to SV and to study the relationship between AVPD and infarct size (IS) and location. Patients from CHILL-MI and MITOCARE studies with cardiovascular magnetic resonance within a week of STEMI (n = 177, 59 ± 11 years) and healthy controls (n = 20, 62 ± 11 years) were included. Left ventricular volumes were quantified in short-axis images. AVPD was measured in six locations in long-axis images. Longitudinal contribution to SV was calculated as AVPD multiplied by the short-axis epicardial area. Patients (IS 17 ± 10% of LV) had decreased ejection fraction (48 ± 8%) compared to controls (60 ± 5%, P<0·001). Global AVPD was decreased in patients (11 ± 2 mm versus 15 ± 2 mm in controls, P<0·001) and this held true for both infarcted and remote segments. AVPD contribution to SV was lower in patients (58 ± 9%) than in controls (64 ± 8%) (P<0·001). There was a weak negative correlation between IS and AVPD (r2 =0·06) but no differences in global AVPD linked to infarct location. Decrease in global and regional AVPD occur even in remote myocardium within 1 week of STEMI. Global AVPD decrease is independent of MI location, and MI size has only minor effect. Longitudinal pumping is slightly lower compared to controls but remains to be the main component to SV even after STEMI. These results highlight the difficulty in determining infarct location and size from longitudinal measures of LV function.

Abnormalities in 3-Dimensional Left Ventricular Mechanics With Anthracycline Chemotherapy Are Associated With Systolic and Diastolic Dysfunction

OBJECTIVES

The objective of this study was to evaluate the changes in three-dimensional (3D) speckle-tracking echocardiography-derived measures of mechanics and their associations with systolic and diastolic dysfunction after anthracyclines.

BACKGROUND

An improved understanding of the changes in 3D cardiac mechanics with anthracyclines may provide important mechanistic insight and identify new metrics to detect cardiac dysfunction.

METHODS

A total of 142 women with breast cancer receiving doxorubicin (240 mg/m²) with or without trastuzumab underwent 3D speckle-tracking echocardiography at standardized intervals prior to, during, and annually after chemotherapy. Left ventricular ejection fraction (LVEF), global circumferential strain (GCS), global longitudinal strain (GLS), principal strain, twist, and torsion were quantified. Linear regression analyses defined the associations between clinical factors and 3D parameters. Linear regression models with cluster robust variance estimators determined the associations between 3D measures and 2-dimensional (2D) LVEF and Doppler-derived E/e' over time.

RESULTS

There were significant abnormalities in 3D LVEF, GCS, GLS, and principal strain post-doxorubicin compared with control subjects (p < 0.001). The 3D parameters worsened post-anthracyclines, and only partially recovered to baseline over a median of 2.1 years (interquartile range: 1 to 4 years). Higher blood pressure and body mass index were associated with worse post-anthracycline 3D GCS and GLS, respectively. All 3D measures were associated with 2D LVEF at the same visit; only 3D LVEF, GCS, GLS, and principal strain were associated with 2D LVEF at subsequent visits (p < 0.05). In exploratory analyses, 3D LVEF and GCS were associated with subsequent systolic function independent of their corresponding 2D measures. The 3D LVEF, GCS, principal strain, and twist were significantly associated with concurrent, but not subsequent, E/e'.

CONCLUSIONS

Anthracyclines result in early and persistent abnormalities in 3D mechanics. The 3D LVEF and strain measures are associated with concurrent and subsequent systolic dysfunction, and concurrent diastolic dysfunction. Future research is needed to define the mechanisms and clinical relevance of abnormal 3D mechanics.

Ejection fraction as a statistical index of left ventricular systolic function: the first full allometric scrutiny of its appropriateness and accuracy

Left ventricular ejection fraction (EF) is a ratio that is deemed to accurately normalize stroke volume (SV) to end-diastolic volume (EDV). Ratios are now well-recognized for not normalizing the numerator, in this case SV, consistently for the denominator, EDV. We aimed to provide the first allometric-based scrutiny of the conventional assumptions that underpin the EF ratio. We allometrically modelled untransformed SV and EDV measurements from 112 preclinical heart failure patients in the Multi-Ethnic Study of Atherosclerosis (MESA), and 864 chronic heart failure patients in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) study. An information-theoretic approach was adopted to assess the relative quality of twelve candidate models for normalizing SV to EDV. None of the conventional underlying assumptions for accurate ratio normalization, for example an allometric exponent ≈1, were upheld for EF. A two-parameter power function with normal, heteroscedastic error was the best model for scaling SV to EDV in both samples. The allometric exponent (95% confidence interval) was 0·776 (0·682 to 0·869) in MESA, and 0·860 (0·857 to 0·864) in TOPCAT. EF was inversely correlated with EDV in MESA (r = -0·67, 95% CI: -0·76 to -0·55) and TOPCAT (r = -0·41, 95% CI: -0·46 to -0·35). Consequently, for fundamental statistical reasons, EF was biased low for people with generally larger EDVs, and vice versa. For the first time, we have demonstrated that EF is an inaccurate statistic for scaling SV to EDV, leading to potential biased inferences for research and individual patients.

Cardiac fluid dynamics meets deformation imaging

Cardiac function is about creating and sustaining blood in motion. This is achieved through a proper sequence of myocardial deformation whose final goal is that of creating flow. Deformation imaging provided valuable contributions to understanding cardiac mechanics; more recently, several studies evidenced the existence of an intimate relationship between cardiac function and intra-ventricular fluid dynamics. This paper summarizes the recent advances in cardiac flow evaluations, highlighting its relationship with heart wall mechanics assessed through the newest techniques of deformation imaging and finally providing an opinion of the most promising clinical perspectives of this emerging field. It will be shown how fluid dynamics can integrate volumetric and deformation assessments to provide a further level of knowledge of cardiac mechanics.

Editor-in-Chief's Top Picks From 2017

Each week, I record audio summaries for every article in JACC, as well as an issue summary. While this process has been time-consuming, I have become quite familiar with every paper that we publish. Thus, I personally select papers (both original investigations and review articles) from 15 distinct specialties each year for your review. In addition to my personal choices, I have included manuscripts that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these manuscripts in this issue of JACC. The highlights comprise the following sections: Basic & Translational Research, Cardiac Failure, Cardiomyopathies/Myocardial & Pericardial Diseases, Cardio-oncology, Congenital Heart Disease, Coronary Disease & Interventions, CVD Prevention & Health Promotion, Hypertension, Imaging, Metabolic & Lipid Disorders, Rhythm Disorders, Valvular Heart Disease, and Vascular Medicine (1-110).

Hypertrophic Cardiomyopathy-Past, Present and Future

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy with a prevalence of 1 in 500 in the general population. Since the first pathological case series at post mortem in 1957, we have come a long way in its understanding, diagnosis and management. Here, we will describe the history of our understanding of HCM including the initial disease findings, diagnostic methods and treatment options. We will review the current guidelines for the diagnosis and management of HCM, current gaps in the evidence base and discuss the new and promising developments in this field.