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Smiseth OA, Rider O, Cvijic M, Valkovič L, Remme EW, Voigt JU. Myocardial Strain Imaging: Theory, Current Practice, and the Future. JACC Cardiovasc Imaging 2024:S1936-878X(24)00301-2. [PMID: 39269417 DOI: 10.1016/j.jcmg.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 09/15/2024]
Abstract
Myocardial strain imaging by echocardiography or cardiac magnetic resonance (CMR) is a powerful method to diagnose cardiac disease. Strain imaging provides measures of myocardial shortening, thickening, and lengthening and can be applied to any cardiac chamber. Left ventricular (LV) global longitudinal strain by speckle-tracking echocardiography is the most widely used clinical strain parameter. Several CMR-based modalities are available and are ready to be implemented clinically. Clinical applications of strain include global longitudinal strain as a more sensitive method than ejection fraction for diagnosing mild systolic dysfunction. This applies to patients suspected of having heart failure with normal LV ejection fraction, to early systolic dysfunction in valvular disease, and when monitoring myocardial function during cancer chemotherapy. Segmental LV strain maps provide diagnostic clues in specific cardiomyopathies, when evaluating LV dyssynchrony and ischemic dysfunction. Strain imaging is a promising modality to quantify right ventricular function. Left atrial strain may be used to evaluate LV diastolic function and filling pressure.
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Affiliation(s)
- Otto A Smiseth
- Institute for Surgical Research, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway.
| | - Oliver Rider
- Oxford Centre for Clinical Magnetic Resonance Research, RDM Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
| | - Marta Cvijic
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Ladislav Valkovič
- Oxford Centre for Clinical Magnetic Resonance Research, RDM Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom; Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Espen W Remme
- Institute for Surgical Research, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway; The Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Leuven, Belgium
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2
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MozafaryBazargany M, Salmanipour A, Ghaffari Jolfayi A, Azimi A, Bakhshandeh H, Mahmoodieh B, Tofighi S, Gholami N, Golzarian J, Motevalli M. Value of cardiac magnetic resonance feature-tracking in Arrhythmogenic Cardiomyopathy (ACM): A systematic review and meta-analysis. IJC HEART & VASCULATURE 2024; 53:101455. [PMID: 39228971 PMCID: PMC11368602 DOI: 10.1016/j.ijcha.2024.101455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 09/05/2024]
Abstract
We aimed to assess the diagnostic performance of Cardiac Magnetic Resonance (CMR) strain parameters in ACM patients to evaluate their diagnostic role. We systematically searched MEDLINE, EMBASE, Scopus, and Web of Science. Of the 146 records, 16 were included. All Right Ventricle (RV) global strains were significantly reduced in ACM patients compared to controls (Standardized Mean Difference (SMD)[95 % Confidence Interval (CI)]: Longitudinal 1.31[0.79,1.83]; Circumferential 0.88[0.34,1.42]; Radial -1.14[-1.78,-0.51]). Similarly, all Left Ventricle (LV) global strains were significantly impaired in ACM compared to healthy controls (SDM [95 %CI]: Longitudinal 0.88[0.48,12.28], Circumferential 0.97[0.72,1.22], Radial -1.24[-1.49,-1.00]). Regarding regional RV strains, longitudinal and circumferential strains were significantly reduced in basal and mid-wall regions, while they were comparable to controls in the apical regions. The RV radial strain was reduced only within the basal region in the ACM group compared to controls. ACM patients exhibited significant impairment of regional LV strains in all regions-basal, mid-wall, and apical-compared to control subjects. Ultimately, despite the limitations of CMR-FT in terms of reproducibility, it is superior to qualitative assessment in detecting wall motion abnormalities. Thus, integrating CMR-FT with ACM diagnostic criteria seems to enhance its diagnostic yield.
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Affiliation(s)
| | - Alireza Salmanipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical, Tehran, Iran
| | - Amir Ghaffari Jolfayi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical, Tehran, Iran
| | - Amir Azimi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical, Tehran, Iran
| | - Hooman Bakhshandeh
- Cardiogenetic Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Behnaz Mahmoodieh
- Young Researchers and Elite Club, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Saeed Tofighi
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Niloofar Gholami
- Cardiovascular Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Jafar Golzarian
- Department of Radiology, Medical School, University of Minnesota, 420 Delaware Street S.E., Minneapolis, MN 55455, USA
| | - Marzieh Motevalli
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical, Tehran, Iran
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Mattesi G, Pergola V, Bariani R, Martini M, Motta R, Perazzolo Marra M, Rigato I, Bauce B. Multimodality imaging in arrhythmogenic cardiomyopathy - From diagnosis to management. Int J Cardiol 2024; 407:132023. [PMID: 38583594 DOI: 10.1016/j.ijcard.2024.132023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/03/2024] [Accepted: 04/04/2024] [Indexed: 04/09/2024]
Abstract
Arrhythmogenic Cardiomyopathy (AC), an inherited cardiac disorder characterized by myocardial fibrofatty replacement, carries a significant risk of sudden cardiac death (SCD) due to ventricular arrhythmias. A comprehensive multimodality imaging approach, including echocardiography, cardiac magnetic resonance imaging (CMR), and cardiac computed tomography (CCT), allows for accurate diagnosis, effective risk stratification, vigilant monitoring, and appropriate intervention, leading to improved patient outcomes and the prevention of SCD. Echocardiography is primary tool ventricular morphology and function assessment, CMR provides detailed visualization, CCT is essential in early stages for excluding congenital anomalies and coronary artery disease. Echocardiography is preferred for follow-up, with CMR capturing changes over time. The strategic use of these imaging methods aids in confirming AC, differentiating it from other conditions, tracking its progression, managing complications, and addressing end-stage scenarios.
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Affiliation(s)
| | | | - Riccardo Bariani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | - Marika Martini
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | | | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | | | - Barbara Bauce
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
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Bjerregaard CL, Biering-Sørensen T, Skaarup KG, Sengeløv M, Lassen MCH, Johansen ND, Olsen FJ. Right Ventricular Function in Arrhythmogenic Right Ventricular Cardiomyopathy: Potential Value of Strain Echocardiography. J Clin Med 2024; 13:717. [PMID: 38337410 PMCID: PMC10856386 DOI: 10.3390/jcm13030717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy is an inherited cardiomyopathy, characterized by abnormal cell adhesions, disrupted intercellular signaling, and fibrofatty replacement of the myocardium. These changes serve as a substrate for ventricular arrhythmias, placing patients at risk of sudden cardiac death, even in the early stages of the disease. Current echocardiographic criteria for diagnosing arrhythmogenic right ventricular cardiomyopathy lack sensitivity, but novel markers of cardiac deformation are not subject to the same technical limitations as current guideline-recommended measures. Measuring cardiac deformation using speckle tracking allows for meticulous quantification of global systolic function, regional function, and dyssynchronous contraction. Consequently, speckle tracking to quantify myocardial strain could potentially be useful in the diagnostic process for the determination of disease progression and to assist risk stratification for ventricular arrhythmias and sudden cardiac death. This narrative review provides an overview of the potential use of different myocardial right ventricular strain measures for characterizing right ventricular dysfunction in arrhythmogenic right ventricular cardiomyopathy and its utility in assessing the risk of ventricular arrhythmias.
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Affiliation(s)
- Caroline Løkke Bjerregaard
- Department of Cardiology, Copenhagen University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark; (C.L.B.)
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark; (C.L.B.)
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, 2730 Herlev, Denmark
| | - Kristoffer Grundtvig Skaarup
- Department of Cardiology, Copenhagen University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark; (C.L.B.)
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Morten Sengeløv
- Department of Cardiology, Copenhagen University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark; (C.L.B.)
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Mats Christian Højbjerg Lassen
- Department of Cardiology, Copenhagen University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark; (C.L.B.)
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Niklas Dyrby Johansen
- Department of Cardiology, Copenhagen University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark; (C.L.B.)
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Flemming Javier Olsen
- Department of Cardiology, Copenhagen University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark; (C.L.B.)
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
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5
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Olivetti N, Sacilotto L, Moleta DB, de França LA, Capeline LS, Wulkan F, Wu TC, Pessente GD, de Carvalho MLP, Hachul DT, Pereira ADC, Krieger JE, Scanavacca MI, Vieira MLC, Darrieux F. Enhancing Arrhythmogenic Right Ventricular Cardiomyopathy Detection and Risk Stratification: Insights from Advanced Echocardiographic Techniques. Diagnostics (Basel) 2024; 14:150. [PMID: 38248027 PMCID: PMC10814792 DOI: 10.3390/diagnostics14020150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
INTRODUCTION The echocardiographic diagnosis criteria for arrhythmogenic right ventricular cardiomyopathy (ARVC) are highly specific but sensitivity is low, especially in the early stages of the disease. The role of echocardiographic strain in ARVC has not been fully elucidated, although prior studies suggest that it can improve the detection of subtle functional abnormalities. The purposes of the study were to determine whether these advanced measures of right ventricular (RV) dysfunction on echocardiogram, including RV strain, increase diagnostic value for ARVC disease detection and to evaluate the association of echocardiographic parameters with arrhythmic outcomes. METHODS The study included 28 patients from the Heart Institute of São Paulo ARVC cohort with a definite diagnosis of ARVC established according to the 2010 Task Force Criteria. All patients were submitted to ECHO's advanced techniques including RV strain, and the parameters were compared to prior conventional visual ECHO and CMR. RESULTS In total, 28 patients were enrolled in order to perform ECHO's advanced techniques. A total of 2/28 (7%) patients died due to a cardiovascular cause, 2/28 (7%) underwent heart transplantation, and 14/28 (50%) patients developed sustained ventricular arrhythmic events. Among ECHO's parameters, RV dilatation, measured by RVDd (p = 0.018) and RVOT PSAX (p = 0.044), was significantly associated with arrhythmic outcomes. RV free wall longitudinal strain < 14.35% in absolute value was associated with arrhythmic outcomes (p = 0.033). CONCLUSION Our data suggest that ECHO's advanced techniques improve ARVC detection and that abnormal RV strain can be associated with arrhythmic risk stratification. Further studies are necessary to better demonstrate these findings and contribute to risk stratification in ARVC, in addition to other well-known risk markers.
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Affiliation(s)
- Natália Olivetti
- Arrhythmia Unit, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.); (T.C.W.); (G.D.P.); (D.T.H.); (M.I.S.)
- Laboratory of Genetics and Molecular Cardiology, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.C.); (F.W.); (M.L.P.d.C.); (A.d.C.P.); (J.E.K.)
| | - Luciana Sacilotto
- Arrhythmia Unit, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.); (T.C.W.); (G.D.P.); (D.T.H.); (M.I.S.)
| | - Danilo Bora Moleta
- Echocardiogram Imaging Unit, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (D.B.M.); (M.L.C.V.)
| | - Lucas Arraes de França
- Echocardiogram Imaging Unit, Hospital Israelita Albert Einstein, Sao Paulo 05652-900, Brazil;
| | - Lorena Squassante Capeline
- Laboratory of Genetics and Molecular Cardiology, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.C.); (F.W.); (M.L.P.d.C.); (A.d.C.P.); (J.E.K.)
| | - Fanny Wulkan
- Laboratory of Genetics and Molecular Cardiology, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.C.); (F.W.); (M.L.P.d.C.); (A.d.C.P.); (J.E.K.)
| | - Tan Chen Wu
- Arrhythmia Unit, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.); (T.C.W.); (G.D.P.); (D.T.H.); (M.I.S.)
| | - Gabriele D’Arezzo Pessente
- Arrhythmia Unit, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.); (T.C.W.); (G.D.P.); (D.T.H.); (M.I.S.)
| | - Mariana Lombardi Peres de Carvalho
- Laboratory of Genetics and Molecular Cardiology, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.C.); (F.W.); (M.L.P.d.C.); (A.d.C.P.); (J.E.K.)
| | - Denise Tessariol Hachul
- Arrhythmia Unit, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.); (T.C.W.); (G.D.P.); (D.T.H.); (M.I.S.)
| | - Alexandre da Costa Pereira
- Laboratory of Genetics and Molecular Cardiology, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.C.); (F.W.); (M.L.P.d.C.); (A.d.C.P.); (J.E.K.)
| | - José E. Krieger
- Laboratory of Genetics and Molecular Cardiology, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.C.); (F.W.); (M.L.P.d.C.); (A.d.C.P.); (J.E.K.)
| | - Mauricio Ibrahim Scanavacca
- Arrhythmia Unit, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.); (T.C.W.); (G.D.P.); (D.T.H.); (M.I.S.)
| | - Marcelo Luiz Campos Vieira
- Echocardiogram Imaging Unit, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (D.B.M.); (M.L.C.V.)
- Echocardiogram Imaging Unit, Hospital Israelita Albert Einstein, Sao Paulo 05652-900, Brazil;
| | - Francisco Darrieux
- Arrhythmia Unit, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-900, Brazil; (L.S.); (T.C.W.); (G.D.P.); (D.T.H.); (M.I.S.)
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6
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Kirkels FP, van Osta N, Rootwelt-Norberg C, Chivulescu M, van Loon T, Aabel EW, Castrini AI, Lie ØH, Asselbergs FW, Delhaas T, Cramer MJ, Teske AJ, Haugaa KH, Lumens J. Monitoring of Myocardial Involvement in Early Arrhythmogenic Right Ventricular Cardiomyopathy Across the Age Spectrum. J Am Coll Cardiol 2023; 82:785-797. [PMID: 37612010 DOI: 10.1016/j.jacc.2023.05.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/19/2023] [Accepted: 05/31/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Arrhythmogenic right ventricular cardiomyopathy (ARVC) is characterized by fibrofatty replacement of primarily the right ventricular myocardium, a substrate for life-threatening ventricular arrhythmias (VAs). Repeated cardiac imaging of at-risk relatives is important for early disease detection. However, it is not known whether screening should be age-tailored. OBJECTIVES The goal of this study was to assess the need for age-tailoring of follow-up protocols in early ARVC by evaluating myocardial disease progression in different age groups. METHODS We divided patients with early-stage ARVC and genotype-positive relatives without overt structural disease and VA at first evaluation into 3 groups: age <30 years, 30 to 50 years, and ≥50 years. Longitudinal biventricular deformation characteristics were used to monitor disease progression. To link deformation abnormalities to underlying myocardial disease substrates, Digital Twins were created using an imaging-based computational modeling framework. RESULTS We included 313 echocardiographic assessments from 82 subjects (57% female, age 39 ± 17 years, 10% probands) during 6.7 ± 3.3 years of follow-up. Left ventricular global longitudinal strain slightly deteriorated similarly in all age groups (0.1%-point per year [95% CI: 0.05-0.15]). Disease progression in all age groups was more pronounced in the right ventricular lateral wall, expressed by worsening in longitudinal strain (0.6%-point per year [95% CI: 0.46-0.70]) and local differences in myocardial contractility, compliance, and activation delay in the Digital Twin. Six patients experienced VA during follow-up. CONCLUSIONS Disease progression was similar in all age groups, and sustained VA also occurred in patients aged >50 years without overt ARVC phenotype at first evaluation. Unlike recommended by current guidelines, our study suggests that follow-up of ARVC patients and relatives should not stop at older age.
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Affiliation(s)
- Feddo P Kirkels
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands; Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
| | - Nick van Osta
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Christine Rootwelt-Norberg
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Monica Chivulescu
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Tim van Loon
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Eivind W Aabel
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anna I Castrini
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Øyvind H Lie
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Folkert W Asselbergs
- Amsterdam University Medical Centers, Department of Cardiology, University of Amsterdam, Amsterdam, the Netherlands; Health Data Research UK and Institute of Health Informatics, University College London, London, United Kingdom
| | - Tammo Delhaas
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Maarten J Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Arco J Teske
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Kristina H Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway. https://twitter.com/KristinaHaugaa
| | - Joost Lumens
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands.
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7
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Addetia K, Mazzanti A, Maragna R, Monti L, Yamat M, Kukavica D, Pagan E, Kishiki K, Prado A, Marino M, Bagnardi V, Priori S, Lang RM. Value of 3D echocardiography in the diagnosis of arrhythmogenic right ventricular cardiomyopathy. Eur Heart J Cardiovasc Imaging 2022; 24:664-677. [PMID: 36056824 DOI: 10.1093/ehjci/jeac172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/11/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
The 2010 Task Force Criteria (TFC) require that both right ventricular (RV) regional wall-motion abnormalities (WMA) and specific RV size cut-offs be met in order to fulfil one of the major criterion for arrhythmogenic right ventricular cardiomyopathy (ARVC) diagnosis. Currently, 2D echocardiography (2DE) and cardiovascular magnetic resonance imaging (cMRI) are used to determine if these criteria are met. Little is known about the diagnostic value of 3D echocardiography (3DE) in ARVC. The aim of this study was to determine whether a combination of 2DE-3DE is non-inferior to the currently used 2DE-cMRI combination in the diagnosis of patients with ARVC.
Methods and results
Thirty-nine individuals (47±15 years) with suspected ARVC underwent evaluation of the RV with cMRI, 2DE, and 3DE. 3DE and cMRI were independently used to obtain RV volumes, ejection fraction (EF) and determine the presence of segmental RV WMA. Studies were blindly classified as meeting criteria for ARVC in accordance with the 2010 TFC. Kappa statistics were used to test the concordance between 2DE–cMRI and 2DE–3DE approaches. Using the 2DE–cMRI approach, 3/39 were not affected, 5/39 possible, 8/39 borderline, and 23/39 definite ARVC. The proposed 2DE–3DE approach yielded 5/39 not affected, 7/39 possible, 8/39 borderline, and 19/39 definite diagnoses. The two approaches were highly concordant (k = 0.71; 95% confidence interval: 0.44–0.84). Although 3DE underestimated RV volumes in comparison with cMRI, interfering, in some instances with the fulfilment of a major criterion, it was able to identify more RV WMA (28/39) than 2DE (11/39), with a detection-rate comparable to cMRI (33/39) highlighting a unique advantage.
Conclusion
The combination of 2DE–3DE for ARVC diagnosis is comparable to the conventional 2DE–cMRI approach. 3DE should be performed in all suspected ARVC patients to aide in the detection of WMA.
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Affiliation(s)
- Karima Addetia
- Department of Cardiology, University of Chicago , Chicago, IL 60637 , USA
| | - Andrea Mazzanti
- Department of Molecular Cardiology, IRCCS ICS Maugeri , Pavia 27100 , Italy
- Department of Molecular Medicine, University of Pavia , Pavia 27100 , Italy
| | - Riccardo Maragna
- Department of Molecular Cardiology, IRCCS ICS Maugeri , Pavia 27100 , Italy
| | - Lorenzo Monti
- Department of Radiology, Humanitas Research Hospital , Rozzano 20089 , Italy
| | - Megan Yamat
- Department of Molecular Medicine, University of Pavia , Pavia 27100 , Italy
| | - Deni Kukavica
- Department of Molecular Cardiology, IRCCS ICS Maugeri , Pavia 27100 , Italy
- Department of Molecular Medicine, University of Pavia , Pavia 27100 , Italy
| | - Eleonora Pagan
- Department of Statistics and Quantitative Methods, University of Milan–Bicocca , Milan 20126 , Italy
| | - Kanako Kishiki
- Department of Cardiology, University of Chicago , Chicago, IL 60637 , USA
| | - Aldo Prado
- Department of Cardiology, University of Chicago , Chicago, IL 60637 , USA
| | - Maira Marino
- Department of Molecular Cardiology, IRCCS ICS Maugeri , Pavia 27100 , Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan–Bicocca , Milan 20126 , Italy
| | - Silvia Priori
- Department of Molecular Cardiology, IRCCS ICS Maugeri , Pavia 27100 , Italy
- Department of Molecular Medicine, University of Pavia , Pavia 27100 , Italy
| | - Roberto M Lang
- Department of Cardiology, University of Chicago , Chicago, IL 60637 , USA
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8
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Hosseini S, Erhart L, Anwer S, Heiniger PS, Winkler NE, Cimen T, Kuzo N, Hess R, Akdis D, Costa S, Gasperetti A, Brunckhorst C, Duru F, Saguner AM, Tanner FC. Tissue Doppler echocardiography and outcome in arrhythmogenic right ventricular cardiomyopathy. Int J Cardiol 2022; 368:86-93. [PMID: 35970442 DOI: 10.1016/j.ijcard.2022.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/15/2022] [Accepted: 08/10/2022] [Indexed: 11/05/2022]
Abstract
AIMS This study aimed at investigating whether tissue Doppler imaging (TDI) is associated with adverse events in arrhythmogenic right ventricular cardiomyopathy (ARVC). METHODS AND RESULTS Transthoracic echocardiography was performed in 72 patients with definite (n = 63) or borderline (n = 9) ARVC diagnosed according to the 2010 Task Force Criteria and included in the prospective Zurich ARVC registry. Myocardial peak systolic tissue velocity (S') was measured by TDI at lateral tricuspid (tricuspid S'), medial mitral (septal S'), and lateral mitral annulus (lateral S'). Association of echocardiographic parameters with outcome was assessed by univariable Cox regression. During a median follow-up of 4.9 ± 2.6 years, 6 (8.3%) patients died of cardiovascular cause or received heart transplantation and 21 (29.2%) patients developed sustained ventricular arrhythmia. Tricuspid, septal, and lateral S' were lower in patients who died (p = 0.001; p < 0.001; p = 0.008; respectively), while tricuspid and septal S' were lower in those with ventricular arrhythmia (p = 0.001; p = 0.008; respectively). There was a significant association of tricuspid, septal, and lateral S' with mortality (HR = 1.61, p = 0.011; HR = 2.15, p = 0.007; HR = 1.67, p = 0.017; respectively), while tricuspid and septal S' were associated with ventricular arrhythmia (HR = 1.20, p = 0.022; HR = 1.37, p = 0.004; respectively). Kaplan-Meier analyses demonstrated a higher freedom from mortality with tricuspid S' >8 cm/s (p = 0.001) and from ventricular arrhythmia with S' >10.5 cm/s (p = 0.021). CONCLUSIONS This study demonstrates that TDI provides information on the ARVC phenotype, is associated with adverse events in ARVC patients, and differentiates between patients with and without adverse events.
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Affiliation(s)
- Sara Hosseini
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Ladina Erhart
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Shehab Anwer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Pascal S Heiniger
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Neria E Winkler
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Tolga Cimen
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Nazar Kuzo
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Refael Hess
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Deniz Akdis
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Sarah Costa
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Alessio Gasperetti
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Corinna Brunckhorst
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Firat Duru
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Ardan M Saguner
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Felix C Tanner
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland.
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9
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Sharma A, Bosman LP, Tichnell C, Nanavati J, Murray B, Nonyane BA, Tandri H, Calkins H, James CA. Arrhythmogenic Right Ventricular Cardiomyopathy Prevalence and Arrhythmic Outcomes in At-Risk Family Members: A Systematic Review and Meta-Analysis. Circ Genom Precis Med 2022; 15:e003530. [DOI: 10.1161/circgen.121.003530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a complex cardiomyopathy with autosomal dominant inheritance and age-related incomplete penetrance, characterized by a high risk of sudden cardiac death. Recent professional consensus guidelines recommend clinical cardiac lifelong serial screening for at-risk family members refined only by age, but family genotype might influence necessary screening. Although numerous studies report prevalence of disease and arrhythmia in family members and explore predictors of penetrance and arrhythmic risk, a systematic review consolidating this evidence is lacking.
Methods:
We searched Medline (PubMed), Embase, The Cochrane Library, and Web of Science for studies that reported prevalence of (1) diagnosis of ARVC per 2010 Task Force Criteria and/or (2) sustained ventricular arrhythmias (VA) in at least 10 family members of definite patients with ARVC.
Results:
We identified 41 studies, including 36 that reported diagnosis by Task Force Criteria and 22 VA. Meta-analysis of 1359 family members, from 13 unique cohorts showed an average prevalence estimate of 25% for diagnosis as per Task Force Criteria (95% CI, 0.15–0.35, I
2
=
96.44%). Overall prevalence of VA among gene-positive family members was 18% (95% CI, 0.13–0.23, I
2
=33.25%) in 7 independent studies (n=597). Family genotype was a significant risk factor for diagnosis of both ARVC (odds ratio, 6.91 [95% CI, 1.27–37.70];
P
=0.0005) and VA (odds ratio, 13.62 [95% CI, 0.91–204.13];
P
=0.06). Male gender was not associated with disease prevalence (odds ratio, 1.18 [95% CI, 0.72–1.95];
P
=0.42) or VA (odds ratio, 0.81 [95% CI, 0.51–1.29];
P
=0.91).
Conclusions:
The prevalence of ARVC and VA in at-risk family members differs significantly based on family genotype. Although recent recommendations provide a guideline based only on age, we propose screening every 1 to 2 years for gene-positive family members and every 3 to 5 years for first-degree relatives of gene-elusive cases, as long as they are asymptomatic and not athletes.
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Affiliation(s)
- Apurva Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.S., C.T., B.M., H.T., H.C., C.A.J.)
| | - Laurens P. Bosman
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, the Netherlands (L.P.B.)
| | - Crystal Tichnell
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.S., C.T., B.M., H.T., H.C., C.A.J.)
| | - Julie Nanavati
- Welch Medical Library, Johns Hopkins School of Medicine (J.N.)
| | - Brittney Murray
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.S., C.T., B.M., H.T., H.C., C.A.J.)
| | - Bareng A.S. Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (B.A.S.N.)
| | - Harikrishna Tandri
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.S., C.T., B.M., H.T., H.C., C.A.J.)
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.S., C.T., B.M., H.T., H.C., C.A.J.)
| | - Cynthia A. James
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.S., C.T., B.M., H.T., H.C., C.A.J.)
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10
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Shang Y, Zhang Y, Leng W, Lei X, Chen L, Zhou X, Liang Z, Wang J. Assessment of right ventricular function using cardiovascular magnetic resonance in patients with type 2 diabetes mellitus. Quant Imaging Med Surg 2022; 12:1539-1548. [PMID: 35111646 DOI: 10.21037/qims-21-376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/24/2021] [Indexed: 11/06/2022]
Abstract
Background Accurate evaluation of right ventricular (RV) function is always difficult due to its irregular shape and movement. Many indices have been proposed to assess RV function, but none have been universally accepted. This study evaluated RV function in type 2 diabetes mellitus (T2DM) patients using long-axis strain (LAS) and other traditional indices. Methods Fifty-seven patients with T2DM and 39 healthy controls were prospectively enrolled. Four-chamber cardiovascular magnetic resonance (CMR) and RV short-axis cine images were obtained from all participants to measure the tricuspid annular plane systolic excursion (TAPSE), RV ejection fraction (EF), peak longitudinal strain (PLS) and four LAS indices. The inter-and intraobserver variabilities were also calculated. Results Compared with healthy controls, T2DM was associated with a decreased LAS (apex/lateral wall) (-17.4%±4.2% vs. control, -19.7%±3.7%, P=0.008) and LAS (apex/middle point) (-17.5%±4.5% vs. control, -19.5%±3.9%, P=0.026), but both groups had a similar LAS (RV/lateral wall) and LAS (RV/middle point) (all P>0.05). After adjustments for age and body mass index, a significant difference was observed only for LAS (apex/lateral wall) (P=0.028). There were no significant differences in the TAPSE, RVEF and PLS (all P>0.05). LAS (apex/lateral wall) correlated with the TAPSE (r=-0.723, P<0.001), RVEF (r=-0.270, P=0.008) and PLS (r=0.210, P=0.040). The inter- and intraobserver variability of the LAS (apex/lateral wall) were lower than the other three LAS indices. Conclusions Compared with traditional RV function indices, such as the TAPSE, RVEF and PLS, LAS is easy to obtain and shows high repeatability. LAS (apex/lateral wall) may provide a more sensitive T2DM-related RV dysfunction index.
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Affiliation(s)
- Yongning Shang
- Department of Ultrasound, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Department of Radiology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yulin Zhang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weiling Leng
- Department of Endocrinology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiaotian Lei
- Department of Endocrinology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Liu Chen
- Department of Endocrinology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | | | - Ziwen Liang
- Department of Endocrinology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jian Wang
- Department of Radiology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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11
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Malik N, Mukherjee M, Wu KC, Zimmerman SL, Zhan J, Calkins H, James CA, Gilotra NA, Sheikh FH, Tandri H, Kutty S, Hays AG. Multimodality Imaging in Arrhythmogenic Right Ventricular Cardiomyopathy. Circ Cardiovasc Imaging 2022; 15:e013725. [PMID: 35147040 DOI: 10.1161/circimaging.121.013725] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare, heritable myocardial disease associated with the development of ventricular arrhythmias, heart failure, and sudden cardiac death in early adulthood. Multimodality imaging is a central component in the diagnosis and evaluation of ARVC. Diagnostic criteria established by an international task force in 2010 include noninvasive parameters from echocardiography and cardiac magnetic resonance imaging. These criteria identify right ventricular structural abnormalities, chamber and outflow tract dilation, and reduced right ventricular function as features of ARVC. Echocardiography is a widely available and cost-effective technique, and it is often selected for initial evaluation. Beyond fulfillment of diagnostic criteria, features such as abnormal tricuspid annular plane excursion, increased right ventricular basal diameter, and abnormal strain patterns have been described. 3-dimensional echocardiography may also expand opportunities for structural and functional assessment of ARVC. Cardiac magnetic resonance has the ability to assess morphological and functional cardiac features of ARVC and is also a core modality in evaluation, however, tissue characterization of the right ventricle is limited by spatial resolution and low specificity for detection of pathological changes. Nonetheless, the ability of cardiac magnetic resonance to identify left ventricular involvement, offer high negative predictive value, and provide a reproducible structural evaluation of the right ventricle enhance the ability and scope of the modality. In this review, the prognostic significance of multimodality imaging is outlined, including the supplemental value of multidetector computed tomography and nuclear imaging. Strengths and weaknesses of imaging techniques, as well as future direction of multimodality assessment, are also described.
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Affiliation(s)
- Nitin Malik
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC (N.M., F.H.S.).,Georgetown University, Washington, DC (N.M., F.H.S.)
| | - Monica Mukherjee
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
| | - Katherine C Wu
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
| | - Stefan L Zimmerman
- Johns Hopkins University Department of Radiology, Baltimore, MD (S.L.Z.)
| | - Junzhen Zhan
- Johns Hopkins University Department of Pediatrics, Division of Pediatric Cardiology, Baltimore, MD (J.Z., S.K.)
| | - Hugh Calkins
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
| | - Cynthia A James
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
| | - Nisha A Gilotra
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
| | - Farooq H Sheikh
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC (N.M., F.H.S.).,Georgetown University, Washington, DC (N.M., F.H.S.)
| | - Harikrishna Tandri
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
| | - Shelby Kutty
- Johns Hopkins University Department of Pediatrics, Division of Pediatric Cardiology, Baltimore, MD (J.Z., S.K.)
| | - Allison G Hays
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
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12
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Casas G, Rodríguez-Palomares JF. Multimodality Cardiac Imaging in Cardiomyopathies: From Diagnosis to Prognosis. J Clin Med 2022; 11:578. [PMID: 35160031 PMCID: PMC8836975 DOI: 10.3390/jcm11030578] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 12/21/2022] Open
Abstract
Cardiomyopathies are a group of structural and/or functional myocardial disorders which encompasses hypertrophic, dilated, arrhythmogenic, restrictive, and other cardiomyopathies. Multimodality cardiac imaging techniques are the cornerstone of cardiomyopathy diagnosis; transthoracic echocardiography should be the first-line imaging modality due to its availability, and diagnosis should be confirmed by cardiovascular magnetic resonance, which will provide more accurate morphologic and functional information, as well as extensive tissue characterization. Multimodality cardiac imaging techniques are also essential in assessing the prognosis of patients with cardiomyopathies; left ventricular ejection fraction and late gadolinium enhancement are two of the main variables used for risk stratification, and they are incorporated into clinical practice guidelines. Finally, periodic testing with cardiac imaging techniques should also be performed due to the evolving and progressive natural history of most cardiomyopathies.
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Affiliation(s)
- Guillem Casas
- Cardiovascular Imaging Unit and Inherited Cardiovascular Diseases Unit, Cardiology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca, 08035 Barcelona, Spain
- Department de Medicina, Universitat Autónoma de Barcelona, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, 28029 Madrid, Spain
| | - José F. Rodríguez-Palomares
- Cardiovascular Imaging Unit and Inherited Cardiovascular Diseases Unit, Cardiology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca, 08035 Barcelona, Spain
- Department de Medicina, Universitat Autónoma de Barcelona, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, 28029 Madrid, Spain
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13
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Allwood RP. Differentiating right ventricular remodelling from cardiac pathology in athletes. SONOGRAPHY 2022. [DOI: 10.1002/sono.12299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Richard P. Allwood
- Cardiology Department St Vincent's Hospital Melbourne Melbourne Victoria Australia
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14
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van der Voorn SM, Te Riele ASJM, Basso C, Calkins H, Remme CA, van Veen TAB. Arrhythmogenic cardiomyopathy: pathogenesis, pro-arrhythmic remodelling, and novel approaches for risk stratification and therapy. Cardiovasc Res 2021; 116:1571-1584. [PMID: 32246823 PMCID: PMC7526754 DOI: 10.1093/cvr/cvaa084] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/10/2020] [Accepted: 03/30/2020] [Indexed: 02/07/2023] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a life-threatening cardiac disease caused by mutations in genes predominantly encoding for desmosomal proteins that lead to alterations in the molecular composition of the intercalated disc. ACM is characterized by progressive replacement of cardiomyocytes by fibrofatty tissue, ventricular dilatation, cardiac dysfunction, and heart failure but mostly dominated by the occurrence of life-threatening arrhythmias and sudden cardiac death (SCD). As SCD appears mostly in apparently healthy young individuals, there is a demand for better risk stratification of suspected ACM mutation carriers. Moreover, disease severity, progression, and outcome are highly variable in patients with ACM. In this review, we discuss the aetiology of ACM with a focus on pro-arrhythmic disease mechanisms in the early concealed phase of the disease. We summarize potential new biomarkers which might be useful for risk stratification and prediction of disease course. Finally, we explore novel therapeutic strategies to prevent arrhythmias and SCD in the early stages of ACM.
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Affiliation(s)
- Stephanie M van der Voorn
- Division of Heart and Lungs, Department of Medical Physiology, University Medical Center Utrecht, PO Box 85060, Utrecht 3508 AB, The Netherlands
| | - Anneline S J M Te Riele
- Division of Heart and Lungs, Department of Cardiology, University Medical Center Utrecht, PO Box 85060, Utrecht 3508 AB, The Netherlands
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Via A. Gabelli, 61 35121 Padova, Italy
| | - Hugh Calkins
- Johns Hopkins Hospital, Sheikh Zayed Tower 7125R, Baltimore, MD 21287, USA
| | - Carol Ann Remme
- Department of Clinical and Experimental Cardiology, Heart Centre, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Amsterdam 1105AZ, The Netherlands
| | - Toon A B van Veen
- Division of Heart and Lungs, Department of Medical Physiology, University Medical Center Utrecht, PO Box 85060, Utrecht 3508 AB, The Netherlands
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15
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Unger P, Paesmans M, Vachiery JL, Rietz M, Amzulescu M, David-Cojocariu A. Right ventricular longitudinal fractional shortening: a substitute to right ventricular free wall longitudinal strain? Heart Vessels 2021; 37:426-433. [PMID: 34402942 PMCID: PMC8369863 DOI: 10.1007/s00380-021-01928-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/13/2021] [Indexed: 11/26/2022]
Abstract
Purpose: Because of its diagnostic and prognostic value, right ventricular strain assessed by speckle-tracking imaging (RVS) has been incorporated into echocardiographic guidelines. However, it suffers from limitations including the need of good image quality and of dedicated software with inter-vendor variability. We hypothesized that RV free wall longitudinal fractional shortening (LFS) could be used as a substitute to RVS, without suffering from the aforementioned limitations. Methods: We aimed to establish in a series of non-selected consecutive patients in sinus rhythm the value of LFS, calculated as [-(TAPSE/RVdiastolic length)] and of several common echocardiographic and Doppler parameters to predict an abnormal RV function, defined as RVS > − 20.2%. Results: Among 144 consecutive patients, poor image quality precluded the assessment of RVS and of LFS in 31 and 4 patients, respectively (P = 0.0018), resulting in a final study group of 113 patients. The intraclass correlation coefficients for inter- and intra-observer variability were 0.97 (95% CI 0.92; 0.98) and 0.93 (CI 0.92; 0.98) for LFS and RVS, respectively. Among all tested RV function indices, LFS best correlated with RVS (R 0.97, 95% CI 0.81; 0.91). Bland–Altman analysis for the comparison between LFS and RVS showed no systematic bias. The area under the ROC-curve of the various RV function indices to detect abnormal RVS was best for LFS (0.97, 95% CI 0.94–1), with sensitivity, specificity, negative and positive predictive value of 83%, 96%, 96%, and 83%, respectively. Conclusion: LFS performs reasonably well to predict abnormal RVS and is more often feasible than RVS.
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Affiliation(s)
- Philippe Unger
- Cardiology Department, CHU Saint-Pierre, Université Libre de Bruxelles, 105 rue aux Laines, 1000, Brussels, Belgium.
| | - Marianne Paesmans
- Institut Jules Bordet, Information Management Unit, Brussels, Belgium
| | - Jean-Luc Vachiery
- Cardiology Department, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Michael Rietz
- Cardiology Department, CHU Saint-Pierre, Université Libre de Bruxelles, 105 rue aux Laines, 1000, Brussels, Belgium
| | - Mihaela Amzulescu
- Cardiology Department, CHU Saint-Pierre, Université Libre de Bruxelles, 105 rue aux Laines, 1000, Brussels, Belgium
| | - Aurelia David-Cojocariu
- Cardiology Department, CHU Saint-Pierre, Université Libre de Bruxelles, 105 rue aux Laines, 1000, Brussels, Belgium
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16
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Claeys M, Claessen G, Claus P, De Bosscher R, Dausin C, Voigt JU, Willems R, Heidbuchel H, La Gerche A. Right ventricular strain rate during exercise accurately identifies male athletes with right ventricular arrhythmias. Eur Heart J Cardiovasc Imaging 2021; 21:282-290. [PMID: 31578557 DOI: 10.1093/ehjci/jez228] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/19/2019] [Indexed: 11/13/2022] Open
Abstract
AIMS Athletes with right ventricular (RV) arrhythmias, even in the absence of desmosomal mutations, may have subtle RV abnormalities which can be unmasked by deformation imaging. As exercise places a disproportionate stress on the right ventricle, evaluation of cardiac function and deformation during exercise might improve diagnostic performance. METHODS AND RESULTS We performed bicycle stress echocardiography in 17 apparently healthy endurance athletes (EAs), 12 non-athletic controls (NAs), and 17 athletes with RV arrhythmias without desmosomal mutations (EI-ARVCs) and compared biventricular function at rest and during low (25% of upright peak power) and moderate intensity (60%). At rest, we observed no differences in left ventricular (LV) or RV function between groups. During exercise, however, the increase in RV fractional area change (RVFAC), RV free wall strain (RVFWSL), and strain rate (RVFWSRL) were significantly attenuated in EI-ARVCs as compared to EAs and NAs. At moderate exercise intensity, EI-ARVCs had a lower RVFAC, RVFWSL, and RVFWSRL (all P < 0.01) compared to the control groups. Exercise-related increases in LV ejection fraction, strain, and strain rate were also attenuated in EI-ARVCs (P < 0.05 for interaction). Exercise but not resting parameters identified EI-ARVCs and RVFWSRL with a cut-off value of >-2.35 at moderate exercise intensity had the greatest accuracy to detect EI-ARVCs (area under the curve 0.95). CONCLUSION Exercise deformation imaging holds promise as a non-invasive diagnostic tool to identify intrinsic RV dysfunction concealed at rest. Strain rate appears to be the most accurate parameter and should be incorporated in future, prospective studies to identify subclinical disease in an early stage.
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Affiliation(s)
- Mathias Claeys
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, BE-3000 Leuven, Belgium.,Division of Cardiology, University Hospitals Leuven, Herestraat 49, BE-3000 Leuven, Belgium
| | - Guido Claessen
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, BE-3000 Leuven, Belgium.,Division of Cardiology, University Hospitals Leuven, Herestraat 49, BE-3000 Leuven, Belgium.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Piet Claus
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, BE-3000 Leuven, Belgium
| | - Ruben De Bosscher
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, BE-3000 Leuven, Belgium.,Division of Cardiology, University Hospitals Leuven, Herestraat 49, BE-3000 Leuven, Belgium
| | - Christoph Dausin
- Department of Movement Sciences, KU Leuven, Tervuursevest 101, Box 1500, BE-3001 Leuven, Belgium
| | - Jens-Uwe Voigt
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, BE-3000 Leuven, Belgium.,Division of Cardiology, University Hospitals Leuven, Herestraat 49, BE-3000 Leuven, Belgium
| | - Rik Willems
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, BE-3000 Leuven, Belgium.,Division of Cardiology, University Hospitals Leuven, Herestraat 49, BE-3000 Leuven, Belgium
| | - Hein Heidbuchel
- Division of Cardiology, University Hospital Antwerp and University of Antwerp, Wilrijkstraat 10, BE-2650 Edegem, Belgium
| | - Andre La Gerche
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, BE-3000 Leuven, Belgium.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
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17
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Migliore F, Mattesi G, Zorzi A, Bauce B, Rigato I, Corrado D, Cipriani A. Arrhythmogenic Cardiomyopathy-Current Treatment and Future Options. J Clin Med 2021; 10:2750. [PMID: 34206637 PMCID: PMC8268983 DOI: 10.3390/jcm10132750] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/07/2021] [Accepted: 06/14/2021] [Indexed: 02/07/2023] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an inheritable heart muscle disease characterised pathologically by fibrofatty myocardial replacement and clinically by ventricular arrhythmias (VAs) and sudden cardiac death (SCD). Although, in its original description, the disease was believed to predominantly involve the right ventricle, biventricular and left-dominant variants, in which the myocardial lesions affect in parallel or even mostly the left ventricle, are nowadays commonly observed. The clinical management of these patients has two main purposes: the prevention of SCD and the control of arrhythmic and heart failure (HF) events. An implantable cardioverter defibrillator (ICD) is the only proven lifesaving treatment, despite significant morbidity because of device-related complications and inappropriate shocks. Selection of patients who can benefit the most from ICD therapy is one of the most challenging issues in clinical practice. Risk stratification in ACM patients is mostly based on arrhythmic burden and ventricular dysfunction severity, although other clinical features resulting from electrocardiogram and imaging modalities such as cardiac magnetic resonance may have a role. Medical therapy is crucial for treatment of VAs and the prevention of negative ventricular remodelling. In this regard, the efficacy of novel anti-HF molecules and drugs acting on the inflammatory pathway in patients with ACM is, to date, unknown. Catheter ablation represents an effective strategy to treat ventricular tachycardia relapses and recurrent ICD shocks. The present review will address the current strategies for prevention of SCD and treatment of VAs and HF in patients with ACM.
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Affiliation(s)
- Federico Migliore
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Giulia Mattesi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Barbara Bauce
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Ilaria Rigato
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
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Kirkels FP, Lie ØH, Cramer MJ, Chivulescu M, Rootwelt-Norberg C, Asselbergs FW, Teske AJ, Haugaa KH. Right Ventricular Functional Abnormalities in Arrhythmogenic Cardiomyopathy: Association With Life-Threatening Ventricular Arrhythmias. JACC Cardiovasc Imaging 2021; 14:900-910. [PMID: 33582062 DOI: 10.1016/j.jcmg.2020.12.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES This study aimed to perform an external validation of the value of right ventricular (RV) deformation patterns and RV mechanical dispersion in patients with arrhythmogenic cardiomyopathy (AC). Secondly, this study assessed the association of these parameters with life-threatening ventricular arrhythmia (VA). BACKGROUND Subtle RV dysfunction assessed by echocardiographic deformation imaging is valuable in AC diagnosis and risk prediction. Two different methods have emerged, the RV deformation pattern recognition and RV mechanical dispersion, but these have neither been externally validated nor compared. METHODS We analyzed AC probands and mutation-positive family members, matched from 2 large European referral centers. We performed speckle tracking echocardiography, whereby we classified the subtricuspid deformation patterns from normal to abnormal and assessed RV mechanical dispersion from 6 segments. We defined VA as sustained ventricular tachycardia, appropriate implantable cardioverter-defibrillator therapy, or aborted cardiac arrest. RESULTS We included 160 subjects, 80 from each center (43% proband, 55% women, age 41 ± 17 years). VA had occurred in 47 (29%) subjects. In both cohorts, patients with a history of VA showed abnormal deformation patterns (96% and 100%) and had greater RV mechanical dispersion (53 ± 30 ms vs. 30 ± 21 ms; p < 0.001 for the total cohort). Both parameters were independently associated to VA (adjusted odds ratio: 2.71 [95% confidence interval: 1.47 to 5.00] per class step-up, and 1.26 [95% confidence interval: 1.07 to 1.49]/10 ms, respectively). The association with VA significantly improved when adding RV mechanical dispersion to pattern recognition (net reclassification improvement 0.42; p = 0.02 and integrated diagnostic improvement 0.06; p = 0.01). CONCLUSIONS We externally validated 2 RV dysfunction parameters in AC. Adding RV mechanical dispersion to RV deformation patterns significantly improved the association with life-threatening VA, indicating incremental value.
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Affiliation(s)
- Feddo P Kirkels
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Øyvind H Lie
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Maarten J Cramer
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Monica Chivulescu
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Christine Rootwelt-Norberg
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Folkert W Asselbergs
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands; Utrecht University, Utrecht, the Netherlands; Institute of Cardiovascular Science and Institute of Health Informatics, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Arco J Teske
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Kristina H Haugaa
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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Cardiac Phenotypes and Markers of Adverse Outcome in Elite Athletes With Ventricular Arrhythmias. JACC Cardiovasc Imaging 2020; 14:148-158. [PMID: 33129723 DOI: 10.1016/j.jcmg.2020.07.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/24/2020] [Accepted: 07/29/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVES This study describes the cardiac phenotypes and markers of adverse outcome in athletes with ventricular arrhythmias with no other discernable etiology than high exercise doses. BACKGROUND Little is known about phenotypes and risk markers of life-threatening arrhythmic events in athletes with ventricular arrhythmia. METHODS We compared high-performance athletes who have ventricular arrhythmia with healthy controls using clinical data and cardiac imaging. None of the patients had family history of arrhythmogenic cardiomyopathy or any other discernable etiology of ventricular arrhythmia. Right (RV) and left ventricular (LV) function was assessed by echocardiographic longitudinal strain (right ventricular free wall strain longitudinal [RVFWSL] and left ventricular global longitudinal strain [LVGLS]). Mechanical dispersion was defined as the standard deviation of time to peak strain in 16 LV segments. RV ejection fraction and presence of late gadolinium enhancement was assessed by cardiac magnetic resonance. RESULTS We included 43 athletes (45 ± 14 years of age, 16% female) with ventricular arrhythmias and 30 healthy athletes (41 ± 9 years of age, 7% female). Athletes with ventricular arrhythmias had worse RV function than healthy athletes by echocardiography (RVFWSL: -22.9 ± 4.8% vs. -26.6 ± 3.3%; p < 0.001) and by cardiac magnetic resonance (RV ejection fraction 48 ± 7% vs. 52 ± 6%; p = 0.04), and had more late gadolinium enhancement (24% vs. 3%; p = 0.03). Life-threatening arrhythmic events (aborted cardiac arrest, sustained ventricular tachycardia, or appropriate implantable cardioverter-defibrillator therapy) had occurred in 23 (53%) athletes with ventricular arrhythmias. These had impaired LV function compared to those with less severe ventricular arrhythmias (LVGLS: -17.1 ± 3.0% vs. -18.8 ± 2.0%; p = 0.04). LV mechanical dispersion was an independent marker of life-threatening events (adjusted odds ratio: 2.2 [1.1 to 4.8] by 10 ms increments; p = 0.03). CONCLUSIONS Athletes with ventricular arrhythmias had impaired RV function and more myocardial fibrosis compared to healthy athletes. Athletes with life-threatening arrhythmic events had additional LV contraction abnormalities. These phenotypes mimic arrhythmogenic cardiomyopathy and may potentially be induced by high doses of exercise in susceptible individuals.
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Cavigli L, Focardi M, Cameli M, Mandoli GE, Mondillo S, D'Ascenzi F. The right ventricle in “Left-sided” cardiomyopathies: The dark side of the moon. Trends Cardiovasc Med 2020; 31:476-484. [DOI: 10.1016/j.tcm.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/26/2020] [Accepted: 10/09/2020] [Indexed: 02/07/2023]
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Baggish AL, Battle RW, Beaver TA, Border WL, Douglas PS, Kramer CM, Martinez MW, Mercandetti JH, Phelan D, Singh TK, Weiner RB, Williamson E. Recommendations on the Use of Multimodality Cardiovascular Imaging in Young Adult Competitive Athletes: A Report from the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2020; 33:523-549. [PMID: 32362332 DOI: 10.1016/j.echo.2020.02.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Robert W Battle
- University of Virginia Health System, Charlottesville, Virginia
| | | | - William L Border
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Dermot Phelan
- Sanger Heart and Vascular Institute in Atrium Health, Charlotte, North Carolina
| | | | - Rory B Weiner
- Massachusetts General Hospital, Boston, Massachusetts
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Pelliccia A, Caselli S, Sharma S, Basso C, Bax JJ, Corrado D, D'Andrea A, D'Ascenzi F, Di Paolo FM, Edvardsen T, Gati S, Galderisi M, Heidbuchel H, Nchimi A, Nieman K, Papadakis M, Pisicchio C, Schmied C, Popescu BA, Habib G, Grobbee D, Lancellotti P. European Association of Preventive Cardiology (EAPC) and European Association of Cardiovascular Imaging (EACVI) joint position statement: recommendations for the indication and interpretation of cardiovascular imaging in the evaluation of the athlete's heart. Eur Heart J 2019; 39:1949-1969. [PMID: 29029207 DOI: 10.1093/eurheartj/ehx532] [Citation(s) in RCA: 188] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/23/2017] [Indexed: 12/14/2022] Open
Affiliation(s)
- Antonio Pelliccia
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
| | - Stefano Caselli
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
| | | | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Jeroen J Bax
- Departmentt of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Antonello D'Andrea
- Department of Cardiology, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Flavio D'Ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Fernando M Di Paolo
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
| | - Thor Edvardsen
- Department of Cardiology, Center of Cardiologic Innovation, Oslo University Hospital, University of Oslo, Oslo, Norway
| | | | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Hein Heidbuchel
- Jessa Hospital, Hasselt University and Heart Center Hasselt, Hasselt, Belgium
| | | | - Koen Nieman
- Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Cataldo Pisicchio
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
| | | | - Bogdan A Popescu
- Institute of Cardiovascular Diseases, University of Medicine and Pharmacy 'Carol Davila', Bucharest, Romania
| | - Gilbert Habib
- Department of Cardiology, Hôpital La Timone, Marseille, France
| | - Diederick Grobbee
- Department of Epidemiology, University Medical Center, Utrecht, The Netherlands
| | - Patrizio Lancellotti
- Department of Cardiology, GIGA Cardiovascular Sciences, University of Liège Hospital, Valvular Disease Clinic, Belgium
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Park JH. Two-dimensional Echocardiographic Assessment of Myocardial Strain: Important Echocardiographic Parameter Readily Useful in Clinical Field. Korean Circ J 2019; 49:908-931. [PMID: 31456367 PMCID: PMC6753023 DOI: 10.4070/kcj.2019.0200] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 07/03/2019] [Indexed: 01/14/2023] Open
Abstract
Echocardiography is the first and is the most-available imaging modality for many cardiovascular diseases, and echocardiographic parameters can give much important information for diagnosis, treatment, and prognostic evaluations. Left ventricular ejection fraction (LVEF) is the most commonly used echocardiographic parameter for left ventricular (LV) systolic function. Although LVEF is used routinely in daily practice, it is calculated from volumetric change without representing true myocardial properties. Recently, strain echocardiography has been used to objectively measure myocardial deformation. Myocardial strain can give accurate information about intrinsic myocardial function, and it can be used to detect early-stage cardiovascular diseases, monitor myocardial changes with specific therapies, differentiate cardiomyopathies, and predict the prognosis of several cardiovascular diseases. Although strain echocardiography has been applied to measure the right ventricle and left atrium, in addition to analyzing the LV, many cardiologists who are not imaging specialists are unaware of its clinical use and importance. Therefore, this review describes the measurement and clinical utility of 2-dimensional strain analysis in various cardiovascular diseases.
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Affiliation(s)
- Jae Hyeong Park
- Department of Cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea.
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24
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Abstract
Right ventricular (RV) function has proven to be a prognostic factor in heart failure with reduced and preserved ejection fraction and in pulmonary hypertension. RV function is also a cornerstone in the management of novel clinical issues, such as mechanical circulatory support devices or grown-up congenital heart disease patients. Despite the notable amount of circumferentially oriented myofibers in the subepicardial layer of the RV myocardium, the non-longitudinal motion directions are often neglected in the everyday assessment of RV function by echocardiography. However, the complex RV contraction pattern incorporates different motion components along three anatomically relevant axes: longitudinal shortening with traction of the tricuspid annulus towards the apex, radial motion of free wall often referred as the "bellows effect", and anteroposterior shortening of the chamber by stretching the free wall over the septum. Advanced echocardiographic techniques, such as speckle-tracking and 3D echocardiography allow an in-depth characterization of RV mechanical pattern, providing better understanding of RV systolic and diastolic function. In our current review, we summarize the existing knowledge regarding RV mechanical adaptation to pressure- and/or volume-overloaded states and also other physiologic or pathologic conditions.
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MESH Headings
- Adaptation, Physiological/physiology
- Arrhythmogenic Right Ventricular Dysplasia/physiopathology
- Cardiac Surgical Procedures/adverse effects
- Cardiomegaly, Exercise-Induced/physiology
- Echocardiography, Three-Dimensional
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/physiopathology
- Heart Failure/complications
- Heart Failure/physiopathology
- Heart Ventricles/diagnostic imaging
- Humans
- Hypertension, Pulmonary/complications
- Hypertension, Pulmonary/physiopathology
- Ventricular Dysfunction, Right/diagnostic imaging
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Function, Right/physiology
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Affiliation(s)
- Attila Kovács
- Semmelweis University Heart and Vascular Center, Városmajor St. 68, Budapest, H-1122, Hungary.
| | - Bálint Lakatos
- Semmelweis University Heart and Vascular Center, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Márton Tokodi
- Semmelweis University Heart and Vascular Center, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Béla Merkely
- Semmelweis University Heart and Vascular Center, Városmajor St. 68, Budapest, H-1122, Hungary
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Sanz-de la Garza M, Giraldeau G, Marin J, Imre Sarvari S, Guasch E, Gabrielli L, Brambila C, Bijnens B, Sitges M. Should the septum be included in the assessment of right ventricular longitudinal strain? An ultrasound two-dimensional speckle-tracking stress study. Int J Cardiovasc Imaging 2019; 35:1853-1860. [PMID: 31129743 DOI: 10.1007/s10554-019-01633-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/18/2019] [Indexed: 12/01/2022]
Abstract
Right ventricular longitudinal strain (RVLS) by 2D speckle-tracking echocardiography (2D-STE) is a useful parameter for assessing systolic function. However, the exact method to perform it is not well defined as some authors evaluate only free wall (FW) segments while others include all six RV segments. To compare the assessment of RVLS at rest and during exercise by these two approaches. Echocardiography was performed on 80 healthy subjects at rest and during exercise. The analysis consisted of standard and 2D-STE assessment of RV global and segmental strain tracing only RVFW and also tracing all six RV segments. At rest, RVLS could be assessed in 78 (feasibility 97.5%) subjects by both methods. However, during exercise, RVLS by RVFW method was feasible in 67 (83.8%) as compared to 74 (92.5%) by RV6S approach. Both at rest and during exercise, RVLS values by the two methods showed excellent correlation (r = > 0.90). However, RVLS values assessed by RV6S were lower (absolute values) than those by RVFW approach (RV6S vs. RVFW; rest: - 27.0 ± 3.9 vs. - 9.5 ± 3.9, p < 0.001 and exercise: - 30.7 ± 5.2 vs. - 33.3 ± 5.1, p < 0.001). Furthermore, basal strain was higher and apical strain lower (absolute values) by RV6S approach. At rest, reproducibility for RVLS was excellent and similar for the two methods. However, during exercise, reproducibility for RVFW method was poorer, especially at the apex. The two currently described methods for RVLS assessment by 2D-STE demonstrated excellent agreement. However, the RV6S approach seemed to be more feasible and reproducible, particularly during exercise. Moreover, global and segmental strain values are different with both methods and should not be interchanged.
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Affiliation(s)
- Maria Sanz-de la Garza
- Cardiovascular Institute, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación Biomèdica en Red Enfermedades Cardiovasculares (CIBERCV), Villarroel 170, 08036, Barcelona, Spain.
| | - Geneviève Giraldeau
- Cardiovascular Institute, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación Biomèdica en Red Enfermedades Cardiovasculares (CIBERCV), Villarroel 170, 08036, Barcelona, Spain
| | - Josefa Marin
- Cardiovascular Institute, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación Biomèdica en Red Enfermedades Cardiovasculares (CIBERCV), Villarroel 170, 08036, Barcelona, Spain
| | - Sebastian Imre Sarvari
- Cardiovascular Institute, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación Biomèdica en Red Enfermedades Cardiovasculares (CIBERCV), Villarroel 170, 08036, Barcelona, Spain
| | - Eduard Guasch
- Cardiovascular Institute, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación Biomèdica en Red Enfermedades Cardiovasculares (CIBERCV), Villarroel 170, 08036, Barcelona, Spain
| | - Luigi Gabrielli
- Cardiovascular Institute, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación Biomèdica en Red Enfermedades Cardiovasculares (CIBERCV), Villarroel 170, 08036, Barcelona, Spain
| | - Carlos Brambila
- Cardiovascular Institute, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación Biomèdica en Red Enfermedades Cardiovasculares (CIBERCV), Villarroel 170, 08036, Barcelona, Spain
| | - Bart Bijnens
- Institució Catalana de Recerca I Estudis Avançats (ICREA), Universitat Pompeu Fabra Barcelona, Carrer de Roc Boronat 138, 08018, Barcelona, Spain
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación Biomèdica en Red Enfermedades Cardiovasculares (CIBERCV), Villarroel 170, 08036, Barcelona, Spain
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Pieles GE, Grosse-Wortmann L, Hader M, Fatah M, Chungsomprasong P, Slorach C, Hui W, Fan CPS, Manlhiot C, Mertens L, Hamilton R, Friedberg MK. Association of Echocardiographic Parameters of Right Ventricular Remodeling and Myocardial Performance With Modified Task Force Criteria in Adolescents With Arrhythmogenic Right Ventricular Cardiomyopathy. Circ Cardiovasc Imaging 2019; 12:e007693. [DOI: 10.1161/circimaging.118.007693] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Guido E. Pieles
- Department of Pediatrics, Labatt Family Heart Centre (G.E.P., L.G.-W., M.H., M.F., P.C., C.S., W.H., C.-P.S.F., C.M., L.M., R.H., M.K.F.), Hospital for Sick Children, University of Toronto, ON, Canada
- NIHR Cardiovascular Biomedical Research Centre, Bristol Heart Institute, United Kingdom (G.E.P.)
| | - Lars Grosse-Wortmann
- Department of Pediatrics, Labatt Family Heart Centre (G.E.P., L.G.-W., M.H., M.F., P.C., C.S., W.H., C.-P.S.F., C.M., L.M., R.H., M.K.F.), Hospital for Sick Children, University of Toronto, ON, Canada
- Department of Diagnostic Imaging (L.G.-W.), Hospital for Sick Children, University of Toronto, ON, Canada
- Department of Pediatrics (L.G.-W.), Hospital for Sick Children, University of Toronto, ON, Canada
| | - Majeda Hader
- Department of Pediatrics, Labatt Family Heart Centre (G.E.P., L.G.-W., M.H., M.F., P.C., C.S., W.H., C.-P.S.F., C.M., L.M., R.H., M.K.F.), Hospital for Sick Children, University of Toronto, ON, Canada
| | - Meena Fatah
- Department of Pediatrics, Labatt Family Heart Centre (G.E.P., L.G.-W., M.H., M.F., P.C., C.S., W.H., C.-P.S.F., C.M., L.M., R.H., M.K.F.), Hospital for Sick Children, University of Toronto, ON, Canada
| | - Paweena Chungsomprasong
- Department of Pediatrics, Labatt Family Heart Centre (G.E.P., L.G.-W., M.H., M.F., P.C., C.S., W.H., C.-P.S.F., C.M., L.M., R.H., M.K.F.), Hospital for Sick Children, University of Toronto, ON, Canada
| | - Cameron Slorach
- Department of Pediatrics, Labatt Family Heart Centre (G.E.P., L.G.-W., M.H., M.F., P.C., C.S., W.H., C.-P.S.F., C.M., L.M., R.H., M.K.F.), Hospital for Sick Children, University of Toronto, ON, Canada
| | - Wei Hui
- Department of Pediatrics, Labatt Family Heart Centre (G.E.P., L.G.-W., M.H., M.F., P.C., C.S., W.H., C.-P.S.F., C.M., L.M., R.H., M.K.F.), Hospital for Sick Children, University of Toronto, ON, Canada
| | - Chun-Po Steve Fan
- Department of Pediatrics, Labatt Family Heart Centre (G.E.P., L.G.-W., M.H., M.F., P.C., C.S., W.H., C.-P.S.F., C.M., L.M., R.H., M.K.F.), Hospital for Sick Children, University of Toronto, ON, Canada
| | - Cedric Manlhiot
- Department of Pediatrics, Labatt Family Heart Centre (G.E.P., L.G.-W., M.H., M.F., P.C., C.S., W.H., C.-P.S.F., C.M., L.M., R.H., M.K.F.), Hospital for Sick Children, University of Toronto, ON, Canada
| | - Luc Mertens
- Department of Pediatrics, Labatt Family Heart Centre (G.E.P., L.G.-W., M.H., M.F., P.C., C.S., W.H., C.-P.S.F., C.M., L.M., R.H., M.K.F.), Hospital for Sick Children, University of Toronto, ON, Canada
| | - Robert Hamilton
- Department of Pediatrics, Labatt Family Heart Centre (G.E.P., L.G.-W., M.H., M.F., P.C., C.S., W.H., C.-P.S.F., C.M., L.M., R.H., M.K.F.), Hospital for Sick Children, University of Toronto, ON, Canada
| | - Mark K. Friedberg
- Department of Pediatrics, Labatt Family Heart Centre (G.E.P., L.G.-W., M.H., M.F., P.C., C.S., W.H., C.-P.S.F., C.M., L.M., R.H., M.K.F.), Hospital for Sick Children, University of Toronto, ON, Canada
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Heermann P, Fritsch H, Koopmann M, Sporns P, Paul M, Heindel W, Schulze-Bahr E, Schülke C. Biventricular myocardial strain analysis using cardiac magnetic resonance feature tracking (CMR-FT) in patients with distinct types of right ventricular diseases comparing arrhythmogenic right ventricular cardiomyopathy (ARVC), right ventricular outflow-tract tachycardia (RVOT-VT), and Brugada syndrome (BrS). Clin Res Cardiol 2019; 108:1147-1162. [DOI: 10.1007/s00392-019-01450-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/05/2019] [Indexed: 12/25/2022]
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Mast TP, Taha K, Cramer MJ, Lumens J, van der Heijden JF, Bouma BJ, van den Berg MP, Asselbergs FW, Doevendans PA, Teske AJ. The Prognostic Value of Right Ventricular Deformation Imaging in Early Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Cardiovasc Imaging 2019; 12:446-455. [PMID: 29550307 DOI: 10.1016/j.jcmg.2018.01.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the prognostic value of echocardiographic deformation imaging in arrhythmogenic right ventricular cardiomyopathy (ARVC) to optimize family screening protocols. BACKGROUND ARVC is characterized by variable disease expressivity among family members, which complicates family screening protocols. Previous reports have shown that echocardiographic deformation imaging detects abnormal right ventricular (RV) deformation in the absence of established disease expression in ARVC. METHODS First-degree relatives of patients with ARVC were evaluated according to 2010 task force criteria, including RV deformation imaging (n = 128). Relatives fulfilling structural task force criteria were excluded for further analysis. At baseline, deformation patterns of the subtricuspid region were scored as type I (normal deformation), type II (delayed onset, decreased systolic peak, and post-systolic shortening), or type III (systolic stretching and large post-systolic shortening). The final study population comprised relatives who underwent a second evaluation during follow-up. Disease progression was defined as the development of a new 2010 task force criterion during follow-up that was absent at baseline. RESULTS Sixty-five relatives underwent a second evaluation after a mean follow-up period of 3.7 ± 2.1 years. At baseline, 28 relatives (43%) had normal deformation (type I), and 37 relatives (57%) had abnormal deformation (type II or III) in the subtricuspid region. Disease progression occurred in 4% of the relatives with normal deformation at baseline and in 43% of the relatives with abnormal deformation at baseline (p < 0.001). Positive and negative predictive values of abnormal deformation were, respectively, 43% (95% confidence interval: 27% to 61%) and 96% (95% confidence interval: 82% to 100%). CONCLUSIONS Normal RV deformation in the subtricuspid region is associated with absence of disease progression during nearly 4-year follow-up in relatives of patients with ARVC. Abnormal RV deformation seems to precede the established signs of ARVC. RV deformation imaging may potentially play an important role in ARVC family screening protocols.
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Affiliation(s)
- Thomas P Mast
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Cardiology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Karim Taha
- University of Amsterdam, Amsterdam, the Netherlands
| | - Maarten J Cramer
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Joost Lumens
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Jeroen F van der Heijden
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Berto J Bouma
- Division of Cardiology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Maarten P van den Berg
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands; Durrer Center for Cardiovascular Research, ICIN-Netherlands Heart Institute, Utrecht, the Netherlands; Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Pieter A Doevendans
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Arco J Teske
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands.
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Cardiac magnetic resonance based deformation imaging: role of feature tracking in athletes with suspected arrhythmogenic right ventricular cardiomyopathy. Int J Cardiovasc Imaging 2018; 35:529-538. [PMID: 30382474 PMCID: PMC6453871 DOI: 10.1007/s10554-018-1478-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/16/2018] [Indexed: 12/17/2022]
Abstract
Both, arrhythmogenic right ventricular cardiomyopathy (ARVC) and regular training are associated with right ventricular (RV) remodelling. Cardiac magnetic resonance (CMR) is given an important role in the diagnosis of ARVC in current task force criteria (TFC), however, they contain no cut-off values for athletes. We aimed to confirm the added value of feature tracking and to provide new cut-off values to differentiate between ARVC and athlete's heart. Healthy athletes with training of minimal 15 h/week (n = 34), patients with definite ARVC (n = 34) and highly trained athletes with ARVC (n = 8) were examined by CMR. Left and right ventricular volumes and masses were determined. Global right and left ventricular, and regional strain analysis for the RV free wall was performed using feature tracking on balanced steady-state free precession cine images. 94% of healthy athletes showed RV dilatation of the proposed TFC, 14.7% showed RV ejection fraction (RVEF) between 45-50%, none of them had RVEF < 45%. Although RVEF showed the highest accuracy in differentiating between athlete's heart and ARVC, only 37.5% of athletes with ARVC showed RVEF < 45%. The only parameters falling in the pathological range (based on our established cut-off values: > - 25.6 and > - 1.4, respectively) in all athletes with ARVC were the strain and strain rate of the midventricular RV free wall. Establishing RVEF and RV strain analysis provides an important tool to distinguish ARVC from athlete's heart. CMR based regional strain and strain rate values may help to identify ARVC even in highly trained athletes with preserved RVEF.
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Cunningham S, Aona B, Antoon K, Rush J, Barton B. Echocardiographic assessment of right ventricular systolic function in Boxers with arrhythmogenic right ventricular cardiomyopathy. J Vet Cardiol 2018; 20:343-353. [DOI: 10.1016/j.jvc.2018.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 07/10/2018] [Accepted: 07/18/2018] [Indexed: 11/29/2022]
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Eising JB, van der Ent CK, Teske AJ, Vanderschuren MM, Uiterwaal CS, Meijboom FJ. Young patients with cystic fibrosis demonstrate subtle alterations of the cardiovascular system. J Cyst Fibros 2018; 17:643-649. [DOI: 10.1016/j.jcf.2017.12.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 12/21/2017] [Accepted: 12/21/2017] [Indexed: 11/30/2022]
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Lee JH, Park JH. Strain Analysis of the Right Ventricle Using Two-dimensional Echocardiography. J Cardiovasc Imaging 2018; 26:111-124. [PMID: 30310878 PMCID: PMC6160817 DOI: 10.4250/jcvi.2018.26.e11] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 06/11/2018] [Accepted: 08/28/2018] [Indexed: 01/12/2023] Open
Abstract
Right ventricular (RV) systolic dysfunction has been identified as an independent prognostic marker of many cardiovascular diseases. However, there are problems in measuring RV systolic function objectively and identification of RV dysfunction using conventional echocardiography. Strain echocardiography is a new imaging modality to measure myocardial deformation. It can measure intrinsic myocardial function and has been used to measure regional and global left ventricular (LV) function. Although the RV has different morphologic characteristics than the LV, strain analysis of the RV is feasible. After strain echocardiography was introduced to measure RV systolic function, it became more popular and was incorporated into recent echocardiographic guidelines. Recent studies showed that RV global longitudinal strain (RVGLS) can be used as an objective index of RV systolic function with prognostic significance. In this review, we discuss RVGLS measurement, normal reference values, and the clinical importance of RVGLS.
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Affiliation(s)
- Ju-Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jae-Hyeong Park
- Department of Cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
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Abstract
Modern advanced imaging techniques have allowed increasingly more rigorous assessment of the cardiac structure and function of several types of cardiomyopathies. In contemporary cardiology practice, echocardiography and cardiac magnetic resonance imaging are widely used to provide a basic framework in the evaluation and management of cardiomyopathies. Echocardiography is the quintessential imaging technique owing to its unique ability to provide real-time images of the beating heart with good temporal resolution, combined with its noninvasive nature, cost-effectiveness, availability, and portability. Cardiac magnetic resonance imaging provides data that are both complementary and uniquely distinct, thus allowing for insights into the disease process that until recently were not possible. The new catchphrase in the evaluation of cardiomyopathies is multimodality imaging, which is purported to be the efficient integration of various methods of cardiovascular imaging to improve the ability to diagnose, guide therapy, or predict outcomes. It usually involves an integrated approach to the use of echocardiography and cardiac magnetic resonance imaging for the assessment of cardiomyopathies, and, on occasion, single-photon emission computed tomography and such specialized techniques as pyrophosphate scanning.
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Affiliation(s)
- M Fuad Jan
- From Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, WI
| | - A Jamil Tajik
- From Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, WI.
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Role of Two-Dimensional Speckle-Tracking Echocardiography Strain in the Assessment of Right Ventricular Systolic Function and Comparison with Conventional Parameters. J Am Soc Echocardiogr 2017; 30:937-946.e6. [PMID: 28803684 DOI: 10.1016/j.echo.2017.06.016] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Indexed: 11/24/2022]
Abstract
Despite the already well-known role the right side of the heart plays in many diseases, right ventricular (RV) function has only recently been carefully considered. Echocardiography is the first-line diagnostic technique for the assessment of the right ventricle and right atrium, whereas cardiac magnetic resonance is considered the gold standard but is limited by cost and availability. According to the current guidelines, systolic RV function should be assessed by several conventional measurements, but the efficacy of these parameters as diagnostic and prognostic tools has been questioned by many authors. The development in recent years of myocardial deformation imaging techniques and their application to the right heart chambers has allowed deeper evaluation of the importance of RV function in the pathophysiology of a large number of cardiovascular conditions, but the real value of this new tool has not been completely clarified. The aim of this review is to provide a wide and careful analysis of findings available in the literature about the assessment of RV systolic function by strain measurements, comparing them with conventional parameters and evaluating their role in several clinical settings.
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Combination of ECG and Echocardiography for Identification of Arrhythmic Events in Early ARVC. JACC Cardiovasc Imaging 2017; 10:503-513. [DOI: 10.1016/j.jcmg.2016.06.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/27/2016] [Accepted: 06/30/2016] [Indexed: 11/19/2022]
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Teske AJ, Mast TP. Moving From Multimodality Diagnostic Tests Toward Multimodality Risk Stratification in ARVC. JACC Cardiovasc Imaging 2017; 10:514-517. [DOI: 10.1016/j.jcmg.2016.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/06/2016] [Accepted: 09/14/2016] [Indexed: 11/25/2022]
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Haugaa KH, Basso C, Badano LP, Bucciarelli-Ducci C, Cardim N, Gaemperli O, Galderisi M, Habib G, Knuuti J, Lancellotti P, McKenna W, Neglia D, Popescu BA, Edvardsen T. Comprehensive multi-modality imaging approach in arrhythmogenic cardiomyopathy-an expert consensus document of the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2017; 18:237-253. [PMID: 28069601 PMCID: PMC5837226 DOI: 10.1093/ehjci/jew229] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022] Open
Abstract
Arrhythmogenic cardiomyopathy (AC) is a progressive disease with high risk of life-threatening ventricular arrhythmias. A genetic mutation is found in up to 50-60% of probands, mostly affecting desmosomal genes. Diagnosis of AC is made by a combination of data from different modalities including imaging, electrocardiogram, Holter monitoring, family history, genetic testing, and tissue properties. Being a progressive cardiomyopathy, repeated cardiac imaging is needed in AC patients. Repeated imaging is important also for risk assessment of ventricular arrhythmias. This expert consensus document gives clinical recommendations for how to use multi-modality imaging in the different aspects of AC disease, including diagnosis, family screening, follow-up, risk assessment, and differential diagnosis.
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Affiliation(s)
- Kristina H Haugaa
- Department of Cardiology, Center for Cardiological Innovation and Institute for Surgical Research, Oslo University Hospital, Oslo and University of Oslo, Oslo, Norway
| | - Cristina Basso
- Cardiovascular Pathology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Luigi P Badano
- Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Chiara Bucciarelli-Ducci
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol NHS Trust and University of Bristol and Bristol NIRH Cardiovascular Biomedical Research Unit, Bristol, UK
| | - Nuno Cardim
- Department of Cardiology, Multimodality Cardiac Imaging Center, Sports Cardiology and Cardiomyopathies Center, Hospital da Luz, Lisbon, Portugal
| | - Oliver Gaemperli
- Interventional Cardiology and Cardiac Imaging, University Heart Center Zurich, Zurich, Switzerland
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Gilbert Habib
- Aix-Marseille Université, Marseille and Cardiology Department, APHM, La Timone Hospital, Marseille, France
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, Kiinamyllynkatu, Turku, Finland
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, Department of Cardiology, University of Liège Hospital, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium and Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | - William McKenna
- Heart Hospital, Hamad Medical Corporation, Doha, Qatar and Imperial College, London, UK
| | - Danilo Neglia
- Cardiovascular Department at Fondazione Toscana G. Monasterio, CNR Institute of Clinical Physiology and Scuola Superiore San’Anna, Pisa, Italy
| | - Bogdan A Popescu
- University of Medicine and Pharmacy “Carol Davila”—Euroecolab, Institute of Cardiovascular Diseases “Prof. Dr. C. C. Iliescu,” Bucharest, Romania
| | - Thor Edvardsen
- Department of Cardiology, Center for Cardiological Innovation and Institute for Surgical Research, Oslo University Hospital, Oslo and University of Oslo, Oslo, Norway
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Gaido L, Battaglia A, Matta M, Giustetto C, Frea S, Imazio M, Richiardi E, Garberoglio L, Gaita F. Phenotypic expression of ARVC: How 12 lead ECG can predict left or right ventricle involvement. A familiar case series and a review of literature. Int J Cardiol 2017; 236:328-334. [PMID: 28283360 DOI: 10.1016/j.ijcard.2017.02.130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/27/2017] [Accepted: 02/24/2017] [Indexed: 11/29/2022]
Abstract
AIMS Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart-muscle disease primarily affecting the right ventricle (RV) and potentially causing sudden death in young people. The natural history of the disease is firstly characterized by a concealed form progressing over a biventricular involvement. Three different cases coming from the same family are presented together with a review of the literature. METHODS AND RESULTS Multi-parameter analysis including imaging and electrocardiographic analysis is presented since the first medical referral with follow-up ranging from 11 to 38years. Case 1 presented a typical RV involvement in agreement with the ECG pattern. Case 2 presented a prevalent left ventricular involvement leading from the beginning to a pattern of dilated cardiomyopathy in agreement with his ECG evolution over the years. On the other side, Case 3 came to observation with a typical RV involvement (similar to Case 1) but with ECG evolution of typical left ventricle involvement (similar to Case 2). The genetic analysis showed a mutation in desmoglein-2 (DSG2) gene: p. Arg49His. Comparison between size and localization of ventricular dyskinesia at cardiovascular imaging and the surface 12 lead electrocardiography are proposed. CONCLUSIONS ARVC may lead to an extreme phenotypic variability in clinical manifestations even within patients coming from the same family in which ARVC is caused by the same genetic mutation. ECG progression over time reflects disease evolution and in particular cases may anticipate wall motion abnormalities by years.
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Affiliation(s)
- Luca Gaido
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Alberto Battaglia
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy.
| | - Mario Matta
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Carla Giustetto
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Simone Frea
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Massimo Imazio
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Elena Richiardi
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Lucia Garberoglio
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
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Mast TP, Teske AJ, Walmsley J, van der Heijden JF, van Es R, Prinzen FW, Delhaas T, van Veen TA, Loh P, Doevendans PA, Cramer MJ, Lumens J. Right Ventricular Imaging and Computer Simulation for Electromechanical Substrate Characterization in Arrhythmogenic Right Ventricular Cardiomyopathy. J Am Coll Cardiol 2016; 68:2185-2197. [DOI: 10.1016/j.jacc.2016.08.061] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/08/2016] [Accepted: 08/09/2016] [Indexed: 10/20/2022]
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Edvardsen T, Sarvari SI, Haugaa KH. Strain imaging – from Scandinavian research to global deployment. SCAND CARDIOVASC J 2016; 50:266-275. [DOI: 10.1080/14017431.2016.1239836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Thor Edvardsen
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
| | - Sebastian I. Sarvari
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Oslo, Norway
- Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
| | - Kristina H. Haugaa
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
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Qasem M, Utomi V, George K, Somauroo J, Zaidi A, Forsythe L, Bhattacharrya S, Lloyd G, Rana B, Ring L, Robinson S, Senior R, Sheikh N, Sitali M, Sandoval J, Steeds R, Stout M, Willis J, Oxborough D. A meta-analysis for echocardiographic assessment of right ventricular structure and function in ARVC. Echo Res Pract 2016; 3:ERP-16-0028. [PMID: 27686556 PMCID: PMC5076568 DOI: 10.1530/erp-16-0028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 09/29/2016] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is an inherited pathology that can increase the risk of sudden death. Current Task Force Criteria for echocardiographic diagnosis do not include new, regional assessment tools which may be relevant in a phenotypically diverse disease. We adopted a systematic review and meta-analysis approach to highlight echocardiographic indices that differentiated ARVC patients and healthy controls. METHODS Data was extracted and analysed from prospective trials that employed a case-control design meeting strict inclusion and exclusion as well as a-priori quality criteria. Structural indices included proximal RV outflow tract(RVOT1) and RV diastolic area(RVDarea). Functional indices included RV fractional area change (RVFAC), Tricuspid Annular Systolic Excursion(TAPSE), peak systolic and early diastolic myocardial velocities (S' and E' respectively) and myocardial strain. RESULTS Patients with ARVC had larger RVOT1 (mean SD; 34 vs. 28 mm P<0.001) and RVDarea (23 vs. 18 cm2 P<0.001) compared to healthy controls. ARVC patients also had lower RVFAC (38 vs. 46 % P<0.001), TAPSE(17 vs. 23 mm P<0.001), S' (9 vs. 12 cm.s-1 P<0.001), E' (9 vs. 13 cm.s-1 P<0.001) and myocardial strain (-17 vs. -30% P<0.001). CONCLUSION The data from this meta-analysis support current Task Force criteria for the diagnosis of ARVC. In addition, other RV measures that reflect the complex geometry and function in ARVC clearly differentiated between ARVC and healthy controls and may provide additional diagnostic and management value. We recommend that future working groups consider this data when proposing new / revised criteria for the echocardiographic diagnosis of ARVC.
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Affiliation(s)
- M Qasem
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - V Utomi
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - K George
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - J Somauroo
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - A Zaidi
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - L Forsythe
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - S Bhattacharrya
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - G Lloyd
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - B Rana
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - L Ring
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - S Robinson
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - R Senior
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - N Sheikh
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - M Sitali
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - J Sandoval
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - R Steeds
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - M Stout
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - J Willis
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
| | - D Oxborough
- M Qasem, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKV Utomi, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKK George, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKJ Somauroo, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKA Zaidi, Barts Heart Centre, St Bartholomew's Hospital, London, UKL Forsythe, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UKS Bhattacharrya, Barts Heart Centre, St Bartholomew's Hospital, London, UKG Lloyd, Barts Heart Centre, St Bartholomew's Hospital, London, UKB Rana, Papworth Hospital NHS Trust, Cambridge, UKL Ring, West Suffolk NHS Trust, Bury St Edmonds, UKS Robinson, Papworth Hospital NHS Trust, Cambridge, UKR Senior, National Heart and Lung Institute, Imperial College, London, UKN Sheikh, St Georges University Hospital, London, UKM Sitali, Guys and St Thomas's NHS Trust, London, UKJ Sandoval, Leeds Teaching Hospitals NHS Trust, Leeds, UKR Steeds, University Hospitals Birmingham NHS Trust and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UKM Stout, Cardiology Department, University Hospital of South Manchester, Manchester, UKJ Willis, Royal United Hospital, Bath, UKD Oxborough, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Middlesbrough, UK
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Alizade E, Yesin M, Tabakci MM, Avci A, Bulut M, Acar G, Şimşek Z, Izci S, Barutçu S, Pala S. Utility of speckle tracking echocardiography imaging in patients with asymptomatic and symptomatic arrhythmogenic right ventricular cardiomyopathy. Echocardiography 2016; 33:1683-1688. [PMID: 27599902 DOI: 10.1111/echo.13338] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Arrhythmogenic right ventricular dysplasia (ARVD) is characterized by the progressive replacement of ventricular myocytes with variable amounts of fibrous and adipose tissue. Several studies have suggested that speckle tracking echocardiographic (STE) parameters such as strain (S) and strain rate (SR) may prove useful in the early detection of right ventricular (RV) dysfunction. Therefore, the aim of this study was to evaluate RV myocardial function using the STE method in both asymptomatic and symptomatic patients with ARVD and to assess its potential role in the differential diagnosis of these two presentations. METHODS We recruited 34 patients with ARVD. Seventeen patients were symptomatic, and seventeen were asymptomatic. RESULTS The RV free wall global longitudinal S and SR were significantly lower in symptomatic patients with ARVD than in asymptomatic patients. According to a cutoff value of 1.35 per seconds for RV global SR, the sensitivity and specificity for predicting ARVD were 88% and 77%, respectively. According to a cutoff value of 17.3% for RV S, the sensitivity and specificity for predicting ARVD were 82% and 77%, respectively. CONCLUSION In conclusion, we present strong evidence that STE-derived global S and SR in the RV free wall are decreased in symptomatic patients with ARVD compared with asymptomatic patients.
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Affiliation(s)
- Elnur Alizade
- Cardiology Department, Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
| | - Mahmut Yesin
- Cardiology Department, Kars Harakani State Hospital, Kars, Turkey
| | - Mehmet Mustafa Tabakci
- Cardiology Department, Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
| | - Anıl Avci
- Cardiology Department, Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
| | - Mustafa Bulut
- Cardiology Department, Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
| | - Göksel Acar
- Cardiology Department, Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
| | - Zeki Şimşek
- Cardiology Department, Kartal Yavuz Selim State Hospital, Istanbul, Turkey
| | - Servet Izci
- Cardiology Department, Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
| | - Süleyman Barutçu
- Cardiology Department, Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
| | - Selçuk Pala
- Cardiology Department, Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
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Akdis D, Brunckhorst C, Duru F, Saguner AM. Arrhythmogenic Cardiomyopathy: Electrical and Structural Phenotypes. Arrhythm Electrophysiol Rev 2016; 5:90-101. [PMID: 27617087 PMCID: PMC5013177 DOI: 10.15420/aer.2016.4.3] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 08/03/2016] [Indexed: 12/12/2022] Open
Abstract
This overview gives an update on the molecular mechanisms, clinical manifestations, diagnosis and therapy of arrhythmogenic cardiomyopathy (ACM). ACM is mostly hereditary and associated with mutations in genes encoding proteins of the intercalated disc. Three subtypes have been proposed: the classical right-dominant subtype generally referred to as ARVC/D, biventricular forms with early biventricular involvement and left-dominant subtypes with predominant LV involvement. Typical symptoms include palpitations, arrhythmic (pre)syncope and sudden cardiac arrest due to ventricular arrhythmias, which typically occur in athletes. At later stages, heart failure may occur. Diagnosis is established with the 2010 Task Force Criteria (TFC). Modern imaging tools are crucial for ACM diagnosis, including both echocardiography and cardiac magnetic resonance imaging for detecting functional and structural alternations. Of note, structural findings often become visible after electrical alterations, such as premature ventricular beats, ventricular fibrillation (VF) and ventricular tachycardia (VT). 12-lead ECG is important to assess for depolarisation and repolarisation abnormalities, including T-wave inversions as the most common ECG abnormality. Family history and the detection of causative mutations, mostly affecting the desmosome, have been incorporated in the TFC, and stress the importance of cascade family screening. Differential diagnoses include idiopathic right ventricular outflow tract (RVOT) VT, sarcoidosis, congenital heart disease, myocarditis, dilated cardiomyopathy, athlete's heart, Brugada syndrome and RV infarction. Therapeutic strategies include restriction from endurance and competitive sports, β-blockers, antiarrhythmic drugs, heart failure medication, implantable cardioverter-defibrillators and endocardial/epicardial catheter ablation.
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Affiliation(s)
- Deniz Akdis
- Department of Cardiology, University Heart Center, Zurich, Switzerland
| | | | - Firat Duru
- Department of Cardiology, University Heart Center, Zurich, Switzerland; Center for Integrative Human Physiology, University of Zurich, Switzerland
| | - Ardan M Saguner
- Department of Cardiology, University Heart Center, Zurich, Switzerland
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Arenja N, Riffel JH, Djiokou CN, Andre F, Fritz T, Halder M, Zelniker T, Kristen AV, Korosoglou G, Katus HA, Buss SJ. Right ventricular long axis strain—validation of a novel parameter in non-ischemic dilated cardiomyopathy using standard cardiac magnetic resonance imaging. Eur J Radiol 2016; 85:1322-8. [DOI: 10.1016/j.ejrad.2016.04.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 04/22/2016] [Accepted: 04/28/2016] [Indexed: 11/30/2022]
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Noninvasive Multimodality Imaging in ARVD/C. JACC Cardiovasc Imaging 2016; 8:597-611. [PMID: 25937197 DOI: 10.1016/j.jcmg.2015.02.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 02/20/2015] [Accepted: 02/26/2015] [Indexed: 02/06/2023]
Abstract
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is a familial cardiomyopathy resulting in progressive right ventricular (RV) dysfunction and malignant ventricular arrhythmias. Although ARVD/C is generally considered an inherited cardiomyopathy, the arrhythmogenic nature of the disease is striking. Affected individuals typically present in the second to fourth decade of life with arrhythmias originating from the right ventricle. Over the past decade, pathogenic ARVD/C-causing mutations have been identified in 5 genes encoding the cardiac desmosome. Disruption of the desmosomal connection system between cardiomyocytes may be represented structurally by ventricular enlargement, global or regional contraction abnormalities, RV aneurysms, or fibrofatty replacement. These abnormalities are typically observed in predilection areas, including the subtricuspid region, basal RV free wall, and left ventricular posterolateral wall. As such, structural and functional abnormalities on cardiac imaging constitute an important diagnostic criterion for the disease. This paper discusses the current status and role of echocardiography, cardiac magnetic resonance imaging, and computed tomography for suspected ARVD/C.
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Réant P, Hauer AD, Castelletti S, Pantazis A, Rosmini S, Cheang MH, Peyrou J, Tomé-Esteban M, Syrris P, Lafitte S, Moon JC, McKenna WJ. Epicardial myocardial strain abnormalities may identify the earliest stages of arrhythmogenic cardiomyopathy. Int J Cardiovasc Imaging 2015; 32:593-601. [DOI: 10.1007/s10554-015-0813-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 11/20/2015] [Indexed: 12/12/2022]
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Mast TP, Teske AJ, vd Heijden JF, Groeneweg JA, Te Riele AS, Velthuis BK, Hauer RN, Doevendans PA, Cramer MJ. Left Ventricular Involvement in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy Assessed by Echocardiography Predicts Adverse Clinical Outcome. J Am Soc Echocardiogr 2015; 28:1103-13.e9. [DOI: 10.1016/j.echo.2015.04.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Indexed: 11/29/2022]
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49
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Nagueh SF, Zoghbi WA. Role of Imaging in the Evaluation of Patients at Risk for Sudden Cardiac Death. JACC Cardiovasc Imaging 2015; 8:828-45. [DOI: 10.1016/j.jcmg.2015.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 04/08/2015] [Accepted: 04/23/2015] [Indexed: 11/24/2022]
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50
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D'Ascenzi F, Pelliccia A, Corrado D, Cameli M, Curci V, Alvino F, Natali BM, Focardi M, Bonifazi M, Mondillo S. Right ventricular remodelling induced by exercise training in competitive athletes. Eur Heart J Cardiovasc Imaging 2015; 17:301-7. [DOI: 10.1093/ehjci/jev155] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 05/23/2015] [Indexed: 11/14/2022] Open
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