Two-dimensional and three-dimensional left ventricular deformation analysis: a study in competitive athletes

Assessment of myocardial function and cardiac performance using left ventricular global longitudinal strain in athletes after COVID-19: a follow-up study

Background

It has not yet been conclusively determined whether reduced left ventricular global longitudinal strain (LV GLS) after COVID-19 contributes to a reduction in exercise capacity. Our own studies showed a possible mild myocardial involvement in the form of reduced LV GLS in athletes after COVID-19 compared with healthy athletes. The aims of this prospective follow-up study were to investigate the development of LV GLS over a 3-month period in athletes after COVID-19 and the possible relationship between LV GLS and physical performance.

Methods

LV GLS was determined in four-, two-, and three-chamber views and assessed offline by a blinded investigator in 96 recreational athletes (mean age 33.15 ± 12.40 years, 53 male, peak VO2 38.82 ± 11.14 ml/min/kg) at a median of two (t0) and five months (t1) after COVID-19. Cardiopulmonary exercise testing (CPET) was performed on a bicycle ergometer on both examination dates.

Results

LV GLS improved significantly between t0 and t1 (t0 -18.82 ± 2.02 vs. t1 -19.46 ± 2.05, p < 0.001). Echocardiographic and spiroergometric parameters were within the normal clinical reference range. Maximum power increased significantly from t0 to t1 (t0 283.17 ± 83.20 vs. t1 286.24 ± 85.22 Watt, p = 0.009) and there was a trend toward increased peak oxygen uptake (t0 36.82 ± 11.14 vs. t1 38.68 ± 10.26 ml/min/kg, p = 0.069). We found no correlation between LV GLS and performance parameters, except for the respiratory exchange ratio (RER) [ρ -0.316, (-0.501; -0.102), p < 0.050].

Conclusions

Significant improvement in LV GLS approximately five months after COVID-19 may be due to mild myocardial involvement during or shortly after COVID-19, which seems to recover. There was no correlation between LV GLS and performance parameters, except for an inverse correlation of LV GLS and RER, suggesting insufficient exercise intolerance at lower GLS values. Further studies on the development of GLS in athletes or in the general population with moderate and severe disease courses would be informative as well as the comparison of pre-COVID-19 with post-COVID-19 echocardiography to evaluate the effects of COVID-19 on cardiac function.

Normative healthy reference values for global and segmental 3D principal and geometry dependent strain from cine cardiac magnetic resonance imaging

3-Dimensional (3D) myocardial deformation analysis (3D-MDA) enables novel descriptions of geometry-independent principal strain (PS). Applied to routine 2D cine cardiovascular magnetic resonance (CMR), this provides unique measures of myocardial biomechanics for disease diagnosis and prognostication. However, healthy reference values remain undefined. This study describes age- and sex-stratified reference values from CMR-based 3D-MDA, including 3D PS. One hundred healthy volunteers were prospectively recruited following institutional ethics approval and underwent CMR imaging. 3D-MDA was performed using validated software. Age- and sex-stratified global and segmental strain measures were derived for conventional geometry-dependent [circumferential (CS), longitudinal (LS), and radial (RS)] and geometry-independent [minimum (minPS) and maximum principal (maxPS)] directions of deformation. Layer-specific contraction angle interactions were determined using local minPS vectors. The average age was 43 ± 15 years and 55% were women. Strain measures were higher in women versus men. 3D PS-based assessment of maximum tissue shortening (minPS) and maximum tissue thickening (maxPS) were greater than corresponding geometry-dependent markers of LS and RS, consistent with improved representation of local tissue deformations. Global maxPS amplitude best discriminated both age and sex. Segmental analyses showed greater strain amplitudes in apical segments. Transmural PS contraction angles were higher in females and showed a heterogeneous distribution across segments. In this study we provided age and sex-based reference values for 3D strain from CMR imaging, demonstrating improved capacity for 3D PS to document maximal local tissue deformations and to discriminate age and sex phenotypes. Novel markers of layer-specific strain angles from 3D PS were also described.

The acute effects of an ultramarathon on biventricular function and ventricular arrhythmias in master athletes

AIMS

Endurance sports practice has significantly increased over the last decades, with a growing proportion of participants older than 40 years. Although the benefits of moderate regular exercise are well known, concerns exist regarding the potential negative effects induced by extreme endurance sport. The aim of this study was to analyse the acute effects of an ultramarathon race on the electrocardiogram (ECG), biventricular function, and ventricular arrhythmias in a population of master athletes.

METHODS AND RESULTS

Master athletes participating in an ultramarathon (50 km, 600 m of elevation gain) with no history of heart disease were recruited. A single-lead ECG was recorded continuously from the day before to the end of the race. Echocardiography and 12-lead resting ECG were performed before and at the end of the race. The study sample consisted of 68 healthy non-professional master athletes. Compared with baseline, R-wave amplitude in V1 and QTc duration were higher after the race (P < 0.001). Exercise-induced isolated premature ventricular beats were observed in 7% of athletes; none showed non-sustained ventricular tachycardia before or during the race. Left ventricular ejection fraction, global longitudinal strain (GLS), and twisting did not significantly differ before and after the race. After the race, no significant differences were found in right ventricular inflow and outflow tract dimensions, fractional area change, s', and free wall GLS.

CONCLUSION 

In master endurance athletes running an ultra-marathon, exercise-induced ventricular dysfunction, or relevant ventricular arrhythmias was not detected. These results did not confirm the hypothesis of a detrimental acute effect of strenuous exercise on the heart.

A review of current trends in three-dimensional analysis of left ventricular myocardial strain

Three-dimensional (3D) left ventricular (LV) myocardial strain measurements using transthoracic 3D echocardiography speckle tracking analysis have several advantages over two-dimensional (2D) LV strain measurements, because 3D strain values are derived from the entire LV myocardium, yielding more accurate estimates of global and regional LV function. In this review article, we summarize the current status of 3D LV myocardial strain. Specifically, we describe how 3D LV strain analysis is performed. Next, we compare characteristics of 2D and 3D strain, and we explain validation of 3D strain measurements, feasibility and measurement differences between 2D and 3D strain, reference values of 3D strain, and its applications in several clinical scenarios. In some parts of this review, we used a meta-analysis to draw reliable conclusions. We also describe the added value of 3D over 2D strain in several specific pathologies and prognoses. Finally, we discuss novel techniques using 3D strain and suggest its future directions.

Left Ventricular Systolic Function Assessed by Speckle Tracking Echocardiography in Athletes with and without Left Ventricle Hypertrophy

The aim of this study was to evaluate selected parameters of strain and rotation of the left ventricle (the basal rotation (BR) index, the basal circumferential strain (BCS) index, and the global longitudinal strain (GLS) of the left ventricle) in male athletes with physiological cardiac hypertrophy (LVH group), and athletes (non-LVH group) and non-athletes without hypertrophy (control group, CG). They were evaluated using transthoracic echocardiography and speckle tracking echocardiography before and after an incremental exercise test. The LVH group demonstrated lower BR at rest than the non-LVH group (p < 0.05) and the CG (p < 0.05). Physical effort had no effect on BR, nor was this effect different between groups (p > 0.05). There was a combined influence of LVH and physical effort on BR (F = 5.70; p < 0.05) and BCS (F = 4.97; p < 0.05), but no significant differences in BCS and GLS at rest between the groups. A higher BCS and lower GLS after exercise in the LVH group were demonstrated in comparison with the CG (p < 0.05). Left ventricular basal rotation as well as longitudinal and circumferential strains showed less of a difference between rest and after physical effort in subjects with significant myocardial hypertrophy. In conclusion, the obtained results may suggest that echocardiographic assessment of basal rotation and circumferential strain of the left ventricular can be important in predicting cardiac disorders caused by physical effort in individuals with physiological and pathological heart hypertrophy.

Assessment of subtle cardiac dysfunction in patients with frequent premature ventricular complexes by real-time three-dimensional speckle tracking echocardiography

BACKGROUND

To evaluate subtle and early premature ventricular complex (PVC)-induced ventricular impairment in patients with frequent PVCs and without structural heart disease by real-time 3-dimensional (3D) speckle tracking echocardiography (RT3D-STE).

HYPOTHESIS

Patients with frequent premature ventricular complexes with normal left ventricular ejection fraction have subtle left ventricular dysfunction.

METHODS

Forty patients (22 male) with a single source of frequent PVCs and 40 healthy controls (24 male) underwent assessment by conventional 2-dimensional (2D) echocardiography and RT3D-STE. Left ventricular ejection fraction (LVEF), and global longitudinal, circumferential, radial, and area strain (GLS, GCS, GRS, and GAS, respectively) and individual segment strain were calculated using off-line analysis software and compared between the 2 groups.

RESULTS

There were no significant differences in baseline clinical or 2D echocardiographic variables including LVEF between groups. However, all RT3D-STE assessed variables, including GLS, GCS, GRS, GAS, and individual segment strain, were significantly lower (P < 0.05) in the PVC group than the control group, and showed strong correlations, most prominently GCS (r = -0.84, P = 0.020), with LV function as assessed by LVEF. 3D-STE measurements showed good intraobserver, interobserver, and test-retest agreement.

CONCLUSIONS

In patients with frequent PVCs and normal LVEF, 3D -STE revealed lower global and regional strain values than in healthy controls. RT3D-STE is a novel, feasible and reproducible method to assess cardiac function and appears suitable to detect subtle left ventricular dysfunction.