Use of myocardial strain to assess global left ventricular function: a comparison with cardiac magnetic resonance and 3-dimensional echocardiography

sST2 levels and 3D speckle tracking as predictors of CAD severity in chronic coronary syndrome

BACKGROUND

Previous studies on the relation of sST2 with atherosclerotic disease mostly focused on the predictive value of sST2 for heart failure. However, there is no definite conclusion about the correlation between sST2 level and a complex coronary lesion morphology detected with coronary angiography (CAG). The purpose of this work was to know sST2 level and 3D speckle-tracking echocardiography as predictor of coronary artery disease (CAD) severity in chronic coronary syndrome (CCS) individuals using Gensini score. This prospective cohort work was performed on 90 participants aging from 18 to 80 years old, both sexes, with stable angina pectoris. Participants had been categorized into three groups: Group I (n = 30): control group scheduled by normal coronary angiography and group II (n = 60): case group which subdivided according to Gensini score into two equal subgroups: IIa: simple lesion (Gensini score < 20) and group IIb: complex lesion (Gensini score of ≥ 20). Plasma sST2 levels were measured in all participants using ELISA technique.

RESULTS

GLS, GAS, GCS and ST2 can significantly predict severity of CAD in CCS, respectively (P < 0.001 and AUC (95% CI) = 0.949(0.881-0.984), 0.980(0.925 to 0.998), 0.908(0.828 to 0.959) and 0.702(0.597 to 0.794)) at cutoff ≥ - 10, - 21, - 12 and ≥ 10 with 96.67% (82.8% to 99.9%), 96.67% (82.8 to 99.9), 86.67% (69.3 to 96.2) and 63.33% (43.9 to 80.1) sensitivity (95% CI), 76.67% (64.0% to 86.6%), 85.0% (73.4 to 92.9), 73.33% (60.3 to 83.9) and 65.0% (51.6 to 76.9) specificity (95% CI), 67.44%, 76.32%, 61.90% and 47.50% PPV and 97.87%, 98.08%, 91.67% and 78.00%, NPV with accuracy of 83.33%, 88.89%, 77.78% and 64.44%.

CONCLUSIONS

sST2 level, GLS, GAS and GCS can significantly predict severity of CAD in CCS.

Comparison of Left Ventricular Function Derived from Subject-Specific Inverse Finite Element Modeling Based on 3D ECHO and Magnetic Resonance Images

Three-dimensional echocardiography (3D ECHO) and magnetic resonance (MR) imaging are frequently used in patients and animals to evaluate heart functions. Inverse finite element (FE) modeling is increasingly applied to MR images to quantify left ventricular (LV) function and estimate myocardial contractility and other cardiac biomarkers. It remains unclear, however, as to whether myocardial contractility derived from the inverse FE model based on 3D ECHO images is comparable to that derived from MR images. To address this issue, we developed a subject-specific inverse FE model based on 3D ECHO and MR images acquired from seven healthy swine models to investigate if there are differences in myocardial contractility and LV geometrical features derived using these two imaging modalities. We showed that end-systolic and end-diastolic volumes derived from 3D ECHO images are comparable to those derived from MR images (R2=0.805 and 0.969, respectively). As a result, ejection fraction from 3D ECHO and MR images are linearly correlated (R2=0.977) with the limit of agreement (LOA) ranging from -17.95% to 45.89%. Using an inverse FE modeling to fit pressure and volume waveforms in subject-specific LV geometry reconstructed from 3D ECHO and MR images, we found that myocardial contractility derived from these two imaging modalities are linearly correlated with an R2 value of 0.989, a gradient of 0.895, and LOA ranging from -6.11% to 36.66%. This finding supports using 3D ECHO images in image-based inverse FE modeling to estimate myocardial contractility.

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

PURPOSE

Left ventricular longitudinal function can be rapidly evaluated by measuring S' and mitral annular plane systolic excursion (MAPSE) using tissue Doppler imaging. Even when the image quality is poor and the left ventricular endocardium is not visible, S' and MAPSE can be measured if the mitral annulus is visible. However, the utility of S' and MAPSE in diagnosing cancer therapy-related cardiac dysfunction (CTRCD) remains unclear. This study aimed to examine the diagnostic performance of S' and MAPSE and determine appropriate cutoff values.

METHODS

We retrospectively enrolled 279 breast cancer patients who underwent pre- or postoperative chemotherapy with anthracyclines and trastuzumab from April 2020 to November 2022. We compared echocardiographic data before chemotherapy, 6 months after chemotherapy initiation, and 1 year later. CTRCD was defined as a decrease in left ventricular ejection fraction below 50%, with a decrease of ≥10% from baseline or a relative decrease in left ventricular global longitudinal strain (LVGLS) of ≥15%.

RESULTS

A total of 256 participants were included in this study, with a mean age of 50.2 ± 11 years. Fifty-six individuals (22%) developed CTRCD within 1 year after starting chemotherapy. The cutoff value for septal S' was 6.85 cm/s (AUC = .81, p < .001; sensitivity 74%; specificity 73%), and for MAPSE was 11.7 mm (AUC = .65, p = .02; sensitivity 79%; specificity 45%). None of the cases with septal S' exceeding 6.85 cm/s had an LVGLS of ≤15%.

CONCLUSIONS

Septal S' is a useful indicator for diagnosing CTRCD.

HIGHLIGHTS

Septal S' decreased at the same time or earlier than the decrease in LVGLS. The septal S' demonstrated higher diagnostic ability for CTRCD compared to LVGLS.

Cardiovascular Biomarkers in Cardio-Oncology: Antineoplastic Drug Cardiotoxicity and Beyond

Serum biomarkers represent a reproducible, sensitive, minimally invasive and inexpensive method to explore possible adverse cardiovascular effects of antineoplastic treatments. They are useful tools in risk stratification, the early detection of cardiotoxicity and the follow-up and prognostic assessment of cancer patients. In this literature review, we aim at describing the current state of knowledge on the meaning and the usefulness of cardiovascular biomarkers in patients with cancer; analyzing the intricate relationship between cancer and cardiovascular disease (especially HF) and how this affects cardiovascular and tumor biomarkers; exploring the role of cardiovascular biomarkers in the risk stratification and in the identification of chemotherapy-induced cardiotoxicity; and providing a summary of the novel potential biomarkers in this clinical setting.

Soluble urokinase plasminogen activator receptor and cardiotoxicity in doxorubicin-treated breast cancer patients: a prospective exploratory study

BACKGROUND

Soluble urokinase plasminogen activator receptor is an inflammatory biomarker that may prognosticate cardiovascular outcomes. We sought to determine the associations between soluble urokinase plasminogen activator receptor and established markers of cardiotoxicity in breast cancer patients receiving doxorubicin.

METHODS

We conducted a prospective cohort study of women with newly diagnosed breast cancer receiving standard-dose doxorubicin (240 mg/m2) at Rush University Medical Center and Rush Oak Park Hospital (Chicago, IL) between January 2017 and May 2019. Left ventricular ejection fraction, global longitudinal strain, and cardiac biomarkers (N-terminal prohormone B-type natriuretic peptide, troponin-I, and high-sensitivity C-reactive protein) were measured at baseline and at intervals up to 12-month follow-up after end of treatment. The associations between soluble urokinase plasminogen activator receptor and these endpoints were evaluated using multivariable mixed effects linear regression.

RESULTS

Our study included 37 women (mean age 47.0 ± 9.3 years, 60% white) with a median baseline soluble urokinase plasminogen activator receptor level of 2.83 ng/dL. No participant developed cardiomyopathy based on serial echocardiography by one-year follow-up. The median percent change in left ventricular strain was -4.3% at 6-month follow-up and absolute changes in cardiac biomarkers were clinically insignificant. There were no significant associations between soluble urokinase plasminogen activator receptor and these markers of cardiotoxicity (all p > 0.05).

CONCLUSIONS

In this breast cancer cohort, doxorubicin treatment was associated with a very low risk for cardiotoxicity. Across this narrow range of clinical endpoints, soluble urokinase plasminogen activator receptor was not associated with markers of subclinical cardiotoxicity. Further studies are needed to clarify the prognostic utility of soluble urokinase plasminogen activator receptor in doxorubicin-associated cardiomyopathy and should include a larger cohort of leukemia and lymphoma patients who receive higher doses of doxorubicin.

Prognostic Value of Preprocedural LV Global Longitudinal Strain for Post-TAVR-Related Morbidity and Mortality: A Meta-Analysis

BACKGROUND

Left ventricular ejection fraction (LVEF) demonstrates limited prognostic value for post-transcatheter aortic valve replacement (TAVR) outcomes. Evidence regarding the potential role of left ventricular global longitudinal strain (LV-GLS) in this setting is inconsistent.

OBJECTIVES

The aim of this systematic review and meta-analysis of aggregated data was to evaluate the prognostic value of preprocedural LV-GLS for post-TAVR-related morbidity and mortality.

METHODS

The authors searched PubMed, Embase, and Web of Science for studies investigating the association between preprocedural 2-dimensional speckle-tracking-derived LV-GLS and post-TAVR clinical outcomes. An inversely weighted random effects meta-analysis was adopted to investigate the association between LV-GLS vs primary (ie, all-cause mortality) and secondary (ie, major cardiovascular events [MACE]) post-TAVR outcomes.

RESULTS

Of the 1,130 identified records, 12 were eligible, all of which had a low-to-moderate risk of bias (Newcastle-Ottawa scale). On average, 2,049 patients demonstrated preserved LVEF (52.6% ± 1.7%), but impaired LV-GLS (-13.6% ± 0.6%). Patients with a lower LV-GLS had a higher all-cause mortality (pooled HR: 2.01; 95% CI: 1.59-2.55) and MACE (pooled odds ratio [OR]: 1.26; 95% CI: 1.08-1.47) risk compared with patients with higher LV-GLS. In addition, each percentage point decrease of LV-GLS (ie, toward 0%) was associated with an increased mortality (HR: 1.06; 95% CI: 1.04-1.08) and MACE risk (OR: 1.08; 95% CI: 1.01-1.15).

CONCLUSIONS

Preprocedural LV-GLS was significantly associated with post-TAVR morbidity and mortality. This suggests a potential clinically important role of pre-TAVR evaluation of LV-GLS for risk stratification of patients with severe aortic stenosis. (Prognostic value of left ventricular global longitudinal strain in patients with aortic stenosis undergoing Transcatheter Aortic Valve Implantation: a meta-analysis; CRD42021289626).

Myocardial mechanics of percutaneous intramyocardial septal radiofrequency ablation

OBJECTIVE

Echocardiography-guided Percutaneous IntraMyocardial Septal Radiofrequency Ablation (PIMSRA, Liwen procedure) is a novel treatment option for hypertrophic obstructive cardiomyopathy (HOCM). The impact of PIMSRA on myocardial mechanics is unknown.

METHODS

Between October 2016 and June 2019, PIMSRA and 3-dimentional speckle tracking echocardiography were performed in 82 patients. Echocardiographic imaging, qualitative and quantitative clinical assessment were completed at baseline, immediately postprocedure and 1-year follow-up.

RESULTS

There was a significant reduction in the peak left ventricular outflow tract (LVOT) gradients immediately following PIMSRA and at 1-year follow-up (resting gradients: from 83.50 (61.25) to 23.00 (41.75) mm Hg, p<0.001 and 13.50 (21.75) mm Hg, p<0.001, respectively; stress-induced gradients: from 118.25 (96.02) to 47.00 (74.50) mm Hg (1 year), p<0.001). There was an improvement in exercise time on stress echocardiography (p<0.001) and distance by 6 min walk test (p=0.034). Immediately after PIMSRA, there was a significant reduction in radial and circumferential strain in the ablated segments (p<0.001), with no change of longitudinal strain. At 1-year follow-up, the radial and circumferential strain recovered in the ablated segments. Meanwhile, left ventricular regional and global longitudinal strain had improved significantly (p<0.05).

CONCLUSIONS

PIMSRA is an effective treatment for symptomatic HOCM that resulted in a sustained improvement in exercise capacity, a persistent decrease in LVOT gradient, and a measurable increase in myocardial contractile function.

TRIAL REGISTRATION NUMBER

NCT04777188.

A Comparison Between Two-Dimensional and Three-Dimensional Regional and Global Longitudinal Strain Echocardiography to Evaluate Complex Coronary Lesions in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome

Introduction

A preliminary assessment of patients who suffer from severe and complex coronary artery lesions, such as three-vessel disease and/or a left main (LM) artery lesion, plays a critical contribution in determining prognosis and treatment plans for non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Therefore, a pre-angiography (i.e., before angiography) predictor was required to cost-effectively evaluate severe and complex coronary lesions to efficiently direct our subsequent dealing.

Aim

This study aimed to compare two-dimensional (2D) and three-dimensional (3D) global longitudinal strain (GLS) at the regional level to assess extremely complicated coronary lesions using the SYNTAX score as a standard of reference in 100 patients with NSTE-ACS.

Materials and methods

This research included 100 patients with non-ST-segment elevation acute coronary syndrome who presented at the Cardiology Department at Fayoum University from December 2019 to July 2020. All patients underwent a complete history and physical examination, hemoglobin A1c (HbA1c), lipid profile, creatinine assessment, 12-lead electrocardiogram (ECG), and transthoracic echocardiography (TTE) to detect global and regional longitudinal strain by 2D and 3D speckle-tracking echocardiography (STE). Coronary angiography was done on all patients within 24 hours of admission after acquiring echo images. Then, the results of 2D and 3D regional and global longitudinal strain (GLS) to predict the severity and coronary lesion complexity in terms of the SYNTAX score were compared.

Results

This study revealed that 2D GLS was −12.10 ± 3.51, which is significantly higher than 3D GLS of −11.64 ± 4.05 (p < 0. 001). The left anterior descending coronary artery (LAD) and left circumflex artery (LCX) territories revealed a significantly higher value using 2D regional longitudinal strain (−11.13 ± 4.47 and −12.54 ± 4.11, respectively) than using 3D regional longitudinal strain (−10.84 ± 5.18 and −12.05 ± 4.29, respectively) (p= 0.017 and p < 0.001, respectively). There were significantly lower 2D GLS, 3D GLS, global circumferential strain (GCS), area strain, and global radial strain (GRS) in the intermediate and high score group than in the low score group of patients (p < 0.001 for all).

Conclusion

2D and 3D strain echocardiography including GLS, GCS, GRS, and area strain are a noninvasive and rapid tool with clinical utility for evaluating coronary lesions in patients with NSTE-ACS. They can be routinely used to diagnose and stratify high-risk patients with NSTE-ACS, thereby potentially resulting in improved patient assessment. GLS as measured by 2D and 3D STE at minimal effort is a significant risk factor for patients with complex NSTE-ACS. In NSTE-ACS cases, the GLS absolute value is significantly associated with the degree of complexity of coronary artery lesions.

The impact of an ultra-trail on the dynamic of cardiac, inflammatory, renal and oxidative stress biological markers correlated with electrocardiogram and echocardiogram

The aim of this study was to describe the effects of a 64.2 km ultra-trail on the biomarkers of muscle damage, inflammation and oxidative stress, and compare the results observed with an ECG and an echocardiogram, both performed before and after the race.Thirty-three ultra-trail volunteers (45.8 ± 8.7 years old) were enrolled in our study. Three blood tests were drawn from each runner, one just before (TPRE), one just after (TPOST) and the last 3 h after the end of the race (TPOST3h).All the markers increased. The maximum concentrations observed were at TPOST3h and were significant (p < 0.001) for creatine kinase, creatine kinase isoform MB, high-sensitivity C-reactive protein, uric acid and for the ratio of reduced glutathione to oxidised glutathione. However, in the case of myoglobin, high-sensitive troponin T, N-terminal pro-brain natriuretic peptide, oxidised glutathione, myeloperoxidase, cystatin C and creatinine, the most significant increases were at TPOST (p < 0.001). Modifications were observed in the medical imaging using echocardiography such as reduction of left ventricule end-sytolic and diastolic volumes and left ventricular global longitudinal strain. ECG showed electrical criteria for left ventricular hypertrophy and incomplete right bundle branch block after the race.Endurance races cause significant physiological stress to the body that can be measured by the increase of different biomarkers. From a laboratory perspective, it is important to take into account the possible exercise performed previous to the testing to avoid a misinterpretation of the results. From a training perspective, due to these increases in biomarkers, it is recommended that runners wait at least 72 h after an ultra-trail before subsequent training. In addition a transient impairment of ventricular function due to dehydration were observed.

Subclinical cardiac damage in cancer patients before chemotherapy

Cancer and cardiovascular diseases, including heart failure (HF), are the main causes of death in Western countries. Several anticancer drugs and radiotherapy have adverse effects on the cardiovascular system, promoting left ventricular dysfunction and ultimately HF. Nonetheless, the relationship between cancer and HF is likely not unidirectional. Indeed, cancer and HF share common risk factors, and both have a bidirectional relationship with systemic inflammation, metabolic disturbances, and neurohormonal and immune activation. Few studies have assessed the impact of untreated cancer on the heart. The presence of an active cancer has been associated with elevated cardiac biomarkers, an initial impairment of left ventricular structure and function, autonomic dysfunction, and reduced exercise tolerance. In turn, these conditions might increase the risk of cardiac damage from chemotherapy and radiotherapy. HF drugs such as beta-blockers or inhibitors of the renin–angiotensin–aldosterone system might exert a protective effect on the heart even before the start of cancer therapies. In this review, we recapitulate the evidence of cardiac involvement in cancer patients naïve from chemotherapy and radiotherapy and no history of cardiac disease. We also focus on the perspectives for an early diagnosis and treatment to prevent the progression to cardiac dysfunction and clinical HF, and the potential benefits of cardioactive drugs on cancer progression.

Every minute counts: in-hospital changes of left ventricular regional and global function in patients with ST-segment elevation myocardial infarction

AIMS

The aim of our study was to assess the effects of an early percutaneous coronary intervention on changes of in-hospital left ventricular ejection fraction (LVEF) and wall motion score index (WMSI) in patients with ST-segment elevation myocardial infarction.

METHODS

The study population consisted of 324 consecutive patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention, divided into two groups, according to the first medical contact (FMC)-to-reperfusion time, respectively, 90 min or less (n = 173) and more than 90 min (n = 151). Moreover, we performed a sub-analysis in the group of patients who showed at discharge an improvement in the LVEF of at least 10%.

RESULTS

In both groups at baseline, patients suffered from a moderately reduced LVEF (40.88 ± 8.38% in ≤90 min group vs. 40.70 ± 8.98% in >90 min group; P = 0.858). A WMSI of more than 1 was recorded uniformly: 1.71 ± 0.37 in patients with FMC-to-reperfusion 90 min or less and 1.72 ± 0.38 in patients more than 90 min (P = 0.810). At the time of discharge, a significant improvement in LVEF (43.82 ± 8.38%, P = 0.001) and WMSI (1.60 ± 0.41, P = 0.009) exclusively emerged in the 90 min or less group. Furthermore, we identified 105 patients who experienced an improvement in the LVEF of at least 10% compared with baseline values. In these patients FMC-to-reperfusion and total ischemic time resulted as significantly shorter, when compared with patients with LVEF improvement of less than 10%.

CONCLUSION

Our study confirms and reinforces the concept that reducing the duration of the time between FMC and reperfusion, as well as the total ischemic time influences a positive recovery of left ventricular global and regional function during in-hospital stay.

Prognostic value of longitudinal strain and ejection fraction in Friedreich's ataxia

BACKGROUND

Friedreich's ataxia (FA) is a rare autosomal recessive mitochondrial disease most commonly due to a triplet repeat expansion guanine-adenine-adenine (GAA) in the FXN gene. Cardiac disease is the major cause of death, patients with reduced left ventricular ejection fraction (LVEF) having the worse prognosis. Longitudinal strain (LS) appeared to be a better predictor of outcome than LVEF in different diseases. We compared the prognostic value of LS measured from the 4 chambers view to LVEF.

METHODS

From 2003 to 2017 consecutive patients with FA were included and LS analysis was retrospectively performed.

RESULTS

We studied 140 patients, with a median age of 34 (26-41) years (Q1-Q3) with age at onset of 14 (11-19) years and GAA repeats on the shorter allele of 600 (467-783) pb. Mean LS was 19.9 ± 5.0% and LVEF 64 ± 8%. After a mean follow-up of 7.4 ± 3.9 years, 14 patients died. In univariate Cox analysis, all-cause mortality was associated with: LS (HR 0.83; 95%CI, 0.75-0.91, p = 0.0002), LVEF (HR 0.30; 95%CI, 0.19-0.49, p < 0.0001), GAA repeats on the shorter allele (HR 1.29; 95%CI, 1.10-1.51, p = 0.002), age at onset (HR 0.87; 95%CI, 0.77-0.98, p = 0.018), LVSystolic Diameter (HR 1.17; 95%CI, 1.09-1.26, p < 0.0001), LVMass index (HR 1.02; 95%CI, 1.00-1.04, p = 0.027), and LVDiastolic Diameter (HR1.12; 95%CI, 1.01-1.23, p = 0.028). In multivariate analysis, LVEF was the only independent predictor of mortality (HR 0.41; 95%CI, 0.23-0.74, p = 0.0029).

CONCLUSION

In FA, LS was not an independent predictor of mortality, LVEF remained the only independent predictor in the present study.

Left ventricular global longitudinal strain in predicting CRT response: one more J-shaped curve in medicine

The aim of the study was: (1) to verify the hypothesis that left ventricular global longitudinal strain (LVGLS) may be of additive prognostic value in prediction CRT response and (2) to obtain such a LVGLS value that in the best optimal way enables to characterize potential CRT responders. Forty-nine HF patients (age 66.5 ± 10 years, LVEF 24.9 ± 6.4%, LBBB 71.4%, 57.1% ischemic aetiology of HF) underwent CRT implantation. Transthoracic echocardiography was performed prior to and 15 ± 7 months after CRT implantation. Speckle-tracking echocardiography was performed to assess longitudinal left ventricular function as LVGLS. The response to CRT was defined as a ≥ 15% reduction in the left ventricular end-systolic volume (∆LVESV). Thirty-six (73.5%) patients responded to CRT. There was no linear correlation between baseline LVGLS and ∆LVESV (r = 0.09; p = 0.56). The patients were divided according to the percentile of baseline LVGLS: above 80th percentile; between 80 and 40th percentile; below 40th percentile. Two peripheral groups (above 80th and below 40th percentile) formed “peripheral LVGLS” and the middle group was called “mid-range LVGLS”. The absolute LVGLS cutoff values were − 6.07% (40th percentile) and − 8.67% (80th percentile). For the group of 20 (40.8%) “mid-range LVGLS” patients mean ΔLVESV was 33.3 ± 16.9% while for “peripheral LVGLS” ΔLVESV was 16.2 ± 18.8% (p < 0.001). Among non-ischemic HF etiology, all “mid-range LVGLS” patients (100%) responded positively to CRT (in “peripheral LVGLS”—55% responders; p = 0.015). Baseline LVGLS may have a potential prognostic value in prediction CRT response with relationship of inverted J-shaped pattern. “Mid-range LVGLS” values should help to select CRT responders, especially in non-ischemic HF etiology patients.

The Effects of Propofol on Left Ventricular Global Longitudinal Strain

Objectives

To determine if hemodynamic changes secondary to propofol administration are a result of direct myocardial depression as measured by global longitudinal strain (GLS). The authors hypothesized that propofol would cause a significant worsening in GLS, indicating direct myocardial depression.

Design

Prospective, observational.

Setting

Endoscopy suite at a single academic medical center.

Participants

Patients undergoing outpatient, elective endoscopic procedures at an outpatient clinic of a single tertiary care academic medical center.

Interventions

None.

Measurements and Main Results

Limited transthoracic echocardiograms were performed before and after patients received propofol for endoscopic procedures. Post-processing measurements included GLS, 2D (dimensional) ejection fraction (2D EF), and 3D EF. Using paired sample Student’s t test, no statistically significant change in GLS, 2D EF, or 3D EF was found despite statistically significant hypotension. In fact, there was a trend toward more negative GLS (improved myocardial function) in patients after receiving propofol.

Conclusion

We found propofol did not cause a reduction in systolic function as measured by GLS, a sensitive measure of myocardial contractility. Therefore, decreases in blood pressure after a propofol bolus in spontaneously breathing patients are likely due to decreased vascular tone and not impaired left ventricular systolic function. These results should be considered in the management of propofol-induced hypotension for spontaneously breathing patients.

Cardiovascular Magnetic Resonance in Heritable Cardiomyopathies

Cardiovascular magnetic resonance represents the imaging modality of choice for the investigation of patients with heritable cardiomyopathies. The combination of gold-standard volumetric analysis with tissue characterization can deliver precise phenotypic evaluation of both cardiac morphology and the underlying myocardial substrate. Cardiovascular magnetic resonance additionally has an established role in risk-stratifying patients with heritable cardiomyopathy and an emerging role in guiding therapies. This article explores the application and utility of cardiovascular magnetic resonance techniques with specific focus on the major heritable cardiomyopathies.

Ultrasound Investigation of Dorsal Neck Muscle Deformation During a Neck Rotation Exercise

OBJECTIVES

Neck-specific exercise can reduce neck pain and increase function, but information on how different neck muscle layers are activated during neck exercises is scarce. The aim of this study was to investigate deformation and deformation rate in 5 dorsal neck muscles and the correlation among these muscles during a loaded dynamic exercise used in clinical practice.

METHODS

Deformation and deformation rate were investigated in 5 dorsal right-sided neck muscles in 20 individuals without neck pain using ultrasonography and speckle-tracking analyses. Repeated-measures analysis of variance was used to measure differences between the muscles, and correlations between neck muscles were analyzed with Kendall's tau.

RESULTS

Deformation in left (contralateral) rotation showed significant differences among the muscles (P = .01), with higher deformation of the semispinalis capitis muscle compared with the trapezius muscle (P = .02). There were no significant differences among the 5 neck muscles in right (unilateral) rotation (P = .46). There were significant differences in deformation rate among muscles in both right and left rotation (P < .01). The trapezius muscles have the lowest deformation rate in right rotation (P < .01). In left rotation, the trapezius and multifidus muscles showed lower deformation rates compared with most of the other muscles (P < .03). Almost all muscles were correlated in both deformation and deformation rate.

CONCLUSION

The quadruped standing loaded dynamic neck exercise seemed to activate all the investigated neck muscles, with a tendency for more activation of the semispinalis capitis.

Evaluation of Left Ventricular Myocardial Work Performance in Patients Undergoing On-Pump and Off-Pump Coronary Artery Bypass Surgery

Purpose: Benefits of off-pump coronary bypass (OPCAB) over on-pump (ONCAB) remain controversial. We aimed to evaluate the early impacts of OPCAB vs ONCAB for varying left ventricular (LV) function baselines by applying the non-invasive myocardial work (MW) analysis, which enables further insights in cardiac mechanics, contractility, and efficacy.

Methods: We retrospectively analyzed 98 patients (55 ONCAB vs 43 OPCAB). Transthoracic echocardiography (TTE) and concurrent arterial blood pressure measurements taken at rest, prior to, and early after surgery were performed. Global myocardial work index (GMWI), global constructive work (GCW), and global work efficiency (GWE), inter alia, were quantified.

Results: Preoperatively, OPCAB patients had significantly lower values than ONCAB patients in terms of GMWI (1404.33 ± 585.41 mmHg% vs 1619.07 ± 535.42 mmHg%, p = 0.039), GWE (90% (60%, 96%) vs 93% (74%, 98%), p = 0.028). After surgery, GMWI was reduced in both groups. However, a more significant GMWI impairment occurred early after ONCAB than after OPCAB (−343.14 ± 35.20 mmHg%, p <0.001 vs −224.04 ± 120.91 mmHg%, p = 0.042).

Conclusion: Despite lower preoperative LV function in OPCAB patients, GMWIs after OPCAB were superior to ONCAB, indicating better preservation of systolic LV function early after OPCAB by means of contractility compared to ONCAB. Further studies should investigate the long-term course of MW response and their clinical impact.

Optimization of a Comprehensive Prehabilitation Program for Patients with Stable Coronary Artery Disease Undergoing Elective Coronary Artery Bypass Grafting

Aim. To evaluate the effectiveness of a comprehensive prehabilitation program including the optimization of drug therapy for patients undergoing elective coronary artery bypass grafting (CABG).

Material and methods. 56 male patients with stable angina referred to elective on-pump CABG were enrolled in a study. All patients were screened for eligibility according to the inclusion/exclusion criteria and then randomized into two groups. Group 1 patients (n=28) underwent preoperative management (prehabilitation) for 14 days, including patient education and physical rehabilitation. Trimetazidine in a dose of 80 mg per day was added to the standard drug therapy. Group 2 patients (n=28) underwent similar preoperative management, but with the standard drug therapy without trimetazidine. In addition to the routine methods of preoperative management, all patients underwent the 6-minute walk test (6MWT) to assess exercise tolerance and speckle tracking echocardiography to measure left ventricular (LV) longitudinal deformation. Serum troponin T was measured in all patients. The measurements were performed at admission and after the surgery.

Results. Patients did not differ in the main clinical and demographic data, as well as the main preoperative speckle tracking echocardiography findings. The intraoperative parameters were comparable in both groups. The rate of early postoperative complications was 61% (n=17) in Group 1 and 64% (n=18) in Group 2 (p>0.05). LV ejection fraction significantly decreased postoperatively in both groups (p<0.01) as well as LV longitudinal deformation as compared to the baseline. Patients receiving the standard therapy without trimetazidine reported a significant decrease in the longitudinal strain after CABG compared with the baseline (p=0.01). There were no statistically significant differences in most preoperative and postoperative indicators of longitudinal deformation among patients treated with trimetazidine. Postoperative values of GLPS-LAX and GLPS-Avg were significantly higher in the trimetazidine group than those in the control group (p=0.04). Group 1 patients reported longer distance covered in 6MWT than Group 2 patients while assessing exercise tolerance: 370.0 [260.0;415.0] vs 242.0 [202.0;350.0] m, respectively (p=0.0059).

Conclusion. The addition of trimetazidine in a dose of 80 mg daily in the prehabilitation program for patients undergoing elective CABG demonstrated better postoperative indicators of LV longitudinal deformation and an increase in exercise tolerance. Obtained findings allowed considering this approach to the preoperative management as an additional method of cardiac protection and optimization of the functional status of patients.

Sudden Cardiac Death Prediction in Non-ischemic Dilated Cardiomyopathy: a Multiparametric and Dynamic Approach

PURPOSE OF REVIEW

Sudden cardiac death is recognised as a devastating consequence of non-ischaemic dilated cardiomyopathy. Although implantable cardiac defibrillators offer protection against some forms of sudden death, the identification of patients in this population most likely to benefit from this therapy remains challenging and controversial. In this review, we evaluate current guidelines and explore established and novel predictors of sudden cardiac death in patients with non-ischaemic dilated cardiomyopathy.

RECENT FINDINGS

Current international guidelines for primary prevention implantable defibrillator therapy do not result in improved longevity for many patients with non-ischemic cardiomyopathy and severe left ventricular dysfunction. More precise methods for identifying higher-risk patients that derive true prognostic benefit from this therapy are required. Dynamic and multi-parametric characterization of myocardial, electrical, serological and genetic substrate offers novel strategies for predicting major arrhythmic risk. Balancing the risk of non-sudden death offers an opportunity to personalize therapy and avoid unnecessary device implantation for those less likely to derive benefit.

[The myocardial infarction size measuring using modern methods]

An accurate quantitative assessment of myocardium necrosis area and the viable zone (stunned and hibernating) in patients with myocardial infarction is crucial for the preoperative patient selection and predicting the cardiac surgery effectiveness. Currently, researchers and clinicians are most interested in the problem of determining the viable myocardium zone. However, only the necrosis zone area directly correlates with the patients prognosis and determines the heart pathological remodeling processes. In the distant period, the data obtained can be used to predict the post-infarction period course or for analysis the relationship of the necrosis zone with arrhythmogenesis, and a number of other indicators. Thus, the necrosis zone and the viable myocardium zone are two parameters that need to be monitored in dynamics in all patients after myocardial infarction. The most accurate and reproducible method for determining the necrosis area is contrast magnetic resonance imaging of the heart, however, this technique is still inaccessible in most hospitals. In this regard, it remains relevant to estimate the necrotic myocardium area by ubiquitous non-invasive methods such as electrocardiography and echocardiography.

Cardiotoxicity of Anthracyclines

Cardiotoxicity is a feared side effect that may limit the clinical use of anthracyclines. It may indeed affect the quality of life and survival of patients with cancer, regardless of oncological prognosis. This paper provides an overview of anthracycline-induced cardiotoxicity in terms of definition, classification, incidence, risk factors, possible mechanisms, diagnosis, and treatment. We also report effective strategies for preventing cardiotoxicity. In addition, we discuss limiting current approaches, the need for a new classification, and early cardiotoxicity detection and treatment. Probably, anthracycline-induced cardiotoxicity is a continuous phenomenon that starts from myocardial cell injury; it is followed by left ventricular ejection fraction (LVEF) and, if not diagnosed and cured early, progressively leads to symptomatic heart failure. Anthracycline-induced cardiotoxicity can be detected at a preclinical phase. The role of biomarkers, in particular troponins, in identifying subclinical cardiotoxicity and its therapy with angiotensin-converting enzyme inhibitors (mainly enalapril) to prevent LVEF reduction is a recognized and effective strategy. If cardiac dysfunction has already occurred, partial or complete LVEF recovery may still be obtained in case of early detection of cardiotoxicity and prompt heart failure treatment.

The effect of varying intensities of lower limb eccentric muscle contractions on left ventricular function

Purpose

The effect of eccentric (ECC) resistance exercise (RE) on myocardial mechanics is currently unknown.

Method

This study investigated ECC RE at varying intensities on left ventricular (LV) function using LV strain (ε), wall stress and haemodynamic parameters. Twenty-four healthy male volunteers completed ECC leg extensions at 20%, 50% and 80% of their ECC maximal voluntary contraction (MVC), whilst receiving echocardiograms. Global longitudinal ɛ, strain rate (SR), longitudinal tissue velocity, heart rate (HR), blood pressure (BP), mean arterial pressure (MAP), LV wall stress and rate pressure product (RPP) were assessed at baseline and during exercise.

Results

Left ventricular global ɛ, systolic SR and wall stress remained unchanged throughout. Systolic blood pressure (sBP), MAP and RPP increased at 80% and 50% intensities compared to rest (P < 0.01). Eccentric RE increased HR and peak late diastolic SR at all intensities compared to rest (P < 0.02).

Conclusion

The findings suggest acute ECC RE may not alter main parameters of LV function, supporting future potential for wider clinical use. However, future studies must investigate the impact of multiple repetitions and training on LV function.

Contemporary Role of Echocardiography for Clinical Decision Making in Patients During and After Cancer Therapy

Early recognition of cancer therapy-related cardiac dysfunction (CTRCD) provides an opportunity to mitigate cardiac injury and risk of developing late cardiac events. Echocardiography serves as the cornerstone in the detection and surveillance of CTRCD in patients during and after cancer therapy. Guidelines from professional societies and regulatory agencies have been published on approaches to surveillance, diagnosis, and treatment of CTRCD, although adoption as standard of care remains limited given the lack of evidence on the prognostic value of asymptomatic left ventricular (LV) dysfunction in the oncology population. The frequency of cardiac monitoring and the appropriateness of the Food and Drug Administration (FDA)-recommended cardiac monitoring schedule in all patients receiving trastuzumab for breast cancer has been challenged. Interruption versus continuation of oncological therapy in the setting of asymptomatic LV dysfunction remains a clinical conundrum given the uncertain balance of the risk of cardiac dysfunction and benefit of oncology efficacy. Despite their limitations, echocardiographic measures of LV function continue to play a pivotal role in clinical decision making, with global longitudinal strain emerging as a promising tool in informing and facilitating the selection of cancer treatment and optimizing cardiovascular outcomes. This review highlights the key recommendations of the existing guidelines and discusses recent developments in cardio-oncology imaging practices with the aim of providing practical guidance on the role and use of echocardiography in challenging clinical cases in cardio-oncology.

Application of strain and other echocardiographic parameters in the evaluation of early and long-term clinical outcomes after cardiac surgery revascularization

Background

Coronary artery bypass graft (CABG) surgery is an effective therapeutic strategy for coronary heart disease (CHD). Myocardial longitudinal strain echocardiography with 2D speckle tracking could obtain ventricular function with better accuracy and reliability than the left ventricular ejection fraction.

The aim of the study was to assess changes in left ventricular function in patients before and after surgical revascularization for a 24-month period of observation, using echocardiography with speckle tracking strain imaging. We searched for echocardiographic predictors of poor early and long-term outcome after CABG.

Methods

We enrolled 69 patients scheduled for elective coronary bypass grafting. Patients were divided into groups based on pre-operative systolic and diastolic parameters, depending on the GLS value and the E’ Lat and E/E’ value. The correlation between these parameters and early and long-term outcomes was analyzed.

Results

Preoperative EF was preserved in 86, 95% (60) patients. Pre-operative reduced GLS was observed in 73.91% (51) of patients and severely reduced in 31.88% (22).

In the first post-operative 6-month period, we observed a significant decrease in the GLS. The GLS was a predictor of early postoperative outcome for intubation time, the inotropes use and length of ICU stay. Diastolic dysfunction was a predictor of the greater inotrope requirements.

Conclusions

Global longitudinal strain and diastolic dysfunction parameters are a good predictors of worse early outcome after CABG.

[Clinical Capabilities and Limitations in the Use of Modern Technologies in Echocardiography]

Transthoracic echocardiography is the most frequently used method for detection of impaired contractility of the left ventricle. In most cases, assessment of contractility is carried out visually "by eye", what increases its subjectivity, is operator-dependent in nature and requires a high level of clinical training and experience of the researcher. Currently in the arsenal of a specialist in echocardiography for quantification of left ventricular contractility sometimes is used tissue Doppler echocardiography, however, this method requires special settings of the image (high frame rate, the allocation of zones of interest), depends on the scanning angle and on operator qualification, has high intra - and inter-operator variability, and significantly increases the duration of the study. Therefore, this method has not received wide clinical application. In the 2000s years an innovative technique of speckle tracking emerged, which, unlike tissue Doppler echocardiography is efficient, does not burden a researcher with time costs, has a low intra - and inter- operator variability, does not depend on scan angle. In recent years, this technology is actively implemented in clinical practice for detection of subclinical impairment of the functional state of the myocardium in different diseases and syndromes: arterial hypertension, ischemic heart disease, valvular defects, and congenital heart disease, heart failure, cardiomyopathy of different etiology.

Mitochondrial proteome disruption in the diabetic heart through targeted epigenetic regulation at the mitochondrial heat shock protein 70 (mtHsp70) nuclear locus

>99% of the mitochondrial proteome is nuclear-encoded. The mitochondrion relies on a coordinated multi-complex process for nuclear genome-encoded mitochondrial protein import. Mitochondrial heat shock protein 70 (mtHsp70) is a key component of this process and a central constituent of the protein import motor. Type 2 diabetes mellitus (T2DM) disrupts mitochondrial proteomic signature which is associated with decreased protein import efficiency. The goal of this study was to manipulate the mitochondrial protein import process through targeted restoration of mtHsp70, in an effort to restore proteomic signature and mitochondrial function in the T2DM heart. A novel line of cardiac-specific mtHsp70 transgenic mice on the db/db background were generated and cardiac mitochondrial subpopulations were isolated with proteomic evaluation and mitochondrial function assessed. MicroRNA and epigenetic regulation of the mtHsp70 gene during T2DM were also evaluated. MtHsp70 overexpression restored cardiac function and nuclear-encoded mitochondrial protein import, contributing to a beneficial impact on proteome signature and enhanced mitochondrial function during T2DM. Further, transcriptional repression at the mtHsp70 genomic locus through increased localization of H3K27me3 during T2DM insult was observed. Our results suggest that restoration of a key protein import constituent, mtHsp70, provides therapeutic benefit through attenuation of mitochondrial and contractile dysfunction in T2DM.

Cardiovascular Disease and Breast Cancer: Where These Entities Intersect: A Scientific Statement From the American Heart Association

Cardiovascular disease (CVD) remains the leading cause of mortality in women, yet many people perceive breast cancer to be the number one threat to women's health. CVD and breast cancer have several overlapping risk factors, such as obesity and smoking. Additionally, current breast cancer treatments can have a negative impact on cardiovascular health (eg, left ventricular dysfunction, accelerated CVD), and for women with pre-existing CVD, this might influence cancer treatment decisions by both the patient and the provider. Improvements in early detection and treatment of breast cancer have led to an increasing number of breast cancer survivors who are at risk of long-term cardiac complications from cancer treatments. For older women, CVD poses a greater mortality threat than breast cancer itself. This is the first scientific statement from the American Heart Association on CVD and breast cancer. This document will provide a comprehensive overview of the prevalence of these diseases, shared risk factors, the cardiotoxic effects of therapy, and the prevention and treatment of CVD in breast cancer patients.

The correlation between cardiac magnetic resonance T2* and left ventricular global longitudinal strain in people with β-thalassemia

BACKGROUND

Heart failure is the biggest cause of mortality and morbidity in people with thalassemia, and iron deposition in cardiac tissue impairs cardiovascular function. Therefore, early detection of cardiac involvement is important to improve the prognosis in these individuals.

METHOD

Two- and three-dimensional echocardiography was performed to evaluate left ventricular ejection fraction (LVEF), left ventricular volumes and diameters, and global longitudinal strain (GLS) in 130 individuals with β-thalassemia using the speckle tracking method. Magnetic resonance imaging (MRI) was carried out on both the heart and liver. The participants were divided into 2 groups based on cardiac T2* values (normal and abnormal cardiac iron load), and the correlation between cardiac T2* MRI and GLS was evaluated.

RESULTS

The statistical analysis showed a significant correlation between cardiac T2* MRI and left ventricular global longitudinal strain. There was a significant difference in global longitudinal strain (P < .0001), liver MRI T2*( P < .0001), and left ventricular ejection fraction (P < .001) between the 2 groups. The optimal cutoff value for GLS was -18.5% with sensitivity and specificity 73.0% and 63.0%, respectively (postitive predictive value = 50%, negative predictive value = 82.3%, AUC = 0.742, std. error = 0.046) which predicts T2* value of <20 ms, according to cardiac MRI.

CONCLUSIONS

The participants with cardiac iron overload had a lower GLS than those without one. This suggests that GLS may be a useful method to predict myocardial iron overload particularly in β-thalassemia patients with subclinical cardiac involvement.

Comparison of two-dimensional and three-dimensional echocardiographic strain in children with CHD

BACKGROUND

In CHD, three-dimensional strain analysis may overcome limitations of Doppler and two-dimensional strain of the left ventricle. The aims of this study were to evaluate feasibility and reproducibility of three-dimensional longitudinal, circumferential, and radial systolic strain by three-dimensional speckle-tracking echocardiography compared with two-dimensional echocardiography.

METHODS

Patients with CHD, biventricular circulation with a systemic left ventricle, and who had two- and three-dimensional imaging performed on the same day from 2010 to 2014 were included. Quantitative two- and three-dimensional strain analyses were performed (two-dimensional cardiac performance analysis version 1.2 and four-dimensional left ventricular analysis version 3.1). Intra- and inter-observer variabilities were calculated on 25 studies.

RESULTS

A total of 30 patients, including 19 (61%) males, with a median age of 3.6 years (0.1-22 years) were included. The mean fractional shortening was 34.6±5.3%, and the mean ejection fraction was 62.0±6.4%. Measurement of two- and three-dimensional strain was feasible in >95% of segments. Good correlation was observed between longitudinal and circumferential strain (r=0.92, p⩽0.001 and r=0.87, p⩽0.001), but not radial strain (r=0.29, p=0.2). Intra- and inter-observer agreements were better for three-dimensional compared with two-dimensional strain, and better for both two- and three-dimensional longitudinal and circumferential strains compared with radial strain.

CONCLUSION

Left ventricular three-dimensional strain analysis is feasible in children with CHD. The reproducibility of longitudinal and circumferential strain by three-dimensional analyses is better. Further longitudinal studies are warranted for the potential clinical application of this new technology.

HIV-infected Children in Malawi Have Decreased Performance on the 6-minute Walk Test With Preserved Cardiac Mechanics Regardless of Antiretroviral Treatment Status

AIM

The aims of this study were to 1) determine if cardiac disease can be detected in HIV-infected children by strain imaging and 2) to evaluate differences in exercise performance between HIV-infected children on antiretroviral therapy (ART) and HIV-infected children not yet on ART and in HIV-uninfected children by 6-minute walk tests (6MWTs).

METHODS

This cross-sectional study evaluated cardiac function by echocardiogram and exercise performance by 6MWT in HIV-infected and HIV-uninfected children 4-18 years of age in Lilongwe, Malawi. Analyses compared HIV uninfected, HIV infected not yet on ART, and HIV infected on ART. Comparisons used χ(2) test, t test, analysis of variance and multiple linear regression.

RESULTS

No differences were found in ejection fraction, shortening fraction or strain in 73 children not yet on ART, 149 on ART and 77 HIV-uninfected controls. As viral load increased, children had worse circumferential strain. In addition, children receiving ART had better circumferential strain than those not yet on ART. Increased CD4 percentage was associated with better longitudinal strain and farther 6MWT distance. As longitudinal strain worsened, the 6MWT distance decreased. HIV-infected children not yet on ART walked a mean of 25.8 m less than HIV-uninfected children, and HIV-infected children on ART walked 25.9 m less (P = 0.015 comparing 3 groups).

CONCLUSIONS

HIV-uninfected children performed better on the 6MWT than HIV-infected children. Lower viral load, being on ART, and higher CD4 percentage were associated with better strain measures. Better longitudinal strain was associated with a farther 6MWT distance. Overall, ejection fraction, shortening fraction and strain measures between groups were similar, so cardiac strain did not detect cardiac dysfunction in this young population.

Speckle tracking echocardiography in acute lupus myocarditis: comparison to conventional echocardiography

Aims

Lupus myocarditis occurs in 5–10% of patients with systemic lupus erythematosus (SLE). No single feature is diagnostic of lupus myocarditis. Speckle tracking echocardiography (STE) can detect subclinical left ventricular dysfunction in SLE patients, with limited research on its utility in clinical lupus myocarditis. We report on STE in comparison to conventional echocardiography in patients with clinical lupus myocarditis.

Methods and results

A retrospective study was done at a tertiary referral hospital in South Africa. SLE patients with lupus myocarditis were included and compared to healthy controls. Echocardiographic images were reanalyzed, including global longitudinal strain through STE. A poor echocardiographic outcome was defined as final left ventricular ejection fraction (LVEF) <40%. 28 SLE patients fulfilled the criteria. Global longitudinal strain correlated with global (LVEF: r = −0.808; P = 0.001) and regional (wall motion score: r = 0.715; P < 0.001) function. In patients presenting with a LVEF ≥50%, global longitudinal strain (P = 0.023), wall motion score (P = 0.005) and diastolic function (P = 0.004) were significantly impaired vs controls. Following treatment, LVEF (35–47% (P = 0.023)) and wall motion score (1.88–1.5 (P = 0.017)) improved but not global longitudinal strain. Initial LVEF (34%; P = 0.046) and global longitudinal strain (−9.5%; P = 0.095) were lower in patients with a final LVEF <40%.

Conclusions

This is the first known report on STE in a series of patients with clinical lupus myocarditis. Global longitudinal strain correlated with regional and global left ventricular function. Global longitudinal strain, wall motion score and diastolic parameters may be more sensitive markers of lupus myocarditis in patients presenting with a preserved LVEF ≥50%. A poor initial LVEF and global longitudinal strain were associated with a persistent LVEF <40%. Echocardiography is a non-invasive tool with diagnostic and prognostic value in lupus myocarditis.

Evaluation of Subclinical Left Ventricular Systolic Dysfunction in Chronic Asymptomatic Alcoholics by Speckle Tracking Echocardiography

By using two-dimensional speckle tracking echocardiography, we aimed to investigate the structural and functional changes on myocardium in chronic asymptomatic alcoholics without any cardiovascular disease. Forty-one consecutive asymptomatic male alcoholics who were admitted to the outpatient alcoholism unit and 30 age matched healthy male volunteers selected as the control group were enrolled in the study. The study group were investigated by using standard two-dimensional echocardiography and speckle tracking echocardiography. The left ventricular (LV) global longitudinal strain and LV global circumferential strain were significantly lower in alcoholics when compared with control subjects. There was no difference in global radial strain between the two groups. To demonstrate the effect of total life time dose of ethanol (TLDE) on echocardiographic abnormalities, we assessed the correlation analysis. There was a nonsignificant weak correlation between global LV circumferential strain and TLDE (r = 0.27, p = 0.083). Speckle tracking echocardiography derived left ventricular systolic function was impaired in chronic alcoholic patients when compared with healthy controls.

Efficacy of an early home-based cardiac rehabilitation program for patients after acute myocardial infarction: A three-dimensional speckle tracking echocardiography randomized trial

BACKGROUND

The effect of an early short-term home-based cardiac rehabilitation (CR) program on ventricular function in acute myocardial infarction (AMI) patients is not yet clear. The purpose of this study was to evaluate the efficacy of our CR program on the improvement of myocardial function using three-dimensional speckle tracking echocardiography (3D-STE) in AMI patients.

METHODS

Fifty-two AMI patients were randomly assigned to 2 groups after discharge: the rehabilitation group, which participated in an early, home-based CR program, and the control group, which received only usual care. All subjects in both groups underwent 3D-STE examinations of the left ventricle within 48 hours of percutaneous coronary intervention and again 4 weeks after discharge. Global longitudinal strain (GLS), global radial strain (GRS), global area strain (GAS), global circumferential strain (GCS), left ventricular ejection fraction (LVEF), and segmental strains were computed. The CR program was initially conducted with supervised inpatient training, followed by an unsupervised home-based training program during a 4-week follow-up.

RESULTS

We obtained segmental strains from 832 segments, of which 319 were defined as interventional segments, 179 as ischemic segments, and the remaining segments as normal segments. At the 4-week follow-up, when controlling for baseline values, the rehabilitation group showed significant improvements in GLS, GRS, GCS, GAS, LVEF, and in all of the segmental strains of the 3 subgroups compared with the control group (P <0.05).

CONCLUSION

Our study suggests that an early, home-based CR program can greatly improve the ventricular function of AMI patients in a short period of time.

Physiological basis in the assessment of myocardial mechanics using speckle-tracking echocardiography 2D. Part II

In this paper, the authors attempt to concisely present the anatomical and pathophysiological bases as well as the principles for echocardiographic evaluation of mechanical aspects of cardiac function based on speckle tracking method. This technique uses a phenomenon involving the formation of characteristic image units, referred to as speckles or acoustic markers, which are stable during cardiac cycle, on a two-dimensional echocardiographic picture. Changes in the position of these speckles throughout the cardiac cycle, which are monitored and analyzed semi-automatically by a computer system, reflect deformation of both, cardiac ventricle as a whole as well as its individual anatomical segments. The values of strain and the strain rate, as well as the range and velocity of the movement of these markers, which are in close relationship with multiple hemodynamic parameters, can be visualized as various types of charts – linear, two- and three-dimensional – as well as numerical values, enabling deeper insight into the mechanical and hemodynamic aspects of cardiac function in health and disease. The use of information obtained based on speckle tracking echocardiography allows to understand previously unclear mechanisms of physiological and pathophysiological processes. The first part of the study discusses the formation of a two-dimensional ultrasound image and the speckles, as well as the technical aspects of tracking their movement. The second part presents in more detail the methodology of speckle-tracking echocardiography, the characteristic abnormalities of cardiac mechanics presenting in different clinical entities, and the limitations related to given clinical and technical issues.

The value of 3-dimensional longitudinal strain in the evaluation of complex coronary lesions in non-ST-segment elevation acute coronary syndrome patient

The aim of this study is to investigate the value of 3-dimensional global peak longitudinal strain (GPLS) derived from the 3-dimensional speckle-tracking echocardiography (3D-STE) in the diagnosis of the complex non-ST-segment elevation acute coronary syndromes (NSTE-ACS) by comparing GPLS to the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score.A total of 59 inpatients with NSTE-ACS in our hospital between October 2014 and January 2015 were enrolled into our study. All these subjects underwent the coronary angiography (CAG) and 3D-STE examination. The results of CAG were used to calculate the SYNTAX scores in each subject. The GPLS was assessed with speckle-tracking analysis using the dedicated software developed by GE Healthcare (Horten, Norway).We grouped all subjects according to the SYNTAX scores. A total of 23 patients (39%) were grouped as complex NSTE-ACS in our experiment. In our analysis, the values of GPLS significantly decreased from low SYNTAX scores to intermediate or high SYNTAX scores (-14.0 ± 2.7% and -9.5 ± 2.8%, respectively, P < 0.001). Multivariate regression analysis showed that GPLS and diabetes mellitus were independent predictors for complex NSTE-ACS. The area under the receiver operator characteristic curve (AUC) for GPLS to evaluate patients with complex NSTE-ACS was 0.882 (95% confidence interval [CI], 0.797-0.967, P < 0.001) with an optimal cutoff value of -11.76% (sensitivity 82.6% and specificity 83.3%). The evaluative value of the adjusted AUC for evaluating patients with complex NSTE-ACS improved after inclusion of GPLS (C statistics, 0.827-0.948, P < 0.001).The value of GPLS is significantly associated with the complexity of coronary artery lesions, according to SYNTAX score. Therefore, our study indicates that GPLS could be reproducible and efficient to evaluate the complex coronary artery disease in NSTE-ACS patients.

Atrial fibrillation per se was a major determinant of global left ventricular longitudinal systolic strain

Atrial fibrillation (AF) may cause systolic abnormality via inadequate diastolic filling and tachycardia-induced cardiomyopathy. Global longitudinal strain (GLS) is a very sensitive method for detecting subtle left ventricular systolic dysfunction. Hence, this study aimed to evaluate whether AF patients had a more impaired GLS, AF was a major determinant of GLS, and determine the major correlates of GLS in AF patients.The study included 137 patients with persistent AF and left ventricular ejection fraction (LVEF) above 50% and 137 non-AF patients matched according to age, gender, and LVEF. Comprehensive echocardiography with GLS assessment was performed for all cases.Compared with non-AF patients, AF patients had a more impaired GLS, a larger left atrial volume index, higher transmitral E wave velocity (E), and early diastolic mitral velocity (Ea) (all P < 0.001) but comparable E/Ea. After adjustment for baseline and echocardiographic characteristics, the presence of AF remained significantly associated with impaired GLS (β = 0.533, P < 0.001). In addition, multivariate analysis of AF patients indicated that faster heart rates and decreased E, Ea, and LVEF were associated with more impaired GLS.This study demonstrated that AF patients had a more impaired GLS than non-AF patients, although LVEF was comparable between the 2 groups. AF was a major determinant of GLS even after adjustment for relevant clinical and echocardiographic parameters.

Non-Invasive Evaluation of Heart Function with Four-Dimensional Echocardiography

Background

The aim of this study is to assess the accuracy and feasibility of left ventricular systolic function determined by four-dimensional echocardiography (4DE).

Methods

Latex balloons were sewn into the left ventricle (LV) of 20 freshly harvested pig hearts which were then passively driven by a pulsatile pump apparatus. Global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS) and left ventricular ejection fraction (LVEF) derived from 4DEand two-dimensional echocardiography (2DE)-derived LVEF were quantified at different stroke volumes (SV) 30–70 ml and correlated with sonomicrometry data.

Results

In all comparisons, GLS, GCS, GAS, 2DE-LVEF, and 4DE-LVEF demonstrated strong correlations with sonomicrometry data (r = 0.77, r = 0.89, r = 0.79, r = 0.93, r = 0.96, all P <0.001). Bland-Altman analyses showed slight overestimations of echo-derived GLS, GCS, 2DE-LVEF and 3DE-LVEF over sonomicrometry values (bias = 2.88, bias = 3.99, bias = 3.37, bias = 2.78, respectively). Furthermore, there is better agreement between GCS, 4D LVEF and sonomicrometry values compared with GLS and 2D LVEF.

Conclusion

Four-dimensional echocardiography accurately assesses LV function. GCS derived by 4DE is a potential alternative parameter to quantify LV systolic function.

Mechanical dyssynchrony and deformation imaging in patients with functional mitral regurgitation

Chronic functional mitral regurgitation (FMR) is a frequent finding of ischemic heart disease and dilated cardiomyopathy (DCM), associated with unfavourable prognosis. Several pathophysiologic mechanisms are involved in FMR, such as annular dilatation and dysfunction, left ventricle (LV) remodeling, dysfunction and dyssynchrony, papillary muscles displacement and dyssynchrony. The best therapeutic choice for FMR is still debated. When optimal medical treatment has already been set, a further option for cardiac resynchronization therapy (CRT) and/or surgical correction should be considered. CRT is able to contrast most of the pathophysiologic determinants of FMR by minimizing LV dyssynchrony through different mechanisms: Increasing closing forces, reducing tethering forces, reshaping annular geometry and function, correcting diastolic MR. Deformation imaging in terms of two-dimensional speckle tracking has been validated for LV dyssynchrony assessment. Radial speckle tracking and three-dimensional strain analysis appear to be the best methods to quantify intraventricular delay and to predict CRT-responders. Speckle-tracking echocardiography in patients with mitral valve regurgitation has been usually proposed for the assessment of LV and left atrial function. However it has also revealed a fundamental role of intraventricular dyssynchrony in determining FMR especially in DCM, rather than in ischemic cardiomyopathy in which MR severity seems to be more related to mitral valve deformation indexes. Furthermore speckle tracking allows the assessment of papillary muscle dyssynchrony. Therefore this technique can help to identify optimal candidates to CRT that will probably demonstrate a reduction in FMR degree and thus will experience a better outcome.

[Echocardiographic evaluation of systolic left ventricular function in heart failure: value of alternative parameters for determination of ejection fraction]

Assessment of the left ventricular ejection fraction plays a key role in the echocardiographic diagnosis of heart failure. The parameter most commonly used is the ejection fraction computed with the biplane disc summation method of Simpson; however, there are numerous limitations to this method, such as the assumption of geometrical symmetry, a substantial intraobserver and interobserver variability, foreshortening of the left ventricle and insufficient image quality for endocardial tracking. Alternative parameters for the evaluation of left ventricular function should be taken into consideration. Speckle tracking echocardiography has proven to be a reliable prognostic factor and a good tool for differentiating cardiomyopathies. Simple measurements, which are also feasible with poor image quality, are mitral annular plane systolic excursion (MAPSE) and the velocity of mitral annular movement (Sm or S'). In mitral regurgitation, left ventricular dP/dt represents the time to build up a certain pressure gradient and is therefore a measure of the contractile force exerted. Three-dimensional echocardiography has proven to be an important tool not only for three-dimensional measurement of the left ventricular ejection fraction but also for multivectoral speckle tracking analysis.