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Sonaglioni A, Grasso E, Nicolosi GL, Lombardo M. Modified Haller Index is inversely associated with asymptomatic status in atrial fibrillation patients undergoing electrical cardioversion: a preliminary observation. Minerva Cardiol Angiol 2024; 72:190-203. [PMID: 38127440 DOI: 10.23736/s2724-5683.23.06446-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND No previous study evaluated the possible influence of chest wall conformation on symptoms perception in atrial fibrillation (AF) patients candidates for electrical cardioversion (ECV). We aimed at evaluating the anthropometric and clinical characteristics of patients with persistent AF undergoing ECV, categorized according to the presence or absence of symptoms. METHODS This study retrospectively analyzed a series of persistent AF patients scheduled for early ECV who underwent pre-procedural clinical evaluation, MHI (the ratio of chest transverse diameter over the distance between sternum and spine) assessment, transthoracic and transesophageal echocardiography implemented with strain analysis of both left atrium and left atrial appendage. Thromboembolic risk and burden of comorbidities were assessed by CHA2DS2-VASc Score and Charlson Comorbidity Index (CCI), respectively. The independent predictors of "asymptomatic AF" were assessed. RESULTS A total of 25 asymptomatic and 90 symptomatic AF patients were retrospectively examined. Compared to symptomatic AF patients, those asymptomatic were significantly older (78.4±3.8 vs. 71.0±7.7 years, P<0.001), predominantly males (84 vs. 44.4%, P<0.001), with significantly lower MHI (2.0±0.1 vs. 2.4±0.1, P<0.001), higher CHA2DS2-VASc Score (5.8±1.1 vs. 3.6±1.1, P<0.001) and CCI (6.8±1.4 vs. 2.3±0.9, P<0.001), and greater impairment in biventricular systolic function and atrio-auricolar myocardial strain indices. On multivariate logistic regression analysis, CHA2DS2-VASc Score (OR=2.65, 95% CI: 1.53-4.60) and CCI (OR=2.36, 95% CI: 1.16-4.66) were linearly associated with the endpoint "asymptomatic AF," whereas MHI (OR 0.76, 95% CI 0.59-0.97) was inversely associated with the asymptomatic status. A MHI <2.2 was the best cut-off for detecting asymptomatic AF patients. CONCLUSIONS MHI is inversely associated with asymptomatic status in persistent AF patients undergoing ECV. MHI assessment might represent an innovative practical approach to AF patients.
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Affiliation(s)
| | - Enzo Grasso
- Division of Cardiology, IRCCS MultiMedica, Milan, Italy
| | - Gian L Nicolosi
- Division of Cardiology, Policlinico San Giorgio, Pordenone, Italy
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Sonaglioni A, Nicolosi GL, Granato A, Bonanomi A, Rigamonti E, Lombardo M. Influence of chest wall conformation on reproducibility of main echocardiographic indices of left ventricular systolic function. Minerva Cardiol Angiol 2024; 72:111-124. [PMID: 38231080 DOI: 10.23736/s2724-5683.23.06475-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND The possible influence of chest wall conformation, as noninvasively assessed by Modified Haller Index (MHI, the ratio of chest transverse diameter over the distance between sternum and spine), on reproducibility of both left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) has never been previously investigated. METHODS Two equal groups of healthy individuals, matched by age, sex, and cardiovascular risk factors and categorized according to MHI in those with concave-shaped chest wall (MHI>2.5) and those with normal chest shape (MHI≤2.5), who underwent transthoracic echocardiography implemented with echocardiographic deformation imaging between June 2018 and May 2019, were retrospectively analyzed. LVEF and GLS were measured twice by the two echocardiographers in a double blinded manner. Intra-class correlation coefficients (ICCs), bias and limits of agreement determined with Bland-Altman analysis were calculated for repeated measurements of both LVEF and GLS. RESULTS Thirty-four healthy individuals with MHI>2.5 (54.9±6.4 years, 58.8% females) and 34 matched controls with MHI≤2.5 (52.5±8.1 years, 50% females) were separately analyzed. In comparison to MHI≤2.5 group, the MHI>2.5 group was found with significantly smaller cardiac chambers and significantly lower GLS magnitude (-15.8±2.5 vs. -22.2±1.3%, P<0.001), despite similar LVEF (61.3±6.4 vs. 61.1±3.6%, P=0.87). In the MHI>2.5 group, intra-rater and inter-rater ICCs were ≤0.5 for both LVEF and LV-GLS, whereas in the MHI≤2.5 group intra-rater and inter-rater ICCs values indicated good reliability for LVEF and excellent reliability for GLS. The greatest bias and largest limits of agreement were detected for LVEF assessment (bias ranging from -1.09 to 2.94%, with the 95% limits of agreement ranging from -13.9 to 21.3%) in individuals with MHI>2.5. On the other hand, the smallest bias and narrowest limits of agreement were obtained for GLS measurement (bias ranging from -0.26 to 0.09%, with the 95% limits of agreement ranging from -1.4 to 1.4%) in participants with normal chest wall conformation (MHI≤2.5). CONCLUSIONS The test reliability of LVEF and GLS is strongly influenced by the chest wall conformation. MHI might represent an innovative approach for selecting the best echocardiographic method for LV systolic function estimation in the individual case.
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Affiliation(s)
- Andrea Sonaglioni
- Division of Cardiology, IRCCS MultiMedica, San Giuseppe Hospital, Milan, Italy -
| | - Gian L Nicolosi
- Division of Cardiology, San Giorgio Polyclinic, Pordenone, Italy
| | - Alberto Granato
- Department of Veterinary Sciences, University of Turin, Turin, Italy
| | - Andrea Bonanomi
- Department of Statistical Science, Sacred Heart Catholic University, Milan, Italy
| | | | - Michele Lombardo
- Division of Cardiology, IRCCS MultiMedica, San Giuseppe Hospital, Milan, Italy
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Sonaglioni A, Nicolosi GL. Does chest wall conformation influence myocardial strain parameters in COVID-19 patients with anxiety disorders? Am J Med Sci 2023; 366:157-159. [PMID: 37290742 PMCID: PMC10246302 DOI: 10.1016/j.amjms.2023.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 08/21/2022] [Accepted: 04/20/2023] [Indexed: 06/10/2023]
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Hohneck A, Ansari U, Natale M, Wittig K, Overhoff D, Riffel P, Boettcher M, Akin I, Duerschmied D, Papavassiliu T. Description of a new clinical syndrome: thoracic constriction without evidence of the typical funnel-shaped depression-the "invisible" pectus excavatum. Sci Rep 2023; 13:12036. [PMID: 37491452 PMCID: PMC10368685 DOI: 10.1038/s41598-023-38739-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/13/2023] [Indexed: 07/27/2023] Open
Abstract
Pectus excavatum (PE) is a congenital malformation with a funnel-shaped depression of the sternum that can lead to cardiac symptoms. However, there are patients with thoracic constriction (defined as elevated Haller-Index > 3.25 determined by cardiac magnetic resonance imaging (CMR)) without visible evidence of PE, leading to similar complaints. Between January 2004 till June 2020, patients who underwent CMR for further evaluation of the heart, due to cardiac symptoms were enrolled and compared to controls. Biventricular global strain analysis was assessed using feature tracking (CMR-FT). ECG and/or Holter recordings were performed to detect rhythm events. Cardiac symptoms were evaluated in detail using a questionnaire. Finally, 88 patients (male 35, female 53) with elevated Haller-Index (3.9 ± 0.8) were included and compared to CMR data from 25 individuals with confirmed PE and 25 healthy controls (HC). Mean age at time of CMR was 35 ± 16 years. The most common symptoms at presentation were palpitations (41%), followed by dyspnea (24%) and atypical chest pain (14%). Three patients (3%) had atrial fibrillation or atrial flutter. Concomitant phenomena were pericardial effusion in 39% and mitral valve prolapse (MVP) in 27% of the study cohort. While there were no differences in left ventricular function or volumes, right ventricular function (RVEF) was significantly lower in patients with internal PE compared to HC (RVEF (%) 50 ± 5 vs 59 ± 4, p < 0.01). Strain analysis revealed only discrete changes in RV strain, implying a purely mechanical problem in the absence of structural changes. RV dimensions were negatively correlated with the size of thoracic indices (r = 0.41), reflecting the extent of thoracic constriction. MVP was more prevalent in patients with greater thoracic indices (r = 0.24). The described cohort, referred to as internal PE because of the absence of external changes, showed similar CMR morphologic findings as patients with real PE (especially altered dimensions of the right heart and a lower RVEF). In addition, there was a high incidence of rhythm disturbances, such as extrasystoles or arrhythmias. In one-third of the study cohort additional abnormalities such as pericardial effusion or MVP were present, with MVP being found more frequently in patients with larger thoracic indices, suggesting a possible common pathogenesis.Trial registration: ISRCTN registry, ISRCTN15355937, retrospectively registered 03.06.2022, https://www.isrctn.com/ISRCTN15355937?q=15355937&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10 .
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Affiliation(s)
- Anna Hohneck
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany.
| | - Uzair Ansari
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Michèle Natale
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Karsten Wittig
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Daniel Overhoff
- Department of Clinical Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Philipp Riffel
- Department of Clinical Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Theano Papavassiliu
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
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Schellenberg J, Ahathaller M, Matits L, Kirsten J, Kersten J, Steinacker JM. Left Ventricular Global Longitudinal Strain as a Parameter of Mild Myocardial Dysfunction in Athletes after COVID-19. J Cardiovasc Dev Dis 2023; 10:jcdd10050189. [PMID: 37233156 DOI: 10.3390/jcdd10050189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/15/2023] [Accepted: 04/22/2023] [Indexed: 05/27/2023] Open
Abstract
Whether symptoms during COVID-19 contribute to impaired left ventricular (LV) function remains unclear. We determine LV global longitudinal strain (GLS) between athletes with a positive COVID-19 test (PCAt) and healthy control athletes (CON) and relate it to symptoms during COVID-19. GLS is determined in four-, two-, and three-chamber views and assessed offline by a blinded investigator in 88 PCAt (35% women) (training at least three times per week/>20 MET) and 52 CONs from the national or state squad (38% women) at a median of two months after COVID-19. The results show that the GLS is significantly lower (GLS -18.53 ± 1.94% vs. -19.94 ± 1.42%, p < 0.001) and diastolic function significantly reduces (E/A 1.54 ± 0.52 vs. 1.66 ± 0.43, p = 0.020; E/E'l 5.74 ± 1.74 vs. 5.22 ± 1.36, p = 0.024) in PCAt. There is no association between GLS and symptoms like resting or exertional dyspnea, palpitations, chest pain or increased resting heart rate. However, there is a trend toward a lower GLS in PCAt with subjectively perceived performance limitation (p =0.054). A significantly lower GLS and diastolic function in PCAt compared with healthy peers may indicate mild myocardial dysfunction after COVID-19. However, the changes are within the normal range, so that clinical relevance is questionable. Further studies on the effect of lower GLS on performance parameters are necessary.
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Affiliation(s)
- Jana Schellenberg
- Division of Sports and Rehabilitation Medicine, University Ulm Hospital, 89075 Ulm, Germany
| | - Magdalena Ahathaller
- Division of Sports and Rehabilitation Medicine, University Ulm Hospital, 89075 Ulm, Germany
| | - Lynn Matits
- Division of Sports and Rehabilitation Medicine, University Ulm Hospital, 89075 Ulm, Germany
- Clinical & Biological Psychology, Institute of Psychology and Education, Ulm University, 89075 Ulm, Germany
| | - Johannes Kirsten
- Division of Sports and Rehabilitation Medicine, University Ulm Hospital, 89075 Ulm, Germany
| | - Johannes Kersten
- Division of Sports and Rehabilitation Medicine, University Ulm Hospital, 89075 Ulm, Germany
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Sonaglioni A, Nicolosi GL, Trevisan R, Lombardo M, Grasso E, Gensini GF, Ambrosio G. The influence of pectus excavatum on cardiac kinetics and function in otherwise healthy individuals: A systematic review. Int J Cardiol 2023; 381:135-144. [PMID: 37003372 DOI: 10.1016/j.ijcard.2023.03.058] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/28/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND A number of anterior chest wall deformities, most notably pectus excavatum (PE), may have a detrimental effect on cardiac motion and function. Interpretation of transthoracic echocardiography (TTE) and speckle-tracking echocardiography (STE) results may be hampered by the possible influence of PE on cardiac kinetics. METHODS A comprehensive search of all articles assessing cardiac function in PE individuals was carried out. Inclusion criteria were: 1) individuals aged >10 years; 2) studies providing objective assessment of chest deformity (Haller index). Studies that measured myocardial strain parameters in PE patients were also included. RESULTS The search (EMBASE and Medline) yielded a total of 392 studies, 36 (9.2%) of which removed as duplicates; a further 339 did not meet inclusion criteria. The full-texts of 17 studies were then analyzed. All studies concordantly reported impaired right ventricular volumes and function. With respect to left ventricle (LV), TTE studies uniformly demonstrated a significant impairment in conventional echoDoppler indices in PE individuals, whereas STE studies provided conflicting results. Importantly, LV functional alterations promptly reverted upon surgical correction of chest defect. In subjects with PE of mild-to-moderate severity, we observed that degree of anterior chest wall deformity, as noninvasively assessed by modified Haller index (MHI), was strongly associated with myocardial strain magnitude, in heterogenous cohorts of otherwise healthy PE individuals. CONCLUSIONS Clinicians should be aware that in PE individuals, TTE and STE results may not always be indicative of intrinsic myocardial dysfunction, but may be, at least in part, influenced by artifactual and/or external chest shape determinants.
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Affiliation(s)
| | | | | | | | - Enzo Grasso
- Division of Cardiology, MultiMedica IRCCS, Milan, Italy
| | | | - Giuseppe Ambrosio
- Cardiology and Cardiovascular Pathophysiology, Azienda Ospedaliero-Universitaria "S. Maria Della Misericordia", Perugia, Italy
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Abu-Tair T, Turial S, Willershausen I, Alkassar M, Staatz G, Kampmann C. Evaluating Cardiac Lateralization by MRI to Simplify Estimation of Cardiopulmonary Impairment in Pectus Excavatum. Diagnostics (Basel) 2023; 13:diagnostics13050844. [PMID: 36899988 PMCID: PMC10001214 DOI: 10.3390/diagnostics13050844] [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: 11/29/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND The severity of pectus excavatum is classified by the Haller Index (HI) and/or Correction Index (CI). These indices measure only the depth of the defect and, therefore, impede a precise estimation of the actual cardiopulmonary impairment. We aimed to evaluate the MRI-derived cardiac lateralization to improve the estimation of cardiopulmonary impairment in Pectus excavatum in connection with the Haller and Correction Indices. METHODS This retrospective cohort study included a total of 113 patients (mean age = 19.03 ± 7.8) with pectus excavatum, whose diagnosis was verified on cross-sectional MRI images using the HI and CI. For the development of an improved HI and CI index, the patients underwent cardiopulmonary exercise testing to assess the influence of the right ventricle's position on cardiopulmonary impairment. The indexed lateral position of the pulmonary valve was utilized as a surrogate parameter for right ventricle localization. RESULTS In patients with PE, the heart's lateralization significantly correlated with the severity of pectus excavatum (p ≤ 0.001). When modifying HI and CI for the individual's pulmonary valve position, those indices are present with greater sensitivity and specificity regarding the maximum oxygen-pulse as a pathophysiological correlate of reduced cardiac function (χ2 10.986 and 15.862, respectively). CONCLUSION The indexed lateral deviation of the pulmonary valve seems to be a valuable cofactor for HI and CI, allowing for an improved description of cardiopulmonary impairment in PE patients.
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Affiliation(s)
- Tariq Abu-Tair
- Department of Congenital Heart Disease, Centre for Diseases in Childhood and Adolescence, University Medicine Mainz, 55131 Mainz, Germany
- Department of Pediatric Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany
- Correspondence: ; Tel.: +49-9131-8541190; Fax: +49-9131-8535987
| | - Salmai Turial
- Department of General, Visceral, Vascular and Transplantation Surgery, Division of Pediatric Surgery, Pediatric Trauma Surgery and Pediatric Urology, University Medical Centre Magdeburg, 39120 Magdeburg, Germany
| | - Ines Willershausen
- Department of Orthodontics and Orofacial Orthopedics, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Muhannad Alkassar
- Department of Congenital Heart Disease, Centre for Diseases in Childhood and Adolescence, University Medicine Mainz, 55131 Mainz, Germany
| | - Gundula Staatz
- Department of Diagnostic and Interventional Radiology, Section of Pediatric Radiology, University Medicine Mainz, 55131 Mainz, Germany
| | - Christoph Kampmann
- Department of Congenital Heart Disease, Centre for Diseases in Childhood and Adolescence, University Medicine Mainz, 55131 Mainz, Germany
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The influence of chest wall conformation on myocardial strain parameters in a cohort of mitral valve prolapse patients with and without mitral annular disjunction. Int J Cardiovasc Imaging 2023; 39:61-76. [PMID: 36598688 DOI: 10.1007/s10554-022-02705-w] [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: 06/26/2022] [Accepted: 07/29/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE To evaluate the possible influence of chest wall conformation on myocardial strain parameters in a cohort of mitral valve prolapse (MVP) patients with and without mitral annular disjunction (MAD). METHODS All consecutive middle-aged patients with MVP referred to our Outpatient Cardiology Clinic for performing two-dimensional (2D) transthoracic echocardiography (TTE) as part of work up for primary cardiovascular prevention between March 2018 and May 2022, were included into the study. All patients underwent clinic visit, physical examination, modified Haller index (MHI) assessment (the ratio of chest transverse diameter over the distance between sternum and spine) and conventional 2D-TTE implemented with speckle tracking analysis of left ventricular (LV) global longitudinal strain (GLS) and global circumferential strain (GCS). Independent predictors of MAD presence on 2D-TTE were assessed. RESULTS A total of 93 MVP patients (54.2 ± 16.4 yrs, 50.5% females) were prospectively analyzed. On 2D-TTE, 34.4% of MVP patients had MAD (7.3 ± 2.0 mm), whereas 65.6% did not. Compared to patients without MAD, those with MAD had: 1) significantly shorter antero-posterior (A-P) thoracic diameter (13.5 ± 1.2 vs 14.8 ± 1.3 cm, p < 0.001); 2) significantly smaller cardiac chambers dimensions; 3) significantly increased prevalence of classic MVP (84.3 vs 44.3%, p < 0.001); 4) significantly impaired LV-GLS (-17.2 ± 1.4 vs -19.4 ± 3.0%, p < 0.001) and LV-GCS (-16.3 ± 4.1 vs -20.4 ± 4.9, p < 0.001), despite similar LV ejection fraction (63.7 ± 4.2 vs 63.0 ± 3.9%, p = 0.42). A-P thoracic diameter (OR 0.25, 95%CI 0.10-0.82), classic MVP (OR 3.90, 95%CI 1.32-11.5) and mitral annular end-systolic A-P diameter (OR 2.76, 95%CI 1.54-4.92) were the main independent predictors of MAD. An A-P thoracic diameter ≤ 13.5 cm had 59% sensitivity and 84% specificity for predicting MAD presence (AUC = 0.81). In addition, MAD distance was strongly influenced by A-P thoracic diameter (r = - 0.96) and MHI (r = 0.87), but not by L-L thoracic diameter (r = 0.23). Finally, a strong inverse correlation between MHI and both LV-GLS and LV-GCS was demonstrated in MAD patients (r = - 0.94 and - 0.92, respectively), but not in those without (r = - 0.51 and - 0.50, respectively). CONCLUSIONS A narrow A-P thoracic diameter is strongly associated with MAD presence and is a major determinant of the impairment in myocardial strain parameters in MAD patients, in both longitudinal and circumferential directions.
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Rodriguez-Granillo GA, Toselli L, Farina J, Raggio I, Diluca P, Fontana L, Valle-Anziani M, Bordoli I, Bellia-Munzon G, Martinez-Ferro M. Usefulness of strain cardiac magnetic resonance for the exposure of mild left ventricular systolic abnormalities in pectus excavatum. J Pediatr Surg 2022; 57:319-324. [PMID: 34579966 DOI: 10.1016/j.jpedsurg.2021.09.008] [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: 08/18/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Systolic dysfunction in pectus excavatum (PEX) is usually very subtle and mainly focused on the right ventricle (RV), leading to normal or unremarkable cardiac imaging findings unless involving exercise stress. OBJECTIVES We evaluated systolic function in PEX using longitudinal strain cardiac magnetic resonance (CMR), a validated parameter for the assessment of the systolic deformation of subendocardial fibers. METHODS This prospective registry comprised consecutive patients with PEX who were referred to CMR to define treatment strategies or to establish surgical candidacy. We also included a control group of 15 healthy volunteers without chest wall abnormalities. Using dedicated software, we evaluated the endocardial global longitudinal strain (GLS) of both ventricles and the endocardial global circumferential strain (GCS) of the left ventricle (LV). RESULTS A total of 50 patients with PEX comprised the study population, with a mean age of 19.9 ± 8.0 years. The right ventricular ejection fraction (RVEF) of patients with PEX was significantly lower compared to the control group both at end-expiration (59.5 ± 6.8 vs. 64.7 ± 4.7%, p = 0.008) and end-inspiration (56.7 ± 7.2%, vs. 62.7 ± 4.4, p = 0.004); as well as the pulmonary stroke distance (12.6 ± 2.5, vs. 15.0 ± 2.0 cm, p = 0.001). The LV volumetric analysis revealed no differences between PEX and the control group (p > 0.05 for all) regardless of the respiratory cycle, with a mean expiratory LV ejection fraction (LVEF) of 61.4 ± 6.0%. In contrast, the GLS of the LV was significantly lower in PEX compared to controls (-21.2 ± 3.2 vs. -23.7 ± 3.0%, p = 0.010), whereas GCS was similar either at expiration (-28.5 ± 4.0%, vs. -29.5 ± 2.8, p = 0.38) or inspiration (-29.3 ± 4.1%, vs.-28.9 ± 2.3, p = 0.73). CONCLUSIONS In this study, we demonstrated that longitudinal strain analysis might enable the detection of very subtle left ventricular systolic function abnormalities in patients with PEX, that are commonly overlooked using the conventional assessment. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Gaston A Rodriguez-Granillo
- Clinica La Sagrada Familia, Instituto Medico ENERI, Buenos Aires, Argentina; Consejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET), Argentina
| | - Luzia Toselli
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602. Capital Federal, Buenos Aires C1429AKL, Argentina.
| | | | - Ignacio Raggio
- Clinica Olivos, Swiss Medical Group, Buenos Aires, Argentina; Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno" (CEMIC), Buenos Aires, Argentina
| | - Pablo Diluca
- Clinica La Sagrada Familia, Instituto Medico ENERI, Buenos Aires, Argentina
| | - Lucia Fontana
- Clinica La Sagrada Familia, Instituto Medico ENERI, Buenos Aires, Argentina
| | - Maxroxia Valle-Anziani
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602. Capital Federal, Buenos Aires C1429AKL, Argentina
| | - Ines Bordoli
- Clinica La Sagrada Familia, Instituto Medico ENERI, Buenos Aires, Argentina
| | - Gaston Bellia-Munzon
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602. Capital Federal, Buenos Aires C1429AKL, Argentina
| | - Marcelo Martinez-Ferro
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602. Capital Federal, Buenos Aires C1429AKL, Argentina
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Sonaglioni A, Nicolosi GL, Trevisan R, Granato A, Zompatori M, Lombardo M. Modified Haller index validation and correlation with left ventricular strain in a cohort of subjects with obesity and without overt heart disease. Intern Emerg Med 2022; 17:1907-1919. [PMID: 35753022 DOI: 10.1007/s11739-022-03026-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/04/2022] [Indexed: 12/29/2022]
Abstract
The present study was primarily designed to validate the modified Haller index (MHI), the ratio of chest transverse diameter over the distance between sternum and spine, measured by a ruler and transthoracic echocardiography (TTE), respectively, in a cohort of subjects with obesity, but otherwise healthy, by comparing the results to the conventional Haller index (HI) measured on chest X-ray (CXR). 100 consecutive subjects with body mass index (BMI) ≥ 30 kg/m2 and 60 matched controls with BMI < 30 kg/m2, who underwent a two-plane CXR for any clinical indication, were prospectively examined over a 6-month period. All participants underwent MHI assessment, TTE and speckle-tracking analysis of left ventricular (LV) global longitudinal strain (GLS). Bland-Altman analysis was used to compare the radiological and nonradiological techniques. Second, independent predictors of subclinical myocardial dysfunction, defined as LV-GLS less negative than - 20%, were evaluated. Bland-Altman analysis revealed a bias of - 4.91 cm for latero-lateral thoracic diameter, of - 0.74 cm for antero-posterior (A-P) thoracic diameter and of - 0.22 for HI assessment, suggesting a systematic overestimation of the nonradiological methodology in comparison to that radiological. Despite normal LV systolic function on TTE, LV-GLS resulted impaired in 76% of subjects with obesity. Waist circumference (OR 1.13, 95%CI 1.04-1.22) and nonradiological A-P thoracic diameter (OR 0.51, 95%CI 0.28-0.93) were the main independent predictors of subclinical myocardial dysfunction in subjects with obesity. The impairment in LV myocardial strain detected in subjects with obesity appears to be primarily related to extrinsic abdominal and thoracic compressive phenomena, rather than intrinsic myocardial dysfunction.
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Affiliation(s)
- Andrea Sonaglioni
- Division of Cardiology, MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy.
| | | | - Roberta Trevisan
- Division of Radiology, MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
| | - Alberto Granato
- Department of Veterinary Sciences, University of Turin, Largo Paolo Braccini 2, Grugliasco, 10095, Turin, Italy
| | - Maurizio Zompatori
- Division of Radiology, MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
| | - Michele Lombardo
- Division of Cardiology, MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
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Molecular Approaches and Echocardiographic Deformation Imaging in Detecting Myocardial Fibrosis. Int J Mol Sci 2022; 23:ijms231810944. [PMID: 36142856 PMCID: PMC9501415 DOI: 10.3390/ijms231810944] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/11/2022] [Accepted: 09/16/2022] [Indexed: 12/25/2022] Open
Abstract
The pathological remodeling of myocardial tissue is the main cause of heart diseases. Several processes are involved in the onset of heart failure, and the comprehension of the mechanisms underlying the pathological phenotype deserves special attention to find novel procedures to identify the site of injury and develop novel strategies, as well as molecular druggable pathways, to counteract the high degree of morbidity associated with it. Myocardial fibrosis (MF) is recognized as a critical trigger for disruption of heart functionality due to the excessive accumulation of extracellular matrix proteins, in response to an injury. Its diagnosis remains focalized on invasive techniques, such as endomyocardial biopsy (EMB), or may be noninvasively detected by cardiac magnetic resonance imaging (CMRI). The detection of MF by non-canonical markers remains a challenge in clinical practice. During the last two decades, two-dimensional (2D) speckle tracking echocardiography (STE) has emerged as a new non-invasive imaging modality, able to detect myocardial tissue abnormalities without specifying the causes of the underlying histopathological changes. In this review, we highlighted the clinical utility of 2D-STE deformation imaging for tissue characterization, and its main technical limitations and criticisms. Moreover, we focalized on the importance of coupling 2D-STE examination with the molecular approaches in the clinical decision-making processes, in particular when the 2D-STE does not reflect myocardial dysfunction directly. We also attempted to examine the roles of epigenetic markers of MF and hypothesized microRNA-based mechanisms aiming to understand how they match with the clinical utility of echocardiographic deformation imaging for tissue characterization and MF assessment.
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Sonaglioni A, Braga M, Villa MC, Ferrulli A, Nicolosi GL, Lombardo M, Migliori C, Luzi L. Comprehensive assessment of biventricular myocardial function by two-dimensional speckle tracking echocardiography in infants of gestational diabetic mothers. Acta Diabetol 2022; 59:1145-1156. [PMID: 35680656 DOI: 10.1007/s00592-022-01906-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/12/2022] [Indexed: 12/24/2022]
Abstract
AIMS No previous research provided a complete biventricular and multidirectional left ventricular (LV) functional assessment by two-dimensional (2D) speckle tracking echocardiography (STE) in infants of gestational diabetic mothers (IGDM) METHODS: A total of 30 consecutive IGDM and 30 infants of healthy mothers were examined between March 2021 and July 2021. Both groups of infants underwent evaluation by neonatologist and 2D transthoracic echocardiography (TTE) implemented with 2D-STE quantification of LV-global longitudinal strain (GLS), LV-global circumferential strain (GCS), LV-global radial strain (GRS) and right ventricular (RV)-GLS, within 3 days of life and at 40 days after birth. Predictors of persistent subclinical myocardial dysfunction, defined as a LVGLS less negative than -20% at 40-day follow-up, in IGDM population, were determined. RESULTS At 2.2 ± 1.3 days after birth, LV-GLS (- 17.2 ± 1.9 vs. - 23.9 ± 3.8%), LV-GCS (- 17.9 ± 2.7 vs. - 27.3 ± 3.4%), LV-GRS (25.6 ± 3.4 vs. 35.8 ± 3.6%) and RV-GLS (- 17.6 ± 3.6 vs. - 22.6 ± 3.8%) were significantly impaired in IGDM than controls (all p < 0.001). At 36.8 ± 5.2 days of life, LV-GLS was still impaired (less negative than -20%) in 26.6% of IGDM. Maternal third trimester body mass index (BMI) (OR 1.89, 95%CI 1.05-3.39) and third trimester glycosylated hemoglobin (HbA1C) (OR 1.59, 95%CI 1.08-2.19) were independently associated with persistent LV-GLS impairment in IGDM. Maternal BMI ≥ 30 Kg/m2 and HbA1C ≥ 38 mmol/mol showed the maximum of sensitivity and specificity for predicting persistent subclinical myocardial dysfunction in IGDM at 40 days of life. CONCLUSIONS IGDM have diffuse pattern of myocardial dysfunction during perinatal period. This dysfunction may be persistent up to 40 days of life in infants of GDM women with obesity and uncontrolled diabetes.
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Affiliation(s)
| | - Marta Braga
- Department of Neonatology, MultiMedica IRCCS, Milan, Italy
| | | | - Anna Ferrulli
- Department of Endocrinology, Nutrition and Metabolic Diseases, MultiMedica IRCCS, Sesto San Giovanni, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | | | | | | | - Livio Luzi
- Department of Endocrinology, Nutrition and Metabolic Diseases, MultiMedica IRCCS, Sesto San Giovanni, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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Sonaglioni A, Cerini F, Cerrone A, Argiento L, Nicolosi GL, Rigamonti E, Lombardo M, Rumi MG, Viganò M. Liver stiffness measurement identifies subclinical myocardial dysfunction in non-advanced non-alcoholic fatty liver disease patients without overt heart disease. Intern Emerg Med 2022; 17:1425-1438. [PMID: 35302179 DOI: 10.1007/s11739-022-02966-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/26/2022] [Indexed: 12/14/2022]
Abstract
Patients with non-advanced non-alcoholic fatty liver disease (NAFLD) have an increased cardiovascular risk. The present study was designed to evaluate the relationship between liver stiffness measurement (LSM) by transient elastography (TE) and myocardial deformation indices of all cardiac chambers in NAFLD patients without overt heart disease. All consecutive NAFLD patients diagnosed with LSM < 12.5 kPa on TE between September 2021 and December 2021 entered the study. All participants underwent blood tests, TE and two-dimensional (2D) transthoracic echocardiography (TTE) implemented with speckle-tracking echocardiography (STE) analysis of left ventricular (LV) global longitudinal strain (GLS), global circumferential strain (GCS) and global radial strain (GRS), right ventricular (RV) GLS, left atrial (LA) total global strain (TGSA) and right atrial (RA) TGSA. Main independent predictors of impaired LV-GLS (defined as absolute value less negative than - 20%) were evaluated. A total of 92 NAFLD patients (54.0 ± 11.1 years, 50% males) were prospectively analyzed. Mean LSM was 6.2 ± 2.4 kPa. Fibroscan results revealed that 76.1% of patients had F0-F1, 5.4% F2 and 18.5% F3 liver fibrosis. Despite normal biventricular systolic function on 2D-TTE, LV-GLS, LV-GCS and LV-GRS, RV-GLS, LA-TGSA and RA-TGSA were reduced in 64.1%, 38.0%, 38.0%, 31.5%, 39.1% and 41.3% of patients, respectively. Body mass index (BMI) (OR 1.76, 95% CI 1.18-2.64), neutrophil-to-lymphocyte ratio (NLR) (OR 4.93, 95% CI 1.15-31.8) and LSM (OR 9.26, 95% CI 2.24-38.3) were independently associated to impaired LV-GLS. BMI ≥ 29.3 kg/m2, NLR ≥ 1.8 and LSM ≥ 5.5 kPa were the best cut-off values for detecting outcome. LSM ≥ 5.5 kPa identifies NAFLD patients with subclinical myocardial dysfunction.
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Affiliation(s)
- Andrea Sonaglioni
- Division of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy.
| | - Federica Cerini
- Division of Hepatology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
- University of Milan, Milan, Italy
| | - Antonio Cerrone
- Division of Hepatology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
- University of Milan, Milan, Italy
| | - Lorenzo Argiento
- Division of Hepatology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
- University of Milan, Milan, Italy
| | | | - Elisabetta Rigamonti
- Division of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
| | - Michele Lombardo
- Division of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
| | - Maria Grazia Rumi
- Division of Hepatology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
- University of Milan, Milan, Italy
| | - Mauro Viganò
- Division of Hepatology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
- University of Milan, Milan, Italy
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Sonaglioni A, Nicolosi GL, Rigamonti E, Lombardo M. Modified Haller index is inversely correlated with true positive exercise stress echocardiographic results. J Cardiovasc Med (Hagerstown) 2022; 23:524-534. [PMID: 35905007 DOI: 10.2459/jcm.0000000000001344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The influence of chest wall shape on exercise stress echocardiography (ESE) results has been poorly investigated. We aimed at evaluating the main predictors of true positive (TP)-ESE in a population of subjects with suspected coronary artery disease (CAD), categorized according to chest wall conformation, assessed by modified Haller index (MHI, chest transverse diameter over the distance between sternum and spine). METHODS All consecutive patients with suspected CAD referred to our EchoLab for performing ESE between September 2011 and October 2021 were retrospectively enrolled. Preliminary assessment of both pretest probability (PTP) and MHI was performed. All patients with positive ESE underwent coronary angiography. Obstructive CAD was diagnosed by ≥70% stenosis in any epicardial coronary artery. Outcome was TP ESE result. RESULTS One thousand two hundred and seventy-five consecutive patients (64.9 ± 13.0 years) entered the study. Subjects with concave-shaped chest wall (MHI > 2.5) (10.7%) and those with normal chest shape (MHI ≤ 2.5) (89.3%) were separately analyzed. PTP was similar in both groups (21.8 ± 13.2 vs. 23.5 ± 13.3%, P = 0.15). One hundred and seventy patients were diagnosed with positive ESE: 129 (75.9%) had obstructive CAD (TP), whereas the remaining 41 (24.1%) had no CAD. Only 2.3% of TP ESE was detected in subjects with MHI >2.5. PTP [odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01-1.04], dyslipidemia (OR 4.37, 95% CI 2.81-6.80), dyssynergy in the left anterior descending territory (OR 8.21, 95% CI 5.07-13.3) were linearly correlated with TP ESE, whereas MHI >2.5 (OR 0.25, 95% CI 0.14-0.67) was inversely associated with outcome. CONCLUSIONS Subjects with MHI >2.5 have low prevalence of TP ESE, regardless of PTP. Preliminary MHI assessment may reduce overestimation of PTP of CAD.
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Sonaglioni A, Caminati A, Nicolosi GL, Lombardo M, Harari S. Incremental prognostic value of arterial elastance in mild-to-moderate idiopathic pulmonary fibrosis. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:1473-1485. [PMID: 35103898 DOI: 10.1007/s10554-022-02541-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 01/25/2022] [Indexed: 11/05/2022]
Abstract
Previous reports suggested that poor pulmonary function was associated with increased arterial elastance (Ea) in patients with chronic obstructive pulmonary disease and systemic sclerosis. The mechanisms connecting pulmonary function and Ea have not yet been accurately studied in patients with idiopathic pulmonary fibrosis (IPF). The present study was designed to assess Ea in IPF patients without chronic severe pulmonary hypertension and to determine its prognostic role over a medium-term follow-up. This retrospective study included 60 consecutive patients with mild-to-moderate IPF (73.8 ± 6.6 years, 75% males) and 60 controls matched by age, sex and cardiovascular risk factors. All patients underwent physical examination, spirometry, blood tests, modified Haller index (MHI, chest transverse diameter over the distance between sternum and spine) assessment, conventional transthoracic echocardiography implemented with speckle tracking analysis of left atrial positive global strain (LA-GSA+ ) and finally carotid Doppler ultrasonography, at basal evaluation. The effective arterial elastance index (EaI) was calculated as the ratio of end-systolic pressure to stroke volume index. During follow-up period, we evaluated the composite endpoint of (1) pulmonary or cardiovascular hospitalizations; (2) all-cause mortality. At baseline, EaI was significantly higher in IPF patients than controls (4.1 ± 1.3 vs 3.5 ± 1.0 mmHg/ml/m2, p = 0.01). EaI was strongly correlated to the following variables: C-reactive protein (CRP) (r = 0.86), forced vital capacity (FVC) (r = - 0.91), E/e' ratio (r = 0.91), LA-GSA+ (r = - 0.92), common carotid artery-cross sectional area (CCA-CSA) (r = 0.89) and MHI (r = 0.86), in IPF patients. Mean follow-up time was 2.4 ± 1.3 years. During follow-up, 12 patients died and 17 were hospitalized due to major adverse clinical events. At univariate Cox analysis, CRP (HR 1.51, 95% CI 1.25-1.82), FVC (HR 0.88, 95% CI 0.85-0.91), LA-GSA+ (HR 0.85, 95% CI 0.77-0.94), CCA-CSA (HR 1.12, 95% CI 1.03-1.22) and EaI (HR 2.43, 95% CI 1.75-3.37) were significantly associated with outcome. At multivariate Cox analysis, only EaI (HR 1.60, 95% CI 1.03-2.50) retained statistical significance. An EaI ≥ 4 mmHg/ml/m2 showed 100% sensitivity and 99.4% specificity for predicting outcome (AUC = 0.98). In patients with mild-to-moderate IPF, an EaI ≥ 4 mmHg/ml/m2 is a negative prognostic factor over a medium-term follow-up.
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Affiliation(s)
- Andrea Sonaglioni
- Division of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
| | - Antonella Caminati
- Division of Pneumology, Semi-Intensive Care Unit, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy.
| | - Gian Luigi Nicolosi
- Division of Cardiology, Policlinico San Giorgio, Via Agostino Gemelli 10, 33170, Pordenone, Italy
| | - Michele Lombardo
- Division of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
| | - Sergio Harari
- Division of Pneumology, Semi-Intensive Care Unit, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Di Milano, Milan, Italy
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Sonaglioni A, Cerini F, Nicolosi GL, Lombardo M, Rumi MG, Viganò M. Left ventricular strain predicts subclinical atherosclerosis in nonadvanced nonalcoholic fatty liver disease patients. Eur J Gastroenterol Hepatol 2022; 34:707-716. [PMID: 35412487 DOI: 10.1097/meg.0000000000002375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The association between nonalcoholic fatty liver disease (NAFLD) and carotid atherosclerosis is still controversial. The present study was designed to assess the relationship between left ventricular systolic mechanics, noninvasively assessed by two-dimensional (2D) speckle-tracking echocardiography (STE) and common carotid artery (CCA) intima-media thickness (IMT), in patients with nonadvanced NAFLD. METHODS All consecutive NAFLD patients diagnosed with liver stiffness measurement (LSM) <12.5 kPa on transient elastography between September 2021 and December 2021 were prospectively enrolled. All participants underwent blood tests, transient elastography, 2D transthoracic echocardiography (TTE) implemented with 2D-STE analysis of left ventricular (LV) global longitudinal strain (GLS) and finally carotid ultrasonography. Main independent predictors of subclinical atherosclerosis, defined as CCA-IMT >0. 9 mm, were evaluated. RESULTS A total of 92 NAFLD patients (54.0 ± 11.1 years, 50% males) were prospectively analyzed. Mean LSM was 6.2 ± 2.4 kPa. FibroScan results revealed that 76.1% of patients had F0-F1, 5.4% F2 and 18.5% F3 liver fibrosis. Despite normal biventricular systolic function on 2D-TTE, LV-GLS was reduced (less negative than -20%) in 64.1% of patients. However, 62.0% of NAFLD patients were found with CCA-IMT >0. 9 mm. Age [odds ratio (OR),1.19; 95% confidence interval (CI), 1.05-1.36], hypertension (OR, 3.73; 95% CI, 1.53-9.11), LSM (OR, 4.83; 95% CI, 2.43-9.59), LV-GLS (OR, 0.49; 95% CI, 0.36-0.68) and statin therapy (OR, 0.10; 95% CI, 0.02-0.60) were independently associated with subclinical atherosclerosis. Age ≥51 years, LSM ≥5.5 kPa and LV-GLS less negative than -20% were the best cutoff values for predicting subclinical atherosclerosis. CONCLUSIONS Subclinical myocardial dysfunction and subclinical atherosclerosis are simultaneously present in patients with nonadvanced NAFLD.
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Affiliation(s)
| | - Federica Cerini
- Division of Hepatology, Ospedale San Giuseppe MultiMedica IRCCS, University of Milan, Milan
| | | | | | - Maria Grazia Rumi
- Division of Hepatology, Ospedale San Giuseppe MultiMedica IRCCS, University of Milan, Milan
| | - Mauro Viganò
- Division of Hepatology, Ospedale San Giuseppe MultiMedica IRCCS, University of Milan, Milan
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Sonaglioni A, Nicolosi GL, Migliori C, Bianchi S, Lombardo M. Usefulness of second trimester left ventricular global longitudinal strain for predicting adverse maternal outcome in pregnant women aged 35 years or older. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:1061-1075. [PMID: 34865191 DOI: 10.1007/s10554-021-02485-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/27/2021] [Indexed: 01/20/2023]
Abstract
The present study was primarily designed to accurately determine biventricular and biatrial myocardial function, assessed by two-dimensional speckle tracking echocardiography (2D-STE), in a prospective cohort of pregnant women aged ≥ 35 years, at the second trimester of pregnancy. Secondly, we aimed at investigating the main independent predictors of adverse maternal outcome (AMO) in the same study population. 80 consecutive pregnant women aged ≥ 35 years, 80 gestational week-matched (18.4 ± 1.6 vs 18.5 ± 1.8 weeks, p = 0.71) pregnant women aged < 35 years and 80 non-pregnant women aged ≥ 35 years without any comorbidity were included in this prospective study. All pregnant women underwent obstetric evaluation, modified Haller index (MHI) assessment and a conventional two-dimensional transthoracic echocardiography implemented with complete 2D-STE analysis of both ventricles and atria at the second trimester of pregnancy. AMO was defined as the occurrence of any of the following: gestational hypertension (GH) including preeclampsia; gestational diabetes mellitus (GDM); preterm delivery (PD); emergency caesarean section (ECS); postpartum haemorrhage (PPH); premature rupture of membranes (PROM); maternal death. Compared to younger pregnant women, pregnant women aged ≥ 35 years were more likely to be found with: (1) body mass index (BMI) ≥ 30 kg/m2 (37.5% of total); (2) significantly increased inflammatory markers; (3) significantly greater left ventricular mass index; (4) significantly impaired hemodynamics; (5) significantly reduced bi-atrial and bi-ventricular myocardial strain parameters, despite normal ejection fraction. A strong inverse correlation between second trimester BMI and left ventricular (LV)-global longitudinal strain (GLS) (r = - 0.84) and between second trimester MHI and LV-GLS (r = - 0.81) was demonstrated in pregnant women aged ≥ 35 years. GH, GDM, PD, ECS, PPH and PROM were detected in 15%, 12.5%, 10%, 8.7%, 8.7% and 7.5% of women, respectively. Age (OR 2.04, 95% CI 1.46-2.84), second trimester BMI (OR 2.40, 95% CI 1.64-3.51) and second trimester LV-GLS (OR 0.07, 95%C I 0.01-0.34) were independently associated with outcome. Age ≥ 37 years, BMI ≥ 30 kg/m2 and LV-GLS less negative than - 18% were the best cut-off values for predicting AMO. A LV-GLS less negative than - 18% allows to identify, among older pregnant women, those with an increased risk of AMO. Both intrinsic myocardial dysfunction and extrinsic compressive mechanical phenomena might affect global myocardial deformation during gestation.
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Affiliation(s)
- Andrea Sonaglioni
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy.
| | | | | | - Stefano Bianchi
- Department of Gynecology and Obstetrics, IRCCS MultiMedica, Milan, Italy
| | - Michele Lombardo
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
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Sonaglioni A, Barlocci E, Adda G, Esposito V, Ferrulli A, Nicolosi GL, Bianchi S, Lombardo M, Luzi L. The impact of short-term hyperglycemia and obesity on biventricular and biatrial myocardial function assessed by speckle tracking echocardiography in a population of women with gestational diabetes mellitus. Nutr Metab Cardiovasc Dis 2022; 32:456-468. [PMID: 34893411 DOI: 10.1016/j.numecd.2021.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/09/2021] [Accepted: 10/13/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS To compare biventricular and biatrial myocardial strain indices assessed by two-dimensional speckle tracking echocardiography (2D-STE) in women with gestational diabetes mellitus (GDM) and those with uncomplicated pregnancy at the third trimester of pregnancy and in post-partum. METHODS AND RESULTS 30 consecutive GDM women and 30 age-, ethnicity- and gestational week-matched controls without any comorbidity were examined in this prospective case-control study. All women underwent obstetric visit, blood tests and transthoracic echocardiography (TTE) implemented with 2D-STE analysis of all cardiac chambers at 36-38 weeks' gestation. TTE and 2D-STE were repeated at 6-10 weeks after delivery. At 36-38 weeks' gestation, GDM women, compared to controls, had significantly higher body mass index (BMI), blood pressure values and inflammatory markers. TTE showed increased left ventricular (LV) mass and impaired LV diastolic function in GDM women, whereas there was no significant difference between the groups in ejection fraction. 2D-STE revealed that biventricular global longitudinal strain (GLS) and biatrial reservoir strain indices were significantly lower in GDM women than controls. Third trimester BMI was inversely correlated with LV-GLS (r = -0.86) and was independently associated with reduced LV-GLS (less negative than -20%) in GDM women in post-partum (OR 1.81, 95%CI 1.14-2.89). A BMI value ≥ 30 kg/m2 had 100% sensitivity and 99.5% specificity for identifying GDM women with impaired LV-GLS in post-partum (AUC = 0.97). CONCLUSION Women with GDM, compared to women with uncomplicated pregnancy, have significantly lower biventricular and biatrial myocardial deformation indices. These abnormalities may be persistent in post-partum in GDM women with obesity.
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Affiliation(s)
| | - Eugenio Barlocci
- Department of Gynecology and Obstetrics, IRCCS MultiMedica, Milan, Italy
| | - Guido Adda
- Department of Endocrinology, Nutrition and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Valentina Esposito
- Department of Gynecology and Obstetrics, IRCCS MultiMedica, Milan, Italy
| | - Anna Ferrulli
- Department of Endocrinology, Nutrition and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | | | - Stefano Bianchi
- Department of Gynecology and Obstetrics, IRCCS MultiMedica, Milan, Italy
| | | | - Livio Luzi
- Department of Endocrinology, Nutrition and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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Koestenberger M, Belyavskiy E. Myocardial strain analysis in infants with pectus excavatum: A subtle method to detect myocardial impairment? JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:929-931. [PMID: 34695241 DOI: 10.1002/jcu.23085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 10/05/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Evgeny Belyavskiy
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
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Sonaglioni A, Nicolosi GL, Braga M, Villa MC, Migliori C, Lombardo M. Does chest wall conformation influence myocardial strain parameters in infants with pectus excavatum? JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:918-928. [PMID: 34523718 DOI: 10.1002/jcu.23064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE To investigate the possible influence of chest wall conformation on myocardial strain parameters in a consecutive population of infants with pectus excavatum (PE), noninvasively assessed by modified Haller index (MHI). METHODS Sixteen consecutive PE infants (MHI >2.5) and 44 infants with normal chest shape (MHI ≤2.5) entered in this prospective case-control study. All infants underwent evaluation by neonatologist, transthoracic echocardiography implemented with two-dimensional speckle tracking echocardiography (2D-STE) analysis of both ventricles and MHI assessment (ratio of chest transverse diameter over the distance between sternum and spine), at two time points: within 3 days and at about 40 days of life. RESULTS At 2.1 ± 1 days of life, compared to controls (MHI = 2.01 ± 0.2), PE infants (MHI = 2.76 ± 0.2) were diagnosed with significantly smaller cardiac chambers dimensions. Biventricular contractile function and hemodynamics were similar in both groups of infants. Left ventricular (LV) global longitudinal strain (GLS) (-16.0 ± 2.8 vs. -21.7 ± 2.2%), LV-global circumferential strain (GCS) (-16.3 ± 2.7 vs. -24.0 ± 5.2%), LV-global radial strain (GRS) (24.2 ± 3.0 vs. 31.5 ± 6.3%), and right ventricular free wall longitudinal strain (RVFWLS) (-16.0 ± 3.2 vs. -22.3 ± 4.4%) were significantly reduced in PE infants versus controls (all p < 0.001). A strong inverse correlation between MHI and the following parameters: LV-GLS (r = -0.92), LV-GCS (r = -0.88), LV-GRS (r = -0.87), and RVFWLS (r = -0.88), was demonstrated in PE infants, but not in controls, in perinatal period (all p < 0.001). Analogous results were obtained at 36.8 ± 5.2 days after birth. CONCLUSIONS Abnormal chest anatomy progressively impairs myocardial strain parameters in PE infants. This impairment might reflect intraventricular dyssynchrony due to compressive phenomena rather than intrinsic myocardial dysfunction.
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Affiliation(s)
| | | | - Marta Braga
- Department of Neonatology, IRCCS MultiMedica, Milan, Italy
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Sonaglioni A, Esposito V, Caruso C, Nicolosi GL, Bianchi S, Lombardo M, Gensini GF, Ambrosio G. Chest conformation spuriously influences strain parameters of myocardial contractile function in healthy pregnant women. J Cardiovasc Med (Hagerstown) 2021; 22:767-779. [PMID: 34487054 DOI: 10.2459/jcm.0000000000001213] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
AIMS Left ventricular (LV) contractility during noncomplicated pregnancy has been previously investigated by two-dimensional speckle-tracking echocardiography (2D-STE), with conflicting results. Chest abnormalities might affect myocardial strain parameters, yet this issue has not been previously investigated during pregnancy. We evaluated the influence of chest conformation on myocardial strain parameters in healthy pregnant women. METHODS Between October 2019 and February 2020, 50 healthy pregnant women (32.3 ± 4.0 years old) were consecutively studied. They underwent obstetric visit, assessment of chest shape by modified Haller index (MHI; chest transverse diameter over the distance between sternum and spine) and transthoracic echocardiography implemented with 2D-STE analysis of all myocardial strain parameters in the first trimester (12-14 weeks), third trimester (36-38 weeks) and 6-9 weeks after delivery. RESULTS LV ejection fraction remained substantially unchanged (P = 0.13), while on the average all myocardial strain parameters showed a small but significant decrease during pregnancy, and recovered postpartum (all P < 0.001). Women with concave-shaped chest wall (MHI > 2.5, n = 29), and those with normal chest conformation (MHI ≤ 2.5, n = 21) were then separately analyzed. Pregnant women with MHI above 2.5, but not those with MHI 2.5 or less, showed a progressive but reversible decrease in all myocardial strain parameters (all P < 0.001). MHI was strongly correlated with LV global longitudinal strain (r = -0.87) and LV global circumferential strain (r = -0.83) in the third trimester of pregnancy. CONCLUSION Myocardial strain impairment during healthy pregnancy may not reflect intrinsic myocardial dysfunction but rather intraventricular dyssynchrony related to a narrow antero-posterior chest diameter and rise in the diaphragm, with consequent extrinsic myocardial compression.
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Affiliation(s)
| | - Valentina Esposito
- Department of Gynecology and Obstetrics, Ospedale San Giuseppe MultiMedica IRCCS, Milan
| | - Chiara Caruso
- Department of Gynecology and Obstetrics, Ospedale San Giuseppe MultiMedica IRCCS, Milan
| | | | - Stefano Bianchi
- Department of Gynecology and Obstetrics, Ospedale San Giuseppe MultiMedica IRCCS, Milan
| | | | | | - Giuseppe Ambrosio
- Cardiology and Cardiovascular Pathophysiology, Azienda Ospedaliero-Universitaria 'S. Maria della Misericordia', Perugia, Italy
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Sonaglioni A, Rigamonti E, Nicolosi GL, Lombardo M. Prognostic Value of Modified Haller Index in Patients with Suspected Coronary Artery Disease Referred for Exercise Stress Echocardiography. J Cardiovasc Echogr 2021; 31:85-95. [PMID: 34485034 PMCID: PMC8388326 DOI: 10.4103/jcecho.jcecho_141_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/17/2021] [Indexed: 01/28/2023] Open
Abstract
Background: The influence of chest conformation on outcome of patients with suspected coronary artery disease (CAD) is actually unknown. Materials and Methods: This retrospective study included all consecutive patients who underwent exercise stress echocardiography (ESE) for suspected CAD at our institution between February 2011 and September 2019. Modified Haller index (MHI; chest transverse diameter over the distance between sternum and spine) was assessed in all patients. Obstructive CAD was diagnosed by ≥70% stenosis in any epicardial coronary artery. During the follow-up time, we evaluated the occurrence of any of the following: (1) cardiovascular (CV) hospitalizations and (2) cardiac death or sudden death. Results: A total of 1091 consecutive patients (62.4 ± 12.6 years, 57.2% of men) were included in the study. Patients with normal chest shape (MHI ≤2.5) and those with concave-shaped chest wall (MHI >2.5) were separately analyzed. A positive ESE was diagnosed in 171 patients of which 80.7% had an obstructive CAD (true positive), while 19.3 not (false positive [FP]). Majority of FP ESE (70.9%) derived from concave-shaped chest wall group. During follow-up time (2.5 ± 1.9 years), 9 patients died and 281 were hospitalized because of heart failure (163), acute coronary syndromes (39), and arrhythmias (79). At the multivariate Cox regression analysis, age (heart rate [HR]: 1.02, 95% confidence interval [CI]: 1.01–1.03), MHI >2.5 (HR: 0.39, 95% CI: 0.26–0.56), diabetes mellitus (HR: 4.89, 95% CI: 3.78–6.32), horizontal ST depression ≥1 mm (HR: 2.86, 95% CI: 1.98–4.15), peak exercise average E/e' ratio (HR: 1.08, 95% CI: 1.06–1.10), and peak exercise wall motion score index (HR: 1.79, 95% CI: 1.36–2.35) were independently correlated with outcome. Conclusions: Patients with concave-shaped chest wall (MHI >2.5) have a significantly lower probability of CV events than those with normal chest shape (MHI ≤2.5) over a medium-term follow-up. A noninvasive chest shape assessment could identify subjects at lower risk of CV events.
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Affiliation(s)
- Andrea Sonaglioni
- Department of Cardiology, San Giuseppe MultiMedica Hospital, Milan, Italy
| | | | | | - Michele Lombardo
- Department of Cardiology, San Giuseppe MultiMedica Hospital, Milan, Italy
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Sonaglioni A, Rigamonti E, Nicolosi GL, Lombardo M. Appropriate use criteria implementation with modified Haller index for predicting stress echocardiographic results and outcome in a population of patients with suspected coronary artery disease. Int J Cardiovasc Imaging 2021; 37:2917-2930. [PMID: 33961159 DOI: 10.1007/s10554-021-02274-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/03/2021] [Indexed: 01/02/2023]
Abstract
The hypothesis that modified Haller index (MHI) integration with the existing appropriate use criteria (AUC) categories may predict exercise stress echocardiography (ESE) results and outcome of patients with suspected coronary artery disease (CAD) has never been previously investigated. We retrospectively analyzed 1230 consecutive patients (64.8 ± 13.1 years, 58.9% men) who underwent ESE for suspected CAD between February 2011 and September 2019 at our institution. MHI (chest transverse diameter over the distance between sternum and spine) was assessed in all patients. A true positive (TP) ESE was a positive ESE with obstructive CAD according to subsequent coronary angiography. During follow-up time, we evaluated the occurrence of any of the following: (1) cardiovascular (CV) hospitalizations; (2) Cardiac death or sudden death. Overall, 734 (59.7%), 357 (29.0%) and 139 (11.3%) indications for ESE were classified as appropriate (Group 1), rarely appropriate (Group 2) and which may be appropriate (Group 3), respectively. A funnel chest (defined by an MHI > 2.5) was detected in 30.3%, 82.1% and 49.6% of Groups 1, 2 and 3 subjects, respectively (p < 0.0001). On multivariate logistic regression analysis, male sex (OR 1.41, 95%CI 1.02-2.03, p = 0.01) and type-2 diabetes (OR 3.63, 95%CI 2.49-5.55, p = 0.001) were directly correlated to a TP ESE, while "rarely appropriate" indication for ESE with MHI > 2.5 (OR 0.16, 95%CI 0.11-0.22, p < 0.0001) showed a significant inverse correlation with the outcome. During a mean follow-up of 2.5 ± 1.9 years, 299 CV events occurred: 76.4%, 3.5% and 20.1% in Groups 1, 2 and 3, respectively. On multivariate Cox regression analysis, smoking (HR 1.33, 95%CI 1.19-1.48), type 2 diabetes (HR 2.28, 95%CI 1.74-2.97), dyslipidemia (HR 3.51, 95%CI 2.33-5.15), beta-blockers (HR 0.55, 95%CI 0.41-0.75), statins (HR 0.60, 95%CI 0.45-0.80), peak exercise average E/e' ratio (HR 1.08, 95%CI 1.06-1.09), positive ESE (HR 3.12, 95%CI 2.43-4.01) and finally "rarely appropriate" indication for ESE with MHI > 2.5 (HR 0.15, 95%CI 0.08-0.23) were independently associated with CV events. The implementation of AUC categories with MHI assessment may select a group of patients with extremely low probability of both TP ESE and adverse CV events over a medium-term follow-up. A simple noninvasive chest shape assessment could reduce unnecessary exams.
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Affiliation(s)
- Andrea Sonaglioni
- Department of Cardiology, Ospedale San Giuseppe MultiMedica, Via San Vittore 12, 20123, Milan, Italy. .,Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy.
| | - Elisabetta Rigamonti
- Department of Cardiology, Ospedale San Giuseppe MultiMedica, Via San Vittore 12, 20123, Milan, Italy
| | | | - Michele Lombardo
- Department of Cardiology, Ospedale San Giuseppe MultiMedica, Via San Vittore 12, 20123, Milan, Italy
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The strain and strain rate imaging paradox in echocardiography: overabundant literature in the last two decades but still uncertain clinical utility in an individual case. Arch Med Sci Atheroscler Dis 2021; 5:e297-e305. [PMID: 33644489 PMCID: PMC7885811 DOI: 10.5114/amsad.2020.103032] [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: 08/23/2020] [Accepted: 11/02/2020] [Indexed: 11/17/2022] Open
Abstract
Almost two decades ago strain and strain rate imaging were proposed as a new, potentially more sensitive modality for quantifying both regional and global myocardial function. Until now, however, strain and strain rate imaging have been slow to be incorporated into everyday clinical practice. More recently, two dimensional strain has been claimed as of greater clinical utility, given that it is angle independent, with improved feasibility and reproducibility as compared to tissue Doppler strain. Nevertheless, speckle tracking strain is reliant on 2D image quality and frame rates. Three dimensional speckle tracking could eliminate the problem of through-plane motion inherent in 2D imaging, but 3D strain is currently limited by low frame rates. Another limitation of strain imaging is that the results are dependent on the ultrasound machine on which analyses are performed, with variability in measurements between different vendors. Despite the diagnostic and prognostic advantages of 2D strain, there is a lack of specific therapeutic interventions based on strain and a paucity of long-term large-scale randomized trial evidence on cardiovascular outcomes. After overabundant literature the same definition of normal cut-off values is controversial and not univocal. Further studies are needed, involving both manufacturers and medical professionals, on the additive contribution, possibly different case by case, of interfering and artifactual factors, aside from myocardial function per se. These artifactual determinants and motion artifacts components could be dominant in individual cases and should always be taken into account in the clinical decision making process in a single case.
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