Endurance Training Minimizes Age-Related Changes of Left Ventricular Twist-Untwist Mechanics

Cardioprotective effect of intradialytic exercise on left atrial mechanics

Left atrial (LA) function plays a pivotal role in cardiac performance by modulating left ventricular (LV) function. Impairments in LV function are commonly reported during hemodialysis (HD), but available data describing changes in LA function are limited. There is growing evidence of the cardioprotective effect of intradialytic exercise (IDE) on LV function, but studies analyzing its effect on LA function are scarce. Our aim was to evaluate whether IDE can limit the severity of HD-induced impairment in LA myocardial function. In this prospective, open-label, two-center randomized crossover trial, 56 stable individuals receiving HD participated in 2 HD sessions in random order: standard HD and a session incorporating 30 min of aerobic exercise. LA and LV global longitudinal strains (GLSs) were obtained before and at peak stress of HD (i.e., 30 min before the HD ending). IDE totally eradicated the decline in LA reservoir strain observed during HD (estimated difference: 3.1%, 95% confidence interval: 0.4/5.8, P = 0.02), whereas it did not affect the other components of LA mechanics. A similar result favoring IDE intervention was also demonstrated on GLS changes over the HD procedure (P < 0.001). Between-session differences of changes in GLS and LA reservoir strain were correlated (r = -0.32, P = 0.03). The cardioprotective effect of IDE disappeared in patients with LA enlargement (i.e., LA volume index >34 mL/m2). In conclusion, even a short duration of IDE at moderate intensity is effective in preventing HD-associated decline in LA reservoir function. Further research is needed to explore the long-term benefits of IDE on LA function.NEW & NOTEWORTHY A single bout of intradialytic exercise (IDE) at moderate intensity can prevent the hemodialysis-associated decline in left atrial (LA) function. This was partially explained by the relative preservation of left ventricular systolic function with IDE. Benefits of IDE on LA function were lost in patients with LA dilation. Further studies are needed to explore the mechanisms behind IDE-induced cardioprotection and evaluate the clinical impacts of the repetitive cardioprotective effects of IDE on LA function.

Left atrial remodeling in adolescents with obesity evaluated by speckle-tracking echocardiography

BACKGROUND AND AIMS

In adolescents with obesity, a left atrial (LA) enlargement has been reported. However, data regarding its function and its stiffness are missing. The aim of this study was to describe LA morphology and function, using speckle-tracking echocardiography (STE) and to explore their potential determinants in adolescents with obesity.

METHODS

Twenty-eight adolescent women with obesity (13.2 ± 1.4 yr) with an illness duration of 130 ± 27 months and 33 controls (14.1 ± 2.0 yr) underwent a resting echocardiography including an analysis of left ventricular (LV) and LA morphologies and strains. A fasting venous blood sample was performed to biochemical determinations including inflammation markers.

RESULTS

LA volume and stiffness index were increased in adolescents with obesity compared to controls. LA reservoir, conduit and booster pump functions were not different between groups. By stepwise forward multivariate regression analyses, systolic blood pressures, cardiac output and sedimentation rate were the independent determinants of LA volume (p < 0.0001, β-coefficient = 0.460) whereas only the body mass index was an independent determinant of LA stiffness (p = 0.003, β-coefficient = 0.413).

CONCLUSION

In adolescents with obesity, we observed a specific LA remodeling, including higher volume and lower stiffness, which could constitute early signs of an altered LV diastolic function.

Effects of aging and endurance exercise training on cardiorespiratory fitness and cardiac structure and function in healthy midlife and older women

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in women in developed societies. Unfavorable structural and functional adaptations within the heart and central blood vessels with sedentary aging in women can act as the substrate for the development of debilitating CVD conditions such as heart failure with preserved ejection fraction (HFpEF). The large decline in cardiorespiratory fitness, as indicated by maximal or peak oxygen uptake (V̇o2max and V̇o2peak, respectively), that occurs in women as they age significantly affects their health and chronic disease status, as well as the risk of cardiovascular and all-cause mortality. Midlife and older women who have performed structured endurance exercise training for several years or decades of their adult lives exhibit a V̇o2max and cardiac and vascular structure and function that are on par or even superior to much younger sedentary women. Therefore, regular endurance exercise training appears to be an effective preventative strategy for mitigating the adverse physiological cardiovascular adaptations associated with sedentary aging in women. Herein, we narratively describe the aging and short- and long-term endurance exercise training adaptations in V̇o2max, cardiac structure, and left ventricular systolic and diastolic function at rest and exercise in midlife and older women. The role of circulating estrogens on cardiac structure and function is described for consideration in the timing of exercise interventions to maximize beneficial adaptations. Current research gaps and potential areas for future investigation to advance our understanding in this critical knowledge area are highlighted.

Cardioprotective Effect of Acute Intradialytic Exercise: A Comprehensive Speckle-Tracking Echocardiography Analysis

SIGNIFICANCE STATEMENT

Hemodialysis (HD) can lead to acute left ventricular (LV) myocardial wall motion abnormalities (myocardial stunning) due to segmental hypoperfusion. Exercise during dialysis is associated with favorable effects on central hemodynamics and BP stability, factors considered in the etiology of HD-induced myocardial stunning. In a speckle-tracking echocardiography analysis, the authors explored effects of acute intradialytic exercise (IDE) on LV regional myocardial function in 60 patients undergoing HD. They found beneficial effects of IDE on LV longitudinal and circumferential function and on torsional mechanics, not accounted for by cardiac loading conditions or central hemodynamics. These findings support the implementation of IDE in people with ESKD, given that LV transient dysfunction imposed by repetitive HD may contribute to heart failure and increased risk of cardiac events in such patients.

BACKGROUND

Hemodialysis (HD) induces left ventricular (LV) transient myocardial dysfunction. A complex interplay between linear deformations and torsional mechanics underlies LV myocardial performance. Although intradialytic exercise (IDE) induces favorable effects on central hemodynamics, its effect on myocardial mechanics has never been comprehensively documented.

METHODS

To evaluate the effects of IDE on LV myocardial mechanics, assessed by speckle-tracking echocardiography, we conducted a prospective, open-label, two-center randomized crossover trial. We enrolled 60 individuals with ESKD receiving HD, who were assigned to participate in two sessions performed in a randomized order: standard HD and HD incorporating 30 minutes of aerobic exercise (HDEX). We measured global longitudinal strain (GLS) at baseline (T0), 90 minutes after HD onset (T1), and 30 minutes before ending HD (T2). At T0 and T2, we also measured circumferential strain and twist, calculated as the net difference between apical and basal rotations. Central hemodynamic data (BP, cardiac output) also were collected.

RESULTS

The decline in GLS observed during the HD procedure was attenuated in the HDEX sessions (estimated difference, -1.16%; 95% confidence interval [95% CI], -0.31 to -2.02; P = 0.008). Compared with HD, HDEX also demonstrated greater improvements from T0 to T2 in twist, an important component of LV myocardial function (estimated difference, 2.48°; 95% CI, 0.30 to 4.65; P = 0.02). Differences in changes from T0 to T2 for cardiac loading and intradialytic hemodynamics did not account for the beneficial effects of IDE on LV myocardial mechanics kinetics.

CONCLUSIONS

IDE applied acutely during HD improves regional myocardial mechanics and might warrant consideration in the therapeutic approach for patients on HD.

Impact of BMI z-score on left ventricular mechanics in adolescent girls

Background

Adolescent weight disorders ranging from anorexia nervosa (AN) to obesity (OB) can impact the heart by causing opposite alterations in its morphology, suggesting a direct impact of body mass index (BMI) on the heart. Cardiac function is relatively preserved as assessed by standard echocardiography. However, few studies have used 2D speckle-tracking echocardiography (2D-STE), which can detect subtle alterations of left ventricular (LV) function by evaluating deformations. This study aimed to assess the link between the BMI z-score of adolescent girls and myocardial function.

Methods

Ninety-one adolescent girls comprising 26 AN patients (age 14.6 ± 1.9 years), 28 OB patients (age 13.2 ± 1.4 years), and 37 controls (age 14.0 ± 2.0 years) underwent 2D-STE to assess LV morphology and myocardial global and regional deformations.

Results

The BMI z-score of our population ranged from -4.6 to 5.2. LV morphological remodeling was significantly and positively correlated with the BMI z-score (R2 = 0.456, p < 0.0001 for LV mass). Global longitudinal strain (LS) and regional LS recorded at the mid and apical levels were significantly correlated with the BMI z-score (R2 = 0.196, p = 0.0001 and R2 = 0.274, p < 0.0001, respectively, for apical and medial LS). Circumferential strains and twisting mechanics were not correlated with the BMI z-score. Fibrinogen and systolic blood pressure were the main variables explaining the alteration of LS.

Conclusion

We observed that the BMI z-score had an impact on LV mechanics, especially on medial and apical LS. Neither circumferential nor twisting mechanics were altered by the BMI z-score in adolescent girls.

Does Hypoxia and Stress Erythropoiesis Compromise Cardiac Function in Healthy Adults? A Randomized Trial

OBJECTIVES

To investigate whether recombinant human erythropoietin (rHuEPO) injections during an altitude training camp impact heart function.

METHODS

Thirty (12 women) moderately trained subjects stayed at 2320 m altitude for 4 weeks while training. Subjects were randomized to placebo (isotonic saline) or rHuEPO (20 IU/kg body weight) i.v. injections. Transthoracic echocardiography imaging was acquired 3 days after arrival to altitude and prior to the first placebo or rHuEPO injection as well as one day after the last rHuEPO injection three weeks later.

RESULTS

rHuEPO did not alter cardiovascular morphology parameters, systolic or diastolic function. In the placebo group, altitude exposure improved left ventricle (LV) systolic function due to an increased twist angle but rHuEPO had no additional effects. Pulmonary arterial systolic pressure was unaffected in either group. Notably, rHuEPO hampered LV untwist rate without affecting LV early filling.

CONCLUSION

rHuEPO provided during mild altitude exposure does not cause any major effects on heart function. The observed alteration in LV untwist induced by rHuEPO is unlikely to have a meaningful clinical effect. Trial Registration Registered on www.

CLINICALTRIALS

gov (NCT04227665).

Additive effects of type 2 diabetes and metabolic syndrome on left ventricular torsion and linear deformation abnormalities during dobutamine stress echocardiography

Objective

The interplay between metabolic syndrome (MS) and type 2 diabetes (T2D) on regional myocardial mechanics and the potential additional effects of their combination remain poorly understood. In this context, we evaluated left ventricular (LV) torsion and linear deformation at rest and under dobutamine (DB) stress in patients with T2D, MS or both.

Methods

Thirty-nine T2D patients without MS (T2D), 37 MS patients free from T2D (MS), 44 patients with both T2D and MS (T2D-MS group) and 38 healthy patients (control group) were prospectively recruited. Speckle-tracking echocardiography (STE) was conducted at rest and low dose DB to evaluate LV myocardial longitudinal (LS) as well as circumferential (CS) strain and early diastolic strain rate (LSrd, CSrd) and twist-untwist mechanics.

Results

At rest, MS, T2D and controls presented with similar resting LS and LSrd while significant lower values were obtained in T2D-MS compared to controls. DB revealed reduced LS, LSrd, CS and CSrd in MS and T2D groups compared to controls. In T2-MS, the decline in LS and LSrd established at rest was exacerbated under DB. Stress echocardiography revealed also lower basal rotation and subsequently lower twist in MS and T2D patients compared to controls. T2D-MS showed major impairments of apical rotation and twist under DB stress, with values significantly lower compared to the 3 other groups. From stepwise multiple linear regression analysis, epicardial adipose tissue for Δ (rest to DB) LS, numbers of MS factors for Δ CS and Δ Twist emerged as major independent predictors.

Conclusion

These results demonstrate synergic and additive effects of T2D and MS on LV torsion and linear deformation abnormalities in asymptomatic patients with metabolic diseases. They also highlight the usefulness of speckle tracking echocardiography under DB stress in detecting multidirectional myocardial mechanics impairments that can remain barely detectable at rest, such as in isolated T2D or MS patients.

Specific alterations of regional myocardial work in strength-trained athletes using anabolic steroids compared to athletes with genetic hypertrophic cardiomyopathy

PURPOSE

Strength-trained athletes using anabolic androgenic steroids (AAS) have left ventricular (LV) hypertrophy and myocardial fibrosis that can lead to sudden cardiac death. A similar feature was described in athletes with hypertrophic cardiomyopathy (HCM), which complicates the diagnosis for clinicians. In this context, we aimed to compare the LV function of the 2 populations by measuring global and regional strain and myocardial work using speckle-tracking imaging.

METHODS

Twenty-four strength-trained asymptomatic athletes using AAS (AAS-Athletes), 22 athletes diagnosed with HCM (HCM-Athletes), and 20 healthy control athletes (Ctrl-Athletes) underwent a resting echocardiography to assess LV function. We evaluated LV global and regional strains and myocardial work, with an evaluation of the constructive work (CW), wasted work, and work efficiency (WE).

RESULTS

Compared to Ctrl-Athletes, both AAS-Athletes and HCM-Athletes had a thicker interventricular septum, with majored values in HCM-Athletes. LV strain was reduced in AAS-Athletes and even more in HCM-Athletes. Consequently, global WE was significantly diminished in both AAS and HCM-Athletes (93% ± 2% in Ctrl-Athletes, 90% ± 4% in AAS-Athletes, and 90% ± 5% in HCM-Athletes (mean ± SD); p < 0.05). Constructive work and WE regional analysis showed specific alterations, with the basal septal segments preferentially affected in AAS-Athletes, and both septal and apical segments affected in HCM-Athletes.

CONCLUSION

The regional evaluation of myocardial work reported specific alterations of the major LV hypertrophy induced by the regular use of AAS compared to the LV hypertrophy due to HCM. This finding could help clinicians to differentiate between these 2 forms of pathological hypertrophy.

Left ventricular function and mechanics in backs and forwards elite rugby union players

PURPOSE

The aim of the present study was to assess left ventricular (LV) morphological and regional functional adaptations in backs and forwards elite rugby union (RU) players.

METHODS

Thirty-nine elite male RU players and twenty sedentary controls have been examined using resting echocardiography. RU players were divided into two groups, forwards (n = 22) and backs (n = 17). Evaluations included tissue Doppler and 2D speckle tracking analysis to assess LV strains and twisting mechanics.

RESULTS

The elite RU players exhibited a LV remodeling characterized by an increase in LV mass indexed to body surface area (82.2 ± 13.2 vs. 99.9 ± 16.1 and 119.7 ± 13.4 g.m^-2, in controls, backs and forwards; P < 0.001). Compared to backs, forwards exhibited lower global longitudinal strain (19.9 ± 2.5 vs. 18.0 ± 1.6%; P < 0.05), lower early diastolic velocity (16.5 ± 1.8 vs. 15.0 ± 2.3 cm.s^-1; P < 0.05) and lower diastolic longitudinal strain rate (1.80 ± 0.34 vs. 1.54 ± 0.26 s^-1; P < 0.01), especially at the apex. LV twist and untwisting velocities were similar in RU players compared to controls, but with lower apical (-46.2 ± 22.1 vs. -28.2 ± 21.7 deg.s^-1; P < 0.01) and higher basal rotational velocities (33.9 ± 20.9 vs. 48.4 ± 20.7 deg.s^-1; P < 0.05).

CONCLUSION

RU players exhibited an increase in LV mass which was more pronounced in forwards. In forwards, LV global longitudinal strain was depressed, LV filling pressures were decreased and LV relaxation depressed at the apex.

A normal pattern of mitral inflow predicts a better prognosis following cardiovascular events in early advanced-age patients

Although a mitral inflow pattern usually changes from a normal pattern to an abnormal relaxation pattern as part of the aging process in healthy people, some early advanced-age individuals maintain a normal pattern. We investigated whether a normal pattern of mitral inflow predicts a better prognosis following cardiovascular (CV) events in early advanced-age patients. We enrolled 425 patients aged 60-65 years with 0.6 < E/A < 1.5. Patients were divided according to their mitral inflow pattern, i.e., a normal pattern group (E/A ≥ 1.0, n = 77) and an abnormal relaxation pattern group (E/A < 1, n = 348), and were evaluated the relationship with CV events. Multivariate regression analysis found that the normal inflow pattern was associated with odds ratios of 0.859 for body mass index (BMI; 95% confidence interval [CI]: 0.778-0.937), 0.529 for hypertension (0.303-0.924), and 0.325 for heart rate (0.228-0.463). During the follow-up period (4.9 ± 1.8 years), the adjusted-hazard ratio was significantly lower in the normal pattern group (HR: 0.119, 95% CI 0.016-0.910). Kaplan-Meier curves showed a higher event-free rate for the normal pattern group than for the abnormal relaxation pattern group (p = 0.0292). Normal inflow pattern in early advanced-age patients predicts a better prognosis following CV events.

Cardiovascular responses to high-intensity stair climbing in individuals with coronary artery disease

Exercise‐based cardiac rehabilitation leads to improvements in cardiovascular function in individuals with coronary artery disease. The cardiac effects of coronary artery disease (CAD) can be quantified using clinical echocardiographic measures, such as ejection fraction (EF). Measures of cardiovascular function typically only used in research settings can provide additional information and maybe more sensitive indices to assess changes after exercise‐based cardiac rehabilitation. These additional measures include endothelial function (measured by flow‐mediated dilation), left ventricular twist, myocardial performance index, and global longitudinal strain. To investigate the cardiovascular response to 12 week of either traditional moderate‐intensity (TRAD) or stair climbing‐based high‐intensity interval (STAIR) exercise‐based cardiac rehabilitation using both clinical and additional measures of cardiovascular function in individuals with CAD. Measurements were made at baseline (BL) and after supervised (4wk) and unsupervised (12 week) of training. This study was registered as a clinical trial at clinicaltrials.gov (NCT03235674). Participants were randomized into either TRAD (n = 9, 8M/1F) and STAIR (n = 9, 8M/1F). There was a training‐associated increase in one component of left ventricular twist: Cardiac apical rotation (TRAD: BL: 5.6 ± 3.3º, 4 week: 8.0 ± 3.9º, 12 week: 6.2 ± 5.1º and STAIR: BL: 5.1 ± 3.6º, 4 week: 7.4 ± 3.9º, 12 week: 7.8 ± 2.8º, p (time) = 0.03, η² = 0.20; main effect) and post‐hoc analysis revealed a difference between BL and 4 week (p = 0.02). There were no changes in any other clinical or additional measures of cardiovascular function. The small increase in cardiac apical rotation observed after 4 weeks of training may indicate an early change in cardiac function. A larger overall training stimulus may be needed to elicit other cardiovascular function changes.

Anabolic Steroids Use Is Associated with Impairments in Atrial and Ventricular Cardiac Structure and Performance in Athletes

PURPOSE

Despite potential severe cardiac side effects, anabolic androgenic steroids (AAS) are increasingly used by strength athletes. However, previous echocardiographic studies focused on the left ventricular (LV) strains but did not assess LV twist and untwist mechanics. Moreover, left atrial (LA) function has been often neglected, and its stiffness, an important determinant of LA reservoir function, has never been challenged. The aim of this study was to investigate the effects of AAS on LA and LV morphologies and functions in strength athletes.

METHODS

Fifty subjects including 20 strength-trained young athletes age 32.0 ± 8.5 yr with a mean duration of AAS use of 4.7 ± 1.8 yr (users), 15 athletes with no history of AAS use (nonusers) and 15 sedentary controls underwent speckle tracking echocardiography to assess LA and LV morphology and function.

RESULTS

Users showed higher LA reservoir dysfunction than nonusers (33.7% ± 10.9% vs 44.9% ± 9.9% respectively, P = 0.004) and higher LA stiffness (0.13 ± 0.05 vs 0.19 ± 0.08 A.U., respectively; P = 0.02), higher LV mass index and lower global and regional LV diastolic and systolic dysfunction (global longitudinal strain: -15.5% ± 3.2% vs -18.9% ± 1.8% respectively; P = 0.003), with a drop of LV twist-untwist mechanics (untwisting velocity: 61.5°·s-1 ± 20.2°·s-1 vs 73.7°·s-1 ± 16.1°·s-1 respectively, P = 0.04). There were significant correlations between LV mass and LV apical rotation (P = 0.003, r = 0.44) and diastolic longitudinal strain rate (P = 0.015, r = 0.33).

CONCLUSIONS

Our results showing significant LA and LV remodeling and dysfunctions in young AAS using athletes are alarming. Screening echocardiography based on speckle tracking echocardiography parameters for early diagnosis, as well as a stronger awareness in athletes and in physicians are warranted in this context.

Cardiac Remodeling and Its Determinants in Anorexia Nervosa Adolescents: Impact of Weight Recovery

Cardiovascular alterations in anorexia nervosa (AN) adolescents include bradycardia and decreased systolic blood pressure and left ventricular mass. However, their determinants remain poorly understood. We assessed the associations between morphological and functional left ventricular (LV) remodeling, autonomic control by heart rate variability (HRV) analysis, thyroid hormones and brain natriuretic peptide (BNP) levels in AN female adolescents without or with weight recovery (WR). Fifty-nine female adolescents including 16 AN patients without WR (mean age 13.9 years (10−16)), 10 AN patients with WR (15.7 years (12−18)) and 33 controls (14.1 years (10−18)) underwent night heart rate (HR) recording to measure HRV (and especially SD1/SD2, the ratio between instantaneous (SD1) and long-term (SD2) standard deviation of R-R intervals, reflecting sympatho-vagal balance), speckle tracking echocardiography to assess LV global longitudinal strain (GLS) and blood test for dosage of tri-iodothyronine (T3) hormone and NT-proBNP. Compared to controls, AN patients without WR presented with lower HR (55 ± 7 vs. 68 ± 6 bpm; p < 0.001), parasympathetic hyperactivity, and higher GLS (−19.2 ± 1.8 vs. −16.9 ± 2.8%; p = 0.009). These alterations were partly abolished in AN patients with WR. In a multivariate regression analysis, T3 was the main factor explaining the variance of SD1/SD2, a sympatho-vagal balance marker. NT-proBNP levels were not correlated with cardiac alterations. AN patients had parasympathetic hyperactivity linked with their rate of T3, and a higher GLS. These alterations were partly restored in AN patients with WR.

Left Ventricular Strains and Myocardial Work in Adolescents With Anorexia Nervosa

Background

Anorexia nervosa (AN) is accompanied by bradycardia, low blood pressure (BP) and cardiac morphological remodeling. Systolic and diastolic functions are relatively preserved when assessed by standard ultrasound methods. However, novel advances based on speckle tracking echocardiography (STE), that could detect subtle and early alterations of left ventricular (LV) function, remained poorly used in AN patients.

Objective

The aim of this study was to assess the cardiac function of AN patients by evaluating LV myocardial strains, myocardial work (MW) and LV mechanical dispersion. We hypothesized that LV strains and global myocardial work would be decreased and LV twisting mechanisms enhanced to preserve the systolic function.

Methods

Fifty-nine adolescents including 26 women AN patients (14.6 ± 1.9 yrs. old) with a mean duration of AN of 19 ± 9 months and 33 controls (14.1 ± 2.0 yrs. old) underwent STE to assess LV morphology and myocardial regional strains.

Results

The global longitudinal strain (GLS) was higher in AN patients compared to controls (−18.8 ± 2.0 vs. −16.9 ± 2.8%, p = 0.006). The area under the pressure-strain loop, representing the global MW was not altered but was shifted to the left and downwards in AN patients, due to their lower BP and higher GLS. Intraventricular mechanical dispersion was similar in both groups. Circumferential strains, twisting/untwisting mechanics were preserved.

Conclusion

Our results strongly support that the cardiac morphological remodeling observed in our AN patients was associated with normal ventricular regional myocardial functions. Only GLS was higher in AN patients, but its clinical significance remains to be demonstrated.

Athlete’s Heart in Elite Biathlon, Nordic Cross—Country and Ski-Mountaineering Athletes: Cardiac Adaptions Determined Using Echocardiographic Data

Twelve world elite Biathlon (Bia), ten Nordic Cross Country (NCC) and ten ski-mountaineering (Ski-Mo) athletes were evaluated for pronounced echocardiographic physiological cardiac remodeling as a primary aim of our descriptive preliminary report. In this context, sports-related cardiac remodeling was analyzed by performing two-dimensional echocardiography including speckle tracking analysis as left ventricular global longitudinal strain (LV-GLS). A multicenter retrospective analysis of echocardiographic data was performed in 32 elite world winter sports athletes, which were obtained between 2020 and 2021 during the annual medical examination. The matched data of the elite world winter sports athletes (14 women, 18 male athletes, age: 18–35 years) were compared for different echocardiographic parameters. Significant differences could be revealed for left ventricular systolic function (LV-EF, p = 0.0001), left ventricular mass index (LV Mass index, p = 0.0078), left atrial remodeling by left atrial volume index (LAVI, p = 0.0052), and LV-GLS (p = 0.0003) between the three professional winter sports disciplines. This report provides new evidence that resting measures of cardiac structure and function in elite winter sport professionals can identify sport specific remodeling of the left heart, against the background of training schedule and training frequency.

Global and Regional Myocardial Work in Female Adolescents with Weight Disorders

Background: Anorexia nervosa (AN) and obesity (OB) lead to changes in SBP (i.e., loading conditions) that may affect left ventricular (LV) myocardial work (MW). The novel concept of LV pressure-strain loops allows non-invasive estimation of MW, this latter being correlated with cardiac energy metabolism. In addition, the study of regional MW can detect subtle alterations in cardiac function by highlighting an abnormal distribution of MW. Objective: The aim of this study was to assess the cardiac function of AN and OB patients by evaluating global and regional LV strains and MW. Methods: Eighty-seven female adolescents, comprising 26 with AN (14.6 ± 1.9 yrs. old), 28 with OB (13.2 ± 1.4 yrs. old), and 33 controls (14.0 ± 2.0 yrs. old) underwent speckle-tracking echography to assess global and regional LV strains and MW. Results: SBP was higher in adolescents with obesity than in AN patients or controls. Global MW was similar between groups. In AN patients and controls, longitudinal strains were higher at the apex than at the base of the LV, whereas they were similar in obesity patients, owing to a decrease in their apical longitudinal strain. Consequently, their MW was higher at the basal level than either of the other two groups (1854 ± 272 vs. 1501 ± 280 vs. 1575 ± 295 mmHg% in OB patients, AN patients, and controls, respectively. Conclusion: Despite altered SBP, the global MW of adolescents with weight disorders was unaffected. However, in adolescents with obesity, the distribution of their regional LV MW was altered, which might reflect specific regional remodeling.

Left ventricular dyssynchrony and post-systolic shortening in young bodybuilders using anabolic-androgenic steroids

Left ventricular (LV) remodeling, characterized by increased LV hypertrophy and depressed systolic and diastolic function, is observed in strength-trained athletes who use anabolic-androgenic steroids (AAS). Previous studies suggested a pathological remodeling with an increase in cardiac fibrosis in these athletes, which could promote intraventricular dyssynchrony. In this context, this study evaluated LV dyssynchrony in strength-trained athletes using AAS, hypothesizing that the use of AAS would lead to an increase in post-systolic shortening. Forty-four male subjects (aged 20-40 yr) were divided into three age-matched groups: strength-trained athletes using (users, n = 14) or not (nonusers, n = 15) AAS and healthy sedentary men (controls, n = 15). After completing a survey, each participant was assessed with two-dimensional (2D)-strain echocardiography. LV dyssynchrony was quantified using the standard deviation (SD) of the time to peak for longitudinal strain of the 18 LV-segments (from the apical 4, 3, and 2 chambers views), the longitudinal strain delay index (LSDI), and the segmental post-systolic index (PSI). Users showed mean AAS dosages of 564 ± 288 mg[Formula: see text]wk^-1 with a mean protocol duration of 12 ± 6 wk and a history of use of 4.7 ± 1.8 yr. They exhibited a greater LV mass index and depressed systolic and diastolic function when compared with both nonusers and controls. The decrease in LV strain in users was predominantly observed at the interventricular septum level (-16.9% ± 2.5% vs. -19.2% ± 1.8% and -19.0% ± 1.6% in users, nonusers, and controls, respectively, P < 0.01). Users showed higher SD than controls (43 ± 8 ms vs. 32 ± 5 ms, respectively, P < 0.01). The LSDI was significantly higher in users compared with both nonusers and controls (-23.4 ± 9.5 vs. -15.9 ± 9.3 and -9.8 ± 3.9, respectively, P < 0.01). PSI, calculated on the basal inferoseptal, basal anteroseptal, and basal inferolateral segments, were also greater in users compared with the two other groups. Our results reported an increase in LV dyssynchrony in young AAS users that brought new evidences of a pathologic cardiac remodeling in this specific population.NEW & NOTEWORTHY Illicit androgenic anabolic steroids (AAS) use is widespread, but data on LV dyssynchrony are lacking, although it could be increased by a higher prevalence of myocardial fibrosis reported in this population. In AAS users, the decrease in LV strain was predominantly observed in interventricular segments. All dyssynchrony indices were higher in AAS users and several segments exhibited post-systolic shortening. These results showed an association between AAS consumption, LV remodeling, and dyssynchrony.

Aerobic Training Protects Cardiac Function During Advancing Age: A Meta-Analysis of Four Decades of Controlled Studies

Background

In contrast to younger athletes, there is comparatively less literature examining cardiac structure and function in older athletes. However, a progressive accumulation of studies during the past four decades offers a body of literature worthy of systematic scrutiny.

Objectives

We conducted a systematic review, meta-analysis and meta-regression of controlled echocardiography studies comparing left ventricular (LV) structure and function in aerobically trained older athletes (> 45 years) with age-matched untrained controls, in addition to investigating the influence of chronological age.

Methods

Electronic databases were searched from inception to January 2018 before conducting a random-effects meta-analysis to calculate pooled differences in means, effect size and 95% confidence intervals (CIs). Study heterogeneity was reported using Cochran’s Q and I² statistic.

Results

Overall, 32 studies (644 athletes; 582 controls) were included. Athletes had greater LV end-diastolic diameter (3.65 mm, 95% CI 2.66–4.64), interventricular septal thickness (1.23 mm, 95% CI 0.85–1.60), posterior wall thickness (1.20 mm, 95% CI 0.83–1.56), LV mass (72 g, 95% CI 46–98), LV mass index (28.17 g·m², 95% CI 19.84–36.49) and stroke volume (13.59 mL, 95% CI 7.20–19.98) (all p < 0.01). Athletes had superior global diastolic function [ratio of early (E) to late (A) mitral inflow velocity (E/A) 0.18, 95% CI 0.13–0.24, p < 0.01; ratio of early (e′) to late (a′) diastolic annular tissue velocity (e′/a′) 0.23, 95% CI 0.06–0.40, p = 0.01], lower A (−8.20 cm·s⁻¹, 95% CI −11.90 to −4.51, p < 0.01) and a′ (−0.72 cm·s⁻¹, 95% CI −1.31 to −0.12, p = 0.02), and more rapid e′ (0.96 cm·s⁻¹, 95% CI 0.05–1.86, p = 0.04). Meta-regression for chronological age identified that athlete–control differences, in the main, are maintained during advancing age.

Conclusions

Athletic older men have larger cardiac dimensions and enjoy more favourable cardiac function than healthy, non-athletic counterparts. Notably, the athlete groups maintain these effects during chronological ageing.

Electronic supplementary material

The online version of this article (10.1007/s40279-018-1004-3) contains supplementary material, which is available to authorized users.

Echocardiographic evidence of left ventricular untwisting-filling interplay

Background

Left ventricular untwisting generates an early diastolic intraventricular pressure gradient (DIVPG) than can be quantified by echocardiography. We sought to confirm the quantitative relationship between peak untwisting rate and peak DIVPG in a large adult population.

Methods

From our echocardiographic database, we retrieved all the echocardiograms with a normal left ventricular ejection fraction, for whom color Doppler M-Mode interrogation of mitral inflow was available, and left ventricular untwisting rate was measurable using speckle tracking. Standard indices of left ventricular early diastolic function were assessed by Doppler (peaks E, e’ and Vp) and speckle tracking (peak strain rate Esr). Load dependency of DIVPG and untwisting rate was evaluated using a passive leg raising maneuver.

Results

We included 154 subjects, aged between 18 to 77 years old, 63% were male. Test-retest reliability for color Doppler-derived DIVPG measurements was good, the intraclass correlation coefficients were 0.97 [0.91–0.99] and 0.97 [0.67–0.99] for intra- and inter-observer reproducibility, respectively. Peak DIVPG was positively correlated with peak untwisting rate (r = 0.73, P <  0.001). On multivariate analysis, peak DIVPG was the only diastolic parameter that was independently associated with untwisting rate. Age and gender were the clinical predictive factors for peak untwisting rate, whereas only age was independently associated with peak DIVPG. Untwisting rate and DIVPG were both load-dependent, without affecting their relationship.

Conclusions

Color Doppler-derived peak DIVPG was quantitatively and independently associated with peak untwisting rate. It thus provides a reliable flow-based index of early left ventricular diastolic function.

Unaltered left ventricular mechanics and remodelling after 12 weeks of resistance exercise training – a longitudinal study in men

Previous longitudinal studies suggest that left ventricular (LV) structure is unaltered with resistance exercise training (RT) in young men. However, evidence from aerobic exercise training suggests that early changes in functional LV wall mechanics may occur prior to and independently of changes in LV size, although short-term changes in LV mechanics and structural remodelling in response to RT protocols have not been reported. Therefore, the purpose of this study was to examine the effects of RT on LV mechanics in healthy men performing 2 different time-under-tension protocols. Forty recreationally trained men (age: 23 ± 3 years) were randomized into 12 weeks of whole-body higher-repetition RT (20–25 repetitions/set to failure at ∼30%–50% 1 repetition maximum (1RM); n = 13), lower-repetition RT (8–12 repetitions/set to failure at ∼75%–90% 1RM; n = 13), or an active control period (n = 14). Speckle tracking echocardiography was performed at baseline and following the intervention period. Neither RT program altered standard measures of LV volumes (end-diastolic volume, end-systolic volume, or ejection fraction; P > 0.05) or indices of LV mechanics (total LV twist, untwisting rate, twist-to-shortening ratio, untwisting-to-twist ratio, or longitudinal strain; P > 0.05). This is the first longitudinal study to assess both LV size and mechanics after RT in healthy men, suggesting a maintenance of LV size and twist mechanics despite peripheral muscle adaptations to the training programs. These results provide no evidence for adverse LV structural or functional remodelling in response to RT in young men and support the positive role of RT in the maintenance of optimal cardiovascular function, even with strenuous RT.

Heart mechanics at high altitude: 6 days on the top of Europe

Aims

The aim of this study was to analyse the underlying mechanisms of left and right ventricular (LV and RV) functional alterations during several days in high-altitude hypoxia.

Methods and results

Resting evaluations of LV and RV function and mechanics were assessed by Speckle Tracking Echocardiography on 11 subjects at sea level (SLPRE), 3 ± 2 h after helicopter transport to high altitude (D0), at day 2 (D2), day 4 (D4) and day 6 (D6) at 4350 m and 5 ± 2 h after return to sea level (SLPOST). Subjects experienced acute mountain sickness (AMS) during the first days at 4350 m. LV systolic function, RV systolic and diastolic function, LV and RV strains and LV synchrony were unchanged at high altitude. Peak twist was increased at D0, continued to increase until D6 (SLPRE: 9.0 ± 5.1deg; D6: 13.0 ± 4.0deg, P < 0.05), but was normalized at SLPOST. Early filling decreased at high altitude with a nadir at D2 (SLPRE: 78 ± 13 cm s-1; D2: 66 ± 11 cm s-1, P < 0.05). LV filling pressures index was decreased at high altitude with the minimum value obtained at D2 and remained reduced at SLPOST. Untwisting, an important factor of LV filling, was not decreased but was delayed at 4350 m.

Conclusions

High-altitude exposure impaired LV diastolic function with the greatest effect observed at D2, concomitantly with the occurrence of AMS. The LV early filling impairments resulted from an increased RV afterload, a decrease in LV filling pressure and a delayed LV untwist. However, the increased LV twist probably acted as a compensatory mechanism to maintain cardiac performance during high-altitude hypoxia.

Left Ventricular Speckle Tracking-Derived Cardiac Strain and Cardiac Twist Mechanics in Athletes: A Systematic Review and Meta-Analysis of Controlled Studies

Background

The athlete’s heart is associated with physiological remodeling as a consequence of repetitive cardiac loading. The effect of exercise training on left ventricular (LV) cardiac strain and twist mechanics are equivocal, and no meta-analysis has been conducted to date.

Objective

The objective of this systematic review and meta-analysis was to review the literature pertaining to the effect of different forms of athletic training on cardiac strain and twist mechanics and determine the influence of traditional and contemporary sporting classifications on cardiac strain and twist mechanics.

Methods

We searched PubMed/MEDLINE, Web of Science, and ScienceDirect for controlled studies of aged-matched male participants aged 18–45 years that used two-dimensional (2D) speckle tracking with a defined athlete sporting discipline and a control group not engaged in training programs. Data were extracted independently by two reviewers. Random-effects meta-analyses, subgroup analyses, and meta-regressions were conducted.

Results

Our review included 13 studies with 945 participants (controls n = 355; athletes n = 590). Meta-analyses showed no athlete–control differences in LV strain or twist mechanics. However, moderator analyses showed greater LV twist in high-static low-dynamic athletes (d = –0.76, 95% confidence interval [CI] –1.32 to –0.20; p < 0.01) than in controls. Peak untwisting velocity (PUV) was greater in high-static low-dynamic athletes (d = –0.43, 95% CI –0.84 to –0.03; p < 0.05) but less than controls in high-static high-dynamic athletes (d = 0.79, 95% CI 0.002–1.58; p = 0.05). Elite endurance athletes had significantly less twist and apical rotation than controls (d = 0.68, 95% CI 0.19–1.16, p < 0.01; d = 0.64, 95% CI 0.27–1.00, p = 0.001, respectively) but no differences in basal rotation. Meta-regressions showed LV mass index was positively associated with global longitudinal (b = 0.01, 95% CI 0.002–0.02; p < 0.05), whereas systolic blood pressure was negatively associated with PUV (b = –0.06, 95% CI –0.13 to –0.001; p = 0.05).

Conclusion

Echocardiographic 2D speckle tracking can identify subtle physiological differences in adaptations to cardiac strain and twist mechanics between athletes and healthy controls. Differences in speckle tracking echocardiography-derived parameters can be identified using suitable sporting categorizations.

Advanced Age Attenuates Left Ventricular Filling Efficiency Quantified Using Vortex Formation Time: A Study of Octogenarians With Normal Left Ventricular Systolic Function Undergoing Coronary Artery Surgery

OBJECTIVE

Blood flow across the mitral valve during early left ventricular (LV) filling produces a 3-dimensional rotational fluid body, known as a vortex ring, that enhances LV filling efficiency. Diastolic dysfunction is common in elderly patients, but the influence of advanced age on vortex formation is unknown. The authors tested the hypothesis that advanced age is associated with a reduction in LV filling efficiency quantified using vortex formation time (VFT) in octogenarians undergoing coronary artery bypass graft (CABG) surgery.

DESIGN

Observational study.

SETTING

Veterans Affairs medical center.

PARTICIPANTS

After institutional review board approval, octogenarians (n = 7; 82 ± 2 year [mean ± standard deviation]; ejection fraction 56% ± 7%) without valve disease or atrial arrhythmias undergoing CABG were compared with a younger cohort (n = 7; 55 ± 6 year; ejection fraction 57% ± 7%) who were undergoing coronary revascularization.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All patients were monitored using radial and pulmonary arterial catheters and transesophageal echocardiography. Peak early LV filling (E) and atrial systole (A) blood flow velocities and their corresponding velocity-time integrals were obtained using pulse-wave Doppler echocardiography to determine E/A, atrial filling fraction (β), and E wave deceleration time. Pulse-wave Doppler also was used to measure pulmonary venous blood flow during systole and diastole. Mitral valve diameter (D) was calculated as the average of major and minor axis lengths obtained in the midesophageal LV bicommissural and long-axis transesophageal echocardiography imaging planes, respectively. VFT was calculated as 4 × (1 - β) × SV/(πD³), where SV is the stroke volume measured using thermodilution. Systemic and pulmonary hemodynamics, LV diastolic function, and VFT were determined during steady-state conditions 30 minutes before cardiopulmonary bypass. A delayed relaxation pattern of LV filling (E/A 0.81 ± 0.16 v 1.29 ± 0.19, p = 0.00015; β 0.44 ± 0.05 v 0.35 ± 0.03, p = 0.0008; E wave deceleration time 294 ± 58 v 166 ± 28 ms, p < 0.0001; ratio of peak pulmonary venous systolic and diastolic blood flow velocity 1.42 ± 0.23 v 1.14 ± 0.20, p = 0.0255) was observed in octogenarians compared with younger patients. Mitral valve diameter was similar between groups (2.7 ± 0.2 and 2.6 ± 0.2 cm, respectively, in octogenarians v younger patients, p = 0.299). VFT was reduced in octogenarians compared with younger patients (3.0 ± 0.9 v 4.5 ± 1.2; p = 0.0171). An inverse correlation between age and VFT was shown using linear regression analysis (VFT = -0.0627 × age + 8.24; r² = 0.408; p = 0.0139).

CONCLUSION

The results indicate that LV filling efficiency quantified using VFT is reduced in octogenarians compared with younger patients undergoing coronary artery bypass grafting.

Cardiac Response to Exercise in Normal Ageing: What Can We Learn from Masters Athletes?

BACKGROUND

Ageing is associated with an inexorable decline in cardiac and vascular function, resulting in an increased risk of Cardiovascular Disease (CVD). Lifestyle factors such as exercise have emerged as a primary therapeutic target in the prevention of CVD, yet older individuals are frequently reported as being the least active, with few meeting the recommended physical activity guidelines. In contrast, well trained older individuals (Masters athletes) have superior functional capacity than their sedentary peers and are often comparable with young non-athletes. Therefore, the 'masters' athlete may be viewed as a unique non-pharmacological model which may allow researchers to disentangle the inexorable from the preventable and the magnitude of the unavoidable 'true' reduction in cardiac function due to ageing.

CONCLUSION

This review examines evidence from studies which have compared cardiac structure and function in well trained older athletes, with age-matched controls but otherwise healthy.

High intensity interval training (HIIT) improves resting blood pressure, metabolic (MET) capacity and heart rate reserve without compromising cardiac function in sedentary aging men

BACKGROUND

This study examined a programme of pre-conditioning exercise with subsequent high intensity interval training (HIIT) on blood pressure, echocardiography, cardiac strain mechanics and maximal metabolic (MET) capacity in sedentary (SED) aging men compared with age matched masters athletes (LEX).

METHODS

Using a STROBE compliant observational design, 39 aging male participants (SED; n=22, aged 62.7±5.2yrs) (LEX; n=17, aged=61.1±5.4yrs) were recruited to a study that necessitated three distinct assessment phases; enrolment (Phase A), following pre-conditioning exercise in SED (Phase B), then following 6weeks of HIIT performed once every five days by both groups before reassessment (Phase C). Hemodynamic, echocardiographic and cardiac strain mechanics were obtained at rest and maximal cardiorespiratory and chronotropic responses were obtained at each measurement phase.

RESULTS

The training intervention improved systolic, mean arterial blood pressure, rate pressure product and heart rate reserve (each P<0.05) in SED and increased MET capacity in both SED and LEX (P<0.01) which was amplified by HIIT. Echocardiography and cardiac strain measures were unremarkable apart from trivial increase to intra-ventricular septum diastole (IVSd) (P<0.05) and decrease to left ventricular internal dimension diastole (LVId) (P<0.05) in LEX following HIIT.

CONCLUSIONS

A programme of preconditioning exercise with HIIT induces clinically relevant improvements in blood pressure, rate pressure product and encourages recovery of heart rate reserve in SED, while improving maximal MET capacity in both SED and LEX without inducing any pathological cardiovascular remodeling. These data add to the emerging repute of HIIT as a safe and promising exercise prescription to improve cardiovascular function and metabolic capacity in sedentary aging.

Left ventricular twist mechanics in the context of normal physiology and cardiovascular disease: a review of studies using speckle tracking echocardiography

The anatomy of the adult human left ventricle (LV) is the result of its complex interaction with its environment. From the fetal to the neonatal to the adult form, the human LV undergoes an anatomical transformation that finally results in the most complex of the four cardiac chambers. In its adult form, the human LV consists of two muscular helixes that surround the midventricular circumferential layer of muscle fibers. Contraction of these endocardial and epicardial helixes results in a twisting motion that is thought to minimize the transmural stress of the LV muscle. In the healthy myocardium, the LV twist response to stimuli that alter preload, afterload, or contractility has been described and is deemed relatively consistent and predictable. Conversely, the LV twist response in patient populations appears to be a little more variable and less predictable, yet it has revealed important insight into the effect of cardiovascular disease on LV mechanical function. This review discusses important methodological aspects of assessing LV twist and evaluates the LV twist responses to the main physiological and pathophysiological states. It is concluded that correct assessment of LV twist mechanics holds significant potential to advance our understanding of LV function in human health and cardiovascular disease.

Progressive and biphasic cardiac responses during extreme mountain ultramarathon

Investigations on the cardiac function consequences of mountain ultramarathon (MUM) >100 h are lacking. The present study assessed the progressive cardiac responses during the world's most challenging MUM (Tor des Géants; Italy; 330 km; 24,000 m of cumulative elevation gain). Resting echocardiographic evaluation of morphology, function, and mechanics of left and right ventricle (LV and RV) including speckle tracking echocardiography was conducted in 15 male participants (46 ± 13 yr) before (pre), during (mid; 148 km), and after (post) the race. Runners completed the race in 126 ± 15 h. From pre to post, the increase in stroke volume (SV) (103 ± 19 vs. 110 ± 23 vs. 116 ± 21 ml; P < 0.001 at pre, mid, and post) was concomitant to the increase in LV early filling (peak E; 72.9 ± 15.7 vs. 74.6 ± 13.1 vs. 82.1 ± 11.5 cm/s; P < 0.05). Left and right atrial end-diastolic areas, RV end-diastolic area, and LV end-diastolic volume were 12-19% higher at post compared with pre (P < 0.05). Resting heart rate and LV systolic strain rates demonstrated a biphasic adaptation with an increase from pre to mid (55 ± 8 vs. 72 ± 11 beats/min, P < 0.001) and a return to baseline values from mid to post (59 ± 8 beats/min). Significant correlations were found between pre-to-post percent changes in peak E and LV end-diastolic volume (r = 0.63, P < 0.05) or RV (r = 0.82, P < 0.001) or atrial end-diastolic areas (r = 0.83, P < 0.001). An extreme MUM induced a biphasic pattern of heart rate in parallel with specific cardiac responses characterized by a progressive increase in diastolic filling, biventricular volumes, and SV. The underlying mechanisms and their clinical implications remain challenging for the future.