Association of high-sensitivity troponin T with left ventricular dysfunction in prediabetes

BACKGROUND

Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) are an increasingly serious problem worldwide. Tissue Doppler imaging (TDI), a non-invasive technique, may evaluate both systolic and diastolic function during the first phases of cardiovascular disease (CVD). High-sensitivity cardiac troponin T (hs-cTnT) can detect subclinical myocardial injury in asymptomatic prediabetic patients.

AIM

We aimed to investigate the relationship between left ventricular (LV) function and hs-cTnT in prediabetic patients.

METHODS

Between 1 October 2021 and 1 October 2022, we recruited 96 prediabetic and an equal number of age- and gender-matched healthy volunteers prospectively. TDI was used to evaluate both systolic and diastolic functions. Hs-cTnT levels were obtained and compared between groups.

RESULTS

It was found that the values for mitral annular plane systolic excursion (MAPSE), E, the rapid filling wave, E/Em, and the peak annular velocities of systolic excursion in the ejection period (Sm) were all significantly higher in these patients compared to healthy individuals (p < .001). Hs-cTnT was an independent predictor of left ventricular diastolic dysfunction (LVDD) and left ventricular systolic dysfunction (LVSD) (odds ratio [OR] = 2.625, 95% confidence interval [CI] = 1.324-4.308, p < .001, and OR = 1.922, 95% CI = 0.454-3.206, p = .004).

CONCLUSIONS

Prediabetics had higher hs-cTnT levels than controls. We showed that LVSD and LVDD functions were negatively affected in prediabetic patients. Our results proved that hs-cTnT levels may be associated with subclinical LV dysfunction in prediabetes.

How to use echocardiography to manage patients with shock?

Echocardiography enables the intensivist to assess the patient with circulatory failure. It allows the clinician to identify rapidly the type and the cause of shock in order to develop an effective management strategy. Important characteristics in the setting of shock are that it is non-invasive and can be rapidly applied. Early and repeated echocardiography is a valuable tool for the management of shock in the intensive care unit. Competency in basic critical care echocardiography is now regarded as a mandatory part of critical care training with clear guidelines available. The majority of pathologies found in shocked patients are readily identified using basic level 2D and M-mode echocardiography. The four core types of shock (cardiogenic, hypovolemic, obstructive, and septic) can readily be identified by echocardiography. Echocardiography can differentiate the different pathologies that may be the cause of each type of shock. More importantly, as a result of more complex and elderly patients, the shock may be multifactorial, such as a combination of cardiogenic and septic shock, which emphasises on the added value of transthoracic echocardiography (TTE) in such population of patients. In this review we aimed to provide to clinicians a bedside strategy of the use of TTE parameters to manage patients with shock. In the first part of this overview, we detailed the different TTE parameters and how to use them to identify the type of shock. And in the second part, we focused on the use of these parameters to evaluate the effect of treatments, in different types of shock.

Left ventricular global longitudinal strain and cardiorespiratory fitness in patients with heart failure: Systematic review and meta-analysis

BACKGROUND

There is no definition for strain deformation values in relation to cardiorespiratory fitness (CRF) in different heart failure (HF) phenotypes.

AIM

To identify the relationship between echocardiographic systolic function measurements and CRF in HF patients.

METHODS

Systematic review and meta-analysis following the PRISMA recommendations. Studies reporting echocardiographic assessments of left ventricular global longitudinal strain (LVGLS), left ventricular ejection fraction (LVEF), and direct measurement of peak oxygen uptake (VO2peak) in HF patients with reduced or preserved LVEF (HFrEF, HFpEF) were included. The patients were divided into Weber classes according to VO2peak.

RESULTS

A total of 25 studies involving of 2,136 patients (70.5% with HFpEF) were included. Mean LVEF and LVGLS were similar in HFpEF patients in Weber Class A/B and Class C/D. In HFrEF patients, a non-significant difference was found in LVEF between Weber Class A/B (30.2% [95%CI: 29.6 to 30.9%]) and Class C/D (25.2% [95%CI: 20.5 to 29.9%]). In HFrEF patients, mean LVGLS was significantly lower in Class C/D compared to Class A/B (6.5% [95%CI: 6.0 to 7.1%] and 10.3% [95%CI: 9.0 to 11.5%], respectively). The correlation between VO2peak and LVGLS (r2 = 0.245) was nearly twofold stronger than that between VO2peak and LVEF (r2 = 0.137).

CONCLUSIONS

Low LVGLS values were associated with low CRF in HFrEF patients. Although a weak correlation was found between systolic function at rest and CRF, the correlation between VO2peak and LVGLS was nearly twofold stronger than that with LVEF, indicating that LVGLS may be a better predictor of CRF in patients with HFrEF.

Normal reference values for mitral annular plane systolic excursion by motion-mode and speckle tracking echocardiography: a prospective, multicentre, population-based study

AIMS

Mitral annular plane systolic excursion (MAPSE) is a simple and reliable index for evaluating left ventricular (LV) systolic function, particularly in patients with poor image quality; however, the lack of reference values limits its widespread use. This study aimed to establish the normal ranges for MAPSE measured using motion-mode (M-mode) and two-dimensional speckle tracking echocardiography (2D-STE) and to explore its principal determinants.

METHODS AND RESULTS

This multicentre, prospective, cross-sectional study included 1952 healthy participants [840 men (43%); age range, 18-80 years] from 55 centres. MAPSE was measured using M-mode echocardiography and 2D-STE. The results showed that women had a higher MAPSE than men and MAPSE decreased with age. The age- and sex-specific reference values for MAPSE were established for these two methods. Multiple linear regression analyses revealed that MAPSE on M-mode echocardiography correlated with age and MAPSE on 2D-STE with age, blood pressure (BP), heart rate, and LV volume. Moreover, MAPSE measured by 2D-STE correlated more strongly with global longitudinal strain compared with that measured using M-mode echocardiography.

CONCLUSION

Normal MAPSE reference values were established based on age and sex. BP, heart rate, and LV volume are potential factors that influence MAPSE and should be considered in clinical practice. Normal values are useful for evaluating LV longitudinal systolic function, especially in patients with poor image quality, and may further facilitate the use of MAPSE in routine assessments.

Clinical Usefulness of Speckle-Tracking Echocardiography in Patients with Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is defined as HF with left ventricular ejection fraction (LVEF) not less than 50%. HFpEF accounts for more than 50% of all HF patients, and its prevalence is increasing year to year with the aging population, with its prognosis worsening. The clinical assessment of cardiac function and prognosis in patients with HFpEF remains challenging due to the normal range of LVEF and the nonspecific symptoms and signs. In recent years, new echocardiographic techniques have been continuously developed, particularly speckle-tracking echocardiography (STE), which provides a sensitive and accurate method for the comprehensive assessment of cardiac function and prognosis in patients with HFpEF. Therefore, this article reviewed the clinical utility of STE in patients with HFpEF.

A Cardiac Magnetic Resonance Study: Comparison of Biventricular Longitudinal Function in Hypertrophic Cardiomyopathy Patients and Normal Individuals

OBJECTIVE

 Hypertrophic cardiomyopathy (HCM) is a genetic disease with an incidence of 0.2%-0.5%. It has a wide range of clinical presentations varying from coincidental diagnoses to heart failure, ventricular arrhythmias and sudden cardiac death. Mitral annular plane systolic excursion (MAPSE) and tricuspid annular plane systolic excursion (TAPSE) are M-mode-derived practical and reproducible measurements of systolic longitudinal displacement of the annular plane. These two measures may be used as markers of the left ventricular and right ventricular longitudinal functions. Currently, there are only a few studies on cardiac magnetic resonance (CMR)-derived TAPSE and MAPSE measurement comparison between the HCM group and normal control group. The aim of our study is to show the differences in CMR-derived TAPSE and MAPSE values between the HCM and normal population.

METHODS

 We evaluated CMR exams of patients diagnosed with HCM and of normal individuals scanned between 2020 and 2021 retrospectively. The patients were from our own institution's and other hospitals' in- and out-patient departments. Data was collected on 36 HCM patients and 34 adults with no known history of cardiac and non-cardiac diseases. All CMR exams were performed on a 1.5 T (Magnetom Avanto, Siemens Healthcare, Erlangen, Germany) scanner. CMR-derived MAPSE and TAPSE were measured on standard four-chamber steady-state free precession (SSFP) cine images and given in millimeters.

RESULTS

 From February 2020 to December 2021, a total of 150 patients were diagnosed with hypertrophic cardiomyopathy. After exclusion, 36 patients with HCM were included in the study and the normal control group comprised 34 individuals. The mean age of the HCM group was 43.2 + 13.5 years, while it was 37.5 + 11.3 in the control group. The female ratio of the HCM group was found to be 36%, while it was 56% in the healthy control group. MAPSE values were significantly higher in the normal control group when compared to the HCM patient group (MAPSE: 14.5 ± 2.9 mm vs. 11.7 ± 3.2 mm; p<0.001), while TAPSE values did not depict a significant difference between the two groups (p=0.627).

CONCLUSIONS

 This study suggests that MAPSE values are significantly lower in the HCM patient group in comparison with the normal control group on CMR scans. Although not statistically significant, TAPSE values are also lower in the HCM group.

The role of conventional echocardiographic parameters on detecting subclinical anthracycline therapy related cardiac dysfunction—The SATRACD study

Background

Subclinical anthracycline therapy related cardiac dysfunction (ATRCD) can be detected with speckle tracking echocardiographic image (STE), which is not widely available in Uganda. We aimed to investigate the role of the two conventional echocardiographic parameters [mitral annular plane systolic excursion (MAPSE) and mitral annular peak systolic tissue Doppler velocity (S’)] on diagnosing subclinical ATRCD.

Method and results

207 cancer patients who underwent anthracycline based chemotherapy were recruited at baseline and followed up until 6 months after ending anthracycline therapy. Comprehensive echocardiographic data were collected at each visit. Global longitudinal strain (GLS) by STE was used as the gold standard diagnostic test to define the case of subclinical ATRCD. Data of the 200 patients who had no evidence of clinical ATRCD were analyzed. One hundred and seventy-two (86.0%) were female, with a median age of 42 years and 47 (23.5%) patients were diagnosed with subclinical ATRCD at the end of anthracycline therapy by GLS criteria. The area under the curve (AUC), cutoff point, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of reduction of MAPSE (ΔMAPSE) were 0.6736 (95% CI: 0.5885, 0.7587), ≥ 2 mm, 74.5% (95% CI: 59.7%, 86.1%), 54.9% (95% CI: 46.7%, 63.0%), 33.7% (95% CI: 24.7%, 43.6%), and 87.5% (95% CI: 79.2%, 93.4%). The AUC, cutoff point, sensitivity, specificity, PPV, and NPV of reduction of S’ (ΔS’) were 0.6018 (95% CI: 0.5084, 0.6953), ≥ 0.5 cm/s, 61.7% (95% CI: 46.4%, 75.5%), 52.7% (95% CI: 44.4%, 60.9%), 29.0% (95% CI: 20.4%, 38.9%), and 76.1% (95% CI: 72.4%, 88.6%). When ΔMAPSE and ΔS’ are used as parallel test, the net sensitivity and specificity is 89.4% and 28.8%, respectively, the net PPV and NPV is 27.8% and 90.0%, respectively.

Conclusion

The ΔMAPSE and ΔS’ showed fairly good accuracy, sensitivity and NPV to detect subclinical ATRCD in Ugandan cancer patients. These conventional echocardiographic parameters may serve as screening tools for detecting subclinical ATRCD in resource limited settings.

Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure and Preserved Ejection Fraction

BACKGROUND

Coexistence of atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) is common, affecting morbidity and prognosis. This study evaluates outcome after cryoballoon ablation for AF in HFpEF compared with patients without heart failure.

METHODS

A total of 102 AF patients with left ventricular ejection fraction ≥50% undergoing cryoballoon ablation were prospectively enrolled. Baseline evaluation included echocardiography, stress echocardiography, 6-minute walk test, biomarkers, and quality of life assessment (Short-Form-36). Procedural parameters and clinical, functional and echocardiographic end points at follow-up ≥12 months after AF ablation were compared between patients with and without HFpEF.

RESULTS

Patients with HFpEF (n=24) were older (median, 74 years versus 65 years; P=0.001) more often female (83% versus 28%; P<0.001) and characterized by more pronounced AF-related symptoms (median European Heart Rhythm Association score 3 versus 2; P<0.001), higher left atrial pressures (median, 14 mm Hg versus 10 mm Hg; P=0.008), reduced left atrial-appendage velocity (median, 36 cm/s versus 59 cm/s; P<0.001), and reduced distance in the 6-minute walk test (median, 488 m versus 539 m; P<0.001). Patients with HFpEF more often experienced AF recurrence (57% versus 23%; P=0.003), repeat AF ablation (39% versus 14%; P=0.01) and AF-related rehospitalization (26% versus 7%; P=0.016). Heart failure symptoms and elevated cardiac biomarkers persisted, even in patients with HFpEF with successful rhythm control at follow-up. Echocardiographic follow-up showed progression of adverse left atrial remodeling and no relevant improvement in diastolic function in HFpEF. Quality of life improved in patients without HFpEF, whereas patients with HFpEF still exhibited a lower physical component summary score (median, 41.5 versus 53.4; P<0.004).

CONCLUSIONS

Patients with HFpEF constitute a distinct subgroup with elevated risk for AF recurrence after cryoballon ablation. Functional hallmarks of HFpEF persist, irrespective of rhythm status at follow-up. Future research is needed to optimize treatment strategies in patients with HFpEF.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04317911.

The relation of echo-derived lateral MAPSE to left heart functions and biochemical markers in patients with preserved ejection fraction: Short-term prognostic implications

OBJECTIVE

Mitral annular plane systolic excursion (MAPSE) is a simple way to evaluate-left ventricle (LV) function. Our aim was to explain the relationship of MAPSE with LV function and biochemical markers in patients with preserved ejection fraction (EF), and to determine whether it has an effect on prognosis in echocardiography (echo) practice.

METHODS

Consecutive patients referred to the echo laboratory between November 2020 and March 2021 were included in the study. In addition to conventional parameters, MAPSE of the lateral mitral annulus was measured in all patients. Patients were divided into three groups according to lateral MAPSE: low (<12 mm), relatively preserved (12-15 mm), and high (≥15 mm).

RESULTS

A total of 512 patients with preserved EF were included in the study. MAPSE was low in 44 patients (9%), relatively preserved in 231 patients (45%), and high in 237 patients (46%). The mean age was higher in the low group compared to the other two groups (p < 0.001) and the body mass index was increased in the low group compared to the high group (p = 0.010). Atrial fibrillation and hypertension were more common in patients with low MAPSE. The rate of diastolic dysfunction (DD) and all-cause hospitalization were higher in the low and relatively preserved groups than in the high group (p < 0.001, p = 0.002; respectively). The pro-BNP level and mortality rate were higher in the low group compared to the relatively preserved and high groups (p = 0.007, p = 0.005; respectively). MAPSE was identified as independent predictor of hospitalization (OR: 0.284, 95% CI: 0.093-0.862, p = 0.026) via multivariate analysis and independent predictor of in-hospital mortality (HR: 0.002, 95% CI: 0-0.207, p = 0.008).

CONCLUSIONS

Analysis of LV longitudinal function by echo-derived lateral MAPSE when LV ejection fraction is normal provides important information about DD and related heart failure and may predict prognosis in echo practice.

Fast assessment of left ventricular systolic function in obstructive sleep apnea patients with automated function imaging: Comparison with mitral annular plane systolic excursion

BACKGROUND

Early detection of left ventricular (LV) subclinical dysfunction is clinically relevant before developing irreversible impairment in obstructive sleep apnea (OSA) patients. Mitral annulus plane systolic excursion (MAPSE) is a fast tool for OSA due to high prevalent obesity; another quick but more comprehensive tool is LV global longitudinal stain (GLS) based on automated function imaging (AFI). We therefore aimed to compare the feasibility and reproducibility of AFI to MAPSE in OSA patients, as a good model in whom obesity is common.

METHODS

A comprehensive echocardiographic examination was done in 186 consecutive patients having polysomnography for suspected OSA. MAPSE was measured by using M-mode to calculate excursion of mitral annulus. GLS was derived by offline analysis of three long-axis views that semi-automatically detects LV endocardial boundary, which is adjusted manually as necessary with AFI measurement. Variability of AFI and MAPSE were compared among the different subgroups.

RESULTS

Despite a relatively high obesity rate (42.9%), the feasibility of AFI was 94% (175/186) and that of 100% in MAPSE. AFI showed excellent correlation (r = .882) superior to MAPSE (r = .819) between the Expert and Beginner. Intra- and inter- observer variability of AFI and MAPSE in Bland-Altman analysis were 5.5% and 6.5%; 6.2% and 8.8%, respectively. In repeated measurements, AFI showed higher intra-class correlation (ICC = .95) than MAPSE (ICC = .87) (p < 0.05). Furthermore, analysis showed that AFI was feasible even in more obese patients (BMI≥28 kg/m² ).

CONCLUSIONS

Even in obese patients with OSA, AFI-GLS is feasible and more reliable for less expert operators than MAPSE in detecting LV longitudinal dysfunction.

Importance of left ventricular contraction for left atrial reservoir function

BACKGROUND

The determinants of left atrial (LA) reservoir function have not been clarified.

METHODS

To elucidate the effect of left ventricular (LV) contraction on LA reservoir volume (ΔV_LA), volume change due to mitral annular downward motion and aortic root anterior motion, which are related to LV contraction during systole, was calculated in 72 consecutive subjects [42 patients without any cardiac disease (control group), 13 patients with heart failure with reduced ejection fraction (HFrEF group) and 17 with preserved ejection fraction (HFpEF group)]. LA volume was calculated using the modified Simpson's method of bi-plane 2-D echocardiograms. ΔV_LA was the difference between the maximum and minimum LA volumes. LA volume change according to mitral annular motion (ΔV_MA) and aortic root motion (ΔV_AR) were calculated by assuming an oval frustum and dented wedge, respectively.

RESULTS

In the normal control group, ΔV_AR + ΔV_MA was 11.7 ml on average, correlating to ΔV_LA (r = 0.55, p < 0.01), and the contribution rate to LA reservoir volume ((ΔV_AR + ΔV_MA)/ΔV_LA) was 56% on average. In both, the HFrEF and HFpEF groups, ΔV_AR, ΔV_MA, and the contribution rate were significantly smaller than those in normal control group. Stroke volume correlated to ΔV_AR and ΔV_MA. The larger the maximum LA volume was, the smaller the contribution rate was. The smaller the rate was, the higher the systolic pulmonary artery pressure was.

CONCLUSIONS

Both mitral annular motion and aortic root anterior motion, which are related to ventricular contraction, are important for the LA reservoir volume recruitment.

Annular plane systolic excursion Z-scores in evaluation of heart systolic function of fetus with heart failure

OBJECTIVE

To compare fetal tricuspid annular plane systolic excursion(TAPSE）Z-scores and mitral annular plane systolic excursion(MAPSE) Z-scores between fetuses with heart failure (HF) and normal fetuses, and to analysis the correlation between CVPS and annular plane systolic excursion(APSE) Z-score(sum of the TAPSE and MAPSE Z-score) in order to evaluate the ventricle systolic function and severity in fetuses with HF.

METHODS

A total of 1012 normal fetuses and 24 fetuses with heart failure were involved. TAPSE and MAPSE were measured by free angle M-mode(FAM) echocardiography. Normal FAM-TAPSE and FAM-MAPSE Z-score models based on GA were constructed by performing a standard regression analysis followed by weighted regression of absolute residual values . Tei indexes were calculated in all fetuses with heart failure and all of them were divided into left heart failure (LHF)group and right heart failure（RHF)group by Tei index. Subsequently, FAM-MAPSE Z-scores were compared between the normal and LHF groups, FAM-TAPSE Z-scores were compared between the normal and RHF groups．FAM-APSE Z-scores (sum of the FAM-TAPSE and FAM-MAPSE Z-score) and the cardiovascular profile scores (CVPS) in 24 fetuses were calculated, the correlation was analyzed among them.

RESULTS

The models used to calculate Z-score for FAM-TAPSE and FAM-MAPSE were constructed, and GA had significant correlation with them (r = 0.949, p < 0.001for all)．Compared with normal fetuses, the mean Z-scores of FAM-TAPSE and FAM-MAPSE were statistically significantly different in fetuses with HF．In the HF groups, all FAM-TAPSE and FAM-MAPSE Z-scores(22/22) were <-2. CVPS ranged from 3 to 8 (mean 5.25 out of 10) and correlated positively with FAM-APSE Z-score (r = 0.762).

CONCLUSIONS

The FAM-TAPSE and FAM-MAPSE Z-scores declined in fetuses with HF and they can provide quantitative evidence in evaluation of heart systolic function, FAM-APSE Z-score correlated positively with CVPS. FAM-TAPSE, FAM-MAPSE and FAM-APSE Z-scores would be markers for assessing heart systolic function and severity in fetuses with HF.

The role of systolic-diastolic coupling in distinguishing impaired diastolic recoil in healthy aging and heart failure with preserved ejection fraction

BACKGROUND

Age-related changes to left ventricular (LV) early diastolic recoil confound the diagnostic value of e' velocity in heart failure with preserved ejection fraction (HFpEF). Systolic-diastolic coupling quantifies passive left ventricular elastic recoil and may be superior to e' in differentiating abnormal diastolic recoil in HFpEF from healthy aging. This study aims to determine the effect of healthy aging and HFpEF on systolic-diastolic coupling.

METHODS

Healthy adults (n = 141, aged 20-90 years) underwent right heart catheterization (RHC) to quantify LV filling pressure and tissue Doppler echocardiography to define peak velocities and excursion (velocity time integral) of the mitral annulus. Separately, HFpEF patients (n = 12, age 67 ± 5 years) and controls (n = 12, age 68 ± 5 years) underwent RHC and echocardiography. Systolic-diastolic coupling was measured as early diastolic excursion (ED_exc ) divided by systolic excursion (S_exc ).

RESULTS

In healthy adults, ED_exc / S_exc declined by 15% per decade of life (r²  = 0.53, P < .001). ED_exc /S_exc was significantly lower in HFpEF compared with controls (0.43 ± 0.11 vs 0.56 ± 0.11, P = .011), while e' was similar (6.2 ± 1.5 vs 6.8 ± 1.3 cm/s, P = .33). Using ROC analysis, ED_exc /S_exc had an AUC to detect HFpEF of 0.82 (0.61-0.95, P = .007), which was superior to e' alone (AUC 0.60(0.39-0.80), P = .39; P = .026 for difference).

CONCLUSIONS

Systolic-diastolic coupling, quantified by the ED_exc /S_exc ratio, declined linearly with healthy aging. The ED_exc /S_exc ratio was further reduced in HFpEF and able to predict HFpEF more accurately than e' alone. Systolic-diastolic coupling may be a useful diagnostic tool to detect HFpEF.

Subtle Cardiovascular Abnormalities in Prader-Willi Syndrome Might Begin in Young Adulthood

Objective Patients with Prader-Willi syndrome (PWS) are known to have a high mortality rate. However, little is known about the exact reason for this, particularly in adults, because so few reports have been published. The present study examined cardiovascular abnormalities to determine the cause of death in adults with PWS. Methods From September 2017 to April 2019, a total of 18 adults with PWS, and, no history of cardiovascular diseases, were enrolled. We investigated the levels of the cardiovascular biomarkers: high-sensitivity C-reactive protein (hs-CRP) and troponin T (TnT). To estimate the cardiac function, we measured the left ventricular ejection fraction (LVEF), global longitudinal systolic strain (GLS) of the left ventricle, ratio of peak early mitral filling velocity (E) to early diastolic mitral annular velocity (E/e' ratio), mitral annular plane systolic excursion (MAPSE) and tricuspid annular plane systolic excursion (TAPSE) using standard and tissue Doppler echocardiography. Results The mean patient age was 28±9 years old. There were 11 men, and the mean body mass index was 45.1 kg/m². Dyslipidemia (82%), diabetes mellitus (82%) and hypertension (83%) were commonly found as comorbidities. Most patients had elevated levels of hs-CRP (mean 1.007±0.538 mg/dL). The LVEF (mean 61%±5%) showed normal values, while the GLS (mean 15.0%±3.0%) was decreased. The TAPSE was mildly reduced (mean 16±3 mm). Conclusion These results suggest that subtle cardiovascular abnormalities have already begun in young adults with PWS. We need to manage obesity and the resultant obesity-related disorders in order to prevent heart failure and coronary atherosclerosis in PWS patients.

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), left ventricular (LV) filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

Longitudinal assessment of ventricular strain, tricuspid and mitral annular plane systolic excursion (TAPSE and MAPSE) in fetuses from pregnancies complicated by diabetes mellitus

OBJECTIVES

To evaluate fetal cardiac function using myocardial deformation analyses, tricuspid annular plane systolic excursion (TAPSE), mitral annular plane systolic excursion (MAPSE) and diastolic function parameters in pregnancies complicated by maternal diabetes mellitus.

METHODS

Myocardial deformation using velocity vector imaging (VVI), TAPSE, MAPSE and diastolic function was measured in 126 women with uncomplicated singleton pregnancies and 50 women with diabetes mellitus. Women underwent ultrasound scans every four weeks from recruitment (18-28 weeks gestational age) until delivery.

RESULTS

Left ventricle strain and strain rate, right ventricle strain and strain rate, TAPSE, MAPSE and diastolic parameters were not different between the diabetic cohort and controls throughout gestation. We did not find any significant correlation between the fetal cardiac function parameters with parity or smoking status. There was however a significant difference in strain and strain rate values in the left ventricle, but not the right ventricle in women with BMI >30 kg/m², and reduced TAPSE values in this same group. Fetuses in the diabetes group had thicker interventricular septum (IVS) throughout gestation.

CONCLUSION

Myocardial deformation of the fetal left ventricle, as measured by VVI, and TAPSE were reduced in fetuses of mothers in association with maternal obesity but not in women with diabetes mellitus. No significant differences in the fetal cardiac function parameters measured were different between the two groups, except for IVS thickness.

Left ventricular long-axis function in hypertrophic cardiomyopathy - Relationships between e`, early diastolic excursion and duration, and systolic excursion

Background

The peak velocity of early diastolic mitral annular motion (e`) is believed to provide sensitive detection of left ventricular (LV) diastolic dysfunction in hypertrophic cardiomyopathy (HCM), but other aspects of LV long-axis function in HCM have received less attention. Systolic mitral annular excursion (SExc) is also reduced in HCM and must be an intrinsic limitation to the extent of the subsequent motion during diastole. However, the effects of HCM on excursion during early diastole (EDExc) and atrial contraction (AExc), the duration of early diastolic motion (EDDur), and the relationships of EDExc with SExc, and of e`with EDExc and EDDur, are all unknown.

Methods

The study group was 22 subjects with HCM and there were 22 age and sex matched control subjects. SExc, EDExc, e`, AExc and EDDur were measured from pulsed wave tissue Doppler signals acquired from the septal and lateral walls. In the combined group of HCM and control subjects, multivariate analyses were performed to identify independent predictors of EDExc and e`for both LV walls.

Results

SExc, EDExc and e`were all lower, and EDDur was longer in the HCM group compared to the control group for both LV walls (p<0.05 for all). In contrast, AExc was lower for the septal wall in the HCM group (p<0.05), but not different between the groups for the lateral wall. In regression analyses of the combined group, EDExc was positively correlated with SExc, and SExc explained 57–86% of the variances in septal and lateral EDExc, e`was positively correlated with EDExc, and EDExc explained 58–68% of the variances of e`, whereas the combination of EDExc with EDDur explained 87–92% of the variances in e`. A diagnosis of HCM was not an independent predictor of EDExc when in combination with SExc, but was a minor contributor to the prediction of e`in combination with EDExc and EDDur.

Conclusion

In HCM, the decrease in LV longitudinal contraction is the major mechanism accounting for a lower EDExc, the lower e`is accounted for by contributions from the lower EDExc and prolongation of early diastolic motion, and there is no atrial compensation for the reduction of long-axis contraction.

Relationships of global longitudinal strain with s`, long-axis systolic excursion, left ventricular length and heart rate

Background

Longitudinal left ventricular (LV) contraction can be impaired in the presence of a normal LV ejection fraction (LVEF), and abnormalities have been reported in global longitudinal strain (GLS), long-axis systolic excursion (SExc), and the peak systolic velocity (s`) of mitral annular motion using tissue Doppler imaging (TDI). However, the relationships of GLS with s` and SExc have not been systematically evaluated in subjects with a normal LVEF, and whether these relationships might be affected by variations in LV end-diastolic length (LVEDL) and heart rate is unknown.

Methods

We investigated the univariate and multivariate correlations of GLS with TDI measurements of s` and SExc (both using averages of the septal and lateral walls), LVEDL and heart rate in subjects with a normal LVEF (>50%) but a low peak early diastolic mitral annular velocity (septal e`≤ 7.0 cm/s and lateral e`≤ 9 cm/s), and thus an increased risk of a future cardiac event.

Results

84 subjects (age 66±8 years, 29 males) with a LVEF of 62±6% and GLS of -17.5±2.3% were studied. On univariate analysis the absolute value of GLS was positively correlated with s`(r = 0.28, p<0.01) and SExc (r = 0.50, p<0.001) and inversely correlated with heart rate (r = -0.36, p = 0.001), but was not correlated with LVEDL (r = -0.15). In multivariate models, SExc explained more of the variance in GLS than s`, and absolute GLS was not only positively correlated with SExc, but also inversely correlated with LVEDL. Heart rate was an independent inverse correlate of GLS in conjunction with LVEDL and either s` or SExc, but made a larger contribution in models which included s`. Interobserver correlations were close for s` and SExc (r = 0.89–0.93), but only moderate for GLS (r = 0.71).

Conclusion

In subjects with a normal LVEF but reduced e`, the absolute value of GLS is more closely related to SExc than s`, and is also independently and inversely related to LVEDL and heart rate. Measurement of SExc may provide a useful additional or alternative technique to GLS for the assessment of LV long-axis function.

Multilayer myocardial strain improves the diagnosis of heart failure with preserved ejection fraction

Aims

The diagnostic and treatment of patients with heart failure with preserved ejection fraction (HFpEF) are both hampered by an incomplete understanding of the pathophysiology of the disease. Novel imaging tools to adequately identify these patients from individuals with a normal cardiac function and respectively patients with HF with reduced EF are warranted. Computing multilayer myocardial strain with feature tracking is a fast and accurate method to assess cardiac deformation. Our purpose was to assess the HFpEF diagnostic ability of multilayer strain parameters and compare their sensitivity and specificity with other established parameters.

Methods and results

We included 20 patients with a diagnosis of HFpEF and, respectively, 20 matched controls. We assessed using feature‐tracking cardiac magnetic resonance longitudinal and circumferential myocardial strain at three distinct layers of the myocardium: subendocardial (Endo‐), mid‐myocardial (Myo‐), and subepicardial (Epi‐). Comparatively, we additionally assessed various others clinical, imaging, and biochemical parameters with a putative role in HFpEF diagnostic: left ventricular end‐diastolic volume (LVEDV), left ventricular mass (LVM), interventricular septum (IVS) wall thickness and free wall thickness, left atrial volume and strain, septal and lateral mitral annular early diastolic velocity (e`), E/e´ ratio, and plasma levels of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP). Global longitudinal strain (GLS) is significantly impaired at Endo (−20.8 ± 4.0 vs. −23.2 ± 3.4, P = 0.046), Myo‐ (−18.0 ± 3.0 vs. −21.0 ± 2.5, P = 0.002), and Epi‐ (−12.2 ± 2.0 vs. −16.2 ± 2.5, P < 0.001) levels. Compared with any other imaging parameter, an Epi‐GLS lower than 13% shows the highest ability to detect patients with HFpEF [area under the curve (AUC) = 0.90 (0.81–1), P < 0.001] and in tandem with NT‐proBNP can diagnose with maximal sensibility (93%) and specificity (100%), patients with HFpEF from normal, composed variable [AUC = 0.98 (0.95–1), P < 0.001]. In a logistic regression model, a composite predictive variable taking into account both GLS Epi and NT‐proBNP values in each individual subject reached a sensitivity of 89% and a specificity of 100% with an AUC of 0.98 (0.95–1), P < 0.001, to detect HFpEF.

Conclusions

Epi‐GLS is a promising new imaging parameter to be considered in the clinical assessment of HFpEF patients. Given its excellent specificity, in tandem with a highly sensitive parameter such as NT‐proBNP, Epi‐GLS holds the potential to greatly improve the current diagnostic algorithms.

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), LV filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F₁ : Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F₂ : Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

Correlation Between Echocardiographic and Hemodynamic Variables in Cardiothoracic Intensive Care Unit

OBJECTIVES

The echocardiographic indices have not been validated in critically ill population. The authors investigated the correlation between some echocardiographic and hemodynamic parameters.

DESIGN

Prospective, spontaneous, noninterventional observational study.

SETTING

Adult cardiothoracic intensive care unit, single center (Royal Brompton Hospital, London, United Kingdom).

PARTICIPANTS

Consecutive adult patients admitted to the cardiothoracic intensive care unit for severe respiratory failure, primary cardiocirculatory failure, and post-aortic surgery.

INTERVENTIONS

Clinical hemodynamic parameters (stroke volume [SV], cardiac output [CO], mean arterial pressure [MAP], and cardiac power index [CPI]) and echocardiographic indices of ventricular function (left ventricular total isovolumic time [t-IVT], mitral annular plane systolic excursion [MAPSE], and left ventricular fraction [LVEF]) were evaluated offline.

MEASUREMENTS AND MAIN RESULTS

The study comprised 117 patients (age 57.2 ± 19; 60.6% male). The t-IVT showed an inverse correlation with SV, CO, MAP, and CPI (r -67%; -38%; -45%; -51%, respectively). MAPSE exhibited a positive correlation with SV, CO, MAP, and CPI (r 43%; 44%; 34%; 31%, respectively). LVEF did not show any correlation. In the multivariate analysis the association between t-IVT and hemodynamics was confirmed for SV, CO, MAP, and CPI, with the highest partial correlation between t-IVT and MAP (R = -58%).

CONCLUSIONS

MAPSE and t-IVT are 2 reproducible and reliable echocardiographic indices of systolic function and ventricular efficacy associated with hemodynamic variables in cardiothoracic critically ill patients, whereas LVEF did not show any correlation.

Assessment of Mitral Annular Plane Systolic Excursion in Patients With Left Ventricular Diastolic Dysfunction

Background

Mitral annular plane systolic excursion (MAPSE) is a well-known surrogate measurement of left ventricular ejection fraction (LVEF) and prognostic factor for many cardiac conditions. However, little is known about its role in assessing LV diastolic function; we therefore sought to identify potential determinants of MAPSE in patients with LV diastolic dysfunction (LVDD).

Methods

Our echocardiographic database was queried for studies of patients with normal sinus. Patients were allocated into three groups: LVDD 0, LVDD 1 and LVDD 2 in accordance with LVDD stages recommended by the American Society of Echocardiography guidelines.

Results

A total of 107 echocardiographic studies were included in the study. The mean MAPSE was 1.22 ± 0.32 cm. Groups LVDD 0 (n = 23), LVDD 1 (n = 43), and LVDD 2 (n = 41) were significantly different in most of the studied variables. Particularly, MAPSE differed between the three groups (P < 0.01). A multiple regression analysis showed that age, LVEF and LV mass index were predictors of MAPSE instead of LVDD and left atrial measurements. Finally, a regression model was constructed to predict MAPSE in the studied group showing that age and LVEF explained a 46% of the MAPSE variation. A two-way contour plot was illustrated to ease the model interpretation.

Conclusions

Age and measures of LV systolic function correlated well with MAPSE. A simplified model to predict MAPSE based on age and LVEF is proposed. Additional studies are needed to examine the potential role of MAPSE in identifying symptoms and overall prognosis in LVDD patients.

Association of High-Sensitivity Troponin T With Left Ventricular Dysfunction in Ankylosing Spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a systemic inflammatory disease, and cardiac dysfunction has not been clearly described clinically. High-sensitivity cardiac troponin T (hs-cTnT) is a noninvasive marker for subclinical myocardial injury.

OBJECTIVE

In this study, we aimed to investigate any relationship between hs-cTnT and left ventricular (LV) function evaluated via tissue Doppler imaging in AS patients with no known cardiac risk factor.

METHODS

Our study used a cross-sectional case protocol design and was conducted between January 2016 and June 2016. In total, 40 AS patients (17 females and 23 males) were age and sex matched with healthy volunteers (20 females and 20 males) and enlisted for this study. Detailed transthoracic echocardiography was performed, and tissue Doppler imaging was used to assess systolic and diastolic functions. High-sensitivity cardiac troponin T levels were measured and compared between 2 groups.

RESULTS

Compared with control subjects, AS patients had lower early (Em)/late (Am) diastolic myocardial velocities, mitral annular plane systolic excursion, and end-diastolic distance from the mitral annulus to the LV apex. Conversely, they had greater systolic myocardial velocity (Sm), isovolumetric relaxation time, and displacement index (p < 0.001, for all). Higher hs-cTnT levels were measured in AS patients (0.45 ± 0.22 vs. 1.11 ± 0.27, p < 0.001), and multivariate logistic regression analyses revealed that hs-cTnT was an independent predictor of LV diastolic dysfunction in AS patients.

CONCLUSIONS

These data show that AS patients had impaired LV functions and increased hs-cTnT levels. Tissue Doppler imaging may be a useful tool for detection of early functional LV abnormalities, and hs-cTnT may be valuable biomarker of diastolic LV dysfunction in AS patients.

Consensus Document of the SEMI, semFYC, SEN, and SEC on Focused Cardiac Ultrasound in Spain

This document summarizes the concept of focused cardiac ultrasound, the basic technical aspects related to this technique, and its diagnostic objectives. It also defines training requisites in focused cardiac ultrasound. This consensus document has been endorsed by the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Family and Community Medicine (semFYC), the Spanish Society of Neurology (SEN), and the Spanish Society of Cardiology (SEC).

Noninvasive Cardiac Imaging and the Prediction of Heart Failure Progression in Preclinical Stage A/B Subjects

Heart failure (HF) continues to grow as a cause of morbidity and mortality in our community and presents a significant public health problem, predominantly in individuals ≥65 years of age. Early intervention in asymptomatic HF subjects (Stage A/B) at risk of progression to symptomatic HF (Stage C/D) may provide an opportunity to halt this epidemic. The ability of cardiac imaging to assess cardiac structure and function permits early identification of those at increased risk of developing symptomatic HF. Systolic, diastolic, and structural left ventricular parameters each predict symptomatic HF, but no single parameter has sufficient sensitivity for screening to identify individuals with Stage A/B HF who are at increased risk of disease progression. Transthoracic echocardiography (TTE) has the advantage over other imaging modalities in being able to measure systolic, diastolic, and structural left ventricular parameters, and it identified at least 1 abnormal parameter in >50% of individuals with Stage A/B HF ≥65 years of age. Moreover, identification of at least 1 abnormality according to TTE in individuals with Stage A/B HF ≥65 years of age had 72% to 82% sensitivity for detection of those who subsequently developed symptomatic HF. Therefore, a case can be made for cardiac imaging by using TTE for community-dwelling populations with Stage A/B HF ≥65 years of age to identify those with increased risk of symptomatic HF who can be offered preventative therapies. Further studies are required to determine the best strategy for identifying the risk of symptomatic HF in younger individuals.

Echocardiographic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care

Proficiency in echocardiography and lung ultrasound has become essential for anesthesiologists and critical care physicians. Nonetheless, comprehensive echocardiography measurements often are time-consuming and technically challenging, and conventional 2-dimensional images do not permit evaluation of specific conditions (eg, systolic anterior motion of the mitral valve, pneumothorax), which have important clinical implications in the perioperative setting. M-mode (motion-based) ultrasonographic imaging, however, provides the most reliable temporal resolution in ultrasonography. Hence, M-mode can provide clinically relevant information in echocardiography and lung ultrasound-driven approaches for diagnosis, monitoring, and interventional procedures performed by anesthesiologists and intensivists. Although M-mode is feasible, this imaging modality progressively has been abandoned in echocardiography and is often underutilized in lung ultrasound. This article aims to comprehensively illustrate contemporary applications of M-mode ultrasonography in the anesthesia and critical care medicine practice. Information presented for each clinical application will include image acquisition and interpretation, evidence-based clinical implications in the critically ill and surgical patient, and limitations. The present article focuses on echocardiography and reviews left ventricular function (mitral annular plane systolic excursion, E-point septal separation, fractional shortening, and transmitral propagation velocity); right ventricular function (tricuspid annular plane systolic excursion, subcostal echocardiographic assessment of tricuspid annulus kick, outflow tract fractional shortening, ventricular septal motion, wall thickness, and outflow tract obstruction); volume status and responsiveness (inferior vena cava and superior vena cava diameter and respiratory variability [collapsibility and distensibility indexes]); cardiac tamponade; systolic anterior motion of the mitral valve; and aortic dissection.

Intraobserver and interobserver reproducibility of M-mode and B-mode acquired mitral annular plane systolic excursion (MAPSE) and its dependency on echocardiographic image quality in children

BACKGROUND

Mitral annular plane systolic excursion (MAPSE) is an increasingly used echocardiography technique to assess left ventricular (LV) function. However, reproducibility and dependence on echocardiographic image quality for MAPSE in pediatric patients have not been studied to date.

METHODS

We analyzed 284 transthoracic echocardiograms performed on consecutive normotensive children without structural heart disease (mean age 12.6±3.1 years, 50.4% female). B-mode and M-mode derived MAPSE measurements were performed and analyzed regarding inter- and intraobserver reliability and the influence of echocardiographic image quality.

RESULTS

Overall, MAPSE measurements were highly reproducible with only minor bias. Both inter- and intraobserver reliability were significantly better for M-mode derived MAPSE (p<0.001). Echocardiographic image quality did not significantly influence M-mode MAPSE reproducibility (p>0.235). In contrast, B-mode lateral MAPSE was significantly better reproducible in optimal image quality (-0.07±1.04) when compared to suboptimal echocardiographic images (0.42±1.59, p<0.001). Moreover, poor quality images yielded significantly lower M-mode MAPSE values (14.3±2 mm) than near-optimal (15.2±1.9 mm, p<0.001) or optimal images (15.1±2.2 mm, p = 0.006).

CONCLUSION

Echocardiographic image quality essentially has a negligible effect on MAPSE reproducibility and measurements. Consequently, MAPSE is a robust echocardiographic parameter with convincing reproducibility for the assessment of LV function in children-even in patients with substandard imaging conditions.

Left ventricular strain and twisting in heart failure with preserved ejection fraction: an updated review

Despite the high prevalence of the patients with heart failure with preserved ejection fraction (HFpEF), our knowledge about this entity, from diagnostic tools to therapeutic approach, is still not well established. The evaluation of patients with HFpEF is mainly based on echocardiography, as the most widely accepted tool in cardiac imaging. Identification of left ventricular (LV) diastolic dysfunction has long been considered as the only responsible for HFpEF, and its evaluation is still "sine qua non" of HFpEF diagnostics. However, one should be aware of the fact that identifying cardiac dysfunction in HFpEF might be very challenging and often needs more complex evaluation of cardiac structure and function. New echocardiographic modalities such as 2D and 3D speckle tracking imaging could help in the diagnosis of HFpEF and provide further information regarding LV function and mechanics. Early diagnosis, medical management, and adequate monitoring of HFpEF patients are prerequisites of modern medical treatment. New healthcare approaches require individualized patient care, which is why clinicians should have all clinical, laboratory, and diagnostic data before making final decisions about the treatment of any patients. This is particularly important for HFpEF that often remains undiagnosed for quite a long time, which further prolongs the beginning of adequate treatment and brings into question outcome of these patients. The aim of this article is to provide the overview of the main principles of LV mechanics and summarize recent data regarding LV strain in patients with HFpEF.

Longitudinal wall fractional shortening: an M-mode index based on mitral annular plane systolic excursion (MAPSE) that correlates and predicts left ventricular longitudinal strain (LVLS) in intensive care patients

Background

Left ventricular longitudinal strain (LVLS) is a modern measurement for LV function. However, strain measurement is often difficult in critically ill patients. We sought to show LVLS can be estimated using M-mode-derived longitudinal wall fractional shortening (LWFS), which is less dependent on image quality and is easier to perform in critically ill patients.

Methods

Transthoracic echocardiographic records were retrospectively screened and 80 studies suitable for strain and M-mode measurements in the apical 4-chamber view were selected. Longitudinal wall fractional shortening was derived from conventional M-mode (LWFS) and curved anatomical M-mode (CAMMFS). The relationships between LVLS and mitral annular plane systolic excusion (MAPSE) and M-mode-derived fractional shortening were examined using univariate generalized linear model in a training set (n = 50) and was validated in a separate validation set (n = 30).

Results

MAPSE, CAMMFS, and LWFS demonstrated very good correlations with LVLS (r = 0.852, 0.875 and 0.909, respectively). LWFS was the best unbiased predictor for LVLS (LVLS = 1.180 x LWFS - 0.737, P < 0.001). Intra- and inter-rater agreement and reliability for LWFS measurement were good.

Conclusions

LVLS can be estimated by LWFS in the critically ill patients. It provides a fast and accurate prediction of LVLS. LWFS is a reproducible and reliable measurement which can be used as a potential index in place of LVLS in the critically ill population.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1876-x) contains supplementary material, which is available to authorized users.

Predictors of transient left ventricular dysfunction following transcatheter patent ductus arteriosus closure in pediatric age

OBJECTIVES

To evaluate the left ventricular function before and after transcatheter percutaneous patent ductus arteriosus (PDA) closure, and to identify the predictors of myocardial dysfunction post-PDA closure if present.

INTERVENTIONS

Transcatheter PDA closure; conventional, Doppler, and tissue Doppler imaging; and speckle tracking echocardiography.

OUTCOME MEASURES

To determine the feasibility and reliability of tissue Doppler and myocardial deformation imaging for evaluating myocardial function in children undergoing transcatheter PDA closure.

PATIENTS AND METHODS

Forty-two children diagnosed with hemodynamically significant PDA underwent percutaneous PDA closure. Conventional, Doppler, and tissue Doppler imaging, and speckle-derived strain rate echocardiography were performed at preclosure and at 48 hours, 1 month, and 6 months postclosure. Tissue Doppler velocities of the lateral and septal mitral valve annuli were obtained. Global and regional longitudinal peak systolic strain values were determined using two-dimensional speckle tracking echocardiography.

RESULTS

The median age of the patients was 2 years and body weight was 15 kg, with the mean PDA diameter of 3.11 ± 0.99 mm. M-mode measurements (left ventricular end diastolic diameter, left atrium diameter to aortic annulus ratio, ejection fraction, and shortening fraction) reduced significantly early after PDA closure (p < 0.001). After 1 month, left ventricular end diastolic diameter and left atrium diameter to aortic annulus ratio continued to decrease, while ejection fraction and fractional shortening improved significantly. All tissue Doppler velocities showed a significant decrease at 48 hours with significant prolongation of global myocardial function (p < 0.001) and then were normalized within 1 month postclosure. Similarly, global longitudinal strain significantly decreased at 48 hours postclosure (p < 0.001), which also recovered at 1 month follow-up. Preclosure global longitudinal strain showed a good correlation with the postclosure prolongation of the myocardial performance index.

CONCLUSION

Transcatheter PDA closure causes a significant decrease in left ventricular performance early after PDA closure, which recovers completely within 1 month. Preclosure global longitudinal strain can be a predictor of postclosure myocardial dysfunction.

High sensitivity troponin T and I reflect mitral annular plane systolic excursion being assessed by cardiac magnetic resonance imaging

Purpose

This study aims to evaluate the association between high sensitivity troponins (hsTn) and mitral annular plane systolic excursion (MAPSE) in patients undergoing cardiac magnetic resonance imaging (cMRI).

Methods

Patients undergoing cMRI were prospectively enrolled. Patients with right ventricular dysfunction (< 50%) were excluded. Blood samples for measurements of hsTn and amino-terminal pro-brain natriuretic peptide (NT-proBNP) were collected at the time of cMRI.

Results

84 patients were included. Median left ventricular ejection fraction was 59% (IQR 51–64%). HsTn were correlated inversely with MAPSE within multivariable linear regression models (hsTnI: Beta − 0.19; T − 1.96; p = 0.05; hsTnT: Beta − 0.26; T − 3.26; p = 0.002). HsTn increased significantly according to decreasing stages of impaired MAPSE (p < 0.003). HsTn discriminated patients with impaired MAPSE < 11 mm (hsTnT: AUC = 0.67; p = 0.008; hsTnI: AUC = 0.64; p = 0.03) and < 8 mm (hsTnT: AUC = 0.79; p = 0.0001; hsTnI: AUC = 0.75; p = 0.001) and were still significantly associated in multivariable logistic regression models with impaired MAPSE < 11 mm (hsTnT: OR = 4.71; p = 0.002; hsTnI: OR = 4.22; p = 0.009).

Conclusions

This study demonstrates that hsTn are able to reflect MAPSE being assessed by cMRI.

Electronic supplementary material

The online version of this article (doi:10.1186/s40001-017-0281-x) contains supplementary material, which is available to authorized users.

Role of Global Longitudinal Strain in the Prediction of Outcome in Patients With Severe Aortic Valve Stenosis

In the present study, we assessed the role of Global Longitudinal Strain (GLS) as a predictor of all-cause mortality in patients with severe aortic valve stenosis (AS), irrespective of their type of treatment. Data of 807 patients with AS receiving complete echocardiographic and clinical examination were retrospectively analyzed. Valve area <1 cm² and sufficient image quality were inclusion criteria; patients with severe concomitant valvulopathy were excluded. Patients were grouped into treatment (aortic valve replacement [AVR]) and conservative (non-AVR) groups. Multivariable Cox analysis was used to assess predictors of all-cause mortality. Five hundred fourteen patients were included and 53.3% were of male gender. Mean age at inclusion was 76.4 ± 9.8 years; 326 received AVR. Death from any cause occurred in 72.9% of non-AVR group and 17.8% of AVR group (p <0.001). GLS (expressed as |%|) was found to be an independent predictor of all-cause mortality in non-AVR group (hazard ratio [HR] 0.933, 95% CI 0.854 to 0.987, p = 0.038). In patients receiving AVR, GLS and history of coronary artery bypass graft were found to be independent predictors of all-cause mortality (HR for GLS 0.912, 95% CI 0.730 to 0.999, p = 0.048; HR for coronary artery bypass graft 2.977, 95% CI 1.014 to 6.273, p = 0.013). In non-AVR patients, GLS <9.7% showed a higher 1- and 5-year mortality (log rank p values of 0.002 and 0.010, respectively). In conclusion, GLS is an independent predictor of all-cause mortality in severe AS, irrespective of their type of treatment. GLS <9.7% indicates a significantly higher 1- and 5-year mortality in non-AVR patients. Therefore, GLS should be regularly assessed for enhanced risk stratification and clinical decision-making.

Galectin-3 Reflects Mitral Annular Plane Systolic Excursion Being Assessed by Cardiovascular Magnetic Resonance Imaging

Background. This study investigates whether serum levels of galectin-3 may reflect impaired mitral annular plane systolic excursion (MAPSE) in patients undergoing cardiac magnetic resonance imaging (cMRI). Methods. Patients undergoing cMRI during routine clinical care were included prospectively within an all-comers design. Blood samples for biomarker measurements were collected within 24 hours following cMRI. Statistical analyses were performed in all patients and in three subgroups according to MAPSE (MAPSE I: ≥11 mm, MAPSE II: ≥8 mm–<11 mm, and MAPSE III: <8 mm). Patients with right ventricular dysfunction (<50%) were excluded. Results. 84 patients were included in the study. Median LVEF was 59% (IQR 51–64%). Galectin-3 correlated significantly with NT-proBNP (r = 0.42, p = 0.0001). Galectin-3 increased significantly according to the different stages of impaired MAPSE (p = 0.006) and was able to discriminate both patients with impaired MAPSE <11 mm (area under the curve (AUC) = 0.645, p = 0.024) and <8 mm (AUC = 0.733, p = 0.003). Combining galectin-3 with NT-proBNP improved discrimination of MAPSE <8 mm (AUC 0.803, p = 0.0001). In multivariable logistic regression models galectin-3 was still associated with impaired MAPSE (MAPSE < 11 mm: odds ratio (OR) = 3.53, p = 0.018; MAPSE < 8 mm: OR = 3.18, p = 0.06). Conclusions. Galectin-3 reflects MAPSE being assessed by cardiac MRI.

Usefulness of mitral annular plane systolic excursion in assessment of left ventricular systolic function in mechanically ventilated obese patients

BACKGROUND

The management of mechanically ventilated patients depends on a combination of clinical skills and measurement of physiological parameters.

OBJECTIVES

We evaluated the role of mitral annular plane systolic excursion (MAPSE) in the determination of left ventricular systolic function (LVSF) in mechanically ventilated obese patients.

METHODS

A convenient sample of 60 of 68 obese, mechanically ventilated patients in the intensive care unit were included in the study. Transthoracic echocardiogram MAPSE measurement (averaged from 3 consecutive cycles) on 2 separate days, vs the eyeball ejection fraction (classic clinical method) on 2 separate days, and vs the biplane Simpson (classic research and consultative echocardiogram method) on 2 separate days was obtained. In patients with non sinus rhythm, measurements were collected over 5 to 10 heartbeats.

RESULTS

There was a significant positive correlation between MAPSE and LVSF assessment using the eyeball method and Simpson method (r= 0.89 and 0.87, respectively; P< .001). Mitral annular plane systolic excursion was significantly shorter in duration (P< .001).

CONCLUSIONS

Mitral annular plane systolic excursion is useful, an easier technique, and shorter in duration compared with the eyeball method in the determination of LVSF in mechanically ventilated obese patients.

Early Ventricular Dysfunction After Anthracycline Chemotherapy in Children

The aim of this study was to determine the effect of induction dose of anthracycline chemotherapy on the biventricular function among children with acute hematological malignancies (AHM) using tissue Doppler imaging (TDI) and 2D speckle tracking echocardiography (2D-STE). Thirty pediatric patients with AHM and a mean age of 9.24 ± 4.14 years performed conventional echocardiography, TDI and 2D-STE. After induction chemotherapy, the RV showed mainly a diastolic alteration in its function manifested in significant reduction in the tricuspid TDI-derived E' and E'/A' ratio compared with the baseline (20.40 ± 3.81 vs. 17.47 ± 3.87 cm/s, p = 0.001, 1.29 ± 0.27 vs. 1.03 ± 0.37, p < 0.01, respectively), while the TDI-derived RV MPI and isovolumetric relaxation time of RV were significantly increased (0.32 ± 0.06 vs. 0.36 ± 0.08, p < 0.01, 24.73 ± 8.62 vs. 28.47 ± 11.51 ms, p < 0.05, respectively). The LV showed post-chemotherapy mainly an alteration in its longitudinal systolic function in the form of a reduction in MAPSE (13.61 ± 2.00 vs. 11.95 ± 1.75 mm; p < 0.001), TDI-derived systolic velocity of lateral mitral annulus (10.98 ± 2.34 vs. 10.03 ± 1.83 cm/s, p < 0.05), 2D-STE-derived global longitudinal strain (-21.58 ± 2.54 vs. -19.18 ± 3.59 %, p = 0.001) and 2D-STE-derived global longitudinal strain rate (-1.76 ± 0.22 vs. 1.55 ± 0.29 1/s, p < 0.05), with preservation of LV diastolic function when compared to baseline. TDI and 2D-STE could be used for early detection of anthracycline-induced cardiotoxicity in the pediatric age group. Early after induction chemotherapy, the RV develops mainly diastolic dysfunction, while the LV showed a relative longitudinal systolic impairment.

Right Ventricular and Right Atrial Involvement Can Predict Atrial Fibrillation in Patients with Hypertrophic Cardiomyopathy?

OBJECTIVES AND BACKGROUND

Atrial fibrillation (AF) is associated with clinical deterioration, stroke and disability in patients with hypertrophic cardiomyopathy (HCM). Therefore, the objective of this study was to evaluated cardiac magnetic resonance (CMR)-derived determinants for the occurrence of AF in patients with HCM.

METHODS

98 Patients with HCM and 30 healthy controls underwent CMR and were followed-up for 6 ± 3 years.

RESULTS

19 (19.4%) patients presented with AF at initial diagnosis, 19 (19.4%) developed AF during follow-up and 60 (61.2%) remained in sinus rhythm (SR). Compared to healthy controls, patients with HCM who remained in SR presented with significantly increased left ventricular mass, an elevated left ventricular remodeling index, enlarged left atrial volumes and reduced septal mitral annular plane systolic excursion (MAPSE) compared to healthy controls. Whereas HCM patients who presented with AF at initial diagnosis and those who developed AF during follow-up additionally presented with reduced tricuspid annular plane systolic excursion (TAPSE) and right atrial (RA) dilatation. Receiver-operator curve analysis indicated good predictive performance of TAPSE, RA diameter and septal MAPSE (AUC 0.73, 0.69 and 0.71, respectively) to detect patients at risk of developing AF.

CONCLUSION

Reduced MAPSE measurements and enlarged LA volumes seems to be a common feature in patients with HCM, whereas reduced TAPSE and RA dilatation only seem to be altered in patients with history of AF and those developing AF. Therefore, they could serve as easy determinable markers of AF in patients with HCM.

Myocardial dysfunction in patients with aortic stenosis and hypertensive heart disease assessed by MR tissue phase mapping

PURPOSE

To identify abnormalities of myocardial velocities in patients with left ventricular pressure overload using magnetic resonance tissue phase mapping (TPM).

MATERIAL AND METHODS

Thirty-three patients (nine with hypertensive heart disease [HYP], 24 with aortic stenosis [AS]) and 41 healthy controls were enrolled. To assess left ventricular motion, a basal, midventricular, and apical slice were acquired using three-directional velocity-encoded phase-contrast MR with a 3T system. Target parameters were peak longitudinal (Vz ) and radial (Vr ) velocity in systole and diastole (Peaksys , Peakdias ). Analysis was done on each myocardial segment. In a subgroup (n = 7 HYP, n = 12 AS, n = 24 controls), measurement was repeated during handgrip exercise.

RESULTS

AS had significantly lower Vz -Peaksys in the inferolateral and inferoseptal wall (P = 0.003-0.029) and Vr -Peaksys in the septum and anterior wall (P = 0.001-0.013) than controls. Vz -Peakdias and Vr -Peakdias were lower in AS than in controls in almost all segments (P < 0.001-0.028). HYP showed reduced Vz -Peakdias compared to controls in all basal segments as well as in the lateral midventricular wall (P < 0.001-0.045), and reduced Vr -Peakdias compared to controls predominantly in the midventricular and apical segments (P = 0.004-0.042). AS patients with focal fibrosis had significantly reduced myocardial velocities (P = 0.001-0.047) in segments without late enhancement. During exercise, Vz -Peaksys , Vr -Peaksys , and Vz -Peakdias remained unchanged in AS and HYP, but decreased in the lateral wall in controls (P < 0.001-0.043).

CONCLUSION

Even with preserved left ventricle (LV) ejection fraction, peak longitudinal and radial velocities of the LV are reduced in AS and HYP, indicating early functional impairment. J. Magn. Reson. Imaging 2016;44:168-177.

Changes of ventricular and peripheral performance in patients with heart failure and normal ejection fraction: insights from ergometry stress echocardiography

AIMS

We assessed the left ventricular (LV) and peripheral performance at rest and during exercise in healthy and heart failure subjects with normal ejection fraction (HFNEF) or with reduced ejection fraction (HFREF).

METHODS

All subjects received echocardiography at rest and with bicycle Ergometer exercise. The exercise images for two-dimensional speckle tracking were acquired with submaximal heart rate of 90-100 beats/min, while images for M-mode and tissue Doppler imaging were stored with attainment of >85% of predicted heart rate.

RESULTS

A total of 80 HFNEF, 50 HFREF and 50 controls were studied. There was progressive decrease of two-dimensional global circumferential, radial and longitudinal strains (GCS, GRS and GLS), M-mode and tissue Doppler imaging long-axis parameters from controls, HFNEF to HFREF patients (all P < 0.05) at rest and on exercise. The degree of exercise-induced, long-axis augmentation (GLS and M-mode long axis excursion) decreased progressively from controls, HFNEF to HFREF subjects (all P < 0.05), while the increase in GCS and GRS was similar in all groups. The ventricular-arterial coupling ratio did not change in HFREF but reduced in HFNEF and controls during exercise (P < 0.01). All subjects had a similar resting heart rate, but patients exhibited chronotropic non-competence during exercise (P < 0.001).

CONCLUSIONS

Ventricular and peripheral dysfunction was evident in HFNEF at rest and deteriorated during exercise. The HFNEF patients had significantly impaired long-axis augmentation at stress that was intermediate between HFREF patients and controls. These findings have relevance to generation of symptoms on exercise in both HFNEF and HFREF.

M-mode apical systolic excursion: A new and simple method to evaluate global left ventricular longitudinal strain

INTRODUCTION

Since M-mode measurements can assess deformation of specific regions of the left ventricle, we hypothesized that M-mode measurements like M-mode apical systolic excursion (MMASE) and mitral annular plane systolic excursion (MAPSE) may be correlated with left ventricular longitudinal strain (LVLS).

METHODS

All subjects of the study underwent a full echocardiographic evaluation and MMASE and MAPSE measurement. Three-dimensional wall motion tracking (3D-WMT) was performed.

RESULTS

Thirty-one patients were evaluated. Significant correlations between MAPSE and LVLS (-0.372; p=0.04) and between MMASE and LVLS (-0.398; p=0.027) were found. LVLS was linearly related to MAPSE and MMASE (in mm) as follows: ST=-10.6 -0.4 * MAPSE (r2=0.14) and ST=-13.1 -0.5 * MMASE (r2=0.16).

CONCLUSIONS

Our results demonstrate that simpler and faster methods than strain based on complex speckle analysis can also have a role in predicting subclinical left ventricular systolic dysfunction.