Impact of empagliflozin on left atrial mechanical and conduction functions in patients with type 2 diabetes mellitus

OBJECTIVE

Empagliflozin, an oral anti-diabetic drug that inhibits the sodium-dependent glucose co-transporter 2 (SGLT2), has pleiotropic effects on the myocardium. The aim of the study is to investigate the effect of empagliflozin on atrial electromechanical delay (AEMD) and the left atrial (LA) mechanical functions in patients with type 2 diabetes mellitus (DM).

METHOD

In total 62 patients (40.3% female, mean age 50.5 ± 8.6 years old) with type 2 DM were enrolled to the study. Participants were used a SGLT2 inhibitor (empagliflozin 10-25 mg/daily) for 6 months. Patients were examined initially and after 6 months with echocardiography. LA volume was recorded, atrial conduction times were measured using tissue Doppler imaging (TDI).

RESULTS

No significant change was observed in LA volumes (maximal, minimal, and presystolic), total emptying and passive emptying volume at the end of 6 months; however, there was a significant decrease in active emptying volume (8.3 ± 2.9 ml/m² vs. 7.9 ± 2.9 ml/m² , p = 0.04). The posteroanterior lateral, septal, and tricuspid conduction times significantly decreased after the empagliflozin treatment. The decrease in right inter-AEMD was statistically significant (13.25 ± 10.21 ms vs. 10.85 ± 9.14 ms, p = 0.011). The changes in inter-AEMD were found to be correlated with the changes in LA active emptying volume (r = 0.408).

CONCLUSION

Empagliflozin may enhance the structure and electrical conductions of the atrium and may prevent DM patients from DM-2-related functional disorder and arrhythmia.

Cardiac remodeling after atrial septal defects device closure

BACKGROUND

Trans-catheter device closure of secundum type atrial septal defects (ASDs) has now become the treatment of choice. Device closure affects the hemodynamics and function of the heart. In the current study, we investigated the remodeling of the heart as assessed by advanced echocardiographic parameters following successful device closure.

METHODS

A prospective cohort study was conducted and 45 patients who were eligible for ASD device closure were evaluated for volumetric, functional, Doppler, strain, and strain rate data of left and right atrium and ventricle pre-procedural and 48 h post-procedure RESULTS: In a prospective cohort study 45 patients who were eligible for ASD device closure; atrial and ventricular volumetric, functional, Doppler, strain, and strain rate data were recorded and compared pre-procedurally and 48 h post-procedure.We found significant changes in the left ventricular (LV) end diastolic volume index (p-value = .03), right ventricular (RV) diameter (p-value = <.001), left atrial (LA) volume index (p-value = .05), right atrial (RA) volume index (p-value = .001), and right and left sided E/e' ratio with a p-value of .001 and .004, respectively. Our findings showed a significant reduction in the strains of the right and left atria and the right ventricular free wall after ASD device closure. LV global longitudinal strain decreased after the procedure but did not reach statistical significance.

CONCLUSION

ASD patients have impaired global strains compared to normal defined ranges. LA, RA, and RV strains show significant reduction after device closure. Decline in LA function following closure was greater in those with larger ASDs. In adult patients undergoing the procedure, abnormal LA function is a clinically relevant issue demanding pre and post- procedural precautions and treatment.

Assessment of Left Ventricular Function and Mitral Regurgitation Severity Early After Percutaneous Device Closure of the Atrial Septal Defect

BACKGROUND

Atrial septal defect (ASD) is one the most prevalent forms of congenital heart disease in adults. Closure of ASDs eliminates left-to-right shunt and reduces right heart volumes, but the effects of ASD closure, on the left ventricle (LV) and mitral valve competence are somewhat inconsistent. Therefore, we designed this study to evaluate the early effect of percutaneous closure of ASD on LV function and mitral regurgitation (MR) severity.

METHODS

In this prospective study, we enrolled 32 patients with ASD secundum who underwent percutaneous device closure in Tehran Heart Center. We used transthoracic and transesophageal echocardiography (TEE) before the procedure and TTE 24 hours after the procedure, then compared obtained LV parameters before and after the procedure.

RESULTS

LV end-diastolic diameter (LVEDD) increased significantly from 44.8 ± 2.4 to 45.8 ± 2.8 (P < 0.001). LV end-systolic diameter (LVESD) also increased but was statistically insignificant (P = 0.063) and LV ejection fraction (LVEF) remained nearly unchanged. Highest alteration was in right ventricular systolic pressure (12.4% decrease; P < 0.001) and mitral early Doppler/tissue Doppler velocity ratio (E/E') (9.7% increase; P = 0.010). The change in MR severity was insignificant using Wilcoxon signed-rank test (P = 0.157).

CONCLUSIONS

We concluded that systolic functions do not change immediately. However, LVEDD and E/E' will increase immediately, resulting from the passage of all blood from the LA into the LV in the early diastole just after closure. We also observed the positive effect of device closure on reducing right ventricular systolic pressure, and at least it does not worsen MR early after the procedure.

Assessment of atria function after percutaneous closure of atrial septal defect using 2D speckle tracking echocardiography

BACKGROUND

Percutaneous occlusion of atrial septal defect (ASD) has recently become a standard therapeutic strategy, but little is known about atria function thereafter. Strain analysis by two-dimensional speckle tracking echocardiography (2D-STE) is considered to be a new tool to assess myocardial function.

METHODS

This study aimed to evaluate atria function by quantifying longitudinal strain in patients with chronic RV volume overload due to ASD before and after percutaneous closure using 2D-STE. 28 consecutive patients underwent percutaneous closure of ASD (18 female, 10 male) were examined, clinical and echocardiographic evaluation one day before, 1 day, and one month after percutaneous closure of ASD. Peak longitudinal systolic strain and strain rate of both atria were analyzed by 2D-STE.

RESULTS

Mean age of the patients was 15.07 ± 8.39 years; mean diameter of ASD was 16.01 ± 2.78 mm; left atrium (LA) diameter significantly increased after ASD closure; and peak longitudinal strain of RA increased significantly one day and one month after ASD closure (48. 77 ± 4.40, vs.55.36 ± 3.70 and, vs. 62.13 ± 3.81%, p = 0.001). LA longitudinal strain significantly decreased after ASD closure (42.55 ± 4.57, vs. 34.79 ± 3.20%, p = 0.001). Furthermore, negative correlation was found between the size of the ASD and delta LA systolic strain and strain rate.

CONCLUSIONS

2D-STE can be considered a feasible and simple technique for assessment of atrial deformation in ASD patients, and it useful to assess the effect of percutaneous ASD closure on atrial reservoir function by measuring peak atrial longitudinal strain.

Comparison of the early cardiac electromechanical remodeling following transcatheter and surgical secundum atrial septal defect closure in adults

Background

Secundum atrial septal defect (ASD) closure leads to electrical and mechanical remodeling that occurs early after shunt disappearance. The relationship between electromechanical remodeling using electrocardiogram (ECG) and cardiac magnetic resonance (CMR) after percutaneous and surgical closure has not yet been recorded in prospective studies.

Objective

We thought to study right atrium (RA) and right ventricle (RV) changes by CMR 3 months after transcatheter and surgical closure and their comparison with electrical remodeling by ECG.

Results

We prospectively evaluated 30 consecutive adult patients with isolated secundum ASD who were referred for (transcatheter and surgical) ASD closure.

There was significant reduction in all of the electrical parameters within the same group as compared to the baseline values, except P wave dispersion (Pd). (P max was 97.33 ± 16.67 (pre closure) to 76 ± 15.49 (post closure) in the device group and 97.33 ± 12.79 (preclosure) to 73.33 ± 16.32 (post closure) in the surgical group, QRS complex was 104 ± 18.82 (preclosure) to 80 ± 18.51 (post closure) in the device group and 106.67 ± 14.47 (preclosure) to 86.67 ± 17.99 (post closure) in the surgical group. QTc maximum was 478.53 ± 36.79 (preclosure) to 412.53 ± 38.03 (post closure) in the device group and 470.53 ± 65.70 (preclosure) to 405.93 ± 63.08 (post closure) in the surgical group, and QTc dispersion was 70.33 ± 24.04 (preclosure) to 60.26 ± 28.56 (post closure) in the device group and 80.73 ± 30.38 (preclosure) to 60.27 ± 28.57 (post closure) in the surgical group).There was no significant difference between two groups indicating that transcatheter and surgical closure had led to equivalent value of electrical remodeling.

In CMR study, we measured RA maximal volume and right ventricle end diastolic volume (RVEDV), RA maximal volume decreased significantly as compared to the base line values post closure in both groups (P value < 0.001). The reduction in RA max volume was more in the transcatheter closure group; however, this difference was not statistically significant when compared with the surgical arm (P value = 0.5).RVEDV decreased significantly in both groups as compared to the baseline values (P value < 0.001). Transcatheter closure resulted in more significant reduction in the RVEDV than the surgical closure (P value = 0.03).

Conclusion

Our study showed early significant electromechanical reverse remodeling in most of the study parameters from the baseline values after ASD closure. We found no significant differences in all of the electrical and RA mechanical remodeling parameters with significantly better mechanical remodeling of RV in the device group.

Long-Term Left Atrial Function after Device Closure and Surgical Closure in Adult Patients with Atrial Septal Defect

BACKGROUND

Studies comparing left atrial (LA) function after surgical closure or percutaneous closure in patients with an atrial septal defect (ASD) are lacking.

METHODS

Between 1 and 3 years after ASD treatment, we retrospectively analyzed the medical records and transthoracic echocardiographic images of patients who had been diagnosed with an ASD after 20 years of age and who had undergone surgical closure (ASD-S) or percutaneous device closure (ASD-D). We measured LA peak systolic, early diastolic, and late diastolic strain values using 2-dimensional (2D) speckle tracking echocardiography (STE) and calculated reservoir, conduit, and contraction strain.

RESULTS

The reservoir strain value of the ASD-D groups was 25.2% ± 7.4%, which was lower compared to the control group (33.6% ± 5.5%) (p = 0.004). The LA conduit strain and the LA contraction values of the ASD-D group were also lower compared to the control group (−13.8% ± 5.8% vs. −20.4% ± 4.7%, p = 0.034; −11.3% ± 4.2% vs. −13.2% ± 2.5%, p = 0.037, respectively). The reservoir, conduit, and contraction strains of the ASD-S group were 27.8% ± 8.8%, −15.3% ± 6.4%, and −12.5% ± 5.8%, respectively, and were not different from those of the control group or the ASD-D group.

CONCLUSIONS

The 2D STE is a suitable method for evaluating LA function after ASD closure. Our results demonstrate that 1 year after device closure, the LA reservoir, conduit and contraction function were reduced in ASD-D group compared to healthy controls, while there was no difference between the ASD-S and ASD-D groups.

Quantitative assessment of contractile reserve of systemic right ventricle in post-Senning children: Incorporating speckle-tracking strain and dobutamine stress echocardiography

INTRODUCTION

The systemic load on the right ventricle (RV) after Senning atrial switch leads to ventricular dysfunction. Quantitative assessment of RV contractile reserve is mandatory to anticipate the need for anti-fibrotic treatment. We aimed to quantitatively assess RV contractile reserve in Senning children by estimating speckle-based global longitudinal strain (GLS) during dobutamine stress echocardiography (DSE).

METHODS

This prospective study compared thirty-one post-Senning children (group I) and thirty controls (group II). In post-Senning children, echocardiographic RV systolic function using one-plane ejection fraction (RVEF), RV fractional area change (RVFAC), tricuspid annulus plane systolic excursion (TAPSE), its Z-score, and RVGLS were recorded at rest and peak DSE. Contractile reserve was defined as improvement >5% in RVEF, >2% in GLS, and/or to near normal TAPSE.

RESULTS

RVEF, RVFAC, TAPSE, and TAPSE Z-score were significantly lower in patients than controls [RVEF:40.13 ± 2.93% vs 53.17 ± 3.17% (P < .001*), RVFAC: 21.17 ± 2.37% vs 37.23 ± 2.13% (P < .001*), TAPSE:13.81 ± 1.26 vs 17.45 ± 2.93 mm (P < .001*), TAPSE Z-score: -3.47 ± 0.46 vs -2.09 ± 0.48 (P < .001*)]. Also, RVGLS was significantly impaired in Senning children than controls[ (-11.89 ± 2.31% vs -22.35 ± 6.73% (P < .001*)]. At peak DSE, contractile reserve was not evident as measured by RVEF which increased none significantly to 42.47 ± 2.80% (P = .063). However, RVGLS improved significantly to -15.78 ± 0.93% (P < .001*) and discovered the masked contractile reserve in Senning children. The 19(61.29%) children who showed masked contractile reserve (improvement in RVGLS > 2%) underwent continuation of anti-fibrotic medications.

CONCLUSIONS

Despite systemic RV function in post-Senning children was impaired at rest and during DSE, RVGLS was useful in quantitative assessment of masked contractile thus promoted continuing anti-fibrotic treatment.

Influence of Percutaneous Occlusion of Atrial Septal Defect on Left Atrial Function Evaluated Using 2D Speckle Tracking Echocardiography

Percutaneous occlusion of atrial septal defect (ASD) has recently become a standard therapeutic strategy, but little is known about left atrial (LA) function thereafter. The present study aimed to determine LA function in 43 children with ASD and 13 controls based on LA strain measured by two-dimensional echocardiographic speckle tracking (2DE-ST). Among these children, 12 underwent surgery (ASD-S), 31 had device closure (ASD-D), and 13 were included as controls. LA strain was significantly decreased after ASD-D but was not significantly altered after ASD-S, indicating that percutaneous occlusion of an ASD might decrease LA function. Furthermore, the size of the ASD device negatively correlated with LA strain. These results imply that ASD occlusion devices negatively influence LA function and might be important when decided therapeutic strategies for ASD. LA strain measured by 2DE-ST should become a good indicator of LA function after ASD treatment in children.

Impact of Transcatheter Device Closure of Atrial Septal Defect on Atrial Arrhythmias Propensity in Young Adults

Atrial septal defect (ASD) is a condition that requires early intervention because of the consequences over the right-side heart. Chronic atrial stretching promotes atrial conduction delay and the imbalance of the conduction homogeneity, which lead to the propensity to atrial arrhythmias (AA). We aim to evaluate the impact of transcatheter closure of ASD on atrial vulnerability markers leading to late AA in young adults. We conducted a prospective, longitudinal study in one hundred patients (mean age 25.2 ± 5.4 years) who underwent transcatheter closure of ASD at Cardiocentro Pediátrico William Soler. P-wave maximum (P_max) and P-wave dispersion (P_d) were analyzed from 12-lead electrocardiogram. Left-side and right-side intraatrial and interatrial electromechanical delay (EMD) were measured with tissue Doppler imaging. Both electrocardiographic and echocardiographic analyses were performed during the study period. Compared to baseline, there was a significant reduction in P max (p ≤ 0.001) and P_d (p ≤ 0.001) after 3 months of procedure. All atrial electromechanical coupling parameters significantly reduced at 6 months of ASD closure and tend to remain at lower values till the last evaluation. Over 9.2 ± 1.6 years of follow-up, 15 subjects (15%) developed AA, of which intraatrial reentrant tachycardia (66.6%) became the main rhythm disturbance. Intra-right atrial EMD ≥ 16 ms (HR 4.08, 95% CI 1.15-14.56; p = 0.03) and P_d 45 ms (HR 1.66, 95% CI 1.06-2.59; p = 0.02) were identified as predictors of late AA. Transcatheter device closure of ASD in young adults promotes a significant reduction of electrocardiographic and echocardiographic markers of AA vulnerability, which persist during the long-term follow-up. Nevertheless, P_d and interatrial EMD were identified as independent risk factors of AA.

Assessment of the Right and Left Atrial Functions at Midterm After Surgical and Device Atrial Septal Defect Closure: A 2-Dimensional Speckle-Tracking Echocardiographic Study

OBJECTIVES

The available literature lacks data on the comparison of the functions of the right atrium (RA) and left atrium (LA) between surgical atrial septal defect (ASD) closure and percutaneous device ASD closure at follow-up durations of longer than 1 year. We sought to evaluate the RA and LA functions in patients who underwent surgical or device ASD closure between 1 and 5 years postprocedurally.

METHODS

The study population included 30 patients who underwent device ASD closure and 30 who underwent surgical ASD closure, who were matched for the procedural time, age, and sex, in addition to 30 control participants. The RA and LA functions were evaluated with 2-dimensional speckle-tracking echocardiography.

RESULTS

The LA systolic and early diastolic strain and strain rate values and the RA early diastolic strain rate in the device closure group were more likely to be abnormal than in the control group. The RA systolic and late diastolic strain and strain rate values, the RA early diastolic strain rate, and the LA early diastolic strain in the surgical closure group were more likely to be abnormal than in the control group. The RA systolic strain and strain rate in the surgical closure group were more likely to be abnormal than in the device closure group.

CONCLUSIONS

The LA reservoir and conduit functions and the RA contraction function in the patients who underwent device ASD closure and all of the RA functions and the LA conduit function in the patients who underwent surgical ASD closure were more likely to be abnormal than those in the control participants. The RA reservoir function in the surgical closure group was more likely to be abnormal than that in the device closure group.

Long term evaluation of electromechanical delay in patients with atrial septal defect after transcatheter closure

Some studies have been showed that electromechanical delay, which may pose an increased tendency to atrial fibrillation, may prolong in patients with various clinical conditions. In addition, the electromechanical delay in patients with secundum type atrial septal defect (ASD) compared to healthy people have been reported previously. Therefore, in the present study, we prospectively evaluated the mid-term and long-term effects of the transcatheter closure of secundum type ASD on the lateral atrial conduction time (PA), septal PA, tricuspid PA, left and right intra-atrial electromechanical delay (ILeft-EMD and IRight-EMD, respectively) and inter-atrial electromechanical delay (IA-EMD) measured by means of Doppler echocardiography. Our prospective study included a total of 45 secundum type ASD patients who undergone percutaneous transcatheter closure from December 2012 to April 2015. All patients underwent transthoracic echocardiography (TTE) before the closure, at sixth and twelfth months after the closure. In comparison of the EMD sixth months after the device closure, there were statistically significant decrease in lateral PA, septal PA, tricuspid PA, ILeft-EMD, IRight-EMD and IA-EMD compared to pre-device closure values. Twelfth months after the device closure, we also observed statistically significant decrease in lateral PA, septal PA, tricuspid PA, ILeft-EMD, IRight-EMD and IA-EMD compared to 6-month post-device closure values. In the present study, we observed that the atrial EMD improves after device closure and continues to improve after twelfth month following post-device closure.

Assessment of right atrial function with speckle tracking echocardiography after percutaneous closure of an atrial septal defect

INTRODUCTION

Speckle tracking echocardiography (STE) for two-dimensional (2D) strain analysis is a new tool to assess myocardial function. The aim of this study was to assess right atrial (RA) function using STE in patients with an atrial septal defect (ASD) before and one month after percutaneous closure.

METHODS

We prospectively examined 32 consecutive patients (nine male, 23 female) who underwent percutaneous transcatheter closure of a secundum ASD between June 2013 and December 2015. Echocardiography was performed on admission, prior to cardiac catheterization and then one month after ASD closure. Peak global RA longitudinal strain was analyzed by 2D-STE.

RESULTS

Patients' mean age was 34.6±8.2 years. The mean diameter of the occlusive devices was 18.5±7.5 mm. Right ventricular (RV) end-diastolic diameters were significantly increased but decreased significantly after ASD closure (43±5 vs. 38±4 mm, p<0.05). Left atrial (LA) diameters (40±8 vs. 37±6 mm, p<0.05) decreased significantly after the intervention, whereas left ventricular (LV) end-diastolic diameters (45±5 vs. 46±4 mm, NS) remained unchanged. Tricuspid annular plane systolic excursion increased significantly (17.6±5.4 vs. 22.3±8.1 mm, p<0.05). After closure of the defect, a significant increase was observed in longitudinal RA strain (26.5±9.6% vs. 35.3±10.5%, p<0.001).

CONCLUSIONS

After percutaneous transcatheter closure of a secundum ASD, there was an increase in RA longitudinal strain. 2D-STE strain analysis appears to be helpful for the assessment of RA function and of response to correction of volume overload after percutaneous transcatheter closure of a secundum ASD.

The year 2014 in the European Heart Journal--Cardiovascular Imaging: part II

The European Heart Journal-Cardiovascular Imaging, created in 2012, has become a reference for publishing multimodality cardiovascular imaging scientific and review papers. The impressive 2014 impact factor of 4.105 confirms the important position of our journal. In this part, we summarize the most important studies from the journal's third year, with specific emphasis on cardiomyopathies, congenital heart diseases, valvular heart diseases, and heart failure.