Dyssynchronous Systolic Expansion of Carotid Artery in Patients with Marfan Syndrome

Velocity Vector Imaging to Assess Longitudinal Wall Motion of Adult Carotid Arteries

OBJECTIVE

We aimed to assess longitudinal wall motion of the common carotid artery (CCA) using velocity vector imaging (VVI).

METHODS

From October 2018 to July 2019, we prospectively performed VVI of 204 CCAs (102 adult volunteers, 57 men, 45 women) in young (n = 40, 20-44 y), mid-age (n = 30, 45-64 y), and senior (n = 32, ≥65 y) groups. VVI parameters of CCA included longitudinal motion pattern, motion parameters (strain, strain rate, displacement), and time-to-peak motion parameters (time-to-peak strain, time-to-peak strain rate, time-to-peak displacement). Statistical analyses included one-way ANOVA post-hoc testing to examine the difference in VVI parameters among the 3 age groups and in paired groups; unpaired t tests to examine the difference in VVI parameters between CCAs with and without atherosclerotic plaque, between hypertensive and normotensive subjects without atherosclerotic plaque; linear regression to analyze correlations of VVI parameters to age, carotid intima-media thickness; and intraclass correlation coefficient to test inter- and intra-observer reliability in performing VVI of the CCA.

RESULTS

Differences in VVI parameters and patterns among the 3 age groups, between hypertensive and normotensive, and CCAs with and without plaque were significant (p < .01). CCA motion- and time-to-peak motion parameters were correlated to age (R² = 0.63-0.56) and carotid intima-media thickness (R² = 0.29-0.22). CCA wall motion dyssynchrony was remarkable in seniors. The repeatability and reproducibility for performing carotid artery VVI were good (intraclass correlation coefficient > 0.85).

CONCLUSIONS

VVI is feasible to assess changes in longitudinal CCA wall mechanical properties and synchrony with aging, atherosclerosis, and hypertension.

Clinical features differentiating Takotsubo cardiomyopathy in the peripartum period from peripartum cardiomyopathy

There are some similarities in clinical features between Takotsubo cardiomyopathy during the peripartum period (PTCM) and peripartum cardiomyopathy (PPCM). Both conditions present as acute heart failure and decreased left ventricular (LV) ejection fraction in the peripartum period in previously heart-healthy women. The present study aimed to evaluate the differences in clinical features and outcomes between PTCM and PPCM. Between January 2004 and December 2016, 37 consecutive patients who demonstrated LV dysfunction during the peripartum period without previous heart disease were recruited retrospectively. The clinical, laboratory, and echocardiographic data of these patients were comprehensively reviewed. Twenty-one (57%) and 16 (43%) patients were classified into PPCM and PTCM groups, respectively, based on echocardiographic findings. The initial LV ejection fraction did not differ significantly between the 2 groups. However, all patients with PTCM showed complete recovery of LV ejection fraction at the 1-month follow-up. However, among 20 patients with PPCM who underwent 1-month echocardiography, only 6 (30%) showed complete recovery of LV ejection fraction at the 1-month follow-up. At the 12-month follow-up, only 10 patients showed complete recovery of LV ejection fraction. The incidence of PTCM was much higher than expected. Although LV dysfunction was similar at the initial diagnosis, the prognosis of LV recovery was more favorable in PTCM than in PPCM. Therefore, physicians should differentiate these two diseases entities, although they have several similarities in acute LV dysfunction.

The Evaluation of Flow-Mediated Vasodilation in the Brachial Artery Correlates With Endothelial Dysfunction Evaluated by Nitric Oxide Synthase Metabolites in Marfan Syndrome Patients

Marfan syndrome (MS) is of the most common connective tissue disorders. Although most patients have mutations in the fibrillin-1 gene (FBN1) and more than 1,700 mutations have been described, there are no mutations in less than 10% of patients. Aortic dilation is the most important complication; it involves chronic inflammatory processes and endothelial dysfunction. Prospective study from March 2015 to January 2017, in a cohort of 32 patients of MS confirmed by Ghent criteria and 35 controls of both genders, with a median age of 26 years (18-56). Patients had no comorbidities such as diabetes, hypertension, and/or neoplasms. They were not being treated with statin, NSAIDs, calcium antagonists, oral nitrates, and/or beta-blockers during 7 days prior to the study and patients with smoking history in the last 4 years. Controls were matched by age and gender. We analyzed endothelial dysfunction by flow-mediated vasodilation in the brachial artery, determining the maximum peak flow in the reactive hyperemia phase with a Philips Envisor device with Doppler capability. Its correlation with serum levels of biological markers that could participate in endothelial dysfunction pathways such as NO3-/NO2- ratio, NO2- , citrulline, TNFα, IL-1, IL-6, IL-10, IL-8, osteopontin, ICAM, VCAM, and NO3-/NO2- was determined. Endothelial dysfunction was found in 21 MS patients (65%). The aortic annulus (AAo) was of 27 mm (22-40) and 24 mm (22-30) (p = 0.04) in MS patients with and without dysfunction. The level of NO3-/NO2- ratio, was of 108.95 ± 12.05 nM/ml in controls vs. 170.04 ± 18.76 nM/ml in MS (p = 0.002), NO2- was of 33.78 ± 3.41 vs. 43.95 ± 2.59 nM/ml (p = 0.03), citrulline 62.65 ± 3.46 vs. 72.81 ± 4.35 μMol/ml (p = 0.06). VCAM median was 39 pg/ml (0-86) vs. 32 pg/ml (11-66) (p = 0.03), respectively. The correlation of VCAM with triglycerides (TG) was of 0.62 (p = 0.005). There were no differences in TNFα, IL-1, IL-6, IL-8, IL-10, and osteopontin. MS endothelial dysfunction is related to aortic diameters, and increased levels of VCAM, L-citrulline and NO3-/NO2- ratio, NO2- . VCAM-1 has a significant correlation with TG and could play a significant role in endothelial dysfunction.

Impaired cardiac and vascular motion in patients with Takayasu's arteritis: A velocity vector imaging-based study

OBJECTIVE

Takayasu's arteritis (TAK) is a chronic inflammatory vasculitis of the aorta and its major branches. In the present study, we aimed to evaluate the motion of the vascular wall and myocardial contractility by using a novel strain imaging method, velocity vector imaging (VVI), in patients with TAK. We also aimed to compare them with another inflammatory autoimmune disorder, systemic lupus erythematosus (SLE).

METHODS

We studied 33 patients with TAK, 18 patients with SLE, and 20 age- and sex-matched controls. All participants were subjected to carotid artery Doppler ultrasonography and transthoracic echocardiographic evaluation. VVI analysis was also performed to assess subclinical left ventricular (LV) systolic dysfunction and to determine tissue motion of the common carotid arteries (CCAs).

RESULTS

Aortic strain and distensibility were significantly impaired in patients with TAK, while the aortic stiffness and carotid artery stiffness indexes were increased. Aortic distensibility was the only parameter that was decreased among SLE patients. The values of CCA peak longitudinal strain, strain rate, and total longitudinal displacement (TLD) were also impaired in patients with TAK. Peak radial velocity was decreased while time-to-peak radial velocity was increased. In the SLE group, peak longitudinal strain, strain rate, TLD, and peak radial velocity were impaired. LV longitudinal peak systolic strain and strain rate were reduced in patients with TAK. Similarly, we revealed impaired subclinical LV systolic function in patients with SLE.

CONCLUSION

VVI is a novel strain imaging technique with additional value to determine early impairment in vascular and myocardial wall motion in patients with TAK.

Characteristics of Carotid Artery Structure and Mechanical Function and Their Relationships with Aortopathy in Patients with Bicuspid Aortic Valves

Patients with a bicuspid aortic valve (BAV) often have proximal aortic dilatation and systemic vascular dysfunction. We hypothesized that BAV patients would have different carotid artery structural and functional characteristics compared to tricuspid aortic valve (TAV) patients. In 28 patients with surgically confirmed BAV and 27 patients with TAV, intima media thickness (IMT), number of plaques, fractional area change (FAC), global circumferential strain (GCS), and standard deviation of CS (SD-CS) in both common carotid arteries were assessed using duplex ultrasound and velocity vector imaging (VVI). Patients with BAV were younger and had less co-morbidity, but showed a significantly larger ascending aorta (43.3 ± 7.5 vs. 37.0 ± 6.2 mm, p < 0.001) and a higher prevalence of aortopathy (61 vs. 30%, p = 0.021) than those with TAV. BAV patients showed a significantly lower IMT and fewer plaques. Although FAC and GCS were not significantly different between the two groups, they tended to be lower in the BAV group when each group was divided into three subgroups according to age. There was a significant age-dependent increase in IMT and decreases in FAC and GCS in the TAV group (p = 0.005, p = 0.001, p = 0.002, respectively), but this phenomenon was not evident in the BAV group (p = 0.074, p = 0.248, p = 0.394, respectively). BAV patients with aortopathy showed a higher SD-CS than those without aortopathy (p = 0.040), reflecting disordered mechanical function. In conclusion, BAV patients have different carotid artery structure and function compared with TAV patients, suggesting intrinsic vascular abnormalities that are less affected by established cardiovascular risk factors and more strongly related to the presence of aortopathy.

Non-invasive assessment of vascular alteration using ultrasound

It is well known that arterial function relates to cardiovascular morbidity and mortality. The noninvasive technology for the assessment of arterial function has developed as the importance of prevention of early cardiovascular disease has been emphasized. Over 2-D and Doppler echocardiography, speckle-tracking echocardiography has emerged as a valuable ultrasound imaging technique that allows for an objective and quantitative evaluation of global and regional myocardial function. Recently, several studies have extended its applicability beyond cardiac chambers, such as artery. Measurement of carotid arterial strain with speckle tracking ultrasound has been shown to be feasible and reliable. This review describes the new ultrasound techniques to assess arterial function and their clinical implications.

Alterations of carotid arterial mechanics preceding the wall thickening in patients with hypertension

BACKGROUND AND AIMS

Carotid intima-media thickness (cIMT) is an established surrogate marker of atherosclerosis. However, cIMT may not reflect the whole arterial changes occurring in various pathologic conditions, such as hypertension. The aim of this study was to evaluate whether vascular properties of carotid artery (CA) in patients with hypertension differ from those of patients with diabetes and controls before the progression of cIMT.

METHODS

Vascular properties of CA were assessed in 402 consecutive asymptomatic subjects who have normal cIMT (131 with hypertension, 151 with diabetes mellitus, and 120 controls). Conventional carotid stiffness indices calculated from vessel diameter and blood pressure, and parameters from velocity-vector imaging (VVI), including vessel area, fractional area change (FAC), radial velocity, circumferential strain, and strain rate were measured to assess the differences between the groups.

RESULTS

In univariate analysis, both patients with hypertension and diabetes showed higher elastic modulus, lower distensibility coefficients and FAC of VVI than those of controls. However, when adjusting for baseline covariates, only FAC (odds ratio [OR] = 0.82, 95% confidence interval [CI] = 0.70-0.97, p = 0.025) and vessel area (OR = 2.84, 95% CI = 1.64-4.91, p < 0.001) discriminated CA of patients with hypertension from those of controls. Also, patients with hypertension showed larger vessel area than diabetes (OR = 2.58, 95% CI = 1.75-3.80, p < 0.001) independent of baseline covariates. No significant vascular parameter was found to discriminate patients with diabetes from controls after adjustments.

CONCLUSION

Despite normal cIMT, the CA of hypertensive patients was stiffer than those of controls and positive remodeling preceded the wall thickening independent of baseline covariates.

Quantitative Assessment of Aortic Elasticity With Aging Using Velocity-Vector Imaging and Its Histologic Correlation

Objective—

Velocity-vector imaging (VVI) represents a valuable new method for noninvasive quantification of vascular properties associated with aging. The purpose of this study was to assess the correlations between VVI parameters and histological changes with aging.

Approach and Results—

Fourteen mongrel dogs were classified as either young (n=7; age, 1–2 years; female; weighing 22–29 kg) or senescent (n=7; age, 8–12 years; female; weighing 36–45 kg). The short-axis image of the descending thoracic aorta was obtained for VVI analysis with transesophageal echocardiography. The location of the image was identified using fluoroscopic guidance, and the aortic tissue was extracted. After dividing the aortic wall into 6 segments, both regional and segmental tissue collagen and elastin contents were quantified and correlated with the aortic elastic properties. In the regional analysis, the M-mode–derived aortic dimensions and elastic moduli except for intima-media thickness were not significantly different between the groups, whereas the VVI-derived aortic area and fractional area changes showed more dilated and stiffer aorta in senescent dogs. Also, fractional area change was significantly correlated with the tissue collagen content unlike the M-mode–derived elastic moduli. In the segmental analysis, the radial velocity, circumferential strain, and strain rates of VVI were more reduced in senescent dogs than young dogs, and the radial velocity and circumferential strain showed independent associations with the collagen content of the corresponding aortic wall.

Conclusions—

VVI was a feasible method for direct quantification of aortic elastic properties with a significant histological correlation.